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Secondary Syphilis.If the individual has already some constitutional taint, such as rheumatism, gout or tuberculosis, the outbreak of constitutional syphilis may be accompanied by an attack of rheumatic or gouty pain. If the individual be poorly nourished or exhausted by excessive mental or physical exercise, or by the use of alcoholics, the appearance of the constitutional symptoms of syphilis is hastened so that the rash may become visible at the end of a month. After the symptoms above described - headache, fever, etc.,- have lasted for several days, the rash appears in the shape of delicate red spots, usually from a quarter to half an inch in diameter. Simultaneously with the appearance of this rash the fever and accompanying symptoms subside. The rash - which is called the syphilitic roseola - consists entirely of these red or brownish-red discolorations of the skin. There is, therefore, properly speaking, no eruption at this time-noting which is elevated above the surface of the skin. Indeed, the skin remains perfectly smooth and even, and is changed in nothing except its color. This roseola is 'more distinctly seen on the sides of the chest and on the neck ; and it is usually more distinct wrhen the individual's skin is somewhat warm. This rash may escape a careless scrutiny; indeed, there are cases in which the patient himself is not aware of its existence until his attention is directed to it by the physician. This is usually the first, though not the only skin eruption which appears as a manifestation of constitutional syphilis. It will be useless to describe in detail the eight or ten varieties, since these can be recognized, not from any description, but only from long practical observation. It will suffice to say that they resemble the different varieties of skin eruptions which have been described in the section on skin diseases. Many of them have white scales like psoriasis (dry tetter) ; some consist of pimples like the common acne ; some appear as little blisters containing matter; others are composed of watery blisters; and one causes the formation of thick scabs upon a raw surface - the last named has been already described on a previous page under the name of rupia. There are certain peculiarities as to the location of the syphilitic rash. Thus one of them is especially apt to occur on the palms of the hands and on the soles of the feet, so that the nature of the disease can often be recognized just from its location. Another feature which is often of service in distinguishing the syphilitic eruptions from those of similar appearance which are not syphilitic in their nature, is the absence of itching. The eruptions of syphilis rarely cause any itching, while the non-syphilitic eruptions which may be mistaken for them - such as psoriasis, prurigo and eczema - are accompanied by more or less intense itching. The skin is not the only part of the body in which the syphilitic infection is manifested. The mucous membranes are also the seat of disease at an early period of syphilis. The throat and the mouth are almost always affected within the first few months after the disease has been contracted. In fact, there are cases in which no rash occurs upon the skin until long after the throat has become sore ; such cases have been occasionally mistaken fc* mild attacks of diph theria. These sores in the throat consist of whitish patches, varying in size from a pin's head to half an inch or more in diameter. They occur on the tonsils, on the roof of the mouth, on the sides of the tongue where it presses against the teeth, and in the groove between the lip and the gum. In many cases one sees nothing unnatural- unless, perhaps, a slight redness of the throat - upon looking into.the patient's mouth; and if the examination be not carried further, it might readily be supposed to be a simple and innocent one. In such cases the examiner should always turn the lip out so that he can inspect the base of the gums and the inner surface of the lip. The trouble will often be rewarded by the appearance of small white patches surrounded by a reddish border. It should be said, however, in order to allay undue and unjust suspicion that patches of similar appearance may be present in the mouth of an individual who is not syphilitic. The distinction between the syphilitic sores and those from other causes can be made only by the practiced eye. These sores appear with especial frequence, and are unusually obstinate in individuals who do not attend carefully to the cleanliness of the mouth and teeth. They are apt to be obstinate also in those who use tobacco in excess. Another manifestation of syphilis, which often appears within a few months after the contraction of the disease, is the occurrence of small moist tumors called condylomata. In a previous chapter we have described the pointed condylomata, which are merely large warts, usually caused by some irritation of the skin, but not due to syphilitic infection. The condylomata which occur as a part of syphilis, however, are not pointed, but flat; they do not look so much like warts as the other variety. They consist of broad, flattened tumors, usually raised a quarter of an inch or so above the surface, and covered with skin or mucous membrane. The surface is often moist and sometimes ulcerated. These tumors occur especially often at the places where the skin and the mucous membrane are joined; their favorite location is therefore around the orifice of the vagina, around the rectum and in the vicinity of the mouth. Syphilitic individuals often have minute tumors, looking like simple pimples, in the corners of the mouth ; these may be so small and insignificant as to attract no attention. The fact is, however, that these tumors or condylomata are extremely contagious ; the least matter or discharge from their surface conveys the disease either to a healthy individual or even to an adjacent portion of the same person. That is to say, that if one of these tumors be located in a fold of the skin, so that its top comes in contact with the skin on the opposite side of the groove, a second tumor will soon be developed at the point of contact If one of these condylomata grows upon the inside of the thigh, a second one will in all probability be developed at a corresponding point on the other thigh. In consequence of this fact - that new tumors are caused by the discharge from anyone - it happens that these condylomata are almost always found in groups, and rarely alone. They may occur on all parts of the body where there are large oil glands and hair follicles. They are found on the genitals especially, on the inner surface of the thighs, in the groins, under the arm, at the corner of the mouth and of the nose, at the back of the neck, in the ear, on the breast in women, and between the fingers and toes. These tumors are more frequently found in women than in men who suffer from syphilis ; this seems to result from the fact that a lack of cleanliness favors the development of these tumors, and that it is possible for women to be more filthy than men in their personal habits. The skin eruptions in syphilis sometimes take the form of ulcers, which may or may not be covered by thick scabs. This is especially apt to occur in poorly nourished individuals and in those who are neglectful in the care of the person. These scabs are sometimes so thick and numerous as to interfere seriously with the movements of the limbs and with the wearing of the clothes. When these ar, removed there remain large foul ulcers, which are apt to be very painful in consequence of the