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Lectures on Syphilis. 
 
 DELIVEKED AT THE 
 
 Chicago College of Physicians and Surgeons. 
 
 G. Frank Lydston, M. D. 
 
 Late Resident Surgeon at Charity Hospital, and at State Emigration 
 Refuge and Hospital, New York City. Lecturer on the Surgical 
 Diseases of the Genito-Urinary organs, and on Venereal Dis- 
 eases, in the College of Physicians and Surgeons. Professor 
 of the Principles and Practice of Surgery in the North- 
 western College of Dental Surgery. Attending 
 Surgeon to the Genito-Urinary and Venereal de- 
 partment of the West Side Dispensary. 
 Member of the Chicago Medical Society, 
 of the Chicago Pathological Society, 
 /^. Etc., Etc. 
 
 Pv 
 
 Reported by 
 WM. A. WALKER, A. M., M. D. 
 
 Attending Physician to the West Side Dispensary. 
 
 CHICAGO 
 A. M. Wood & Co., Publishers. 
 
 1885. 
 
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COPNR\GV^, \&&S, BN &. VHKU^ ^DSIOU, M. D. 
 
 O'Neil & Gkiswold, Binders, Chicago. 
 
TO 
 
 JOSEPH W. HOWE, M. D., 
 
 late professor of clinical surgery at the 
 bellevue hospital medical college; surg- 
 eon to the charity hospital, and 
 to st. francis' hospital of 
 new york city, 
 
 These Lectures 
 
 are affectionately inscribed, in memory of pleasant 
 
 hours of study, by his sincere friend 
 
 and grateful pupil, 
 
 The Author. 
 
PREFACE. 
 
 These lectures were originally published in The Western 
 Medical Reporter, and they have been collected and re- 
 published in their present form, with but little revision. An 
 earnest attempt has been made to present to the student a 
 plain and practical idea of the subject of Syphilis, as taught 
 by our most advanced pathologists and syphilographers, in 
 conjunction with practical points drawn from personal observa- 
 tion in hospital and dispensary practice. The views of 
 Fessenden Otis have been adopted, as the most logical and 
 scientific which have yet been offered, in explanation of the 
 pathological phenomena of the disease. It is hoped that these 
 few lectures may prove more valuable to the student, than 
 some of the larger and more comprehensive treatises. 
 
 125 State Street, Oct. 1st, 1885. 
 
CONTENTS. 
 
 Lecture I. Definition of syphilis. Its contagiousness and 
 wide diffusion. Origin of the disease. Its decreasing ma- 
 lignancy. Duality of syphilis and chancroid. Experiments 
 with animals. Period of incubation. The syphilitic cell. 
 Harmony of the bacillar theory with the physiological path- 
 ology of syphilis Pag-e 9. 
 
 Lecture II. Initiatory period. Importance of the syphilitio 
 cell. Anatomy and histology of local manifestations of the 
 disease. Adenopathy. Varieties of induration. Necrobiosis. 
 Chancrous secretion. Vaccinal syphilis. Poison bearing 
 secretions of syphilis. Dependence of contagiousness on the 
 syphilitic cell Page 29. 
 
 Lecture III. Modes of transmitting syphilis. Absence of 
 primary syphilis in foetal infection. Infection by kissing. 
 Colle's law. Danger of infection by syphilitic child. Illus- 
 trations of methods of transmission. Varieties and treatment 
 of chancre. Mixed sores. Syphilitic bubo Page 47. 
 
 Lecture IV. Period of general infection. Progression of 
 syphilitic cells. Apparent periods of incubation. The rose- 
 ola. Syphilitic fever or prodromes. Syphilitic sore throat. 
 The papule. Alopecia. Onychia. Pustules, ulcers, mucous 
 patches, tubercles, and condylomata. Iritis. Duration of 
 active period Page 67. 
 
 Lecture V. Period of sequeke or tertiary period. Syphil- 
 omata, or gummata. Tendency to necrosis of gummata. 
 Non-infectiousness of gummy material. Lymphatic obstruc- 
 tion. Stages of syphilis. Precocious syphilis. Syphilides. 
 Duration of syphilis. Prognosis of syphilis. A typical case 
 of syphilis Page 93. 
 
Lecture VI. Treatment of syphilis. Excision of chancre. 
 Effects of mercury. Action upon the blood. Action of 
 iodine. Proper time and method of giving mercury. Dura- 
 tion of treatment Page 113. 
 
 Lecture VII. Evil effects of mercury. Popular prejudice 
 against its use. Mercurial depression, ptyalism, stomatitis, 
 rheumatism, and possible ulceration and necrosis. Iodides 
 in syphilis. Injurious effects of the iodides. Questionable 
 preparations in syphilis. Local measures. Syphilitic necro- 
 sis. Page 133. 
 
 Lecture VIII. Congenital and acquired syphilis in children. 
 Methods of hereditary transmission. Intra-uterine syphi- 
 lis, and syphilitic abortion. Masquerading of syphilis in 
 children. Appearance of the syphilitic child. Hutchin- 
 son's description. Lesions in the child. Apoplectic effu- 
 sions. Hydrocephalus. Sudden death. Prognosis and treat- 
 ment Page 149. 
 
 Lecture IX. The nursing of syphilitic children. Possibility 
 of healthy child being born of syphilitic mother. Attenu- 
 ation of virus. Hutchinson's views. Escape of child after 
 seventh month of pregnancy. Insusceptibility to infection. 
 Danger of infection in nursing. Desirability of artificial 
 feeding Page 169. 
 
 APPENDIX. 
 
 Selected formulae for the treatment of syphilis. . .Page 177. 
 
Lecture I. 
 
 Definition of syphilis.— Contagiousness of the disease.— Its wide diffu- 
 sion.— Origin of syphilis.— Ancient knowledge of the disease.— Its 
 present benignity as contrasted with former malignancy. — Expla- 
 
 . nation of the decrease in malignancy by evolutionary laws.— Duality 
 of syphilis and chancroid.— Attempted inoculation of animals with 
 syphilis.— Successful inoculation of the monkey. —Rapidity of absorp- 
 tion of syphilitic poison.— Second attacks of the disease.— Venereal 
 diseases of the lower animals.— Duration of incubation period of 
 syphilis. — Peculiar induration of chancre. — Nature and local results 
 of the syphilitic materies morbi.— Properties of the syphilitic cell.— 
 Its effects and importance during the natural course of syphilis.— Har- 
 mony of the bacillar theory with the "physiological pathology" of 
 syphilis. 
 
