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·HANDBOOK OF VENEREAL
INFECTIONS
R. GRENVILLE MATHIERS, MA, MD (Cantab)
F.R.F.P.S.O. PL.D., A.R.LC.
Voornal Diaraus Ofiar Coaty Borough of Walany Piriting
Phymicus Na Law (Infections DUI) Hap, alhory
LONDON
SYLVIRO PUBLICATIONS LTD
I WELBECK STREET W1
14

·To Sinus
NAZY
A MOTAD Y
ou (ATO) 1), VATRON

·CONTENTS Iatrodactha and legal aspects Chapter 1 5 Chapter II Palcola la relation to reacral benes 9 Chapter III. Goponthose to the malo 19 Chapter IV Goncatat in the famille 38 41 47 Chapter V Systemic gonococcal tnfectio Chapter VI Valro-niglatts und ocalur infections Chapter VII Eady syphills. The primary lealon Chapter VIII Earty syphill. The secondary Hage Chapter IX. Latent syphits Chapter X. Late syphilis Chapter X Syphilas of the devod system Chapter XIL Syphills and progrency Chapter Yni Other wordel infections 69 71 80 98 106 Chapter VIY The portation of Teereel das

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·INTRODUCTION AND LIGAL ACTO 3 CETTE I INTRODUCTION AND LEGAL ASPECTS OF VENEREAL DLSEASES With the introduction of peolestie into the troutoocot d veermal dbases the number of petite trating there infecthos bu berak Thits moal ha fotonded to be a handbook for such pactitionen, mentor student und those taklog op the story of veneral da The book is not ahamtive but I want to give on D-round knowledge of recarnal data. Modern treatment for emphastood od do puceb devoted to out-tooded method. Veertal infections are social and public health problon which will only be candicated by pobilc education adoquato free treatment and badirect action to discourago promiculty loproved methods of treatment now render patients 900- blections moch some this befort. In consequence the problad constituted by those who dhcoattone treatment before mare la schieved a not so redoos us hitherto Veereal dbansa and Dot notifiable and no compoklon an be wed to make a pierer anderpo traatment except under certain circumstanca (ver Defence Regulatia 33b). Many people would lice to to some legal restraint on the mamboo of metal there and compubory potilaa tlon bat bort practitioner bokeve that this would hand to concohept of Infection Vecercal date, u far as the public health services concerned, une foothon, uppby's and soft word of which fononta by tar the component. Trichomcau Infesta tion buscally regarded a rectal Infection und in the ports and overseen lymphogtumulona Inguinal and bongolosl nicegatire nolana muy bo len zod are toner miltted by coltos Uack the Hatrimom! Capa Act, 1937 the courts will praat decree of poliity Here partner to the tournage u pering from real des a commuudable form at tbe turned the marthage. The petitioner ·6 RANDOOK OF YOTITAL LTLCTIORES (I) Muut hare becaonanso of the tofaction in the other at the time of the manage (1) Kost inetituto proceedings within ooo your a tho dato of the manage (3) Most not have consented to marital Intercoato anco the discovery of the infection in the other Free treatment of renarenl dbang tinder conditions of como recrecy uro provided by loal wrthod to under the Public Health (Veneraal Dhaka) Regulattoos 1916 and the Public Health Act, 1936. These regulations by down the qualifications required at modical practitioncs appointed u veel dbeans oflicto. In iddition overy County Council and County Borough has to provide facilities for the treo diagnosis and treatment and the prevention of Venetcal disonson in their use. All practitioner ure entitled to mend specimen from their patients to the Counds Labortodon for contration, at the cost of the tothority for sprochaetes or gonococd la mes or for a Woman test on the blood or cerebrospinal final. In addition arango ments are made at special contra for the tree treatment of all patients wherover they live or whatever their finance! mauns. These cinia must not be designated us for veneroul dhon na ipd nothing must be done to distingubah the patients who attend for treatment of the better Woch publicity, to given to these facilities by pose etceten. The local authoaty must sopply doctors, pacthing in their Iron and who uro qualched to treat rescroal diction with ppplies of everlabs for the treatment of syphill bo o in which the modtaal officer of approved fortitution bas Latbarhed the dininistration of these drag. Repayment of tho court to tho local cotharlty County Council or County Borough snow cloded to the block got paid by the Hinntry of Health Any practitioner rogairiog help or advice to the treatment of any as of venant dans an obtain it from the public balth departaat o baba authority The establishment of these cinia be beped in the marked fall to the tacklace of renanal dhoora which ·DE TRODUCT AD LIGAL ATITI 7 ha crtirred, peally in malas. Great difficulty b opad encored honorer to getting patient to attend after the Tyraptors baro disappeared although they are bot cured. In the parts patients an ardy stay under trontment long coough and to maintain contiuntoon treatment unngo Dents are been made with hospitals and clinta ta a parte of the radio and lists of these places were tree treatment ba anulable u ropplied to striea in the veneraal doen dimi ol the ports. Under the Vocal Data Act, 1917 only a roghtered Dodal practitioner tony trout any perro for venarul dene for roward a giro any advice, duectly or indirectly on the treatpent. An unqualified practitioner amot era Loy advico la copaection with the treatment or provention a veneraal date. In the data of the local wothouttaa patenta kro orally known by 1 oomber uod patient can rumala completely anonymous 4 they wish. There is no companion on them to tacame their numa o udarca. A practition an, bowover bo mede to declare in court any Information ho may pontorarting a cuno. Il both parties to a noility Como tonder the patrimonial Cango Act request. pouc titioner to give a report on the condition of mo of the to the solicitoa for both parties be must do re DOPO RIGULATION 33B The regulatoa wa tatrodorced in November 1944 und to be force. It seems Icely that the poven given under I will remain fo ford for me time whether mode detoco regulations or other site. It provides for the compulsory treatment dar of venoral disasowbo har beon down, to be routes of Indection had bo ure not roluntary undergoing treatment (1) When Teenal di panctitiopon receive froca patients undagobe tratment for recrual disetso Infer matice about the route tafection they must notify tbe Vedial Oics of Health of the County or County Boroghe in which the contest stated to be the source of the lofection roodos op Farm 1

·8
HANDBOOK OF YONTAL OTECTION
(1) When notices have been received that two or more
patients have been infected by the memo perm the
biedial Officer of Health requires that provon to submit
to medial enamination
(3) If the contact b free from yeneral del canace
certifiato given
(4) If farther eamboation of treatment k seeded the coa
tact - given watten notice to attend and failor
structions until certified free from vencral de la
commonlablo far If the patient default the Medical
Officer of Health anst be inlormed
(5) Fulare to mbmit to examination or to conto de to
attend for treatment makes the patient lable to promo
cution
The Miletry of Health requires veneral discuss odice
to keep a record of the number of notifications focalrod und
has to be loformed periodically of what action has been
taken in connection with them

·DOLLY 9 CEAS 11 PENICILLIN IN RELATION TO VENBREAL DISEASES The advent of peak Oin bato the traatment of the main Tederal disas, poorba od rypbta, bus revoli tooined the great o gach con. After the first ca turut reports boring that this drog ny letbal to fooocood and prochactar attention has been loonungly devoted to defining the opthama dono required and the time for which much does would be given. The troub.cat cbedalen in de at the present timo ere to some extent of partmental doce most of the work on pensaitun ta thene dette has been done in the Sarrion where it la pomable to toputate all patients. In trillian lite and apeundy in the clipla, which trat the preat majority of these chia ambulant frontment to rely regalred. IA consoqoenco the dono ard and the methods at idoralatantea laro had to be altered to comply with these requirementu. The arly good results of panici In vencal dheures We bot malatained to practice when peollis because more plentiful and wus und Doro extendrely This discrepancy in the remlts obtained nibed fount of the pro doction o drug reistoce u wus known to occur with Foocood to the alphopamide compounds. No cridence u found for the developonent of toch drog routance to La vitro test and mo por mor that condmarcal pealalta u mixture of at least foor pealchio vblche probably dit in the cocaposition of their odo chuim. The four types al pealculia are born by the letter GX, fand K. The relative amounts of each of these vary from 000 emple a penicilin to soothe Tbo radons typa at panlila Luo differ in the ho tro uod in vitro clects Pealeha K relatively ineficacious became #bapidly destroyed the body where the other penila i toneriat to destruction Commande pealeta which produced by, deep growth of the pould n found to contain high proportions of penicillin K dose to the netbod a pro- ·ΙΟ HADDOOK OF YEAL TECTIONS duction and thy nus the case of the decreased clinial efect. Thla predaoinance of penicilan K in comercial preparations now adjusted and they coutelo maloly penlemin G which later than us spirochaetochtal u my of the other type Following this chango the position of penicillin favoareal dbreason has been faldy well ovulaated and its oite la changed ndically the treatment of thero diena Unti penicilin ww med ba ryphilis the treatment of thb dheux huud uways been attended by moc danger because of the toacidity of tho drugs med. These dangers wete Doch greater if the doar nu incroud of the pedod between Injections decreased in order to shorter the period of trout ment. Trantment with barvy metal normally attended over a minimum of two years and crea in the Services, where patients are moda docipline och coone of treat ment were only completed in Alty per cent of a so Thus the discovery that peolanin pompa u procheto chal action we received with enthadon daco It seemned to offer a curo of syphilita la short period of the without prodoctog uzy dangerous toric cicct. Thiba atra bes not been realed completely but pentahin does render the patients non-tafections mach sooner than an be achieved prith any other form of treatment od the total perlod of treatment hu been shortened condembly In early syphill, whatever the total donge med Treponema pallidum dbappeen from the forfaco bestons to twelvo bonn, the lesions haal spidly od posttro serological reaction tend to becomo negative. If the total amount of penlanlin given i mall, relapwe OCCW) Theme repro box la rulou nyn (1) (.) Tho chapero fails to heal and break down again. (b) The chance boals completely Accompanied by dgns of sccoondary syphitle. (c) Tho potimary lesdoa semains hauled bat secondary la derelop and the Woscop reaction becomao positive. The rape lesions are often mod may be annoticed by the patient. Hence the ano rappers uod & ·II mitul reglaa matahny, be torpected at rootine follor-op enumbuations nice coodylomata Coromoo in this un. (1) Sorologal depa. In microfoly treated as a porttimo rerum becoma Degative in to to tvo months. Roape suborn by the wrun becoming pooltin gain. In an treated with pencing along the bota dange at reaper. Such a roape mama, mfortunately that the patient may become Infectious ugata whereas to the past, Inadequunto troutment with hary metal only meant that the patient w danger to himsell but not to other. The proveat view to that penalin should be rapported by trent ment with unrenic and bhumath In order to commidato 1 curt It cannot be stated with certainty bow fur ponicillin ao replace the traditional remediler bat from the respective rewalte obtahad to early syphilis it seems that a dose of 3 mega onlta o penicilin ven over a period dweren dan & theapeuticals equal to twenty Injection of areal and twenty lajection de bismith. This means that ono court al pealelo soqpivalent to ope your's treatment with the heavy metal. In consequence troetant for pc lane palodaus mu tult to be becamery mo the part in so now required and the total period of treatment broduced toura two you to around months at the mort. Although when peolella k ned alone, treatment an bo completed u days the results o dot as good as thoso obtabbed wbed metal slono uro med. On the other hand och metul chemotherapy must be maintained for at last two years und the barely posedlo stoce the default ato is very High. Probably the pbatitution of two como o metal by peabalho dos moni chetlas of traitment to be completed. Lo socio clinto the treatment of any syplus bcoce pleted ha de Teol, but each treatment ben mostly to the raporta vben petients will not say noder treatment for . boger period. Wherever porable it to debbie, to treating audy syphie, to spread the bedroomcaba over !

·u FATDOOOK O VEREAL DT LCTICOS popod of tis month very little difficulty & aperlaced in Setting patients to attend for such a peatod, ogocely when they are told tho serioara ti the bofection. It was not bo forgotten that, untreated me out of three mobilita Houd rarolt at the disease Wheo pealemin muu wed in to the tratment of sypiales the origlaul plan ns tout at the maintenance of relathrey constant loves of the antibiotic fa the blood over an urbitrary minimiza pelod o aight der Stace pendohio I readily absorbed from the then after put atent Injection und h rapidly excreted by the Eidney to slotala chariotherapeutic lovel la tha thuras It S Decorary to listen 10 aqueous solution at abort Internik Atots were, therefore adattted to hospital and received duty in lections ono every tire bour, for total period of seven day. Tbo mrmit absmod were as follow With total dose of 60 000 units the Gulfuro nato mu 100 per cent. With total dose of 300 oo unite the falhiro rato mus 75 per cent With total dose of 1,200 000 units the Indore ate us 15-20 per cent With a total damage of 3-4 mega spits the tafections relapse ruto bs betwort wo w two per cent and run tat have been deprtino at the end of ex maths la o per cento Stonegativo primary cars and to about 70 per cent of pocosdary syphilitia a It la nich remain those with bave detenuaal vertereologlad Dot to rely oo perkelling alone but to wpplemiet this trotract with unrenic and bhunath Anteront loa than see per cent bayt bad moco canood relaptos und tbtro bave bees ao ar ol kerbart al relapse. In addition meat work bsve tectonied tho total amount of peale mlio uned to kertaa mai multe stret over fourteen daya The bone tramoat Acciated the administ of patients to hopital und this pot aiman porok opecally in onlan tile In addition three hourly injec thons cluso the patient sech locouveulence aperta Dy at ·Taid by duble deposit of about the the denty 1 tko oll o that the penicillin readily redutora Socha propert Vhouty The epension be to be mined by C The propertie is difficult to dinner bromo o MI A dry syrloge must be mod atberhe tolikort tends to make the socle become blocked. The pare k ulo wanned the peoidh torpension data and the penicillin al x mixture dan op dit wide-bore The paperdob theo lolote deeply both Asculasty into the bottock with the place of delay Commercial penicillns ut Dore coming at the marty DICILLIX 13 dicht. Experiments are therefore arried out with any portemon lojatics and this work showed that a constant level of penicillin to the blood stream mot 1 peceruary confitlan for airo Intertofttent penicillim tbaupy k po Armly established in the tratment of typuuta od thr reapuc ante o mo hilgher than with scheras o trestnym Ftoployme three hourly mlections Instead of being aqueos folutions of penicinio boten: teot therapy has been combined with the mode Vehicles so that the affect done injection Los meo of peoleillion peotonged for round twenty brant Farm Wyle peoldin blood Lovels and Dot Decorary for that al ryphilis the iso of Auch vehicles but content prokletin Hoce a great mustage occurs with large barevor na sghoone solation Suspensions of pancia ha anchh al meno med ut fiat bot. Arch. _ ndependen der duced commercially give dittically be redidoilar the pealellin lo the od loomediately, before Iose It was thout a considerable amount of thelt storedred Isti the penicillin which had settled to the bottom a tor mbeturt wa rediffused in compequence the peolemas on om wuppeaded in a mixture of foar to tre per cent betres arachle dolud contaba 125,000 bits per cobkcrollert The beer was aurria the pendema with it to the formula thoa whilch & Dow the articole BP preparation in Peakcillin oloom giva diective blood precies were to per shathok for twenty to twenty four hours Rod Postcellent anlal roll needle ·14 HANDDOOR OF YOTRIAL INFECTIOA which are not so bacoos id are much onda to hand, Host of these propantiocy uro ompendioma in ethyl Oleato. II. wide boso needlo b med fich aupendloos do pot Tequire wurmlag bat Itu adrlable to two dry syringe und Docdlo. With these slow release pospensions and infotton per day of 500,000 wlis bgtved ud i Cound commonly conalt of fourteen lajections. Hanhelmer racions ad very nurd and usually consist of rha to temperaturo follow ing the first fow Injection... Recently weedy injections of 0.5 mogu units of pealing to all war muspension bave been mod. Such a method a very convenient for cinc port and so far the resulta bero been retidectory Staco the futrodoction of penicillin tbey in syphilis werological investigations have been ardad oat at mochi borter internal thn was the custom with the old methods of tratment. This frequent teating has abown that there bus been sharp increase in the number of discrepancies between tho molte of the Westend raction and the flocculation toets rich as the Kabin in parallel tests. The Kabin.concatently positive when the Wessmann auction sa negativo or doubttal. Lo que o pomary pora treated with ponlehin the Kebun becomes podtivo only to forert to negativo a quickdy wbereas the amount of developed antibody bagufficient to fix complement to a degree decat try to givo podtire or even a doubtful result in the standard Wamemam reactioa. Apparently the pro chucta aro Hiled to quickly by tho penicilin that iber timo of actioa u unten a very limited. Thos It has adyto ablo to have a precipitation prologlal test done at Homo tumo during surveillance after treatment in addition to tho Opal Waseman rauction. In lato syphim tho action of penicillin imped and farounable us to arly syphilis. Althoagh a deade most paw before its ultimate tect can be completely ovaluated it la deritable that all these co with the exception of those with gou ardiovascular disease, bould hare the beneat of penicillin in addition to other formats of treatment The present poultion is that penicilin rcphets four courtes of tree traent with beavy Detab and the previoon total of ·FOLLD IS trautment b then made up with hairy matah. Pemilihan me abould not be relied opon although prolonged masive dows and cultiple coarse my eventually mato this pondibis In curdiorescobar Abons penicillin s too powerful mo anti-pirochucal pubstana wore nte at abrorption cannot be properly cootrolled. In curtepena should not bo med for each as Al rgporta of its me to this connection have streamed the povero eochemer rauctions which havo realted In the prevention of pre-outal syphila tho molts dag peolatin buvo been better than any obtained with the previous la of tromtorent. A fall course of pealdiliin therefore given to pregnancy and after dottraty cotton od uvent und biomath are gred on an interanca buda- In prurosyphilla penicilin producen altalaul and kero hoghaal repult whichi wo equal. U pot mperdor to thone obtulaed with a realaus und berry motak. Both genul pered uod taba respond roll. All attempts to detect penicillin fin the casobrospinal Bold after standard motex pou cubur dores have failed. Although thb might wall moun that pentola doar dot per the blood-brata barrier there k no doubt that pentito cut un adequate therapeutic elect a Deororyphit... Powietly this occurs because it is provent ha diectivo coocomntion in the miomto petrocaber out of the baby The greatest ofect ba tho qual Anid with spid rodoctlon En cell and protein content to warda pormal in most card menm ponukcubr typbilla treated by parenteral infection la parenchymatoos Douro typhla constablo beproremont occurs to the patho baglal cell content and total protein d the cerebrospinal Dald of many aw u well as somer decrease to the laterity of the retologlal reaction. The effect on tored for real or months after treat.cat bau comod and in wytoptomatic cotrosyphill peoleilla is for aboard of other methods to redoding an absormal tout duld to Domnl picture. Infection directly into the cerebrospinal folds Bot ud vable because resthous de very common. The mildet ·16 HANDBOOT OG VILLAL DOFTCTIOD reactions cooubts of pyreut und geselbed pain after the firut intratheal infection od korero pleocytou mainly polymorphoguclar occur in the field. This ploocytaus perista throughoat the course of intrtbeal pendant, Marcuber, twitching and generulbod coorabaho bere occurred in casa di gram parede od death from chrook pendalian Encophalopathy has been reported Lesboot of the anda equire baro Rho occurred and in taber the int Injection ha otten followed by pyrada and generalized Dervo root pain Hoorbeiner reactions sometima occar to the treatment of neurosyphilis but theto mully consist of a pyrocal reaction following the early dora. Rardly encabution of ymptool used thrombosis Domain In Thor of this fertions of bomuth are best gyen before bulag penicillin In meningovascular syphills thero bi napod mbudence of clinical syraptorta and rapid traprovement ha the cerebro spinal fuld which becoma partnal in two to four weabo. Tha Wametann reaction decrous to fateority more powly and may bocomo Degativo in two to four months There were to be an actual reloctivo action of penkenho on putbological cerebrosploal dulda or beningos doce there bo do panld decrease in tho krologial reactions of the blood If no other treatment accept penkeilla fa uued the blood WurmANA raction may remata ponitivo to definitely Thi's obrenation together with the boding that relapa muy occur the cerebrcaptoal taid that bas becoce Dormulare arguments for following up the course of peale Imn with uncal and bigmath therapy In parenchymatous neurosyphilis the initial effect of penkallio on both the symptomatology and cerebrooptom! Molt bon very good Tbé cells and protein content of the fuld may becomo normal within four weebs Lod the Waremman reactka neputine to two months later tho Hold may becorao pouitive yun so that perfeithin therapy pould be cornblaed with the tal code of fover thenpy in stene! Paras od Tsypepude la tabes Apother advantage to the the of penicilo ta general pare the big laproveracat in the patients general coodition which ·DACILLIX 17 follows its mound this bu made for the app powinile In many axbo which it would bare bore pollo previously lo peoraryphit's treated with penteftin dinical Improvement annyi be pected to thi atent to which symptoms and signe dopeod on miettimo rather than on depenonton No type of treatment ag replace dead nerve celle uod Abre tract although further destruction an bo prirented. Il peakaita tratment of syphili's Ben nak us out of the grott modal udnoce at the mar tho itect in Footboa sore moro making The docet bon goncation doon not seem xo revolutionary - it might since the rulphonamka had already stopped the necesty for todtions prethral nshoabs In the mafarity of cam Unfartonately tbo albonanda kmetima produced severe toric effects and wo many poococd developed drug rektance. Thila effect has not beca tocountered with penicillo and the phoramide drog restant care repood rondly to the editinion of penicilo. A magla bojection of os gan of Areptomycia bus recenty been phown to be canttive in Fooch ro that drog restance to penicila doon Brelop It seerns nety that we eball moon have another edectiva drag The treatment of Focaboea with penicillita be the fol lowing citects (1) Treatment to completed with a stogto tajection. (2) There are no took aletta. (3) Earty are a broaght about to at laut go per cent of un compliated and (4) Asyraptomatic curler states are not produced Tbc abore elects are produced by ons injection of 0.3 mega mais o penkeilbro bo all ne potpendon Alternatively Orlo or two fotrupuscolar bolections of us oon solation of penldit.co ao be oned but the dintol fupradina that 00-nr pensions tre the higher cure nato la roman be core rate way around 80 per cent after u dogle Baletion. In poch are it us wail to combte the second ·18 HAXDBOOK OF Y DESEAL DTECTIONS Injection with oral treatment with alphoramides. Thero kno doubt, bowever that the two of panlallin boa con pletely revolationbod the treatment of gooxcarbas. There bu boo a tremendoua reduction to the dmthin a dibility uod in the incidence of complications. Since the gooococco 00 of the most sortive orgalom totho action of peniamis anal therapy bas beco attempted. TWO million units of penicillin wel diluted and melomed when the stomach b compty glvo companble blood level to those obtained by infection. There may be fodividual nustations, bomorat to the levels obtained and there to rely on Injections Any destro to wo largo doses of penica to the trent ment of poacorbice mot be related. The amount of penfatin used should be tho Ballest pomiblo efectivo doo alace with larger dans tbero ha come danger of the promener of early syphila being marked Fever and child pocuring with the use of penicillin in grootboas and strongly ang gestivo of additional Infection with syphilla A promry oro may develop in tho ucal way or this may be aborted and sign of recondary rypbill boi tho mual or pattcutated forth dovelop later in some cmos a podttre lect mann rauction may be the only sign. Provided porrellence prolonged for three months after tnfoction, bowerer tharo cards to bo no dangor af concomitant syphilitic to fection being overlooked ·GOOITA O T. XAL 19 CHAPTER 11 GONORRHOEA IN THE HALB THE PRNUARY LESION Gonorrbon by lor the common torn at renere Hafection in this cantay The Dretso bas three stage (1) Tbo petmery lata prethritis (1) Local coropliations of the pomary kazdou. (3) Systical infection. It by doo to infection with the ponococeos which b a Gram-negrthro bun-shaped diplococtin. In codate the organica largely intrarenlar i distribution und cominophila to commonly present in the pus. The popococcos a strlet paradto and to spread by direct tamper co tom co hot to woothe Italim only for a few boms outuda tho botnan body Dillorot verplogical types edit but are not important clinically Infection Logohod by al intercourse with an in fected person Acadeanl contamination be grout furtty Tho infection very pertinent. The mortahty low but lavalamb high in the motrated also. The local Jadoo ba afton thought to bo triling bat once de ultetico Infection has occurred the date tood to be du colt to mudiate. There are often comidablo periods of freedom from toxk lects and toetastatic complications may not develop for yan etter tho potovary infection be occurred. The incubation period between 4 and 14 dana Deslocally it is proicoged up to 3 weeld, specbaly in Te-afection. Factors pro-asporing to infection ere Hypospadia Phoodie Large mata asifice By the time you prom oth the pana la widely decorated througb tbe loro o peniti tact.

