of pustular syphilis, with sore throat and iritis. I have often seen the symptoms of secondary syphilis reappear after indulgence in wine; and it very frequently happens that patients who have once suffered cannot indulge in the stimuli which, before disease, they used with impunity, without syphilitic symptoms showing themselves. An extreme cold sometimes retards the development of constitutional syphilis. I was consulted by an officer, in one of the Arctic expeditions, who had symptoms of secondary syphilis before leaving England, which entirely disappeared under the cold of the Arctic regions, but which reappeared when he returned home. These facts show that, independent of the specific condition of the blood, occasional causes have a great influence both on the development and course of constitutional syphilis.

CHAPTER XV.

DIAGNOSIS OF SECONDARY SYPHILIS.

THE diagnosis of secondary syphilis is not always certain either in its acute or chronic form. When eruptions on the skin, or diseases of the throat, make their appearance within a few months after the existence of primary syphilitic diseases, and these symptoms have the well-known peculiar appearances of secondary syphilitic diseases, little doubt can be generally entertained of their nature; but in many instances, diseases which resemble syphilis are not syphilitic, and symptoms are really due to syphilis, which sometimes have not the characteristic aspect of this disease. Even M. Cazenave, with the experience of St Louis to aid him, sees great reason for doubt on this point. "I repeat," says this author, "that it is of the first importance to distinguish a syphilitic eruption from one which is not syphilitic; but how are we to arrive at such a result?" (Op. cit., p. 549.) It is difficult, in some cases, doubtless. I have already said that diseases of the throat and skin of peculiar aspect, occurring shortly after a primary disease, are generally syphilitic, especially if the patient have never before been subject to diseases of a like character. Sometimes our difficulties are increased by the patient stoutly denying the existence of any primary disease.

The symptoms of secondary syphilis, in its more acute forms, are seldom met with alone: secondary syphilitic diseases of the skin, whether scaly, papular, pustular, or tubercular, rarely occur without other symptoms of syphilis being present at the same time; and these concomitant symptoms are most commonly found in the throat in various forms of ulceration, of the soft palate, the tonsils, or the fauces. The sub-occipital lymphatic glands are also commonly enlarged in such cases, but they are also very frequently not affected.

Secondary and vesicular affections of the skin, rare forms of disease, but of which I shall record a few examples, may be confounded with various forms of herpes, particularly herpes

zoster.

Scaly diseases may be mistaken for the ordinary forms of lepra or psoriasis, or the reverse, and I believe this is a very common error; I have seen numerous examples of it. I have recently witnessed a very formidable case of secondary pustular syphilis, which, in the onset, had been mistaken for smallpox. The syphilitic pustule on the face may also be confounded with

acne.

Whatever difficulties may surround the diagnosis of the more acute or earlier forms of secondary syphilis, these difficulties are vastly increased where syphilitic symptoms occur in an isolated form, after many years of apparently good health, and occasionally when the patient denies ever having had a venereal symptom at all.

CASE XXIII.

Chronic disease in both testes, occurring as an isolated symptom of secondary syphilis; the diagnosis of the disease made out from the history of the patient's children; the patient denying the pre-existence at any time of any form of syphilitic taint.

A. L—, æt. 46, was admitted into the Queen's Hospital, for an ulcer on the scrotum, and enlargement of both testes, in November, 1850. Both testes were large, heavy, hard, and lobulated; and on the scrotum was a foul, dirty, deep ulcer, with thickened edges, which had first commenced as a pustule some weeks previously. This man had been married many years, and was the father of several children. He denied firmly that he had ever had gonorrhoea or syphilis at any period of his life. On stripping him, however, there were, on various parts of the body, cicatrices, which appeared to me similar to those which are left by the healing of sores consequent on the venereal pustule; but, having had smallpox, it was not easy to say to what they were due. On questioning him as to the health of his children and wife, it appeared that the first three children were alive and healthy; the fourth died at nine months

old, and had sores on the genitals and on the nates; the fifth died at three months old, with similar sores; the sixth was born dead, and had blotches on the body; the seventh died of smallpox at fifteen months old, but previous to this had sores similar to the other children; the eighth child is now alive, but has had the same sores, and is reported to be sickly and wasting. The wife is reported to be healthy, but some months ago had an eruption of blotches as large as half-crowns. The patient was placed upon an appropriate anti-syphilitic treatment, and left the hospital with the ulcer healed and the testes much reduced in size. He took ten grains of the pil. hyd. chlorid. co. every night; the iodide of potassium, in five-grain doses, twice in a day; and after the healing of the ulcer on the scrotum, was directed to use friction on the testes with the unguent. plumbi iodidi.

It will be noticed that in this case, the disease in the testes occurred as an isolated symptom; there was no other concomitant to assist the diagnosis; but the condition of his children at once removed any doubt as to the nature of the disease in the testes. Syphilitic sarcocele very commonly occurs as an isolated symptom of constitutional syphilis, when no symptoms of the existence of this malady have been present in the system for years.

The ulcerated syphilitic tubercle on the face is very likely to be confounded with lupus. Cazenave considers the diagnosis, under many circumstances, as exceedingly difficult, but gives some rules which may guide us, which are not certain. The syphilitic tubercle is larger and rounder, of a dusky copper colour, and much less prone to ulcerate than that of lupus. In the ulcerated condition, the two forms of ulceration differ in some respects the "syphilitic ulcer is deep, its edges swollen, of a dusky copper colour, and sharply cut; the ulcer produced by lupus is if a dull red colour, and looks as if confined to the surface of the skin."1

1 'Manual of Diseases of the Skin, by Cazenave and Schedel, translated by Dr Burgess,' p. 257.

CASE XXIV.

Ulcerating syphilitic tubercle of the lip and nose; close resemblance to lupus; no other concomitant or anterior symptom of secondary syphilis; cure by the mercurial fume, &c.

J. L, æt. 36, was admitted into the Queen's Hospital in March, 1851, with a foul ulceration affecting the upper lip and alæ of the nose. The ulceration was not deep, nor were the edges thickened or sharp, but it was surrounded by a deep red areola; it had destroyed the central and a portion of each lateral cartilage, and had burrowed deeply into the integument of the upper lip. The disease had commenced in the upper lip, in the form of a red, hard spot or pustule, which then broke and spread by ulceration; the ulcers had destroyed the alæ and central parts of the nose, and were covered with thick black crusts. This patient had suffered from several attacks of primary syphilis, but had never had any symptom of secondary syphilis, except the one now present.

Many who saw this case considered it as lupus; it was admitted by the house-surgeon as a case of lupus. Without having any positive data to guide me, I believed it syphilitic, and consequently placed the patient on an anti-syphilitic treatment. The ulcer was poulticed to remove the crusts, and the ulcers were then dressed with a weak black wash, and the fume of the iodide of mercury was used every morning. A change in the aspect of the sore was soon visible; and the patient was discharged under the month, with the ulcer quite healed by a good, firm, but red cicatrix.

The symptoms of secondary syphilis assume many varied forms, and sometimes affect internal organs, producing symptoms which closely similate those which are reputed to belong to other diseases.1 I bring forward a few cases which forcibly illustrate this proposition.

1 I refer the reader for many valuable facts to the remarkable work of M. Prosper Yvaren, 'On the Diagnosis of Syphilis, On the Discases which Syphilis may simulate, and On Syphilis in its latent state;' this contains numerous examples of the varied and unexpected forms under which syphilis may appear: also to the recent publication of Virchow On Constitutional