irritation to which they are subject from the clothes. When these ulcers heal they leave large scars which, for a time at least, exhibit a dirty brown or copper color. This peculiar color sometimes serves for the detection of syphilis, even after the symptoms of the disease have subsided. Another manifestation of the disease consists in the appearance of lumps in and under the skin. These must not be mistaken for enlarged glands, which occur in a few weeks after the contraction of the disease. These lumps appear in the skin on all parts of the body, though especially often on the skin of the head and face, on the forehead, nose and lips, on the shoulders and thighs. These lumps, which may reach the size of hazel nuts, or even larger, disappear under appropriate treatment without causing trouble, but if not treated promptly they are apt to result in the formation of ulcers, which may occasion the patient considerable pain and annoyance. Another manifestation of syphilis, which often occurs at the same time with the appearance of these lumps on the skin of the head, is falling out of the hair. The hair becomes dull, loses its natural luster, and comes out upon very slight contact. Sometimes whole bunches of it will be drawn out by the comb or even by a stiff brush. The individual may become quite bald, though the skin of the head is found to be covered with thick scales. Sometimes the loss of hair affects the eyebrows and eyelashes, the beard, and even the entire surface of the body. This loss of hair usually happens only in individuals who are in a debilitated condition, either from the ravages of the syphilis itself or from some other impairment of the health. Under appropriate treatment the patient's general condition can be readily improved, after which the hair grows again as luxuriantly as before. Another manifestation of the syphilitic poison is a disease of the nails. Properly speaking, the disease affects the skin around the nails and the surface upon which they lie - the bed of the nails. The skin surrounding the nail becomes red, swollen and painful ; in many cases ulceration results, so that considerable matter is formed and escapes at the sides and from under the nails. This disease affects the toes as well as the fingers ; the fact occurs more frequently on the former than on the latter. In consequence of this affection the nails become uneven, knotty, deformed and discolored ; they are usually loosened and drop off, though new nails grow again when the ulceration of the surrounding skin ceases. These new nails are not usually so regular and natural in appearance as the former ones were. Syphilis also causes a disease of the nails themselves, without affecting the skin around them. In consequence of this disease the nails become discolored and deformed ; they are dotted over with white or brown specks, and the free edge of the nail is often broken off. Such are, in brief, the affections of the skin and mucous membranes which occur during the first six or eight months after an individual has contracted syphilis. The number and extent of these eruptions, and the injuries inflicted upon the individual in consequence, depend largely upon the person's general health and condition, and upon the treatment pursued. If the subject of the disease has always enjoyed robust health and taken care to keep himself in good physical condition, he may escape most of the affections which have been described in these pages. If in addition he place himself under appropriate and skillful treatment, his chances for suffering but slightly from these affections are very good. When properly managed an individual enjoying good health in other respects need suffer, during the first six months, almost no other affection of the skin or mucous membranes than a soreness of the throat and the simple rash on the skin which has been described under the name of roseola. The serious affections of the skin occur chiefly in persons of poor constitution and in a debilitated condition. Generally speaking it is therefore true that syphilis creates far more havoc among hospital patients than among those of the better classes who are met with in private practice. While these affections are manifesting themselves on the skin of the syphilitic individual, other changes are frequently taking place in the internal organs, and it is these which constitute the danger of the disease. The eruptions which appear upon the skin are often very annoying, and sometimes give the patient much bodily discomfort ; but they rarely, if ever, are sufficiently serious to threaten his existence, or even to interfere with the perfect performance of his bodily functions. But the changes which occur in the internal organs, though not so readily discovered as the rashes upon the skin, are none the less real and are far more serious. It is beyond our province here to attempt any description of the diseases of the internal organs which are caused by the presence of the syphilitic poison in the body, yet a few of them are so important that brief reference must be made to them. One of the first of these consists in the impoverishment of the blood. This is manifested by the pallor, lassitude and loss of strength which the individual suffers, usually within the first three or four months after contracting the disease. This pallor and impairment are sometimes so great as to unfit the individual for the performance of his usual duties, and even to confine him to the house or to the bed. Sometimes the syphilitic poison affects the brain, resulting in the growth of tumors, which press upon this organ and prevent the performance of its usual functions. The resulting symptoms vary with the part of the brain affected ; sometimes the individual suffers a stroke of " apoplexy" or paralysis; at other times the movements of the eyes are impaired so that the individual has a persistent squint, or inability to move the eyeballs in the natural way. Thus it may happen that the patient is unable to turn one of his eyes inward toward the nose, or outward in the opposite direction. Sometimes the upper lid droops and the patient is unable to open the eye as widely as before. There may also be a difference in the size of the pupil. At other, times the power of motion and the feeling of the skin are impaired. The patient may have certain spots on the body which are quite numb, and in which he has no feeling In fact, there is no limit to the number and variety of the ailments which may affect different parts of the body and different organs, as the result of infection by syphilis. The disease may affect all the different organs and tissues, and may result in a great variety of disorders which often simulate other diseases, and whose nature may not be for a long time suspected. A frequent manifestation of syphilitic infection is the occurrence of pains similar to those of rheumatism, which may be felt in any part of the body, but are especially liable to affect the legs between the knee and the ankle. Sometimes these pains are extremely acute, and render the patient restless and miserable; he is unable to obtain the necessary sleep by day or by night. Sometimes these pains are accompanied by a perceptible swelling and thickening along the shin-bone; in this case the bone itself is tender upon pressure. The thickening and swelling may extend along the entire course of the bone, from knee to ankle, or may be perceptible only at certain points of the bone ; sometimes lumps of considerable size, even as large as a hickory nut, are to be found at one or more points of the bone. These pains are sometimes erroneously regarded as