·18 HANDBOOK OF VELLAL DOTECTION pjection with oal treatment with sophooamides. There b no doubt, bowever that theme of penicillin has com pletely revolutioabod the treatment of goodba. Then bu been a tremendous sodactlom to the duritton o dability and in the locidence of complications. Stoco the gonococcos a coo of the most sendtiro organice to the action of penicillin qal thompy bas been attempted Two million units of poolchiin well diluted od smloved when the stomach as ampty stvo comparable blood loves to thoro obtained by Injection. There may be individual wrtations, bomover in the levels obtained ind it f mic to rely on injections, Any dadne to to large doses of penicilin in the treat. ment of gonorrhoea maoist bo resistod. The amount of pooldilla used abould be the smallest porable afectivo domo poco with larger dora thero b kome danger of the presence of early syphils betog mukod Fever and chill's occuato with the use of penicillin in gooonban are strongly gortive of additional Infection with syphilia. A promary soro may dovelop in the wal way or this may bo borted und nga af accondary syphillita ta tho bol or attem ated form develop later "La somo Cutos a positive Women mann reaction may be the only digo. Provided forrelanco prolonged for three months after Infoction bowerer thero noems to be Do danger of concomitant ryphilit - foction belog overlooked.

·COOKHOA DI TEL MALI into ano spochoen glen and the roander into second gus. Acetle add b added to each spokea to obrato way bare due to the presence of phoeptates or arbonato Hurine ramaboing to the best w polute to lavoromet of the ante for protbiry id la the second glue to favore tort of the posterior protten. In 73 per cent of the the pontedor prethra is affected when the patient a fost ween. Diimti aurus A prothnal dhchiurgo can be dae to (1) Infection with other agunkons. Can be detected by tbo De The urethn vory restant to tafectioa by moet Progenic organisers and actoe bavily infected with staphylococd. B Call and Mycobacterium Tuber culos may be pared for toonths withoat any prethru brotina towaltig On the other hand tofortion from the Rise of dirty Instruments or from coltom does Ocer especially tho porucom tam brune tas abraded. The organismos most frequently concerned ero ( OB Coll. Urally tema ddedy men from qual malprush. The discharge thin and mopurokomt in contract to the thick, craumy pus from infection with the godococcus epididimytis bar 2 frequest cotopboatia (6) Proteus vulgaris The docharge be fool and broralab white. (c) Staphylococe Thi diecharges relowish white and purpleat. It toy real from the presence aktas or fordon body to the brothn. Removal of the Louret de triation is followed by npid dandog of the discourse (2) Intrarethal chance. The discharge berons and dark ground camination reaab Titpopers pallxclum (Trichomonas goals. The specific organla k ·& HANDBOOK OF TEZRAL DICTIUS Hentifiablo to ed or bangtag drop papuntout. (1) Non-gecific urethritis. Jelly a thus Infection. (5) Escontro coltos or mustarbation. Dochargo wetery No organima o pas cella present (6) Uke od overstrong entiseptia la prophylaxe. History dbachargo macol (1) Malingastag in the savicon. Due to batter or match hads being inerted into tho mratha. When the acuto phase of the dhuro hws pamod only a little redoen of the matus may be seen. No discharge may be obtainable from the anterior urethin und prostatic boanga ba then Decorary With the patient bent forward the forefinger then foarted fato the tectum and the apper edge of the prostato felt for The gland to then stroked with modanta prekur from without ward text on onoodo and then on the other If the patient com platom hittady either the prostato ha inflamed of the promuro orod too great Tbo specimen bs collected wi band at the montus which should have been cleansed previously or in tho urine glass which should always be held mider tho peals.darlag prostatic mga If no spectros obtained in this way it may be in the urino pamed immediately afterwards or, bary thrond may be present. The store ferred to slndo with a platinom boop dried with blottitor paper applied to its edice and tho thrand then smart over tho Illde. Jo difficolt cases the gooococal fixation test of the patient 1 serm may be valuable. The untisto med s made from pure cultures of gonococal. The text is only positirt In chronic auto where the halection bus prad from the unterdor arethin This positive ropalt for an of upper eatly uncomplicated gogonite fodiates the posibility of un mendkanted pon-draining focus, LA as in which the clinical ad microscopical foding und Inconclusive gonococal infection may be apposed by coltiration d tho organism from the urethral secretion or from the depault obtained efter contrazbog the oute The gooococcus bs di cult to go. It peeda ·GONORRE DI TA KALI (1) Mata cariched with blood mon britrocele fold ar 488 bomen. (3) The culture tubes mod to 37 C batore inocula thos. Growth bylable m 48 bom. The colonia are round, decrete, semi-transparent dha Later the edge become created and modtatok merking becom. vbble TRADIOT Efforts, post annyi be made to make contacts attend for enumiration Gospel Core is obtafoed more quickly in the patient resta Ia bed but wonally treatment hau to be carried out to a ambulant patient. It to the patient most rent u much pow.blo and avoid exattoo, pechaly tenor, celtag and doctor Tho contaglous nature of the tafection should be explained to the patient. Urethral dhacharro mort Dot come to contact with bantay sat ortowe Tbo patient must wah hits bandas utter contact with the genitala. Perrone clothing abould be morked in s por ceat Dettol or better hm, baled He abould rari pospesory bandare and sorrowd the peak with grozs Salled dren sing would be burnt Vbiting d pabtle baths or swimming pool is forbidden, ab coltin Duel Alcobail pices ud motard most be avoided. Drink brre quantitia of fuld. North Hot baths or foonentations relieve the pain. Sprakis Treasut An intramuscular injection of 0.2 meg alts of penicillin la al mar suspension ut dve into the battock. No geral prepratio or dlet . Deeded and then tre tro odk kegoebe Alternatively two intrunicular hojections a 10 queous solution of penicillin an be great bon dred tborand units are given to the morning uod the age ·24 LAKDDOAK OF VERLAL INTECTIONS dove repeated at night. Fever and chill occurring after the injection of penicillin and strongly niggestive and tooal Infection with syphill If the urethal dischargo pendols of foococe are still demoortable in gaan or alter prostatic musugo the bo jection of penicillin should be repeated and it peccamry 1 sccood timo Repat tojections of penicillin an be com blood with pulphopamides by month if felt Decry Relapse eu lly abom in the form of a mucold decharge within too days With this method of treatment there has been a tremendos reduction in the duration of diability and to the incidence of complications. The discharge clean within twenty four houn in over 90 per cent of aux and po Bodococci an be found to Roan In aux of fallare with penkchila Alpbonumides aro giren Sulphadudne or cul phathocole aro best used for umbulant patients. Thrograms are given immodlately followed by ane gnum four times day for three days Tbo tablets may be allowed whole or crushed 2od ruspeaded to water Nansea or vomiting may occur but other torde afecta aro rart. 11 the infection peralats another sulphocamide compond to toad in the mrao donge. Drug rabtance is common with the alpbonamide which tbero and the funt draps of choice. Poobcilio ls moccerdal in theso drog reabstant ases and so far drug robbanco bas Dot been found to occur with penicillin Axtupla irrigabons When the patient does not respood to repeated couran al peakmia and different culphonamidas daly trrigation are required. Irrigation mit not be attempted during the acute stage of foonbon doce this borrax the danger of spread of the infection Appeatos required (1) Qunut doocho an a irrigator two feet above here of winary matus, (1) Su feet of rubber toblog with = glass of metal arcthrul Bocale ba vingronoded blant opd The ·CONORIELA DE THE WALL 25 Dorado b Rullised by being ud stored to bintodide solation 3) The Legathy latha potundam permanganato 1 10,000 shomld be bated to 135 F The patient eruptie bis bladder daim the mattor, in Krts the partie fruto the matos und Vom the auld to Bow into tbe ethis. When the wethm feels distende he stop the flow bry squeezing the robber tubing betwem tbe thumb and the palto ad the band remove tho mantle und wom the trud to tow out at the urethm. Thlab Tepated tentina After thi, bo filla tho urethin apain and strains a start ing to picturato. Tbb ellom the vedcal sphtactar to relax und the boton do foto the bladda When the bladder foelo fol the low stopped the sono removed and the patient micturates This procedure is reported thace. Gooococcal vaccines uni used in addition to Irrguttan. A stock vectus a fantocord and cocondary arpenkou med. An Inhal slovesno non orgaans b bajerter labradoicnlarly and this ba bcraind trico vectly cotil 50.000 million arpantera aro betog given. Tot done b coatinaed for four bojections. Fullord of trattaat may bo due to Eccomive ose alucobol. Streadotti etertid. The presence of deep Rated fod of mlectioa b Littré, glands. roborocoas temas, prostate cod sebral polda COD O Curt Then test are cardio out one week after the mosperdoa of treatment und in the breace of may clinical sy optom o wyna (1) The aty morning tribo od urine which bus been bed for ut la Lour hoon hoold bo eminet for heavy thirteda. (3) An attempt made to obtab dcbur at the matu. Both discharge and thinda uno stered and taked for gooococc.