 Gentlemen: — We take up this morning the most 
 important subject which it is my privilege to pre- 
 sent to you, and the most interesting of those 
 affections classed as venereal diseases. Syphilis, 
 or as it is sometimes termed "lues", is a dyscrasic 
 or constitutional affection of the type known as 
 "blood diseases," due to the infection of the organ- 
 ism of a human being with a peculiar morbific prin- 
 ciple, or virus, or hypothetically, a germinal 
 disease cell, unknown as an entity, but plainly 
 manifest in its pathological results. Its manifes- 
 tations are, to all intents and purposes, a lesion 
 which is primarily local, but which is followed by 
 a succession of morbid constitutional manifestations 
 appearing at variable intervals, running a some- 
 what definite course, and being more or less 
 amenable to treatment. The virus of syphilis has 
 not yet been isolated, although we are justified in 
 
10 Lectures on Syphilis. 
 
 the hypothesis that it is a degraded cell of micro- 
 scopic size, and possessed of most potent evil pro- 
 pensities. In many respects syphilis resembles 
 the exanthemata, inasmuch as it is transmissible 
 from the diseased to healthy individuals, has a 
 period of incubation, a stage of eruption, another 
 of decline, and a period of true sequelae. A very 
 minute quantity of the syphilitic virus is sufficient 
 to produce the disease, although it is fortunate- 
 ly only contagious, and not infectious, in the 
 proper sense of the term. The wide diffusion of 
 syphilis through the human family, will not be 
 fully appreciated by you, until you enter private 
 practice, when, especially if your field of labor 
 lies in a large city, you will soon come to believe 
 that no one is above suspicion. Perhaps this is an 
 exaggeration, but it is certain that syphilis, like 
 accidents, is liable to occur in the best regulated of 
 families, and often serves to explain otherwise 
 obscure cases of aristocratic aches and invalidism. 
 The origin of syphilis is not definitely known, 
 but it is probably quite an old and respectable 
 disease inasmuch as it is more than likely that 
 some of the forms of leprosy of bible times, were 
 instances of syphilis. Indeed, syphilis and leprosy 
 were confounded only a few centuries ago. Nearly 
 all accounts of syphilis state that the disease ap- 
 
Lydston. 11 
 
 peared in Southern Europe in the latter part of the 
 fifteenth century, the supposition being that it was 
 imported from America by the sailors who accom- 
 panied Columbus or Amerigo Vespucci upon their 
 expeditions. The morals of the country at that 
 time being none too rigid, the disease spread 
 rapidly, being later mistaken for leprosy. It has 
 since been recognized in every part of the world, 
 as a distinct disease, and has come to be quite well 
 understood. There is a fact connected with the 
 history of syphilis, which is not generally known, 
 that may be of interest : I am informed upon re- 
 liable authority, that the disease was described by 
 the Japanese historians several thousand years ago, 
 and that documents are still in existence, which 
 contain ancient descriptions of the affection, that 
 are exceedingly accurate. This would indicate the 
 Asiatic origin of the disease, it having been brought 
 to America by those nomadic tribes who settled 
 this country some centuries ago, when America and 
 Asia were united by the peninsula now represented 
 by the Aleutian Islands. As still further evidence 
 of the antiquity of syphilis, may be mentioned the 
 fact that recent translations of ancient Chinese 
 medical writings show that the disease was known 
 in China two thousand years ago. Moses was un- 
 doubtedly familiar with the disease, a fact which 
 
12 Lectures on Syphilis. 
 
 makes it still more ancient and respectable. Dur- 
 ing the earlier years of the existence of syphilis in 
 Europe it was so malignant and widely dissemi- 
 nated, as to have been recognized as a form of 
 plague, which created great havoc, and in fact 
 nearly destroyed the various armies of the coun- 
 tries afflicted. The disease has gradually grown 
 milder in type until at the present day the very 
 severe and exceptional cases have come to be 
 classed under the head of i ' malignant. " Now there 
 must be some explanation for this, and I think it 
 would be well to digress slightly, and see if we 
 cannot find logical reasons for the steady diminu- 
 tion in the virulence of syphilis. In the first place 
 it is obvious that improved sanitation, with a stead- 
 ily increasing knowledge of the pathology, and the 
 consequently more rational measures of treatment 
 of any particular disease, must eventually result in 
 modifying its severity. This has been especially 
 true in the case of syphilis, but I think there is an- 
 other more powerful influence which is constantly 
 manifesting itself in the case of contagious diseases 
 in general, viz : the fact that disease occurring in 
 individuals of one generation imparts a certain 
 degree of immunity to their descendants. 
 
 A very interesting article bearing upon the influ- 
 ence of heredity and natural selection in modify- 
 
Lydston. 18 
 
 ing different contagious diseases, has been recently 
 written by Prof. Lyman of this city, which is so 
 logical in its application to these different affections, 
 that I think we may apply it to syphilis as well. 
 The doctor cites as an illustration of his views, the 
 extraordinary malignancy of measles among the 
 natives of the Sandwich Islands, a few years since. 
 These people were never affected by measles until 
 it was imported by the whites, and consequently 
 had not acquired tolerance of the disease. 
 Although the population of these islands was al- 
 most decimated at the time, the disease has steadily 
 decreased in its malignancy ever since. Another 
 illustration cited, is the peculiar malignancy of 
 variola among the negro race. Small-pox was un- 
 known in Africa until imported by Europeans, and 
 after its introduction created fearful havoc among 
 the natives. It has not yet had time probably, to 
 become very markedly modified, but a steady modi- 
 fication is to be expected. When an epidemic at- 
 tacks a community it attacks those susceptible to the 
 disease, and modifies their organisms in such a 
 way that they become tolerant of future attacks 
 and this tolerance they transmit in a measure to 
 their descendants. A certain number of individ- 
 uals are insusceptible to the epidemic influence, and 
 consequently escape the disease. This insuscepti- 
 
14 Lectures on Syphilis. 
 
 bility is also transmitted to the next generation. 
 These facts illustrate the influence of heredity. As 
 1 have stated, a certain number of individuals are 
 primarily insusceptible to the disease and conse- 
 quently escape it, while those individuals who are 
 susceptible to it, are attacked, with a fatal result 
 in the case of those least able to withstand it. 
 This illustrates the influence of natural selection. 
 Applying this theory to syphilis, we may readily 
 see that the disease has probably destroyed those 
 subjects least able to resist it, and that the im- 
 munity from the disease acquired by exposure to 
 its influence in the case of those who survived, and 
 the primary insusceptibility of a certain proportion 
 of individuals have been transmitted to successive 
 generations, until at the present day syphilis is a com- 
 paratively mild affection. It is of course admitted 
 that the insusceptibility of one generation, may 
 depend upon the inheritance of unequivocal syphilis 
 from the parent stock, but in certain instances the 
 transmitted impression is very attenuated. 
 