rheumatic ; but from rheumatism they are readily distinguished by the fact that they are much zvorse at night, while the rheumatic pains do not follow this rule. Rheumatism moreover is usually worse during a change in the weather, and during rainy weather, while the syphilitic pains do not thus vary. Hereditary Syphilis. - Syphilis is one of the diseases which is known to be transmitted from parent to child. It may be manifested in the child at the time of birth, or may become evident some months, or even years, afterward. The symptoms of syphilis derived from the parents - and therefore called hereditary or congenital syphilis-vary somewhat according to the stage of the disease with which the parents were affected at the time of conception. Syphilis is a frequent cause of abortion and miscarriage, and in general it is true that the chances of abortion are greater if conception take place soon after the disease is contracted than if it be postponed until a later period. If conception occur during the existence of the primary sore, or during the presence of the secondary symptoms - that is, within six or eight months after the disease is contracted - abortion almost invariably occurs ; and if a pregnant woman contract the disease during the first six or seven months of her pregnancy, a miscarriage usually results. Thus it often happens that a woman will suffer two, three or four abortions, and finally bring into the world a living child at full term. In these cases it is usually observed that the later children are retained in the womb a longer time than those which were conceived immediately ^.fterthe disease was contracted. Thus the first abortion may occur at the third month, a second at the fourth or fifth month, a third at the sixth or seventh, and so on. In other words, the ability to retain and nourish the foetus to the full term increases when the virulence of the syphilitic poison wears itself out. The symptoms of congenital syphilis which appear at or after birth, are usually seen on the skin and mucous membranes. Sometimes the child is brought into the world with a rash upon the skin, consisting of large blisters which may contain watery fluid, or may have pus (matter) in them. Such children are often born dead, though they may have lived until within a few days or weeks of birth, and if they are born alive, they rarely live more than a few weeks. Many children born with the syphilitic taint are apparently healthy at the time of birth, and remain so for several weeks. The appearance of the symptoms usually occurs within three months after birth, occasionally some weeks later. There are cases in which the first symptoms appear at or subsequent to puberty. As to the source of the infection, it seems well established that the child can be tainted with syphilis by either the father or the mother. In the majority of cases it is apparent that the disease is derived from the father. And in general it is true that the more recently the father has suffered from the disease, the more probable is the outbreak of virulent syphilis in the child which he begets. Yet it must be remembered that the father communicates the disease to his child in the act of propagation, not by the contact of his person, but because a part of his body enters into the composition of the fætus. This explains the fact that a man who has no symptoms whatsoever of syphilis, and who may have been apparently free from the disease for months or even years, begets, nevertheless, a syphilitic child. The fact is that the disease is still present in his system, though it may have been so controlled by treatment and by sanitary measures that it does not manifest itself in his own person. Many a man who has long been free from the signs of syphilis and congratulates himself that he is entirely cured of the disease, has been horrified to find that the skin eruptions and other ailments which affect his new-born child, are due directly to the taint derived from himself, which he supposed had been long before eradicated from his system. Another curious feature in the matter - which is, however, explained by the fact just stated - is that the mother may remain entirely free from syphilis even though she bears several syphilitic children. This results from the fact that the wife contracts the disease only when the husband has some eruption, either on the skin or on the mucous membranes. Months may elapse at a time during which the man remains free from these eruptions and from sores in the mouth, etc. ; and during this time he does not communicate the disease to another individual unless some of his blood be transferred to that person. Contact alone, no matter how intimate it may be, does not, therefore, transfer the disease ; and the wife remains free from syphilis, although as the result of that intimate contact the foetus exhibits the syphilitic taint derived from the father. It may thus happen that a woman bears syphilitic children to one husband, and in after years brings into the world healthy children by a second husband ; for the disease is entirely a physical one, and leaves no trace upon the woman unless it be communicated directly to her person. Another curious feature about the diease is, that a woman may contract syphilis from her own child ; for the infant is apt to develop in the first few weeks of life certain sores in the mouth, which are due to the syphilitic taint, and are just as capable of communicating the disease as the sores found in the mouth of an adult who has contracted the disease in the usual way. If the mother have some crack or abrasion on the nipple - and few mothers escape these annoyances - the disease will almost certainly be communicated from the child to the mother by the act of nursing. Hence this curious state of affairs: As the wife of a syphilitic man, and as the mother of a syphilitic child, during the nine months of pregnancy a woman may escape infection ; and yet as the nurse of her own child she falls a victim to the disease. Yet it is true that such women seem to have a certain protection against infection by their own children. Cases are known in which a syphilitic child has been nursed by its own mother and the latter has shown no signs of the disease, yet the same child has afterward communicated syphilis to a healthy wet-nurse. Hence it has been supposed that a woman who carries in her womb the child of a syphilitic father does really experience a mild attack of the disease, and that this attack may be so mild as to escape attention, while it is sufficiently intense to protect the mother from subsequently contracting the disease. The whole subject of the relation of the parents to syphilis in the child is summed up by Professor Neumann in the following words : First-Syphilis occurs in the child the earlier if the father have contracted the disease at or about the time of conception; yet fathers suffering from advanced syphilis can also beget syphilitic children. Second-Appropriate treatment applied to the father, or after conception, to the mother, usually exerts a favorable influence in protecting the fcetus from syphilis. Third-A child acquires syphilis from the mother in most cases only when she has recently contracted the disease. It seems that if she become syphilitic after conception, she is not likely to communicate the disease to her unborn offspring. Fourth-If both parents are suffering from syphilis at the time of conception, the child exhibits the most intense forms of the disease. Fifth-The communication of syphilis from parents to their children is the rule, although exceptional cases occur in which the offspring are born