·20 HLANDBOOK OF YONELAL TEC1000 (3) Smas une coude of any prostatic secretion obtainabla If no evidence of persisting fafection is obtained (4) Fil the anterior urethra with it 6 dilation of Logar sodine This may buroko dachart by the next day which should be mamined for gonococd. Theo test thould be repeated each week for one month aod than monthly for two months. The interior uretan abould then bo camlood with 1 urothroscopo and tad szod metal mind passed into the bladder. At anchor amination dgns of typhli hoold be searched for and at the but oxumination blood Warmann reactions donc to exclado the posibility of concomitant syphillike having been acquired COMPLICATIONS OF THE PRTLARY Lasscom Accompany as the acuto phano a gonorrbaee local cort plications may DOCALE Some of these un pot truly com plication bot aro past and parcel of tho lyndon of the mucous membrane of the orogenital tract They compriso (1) Butwo-podhu A koperficka inflammation of the game and tho opet surface of tho prepoce occun in those with long forelda doc to the retentku of secretion. If the opening to the preprxcc be already omall phimords may develop. The coa dition clan with local chearning () Prostatitu If the posterk urethana ta lavolved to the scato go of the discure the prostate poctially never waapa tafection Tho gonococd penetrate into the practatke docta and aus mild atarrbal toitammation whilch dums back the card thon in the glands. At this stage thero ano do propio bat the prostato s felt to be tonder enlarged and podaar Prostatic mutago prodaces hary thraids which are in the orao pred after the manage has been performed. Gooo cocci are demonstrable in these threads if they are stubbed The Inflammatho may stop at toba ntage o progress to ·COOTORIKA IN THE WALL suppunto la the gland qucou Thilo ama paha and dis confort in the perineam uod factand frequency of micturthe When the pos bralo through tho glind wall a prostatic abecer develop At this stage thadla Sovero pain to permoom and rection socially on dobrocation. Forthe frequency of micturtion Pover Latar moary obstruction supervenian and there may bo complete retentioa. On palpation the prostate se vay taader and terre. Pradination may be prescott Tho partbeam b red and molla TREATWOLT The patient mort bo in bed ca a fold diet. Hot baths and bot applications to the pertraun rallore the pain. Rotontina de relieved by supta pub oporation or the papago of a nabber atheter H bot baths and solutives do not prodoce the dated ranlt. Systemic penicin begren labuducudurly 10,000 units every three hours hqpooms solation, or capboouniden starting with two mums followed by one rum opoy lour boon Traatment is continued until the condition how clarod and the tempeatore rotarped to mouml Ilan become potats lato tho toctom It must bo opened promptly This may be accomplished by promoting metal round or atheter which ocentes the pos lato the brethn or by Location of the prostate through a urethraecopo. In other caso it may be adriable to approach the land through the pedream und dnbn the bace by this soate. The abuceta pod pot be allowed to bors into the section becaus of the danger of secondary infection and the bak of. fatala developing In chronk mlection of the prostate mungu arhed out daily and the arethn Ingated locoadiutely afterwards. Coropilation of the primary, koboa bom tho pale uto due to the infection analog blockapo of the fact of the various stand opening buto the poboary retena Soch 20 ·30 HANDBOOK OF YLIMIAL DICTIONS epithelial cells begla to appear The ormo Lomas to turbidity but contain threads and stands which may boat or tak to the bottom of the glass of they wo cotaposed chlety of pon colk This mage may be accompanied by a vuiety of symptoms (I) IDcrud som dodre. (2) Frequentarections (3) Frequency of micturition. (4) Dlacomfort in the perinata. (3) Gemal II-health with pegue aches and patos Os camination there may be some redoen at the matos Rod come local fultation. A clar descargo aun bo ar premod from the train nod to this goocord aan be detectod when man uro stufaed. Small you may be palpablo along tho count of the mother. The prostatos hard onlarred and nodalar Often only ano lobo b affected. Tho weminal realcles aro palpable showing that they aro alvo involved. Kunago erpremes bag thrudos o mocopos from tho ducts and those ain bo recovered from the artoo pened after the mange bas been door As a result of the chroak Intamination the pubmucos thund of the orothn bocomo infiltrated with round cells And this is followed by the laying down of now cooprettro three to the dorper trues of the corpus sponglocam Tube gradually become converted lato war these and the pub soqnent contraction may lead to a trethral stricture. This stricturo may tako varying forms dependbog upoo_tbo utaation and depth of the preceding intammation. Tbor the stedeture may be Logar ananlar of tortuous. Tbo urethra dilate bobind the stricture and the reporting retro tan of urtad ar chroate arritation of the race Thb Inoltation to respooblo for the chronle glect which ocean in wricture. Kardly if ulceration develops, ulary finla result. Tho bladder abo hypertrophies and data nod bydronephrogba may abo develop TRLATEXT The general meer ure the Ane u for acute gooonbare The Infectivity of the conditions out be ·GCOWORTHOA DTLE YALE 31 Krsmod. Peale 0.2 mene ooit uns eren coubted with sopladbrine or alphath pole 1 gous fatio fot loved by I gaan overy four hou for three days Regular prostatic mura drta dally for i wreck und the weekly for t month nilable in addition. Large cold ounds should be passed in obstinato come and att of rauch bodeft if i gal strictart present. In rektant cha fever they b valable. This can bo givee by motos of forer abinet Fight hoan apopt ut a terpautare of 106 Fur pufficient. Alternatively lover oun bo produced by the Injection of T.A.B. vaceto. Injections are oven at Kuteryal of woven days. Fifty pohon apuains are giren on the act occask the dare being doubled ut auch Robmequent injection. Owing to the station produced 1 courto thould not cookst mord than dr la focoras. Stricto are treated u follow (1) Permeable and paste stricture Intermittent dilatation by the past olovatel sounds or tho purse of a brethaal dator och o Kobl mans, which can be expanded in the strictor pret toccd. No anche violenco must be reployed. The dilatation Warried out twice weekly for fx meeld od theo weekly for ex vecka Thereafter sounds et permet monthly for the pat dx months and every path for further two you. () Impermeable but pastebte Arictes Retention is rettered by the page de metal catheter ulter volatives, bot baths and tippine bare becas aborto ktered. Internatttent dilatation is the curde ou u above w Imparable and to permette drican External urethrotomy sessployed us ta ledboosos method by cutting down through the parton, a (b) by exciting the strature and start teettera around rubber atheter ·37 ILANDDOOR O LOCAL DICTIONS CHATTE IV GONORRHOEA IN THE FEMALE THE PRIMARY LESION The primary lentoa fa the femalo is situated in tho urethra and cervix. The detection of poportra to the femalo ba notoriously difficult slace tho symptoms and the may bo trval A full syma ecologlal and obstetrial history should be taken stoce symptoms may be due to the precoco of gynas.ccological disordeni ach y utaboo prolapec, polypr cervical crogloos etc. Symplomas Aro ubeen in a high proportion of chaos. Genarul 11 balth common. Froquency of mictorition. Vughoul dacharge + or - pruntus vulno Ophthalmla Decutorum may point to a symptomica Infection of tho mother Eraminahon This to anled out with the woman in the Hithotomay podtion. The bomer abdomen public war and Anguinal plands aro palpated Tho vuln be inspected for you at boflammation and discharge. A fingers then takerted fanto to vagina and the uredbna stripped from above downward Ammar b made of Roy accretion obtained Abiraantal countation of the pelvis then added out and any abnormality of the doca doted. Finally . specalina loserted into the veglan the cervix capored uod gan taken from the cervial anal. If the hbtory and clinical syns of mild laflammation of the genital tra are suspicious o godococal infection but the rear ure Degative the cervix is daged and provocative painung with i per cent Hver altrato anled out. Sman ire takto of the carria! secretle tho next day If there are negatire further ·GONORA DN THE TRIALE 33 mag pould be take immediately after the next menstrual pead. In spelons que cultures may be necorary to demonstrate the pretendo o gonococe. For completo ex custop of gunococal Infaction obrarystion for a period of three poaths may be nechty Difinala depois (1) Trichomcou regtalt's pettic orpoatem fortad. (1) Leucorrboek dote to amente awart, prolonged adding a to cerrial cradca ) Vytal thrh_white patches present on neiral wai. Odlom ahlam wadly demonstrable la RDAN Geocal Naing Specit, are the gmc u for the male. Specific treatment not u xocental to the femalo u be the male and local tra troeot is required maro afton to dour op persistent charge ar aodoa. Located at Thb bext arried out in the form of dry toilet of the gestela The vin b wpad dry and local cotboptio plied rhoog the leagth of the urethra by mou o cotton wool on to probee. Anginal specul b then fotod, any recrethon protest mopped up mod entireptia applied aboy the constal anal wtb prober. Saltablo antieptia 1 por cent mercurochrome 1 pe tot tre nitente. 1 per cent ploric acid. Foally tho rapinal nalt ud walls are barly lositlated with threr proteinatt porrder na the speculum ke with dawo Socb treatment arried out detty for us long u required For a paste mode or bucato cervicitis appllaattoos 10 per coat plak kod ure optred id lor de teruk anatoshatho may be proury for tal corte ·34 HANSOOK AT YDERLAL YUCTIONS CATDA o Con A week after aspersion of treatment poctinens tam from the urethr und carlal aml rould be tamod to stalned auf und alture. In addition the outca od Bartbolin . ducts and the per-urethnl docts should be cumined and man made of any secretion obtained from than Sach an apumination is repeated ach week for a month And the monthly for three months. At the final canlon ton provocative painting of the trethn and cervical anal bodno with 1 per cent dllver oltrato solation followed by the aumination of man the next day. A specimen al blood b to taken for a Woman raction TY A Lozat Loal treatment by the wet method is preferred by som practitioocty Tho valva is clamed od tho uction and bladder are then Indgated us in the male with a douche can and blant-endod Doorloping potatum permanganato I 10,000 banted to 15 F A speculum la then tmerted into the vugma and the nutnal opithellum danned with smbs. After the the cornical anal b muuhed out through u buck Bow tmgutor wag the mino lotion us for tho trothn Tho vagina mopped dry and promo peck moaked in 5 per cent lcthyol and glycertoo foarted. Sach trontment barried out daily at ont and redocod in tro quency us improvement occurs COMPLICATIONS OF THE PRIMARY LESION These compro Bartholhaltbs Salplogtis Proctitis Bartholinis Infection of the doct of Bartboll o gbands is also and its orífico radily becomes blocked by bolammatory dome. Atender fructuating seiling farms in to ·GOOOLA D THE TW Tenderness and reddity are proxect OTC mer abdomen and thero ba an II-demed torx En torn Localcos on goal oamination. Il bucets forms a man becomes palpablo ore the proba F15 may form ba the pooch of Douglas and, Early Elected, 1 pavic becas develope with : Copco Lorus ha The focus of Infectha limited to the pay doeslom which form eroand the brim. Abo the retric pattoo.com Reems to be non restant to boleto te kthe parltoocan in the upper put of the abdorlarity In Copequence opertoa b pot alla is a tot a ty stage. Lable cold intestino und the remondd to cately in Soch an pentido, fuvolnio #doa berpanthea of Hamed malplas with the patient in the Treadelenberg poattilaa, arial with it a gaat ik dan general blastilable ba wa differentiation fra tre appendice perioaltos. The only time that opentinatarly apo bo osporedble. ponte for part of the labom mesos de passa a se duct an be seen ut bolight red spol. Treatment b by ytek pendet. Darocany mpiration of the infamoatory mess with ceral Entro of pealelin may be Decorary and many Erste k required Selpingitis. This to the most weloos coraplotno teab med may be combined with pelvic peritone Symptoms comprise Lomer abdominal pain, Halabe, Vomiting, High temperitur, Vagimi discharge Vetrarsta gta the patient general symptome TREATMENT ·36 HANDBOOK OF YOURLAL DOFECTIONS Ganool Tho patient is purred to the Fowler position und bot fomentations applied to the lomu abdomen. Hot naglal doochas it given frequently or prelerbly Ellot. cootindons flow doucho med This acts us a Latemal bot focentation and also ruba umy yy dbachango which may bo prezent. If pala perte upita or tab codedoc CO BPC are given us required. Specific Water soluble paulatila i administered wytemially +0,000 units tatramusculady overy three born will symptoms have been a breat and the patient uebrile for two dayi. Oportos If z tabo-ovuttan abacom develop a laparotomy b per formed and i dni imarted into the aboca After tha Amal test of cure of the govorba tabal la lattan s carried oat to make certata that the Faloptan tuba uro still patent If not, and the patient is very deurops of having children open tiro removal of the tobal occludon may be possible. This operation abould be defertod for one year after the alpingith has cleared op. Proces Occun dot Hafrognently in adult womer uod geita! ro-tolectloo from thl source common. Pealellin and wolphopumidos are not very ethanciom and it is better to start local trontment immediately Daily Indgation with I 5,000 potantum permanganate la performed followed by the fraction du porotargol posary lo long standing to fection this must be supplemented with local applications to the emal mucou of the Amo Latkeptio u uro wed for the CRTVİr. These are applied through proctoncope. If fiseure---Do or part-rectal bacen forta theke are treated morgially CHRONIC GONORRHEA Chroor gwoonten in the female et rary Intractable dbase gley The to moich a bealth. Vegee iches ·GONORM THE Texas 37 und paulos in commcm und low back che ama poch dability. The perods aro bacused to the amount batt 10d the duration of the Bow Theras moont zghmal die charge. On saamlostioa the urethral orifico appard por mal bat duty bocold discharge aan frequently be ex permed. This dischargo b dao to the buvotrement of Skene. tabalas perkthy u toal of cofection. Thoy fill up uod Intermittently discharge their contrats. I tho urethral maats is opened the openings of the good docta un poco to be rod and inflamed and pos aan bo made to adde from them by proporo through the anterior ruglaal wall The cervix frequently shows a chronic drodou. Nabothlan fonida, u prevent, bodicato portal healing Ganococd art very difficult to detect in the cenrial xccretion at this stage of the discuso end provocatto paint Ing with i per cent dlver nitrato bahenthal If the moun art Degatire they should bo reported Imediately after the bext menstrual period. In cases where the history in picious and tho merry are pegative coltare for gonococa cential. The cotaplement fins toe test babo motal 4. dagposti ald TREATMENT Systemk penkia, o 3 megt units in all wux pospension boven datty far three den combined with colphadition, tro gruntu statim followed by congum overy four houn for three day. Following the local treatment with natt reptila applied to the permeting fod of infection may be Toquired ·38 LANDDOOR OF YZTEAL NOTIC003 Cart Y SYSTEMIC GONOCOCCAL INFECTION Blood traum infections may occur ut my age of the divane. Rare with modern chemothenpy they uro por Boon mainly to beglected cover. Thoy the oceur about the third week of Infection when tho baldbcbargo la teoding to clear up Seption and Prancia The most seriods (and nrest), complication Chanc, terbrod by high fover math, chills houdache love of appetito and ida nube The gonococcus a Wolated on blood colturo Vegetations may appar on the bart valves with the dovelopment of acuto bactabal eodocarditis In milder blood straum infections the ceilabr thipoo plana uro most commonly affected especially round the Joints role of the foot and lotos to that gonococcal functite with mbroquant fafnt Infection is one of the commoet cocaplaints of the diseases Antkritus Infection commence u periarthulur fibro-functie The mammation is always extensive ed eroms or parulcat exudata may form from which tho gonococcus b Incora ablo. Tho typorn mombano is attacked becoodudly It becoolon spoggy red and gronlating and extenda over the articular artilago u pannus Peri-urticular fibrosa very common und lads to fako ankylosbe. The posibility of obtaining I movable joint la poor The point infectiog may be (1) Womrticubr-one bigo Jotat affected. Sappunto tully occag. (2) Polyarticubr-many small jointe uiected coodary to periarticular Abro-fuscita The fold's most commonly efected on the Stenochoricukr ·ISTOCIT GOXOCOCCAL DICTION 39 Tamperomodibolar Tural end arpal Vertebral, Dlduguishiwe features. (1) Ortodden acute and painful (2) Partidiected teree hot rod whiny ) Gardul Imprurenent to a palet where the conditio b wallonuty with coordeabls realdaal diubalty Poker back and fat loot are cocoman development to young adulta. Diferential diagnosti (1) Gout-canctorustic top hi present (3) Acuto sesuat-pakes more tres foint to folat and gradually increasa ha sovelty 3) Anaphylactic reaction Tematyronitas Occor roomd the web ad inkie Pos toronto ba mon. Omet fooddea and the sheaths become swollen and teoder All prvement restricted. The condition hos Kroof tendency to becomo chronk and depeno uhelns form to the tondoa shortha pamurrently restrict ing moregent. A sympathetic serlo enlou may occor the neighbouring fonto. SHL Laslon Cocope w urticarial or aythematoo Ladoos sythema multormo and byporten todo o palms und oben Rarer montertadors, Bortit, youth, Pertatith. Plenkty Weningitis.

·40
HANDBOOK YOLL ACTO
TUATUIT
Gomora
Rost in bod.
Immobilisation of the palafal port to plaster or by
extension,
Specifc
(1) Penicillin 15 000 units intam colarly every 3
bour
() Sulpba drags grume followed by 1 Ann every
4 khun
Applation of poppanting fonts is pecetasy followed
by the injection of peolellt solution 1,000 units per cubic
centavetre. Rarely open operation is required.
Chronto casa require mag, activo mortidents and
Vaccho thenpy is welu! Wrenching of an
ankylosed Joint or fat foot be unwise doce At may be fol
lowed by a fare-op of the condition.

·YULFOVAGINOTTS UD OCULAR DTECTION CHAPTE VI VULVOVAGINITES AND OCULAR INFECTIONS Volvonghits a condition formd ba children. There may be a craplaint o vaginal dicherre with barning of the valvu decorolart coliting or frequency and pain co míctarition Occudowly thero ba ittle complaint Lod the mother brag the child up became the bus food the discharge on the clotbing A natul decburge which may be prolone b found cromotion. The vuln and introitus te reddenol und powly adematous. There may be courgoseat of the gabal gland. The ons may bo rod and wollen La 1 chronic and there buscanty chargo thin porth keat or omico purulent. Sorenew and intation of the rain are promat with Injection of the procom membrane per Honlady in the cell between the hyped and labla mioon Vulvovaginitis may be goococcal or non-gooococcal la ariglo aod pococcal catre In the minority. In the Yux majority tho tofaction is DOD-RIU) in origin and bon doe to codental Infection id fomites, Produs posure factors. (1) The vulva ochid relatively to protected LE tbo bbl me for develop. (a) Tho mucous membrane is then and Los reaktant to mfection than the adalt. Alter the first few reeks of lite the riglmal keration & kanty rod ulipe. With paberty, the moretop it. Creus iod became strongly add and bacterial. The acid raction appeals the lower boddenco o falection La your babies and strikes over 10 youp 4 The diagnoda bude on cal door od the Hodiny of gonococd bo mocens ind cultures. Complications (1) Cavidu batimo. (1) Urethritka sa osial but comitia wscommon ·42 BAXDBOOT OT VILLAL VICTIONS (3) Endocritis Alpingits or pelvic peritonita occur rrdy (4) Valvovaginitis may occur CODCurrently with poco cal ophthaft but not during to find for moba Ilfc. Later a vaginit's in a child with ophthalmia may bo CTET looked ΤΑΤΟΥ (1) Attarapta are made to And the source of the Inter toomaly parental. (3) Gage ! Card must be taken with bed-pona batb mater thermometer und clothing to prevent spread all the fectioa. (3) Cound routing In-patient treatment during the acute sage Tho provision of some occupation auch us purules to prevent the danger of illo banda Splinting at the elbom may bo necesy Ultraviolet light for debilitatod children. (4) Specific insament () Peakcillin Up to 3 years of 280 20 000 units ftramuscularly repeated twice. Up to 5 yoen i 30 000 mais repeated twice. Up to fo yan of uge 100 000 tilts repated After 24 boun no abnormal chiascal que are food ud med ind cultures are free of pas celo od code in 48 boon. Very few falora are obtained with penicillo and its niso has otrated the need for kaal treatment. (9) Sulphudiarino Up to 6 months of ye i malo per powd body Waght par day ·YULYOTAGITTIS UD OCULA OTECTIONS 43 Up to I yar It mums per day to four hourly docs. Up to yan grams per day in four hourly Up to 5 yean 3 ms per day to four hourly dates This b continded for days (D) Sebo brol I migram by moath ach day Trentment may be necesary for 1 month The simulate the appearance of glypogen to the spithellal collo Uning the nighna and of Ectic add larment in the nela rocretion. The criterion of ropone is an old raction at the vigoal Merctlon. If the above methods full loal tradiment faut bo ouod. to the auty pago tho child sits in bath tuto daly for bulan boor at a time und bonde fouentatoos aro pplied to the valra in between tbo beth Following this rapon ha indpated with I per cent lactic add wolution by pants of a sott rubber catheter Tho urethro ba patated with I per cent mid dlver protetorate B PC Relapeces and frequeat. Dronlly due to (1) Rolafaction from an oideatly treated urethan or from the cervix und rectura (+) Pertence of magturbation a) Bad kycleak conditions at home. Crisis of an Nopattre test by films, mitaro iad gonococcal tation et for a mlohom 4 Donths after antion of treatment The mother or must bould leport the rain dally "Vorforocorcel ulooptube. Doobo Staphylococc.

·HANDBOOK of youDTECTION B Call Pocurococd, Trichomonu ngioalis Chicken por Sarket forar Diphtbere Treatment au for gooococal auses OCULAR INFECTIONS OTTHALVLA NEONATORUN Ophthalmla Doogatorta ben due to the gonococcus arison from infection occurring during the pumnge d tbc infuats bead through the vagina. Approximately fifty per cent of churo Dot doo to the pooococcuM. The coodibon an lad to lapaired vision due to opacities of the corner und permanent blindaco may result Tbc maternal to foction may be obvions or ipparcntly trivial with ler tytoptoms or agros The focubation perbod is short and in 1 to 3 days after birth the eyelids become pofly and stick together The confanctirao become intamod and thero ka paruleat exudate Ulceration of the corne then occun cod muy be followed by Hooghlog perfonation and destruction of the eyeball One of both cya taay be affected Propkylar (1) Wipo thr child dyelids with stenle amb upon tbo banda bom od before the cyes and opened. (3) Instll opo drop of fresh i per cent solution of frer nitrate into ach conjunctival me. This may be for lowed by a ractiovary coafonctivities which is at Inportant. TATTET dler" been confirmed by the deta pulture of pay from the 7 ·TULTOVAGLIATTI AD OCULAR DOFECTION 43 anjonctivul mc treatment morbo u coergetic o porablo if the woodition to be dare add the dght uved. Gouere. (1) If o gyd only affected it tuld be covered with #thede to piereat betection of the other se (1) The baby sboull sleep on to affected sche ) Sprinting b udvisable to provat mobbing of the eyes, (4) If the come la involved atropio pulphato. I per ceat instilled od the popull kept widely dlated with furtha batillations Decorary Specific L The drug af chalco penicilin in solution containing 10,000 muita per cubic continetre. Pealemlin gyo okatment la not multa bilo dnce it k auly extruded od the curo rato obtabned with it is very low be the of baroellas cootaluhan pembelian baho to be deprecatod since they are froqually extruded from the confonctral mc buy the constant mening of the kb. (1) AB pus b muhod out of the conjunctimal se with mm ball porcual aline. (2) Ouro drop of tho penkallin sotutka the bottled into the eyo ray mtante for ball en boor Any discharge wilch forms by wiped any with cotton rool mattoned with line. (3) Lostil penicillin drops wery 15 minutes for der ocoudoun. ( Ingti penteMin drop chery hour for de oculos (3) The drops ce contined way a boon until the eye ha qolto dry and lot = furthe tretro bours after this bar occurred This treatment to tedious but it cares the most majority of Caka 11 desired menni rykenk therapy an be em ployed injectie of 200 000 wita od pencint in culto stattdetre of sterte, pyrogn free distilled water une premi every 3 barn deeply bata the buttock. For sech bajec toor ure trually needed. If doubt ek u to the cu ·46 FLANDROCK O YAMAL DOCTROIS pletenen of care folowing this manive tystemic therapy Han be opplemented by mostatas o periclita kalatoo 10,000 units per cabic centimetre containing I po ceot methyl collolor. Such istillations are reparted at two boruly intervals for us boun after ciascal core. II Salphonamide compounds have the advantage being user to administer than pealilla bat the results obtained uro inferior Thom soos poosda 250 w Ded when it is importble to me penkia or when the poor to perolemia buntistactory Trotinent by coldencod with 4 grains followed by a grains every four bows god treatment to contanod for 4 boon after chia) to has rarolted. Tho tyo may abo bo favotred at any tione during tho coane at a gonococcal veneral Infection by traderepot a infection from the geoltulla to tho conjonctiraa The core at the dbrouse stico ophthalmola neoortorum. TRITIS Thlaba e metextatic coadition commonly a wociated with arthrith. Umually anlateral. There be pala la and OTOT the eyo, mbty vision and rednom uroand the margla o the corner Photophobl may be present TRATITET (1) Local baat. (1) Gutte atroptoe i per cent fa fastilled and the popul fally dilated the papers then kept fody dated until there bave been so symptoces for 000 mack (3) Systemie penicillin is given to eradicate the aupal foon which mouly present in the prostate or Penal radcie.