 One of the most important results of modern 
 scientific medical research, has been the establish- 
 ment of the duality of the poisons of syphilis and 
 chancroid. The experiments proving this have 
 been numerous and conclusive, yet, strange as it 
 may seem, there are those who continue to believe 
 
Lydston. 15 
 
 in their unity* This difference in opinion has re- 
 sulted in a division of authorities into a unicists" 
 and u dualists". The obscurity which formerly 
 clouded the minds of surgical authorities, regard- 
 ing the venereal diseases, seems very remarkable 
 to us, who have taken advantage of their errors. 
 John Hunter, the greatest surgical philosopher of 
 the eighteenth century, believed that there was but 
 one venereal disease, and that a constitutional 
 affection. He believed this, because he had pro- 
 duced constitutional syphilis in himself by inocu- 
 lating his arm with gonorrhoea], virus. He labored 
 under this delusion until the day of his death. 
 Fully half a century later, Ricord demonstrated 
 the error of the great master, but he himself did 
 not recognize the difference between syphilis and 
 chancroid. Fifty years later, their duality was 
 shown by Bassereau, one of his own pupils. I 
 will not enter into a lengthy discussion of the 
 different authorities and methods of research prov- 
 ing the duality of the two poisons, for the fact is 
 generally accepted ; but I will mention a few facts 
 bearing upon it. We can all fully appreciate one 
 of the most powerful arguments of tho unicists, 
 viz: u That general symptoms frequently follow 
 
 * Among those who adhere to the old theory, may be mentioned 
 Kaposi. Many prominent English surgeons are also unicists, hence 
 the confusion of terms existing in most English works upon syphilis. 
 With them, chancroid is also and erroneously termed, '"'local syphilis." 
 
16 Lectures on Syphilis. 
 
 an apparently non-indurated, simple sore, but 
 these cases are simply exceptions to a well estab- 
 lished rule. I have seen, it must be confessed, 
 very innocent looking sores followed by secondary 
 syphilis, but quite rarely; sufficiently often per- 
 haps, to render me cautious in the matter of prog- 
 nosis in every sore, however innocent looking; but 
 not often enough to shake my own convictions as 
 to the duality of syphilis and chancroid. When 
 chancroidal poison is deposited upon a raw surface 
 and said surface is cauterized soon afterwards no 
 chancroid results. If, however, the syphilitic virus 
 as contained in the secretion of a chancre or syph- 
 ilitic ulcer, be thus inoculated and cauterized, 
 syphilis will result, as a rule. Hill cauterized a 
 ruptured freenum twelve hours after intercourse, 
 but syphilis developed as if nothing had been done. 
 Fournier cauterized a chancre six hours after its 
 appearance, but syphilis followed. Excision of the 
 primary sore has been practiced, and has recently 
 been revived, but has not as yet been proven to 
 prevent the development of syphilis. It has seemed 
 to modify it in certain instances, and in two 
 personal cases, the subsequent secondary manifes- 
 tations were very mild. This proves nothing 
 however. The facts that I have given you are suf- 
 ficient in themselves to prove the non-identity of 
 
Lydston. 17 
 
 syphilis and chancroid. Syphilis is essentially 
 constitutional, (even if primarily local) while chan- 
 croid under all circumstance is a purely local affec- 
 tion. 
 
 Attempts at the inoculation of animals, with 
 sj-philis and chancroid have shown a marked differ- 
 ence between the two diseases. Syphilis is not 
 transmissible to the lower animals while chancroid 
 is, although with a certain amount of difficulty. 
 Depaul, however, speaks of a syphilitic monkey, 
 and Martineau has recently claimed to have pro- 
 duced a hard chancre upon the penis of a monkey. 
 This animal was afterwards exhibited to the French 
 academy, with unequivocal secondary lesions, thus 
 proving the communicability of syphilis to the 
 monkey. Neumann, however, in some recent ex- 
 periments upon monkeys, cats, dogs, rabbits, and 
 horses has failed to produce syphilis. If the state- 
 ment that syphilis is transmissible to the monkey 
 alone, of all other animals be true, it would seem 
 to be a powerful support to the Darwinian theory. 
 The course of syphilis and chancroid is sufficiently 
 distinctive in typical cases. In conclusion, we 
 might ask the unicists why, if the poisons of 
 syphilis and chancroid are identical, all venereal 
 sores are not followed by constitutional symptoms, 
 when allowed to run their natural course without 
 
18 Lectures on Syphilis. 
 
 interference, and why also, all sores are not auto- 
 inoculable ? 
 
 Syphilis may be either hereditary or acquired, 
 and is essentially the same in its manifestations in 
 either instance, save that, as we shall see later on, 
 hereditary syphilis has no primary stage. Acquired 
 syphilis is in every instance due to confrontation 
 and inoculation with a peculiar poison or virus 
 derived originally from some individual suffering 
 from the disease, and which virus is contained in 
 either the secretion of a syphilitic lesion, or blood 
 from a syphilitic subject. 
 
 The length of time necessary for the absorption 
 of the syphilitic virus after the inoculation of a 
 healthy tissue, is unknown, but it is unquestion- 
 ably very short, although no direct experiments 
 have been made. Abrasions have been cauterized 
 within six hours after suspicious intercourse, and 
 yet syphilis has developed. Hill, as before stated, 
 relates a case in which he cauterized a ruptured 
 fraenum within twelve hours after exposure, and in 
 which syphilis followed. Numerous experiments 
 have been made upon poisons bearing an analogy 
 to the syphilitic virus, which are very instructive 
 and allow us to draw some conclusions with refer- 
 ence to syphilis. The experiments with the virus 
 of vaccinia have been especially interesting. Seven 
 