healthy, notwithstanding the syphilis of the parents. (In these cases the syphilis of the parents is almost always of ancient date, so that it has worn itself out in their bodies and is no longer communicable.) Sixth-Hereditary syphilis is generally communicated to the child by the father. Mothers who bear syphilitic children generally remain apparently healthy (when the syphilis is derived from the father); yet since such mothers are not usually infected by nursing their own syphilitic children, we must suppose that they have really Qxperienced a slight attack of the disease which did not make itself sufficiently prominent to attract attention. Among the symptoms which mark the hereditary syphilis of infants are various eruptions on the skin, to which reference has been already made. Sometimes the rash affects merely the palms of the hands and the soles of the feet; at other times it occurs chiefly around the buttocks ; in other cases it is manifested by thickening and a discharge from the mucous membrane of the nose. These latter cases are those in which the child suffers extremely from " snuffles " ; in consequence of the thickening in the mucous membrane, the infant is unable to breath through the nose unless he make considerable effort and noise. As the child grows older the syphilitic taint is manifested by the peculiar shape of various bones in the body, as well as by derangements in different organs of the body. Syphilis shows itself in these children especially in the shape of the head and of the nose. The forehead is apt to be quite prominent, especially the upper part, while the lower part above the eyebrows is somewhat sunken. The bridge of the nose seems in many cases entirely absent, so that there is no elevation of the skin between the corners of the eyes. The point of the nose is consequently considerably elevated ; in fact, the impression derived from looking at such a nose is as if the entire organ had been revolved about an axis running through the nostrils, so that the base of the nose is turned backward and the tip of the organ upward. In consequence of this shape of forehead and nose, the upper part of the face looks in profile bow-shaped. The mouth is usually somewhat sunken and the chin prominent; the entire face has been described as " concave" - that is, the upper part of the forehead and the chin are the two most prominent points, while the intervening space is hollowed out. The nose of such an individual is apt to be short, thick and broad, and it widens rapidly toward the eyes, so that the base of the nose attains an extreme breadth. In many cases these individuals suffer from obstinate and troublesome catarrh. Another feature which is characteristic of secondary syphilis is the peculiar shape of the middle teeth in the upper jaw. The edge of such a tooth :z usually hollowed out in the middle, while the sides extend dov.n into points; hence the tooth is described as being " ch'sel-shaped." Ano ier affection which is due to congenital syphilis, is an obstinate affection of the eyes. This does not usually manifest itself until the period of puberty. The front of the eyes becomes somewhat white and opaque, or as the patient describes it, there is a " scum over the eye." The sight may be for a time almost lost, but is recovered again usually under proper treatment. In many cases the second eye is affected soon after the first, or after recovery in the first eye. The subjects of hereditary syphilis are susceptible also to paralysis, and to other manifestations of disease in the brain; these may be manifested in childhood, and may occur without apparent cause. These children are also subject to various deformities of the bones, and to disease affecting the bone structures. Thus these children are frequently afflicted with caries or necrosis-diseases which consist essentially in the mortification of the bone, as a result of which the skin and flesh over the bones become ulcerated and produce matter. These affections are very obstinate, and may last for a considerable time unless the cause of the disease (syphilis) be recognized and appropriate treatment be employed. Treatment,- Syphilis is practically an incurable disease. By this it is not meant that individuals once affected with syphilis never recover entirely from its effects or never cease to manifest evidence of its presence in the system. It is meant simply that the cases in which recovery occurs do not constitute the majority; on the contrary, they form a small minority. It is always possible, except in very much debilitated individuals, to cure the usual manifestations of the disease on the skin, mucous membranes and in the bones; and in many cases it is possible to relieve serious symptoms, such as paralysis, which result from syphilitic disease of the brain. In fact, the physician who is called to a case of paralysis or apoplexy is always rejoiced to find that the patient has had syphilis, since he knows that if the disease be caused by some change in the brain due to syphilis, the chances for the patient's recovery are much better than is otherwise the case. While it is thus usually possible to cure the different outbreaks of syphilis, as they occur from time to time, the physician is never certain that the poison is completely eradicated from the patient's system. The individual may enjoy months and years of uninterrupted health; he may be entirely free from even the slightest manifestation of the disease ; and yet five, ten, or even twenty years afterward, he may be afflicted with an ailment which points unmistakably to the syphilitic poison as the source of the difficulty. Perhaps the most critical test of a man's freedom from syphilis is to be found in the condition of his children, for it often happens that the man himself may remain for a long time quite free from all evidences of the disease, and yet, at the end of that time, may beget children who illustrate the fact that the sins of the father are visited upon the children. In view of this practical incurability of syphilis, or rather of the impossibility of determining that a man who has once contracted the disease is completely free from it, the question naturally arises, whether an individual who has once suffered from syphilis is justified in marrying at all. This question has been the subject of much observation and thought on the part of medical men, and opinions still vary because the facts observed in different cases also differ. There can be no doubt that the prevalence of the disease would be restricted if all men - and women too of course - who have once suffered from the disease, would refrain from marriage and from all unnecessary personal intercourse and contact with others. Yet this plan could not and of course would not be adopted ; such a demand on the part of society would hardly be justifiable, since many cases do occur in which individuals recover so completely from the disease as to be quite free from it themselves and to beget children who exhibit no evidences of the poison. Since, therefore, such individuals can not be asked nor compelled to refrain from marriage, the important question is, slider what conditions may such a man feel justified in marrying ? To answer this question we must realize the risk which every man who has once had syphilis imposes upon a woman and upon unborn children by assuming the marriage relation. It must be remembered that the ability to communicate the disease does not cease when the primary sore is completely healed. It must be borne in mind, that for some weeks or months during the first year after contracting the disease, the touch of his