·SYPHILD. 47 CHAT VII SYPHILIS Syphib Teneraal dient and by infection with 1 sproche to the Trepoocul pallidum Tub organim entoo the body through the skin o mocows membrano und widely diseminated throagboat the body bedoro e bal Ledion develope. The dheur an mbako almost overy other Hoce every are for the body s babilo to Intoctton and pola mort elny be borno in rand to differential Hugo. The Treponema pankdan ba dallato plou filament 6 to 4 boog with 6 to is cola which are col nod regler The ends no pointed and tapering It an only bo demonstrated in tuostained preparation by dark gromad Gumination apd this method a oned lo venerology The organism bom e rotatory carlow movement and who moviments of fadon. Multiplication z by transve blousy Burlon. Cultura a very difficult and only occurs under an.ccrobic conditions to special media. The bear has been trang muhted to money and nbolts by boocabation into the genitalle. Tbo potrochota aro Lound to buryo purab to the cbanco iod it trudate. They at bo present in the buboo uod mucondary lalon. In other ladans the strocartas uro present in far la number and prolongod sourch holten bocorry for their detectica. The Infection to acquired through anal intercount but tbt leaba may bo congenital and accidental on the Hpa tongue or ongan. The coup d the dietro & divided foto four saga o diicrent sets of these dorp hyper sendirenc which are them to react afbciently sharply to protna symptoms of diverse (1) The primary chacare (3) The condary bloos al ik od mucous meo ·LLAMDBOOK OF REAL DOPCTTONS bruges stuttag 3 months after blection cod busting about 2 yehz. (3) Tettary sage-gummata of skin und destruction of deeper structura. Comme ces about 5 yas after hafectham (1) Quaternary thage-oreningo-ruscular ryphis and Deorological doordan. The primary and sccundary ledom constituto austy typatib. From 15 to 40 per cent of syphilba ha acquired without the patient noticing any lodon. Thilab most frequent la women and pregnancy especially seems to favour the occurrcoco of asymptomatic dhaus Syphilito mfortton coordy a marked degree of komunity which is an framunity of Infection. In ordinary clicam ranca a typhilitic patient cannot be re-infated. Once the quocbactes aro destroyed bowever the immunity s lort. Hidological chansu When the prochetes have pcoetrated the murface of the body they pun tato tho pertvascular lyophetias nod from theropen to the regloral hymuph nodes und foto the blood streama. Wherever the sprocketo rettlos a grande produced composed of a accumulation of bymphocytes and plan cells. This batter od b the chance the call of syphilis Tbo never those to highly recobar umlike the letons of tubercutod Later the endothellam of the capa? larla become sollen od obstruction may be prodore FTbroblasts are eventually stimulated and marked Abronha occur ta baling In bate lettoos Decorada I frequest od A mocated with the presence of plant cells. Such an of Doctor ure nderred to as gummata, THE PRIMARY LESION Avtoblo Leston Eppad 4 to 6 veeb after lalection bot the tocabation period may vary between 10 200 Go day ·1 laditation extcoda tome databa lato de dr The regional Igraph boda bocom lard lod botty but Dcomo accumulation of lymphocyla hd ma colla aroond be all rounds Obitontit adunhalts an Detractlog of the butt. Halo omy tpoptant pouły within few meet loving our be for sal If the chance betwed on the prepababa major The propery late the chance, bly single bat may be moltiple. It is toally on the golatka Fran glene prapaces commonly within the wary matos, body o peso má bhone La pobkc repina Labu minora ou ntol Vagttab surety the site of a chance Exin-genital chanda at omally on the tipo, toda ar frmger. 10 perrence of the chancro Plost forms a bord painlex red rapale which con large to the size of a pea in the olama (1) Ronod or oval (1) Edge ruled and indonted. Floor built up love with the edge, chell sed in colour bater glosty and coppery (4) Freely morbike rounding the chance. (6) Pink uroole around the rolan. (7) Palplan llatology the surroundings iodantien mootba. Fibroblat coramo ·HANDBOOT of YDTEAL OTECTION oderna troquently occurs and the presence of the chance bully mbard Differential custools Chacrosd. Ulcer odgo todortnined, Irregular outline Sodaco pitted May be painfal No proudding induration Herpes Ubeen multiplo, very shallow No kadarution Il coalescenco Ocean the margin b mdo op of the memets of all direla Scabiotic nu Mound lite Not rodod No creola Not incurated. At this stage the diagnoos bs confirmed by detection of tho orgafun and treatment boald pot be commenced until the daguos cortala Antyphilic traktorent given beforo camination ditainbshes the Htetthood of todmg the spirochaete in the audete Velhod of obtaining the malmul for urtprowad Arantumaton If antieptias baro been upplied to the pronary art yret dresing of giore souted to seribs alto be applied for 24 to 48 hoon. After this the more blamed with a mbanted to nam alle tolotion upd the margin Kraped 1lghtly with a blant instrument. Ob squeerlog the las of the chance rerum codes It this series bloodstained it be repored with dry guze and the squeezing coo ·ST troed unti dar toate bobtased. The ho collected apillary tube and one end of the tobe b then sealed han thre. When the palomary sro ba to the process of haaling microscopre mamination of the condato may be negativa. A padtiro teolt an then aften be obamed by Rund ponctore. A brit bore Beedle attached to a hypoderate singo ba toserted into opo at the enlarged regional glanda which bred between finger and thumb On Action betong eppiled i little glued thuld than obtained to the yonge. After about a week from the one of the pomury more the Western reaction as be employed. This reaction become programetrely mone pronounced antil it is markedly poattivo in to record sayod the discuss DARB GROUND MICROSCOPY Used to make ville delicato argunms och us the Treponema pallidom which do not cause polibclant retouc tion of light to be this by other man. The arginta maminated by oblique Tight only mod nr do not enter the harrd of the microscope wlew kuttered by objects of different refractivo moila tram that to which they are to pended. The organizace sppour boghtly womentad agabost dart background the cammation requires (1) A dark ground condenter (2) A stop to reduce the aperture of the objective when u ordinary all towerdoo le ored. (V Abright toart of light. Condor The copre ba pecual tembambalal oor with centrul stop so that only the palpbenl ny of Opht und tangnitted There for a bolo come the yer a which b focused on the spoon. This condeo replace the ordinary one wppiked with a microscope for anal bacteria loglal work on the upper parlace hro rog art groupd for centros porpora

·52
HANDBOOK OT YDTIAL IXFECTIOU
2
Diaspon ikoetas polist of ways through condomar
Stop
This comist of all fund shaped piece of valoanito
which fit into the objective behind the back loh. This
reduces the numerical objective to be than 1.0
Anbbon filament lamp ba tho best consisting of broad
fat nbbon of tangtter between two stoat electrodes. It
wala through a thinefarmer The bulb i enclard A.
ventilated chamber with a condensing lens.
The preparation has to be a thin a pouble so that
the moving objects are us for u posebke, A one place.
Special Hoa ito made to that ben tho cover up
applied tho prepenthou hus definito unifoca thikkoon.
The elde has to be around 1 metro thick and must
be dan and cocepletely free troca frank.
Technique
Attrony light directed by the mirror on to the con
denger Uting bow power objecthe the two slag.oe
the apper partice of the anodenser att de concentric
with the beld.
The modenser is then nacked up until it too bus tho
imder parlace of the wido . thio film od bolerventar
The spedom is viewed with a low pore objectire bo

·SITHILI
1 patch a chat keen to the bed. The's brought to the
centro of tho held by altoding the minor
The couden is then racked down while watching the
patch of light until this is at it smllest and brightest.
The objective is then changed for the offlmmention
objective i spot of od placed on the cover all of tho
proanto nod the microscope toponed. It the loco
b bury od 1 dormed the focus of the codeder needle
admonet.
Threo 100 fpecific opbrochados uno commonly prevent
to peopen. Thou are
(1) A couro argano with fow spiral
(1) Asmall tat prochaete with two or three cout.
3) A clonety, colled solar sprochaete maro fodble
than tho sboro It w tricothick u tho Treponema
pulchum moves foster and bus fewer code

·54 HANDBOOK OG YDERIAL DTLCT1000 Cuarta VIII SECONDARY SYPHILIS After the appeandco of the change thero ba alat period. Thens to 3 months after infection the West man raction become portivo in parly aura nod the discuto present sycoptoms of generace Infection. This Ho penite for months op to i astmom ol a year Van fudws. (1) Headache. (2) Pover (3) Various la nube (4) Various mloor manifestations Tho malo manlientation is the ulan laloas. They are (1) Symmetrial in detribution especially on Decor aspects of Imba. (2) Coppery in colour (3) Polymorphic maculas, papalaa eteetat present together (4) Diappear witbout treatment. Tho comumopat fotos are 1 This maculo-roseolar sypkt.de Commence u a falnt erytheme on chest and abdomen and develops into round or oral spots which muy bo dto uod appear to bo situated to the deeper la sua ofibo alto The nih sporoada sorty over the whole body with an the colour deepersBrownish plementation is left for some Wecbe. The toh b very faint and may be dificult to the Recrudescences and common. . The popular rypaids Art (1) Flat topped or (0) Follcolar May become taly o postalar The paprikes coast of rabied spots bright ralat furyt ud o diferent kies. Later ·Roman SMS 55 become dol red and finally fade to laure broma pigmented spot which pent for kue tinc. 3. Rupie Oooun about your after the more and be more Love typhlikde. Individual postules form which become correred with a dark brown maab The omdatymg alen tico track and bactendre layod crust ure formed tatil luminated appannce k seen. The proces ka chrool poé and a healing lampes cicabar sein with pleated bordeos which point for youn. The eraption beauty contased with kapetigo 4. The modular typ habido A late manifestation after clanded with the tarthary tace of syphill Lelom very from 1 to 10 centimetro to theraeter The texton caniste af deeply set, krowth red sodales met banquents of treiles The Dodales art abon gomata apprometry s milimetro ba ameter Thound the world to date appay attend and pittel The doen dowly atracts. Found round the hac crat, bouldeg und Berar portaca o the jalats. 3. Condyloonde. Octw between bottocha dor of suotum on tho babia od mpper and inner idea of the thighs. They vo dve to the popular syphillde occurring in mano moket are so that the popular becoone promlocat uod mart-Ho with a greybbwtte apparence Throud In the thrott epal roy dear-cut nicon form with mat truck appearanco. In addition thero may be a ose Blondi and bryatta Vior manifestation (1) Goenalised Hebt dette affecting specially the Spitrochlar and celei Ganda (2) Alopecia. (3) Amba ·56 FLANDDOOR VIDEAL DICTICOS (4) Initis (5) Symmetrial subacuta pabostits of long bood. (6) Acate neponta (7) Acute myelitis Differential diagnosis All the operical lesions of the secondary star an be confused whh any other uldn discus. In syphilh, bor ever the ruh has different appanaca on different parts of the body Thus it la dry on the trunk and the whole moist papáles occur on the warto perts and coodylomata appear in moms areu Non-typhllitic dermatitis on the othor hand almayı runs trao to type wherever It S Mtuated The diagnosis confirmed by : poultre blood Westermann reaction whilo a negative action bigbly synihant la 1 opected care of secondary syphill. Tlu Tapomons Reaction If red cells of an animal A are lojected into an unbox! B haemolystou develop in the serum of B If red blood cella of A are now mixed botant to be with herutn from B hemolys occan. This lucmolyab doas not occar if the torun from Bb Art beated at 36 C for 3 montes doce thla destroy the complement prescat ta korim od that complement la necesary for bewolyus to occur Comple tomt b present in any fresh tuto and so the addition of Lerum from my animal to the mixture of bated hrupo hyun and red cell will those homolya, Whenever bacteria ano mlied with scron con tantag uutt bodlon to the bacteria complement is fized That the herum used contains the appropriate antibodfes as bo teated by adding the mixture of bacteria and scrum to & harnolytic ricon which bas been banted to destroy.com platnent. Il bomolyzás occan then the rerum tested does pot contain antibodies to the bacteria med This couplement fortida test is the best of the WANT mann reaction which is not a true Lumundty macho bora fication of complement by an emotion of Lipold cabeticht od the beated serum o un blated person. The antly + ·BECOMMARY SYPHILO 57 wood kan boholic extact of sheep beert tuds to which pore cholesterol has been added. This is mbred with the merom from 3 cubic cotimetros of the patient. Wood. The occurrence of complement fuatia k torted by the addition of wheep red cells plas the krum of abbit wilch bota been Enmanbed with sheeps red cells und bated to destroy it natural complement. Eaci recent wood in the test must be scruntuy stan dardised and the wount of complement tood be poich that the weakest retthon observed can be accepted u pecific The Westman rraction boot only qualitative but also quatitativo enco results aan bo recorded us strongly pod dre (+ + +), padtire (++) or markly positive (+) The quantitatiro tertiog bi important in amming the results of trontment and the completenes o cure The reaction tends to become poultivo two weeb atter tho apparence of the pomary soro mod b markedly pod treh the recond stage. A negativo roactica to a Roxpected care of secondary syphilis a highly splificaat but in bateat or tertiary care negative renit does not exclude the dhet Poultre reactboot have been recorded in leprory yaws, rotapering tiver and trypanosombark Soch dbu u pure bowever to teropanto climaton. Fabo podtive reactions have aboo been reported in cancer cotone of the Hyer Infectious mononucleods and atypical poeomont. Those, before accepting a podtive ro actlon, carefal inquiry at bo mado foto the possibilty of I betog doe to 000 a tho above conditions. lloy place now combine theme of the Wewe mama reutha with locculation test for syphics. Thate tests are based on the fact that precipitation or foccolation occurs when syphilitic sunt mixed with organ atracta Tarlot reactions have been deredbed Sigma, Kuba, Heroicte, etceter. The reports obtubod with these tacts are raty dlar to those obtained with the Wiseman reaction to rootino work In syphilitia treated with pool lin, bort the tocculation reaction toda to bo podtive When the laskma reaction is depth und more pod.