Lydston. 19 
 
 children were vaccinated by Martin and the site of 
 the operation destroyed by Vienna paste at periods 
 varying from one to twenty-four hours thereafter. 
 None of the children had vaccinia; but all but one 
 were protected from variola as was proven by the 
 failure to inoculate them by a second vaccination. 
 Clerc vaccinated a number of children, destroying 
 the spot with nitrate of silver one hour afterwards, 
 but vaccinia was not prevented. These experi- 
 ments suggest that possibly vaccinia consists of 
 two essential elements; a local and a constitutional, 
 which permits the destruction of the morbid im- 
 pression causing the local process without any 
 modification of the constitutional manifestations of 
 the virus. Whether the same view may be taken 
 of syphilis, remains to be seen. In France, numer- 
 ous experiments upon animals have been made by 
 different surgeons, with the poison of glanders. 
 The seat of the inoculation has been excised within 
 one minute after the introduction of the virus, yet 
 glanders was not prevented. It is probable that 
 the virus of syphilis is not absorbed as quickly as 
 some other poisons, but reasoning from the experi- 
 ments cited, the period required must be very short. 
 Unlike chancroid, true syphilis is very rarely 
 contracted twice. Second attacks, however, have 
 been reported. Diday has collected twenty-five 
 
20 Lectures on Syphilis. 
 
 such cases, twenty of which were in his own prac- 
 tice. These cases are especially interesting, both 
 from their rarity and the fact that they most con- 
 clusively prove the curability of syphilis, for were 
 the disease not curable, a second attack would be 
 impossible. A few of Diday's cases were con- 
 tracted during the existence of tertiary manifesta- 
 tions of the previous attack, and this too is an im- 
 portant fact as showing that the u tertiary syph- 
 ilides" are not syphilitic at all, but are simply 
 non-transmissible sequelae. The longer the interval 
 beween the first and second attacks, the more severe 
 the latter is likely to be, but in the majority of 
 cases the second attack consists in the primary 
 symptoms alone without any further manifestations 
 of the disease. This of course, lends color to our 
 doubts as to the accuracy of the diagnosis in dif- 
 ferent cases. I have seen in my own experience 
 two cases which I believe to have been a second 
 attack of true syphilis, the data of which I am un- 
 fortunately unable to present to you. In each 
 case there had been a previous attack of true syph- 
 ilis which had been diagnosed by two prominent 
 gentlemen, one of whom was no less an authority 
 than the late Dr. Bumstead. There is no doubt in 
 my own mind as to the condition for which I treated 
 these men, and I can hardly question the accuracy 
 
Lydston. 21 
 
 of the first diagnosis. There are several sources 
 of fallacy in determining the existence of a second 
 attack of syphilis, which must be remembered. 
 1st. — In the first place you may have some coinci- 
 dent eruption accompanying chancroid. 2nd. — 
 Ecthyma may be mistaken for true syphilis, and, if 
 following a genuine attack, be cited as a case of 
 second infection, or the first attack may have been 
 ecthyma, and the second true syphilis. 3rd. — A 
 chancroid or mucous patch may become the seat of 
 such marked inflammatory induration that it is 
 mistaken for true chancre. 4th. — A tertiary gum- 
 my ulcer may be taken for hard chancre. 
 
 I have already mentioned the non-transmissi- 
 bility of syphilis to the lower animals and cited 
 the exception of the monkey as claimed by Mar- 
 tineau. It is, as we have already seen, a demon- 
 strable fact that syphilis differs markedly from 
 chancroid in this respect. But it is claimed that 
 animals also have venereal disease, or affections 
 contracted only through sexual intercourse. There 
 is an affection somewhat analogous to syphilis which 
 affects horses and asses. This disease, termed the 
 doury, is only transmitted during sexual inter- 
 course. It develops after an incubation of four to 
 six weeks, with the phenomena of fever and cut- 
 aneous tumors, and sometimes the mucous mem- 
 
22 Lectukes on Syphilis. 
 
 branes, eyes, and bones may undergo pathological 
 changes, atrophy or paralysis sometimes following 
 in extreme cases. The disease lasts from a couple 
 of months to three years, and is not auto-inoculable. 
 A local contagious venereal disease is also seen in 
 these animals according to Lancereaux. Inasmuch 
 as these affections differ from syphilis in a marked 
 degree, and particularly in the matter of inocula- 
 bility, their analogy to that disease is probably very 
 slight. It would seem that mankind has the sole 
 monopoly of the doubtful luxury of syphilis. 
 
 After the poison of syphilis has been absorbed, 
 a certain period elapses before its morbid effects 
 become manifest. This period is known as th^. ; 
 stage of incubation, and lasts upon the average 
 about twenty-one days, but varying considerably 
 from this in different cases. Fournier relates a case 
 in which the period was seventy-five days, Guerin, 
 one of seventy-one days, and I have myself noted 
 one case of seventy days. Instead of being pro- 
 longed the period may be shorter than usual, thus 
 Hammond relates one of three days, and the late 
 Dr. Nott, of New York, reported his own case as 
 developing within twenty-four hours after wound- 
 ing his finger in operating upon a syphilitic subject. 
 Dr. R. W. Taylor, of New York, reports one case 
 in which the initial lesion appeared upon the second 
 
Lydston. 23 
 
 day, induration upon the fourth day and general 
 symptoms during the sixth week, and another 
 in which the chancre appeared at the end of the 
 first, and the general symptoms during the fifth 
 week. Practically, gentlemen, we may accept the 
 statement that as a rule, true chancre does not ap- 
 pear before the tenth day. Any sore appearing 
 prior to that time, is probably chancroid, while any 
 appearing later, is quite likely to be true chancre. 
 This is a useful practical rule to remember, although 
 it must be confessed that it is often of little service 
 in diagnosis, inasmuch as the majority of individuals 
 contracting venereal disease are in the habit of pro- 
 miscuous intercourse, and therefore absolutely un- 
 able to determine which of their numerous adven- 
 tures has been the unlucky one. Whenever the in- 
 duration of a sore is characteristic, we are of course, 
 in no wise dependent upon the period of incubation 
 for a diagnosis. 
 
 Induration of a peculiar type is the distinguish- 
 ing feature of a syphilitic chancre and the manner 
 of its formation and its histological characters are 
 consequently a matter of considerable importance. 
 This brings us to the consideration of the patholog- 
 ical changes of syphilis, or as Otis terms it, the 
 "physiological pathology'' of the disease. We ought 
 naturally to begin our study of the subject, with 
 
24 Lectures on Syphilis. 
 
 the consideration of the primary or initial lesion, 
 and beginning at the seat of infection we have a 
 number of quite important changes. We have first 
 the absorption of a peculiar morbific principle or 
 "virus," which although unknown as an entity is 
 only too plainly manifest in its pathological effects.* 
 The most probable view of the nature of this virus 
 is, that it consists of a degraded infectious cell of 
 very minute proportions. However lacking we 
 may be in positive knowledge of its nature, we at 
 least have tolerably definite views of the manner of 
 its action. The first effect of the syphilitic virus, 
 is the production of a gradually increasing accum- 
 ulation of lymph or white blood cells at the site of 
 inoculation, which is brought about by a modifica- 
 tion of the normal leucocytes and connective tissue 
 elements, by what we will term the ' 'syphilitic ger- 
 minal cell." This modification probably begins 
 immediately after the absorption of the poison, but 
 is more or less gradual in manifesting itself, hence 
 we have a certain period elapsing before evidences 
 of its action are exhibited. These accumulated 
 cells, previously normal, contain the "germs" of 
 the syphilitic poison, and their constitution is now 
 
 *I regard the bacillus claimed to have been discovered by 
 Lustgarten, as yet to be proven. In any event, its existence does not 
 modify the pathology of the disease, for Lust gar ten claims that it acts 
 by incorporating itself with the white corpuscles. 
 