lips is often sufficient to communicate the disease. Furthermore he does not know at what time in subsequent years sores may break out in his throat or mouth, or about the genitals, which are just as virulent and contagious as the original primary sore. If a man bears all these things in mind ; if he realizes that his most affectionate caress may deal disease and even death to an innocent and trusting woman; if he remember further, that his children and hers may rise up to curse the day and the man by whom they were brought into a world of disease, he will listen with more patience to the warning which the accumulated experience of medical men pronounces most emphatically for all those who have once suffered from syphilis. It may be safely asserted that under no circumstances should an individual marry within two years after the last manifestations of syphilis have disappeared. And even at this time he should not take the risk unless his general health is such as to encourage him in the belief that there is none of the poison lurking unseen in his system. This period will, in most cases, be at least three years after the disease was contracted. In order to determine so far as possible his freedom from the disease, the patient should of course submit himself to the most careful medical examination. More than that, he should, from the very beginning of the disease, keep himself under constant supervision by the best medical man at his service. The chances are great that if treatment be discontinued so soon as the first manifestations of the disease have disappeared, subsequent outbreaks of syphilis will occur. In order to secure the greatest possible assurance of success in getting rid of the poison, both treatment directed against the disease and the most careful attention to the general health should be maintained for months after the disappearance of the symptoms. By this it is not intended that the patient shall take medicine regularly every day during the entire time ; in fact experience has shown that the best and speediest results are obtained by omitting medicines for a time and resuming them subsequently at intervals, but it is meant that the patient shall remember that the first object of his existence is to do everything possible to rid himself of the syphilitic poison. This will include the most careful attention to the ordinary rules of health, good diet and proper exercise. For it is abundantly shown that syphilis is the more dangerous and persistent as the general health of the body becomes depreciated. The worst cases of the disease are found in those who, either from hereditary taint or neglect, have become reduced in their general health ; the ravages of the disease, even including the primary sore, are much less in healthy and robust individuals. If the patient conscientiously observe the principles laid down in these lines ; if he regards it as a duty to keep himself under the direction of his physician so long as the least symptom of the disease remains ; and if he have the moral courage and the self-control- the regard for the happiness of others which he would have them observe toward him under like circumstances-he may console himself with the assurance that, sooner or later he may, with a clear conscience, follow the natural instinct of a man and marry. Yet it must be admitted that even then there remains a possibility that disaster may follow ; and in this case, if he have the least spark of manhood, the least grain of affection for his wife and children, he will regret with the keenest remorse that he did not choose the wiser, though perhaps less blissful lot, and remain single. Surely nothing could inspire a man with more bitter regret than to see in his own wife and family the results of his selfish course manifesting themselves by the most loathsome and incurable of diseases. Such sights are unfortunately common in the observation of physicians. That an individual who is still suffering from syphilis should most carefully avoid all contact, direct or indirect, with other persons, seems so self-evident, that a statement of the fact appears unnecessary. Yet it is unfortunately the actual fact that such individuals are extremely careless, and even criminally negligent in distributing promiscuously the poison which emanates from their own persons. The prevention of syphilis has occupied a great deal of attention on the part of lawmakers as well as of medical men. The matter rests, of course, chiefly with the individual, since in the vast majority of cases the disease is contracted through the gratification of the sexual appetite. Since it seems impossible for men to testrain themselves from the unlawful indulgence in such gratification, the attention of those interested in preventing the disease has been chiefly directed to the regulation and supervision of prostitutes. This question has, of course, a moral aspect, which should be considered before the means for executing it are discussed. It is not our purpose to consider this moral side of this question ; it may however be proper to state that, from the medical point of view, the attempt to restrict the spread of syphilis by official inspection and regulation of prostitutes has not been particularly successful. It would be out of place to state in detail the reasons why this plan, which is apparently so complete, has failed. Yet the experience of Paris, Berlin, Vienna and other European capitals, has proven the inefficacy of this procedure in limiting the prevalence and spread of syphilis. In this country this method has not received the sanction of public opinion, and has not been carried into effect to any great extent; yet we are thus far, as a community, less afflicted with the disease than most of the peoples of Europe. Various plans have been proposed for protecting the individual from contracting the disease during intercourse. Without mentioning these, it may suffice to say that no reliance whatsoever can be placed upon any of them. The force of this statement becomes apparent withont detailed discussion, when we remember that the disease is communicated by any discharge from the body, and by the matter contained in any sore of the individual suffering from the disease. Thus instances are known in which the disease has been communicated by the scratch of a finger nail, there having been a syphilitic disease around the nail at the time, some of the matter from which had been introduced into the skin by means of the nail. It has been proposed to cut out the primary sore so soon as it becomes visible, in the hope that by removing this portal of infection the syphilitic poison might be prevented from getting into the body. This plan has been carried into effect in a large number of cases by different physicians. The results reported are almost unanimous in proving that this method is quite ineffectual in preventing the virus of syphilis from entering the body ; since in nearly all cases the disease has been manifested in just the same way subsequently as in those cases in which the primary sore has not been cut out. The operation is a trifling one, and it may be well in every case to give the patient the benefit of the possibility, but the fact is that the primary sore does not exhibit the characteristic of a syphilitic sore until after the poison has entered the body. Hence, although the sore in the skin may be completely removed, it is already too late to prevent the access of the virus into the system. The treatment of the disease should in no case be undertaken by the patient himself; his ability to manage the affair ends with the first manifestation of the