·58 HANDDOCK OF YOTIAL OICTION tivo flocculation rates are obtained in audy syphilis tban with Wuermann , tat which frequently never become positive. TILATOT In early syphilis treatment alms at bealing rapidly the Infectoas loulons and tral andlation of the prochacte from the body by the pe of penicillin and anak and blouth compounds Until tho we of penicillin in syphilis tho treatment of thil dbouse had always been attended by some danger beam of the toxicity of the heavy metals which were med. Thene dangen were much Increased if the doar wu nabed or the period between injections decreixed In order to tharten the period of treatment. Sach treatment with heavy metal atended over 1 minimum period of two yan and wu nrdly completed in the majority of carol Penkelin bus no dangerous torde effects la carly syphinih, A mild cacerbation of symptoms does occur in omny asa und pyradal reactions to common but thero no relatively - unimportant. In addition the advent of penicillin fato tho treatment of arly syphilla bu ndically shortenod the period of treatment but if robianco la placed upon the compouod alone around fifteen per cent of arcs relapse In consequence course of pendenta is roloforced by coonia of Infections of beavy metals. In most cas the perfod of tratment pot extends over six months. Penicilla abo pontemot tho great drage that it renden the patients Don-infection to shorter time than wus poodblo previously Tho further compounde med In treatment al nhills and compounds of u cake both mercury and bodibo. Arxo preparation The Amenical propantony od aroorpank compound in which the arealet ether trinlent a peatamaleot, The mala trinlent componad med neo-urbenamboe B.P. which b mold andere variety of proprietary name It . yellow powder containing approahnately twenty per crot ·SECOWARY SYPHILIS awrenc. For administration the dose, QIS to 0.6 amb dired to s obscure there adattied to und Infected lotartooauty Immediately after solution. Il the rotation as pot mod food after preparation it becomes rary tork. Noo-umpborum too an also be gre intrmonlarly bat is rey peintol when administered to the my After a Anglo Intarons fafection pootoqbengolo Appou in the urino mchangod after the mirates and per Hab for Avoto boms. After this ukan prosent in the time for some day. It is also present in the fores in large amounts than to the ortos. After the first for plotas following Injection po 100-urphenamie bs present to the blood, but in uenic reactie obtatoabto from the liver end booe marrow for oroand fire dan. Apparently the total cucretion is show and come la porod to the body and mdrally reland into the circulation. Pentanalent compounds are excreted moro npidly and do not sem to be fired by the three cols to the name extent u the trivalent compounds. Ooo tnfection of the urrenbank Ha most of the strochueta bat a few survivo aod multiply In pactice, thero font repeatod in Jocttons of the uren als auro giver Thero are divided into course of tea foafections with an interval between conna ko that largt stores of Lorento and not built up to the body which may be released later to give otho to rectas. The trentaal compounds have to be tood with wpecial are and fin low down in the case of Malnatutioa, Old and feeblo patients Dircare of the bart, praat veel a bizta, Nephritis Dlabetes In the majority of cara berp those coodittoos ht It better not to use the intental compoooch but rely ntbar on coc of the other beavy metals 1 pkere lo sometimes med en place of beo-utphen ·HANDBOOK OF VERLAL DETECTIONS umla. It is tonlat compound of parenk und thought to be the active abstanco into which pourphe umino is coorated to the body Tbo dovo h 0.04 to 0 0 gruna given intravenously Acetylerser i sold in amponlas of three cubic centimetros containing o 15 grams of ironia Gtren by totramokcobar fojection Its of low tarctty d bawed mainly in ea bere hatoleranco to carphonamine prosent. Sulpkorsphronius B.Pb farpaldatryde blauphito derivative of ursphemaning containing about twenty per cent of urenk. It does not orddbo oslly and an bo gtren by to trmmcakur njection soce i blo tritant to the tform than 900-uophetamine Its main se ba ba tho treat ment of children with congenital syphilita Tbe donc 0.01 grims per llogram body weight. For adults tho donc la 0.1-206 grus. Trypantomido dos 1-3 grams for a pentanlent intens compound containing about twenty five per cent of ancake nt and for trypano mlada ind to Dotted for arly rpybilla bat hartaerred for Detrologlal anses. Like al pentavalent wscal compounds it bulability to prom duco optic atrophy whereas viadal disturbances are never produced by the trivalent compoanda Tboso viral dit turbances with typorumido clear up when the drug in dls. continued. Sloversol la the only compound for which to claim has bedo mdo that it is active when taken by mouth No gront rellence in prezent placed upon its cuso but it has to be employed when lojactions ure pot tolerated. The dose a guing 4 to u thirdoo dully Taric effects of Armcal compounds When arsenical ene mojected Intt repoorly there ut, u genal rule to symptocas but in foore che there are ractions varying from a light tocoarceleace to scrious dit andetWater compound is used they all have to deacy to demast the apillary epithelia. Effects occurring inmediat ly after tejection Fantas, ·Paticats receiving ephembe temporis hoolt prt - Tbeo uro the m-alled paplylactid synaptoms. They occur when the colectia i tren o foll stomach BOONDAIT YAILIS Hadache, Flashing a face Gldings Nama General mlake, Profo mating Dypnoa Rattanens Tretor Patr in gomma kod teeth, Oceastomly vomiting od danboa There may be a fal in blood prendre There symptoms are prey rerons Laprabisce sot un due to the too spid injection of the maial, II the reactions amour with lower topathosphory infection of as cable centimetre of the 1 1.000 should be given totammenlady xe més beleza fatore nicomotor motore Alternatively acetylanes, which infections of uronical stance the reaches t of a stred by intramuscular Injection on belote lor neo-enphenanine. Efects occurring kowe Lola They cacaprine Swelling of lips and tongue Cyanoba Serere dyspnoa Urtlarin soptions Herpa lablalle. Stomatitu, Headacbe Pyteria ·62 HANDDOOR OF VROEAL DOECTION have any food withio two hours of the injection. The ructions do not seen to be dae to a direct trade difect of the urreal bat to an altention to the blood proteins aanged by the colloldal futuro of the wsphemumino compowd. They do not occur after tntnmokuhar fojection. They are arrested by es bajection of adrenaline of by the previous adminbtration of ephedroo by mouth or al benadryl. Lalu affects These are dgns of Intolerance and u malo all for tho termination of treatment by the infortion of urenlcal.com pounds or at least aan for the groutant caution to the dom.co and time betwocu miccoadro Injection (1) Albumeixeria. Occuo following damage to the glomerular epithellun (a) Stomatitis (3) Dermatitis Commences u an erythem which become very Itchy Apd dovelops into an exfoliative dermatitis. Its toodenco ba dependent upon the intemity of treatment. The appear anco of dermatitis contraindlates any further we of irphenara no compounds in that auto (4) Jesudico Tho great majority of cars of fondico which develop durtag treatment with Lorenlaub in belleved to be ono of bomologous som jaundice aused by the trofer ol. viras from oto patient to another by imperfectly sterilibed syringen Afreably boiled syringe should bo used for each talection. The incidence of the jaan die mees to be rdated abo to poor fcoding (5) Cabral symptomi - Arsenal cocephalopathy It occurrence is rare with ordinary methods o treat bent but a fairly frequent to patient treated by falendre methods. The syndrome truly occun arly and prepunt worden are partkularly exceptible. It haused by a dina took action of the local al compounds on the bo apilbris. Severe badache und dental confusion de ·SUDUTY SYTES 63 protatis velop. They m followed by the owner of pileptiform convulsions, tree and bypassitablity Somlatopor muy then came and be followed by come ind dath. Immodiate treatment cookhts of removing co-ball plat of blood by resepancture and the frequent seasnal of canebrospinal Auld by lambar poncture. Curas should be used to the Fowler poultion In addition B.AL bad mlaktered (mod beton) Jari Haxhmer ruction Consists of a temporary Interifcation of tho syphillit process brought about by treatment is due to rellig und dann around the local munifestattom of typhila This may urbo from the poorous action of the freod from the daud prochaste. It occurred i dan- Toms to sortith uod coronary obstruction dico corapleto steroba of the coronary utedos may be produced and mb quent ventricular fibrillation. Biomstk come poswds Arcaial componada wuck with great rapidity but thats major effect woda off after a few dayu Dhuruth who haus a specific destructive elect on the sperochaeto of syphilis. In consequenco ble mouth b stres to treatment that the bumedhato action of the utenlo is obtained and breto forced by the power and most prokuod action at the btanuth. In addition some optrocheta may borduttrelo boendtive to compounds of arsenic bat #sunlikely that that organlan will be rectant wno to bemuth Bharath compotuoda hava po ection ba syphilie ben taken by mouth and are too butant for mabentancom - fection Iata resposta fections are very tank and the dres bnpbelly excreted. In consequence in the only soltable method od admtalstration in the treat meat of syphilie. Sotidieat treatment amot be gren at couco to all the prochaeta and tratmeots ut main bababang the maximal conceptation power to the thrones for a long period This concentration is very near to the toxk ke A nirety of compounds bave been trked bat Downdays the main preparations twed ut the trotublo intramuscular infection ·64 HANDBOOK OT YERIAL IXTECTIONS corpomado consting of speare of bespath metal tho salicylate of the oxychloride The propeading medias may bo wtery or oily The British Pharm.copobal prepuntos Injectio Bomuthi wbich sa mu poslan of finely divided metallic burguth in a solution of glucose and Injectio Rinuthi Salicytate which contains a perspension of bioath alicylate fa alivo al, un inoop tho otot rellable and convenient preparations which bave been usod. Whatever propantou li used the done b tho equivalent of o 2 grum of blurmath metal, Bluth prodoca chronic farm of Intoxlation la como patients when given in the usual way in course of ten bajectrons Tho adiest symptoms are Lors of appetite Vamitag Darbon Salivation Stomatita Later ulceration of the game, tongue and mocos em brea of the mouth occurs. The urine contafos albumen und austa. Blumath frequently amas the formation of a blue line on the margin of the game bat ths doo not all for the termination al treatment. It is doo to the presence of gingivitts and does pot occur in the cdentalom. Trat ment must be stopped bomover if stomatitis or albo minurla occan Vercury compound Diercury compounds have a spedic destructive dledt og the spirocbacte. Their Yulae in treatment b cadoubted ulthoogh their position has been usurped to a great extent by blanath especially Hace mercury auonot affect organter in the central nervous system and no proropeat t obtained from its also in tabe of groenu parne. Ib use to these forms of sypb It's be to treat any other moifestations of the disease which may be present to conjonc tion with the hearosyphilis. The best effect from roercury bobtaleed by rapid absorp ·gcompany ITIL 65 tion and proloaged occretion Esch method of administa tiore hau ta dvantage und dhadnuntaga Onl tratmeat least bedreigt od Liquor Hytary Perchlor in thirty mlodra domo by the best preparation for adolts. For children PL Hydrarg cum crete tood. The prodoction of diantca tho minbi daudvantage of oal thanpy It soally controlled by the adition of Tinct. Opt to the mixture. In chmured pulv fpecic com oplo cats 1/1 wted. Iponction rolda disturbance of the gastrobo tortiral tract. Hall to one dracboa o mercury ointment h rabbed to daily to different part of the body Tho aume wa must not be Deed repeatedly became of the danger of battation being produced." Trestment by coatfoued for two wechs. Aboorp- Hoo l sow and the amount ab arbod is unknown in any 000 lo adaution it bemeny procedura. Sob sutaneous malection bray paintil but hinamonucular mec tonka barourito method at adunkstation by NoC. The compound med is tho alkylato of mercury a a ten per cont Barpetuloa to a vegetable all An to poction of I cobic cuttmetro b gtren coco a week. The infection belowly beabed and Lorme depot from which miercury hamda Tren tent with more cota-indicated by achada uod Dephalth. It tooth efects are Storrathi. Nupiritha Calth Decoratiti Salination appena first and on this is marted the toe at the drop should be abundonad. The roauro valoa of ek benuth and mercury aro u Lollow Capanke urxealaala mo opid in action and the wed in the early so of the hand butt bred to topplement the action. Breutb far more supld has ucha than percury and was able to prodoco took toch. Il especially doadors in late sypuilla and in biroath has lood opplented unicuic in the treatment aby taken op. LVL ·66 HANDPOOL OF VRIEPLAL DULCTION of typhilis. Mercury is now preu daring the Internals between cotime of Denk and blenuth. In this my toxic effects from the mercury and ture and yet adnatago an be taken of its undoubted thesapeatic vibro. Todos compounds Tho caly compound of ladino uted to treatment is the potundum malt. It med because of its power to aboard now fibrom Haus und in this way it la boped to relax uy embedded plrochactes so that thoy an be dealt with by the other spirochaetocidal mbytice administered. Potuntum lodido may cause del atarth and a postalar akin nish. There symptoms clar moon after stopptog trautment Tratmal of How of intola.co The appearance of any signs of latolerance to the beary metals all for immediato compartioa of trantment with theke compound In tho put only symptomatic traatmeat wu pondble Thos cases of faundico aro gire a high curbo hydato diet and the constamption of fats redocod. Ecollatiro denunaita bs treated with each ototment and pesto u the condition of the shto ut any particular thone demuddaIo addittoa sigars of Intoleranco are now treated with B.AL (British and towbalte) B.AL - 23 dimer apto propanol. It wu found ua result of planned research for the lookery of Sopply and we developed us in antidoto to the local and rotemic damage and by contamination of the kidn or eye with wentaal volant mon. In the pure nato it as colourles all readily salable la tat solvent und solable to the extent of dx per cent to water Ib efficacy us o arxealal antidote d Its power to restore the the damage and by tricoloals depend opoo its ability to form relatively stable ring componnda with errepoxdes. In this may the reaction of tho arrencab with the times a dimtokhod uod ita arimary ceretion from the synem is tocraod. BALL obtained to empoole containing scobic centimetra das per cent solation dissolved in inchil ol. The uponla in nitrogea ilued ·SICO MATT SYTAULIS 67 and have been seleed by heating for coo bour ut ipo C It bere by intramuscular tafection Tbo domage for a Darba dred doit Day I Foar mjection of 1. et 4 hourly intarvike Dants, 3 and a twice dally Therauto-cono given dally u long u required. A rheto temperaturo common after the first injection Other rachada wbich may occur And Paboa form, leg abderaou and boud Nandon Lod rorolting Lachrymation Perspintoa. In ordoletivo dermatitb, which to the moont foured of 11 the toric rouction to beavy metal, the resulta aro better than were obtabed with symptomatic treatment. Halling cally complete to a day. Good rorult baro who been obabod fi asendal cebulopathy If any tendency to relapso lo noted after the termosthod of treatment to fotbor infectious of B.A.L. 20 giro on the first day followed by ano bajection on the next day Schome of treatment of certy syphilis The patimt most be mrned of the danger of infecthing theo. Coltos la forbidden entirely for the first thirdo ootat. Following this it los perrolttod a condom & woc by the malo daco otrocaste an be excreted to thoa and the carval ons Abobol and constipation must bo avoided. The teeth odgora bould bo anted by a dentist and whatever tretinet scopury carded ont Specific trodmor 11 the patient an be borpituled a total d 7 mag uit pealdition in given la qucos solution to thite boardy dores o 0.125 mg alt for a total pedod o we days In umbulint aua i dally tafection des moeg volts 4ca) o penicillin in al-mi pypeodoa prea for 14 ·HANDBOOK OF VRIERLUL IMTECTIONS At the cod of this period the Wenemouth and Kebun raustloos are tatod and I couro urnenke und bemuth ghren. Ter Weekly In factions on umbenath metal pro gloco together with 045 mums at Doornphenamboo for the famle und ob gnome for the male. The Wa non reaction is now negatire and the Kabn probably so. A further courts of ten weedy Injections of bli math art then given by which time both kerological reactions in negativo It'not after a maths ret during which there mercury and potassium iodido are givea by moath, further Corums of antenic und btanuth comited Lodbermath me are given mtll tho krbloglal reactions and negative After this the patient may be regarded as provisionally cured but must be kept under observation for at laus two your The blood tested every three months for the fost your uod every dx months in the second year Tbo sploa! fald be tested at tho cod of treatment or arlier if the blood reactloos in resistant. If the frald is bormal further gummatione ad aneceny If ansons are reaktant to roch treatment they most bo admitted to bopital for intensive treatment. Penkeltillon 7 Doega units are given in boven days in three hourly dama and to dally injectloos o o o muaplanide. Antenlaul trade elects are nro. This course be the followed by tea weekly Injection of bramuth I the cerebrospinal Tald remaks poultivo the scheme of treatment girea for symptooth Deuro-sypluts to followed If it baccary that the period of treatment should be shortened to sections of Anal and tomath and be preo twice weekly The date of neo-robotmino A theo srdprced to 45 gms for smale and to o3 mm for female Treatment prgd over a longer period b moro cucions, however and only special cooulderations should wunnt the charteded form of treatment ·LANDT STELIS Charm LX LATEINT SYPHILIS The arty manifestation of syphilis ad petimited. ceuring, pantacouły u the mult of poodly mndenstood Immonologlal reaction. Thus the highly Infectiona lesions on the di cod mo.com membros matre and the dimana becanda wtent with no tyoptorns or rigos. The diamond as not been endanted notopey mumtortions of such patient havo roverlad treponemate to ridots themes moly the corta. chronic informatory procs com to follow the scuto secondary stage ansku stropy of the organs and severa Abrods. The group of latent syphilities cooperate the brgest group which ba cocottered ba paac er. They are only dagooned by the verological touctions which bald be repeated at last once before dagood's obtent wyphlia is made on this bass alone. A repetition of the blood tort muy show that there bu been sooo error In the cake or hboritory Treatment i ewential to from wall the oventral development of late malfestations of the deno. Untreated to -30 per cent of a develop och manifestations. Eres modeints treatment reduce the 10 1-5 per cent TESTANT Canto trout.cat oecenery at the gatet doos It has been computed that is per cent of dolcally latent syphum.- Dia barve sortic diaceto Tho raajority of these are cured by mlubna trentment but if Intensfre thenpy ha comunenced kotha tely than by the delati Tero Jurbich Herthelme reaction to pouble daath. (1) A course of io to fections of 0.3 pruns blurth vo pren und . arenl watch is maintained for any paccord al pub a dyppoa. It prosent a further count of beooth legtren before proceding further to it be (1) Perlato 7 me units, prea h divided dong.

·70
BANDOOOL OYOMTAL TECTOS
(3) 10 Teeldy Injection of noo-urberamino nod
bittnath
(4) Opo months
() 10 weekly Injection of bigmouth.
(6) 10 weekly infections of ineni and bisunath.
It la not necemury to achlove krolophaal roveraal to the
blood but tho cerebrospinal fuld most be notiaal. Il Dot,
further contra o wako und bemath aro Doccery until
thlon bachiloved. In resistant au malarla therapy to co
ployed amblood with Injections of Trypurpoldo