Lydston. 25 
 
 greatly modified. They have become larger, more 
 granular, and contain numerous nuclei, are infec- 
 tious, and have their powers of proliferation and 
 amoeboid movement exaggerated. In addition they 
 present a marked tendency to retrograde metamor- 
 phosis. When removed from their original situa- 
 tion to the tissues of a healthy individual, these 
 cells, by virtue of their infectiousness, produce 
 changes in the normal leucocytes in their new en- 
 vironment, exciting rapid proliferation in them, as 
 well as undergoing rapid changes themselves. 
 Now, how does the "syphilitic germinal cell" act 
 upon the normal leucocyte? It is claimed that 
 through degradation the syphilitic germinal cell may 
 be but 1-100,000 of an inch in diameter, being per- 
 haps merely one of the nuclei of some infected and 
 degraded leucocyte, but retaining all its morbid 
 powers of proliferation and amoeboid activity, the 
 latter being especially marked. As the white blood 
 cell or normal leucocyte is 1-2,500 of an inch in dia- 
 meter, it is obvious that by virtue of the peculiar 
 affinity of the syphilitic germinal cell for it, the two 
 may become incorporated, with the result of the 
 modification of the leucocyte which I have des- 
 cribed.* 
 
 *By supposing an incorporation of the bacillus of Lustgarten, with 
 the leucocyte, instead of the hypothetical cell described, we can at 
 once harmonize the bacillar theory of the origin of syphilis, with its 
 "physiological pathology." 
 
26 Lectures on Syphilis. 
 
 Now gentlemen, I wish to impress upon your 
 minds a thorough understanding of the nature 
 of the modified cell which I have described, for a 
 knowledge of this cell is the key to the study of 
 syphilis. Just as the leucocyte is the primordial 
 cell in the normal physiological processes of growth, 
 so is it the basis of all pathological processes, — 
 and particularly those of syphilis — when it is mod- 
 fied in the manner peculiar to the particular morbid 
 change in the tissues. Taking as our point of de- 
 parture, the initial lesion of syphilis, we have a 
 localized proliferation of this very cell, and follow- 
 ing it in its course, we have thickening of the 
 lymphatic vessels and enlargement of the lymphatic 
 glands, produced by this same cell accumulation. 
 The cell now travels on, enters the receptaculum 
 chyli, and is finally emptied into the circulation by 
 the thoracic duct, to be then driven to the super- 
 fices of the body with the general blood current. 
 In the different tissues we now have various secon- 
 dary phenomena, and we will briefly consider some 
 of them. General enlargement of the lymphatic 
 glands occurs, as a result of the proliferation of the 
 cells carried to them by the blood, and an accumu- 
 lation of infected germinal material collected by 
 the absorbents from the superfices. Engorgement 
 of the fauces and pharynx now occurs and is due 
 to a "localized cell accumulation" in the rich net- 
 
Lydston. 27 
 
 work of lymphatics, which as we shall see later on, 
 is a marked feature of the anatomy of the fauces, 
 tonsils and pharynx. Mucous patches are likely 
 to occur, and are simply papules upon moist mucous 
 surfaces, due to a circumscribed collection of the 
 characteristic cells. The same description will ap- 
 ply to the true papule upon the integumentary sur- 
 faces. This papule may have an excessive accum- 
 ulation of cells, and become a tubercle, or, from 
 pressure upon and interference with the nutrition 
 of, the normal tissue elements by the cells, in com- 
 bination with their own tendency to retrograde 
 metamorphosis, we may have a pustule formed which 
 may break and result in ulceration. Nodes or pe- 
 culiar periosteal swellings occurring in syphilis, are 
 simply collections of proliferating syphilitic cells. 
 You will notice that I have not mentioned syphil- 
 itic roseola, and you perhaps fail to see how we are 
 going to explain it, but by a little roundabout 
 pursuit, I think we can again catch our cell at work, 
 not this time by a localized accumulation, but pro- 
 ducing the syphilitic roseola by its effect upon the 
 sympathetic system, which becomes manifest in 
 capillary dilatation and stasis. I think I have 
 shown you the potency of the syphilitic cell in the 
 pathology of syphilis, and I will next endeavor to 
 demonstrate the therapeutic importance of a thor- 
 ough knowledge of its properties and actions. 
 
Lecture II. 
 
 Initiatory period.— Importance of a knowledge of the properties of the 
 syphilitic cell in the therapeusis of the disease. — Anatomy and his- 
 tology of the chancre and of syphilitic lymphitis and adenitis, so- 
 called. —Condition of glands in general adenopathy.— Definition of 
 the initiatory period.— Varieties of induration of chancre.— Cause of 
 chancrous " ulcers."— Extent of induration. — Duration of i dura- 
 tion.— Character of chancrous secretion.— Cicatrix of chancre.— 
 Chancrous secretion not auto-inoculable.— Course of syphilis in 
 hetero-inoculation. — Vaccinal syphilis.— Multiple chancre. — Poison- 
 bearing secretions of syphilis.— Necessity for the presence of the 
 syphilitic cell in contagious secretions of syphilis. 
 
 Gentlemen: — In my last lecture, I endeavored 
 to demonstrate in a general way, the pathological 
 importance of the syphilitic cell, by following 
 it in its tour of mischief, and noting briefly its 
 results. Now, as I have already stated, this cell 
 is not only important as regards the pathology of 
 syphilis, but a knowledge of its properties and 
 actions, is absolutely indispensible to the intelli- 
 gent application of remedies to the cure of the 
 disease. We will premise that the natural course 
 of the syphilitic cell is to accumulate in, and ob- 
 struct, various tissues, thereby forming neoplastic 
 masses very similar in structure to inflammatory 
 neoplasia, and finally to undergo retrograde meta- 
 morphosis and elimination, which result eventually 
 in spontaneous cure of the disease.* The danger 
 of permanent injury to the tissues is proportionate 
 
 * Vide Otis, "Physiology and Pathology of Syphilis." 
 