disease. It is only proper to emphasize with all the weight of medical experience, that the only proper treatment of syphilis consists in a careful avoidance of exposure to it. This is not a mere question of morals or of religious observance ; it is a matter which underlies the happiness of the com munity, individual and collective. He, therefore, who exposes himself to venereal disease does not endanger alone his own health, peace and happiness, but assumes a risk for posterity which is criminal on his part. The physician alone can understand the terrible nature of this disease, and could the people but see a tithe of what is witnessed by a physician who practises in this line, there would be such a wave of popular feeling and action that if it could not sweep prostitution far from the habitation of enlightened man, would at least restrain its ravages by sanitary laws even more stringent than those applied to smallpox and other contagious diseases. The opinion is strong among many medical men, that the person who communicates venereal disease should be punished as severely by the law, as he who would voluntarily spread smallpox, commit arson, or murder. " -Bulkley.) Wherever it is possible the patient should place himself under the care of a physician, and not attempt to treat himself. For in no other disease is it more important to remember that treatment is always directed to the patient and not to the disease; and the treatment in cases of syphilis varies extremely, according to the condition of the patient and his ability to withstand the ravages of this formidable affection. Since many sufferers from the disease are unable to place themselves under the immediate care of a physician, the general plans of treatment will be outlined here. It must be again remarked that the various manifestations of the disease are so numerous and so different that they can be recognized only after long observation and experience with such cases. Treatment of the Primary Sore or Chanere.-The first thing to be ascertained is, whether the sore is really syphilitic or not. The treatment will vary greatly according to the nature of the sore, for several varieties of sores or ulcers often appear upon the genital organs ; some of these are derived by contagion, others are perfectly innocent and harmless. It is, of course, important to distinguish the latter from the former, for the course and duration of the contagious sores can be materially modified by treatment. On the other hand, the simple and innocent sores are only aggravated, prolonged, and made worse by the treatment which is adapted to the contagious ulcers. The primary sore or chancre of syphilis cannot be distinguished during the first few days of its existence from several other sores. It is well, therefore, to adopt certain measures of treatment which are applicable to them all. If any sore or pimple appear on the genital organs after exposure to the possibility of infection, the spot should be at once cauterized lightly. This may be done by touching the sore with a stick of lunar caustic. Considerable care should be exercised not to allow the caustic to touch the healthy skin around, and not to press it too deeply into the skin, for in these ways a large and ugly sore may be made where only a simple and innocent one existed. It will be best to apply this caustic lightly at first, so as to touch the entire sore surface. A small piece of fine lint, on which vaseline is spread, may then be placed over the spot, and held in position by strips of adhesive plaster, or in any other convenient way. In twenty-four hours the surface which was white after the caustic had touched it comes away in pieces accompanied with considerable matter. When this has occurred, it may be well to touch the surface once more, and dress it as before. In most cases it is not advisable to employ any further cauterization. In a few days after the sore has been thus burned, it will heal entirely if it be not of a contagious nature. If, however, it be a true chancre, it will remain open for some days or even weeks. If this be its nature, the patient will soon observe that the base - that is the skin surrounding the sore - becomes very hard and elevated above the general surface of the skin. Under such circumstances it may be advisable to cut this sore and its hardened base out entirely ; for, although there is but little probability of preventing constitutional syphilis by this procedure, yet it may be well for the patient to have the benefit of the doubt. Furthermore the wound wThich is left by the removal of the chancre often heals more rapidly than the sore itself would if it were allowed to remain. In some cases it will be found, after the sore has been cauterized as already directed, that it remains obstinately open, although its base does not become hard and raised as in the former case. The sore is quite shallow, surrounded by a red line and covered with a dirty white layer of matter. This sore will probably be not the chancre of syphilis, but the venereal ulcer. This ulcer and the treatment appropriate for it will be described in subsequent pages. There is a third form of ulcer which frequently appears upon the sexual organs; this is the true herpes, or " fever blister," precisely similar to the fever blister which often appears on the lips. It often results in the formation of shallow ulcers which for a day or two closely resemble the venereal ulcer. If the patient has a guilty conscience, these ulcers may frighten him into the belief that he has contracted the disease. If, however, he abstain from further treatment than a single cauterization with lunar caustic, and then await developments, he will see that in three or four days the ulcer has healed entirely. If the patient have a true chancre - and he may rest in that belief if it persists for two weeks after the use of the lunar caustic, and if the skin around it becomes thickened and hard ; if he be satisfied from these signs that the sore is of syphilitic nature, he may dress it simply by dusting upon it powdered iodoform. This will be found the most serviceable of all dressings for contagious sores on this part of the body. The iodoform may be applied by simply sprinkling it upon the part from the point of a knife-blade until the sore is thickly covered with the powder. This substance is not of the nature of a caustic, and occasions no pain ; a very slight smarting, which lasts but a few minutes, is the most serious effect to be anticipated. After the sore is covered with the powder, a piece of lint or of cotton wool may be laid over it so as to keep the powder from falling off; and this lint or cotton may be bound on by means of adhesive plaster. This iodoform dressing may be renewed morning and night; in a few days the surface of the sore, no matter what its nature may be, will be clean and red, and look as if it were healing. The sole objection to the use of iodoform is the fact that it has a most pungent and by no means pleasant odor. For this reason the patient should be extremely careful in handling it, not to get any of the powder upon his fingers or clothing. The odor will attract attention, and excite the curiosity of the inquisitive ; and for those who have had a similar experience, the odor of iodoform suffices to betray the patient's secret. This odor can be obscured to a great extent by the use of the attar of roses, two drops of which are usually sufficient to mask the smell of a drachm of the drug. Sometimes the sore gives considerable pain and uneasiness ; in this case it may be dressed for a few days, until it becomes less irritable, with the