·LATL ITTHILD-TEATUIT FTAGI 75 CHAPTER X LATB SYPHILIS-TERTIARY STAGB Occa : to 10 years after infection. It durition la onlinftod uod recrudescence 410 commnoo. The main mintestation by the formation of gamata Shu A Ato pala swelling develop which hater softens, tapturou aod anker derdops the bas chancechte septigaons oattina. With treatment completo absorption A occur Hubarution bus not muperreood. Uca bal with a thin tsao paper or which a pathogarmonio. Nos como o Calves Shoakter bleda, Nono and face, Fico parface of joint Subcadawow does Robbery humps Love and enlargo op to to centimetros h dipeto Paralan. Necrosta occars to the centre and this pocrotic materhal discharge through a doos laavtoy deep nicer with a procbed ont appannce. The beso covered with toogti nub-leather blough and there foul doctrp Card mot be taken to discottate deose almatian which ocean in the lower part of the loand the Drott, was gommatou nicentiam nolly adtects the appe port of the lege A retou aker bo moro pantal Gregobr and the side urbond b brown and octconton, Town Chengo uro milos (1) Leucoplab tortcod metabone thickoned od ·72 FAXDDOOR OF YOYDEAL DICTION (1) Glowlith diffuso gumumatoos Infiltration develops resulting in a hard, burge tongue with deep fara Facle There may bo a diffuse latenuitlal myoeltes which affects tho flexor macia predomimntly Flextion of the jointi palpful and I untreated the cooction become one of per manent fledon of the joint A localisod gumm occurs in the Triceps, Rectus abdominis. Storpamustala, Biceps Gustrocnemil. The gummonta are palpablo es definito kumpu. They may break through tho ilin and form typical olen or they may rotrogram and calcify In addition the macho muy bo wollen und harder than normal Boras Clavidla Steam Riba Dost commonly affected Troda Fenar A localrod gumica forme. Necron's occurs to the centro and an ulcer may form Anabod arde tvory baso b palpablo underneath Gowing palos ut severe specially during the night when the wrath increases the local circolation. In the akull ada occan und perforation of the hard pabto common. Dilo artetis and periostita are more oftea manticata toos of congenital typhels. Subro tible for Dactylus Affoct the pbabogos of the fingers od the retauspab ·LATI STIILITEITIATT ETADE 73 by the feet Cano a fimm pablow diffono speling of the bone. The overlying & reddened to small degree. No puta. The condition ho i grat tendency to sportancos remotation laying permaneatly shortcod boce Oczdoaklly roquest form It is dietlagubbed from tuberculosti by the present of other manifestations of typbills Veroid pain in the back to patient with other booy kotloos of typhi sonld be the possibility of pol arla batang promot Tho cestial vertebe no mort commonly flected. Joh. Mart afections are manifestations of congenital syphilha. Curoak typovita b common. Charcot fotot complate Detro-syphilis uod be present to folets which aro mbject to tre and work. Tauns púy a great part in the methology In fummatoos thith the synovial membrano vory thickened uod the fotot bin miformly, mbargod. There's no pelo on movedent and no waiting of the Branchen Sorian gooimata aro frequently pulpablo on the horiem. Talon (1) Siepte mero Intermuration with non rcea on the back of the wodt nod in troot of the abil. No o estivo frammatkan prosent. Como dito ability too to the formation of adhealoon hudo tho sbarth. (2) Guamator. teco-sypovita (6) Dilfur thickening of the aboath. (6) Localised inregular qutumate. Gumton borstte occan u utodoleat, thrply do toed tour The pre-patelar burun uod the one or the tuber kchlou are the one wally affected. Escoca clad May be atlected by a disse garagatoos tateetitaal to fl- ·72 LADDOOK O YDILAL DICTIONS (2) Gloult's diffuse gummaton Infiltration develops toksalting to a band, large tonguo with deep from Nachos There may be diffusa interntithal myouts which lect the flower moncle prodominantly Fledon of the fotot pulnful upd if untreated the condition become one of per manent fladon of the folnt A localked gumm occurs to the Triceps, Rectus abdominis, Startomagold Biops Gastrocnemil. Tho gummata aro palpablo u definite Inmp. Tboy way break through the skin and forta typical olan or they may rotrogram and caldity In addition the mosche may be Iwollen und barder than parmal. Bonas Charlelo Sternum Ribs most commonly affected. Tlbla Four A localised gamma forma Necrot occurs in the centre und an uker my form. A rated circle of frory bono palpablo moderaath. Gmwing palo ure severe especially during the night wen the warmth increases the locul arculatha La tho skull ada occun and paforation of the bord palate to common Didate ostetha uod periostitk uro bore often manifesto Hops of congenita) syphilis. Sabro ubla" fortes Declytitis. Affects the phalanges of the finger and the motraspob ·73 LATI IPEDISIITATT STAGE May pour poutaneously or only on exertion Com minly food by sogla pectors Pulation volblo ha optatampal dotch. Syntolke sortie monour with cond pupd accentuated. Volcu bacodbonne Trzchod tog procent. Wub aortic facom potesco cardiac uthor is commco Gamal congatlan a cedera bare X-Try la tortit tho Lett rentrico is moderately charged. Aortic Hadow rucally largo, especially an dght whicken La bo competence the left ventede smarted to the left with berenand convexity of the lett border of tho bart mod coated pulation Dijoutiel zurrosis Carduc duo occurrtag to mides fife with no ato tedert history of the fore or thyrotoadcorba k strongly rapportive of syphilo So abo s the occurrenco olangina pectode betart the road 40 Tbs dlagos bar toptirined by Audiny pidence of syphill in other purta of the body and a pauttivo moraloplal result. In the lato are the Wannpann reaction may be pregatiro and the daprodathoo roached on chalal ground alooo. Prognosis Usta roonabto. It mmtreated the condition progrener. The proports is worse to the presence of Aortic Encouapetech, Iurorement of the coronary uteria, Anglma poctock, Secubur maria. Seartlar asaru Hay wild woodtog trustees or decoding part of auch a tho Lotta, hoeury of the coodlac od la betryd physical to whereus Deuty at the other parts o co mably of optool ·76 LANDBOOK OF VOLDAL INTECTION According arck Tho symptoms of sortits uro present together with a fcoling of engorgernet of the freo uod neck, ospecially on stooping Signu Cardbac Fuco congested Enlarged roles on chest. Pobo deficient on ano oda. Pubation or paletto sveltog present in right second or third intercostal space. Synote thrill palpablo. Dullocus on percendon on dght odo of Hanum. Second aortic sound accentrated Syntolkc murmur over palatllo ara. Pulmonary Proware oo tight parterial bronchus producer Dulness and weak air entry over right apper pune. Dyspace Stridor Hinh anh. Abdaction penalyus of right recorret haryagaul dent. TERUTH and demang ock Symptoms are producod u repult of proward by the La curyan on purrounding structura. Dyspooen. Coast and futum Dysphagla. Pain ander sterana between Kapule. Tudod chcet. doro un Swelling of fact, Deck and left m. Palos In lo Later paralyst ·The pensateuco of poulting What ad potatin odide, at 10-70 by booth. Thisha Tratment to started with 4 weety bec obtenath too followed by a course at penldilta tota la s mogu unfts diren over a polod of 7 day. Gammela od alcen If there bado kumpleat of Hret foethon and (1) 10 weetly injection on tod both LATE BYTHILLTECTIARY STAGE Any of the signat meatised abore may bo prenant together with Dilatation of het papel Hiccough or paralyo alat bemaphragm. Boatyardia Tho dagoon's so confined by the demonstration of a puhuttu selling on the Xay men od the propose of other signala a typhilik. A mallestinal tomoor k ruled out by the bence at acheada. Proprii A slow Increase in de occun. Comicdion.. (1) Raptors of aneuryo into plounal alty media town acoplagos (2) Propre effects Intructable pato. Purplaten TRILATVET In late syphilis Internative treatment is not required Endla too tho denso a not almay pouble and the to health the best gulo to treatment rather than mam rmation has the beastsin the cliente per protes. course of treatment. The atm of treatment (1) Haal lelah (2) Render patient non-infectious (3) Prevent development of further ledare beul naktly onder this restre albumiporis or bematuria pre ·78 HADDOOT OYUCIAL DICTIONS (a) to weekly tofortkms of blurmuth, 3) Weroury and potundum focida by mouth for 4 weeks Tho above three coming in the repeated utl the Wamet dunn nactlog bus ather become pegatiro of reached Ho lomreat quantitative vale. After two yan treatment all usenic od bisemoth b stopped respectiva a to Wurmenn ruction Therefter small doses of mercury and potentiam hodido aro gtven by mouth during altermato mooibo for the Dort 4 you. In this way the sederal balth maintained at its murmum levd. In the presence of liver officiency bodides kod biopath are given for 3 months. A conno of penicillin e then gren and followed by toodenuto doma, o 30-45 gam, al doo Arrpbetamido. With regal discaso acetylemn, 30. nood la pbaan of neo-upbeaamtoo Circulatory rypha Spedic treatment of droulatory syphill an only pre vent catension of the lelons. It annot restore the dama which has already been dono und the bealing proceftorell may be dangerous enco fibrosis of chronically in tamed Lorik vulrus muy make them moro incompetent than crer In addition jártsb-Horzheimer traction con au code plete occasion of the orifices of the coronary uterlar The reuults of treatment ura therefore limited. The curliet treat met of circulatory syphilia an be instituted the better doce, Opco sovere symptoms have developed, the mort pottet Temedios cannot be med. Good trustnet Rost. Gaduted cocercises Adjustment of the patients way of lule to the louat al arilac danao. Digtalls and manly for congestire fallort. Glyceryl trinitrate for engleza pector ·79 UTI SYPHILI-TIITIAIT ATAOL Specific instant Uted after the gromnl magre baro yulded thetr martum bcocfit. (1) Putautum lodde mots romig tdl u ghren by mooth for 3 months (1) Bistruth a prima injected really for 4 reels tallowed by ai gauns veekly for 8 week. Fotbowlug the preparatory counc, mental are grea pro Yuld metus pector's dy pooeks or cougartin taitara, brathontou com mild certion, ang buat and the patient a moder 50 yeandi Acetylarna med starting with i dom of I coblo centi bet and the dove la tben padoally tacreased to y cable contactos und 10 bonfection oven to all Axcood Cour lo tajections of boronth in the rama with potentum lado by mooth followed by a further State of months. For the rest of the patient's life e core of month followed by come counted acetylamn la stres cache year Where thero uro contrato fications to treatment with ansenicab rodenco is placed upou buvuth By och methods which must be uningod to each lodh Whats requirement, the syphitic procent aan bo urtarted a retarded Untrated to contion of life with circulatory polls in lood gradWith treatment this is prolonged on one to opphis are treated on the same lives, Penen symptom rogoro tymptomatic treatment and porna natuto an Koetina bo treated surplaally pid or udallgation Docally beteg employed. Attempts to abitant morbic magna in nrely made the deta ·80 RANDDOOK OF VOORAL INFECTION CHATTE Y SYPHILIS OF THE NERVOUS SYSTEM Tbo DIYODA system is infected In 80 per cent dans la the secondary stage of the infection Headache irritability ud motal fatiguit may be prescat u oodence of this infection and the cerebrospinal tuld cahibit a poultive Wurun test an increased number of lymphocyta and ndod ubuman levd. Sateethma the Wascom reaction polive In tbo cerebrooptual tuld before # poultive in the blood. In tho majority of cards the infection of the Dervous system dios oot either spontaneously a a cralt of treatment. In other cases the infection pents and eventually give rise to symptoms and ages. Thes 15 per cent of care develop meningovascolar rypbil ş pa cent tabes dorms and 3 per cent general paras Al treated The cerebrospinal fuld must always be empted to overy Case of tasty syphilis. This to assally dorso daring the 1 youn surveillanco after a courro o tratment bu beta com pleted. If the fald k pot pormal in respect of the Weer maon rouction cells or albumen content treatment must be glven tuntil the tald to normal. 11 tbe told I found to be normal no further camination is necessary slace to fald Dever becomes pathologlal later la ad of Satent syphills this crimination of the cerebroplaal And B especially ta portant In case of neurosyphills tho Wawermana reaction the blood is almost any positive and the fuld any sbow changes from portality in actire ano. A pomal fold means that the infection has died oot Lango 1 col boldal gold test gtre usetal talotration whien the depos la between taba dorals and general pareste bat to add the test doo vilac tos diderentatic Droro wyphilis from other dia of the nervous syster Lange test depends upon the predpitation of sold out da colada solution of the metal by pathological cretino sploal Buld. The text is performed by piscing scabóc conti betres of the colloichal Bold solation baserta of test tabes ·FYTHILD OF THE ORTOUS MIT 81 and adding to ach cubic coattractro of progresstrey, bo and dilation of the cerebrogtoal indd 1/LO DO Flp otceton. The ropulta uro rad u boun later Tbe latenty of the rouette deteabed by the degree of chance to colour in the molation to ach tribo. Thus the patral colour b red and to order of Intensity the change (1) Rat (1) Bluhh red. (3) Reddish ratet. (Blou. ) Completo docolortation. Tren molts are reported by giving the number of the rtectia occutoy to ach toba. La menina porzicular typhills and mandag to the change occurs to the higher ditutions and the resolt renda voor344300 Ingol purse the greatest reaction occm mi the low dinations 35554433**. In tabos the changes occur in the middle In the central nervous to the seatbal lado do pot dutter from those foood h other parts of the body pertracolar collection of lymphocytos uod plasma cella develops Thiba ba aften followed by lovislona tho remed wal with the development of endurteritis obliteam which may cause vocular thrombod Such thrombonis may amo un infarct and softening of the part of the brain Dected The symptoms and gos of house in the detto pyutem may bo predors loantly Deanpaul muscular or parece contou although the loos u Dot Himited to fost 000 althou structural Tbe mods of orld of the puro chymatou belons not enactly know. Frogoently strocactos andot bo found to their neighbourhood and the Inflammatory bloos in often pot watcheat to account for the widespread and progreato da For descripttro puspores the ladoos ue dilded into (1) Jiento conscubr kudonde (+) Preachymatos lesboot-tabe dort ftmalparais of the bar tibes 0004 31100 LYL ·82 HANDBOOK OF DITAL DICTION Suche spuntoa is not an absolute no doce vankar ed meaingeal lesions are present to come attenti alcune Thru the change found in the cerebrospinal indd to ma of parenchymal deciso uro duo to legloos in the menges The parenchymatous lesions appear later than the latenet thal mo bat thero a otly a blatory of eartler nervoo sytoptoms which responded quickly to traatment. The sytoptoos are dae to beal meningitis. The internal meg gate that there has been slow proces going on which colmimta la destpentivo ladions the nervous synco There is some evidence for a corotrophic strain of sptrochaota and married partner of tabetic patients are trico u probo to develop Deurosyphile us other groaps of typu tbc anal Tbo ady lektons to those developing pedro syphilis are often les revero than to other area and Dentrovphill definitely less freguent in those who bere korero healoos to the secondary and tertiary sagor. Tabebas and puretle aro Dot accedly tree from other manllatation of syphilla borover ind i areal mamination post be made to exclude the presence of Rotith or gummuti. In beurosyphills the span of life med to be only 1-11 yean. This period is now greatly attended. Complete rembedio occur in za 40 per cent and improvement to 60_-70 per cent. ASYUPTOMATIC NEUROSYPHILIS In about 15 per cent of other who latent cases of typillo the cerebrospinal fluid abom pathological change the findings omphusboo the toportance of routine cabrospinal flold nominations in all lateat asam The ases are divided into thrco groape depending upon the Lovelty of the changes. Typo 1bor minimal boormalities The cell couat und proteazno alightly becaused. The Westimado reaction b negative Type m-or maximal charge Cole kod proteto Greatly focreased. Veremon's test postire Lange coloidal gold test gtige paretk response ·63 TTLE OF THE IT TO TYSTO Type I-scarles all can not to ring into the toro types Lord TraT Athropa peale te does not pesante into the centra sphal te hos decoradable quantities a dina iet bo Dualtat on Intrumoalar basection. Injection durnothy bato the cerebral stuld bin tous und wool be anunciloyal stance chroole penteim scephalapathy bas lol ped the PLETE. (1) Perletto, a man volt, s given spread ort 14 days (3) Tea veekly fahertons Trypausamick, 3 games, combined with blurgth, 0.1 poin Opal potendo hide and percory for one or more ) Repeat course of peocha. Type I come alrerat to Dotably latomtog the scheme af frantsent. Futy per cent of Type II ako beror Normal la Type I che iad those of Type Il web abportal Bodhip um present art (1) Teen Woly bajections of biomoth 0.2 (3) Tea weekly injection of Tryparamida, 3 man, tot buth, 0.. pam. ) Oral potentum folido aod percury for at month, There course we sopeutud mul treatment has been pre format period de your By the time this Bold bas brocante Borza hboog 40 per cent of cars with Type it changer will still bara i postire Weate radio Il ter a yan treatment, the cell and protela content at the cerebcortal duld here not retsed to sawal of Lupi cobordar gold text prea peretic respose mer therapy in stress us tos and pares. The followed by como una und Banath ta the told a bucal for 1 tespecto essent les regard to Warentest NENINGO-VASCULAR SYPHILIS. The leziomy of Beingo-nixcobar rypbiller bare ea susly Court and rysoptorsus appear within i ytan d action.

·SANDBOOK or vrtul IMECTIONS TUTUIKT Two courses of pealalin ans srally grea since the train movement in the cells and proteins in the cerebroonestu! tind welche berita in a few dant continues la modlit. Increuloy tho dantka of treatment od the dito at the dow abro fraprove the result. As symptoms are dire mainly to rescutar thrombouts arly fatosstve treatacot must be avaited. Erest antydet reaction to the diseased retseb mayland toe grat toch in the area of Dersoas teste Afected or may canche perma Doot destruction of nervo coll. Schemes of Ireatment (1) Oral potasium folide grattu 100 with the Hydraty Perchlor mais 30 l.de fer coe moet (+) Tea weekly injections of barranth 0.1 g ) Penicillin, 7 weg units, given over 4 days (4) To Meekly loyertions of Trypananiko 3 gratis combined with biarach, Q.I Simo () Ona pobudam fodide and secury lor ce month (6) Kopeat counts of penimbo. () Teo weekly injections of bugth o in (8) Tea weekly injections of Trypusmakse 3 grau, wedd breath, Osmus. (9) Oral potassium iodide and mercury for one mouth Courses 7 & Lad 9 are repeated until treatment bas been stven for a period od 2 you Panalytic symptoms and signa clear rapidly but panlaged treatment and about too are regated beyond this time. The cerebrapinat hold plante examined trery 3 mootba od bready amar because Dorma in cell coin tod chemical testa The Bleekermans ronction brearea Degatire la paly a minority do after 3 years frentment the cerebrarptaal dards of oral In a rerpect escept the permas raction, fever therapy is given lachowed by further courses of ook and biomas antư this real has been selerede Sometimes, ka pite of treatment the cereberentaal Dhaka ·87 STAHILI O TRE TOUS SYSTEY dovelope paretic guld coi Lo soch aura fover thenpy b teatbals for real perada. PARENCHYILATOUS LESIONS. Tabes Dots Five per cent of Introatod are di syphills develop taber. The longer the focabattoa porded the wilder tho dhean Infoction of males parecanimate ora formala in the natio 10 to 1 Tbo lalom uro bo to a fibroblastfc Inoltation of the portatlar nervo roots where they enter the spinal cord with mocondury degeneration of the nervo abro originatag to the celor of the portador root rungta Tho postolo cotone... become grey and tramluceat doo to the acerolas und the planchnold become thickened over the canal portion d to cord The degeneration to the cord commence first in the Lambur region in the churon a Gall Let's tract and other collateral to the cond may also be affected and degerente condarly In the arthropathtes there byparplanet of the cartilage followed by destrictions and osteophythe outgrowths. The typortal duld to increased. Tauma playa part to the prodoction of the condition. Thresta en oftea described in tabor (1) Iceptent or proaturk, (a) Ataxi, (3) Patalytic, but this divisioa b un artificial ooe. Symptome and pas a baro bero present for you witboat arba beng preprat end there ax canoot by any meam be aded curly ase. Any of the undermentiooed symptoms ud don may bo present are bot asually the ca potating to bateria race with the fuoctions of the posterler Derne mood appear fixt. The onset ba wally gradual aod lookous bat to a few and it is rapid and marked about present ata in anunt commento three months arlor Setary yapters appeur first ·HADIOOF OF YZMAL DICTIONS Lighting paio One of the commonet symptoms altas mistaken for rheumatom Tho paime ato sharp and of short ducation and careful Inqahy cits that the pains tan acrom the Imba and pot lloat their length us on the matte Tho lep uro affected more often than the uno and the pain do pot affect the pointa. The pair crantonlly couro Low completo destruction of the posterber roote Parvathada Nambach und tragling occur A vention of Walking on cotton wool very commcu. Ocular rymptoms Ually the first to appaur Dimna of violon opens and programa to totul bibodnom to 3 to 4 yeun. Diplopte is ofta trabalt and b duo to panty's of the atra-ocular muscles Rarely total ophthalmoplegla remults. Ptadas may bo unbatenl or bilateral Dificulty 1x multing Due to love of afferent impulsea from the muscle, tendoor and folats und coomences to the lower thembu Tho progrew to low aod nilablo. Thus it may stop at thos of allgbt inco-ordination or adranco to no ator pit and finally to a paralytic stage w that there is a bitty to dream or fad Tbo mme laterruption of flereat bompulsos a responublo for dificulty la malking in the dark and brability to work the face without boocking the band against the mashtap. Spklaclors Often affected. Thero & delay und dilicalty la balctart thon dae to the low of enory impubes o that farther dit tendon of the bladder pocohery before the dedre to mbeturato beoooo lent. Later there be danger of retention developing with consequent cywie. Constipation is coonon [opoteoce 6 al. Trophe Latlonu. (1) A perlanting sker under the great too in tbe sport constant The aker may penetrate to the bove ·89 MTHILIS OF THE MOTYOD STOTIN (1) Charcot s fonts. There ar putulos, nopid saling of the font, only the knee. Only, 200 folat 5 afected. A fel folat eventually develope Britta af the bones. Cras Combat of protys of polo ta wurdons orpim Chantastic of the aurty tags (1) Getric Severo optaastric paulo Repeated romlthy Pillor rating Recovery rapid. (1) Laryngeal Dyqpoor and naby rupination develop Way be fatal Cardac Attack d anglou pectoch. w Rardy lotesthal, realcal and neal aber develop Earty opus Aboormal yapis Contraction to light light or shogy tets or poorly urbainod. Inequality or regalartty od outllor, Los of palo senatoo over Now Bocy troca second rib to aabutica, Ulnar borders of farem Calya Low of ankle forte Later on. Loud of drop para sensibility Promare on baces and tendo Achilo malolan Inpatroont of meado Pradest annot tell to what position limb bas be placed Lou o boalbatin antion Romberg Inigo Duty Blaster with teet torebes latered you are doud.