30 Lectukes on Syphilis. 
 
 to the amount of the accumulated cells, and the 
 length of time they remain in contact with the nor- 
 mal tissues, thereby producing secondary changes 
 in their structure. Understanding these facts, we 
 most naturally seek for remedies, the administra- 
 tion of which tends to remove new formations and 
 cell accumulations, by favoring or directly inducing 
 retrograde metamorphosis in, and elimination of, 
 such morbid material. These remedies will receive 
 attention later on, as I now wish merely to impress 
 you with the importance of an accurate knowledge 
 of the pathology of syphilis in explaining the ra- 
 tionale of their action. You will readily appreciate 
 the fact that a careful study of the characteristic 
 cell which constitutes the basis of all syphilitic 
 processes, will enable you to thoroughly under- 
 stand the disease in all its manifold forms. 
 
 Now let us see how this little cell which I have 
 already described to you, brings about the various 
 changes characteristic of syphilis. As we have 
 seen, the first manifestation of syphilis is a peculiar 
 lesion characterized by induration. This is due to 
 a localized accumulation of cells, which are infil- 
 trated in the meshes of the connective tissue, and 
 the adventitia of the blood vessels, forming a cir- 
 cumscribed mass. The cells vary somewhat in 
 their general characteristics, those in the coats of 
 
Lydston. 31 
 
 the vessels being either round, spindle-shaped, or 
 branched, but the bulk of the mass consists of the 
 characteristic round, multinucleated granular cell, 
 which we have already known to be a modified 
 leucocyte. These changes are very similar to those 
 seen in simple dermatitis excepting that there is no 
 serous exudate, the induration being consequently 
 dry and hard. This absence of fluid is due to the 
 thickened walls and contracted lumen of the vessels, 
 which renders it difficult for the serum to exude 
 from them. For the same reason, there is anaemia 
 and innutrition of the neoplasm.* 
 
 The small blood vessels throughout the body are 
 surrounded by "peri-vascular lymph spaces", and it 
 is even claimed that the tunica adventitia of the 
 smaller vessels is really a part of the lymphatic 
 system. You may thus readily see how intimately 
 the blood and lymphatic vessels are associated. 
 There is a constant current from the tissues to the 
 lymphatics, and it is very evident that after a time 
 the morbid cells about the neoplasm must neces- 
 sarily as they extend, enter the lymphatic circula- 
 tion. This explains the circumscription of the 
 induration, the cells, after a certain time, being 
 removed as fast as formed, thus limiting their local 
 development. We will now assume the ground 
 that the first manifestations of syphilis are purely 
 
 * Vide Besiadecki. 
 
32 Lectures on Syphilis. 
 
 local, and see if we can give a logical explanation 
 of them . 
 
 In a few days after the development of the initial 
 induration of syphilis, or chancre, the lymphatic 
 vessels leading from the infected surface begin to 
 enlarge and become hardened, feeling often like 
 pieces of pencil or wire under the skin. This is 
 due to a low grade of inflammatory change, asoci- 
 ated with a localized cell proliferation. Now, it 
 may seem strange to you that this alteration in the 
 lymphatics does not occur immediately after the 
 appearance of the chancre, instead of after an in- 
 terval of some days, but it is explained by the fact 
 that the cell accumulation constituting the chancre 
 must extend until a lymphatic vessel of some size 
 is reached before the cells can enter the lymphatic 
 current, the absorptive power of the small lymphat- 
 ics being annulled by pressure and local irritation. 
 A strong argument in favor of this view is the fact 
 that the period of incubation is shortest, and the 
 chancre smallest, in those parts most richly sup- 
 plied with lymphatics. There is also less connec- 
 tive tissue proliferation in such localities. An ex- 
 ample of this, is chancre developed beside the 
 frsenum praBputii. The changes in the lymphatic 
 vessels gradually extend along their course, the 
 morbid and infectious cells meanwhile travelling 
 
Lydston. 33 
 
 slowly on in the lymph current, and finally reach- 
 ing the lymphatic glands. Enlargement of the 
 glands now occurs, those nearest the primary sore 
 being the first to enlarge, but general syphilitic 
 adenopathy eventually occurring, and each gland, 
 however small, becoming consequently a depot for 
 the production, storing up, and finally the distri- 
 bution of the abnormal cell growth. Each lym- 
 phatic gland, as the proliferation of cells goes on 
 in its substance, becomes hard and woody to the 
 touch, being nothing more or less than a neoplastic 
 growth precisely identical with the chancre itself, 
 and presenting the same microscopical characters. 
 The changes at the site of infection, and in the 
 lymphatic glands first involved, may be termed 
 the "initiatory period" of syphilis, and up to this 
 time no blood changes have become manifest, all 
 the changes being apparently local. I will now 
 leave the consideration of the progress of the syph- 
 ilitic cell, inasmuch as we have traced it to its des- 
 tination in the lymphatic glands, and allow it to 
 remain undisturbed until we have given a little 
 more attention to the initial lesion, and other im- 
 portant points in the study of syphilis. 
 
 In the first place the initial induration may pre- 
 sent itself under several different forms, a study of 
 which will be quite profitable. 
 
34 Lectures on Syphilis. 
 
 1st. The first form is what is termed the parch- 
 ment induration, which usually underlies an ulcer- 
 ation, and may escape notice unless carefully 
 sought for by pinching up the lesion with the 
 thumb and finger, in such a manner as to press 
 lightly upon its edges without bending it. This is 
 the commonest form according to some authorities, 
 and I have found it so in hospital practice. The 
 last four or five cases that I have met in private 
 practice have, however, been beautiful examples 
 of the Hunterian chancre. 
 
 2d. The induration may be somewhat like a split 
 pea beneath the skin, its convex surface being capped- 
 by the ulceration. This induration is plainly 
 marked, and freely movable with a feel like wood 
 or bone, or perhaps more nearly like cartilage. 
 
 3d. The induration may be quite extensive and 
 extend beyond the bounds of the ulceration, reach- 
 ing very often, the size of a chestnut or almond. 
 There may or may not be ulceration. When an 
 induration of this description is ulcerated, its con- 
 vexity is sometimes capped with a funnel-shaped 
 ulcer, the whole constituting the so-called Hunter- 
 ian chancre. We meet with many cases in which 
 there is merely a hard purplish lump with no ulcer- 
 ation, or at most a very superficial erosion capping 
 the induration. 
 