following ointment: Wine of opium, - - - - Half an ounce. Simple ointment, - Eight ounces. This may be spread upon lint or soft cloth, and laid upon the surface, where it is kept in position by adhesive straps. Instead of this, the following lotion may be found more soothing: Wine of opium, - - - - Four drachms. Lead water, - - - ' - ' - Four ounces. Mix and apply upon soft cloths. By means of one or another of these applications, the chancre can be finally healed. Soon after this occurs, if not before, the sore has become entirely healed, the first manifestations of constitutional syphilis appear and demand attention. It is sometimes possible to avert some of these manifestations by beginning constitutional treatment early ; but in nearly all cases the eruption on the skin and the soreness of the throat appear, no matter how early treatment may be begun. As is generally known to the public, there are two remedies which are commonly used in the treatment of syphilis by all physicians. It matters not how emphatically a medical man may protest that he does not use any mineral remedies; that he employs only vegetable substances ; the fact is, that without mercury and the iodide of potassium syphilis would be today as intractable as it was five hundred years ago, when it devastated certain countries in Europe like a plague. There is, of course, a popular hue and cry against mercury; in fact, this objection to the use of the drug has become such a strong prejudice that many physicians are careful to conceal the fact that they employ mercury in the treatment of syphilis. This objection has sprung from the abuse of mercury, which was so common among medical men a century ago. There is no doubt that many individuals have been injured seriously and permanently by the preparations of mercury administered by their physicians ; but this does not alter the fact that mercury, properly used, is one of the most valuable drugs, as well as one of the most innocent remedies that we possess. The excessive use of this substance and the abuses that accompanied it, caused physicians to employ more caution and to study its effects more carefully. The result is that it is now possible to employ the various medicines containing mercury without the least danger of causing any injury to the patient. This successful and safe use of mercury requires skill and experience on the part of the prescriber. It follows therefore that the non-professional person cannot be too cautious in administering any preparation of mercury, and that with the exercise of all possible caution he is very apt to inflict damage. There are no rules which can be laid down for the use of mercury, which will apply to all cases. Hence only an outline of treatment will be given in this work. Mercury may be administered in any one of four ways. The most usual and convenient mode of administration is by the stomach', in the shape of pills, or of liquid preparations. Yet this method is not always practicable, since some of the forms of mercury are apt to cause irritation of the stomach and bowels. In such cases it is customary to resort to the second method-the use of mercury by anointing the skin with ointments containing the drug. This method has certain advantages, but is extremely tedious, wearisome and unpleasant. In other cases the drug is administered by hot air baths impregnated with the vapor of mercury. The fourth method consists in the injection of some form of the drug under the skin. The only one of these methods which can be entrusted to the non-professional is the usual one, which consists in taking mercury in the shape of medicines by the stomach. For this purpose one of the following prescriptions may be employed : Red iodide of mercury, - One grain. Extract of gentian, - One scruple. Extract of nux vomica, - Four grains. Make twelve pills, and take one after meals morning and night. Another form is the following : Bicyanide of mercury, - - - One grain. Quinine, ------ Twenty grains. Extract of gentian, - Twenty grains. Mix, and make twenty pills ; take one morning and night. This latter prescription is especially useful in those forms of syphilitic skin eruptions which are characterized by the presence of scales or of pustules. In other cases it may be well to use the following prescription : Bicloride of mercury, ... Half a grain. Extract of gentian, - Twenty grains. Extract of nux vomica, - Four grains. Mix, and make twenty pills ; take one three times a day after meals. Whenever the patient takes mercury in any form whatsoever, he must keep his attention fixed upon the condition of his mouth ; for the earliest manifestations of the injurious effects of the drug occur in the shape of an excessive secretion of saliva, and of sponginess and bleeding of the gums ; in fact, the teeth may become loosened and fall out. This is the condition known as " salivation. " Until this occurs the patient may rest assured that the drug has not been taken in excess, nor in such quantities as to do him harm. It is, of course, desirable to avoid salivation; and this can be easily accomplished if the patient will take pains to keep the mouth clean, and to note every day whether or not he experiences the least tenderness in the gums when the teeth are firmly pressed together. He should be scrupulously careful to use the tooth brush at least twice a day ; should rinse the mouth out after eating and after taking the medicine ; and he should avoid excess in the use of tobacco, since this irritates the mucuous membrane of the mouth, and predisposes to salivation. So soon as the patient feels the least tenderness when he presses the teeth firmly together, he should discontinue the use of the drug or medicine which contains mercury for at least ten days. The tenderness in the mouth will usually subside in two or three days after the mercury has been stopped ; and a week subsequently he may resume the use of the pills again. In fact it is desirable to stop the use of any medicine which may be employed in the treatment of syphilis after it has been iaithfully used for five or six weeks, even though no symptoms be produced by it; for experience has shown that the best results are obtained by giving the patient an intermission of a week or ten days occasionally, after which the medicines may be resumed. Mercury is extremely valuable, in fact indispensable, in the treatment of those forms of syphilis which occur during the first five or six months after the disease has been contracted. It is during this time that certain rashes appear upon the skin, in the treatment of which mercury is especially valuable. After the expiration of six months mercury is not so frequently employed nor required. After this period, reliance is placed upon the iodide of potassium. This remedy may be used with far more freedom than mercury, since it maybe employed in excessive doses without causing any other ill effects than a rash upon the skin. The iodide of potassium is especially valuable in the treatment of syphilitic affections of the internal organs. Thus one of the most frequent and annoying symptoms of secondary syphilis is pains in the bones, felt especially at night. This symptom can be relieved only by the iodide of potassium. By the use of this drug these pains, which often deprive the patient of sleep, and hence impair his strength materially, can be speedily and surely relieved. The iodide of potassium is almost always taken in solution. Its efficacy seems to depend chiefly upon the iodine which enters into its composition ; hence it is customary to prescribe some iodine at the same time with the iodide of potassium. The following