·FUTSOOF OF YDERIAL DICTIMS Alark galt Foot naked higher than normal, tornano add slapped domo na to the ground, 10.co-ordioethan of Doramenti Koe jerba bort. Lod of bone viza tipa Kec External ocular paldies Hypotaola and parah Charcot faints. Blood Yamoriam reaction poulting to yo pero mrly ches Cerebrortal finid W.R. + la go per cent o catch Luetik gold crve. Call 80 + per cubic mawimetro. Globulin + Dwuoms. Aroy Robertog, poput together with ano pamp diagnostic espreally the presence of disturbances atlon Diderotiato Popkorni The bilgtu sepang pult a different and b doo to the leg bicho tot be too may daur the proced. not stick Llobtalog pulse od tre dyos at aber Drosemitalud clarotur Inco-ordinatioo und spustic paniye Docter bort pain and ye shads aro abycot. 1 out abdomen la the recent arises there be po splety and then are of byparatoria present Cerebellar dette Ao ughtning pala of knory disturbances. Ka pricht Hachche vomiting tod paptordera prokot.

·+ ILU TELE XESTOUS SYSTEM 91 Coo Vay ndable. The condition may become stationary at y de Recovery move on but there mury bo boprovenient. In the panlytic tego dnth occia from preko Depbuiths, tuberculosa s pramonla TWATOT Gard wins (1) A babetic should never be confered to bed above this ung mos un hicreare in the rade It coafute ment to bed is decernery fat edy, Toumaan Cercle and roeducation d marco lod faint and to nential. (z) Focakei orecision are given under the supervision of a plytotherapist for the atada. w Shoce blader omtion taspatred to patient wort be told to empty big bladder rogolasty every 4 boud during the day and before rettitag at night (1) Aspiring and other malgrados are necesary for the Wputebag pabos which may bo beroased at the besta ning of specific treatment. The administration of bolelo may about an attack. Good reelta havo been abbred from Infiltrating the area of ska Miected with proctoatde. Frequently morphine k required. pptic atrophy sa programdyo ba so per cost of cruce la spite treatment where this present tho optic leto moet bo motored socantely and trypamido very cautiously doce the comported thall teada cause optic atrophy A casa d occopetico may be necessary because of atura a optic atrophy (1) Orthopedic mere ae necemary for Caeroot points iad pathological fractural Spreife fred med (t) Onal bodies and mercury for so mootb. ) Bientath 0.3 runs for ouo mooth.

·32 HANDOOOX o VAL IKTE TIIN (3) Perimin. 7 megt unite pirea opt o partod a 14 days Ons hoddas end mercury for one month Four voelty Infection of break, 0.8 grumu. (0) Repeat coarse of penicilin. (7) Weeldy Lojections of Trypunnide commanding with Inn per week for foar lojections. The real batch are charted each week end # there any dimmbarathog in the fields treatment with tryparamside by stopped and acetybırma aked in to plach If there b no optic atrophy typeramide to 3.5mm dove the shira weby unti 30 grams have been givet (8) Oxal todides and mercury for one month. (9) Te weekly tajections of both, o : on (10) Tort weekly Injections at trypurenkte combined with broth The cerebroeptrad fold i entorderary 6 moolba and treatment to continued with coarna & And 10 u kome a to provenant occardog us for mianom period al Ocaudomedy establosbed ama of abos are more la stra the corebrospinal full be completely sonnal. La macho con the dirouk keems to be burnt out math alone are stress not to nie the petrocyphus, bet to prevent tbo appanace of any other typhone mande tatic. GENERAL PARESIS. Occurs to 3 per cent of syphillitice lately on. Oaren between the age of 35 and 45. deneatha. Pathology Toote o programare degeratica dl the arrebral carte so that be convolution beste rested. especially on the frontal and middle oben The sad become word. The The atrophy ulete the bite master peedan muy yeatnca are dilated as the lo correased. The best Two couns al ho Ashow faces.com ·93 STELN OF THE VOUS SEM Pandyma i gruplar especially over the floor d the fourth Yeotide. The puhuchodd i thickened and opeque. It Baderent to the underlying cortes und renovat blog put of the Andelytoy coctox with tt. The dans Hickened potatur ad heront to the boer table of the hl. In addition there may be desperation of the part tabor colmana of the photo cord nod the pyramidal tracta condary to the changes to the cortez The demnentlass divided into stop (1) Prodroms condition. Wala manfestations At this tapo most complaints come from the relativa al the offerer There is a Hitle change to personality The putient becoma bittable and indulges boutbuot of tomper Alloctions may change ood. fitoarft durchter bo tregueatly abused, there is a slow change in intelectorul bocnltia end moal outlook Buster vln ato neglected od koballo and were a coramco. The manory poor Fatige conotoo after mlalmal phylocal or mental exertion. Amen preriously proud of his pour anca becarpa ardon und his clotha uroullowed to bicono getred and crampled and stabbed Itb food and datok There ar bitter complaints of over herdache, terocablog migraine. Physical mellatations Stardoy peech. Trector of tongue und Ipo. Slowen of speech We of polbabla of words Pupuaequel Angl-Robarte rodromoa Ptoch Temporary diplopte Optic atropery Abacat deep redere.

·94 HANDBOOK O VEIAL DECTIS (a) Fuly alabashed disorder laza A condition of encroachios web pcbolis is the cotton The patient & listean, tits aboat and repetate. He abom no concern about weals or personal appenzact. Habla degenerate La frequently there develop an alted stato with gradioes delusions. The patient is continually planning and scheming Becoma widly atraragant. Bounts of permonal atta botoents aod ponceudons. Restlessen and Kleeplommen an marked. Physical Fuco famoble Tremors marked Speech change at find there is difficulty in comumendog with some trembling of the lips. Later the speech become bluered and thero & dificulty in proportadas linguas dod dentals. Writing-difcult beat of the treroor and thero la tendency to leave out cmental syllables and words. This time very chancteristic Pupilo frregular onequal or poprich. Seacres aro common in Filothing At or temporary hom of conscooters (tApoplectic (II) Epileptiform one knother wo nipsely that status op Depticos occon. The store ud frequently followed by tandent mono plesta o bemiplegte Galt tmsteady-Discolty In dimblog stain. Teodocy to trip OTET Halt mastic or occasionaly tabetic. (3) Tamind stage Stage of complete desnentla. Paient belpless and bed riddeBladder and rectal syuaptoras develop Fat, Hay percceed ·SYTRILIS OF THE VOUS AT 95 fatoom and filthy Death occurs from abastion or Intercutent infotha Blood. Woman reaction podtiro in 100 per cent of an. Cerebrospinal tolia. Wabermann reaction poultinh Calokdal gold curve 355555443371. Protein tochased. Calle, 10000 per cobke mlinetre Differentual deponis The diagnose in the arty stages is very dificult. Tho kymptoms tremblo thons of other mental disorders. A Woerman reaction should may be done and the cerebromptoal fold onmined to such cuxo o mehal di ardar Brda tawon Il to the trvatal lobo dmulton general pared in nare ar Symptoms of creared intracranial prekoro ed present and the typhilitic ractions and Degative. Dugeminded sclerosis Canfion is because of tho saltod mental stato which to present ha estabilabod cure. The symptoms and upp uro Dially chance to add syphilitic reactions pegatirt Howrotia Idiocy Chincteristic upandco. Prognoosi Death within 5 yan a beginning of tannial page if mtrented with trattoeat there b a rotorblo CHADCO of becoming well TEADUOT Tbo shorter the duntion of die the better the repando to treatment irrespectira od the wredty at the symptom Gruodioso patients orally show Do Improvement ·96 ILANDBOOK OF YENLETAL IMICTIONS the melancholics. In jarenllo genem para's the response to treatment is bad bat further deterioration of intelligena an bo prevented Treatment is started with ten weekly bajatloos o bis, math o 1 game. This be then followed by a course of pealentin 7 mera mits, stren over a period of fourteen dar Tabs roula de staking improvement to tho patients general condition und by its the first more patients are able to have fever therapy than w powdbio before the Introduction. If the genel condition la atit, poor fever therapy is beld ta abeyance and so weekly Lajections of Trypanamkdo we given. Coone ol Tryparumido god bianuth are then hadated until the general coodition has improved Fever therapy would be given whenever poneblo doce this form of treatment atves the best results. Two methoch of treatment at enllabio mlarla boctilation und dectro- Pyret Electroppede a nler than malaria loocolation and is more convenient kloco tho pyretha an be induced at any hour of ny day Tho cact degree of pyrexia and its donation are endly regulated and malaria Localation sometimes fails. Contra Indiations to fever therapy art Advanced agt. Marked malnutrition Active palmary taberculant Aortic aneury. Uncompensated ardiac doute Diabetes mellitos. For moabria therapy i mupply of blood mlected with belga tertan Palara b obtained from the Mktry of Health Room 44 Wattehan SW 1 The blood, defibrimated or dinted come to a serlo tubo packed lo! thermos flauk containing ice and poculation must be anked out within 4 bour of the specimen belog collected Two to s cubic centimetres of the blood may be to fected into vedonly or subcutaneously The locabation period 1 to 3 wees. After the int rise of temperatare brood en are taken und esamloed for the malarla yanaute Wbro ·SYPHILIS OF THE MOYONI TE 97 the tempeature begło to rok recorded may ball-boer mul it'l Dormal yan. The temperaturo ballood to de to log Find, 'I the cardiac conditoo bathtactory I dont une allowed. Abordut Rippla af fraid od sto.come tre given throaghout the cound of the fover 200 I watch kept on the blood pressure. A apidly falling blood premature ba mening dardac colapa coreoplay Lod the fever most be trainated. The rigor b terminatod by pooping and bot drinbs and the mark b terminand with quente, grubs ude for to den. For dectropyrexha the boductotherra or Kettering hyper therm wed. In the Inductotham a high frequency Curtea pared through a cod k mod and the patient hem to bo phuced to a spochal abinet. In the Kottering hyper therm the patient i temperature brassed by the teapon tours and humidity of the ar to the cabinet Tho paskent temperature is taken overy 30 mlimator Ode Hitro al mine b ghres intravenously balors and during the fever oncloa. Fire how lov trestmest gra with a marmo tem peatures of 104-105 F matatatoed for st boas opo a week for us weeks. Tbo fover poetoa in locomtional H Tbo temperature sbor above Too F Fal in blood proport. Collapec Vinde cumpe Corebral or pulmonary cedera. Hental changes occur in one south. The patient boatract more alert eod In tooch with reality Habita improve Led be an po boro after two months and retom to rock I three months. Following tever thorpy the scheme of treatment (1) Te weekly bajection of Trypanmida, 3 grams, with buta, 3 TRIA (a) Te weekly lajections of bemuth o 1 gram ) Oral fodides and mercury for one month. Two och coana are oven ach your for three you. If later then py anot be stren reboco placed on Acha coona Jone LY - ·HANDBOOK OF VROLLAL DOECTIONS CHAPTER YU SYPHILIS AND PREGNANCY The great danger of ryphilts during pregnancy to the production of u infunt with the stigraata of congenital typhila Although soch Instances are nro they are all preventable. If a blood Wanemann text is performed an every pregnant woman ut ber first intepatul cammatho Hufficient traatment on be given belor delivery to provest any doans in the foetus Infection of the foctos oceans by transplacental parage of tho awative prochaeto via the lymphatta of the cord of by La embalo da prochantes arried by the velm of the cord. Infection seldara ocorn eurlier than the fifth month of pregnancy Pregnancy bas an ameliorating effect on material wyphob and Antal puanifestations of the disaar ure only abount Serologlaal reactions are therefore the only way of detecting then came in practbe. If the Wumenmann reuctions positivo in two tests during pregnancy treatment of the mother is imperative to prevent die in the child fection by tho father by means of Infected women without infection of tho motber does not occur 11 the mother scguires syphilis lato in pregnancy the chud may encape intra-uterine infection but develop typial propery sore after birth. Congenital syphilis manifesto imeli fa the majority d chOdren within the first three months of life. Occidonally the manifestations are delayed until the age of 1 ano nrdy unti puberty Syphill's may produce the following manifestations doring pregancy (1) Abortion (1) libcarriage Preraatart birth () An intot born with stype (Florld typhII.) c) Infant bora healthy and wgts appear bater (6) Syphills tarda Congenital syphilis din fross the squired deset that there is no primary race and the secondary sod ·SYTAIL AUD CAWAY 99 Flavor us tertiary waga we all med op together. Is coprogosce the modestations und best dalt with ta tha different strac te of the body The following lesions may bo prescat o develop 1 MAUSXO. There may be no sgos typhill's present and yet tho sportion of Pīl. Hydrary commorete la followed by su peling plonin meghat. In other obvious Nos of sypbits to present as well as maing L Scox Lako Aro pot cornmoa fost at hirth bat appear around tho san al 6 reeks to Incotha. Lecho papular raak The the commodat ikla leckan. Tbe pecnla ure modt COMEDCO on the Houth and chlo Neck. of Lo Napkin arta In the depla ara and other parts was there ba kitation the matnler often coalesce and male prototy (1) Erythomalows rask Asteca tha mapka ra and purrounding puts Dieren thated from botertdipo by the brotvement of the depths of the Ho folder (6) Recidas. At marytos wbore skin and mocoos membranes moet metres develop and love kao bich date out from the ariton (hy) Bellow rok, Affects specially the palms and roles. (v) Condylomata Appeur arouod s yeen of 4. Aro seo around the um id totutum und to the cards bero the skin ba Dokta (1) Incinto lesions Thlaba deeper loddon tumally scanapeerbot thompa Sdu don Thanthi tento o the in which may L7 ·100 BARDBOOK OF VITAL WIT become tinkled and me a cald40-bait tint. The palmu of the band and soles of the foet becomo purplo add pony Later peeling occan Thia tofiltrativo change b raponibile for the old man" appearance of an inlant with come genital syphib. (vih Har The eyebrows art kost end the has over the back and sides of the bad abo last. lo sob axon the border la more abundant and long and first resemblidag for That farms tho wo-called syphilitic wig bot bo present apart from congenital syphilk. (vi) Note There become opaque and irregular They may be sled and the det mul bormal in apponanco. (3) LESBOX Or Wucous MEKIRAKTS Are benety always present to some degree, especially for the bose (1) Now A chrokc nani atanh developing giring photo characterbaik annte The amount o discharge barubk but contains the Treponema pallidom and is highly code tagion. In charoak mual obatraction with talammation over the turbinates and anal septum the resulting andre premure to the Dome produces inking of the saml astha with the formation a sadole bote (a Lerynx The Inflammation may be rimaple atarrhal or erted to extendre aketation It ghres rbc to a chance teristic boarx cry and to no merece candy muy prodoce doation in later we gommatom skedios y pro doce respintory obstruction and pridor + Boxy Lastovo Appeas set 6 to 11 month Sight bytipoepbaly and lipping on the footzdelis, (6) Cripto-tabes Softening Serie is part of the skall, apokaly behted the mastokt proce ·MALIS 10 UKCY IDI ) Putrot's poden Bondag develops over the frontal od puchatel bron (Iv) Enlarged ratos prevent over the ralp rele () The palate may be perforated to childhood or later Insult Hito. Long bones (O Etyektis. Ad fection of the front low months of lis eppautas before the meal for survy from which condition # mot be dulcreatlated Tbeobs Early be of movement Acute tendernon co Prodaco parado paralyla. moreet. Sypumetrial ledana. Upper limb tavolrod more often than the lower Hob The boor bs meally thickened at the oppbynal bom. Dianto separation of the spiphyts may occur tollowed by recoocary infection of the Kaitot. (0) Dactylatos Octan about the recond year of lio. The protocol pbulance of two or more diets in favored and fingu uro elected more often than too. The twelling totform und motrated, brombs down and the barges. (W) Perloctitis Appen wround the sixth year old Hic Tho tible ba tho bone woully lected. Loos form Abro tiba regatta with the boo thickened from before buchmards und chryod with the coarexity booldag lovarde The subcuted.com border love to sharp edge to the other form the tibia becora coothapod with the speca the coas at the lower (tv) Ostromy The patient completos chlag pain in the loop boone which enlarge and an teader to prepar. The booo b comooth and oppuation murety sceim. The conditiva bu b be duerotated troma cartocal Loquilled tritta ocean in the dardha, tenom ud ahe uod produces a ballied by ·10 FAXDDOOX OF YDERIAL LYICT100 (v) Jalats Three type of disease occur (a) Suppunttro arthritis resulting from epiphylik od mpantion at the opports. (5) Arvood the use of ten yen. Daten durcok synouttes occur with ustoa (tattoo Jatob) There kumaltlou ook with bttle palo so that moverseat of the folat k not limited (c) Octeoarthritit with outcopbytke formation appear Around tho age of 18 year Thero k limitation of Dorement and the artilago may be coded and the underlying boot abo attacked. (v!) Porn.net teru Only the permancot teeth are attected. The lacheory art Dotched and the pro-rolan are domeshapod. 5 VACORAL LESIO (1) LN Become enlarged ather from diffuse tolandital hepatitis or trom defroſte gacompaa Jaundico and excites may dovedop 2 Salcos Becomo palpable Defalto gommata are tast. (an Kids Parenchymatot nephritis or haterstitial Abrons may develop Haruryuual hemoglobinurle to commonly syphil Etic la origio (tu) Orchitis baly creslooked since it is partne. The colors poent may be dildose or darbed late u Hra o relax tom tollicicat treatment Syphol k pctically the only awe of enlargement of the testa ooda the art of 6 moaths. (V) Paulo-koukamu inform Although the white blood cells are beroerd bo strober Do Immatore cells are loand la bocan.