Lydston. 35 
 
 4th. There is a variety of the parchment indu- 
 ration sometimes seen, which is especially apt to 
 escape attention, so insignificant does it seem. It 
 consists in a very superficial cell infiltration, pre- 
 senting a very slight induration when lightly 
 pressed upon. In appearance it is a slightly 
 brownish patch covered by very fine scales, not 
 unlike a minute patch of psoriasis.* 
 
 The occurrence of ulceration in the chancre is 
 quite important, and is explicable aside from the 
 various sources of irritation which may exist as an 
 exciting cause, by the histological characters of 
 the lesion. As we have seen, the chancre consists 
 of a localized cell accumulation, which not only 
 presses upon the capillaries, but actually invades 
 their walls, thus causing a diminution of the blood 
 supply and a relative anaemia and innutrition of 
 the neoplasm and the tissue involved by it. This 
 innutrition gives rise to molecular disintegration 
 of the superficial layers of the lesion, which break 
 down and form an ulcerated surface. This process 
 is termed by Besiadecki, "anaemia of tissue," and 
 by Virchow, "necrobiosis". The secretion of this 
 ulcer is scanty when unirritated, for the same 
 reason £iven for the hardness and dryness of the 
 induration, viz., absence of serous effusion. It 
 
 * Called by Otis, superficial induration in the form of the "dry 
 scaling patch." 
 
36 Lectures on Syphilis. 
 
 contains, however, the syphilitic germinal cell, 
 and is highly contagious. 
 
 The induration of chancre is variable in its ex- 
 tent according to the tissues in which it is situated, 
 and is proportionate within certain limits to the 
 extent of surface primarily infected, e. g. , when 
 a cut or abrasion is inoculated with the syphilitic 
 poison, the resulting chancre is likely to assume 
 the size and conformation of the traumatic lesion. 
 Chancres of the nipple, lips, skin, and behind the 
 corona glandis are likely to be extensively indu- 
 rated. In such spongy tissues as the glans penis, 
 the induration is apt to be very slight. The spar- 
 sity of connective tissue beneath the mucous mem- 
 brane, and the extreme tenuity of the mucous 
 membrane itself, will perhaps serve to explain the 
 latter fact. In quite rare cases of chancre, or ap- 
 parently simple lesions followed by constitutional 
 syphilis, induration appears to be entirely absent, 
 but this is perhaps due to the fact that it has been 
 overlooked through inattention, or its co-existence 
 with chancroid, or it is so slight as not to attract 
 attention. After a chancre becomes phagedenic, 
 induration at once disappears. In other instances 
 a sore may not be watched long enough, or indura- 
 tion appears and disappears within a very short 
 space of time. 
 
Lydston. 37 
 
 In simple chancre the induration most generally 
 precedes the ulceration, but it often follows it, 
 coming on in the course of the first week. This is 
 usually due to infection with some local irritant, 
 chancroidal or otherwise,, simultaneously with the 
 syphilitic infection, and is the invariable course of 
 mixed sores, and it is highly probable that the ma- 
 jority of cases in which induration follows, instead 
 of preceding, ulceration, are primarily either chan- 
 croid, or simple exulceration. In fact I am inclined 
 to believe that this is always the case, and we may 
 accept the rule that, syphilitic ulceration is always 
 due to ^necrobiosis" or "ancemia of tissue" unless 
 there exists some source of irritation, simple or 
 specific. I emphasize this more particularly be- 
 cause this method of ulceration is the type of tissue 
 destruction, seen throughout the entire course of 
 syphilis, and I wish you to remember ulceration as 
 in certain instances the result of simple innutrition 
 from pressure and tissue obstruction. It matters 
 not whether the molecular disintegration produced 
 by the syphilitic neoplasia, or occurring within 
 them, results in an open lesion, as an ulcer, or 
 occurs in the form of a softening node or a pustule, 
 the process is the same throughout. If you will 
 but remember this fact, gentlemen, you will have 
 no difficulty in comprehending the pathology of 
 syphilis. 
 
88 Lectures on Syphilis. 
 
 Induration of a chancre may be very transitory, 
 and as I have already indicated, may disappear so 
 rapidly as to be overlooked. It has been observed 
 to last only twelve days, but such cases are very 
 exceptional, the ordinary duration being from one 
 to three months, but in rare cases lasting for some 
 years. The discharge of a syphilitic chancre is 
 very scanty and sero-purulent, for reasons already 
 given, and retains these characters throughout, 
 unless the sore becomes inflamed, in which case it 
 becomes profuse and purulent, and perhaps bloody. 
 Some cases of chancre appear to exhibit a marked 
 tendency to bleed, and I have observed a number 
 of cases in which this symptom was quite persistent 
 and recurred upon the slightest manipulation of 
 the sore.* The scar left by chancre, depends upon 
 the depth of the ulceration, and in many cases noth- 
 ing is left but a livid or ham-colored spot, which 
 perhaps becomes of a coppery hue later on, and 
 finally fades completely. 
 
 I have already mentioned the fact that syphilis is 
 not auto-inoculable, this being a very important 
 point in the differentiation of chancre and chan- 
 croid. Many attempts have been made with syph- 
 ilitic secretions, and especially the secretion of the 
 chancrous ulcer, but auto-inoculation has thus far 
 been found impossible as a rule. When a chancre 
 
 *The so-called "hemorrhagic chancre." 
 
Lydston. 39 
 
 is inflamed and secreting profusely, its secretion 
 will produce a pustule if auto-inoculated, acting 
 in precisely the same manner as any other irritant. 
 This pustule may be followed by ulceration, but 
 never by hard chancre. There is a question in my 
 own mind, whether, if blood be drawn from an in- 
 itial lesion before ulceration occurs, i. e. early 
 enough in the course of chancre, it may not be ca- 
 pable of inoculating the individual possessing the 
 lesion. This doubt is due to my inclination to the 
 belief that syphilis is primarily local, and has been 
 enhanced by a recent case which I have observed. 
 I excised a large indurated chancre with a slight 
 surmounting ulceration, from the penis of one of 
 my patients, taking the precaution to wait until the 
 process was apparently stationary, and the chancre 
 fully developed. The ulcer was first cauterized to 
 prevent contamination of the wound by its secre- 
 tion, after which the indurated tissue was thoroughly 
 excised, the incisions being made well beyond the 
 borders of the diseased tissues. An irregular 
 wound was left, which was closed with several cat- 
 gut sutures. On the second day, the wound had 
 united and everything looked well, but on the 
 fourth day, induration of the edges of the wound 
 began, and in a few days had involved their entire 
 extent, and the surrounding tissues for some little 
 
40 Lectures on Syphilis. 
 
 distance, and finally attaining the size of an almond, 
 being at least twice the size of the chancre excised. 
 Now all this looked very singular, as 1 had removed 
 all the indurated tissue, and if constitutional syph- 
 ilis already existed, no infection of the cut surfaces 
 should have occurred. As I can see no other ex- 
 planation, I believe that the infection took place 
 through the medium of the blood which escaped 
 from the chancre. It is certainly peculiar that the 
 resulting chancre should be proportionate in extent 
 to the cut surfaces, and of a similar shape. But 
 one swallow does not make a summer, so we will 
 have to accept the diction that syphilis is not auto- 
 inoculable. 
 
