as being presented by the skin. There is simple congestion, representing roseola; inflamed patches and rings, and milky stains, representing erythema; aphthæ, representing papules; circular spots, more or less raised, representing tubercles; and ulceration, carried to every degree, from mere superficial abrasion of the papillary layer to deep ulcers, which lay bare blood vessels and expose bones.

I pass over the greater part of these appearances, as being merely symptomatic of constitutional syphilis, and unattended with further interest. There is, however, an appearance, very frequently met with on the tongue and mucous membrane of the mouth, upon which I desire to bestow a few words. It is the appearance to which I have given the name of "milky stains." The milky stain apparently results from a slight degree of opacity of the epithelium, and is therefore not unlike that change which we meet with in the epiderma of the palm of the hand in erythema palmare. The epithelium thus altered, is thrown off by exfoliation, and a smooth surface, from obliteration of the papillæ, is left in its place. I have so frequently seen this peculiar milky appearance of the mucous membrane of the mouth in constitutional syphilis, that I regard it as a pathognomonic sign, and one of great value when no other symptoms are present.

The erythematous patches which appear on the tongue, and those circular spots which often rise up into the form of distinct tubercles, are always attended with obliteration of the papillæ of the membrane; the surface is red, and as smooth as glass; and sometimes a considerable extent of the tongue, nay, the entire organ, is in this state.

There is another condition of the tongue in old cases of constitutional syphilis, and which I am also inclined

to regard as pathognomonic. I mean the deep grooves or fissures, sometimes longitudinal, and sometimes both longitudinal and transverse, which are met with on the surface of the organ. These fissures are not the result of ulceration, but appear to me to be produced by that kind of interstitial absorption, which I have before described as existing in the skin. The fissures are sometimes associated with the milky stains, the obliteration of the papillæ, and sometimes with a swollen state of the whole organ. The milky stains are the exterior manifestations of an altered state of structure of the tongue; the altered texture is removed by absorption, and the fibres, drawing the sides of the organ together, throw the mucous membrane investing these points of absorption into a fold, the convexity of which is directed inwards.

Aphthæ and the smaller kinds of ulcerations are usually met with on the sides of the tongue.

The following is an instance of the development of tubercles on the tongue, and the case is further interesting from the occurrence of the primary sore in an unusual situation.

CASE 59.-A gentleman, aged forty-two, a widower, consulted me in the month of August, 1850, for symptoms of constitutional syphilis.

He stated that, in his younger days, he twice had slight gonorrhoea, which soon gave way to treatment. That in the middle of February of the present year, more than a month after suspicious connection, he observed a small pimple at the root of the penis. The pimple slowly increased in size until it became an ulcer, which was hard to the touch, and as large as a finger-nail. Under the advice of his medical man, he dressed the sore with black-wash, and used inunction for the space of

six weeks, by which time his mouth was tender, the sore quite well, and the hardness of its base gone.

Six weeks after the healing of the sore, he became aware of the presence of a slight elevation on the surface of his tongue. This was found to be occasioned by two flat syphilitic tubercles. For this affection he took the bichloride of mercury, with tincture of bark, until his gums were again tender, by which time the tubercles had disappeared.

Two months later (July), he observed a few large pimples on the penis, then a few of the same on his arms, and afterwards a tubercle on the tongue, and a sore on the lip. On this latter occasion, he visited me with his medical friend, and I prescribed the iodide of potassium in three-grain doses, with sarsaparilla, three times a day. He continued this treatment for twenty-five days, and took a vapor bath every third day, when the eruption having entirely disappeared, he was permitted to discontinue his medicine. He was advised, however, to take a vapor bath every third day for some time longer.

LOCAL ACTIONS OF SYPHILIS IN THE NERVOUS SYSTEM.

The only evidence we possess of the special action of the syphilitic poison on the nerves is derived from the extreme state of pain which is frequently met with in association with constitutional syphilis. Sometimes this pain seems located in the nerves themselves; at other times it appears to be the manifestation of a morbid state of the tissues around a joint. It is remarkable also that the exacerbations of pain are most severe at night, when the body is composed for rest; hence they have been named nocturnal pains. I will adduce a few examples.

CASE 60.-A young military officer, of delicate consti

tution consulted me, in the month of June, for an eruption on the skin. It consisted of pimples of a dull-red and brownish color, scantily dispersed over various parts of his body, but chiefly on the face and arms: lichen syphi liticus disseminatus. The eruption was on the decline, the pimples were faded, and upon some the cuticle was in a state of desquamation. He looked pallid, his skin was yellowish and muddy, and the conjunctivæ discolored. He said that he had no soreness of throat; but, upon looking into it, I found the fauces of a dull-red color, and congested.

On inquiry, I learned that he had contracted a venereal sore in the month of December preceding. The sore was of small size, and situated on the prepuce. It healed in three weeks, but was followed by enlargement of an inguinal gland, which showed a little tenderness from time to time, and at the end of four months suppurated. He took mercury for the cure of the sore, but not to such an extent as to cause tenderness of his gums. At the time of his visit to me, there was no hardness at the seat of the sore, and the inguinal gland was well.

In the middle of May, namely, four months after contagion, he was suddenly seized with a severe pain in the head, which passed off in the evening under the excitement of a ball. Next day the pain returned with increased intensity, and continued without intermission for a fortnight, when it began to abate. It was always worse at night, and seemed to increase when he laid his head upon the pillow. During the following week, he had still some pain at night, but not of the very severe kind noted above. He described the pain as being a violent throbbing all over the head, but chiefly in the temples. He had, besides, an occasional aching pain in his knees.

The neuralgic pains were accompanied by the ordinary train of febrile symptoms and profuse perspirations, but he had no sore-throat.

Nine days after the invasion of the syphilitic fever, the lichenous eruption appeared as scattered pimples on various parts of his body, and suggested to the physician who attended him the idea of chicken-pox. Fresh pimples appeared from time to time for the space of twelve days, since which time there has been no new eruption, and that already out is evidently on the decline.

His treatment had been antiphlogistic during the continuance of the febrile symptoms, and was succeeded by the decoction of sarsaparilla, and bromide of potassium.

CASE 61.-A gentleman, aged thirty-four, a widower, consulted me, in company with his medical friend, for an eruption which had occupied his skin for more than two months. The eruption was of a mixed kind; roseola in circular blotches (R. orbicularis), and lichen disseminatus, the pimples being small, and some few surmounted with pustular heads. On examining his throat I found it congested; there was the impression of a superficial ulcer, now healed, on one tonsil. His tongue was coated and yellow; skin and conjunctivæ muddy.

He informed me that, five years before marriage, now seventeen years since, he contracted a venereal sore, which was situated on the prepuce. He took medicine for its cure, but his mouth was not made tender. The sore healed in a month without after consequences.

Nine years subsequently, namely, five years back, a second sore made its appearance on the seat of the