·STTAL AND PIECUNCT 103 6. Lars Of The Norroos SDL ( Instruital Last Appas between 7 and 9 youd of yo. The compan became opaque in patches the opesty pradlag from the margta to the ceatri The tatarumation may prad to the otho or The coppa become volarbod ind RIDO 1 paket bu. Wenkenbrug of the corna pray follow with balgfag forned from the poor beide the globe Treat Dent porer produce 1 completely clear como (6) Baten Lustness Occon npidly without preceding symptoms. Is tom maner to the femalo. (9) Juvenilo taber a very nre v) Jovailo geral parado b fality common around tho ipo of 10 to 11 When a child is born with whicos coormation of the damals am bo obtained by emtoration of the placenta. The ta haavler than pormal and grousy in appannc. Intatt und common. Licroscopionly the typical vascular und ped muscular changes of syphilis pro scon. Serological text an bo paformed on the card blood o venou blood and dark ground oamboation of scraping from a portion of the umbriaal cord may show the Treponema pallidum Between the rocand wad third week of Wordlologlaal mamluation of the Loog bopes shom parloutits and broadening uod Irregularity of the oppbywa! Hne. In lato childhood and adolesctoca dlagoon's tim pot cury Rod congenital cypkills was always be borse in mlod when u obucuro ledica k met with. The mother's child beurtog blatory k beptul and the stigmata o marller congenital syphim Tho commcdet stigmata in Teh- Notchlag of the incions () Domlag of the pre-mobo. To-Thickened and carved Fear Radlating mats at cowon a tho mooth. Eyes-Cortel opacitla ( Synccbb from previous Iittis ·Toy FLANDBOOK OF YOU DIECTIO: Nossa Sedlo thaped. Eerbsoluto datea The Wawermann raction may be podtive bot It toods to dhe oat after puberty TULATION (2) Daring NCRACY A woman who bou bed syphib should not her children cotil 2 years have elapsed etter treatment Erce then. course of to finjections of weak and broth b carental during pregnancy to ensure the beth at a healthy child Syphilitia louod obra pregnant are wealty diagnosed about the third month of their preçoadcy Sereo meo aots of penialia are given followed by 10 weekly bopec toms of Deo anpbenamiot, 045 mms and bloodth a grams and then boreuth aloes, too bojection being stopped 4 weebs before delivery After delivery a farther course of armen nad bortguth combined and then bharath alone ure givent Further marvelence then us for coal Latest syphilis. (3) Treatment of the baby (a) Those with slippe Penlemin b not three bomediately ance thero boa Mkel bood of acate cancerbation of symptoms especially catarbal and lotants tend to drown to thett ow scretioas. (1) Commerce with PIL. Aydrup, ctum credegrubas td.s. for 4 weeks with the addition of poh pecue. cum. oplo mainu I/12 If this causes darbat (2) Follow otth penkallio Tbe done to 100,000 Baits per Worter body weight, Atver tntrumokbusty divided into three boarły doses and spread over 71 dan (3) Salphan beruptae .01 m per kilograma body weight and 004 mm bisa dib metal per kuo meekly lor ro reelo Alteras livey binoth an be fire tatruuru alrty nod savanot only The doma forands net i wek Quarter tablet of 15 mms darby act. & reeks Hall tablet duity ·STIILIS AND CUNTY 103 (1) To meetly hjections of blength alooc. (5) Alter 4 weels internal repeat the comme datendo comblood with Hemath and then bemuth Joe (b) Latest cogenttal rypbits. The object of treatment b to prevent the future develop met of Rettve lessons of which foteatittal beatitis and daufnen ard the most frequent. There wally appear before the 4 of 15 yan but ther development may be delayed into the late twentie There is a poor prospect d irrorslag the Wucmamn reaction This ally only occur in 40 per cont of us Schenu of trudiran (1) A cotxe of penlemin in the dowos detallad above. A harmlen Babetter reaction condetag oder tee of tomperaturo f common. (2) Thice coone of unrenk combined with bigmath wod batoomth wone uro pren with me tooth rent between ach cotxe. The penubstance of poultivo Wawermum is no gaitance in the male lo the lonalo a further course of antenke und bismath dould be given daring pregnancy although Die of third povezation syphill bis bon reported to wblch the mother had received even minimal treatment. (c) Lato corsuite typ kulit. The report to all forms of treatment poor later tal keratit and fuveabe gooenal para aro ospedally refractory Scheme of trednou (1) Penicillin 100,000 units per llo body weight, (1) Aalylam com and bluuath for to reely. 3) Booth Jode for 10 weeks. (1) Alter one month, int coothane with monk ud bhath A miomum of 1 year treat is required.

·106 HAMDHOOT YODAL DICTrous CHAT WIL OTHER VENERAL INFECTIONS Ckoncroke A recreal dkeure effecting men and women. In this conntry it boally encountered in the porta. Due to mfection with Ducroys bacillos which bi mtoate Gam Degative rod mually found cita-cellularly to groups or chaft. The infection commer. In men doce the cold vaginal scretion tobibits growth of this organbom. Withto 24 hours of Infection and papale appen og the genitalia become vedicalar Rod then pustalar Pially clar-cut nicer develops which pred fabrly quickly tod, I recoodary baiection occurs, aita extendvo destruction of tho genitalla. The ulcer to Iregular with ondermoed edgo ad a soft bregular bas. Antolaoculation of Delight bourms perto is common. Tho doutoing, lyoph saat nphilly becomo infected and swollen. The bafection and! limited in non-infected as and the wore baals to 3 week. Dark ground cumination of the trudatos important to ccloda tho presence of T palliklum. The dagoon confirmed by the detoction of Doctoy's bucius to man. Truto Tho wore is kept can with Alipo druang and the erudate canined daly for I paisdom Solpła dmp in given by mooth starting with i gus followed by a gran Pour time a day for five days. Such treatment does not intefort with the detection of T pauidam. If oppuration has occurred in the Aguinal glanda the abaceo ba upinated dady und the carity rubed oath 1 per cent mercurochromo Il rupture of the abecem bus already occurred the una bwddy_tocked and the arily packed with gatto sonked In BIPP The blood b teded ach mooth for 3 months to contado concomitant syphilic infection, Nor-Speaks Ordinis Doe to i vous tofcetion. May be acquired from swim molog baths. Caurs very little diability od urethral dib charge les the only reapton. Oiganbas annot be found ·OTO YERAL DOLCTIORES 107 In direct mad ar an culture The Machampo opode to tractions of Doo-esperamine tatareonly repeated trico cokly for 6 Injections Tachomonas efectos ThS 8. rongoal intection in rogt aus und be frequently sociated with gooonb.com. A history detalfotencound. boully from 3 to 19 day prior to the case of symptoms aan olly bo oblamed. 'For a long the Tochomopus nga is regarded us in locidental prophyte of no pathological difunco bat it DOT recogafood to be a frequent ad of a rygtnal docharge and roarch for the auntir trichomonad tmpertire to all cases where foort.com ruled out. Infection after the menopano la Pro-diaparing tuctos art Loreley of the patho rutal secretion by Infection with the goodcocco, B co od stroptococd. Tom Undanline Preatnce of cerral etodama. Geoon dobility atter local The porwal ph d the goal recrution 38 to 4 duo to the presence of Doderlein" becers and borering of the dilty to a pH between 1 and 6 reams to be pecesary belore the trichompoons becomes patbotok The infection and Etching and bambor of the external sentitola. Vaginal dacharge os produse bull bod aching palo to the lowa abdomen comitaa. Sometimes bladder proptous en present partig wethritis a tripoultis ad severe are dypervenia pod of the valve and lelling o discomfort to the nestoa uro prezent. Os comitation the discharge is preght hollow thila, Lrothy and rith mosty odoar Tho ngoal maconha bounded. Desgramation stras riso to chanctala ww berty spots which bleed on bortrumentation. The damora confirmed by the detection of the actrichoucoid ta fresh FooD or larging drop propantiems mmg dark prodod hlation, contratto of doubtfal bietetla an be obtabood by culton a tho organban Spesin.com ·108 RAXDbOOR OF YOU. DOTLETION for these arestimation we obtubred from the potaker farnly with a long tapering slag tabo and rabba action ball Trichomotru vaginatis s -18 long and may be either round or oral. It bu no modal ting membrane about all the kogth of te body with 4 anterior sure the There be large omul sochea. The orase a recognised to a hanging drop preparation by its aty mbonascate al partial rotation ‘T ngintis an be stained in tears (1) Before drylag the anar it is bed over the mouth of a bottle containing a pet stot de ned. (1) Dry witboat the help of haat W Fix a part methyl alcobol for 10 minuten (4) Dry in ur (5) Pour oa Glemta stutt and leare 1 hour (6) Wash to tap water and dry THEATXDWT (1) The vagter is mopped dry (3) The whole vagina is havily basofitated with Plenicol powder (Wyeth) (3) Te patient ist abe pinago gemmary high ponible sco the nine and sight for 6 otght after thorough washing of the hands Tbo pontasy k batt bort lyttug down and the upright poultion should pot be repared until next morning a duper should bo warn to prevent satnlag of the night clother. (1) The basuflation ba tbeo repeated and who isother couts of 6 pakeries inserted into the vagina (5) The Insertion of pereistes scootmoed each night dorm the sert three monstrma parlads. Il rednimica occor picngol should be replaced by Acetamol nginal compouod tablets which are inserted at night will up in the naglas utter retiring The next morning douching with a walthen of videos we drachas to ope piata wa water barried out. The b done ach day for one week and then oa wernate dan for the more retu. Parktece o falection may be due to the preskoce a podhpored govorberal infection Consequently to further count of ·OTHO YRITTAL DICTICA 109 trantricot Deaded this boald be comblood with a pale pbourido corpood by mooth. Yda Lo the mula menaltod balano posthitha dovedopo with blaation d the interior ortthru. Symptarna uro methal dincbargo, frequency od dyrada. Indraut. The baluno posthith clan with local canlıdem. The urethittb dan wben tho orto b made strongly alatino with wodhun trato, gnbus 40 q.1.d and kept atalino for day peccamry un emulsion of plan.galas bo te wined bto the drobna. Relepeo commonly tollon ence Art conkuption of alcohol Go Werts. Qocur to both male and famile Avocated with Godont.com, Tdcbam.com intestation, Loal Actation Too arts are doe to the one whos which came warto debere In the body Found on the plana pena coronal molcus nod touer aspect of tho proprio to mules. In formala they are limited to the volna. Le the mystery cleaning and dryting with dosting powdar kothaluat. Later apply trichloroacetic acid after the arytas bare detiquenced an aport to ar a : 25 per cent oly sospeedan od podopoytin. Woes extensivo ans une bovalved I-ay therapy regatrod. Lymphosen loma Incuiels Avtrou des with an focubation perdod of low dare A goal herpetiformo alcer then appear on the plane penis a the valna. One to three weeks later marganet of the bigomal glande occon sccamopanked by fever and Loco tock Later the glands become matted together factoa theo occin the she becoma dharent to the timmtary mas and multiple de form. Elephant at the lower tub mod of the rom my Lollow the lymphatic obstruction ud fibrada espectally mas acabarged dapda har bera respond ·110 HAYDROOK OF YERIAL DOCTOX3 The diagnosis ofirmed by Fras text Ad Intre cataneous Injection for cubic centiretro bo lolowed 48 hoan later by ao blammatory area ceatimetre la diumeter with contal roce of terror Trento Rat ha bed. Simple diet Specific (1) Hany early casos respood to the pla drug. (*) Intravenous tofactions of per cent podium ant body bertanto crery fourth day starting with in the done belog tecreased slowly to 2 sau A total of 0 grains 6 stven. Non-speciác (1) puppuntion is present fociton with Ire dramago is Decor Sinona are packed with ralphodumaide powder (a) Protein sbock Encued by tho ithredos do fection TAB vacce every third day starting with 100 mbilon organisons and incredat to you antio arguabus IN al Ukrati Crewoma A nre forms of chronic ulceratina en la ba tropica and resulting from crual intercourse The Bleonatos recta the inguinal reg for and spreads to neighbourtay posts by antoinoculation Actiołosy malooma. Tbo Arst lesion #papale on the glam pendle or labia mhon which grom mto i muperficial pice 'This extenda Nowly and attect the poolt part of the grodo kad perineum There in this doncbarre Healing to o part I accompanied by destro longorher The dhondo may but for year Biopsy may be accesary to eached epithelioma Tralci (1) Exesse whole wo to tasty ases (3) Aattooay us for lyopbogrameloma bogatnak ·TIL HENDATION OF VILLAL DIRELD IN CHATO XIV THE PREVENTION OF VENERBAL DISEASES The question of the prevention of veneral durante ta barre con lorolving moal consideration ullu Dedal aspecto. Aprout number of those ffected and cured but in many are the digna of infection are other Wilgbt er and ignored by the sufferer. A bargo number of thero battes cues are permanently damaged and their lito motard. In addition bosband may be aware that bo las contracted syphilis and may th wittingty Infact hb wife who ardes the additional danger of producing an Intact with congenital syphilha. Wany women bare daired children and had frequot abortion only for 1 postire nero Joglal rolt to be discovered oventoully. Thanc cho are tout tragedios und the discovery of the infection does not help the stability of the marriage. The prevention of infec too baho made moro di cult by the fact that the dresses an be taunmitted not only by those who wa kufang from the diretto bat aboo by thomo focubetty tho dicas Hany of those who have been treated and to do active Ages ał doans atter bare i continul far of a recurTEDC and this far may develop lato mentul obceton. Bilorts to discount probaculty have tittle chance of Accem od separation of honband and wife due to boring aharap sa factor to promottag promiscuity, to the avio durtat the war the bridence of vaeral de In poltrone rapidly after 20 year's service oversets. An attempt bou been made to reduce the number of Inloctions and The mapority of these are made with ay poruke. In tot amber of these women tho sipas of Lafection are shot and uro porod. Defence Regula thou o wus destined to being these poople mdo treatment at lett ontil they went do kogor totection. In additioo dhal prophylaxis after espacart an materially redoce the potaty a fincan occurring Thero mau oro brequently ball became the pouca fuvolved la drwok at the two of pocure and prophyta ·II HANDBOOK OF VOTRIAL OTECTION out the post morning. If possible prophylack abould be performed within an board apoeiro or at last within 4 hours of exposure. Individual prophylaxus (1) The mouring of a coodom gira eficient protection to the penis but tho pobo and lower abdomen are not protected. They annot, therefore be rolled trpoo & the molo mear of prophybu (1) Wash the genitalla parto.com and lower abdomen with soup and water Spread on to per cent alomel ototment. Lostll into the trethn 10 cubic centimetra od s per chot mild silver protetieto B.PC This bo retalbed In the mothn for 5 minuta by bolding the game penia. The bladder aboold not be emptied for sevenl bouts after this Fowell Prophylax! I pore dumcult for the female since she an nrely didnfoct the urethn lennef (1) Wash valna, perineum and lower abdomen with Op and water Dooche with 1 300 Dettol solution Rab alomd Ontment on pubes vain and introitus ngine. (4) I' poolble introdoce 10 per cent mild silver protdoute Into the cervial anal with a probo and instills per cent solation into the aurethri. If prophylactic traatment in carried out by a doctor the paticot should return for camination ope reek later nod quo after 3 months when a blood test should be patoned to orchide syphil. The practice of glving amal doses of golphonamikos u. prophylactic masure bo to be deprecated 'This commonly iraults to drag resistant bacteria penktag und make her medication of the tafection on ducalt. With penicillin the danger b grater soce syphilitie Inloction may be maite od po evidence of It discoverod ant poath bater ·INDEX Alb A uty ya Mb Aborta pers Alec Barthotha's het hypher pachttual, benever the tab prostata d pole, 15 ELL ncy Cu dros That's her on Contot bent. 3. * * Ada portrou Prod Cinthy het7+7 Arroka tretmt. Liter both Chittoa jobath ros Mrry Cododel oldun Adapterylactol miction, er Contato DS Ayo 147 Coachyotte Amb tot, 771 Cotal Type Automaty Lottots Cowper duda Aorta copo 75 Crudo bew Aabot Creme bebe Aty - Roberto Cette con Aswalal berlopette por do you All bordet Art 13 Atade D Desty the ni po Dart pudore BAL..7 Decorada Balo portals Det er non, 1 Beather, Dennetta, wrth corpo Dhe brother Dec, ' alm W Deroon pii7- Dotych, po pl Ben 13 Cesky so tact Posts Cardal Hanabol Carbon ML 7 upom ht, ·Eplatynos 103 Erythesato sto sempre puls, cual sphik rog broer en stor 6 Epintati dermatit, 64, 6 H Humoportuori, ma Heart, plain 74 pe blau Hentblot ruction, M. Hardtop Lodo, da listed on both, * Incababa period of chunarod, w Fathepla tubes, oorhon Prve themy poortbook, bol surnud, 06 philos. # at the honey plalt 9 Florication tots : In dezate cadou Fortom een of ophta lehen latent peaker, 14 Interrutu katiche, Fru twet, 10 bochocs, as abb A werderpool, M SottraA Catcher to Cowparna, pa Irtio, ir Cantal narto, o Cand mactan, ir J Glum twent to poorhonen Cort, 19-11 Jarl Herbelom wactos, mo Cloutie 7 Laredo 42, Cococaconnu jotte, Charcot 73 m ruolo Chetia, Cocacoco lation test, a perococcal section, the Concrc. mptul 7 album, couphantom of **** da er 49 coderm care la www Konu datorn dit. * Ortal do AD Ao ton ha a randon uk Laborny Location. the faste 4 Lu Ma Me 3 Larytu, wrth 74 wcale trou penod, Latr pathe 7 be treabowo w termeln Samat ptubes los trwale Leopar was colocations, the om or wty punkchor me Lynh di codi conti 3:57 mate , hack betreat fork u trunk mm fat Dan in my Get ruin teparten at ·be its blood baru) Wabcowoker nyplace 54 Jane there patie woeyplank ada oral cames Act, to cray 16 kot cherche soportbook in coppen cypel Chi nh tu y compoule buty wław platen Hatte Porto bapordane, 17 h Macam wdy byphile IT ed uppe da Ja tiet plula 6 recher kete aos pl. 37 N pophtheid, Xabod loben pretul rek, 15. Ww-up condil ya 10 tablo Suptube vorige make syphibe 15 abwechature ) ptops te. cerebcoupage typ.. contratto be Pedardid 74 today daran, at Pinto 7 pol, roy by Poetbal ab. 30 o per Potem obce, control Tibet www.so .993 Proury corr, - Proctite car Protyol y Pege naar optry to The reactyoston, Prophylaxon, na 21 n place u Pronka then Hoe Presch Kottare) Prorat pattern Promotion pobl of mother Podobne at, 103 Ophthala ora 48 Probopal O Atrophy Pobo Haulth Act .. httt Orlit, Pedoc HR () Papito o Ob 11 Pue Ostroartkittis, I'mdal trwbt Orbit by TAB Motor J to the poor. * woeypatin, hoobado cercale bypas trophe Tap the Paul slip battlu *** Two won, X 2. A TOP babet Tikroede Borge 4 Tuddin, ·1 times Lutown IT6 non opeast, the aber til 7 of completary art. 14 Lotpote in. 7 SD, ? mababaro tron 72 al con la pronbort, o troth, tout Seputati wa 7) Krakaldherpenda ooster 74 Et path, 44 tot Son foot chance petonary Aime Seroch, tron yapt cash ootary 54 an Sipas tat SD tobom, Skraca, totho TA noche) dederatual typing Tuborn 0-09 Tout back withoo, Turth 13-03 Sok. Teorgorith. 75 Splaaladie. 73. Storatite, ou oz. 45 Terreppum ol. 74 Thota, bre, 72, Kumando Streptoorygio, boorhonn Torre syphilol. 7 Subotol, ta raro rebehlo, u Tirporta pasidaro berketuru, 31 Iskboooo nuk to plan, Iparraiche Tabourn Abec border To do tnt o and drug recen In curacakt, word Tract paarbor, u neboom roporrbom po. V poontoen, 4 In hypoamb banke Urral tritt Ustbarth opithelou, duperedel dus oma ol, # w proplytande of goonboa, trecato m protautis, o V атак рото е sáo tre - wants retro ruptum, $ Sp. prot. 107 Sroglo. 1L arom katon Sport Termal Dream Ley Spotta ba pret at the KOD Toroolo te 71 relepe o Bawot, to Ivy trutor) om, the o sortu 14 odborn af burn daardoor beton 71 be powerp de plimit 7) my na obrert 7 al wat aluant n en primer med al punto worry my of onder to purple wwwser de Why metal po 774

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