formula proves very agreeable and efficient: Iodine, ----- Eight grains. Iodide of potassium, - - One ounce. Syrup of sarsaparilla, - - Eight ounces. Mix and take a teaspoonful after meals. The sarsaparilla is used in this prescription, not for any effect of the drug upon the disease, but merely because it forms a pleasant medium for administering the iodide of potassium and the iodine. In most cases it is desirable that the patient should take both mercury and the iodide of potassium for a considerable time. The following prescription may therefore be administered so soon as it becomes evident that the patient has contracted syphilis, though in most cases the benefits of the iodide of potassium become evident only after several months have elapsed. Bichloride of mercury, - One grain. Iodide of potassium, - - Four drachms. Syrup of sarsaparilla, - Water, - Each two ounces. Mix and take a teaspoonful after meals. It is the practice of many eminent physicians in this department of medicine to begin the treatment of syphilis by rubbing mercurial ointments into the skin. The disadvantages of this method are the trouble and time necessary to accomplish the rubbing, and the unpleasantness to the patient. Yet in some instances it is necessary to administer remedies by some other means than as medicines to be taken into the stomach, for some individuals cannot endure the preparations of mercury upon the stomach ; they are troubled with vomiting and diarrhea whenever these medicines are taken. In order to rub mercury into the skin a preparation is made in the shape of an ointment. For this purpose the ordinary mercurial salve is used. The patient should take a warm bath and wash himself thoroughly with soap ; these baths should be repeated after every fifth or sixth time that the salve is rubbed into the skin. As much of the salve is taken into the hand as will comfortably fill the palm - say a quantity as large as a hickory nut. This should be spread around upon the hand and then rubbed into the skin. It is well for the patient to anoint himself in this way in a well-ventilated room at such hour of the day as will permit him to rest for an hour or two afterward. The patient should select different parts of the skin for the inunction (as the rubbing process is called) on successive days. Thus he may on the first day rub the salve into the inner surface of both thighs ; on the second day the inner surface of both legs (below the knees); on the third day the front of the body, chest and abdomen (avoiding the nipples and armpits); on the fourth day he may anoint the loins and the sides of the chest ; on the fifth day the back, and so on. The object of this change is the avoidance of unnecessary irritation of the skin. After he has gone over the entire body in this way (excepting, of course, the head), he may begin again with the thighs. It will be well for the patient to make these inunctions in a warm room, so that the skin may be active and the ointment may penetrate thoroughly into the pores. In rubbing he should so far as possible rub in the direction of the hairs, so as to avoid irritation of the skin. These inunctions may be continued until the syphilitic rash for which they are used has disappeared ; this usually occurs by the time twelve or fifteen inunctions have been made. It must not be forgotten that whenever a patient is using mercury as a remedy he must always watch carefully the condition of the mouth, and must stop the use of the drug so soon as the slightest tenderness ol the gums upon pressing the teeth together is observed. He will also remember that unpleasant symptoms in the mouth can be avoided to a great extent by careful cleansing of the teeth and rinsing of the mouth ; it may be advisable also to harden the gums and the mucous membranes by frequently rinsing the mouth with brandy and by using one of the following gargles : Alum, ----- Two drachms. Chlorate of potash, - Three drachms. Water, - Half a pint. Or a gargle of tannin solution may be used, after the following formula : Tannic acid, - One drachm. Tincture of opium, -.,.-,- Twenty drops. Water, - Ten ounces. These inunctions are especially valuable in those skin eruptions in which scales are formed ; for cases in which syphilis is manifested in affections of the eyes ; in congenital syphilis; and in short, wherever it is desirable to secure the effect of mercury rapidly. The oleate of mercury constitutes an admirable ointment for inunctions in syphilis ; it is said to be absorbed and to produce the effect of the mercury more speedily than other ointments. One of the troublesome symptoms of syphilis during the first few months after the disease is contracted, is the occurrence of sores in the throat; these may also be present at subsequent periods, even several years later. This difficulty is often overlooked by the patient, who imagines that he has simply an ordinary sore throat from cold. Yet if the throat is carefully inspected there will be seen not only a general redness, but also numerous white patches scattered here and there upon the tonsils and in the mouth. The treatment of this sore throat consists in touching the sores occasionally with a stick of lunar caustic ; this may be repeated if necessary on the third or fourth day subsequently. Meanwhile the patient should use a gargle consisting of borax or the chlorate of potash, as follows : Borax, - - - - Three drachms. Water, ----- Eight ounces. A strong solution of alum will also be beneficial. It must not be forgotten that the patient should always take constitutional treatment, as already described, whenever he has a manifestation of syphilis in the throat or elsewhere. If he use local applications alone, he will perhaps fail to heal the sores, or at best will succeed after long and tedious effort. The small tumors, condylomata, will sometimes disappear by the use of the constitutional treatment, without local application ; but it is advisable to place cotton wool around them and in the folds of the skin where they are usually situated. Their disappearance can be hastened by using in addition to medicines taken internally, some remedy which is applied directly to them. For this purpose we may use the following mixture : Corrosive sublimate, - Two grains. Alum, ------ One drachm. Camphor. --.._- Half a drachm. Alcohol, ----- Two ounces. Glycerine, ----- One ounce. Water, - - One ounce. The condylomata and the skin surrounding them should be carefully washed, and the above lotion applied by means of cotton wool or a soft cloth which is dipped into the lotion and then dabbed upon the tumors. If the tops of these little tumors be ulcerated it will be better to employ the following wash : Corrosive sublimate, - : - One grain. Alum, ----- One drachm. Alcohol, ------ One-half ounce. Ether, ------ One-half ounce. Collodion, - One-half ounce. After the condylomata have been washed and dried this liquid should be applied with a camel's hair brush. In all dressings of syphilitic sores it should be remembered that the matter from these sores is highly contagious and can communicate the disease ; therefore it is very important that all cotton, lint, cloth and the like, which has been in contact with the sores, should be burned immediately when removed from the skin, and care should betaken that the brushes and instruments used for the same purpose be kept apart from everything else, to prevent the possibility of accidental contagion. But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy! Also, please consider sharing our helpful website with your online friends.
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