 The course of syphilis in hetero-inoculation is in- 
 teresting. When any secretion containing the 
 syphilitic cells, such as discharge from a syphilitic 
 chancre or mucous patch, or blood from a syphilitic 
 subject, is inoculated upon a healthy individual, 
 there may be a small pustule following, just as a 
 fester may form from the prick of a clean lancet, 
 but this only lasts a few days, and is generally ab- 
 sent, there being nothing to indicate the site of the 
 inoculation unless perhaps a speck of dried blood, 
 until after a period of from ten to forty days, when an 
 indurated papule appears. This becomes ulcerated 
 most likely, but may not do so ; the neighboring ly m- 
 
 
Lydston. 41 
 
 phatics become enlarged, and general syphilis fol- 
 lows. In cases of vaccinal syphilis, or syphilis ac- 
 quired accidentally in the operation of vaccination, a 
 somewhat different course is followed. The incu- 
 bation period of vaccinia expires first, the charac- 
 teristic vesicle appearing and running its usual 
 course. After a time, however, the vaccine vesicle 
 becomes an ecthymatous ulcer with an indurated 
 base, or induration appears and runs its course 
 without ulceration. When a subject already syph- 
 ilitic is vaccinated, we are likely to have a char- 
 acteristic secondary syphilitic ulcer resulting, after 
 the typical vaccinal vesicles have first formed. 
 Such an instance recently occurred in one of my 
 own patients, although he was under the influence 
 of mercury at the time. A very important source 
 of error with regard to vaccinal syphilis, and one 
 which you should always bear in mind, is that the 
 local and constitutional disturbance produced by 
 vaccinia, is liable to develop latent syphilis, whether 
 hereditary or acquired, and that the vaccinator will 
 probably get the credit of having inoculated the 
 disease. In such cases you will usually observe a 
 more or less general eruption starting in the vicin- 
 ity of the sore, instead of the typical period of in- 
 cubation, followed by typical induration and after 
 a variable interval, by glandular enlargement and 
 general syphilis. 
 
42 Lectures on Syphilis. 
 
 When the syphilitic poison is inoculated upon a 
 number of raw surfaces simultaneously, or after a 
 few days' interval, chancre appears usually at each 
 point at about the same time. This is a valuable 
 point in differential diagnosis, for chancre, unlike 
 chancroid, is usually multiple from the beginning, 
 or not at all, while chancroid may become multiple 
 by auto-inoculation. A few apparent exceptions to 
 this rule have been noted, and Wallace cites a case 
 in which he succeeded in inoculating a man with 
 syphilitic u virus," and producing a true chancre 
 when the patient was already in the eruptive stage 
 of the disease. Fournier estimates that about two 
 per cent, of auto-inoculations of true chancre are 
 successful, but presumably only when some inflam- 
 matory change in the sore exists. I have already 
 expressed my belief that a greater proportion 
 might be successful if performed sufficiently early 
 in the course of the disease. The practical rule, 
 however, is that auto-inoculation of true chancre, 
 is not feasible, but may possibly succeed very early 
 in the course of the disease. In the sta^e of sc- 
 quelce i. e., the so called ''tertiary period" the se- 
 cretion of chancre in another person may be inocu- 
 lated, although rarely. 
 
 The consideration of the various secretions, phy- 
 siological and pathological, capable of transmitting 
 syphilis is very important, and they have been 
 
 
Lydstox. 43 
 
 quite exhaustively studied by different observers 
 among the most thorough of which have been Bas- 
 sereau, Diday, Rollet, Fournier and Clerc. These 
 well-known investigators have arrived at practically 
 the same conclusions. Inoculations with the secre- 
 tion of chancre, mucous patches, any secondary 
 cutaneous or mucous lesion capable of yielding a 
 discharge, and of syphilitic blood have been made 
 with entire success. Whether the blood is poison- 
 ous between the periods of active manifestations of 
 the disease, has not been determined by experiment 
 but from observations made upon vaccinal syphilis, 
 it probably is inoculable, and I can see no logical 
 reason why it should not be so, inasmuch as each 
 successive crop of lesions is not due to new devel- 
 opment of the syphilitic germinal cells, but to their 
 renewed activity. The secretions of lesions not 
 syphilitic, occurring upon a syphilitic subject, are 
 not inoculable unless mixed with blood, e. g. , the 
 secretions of gonorrhoea and chancroid occurring 
 in a syphilitic subject, produce only gonorrhoea 
 and chancroid, unless there be an admixture of 
 syphilitic blood. Diday inoculated pus from acne 
 pustules, produced by the iodide of potassium on a 
 syphilitic subject, but with negative results. It 
 is also true that vaccine lymph derived from a 
 syphilitic subject, is not capable of producing syph- 
 ilis, unless it contains some of the patient's blood, 
 
44 Lectures on Syphilis. 
 
 This should render us none the less cautious, how- 
 ever, for it is very easy for a small quantity of 
 blood to become mixed with the lymph, and 
 remain undetected. The vaccine scab, from a 
 syphilitic patient, is always dangerous, as it invari- 
 ably contains a certain proportion of dried blood in 
 its composition. Inoculations with the secretions of 
 tertiary lesions and with blood during the tertiary 
 stage of syphilis are negative, although there have 
 been apparent exceptions to this rule. Bumstead 
 relates a case of inoculation of a surgeon's finger 
 while operating upon a case of tertiary necrosis of 
 the skull, and I may also cite the case of one 
 of my personal friends who inoculated his 
 finger while operating upon a rectal fistula in a 
 patient suffering from tertiary syphilis. In due 
 time a chancre appeared, and was followed by a 
 well-marked development of secondary manifes- 
 tions.* 
 
 The non-transmissibility of syphilis during the 
 tertiary period of the disease is perhaps the strong- 
 est evidence in favor of the view that the lesions of 
 this stage are not syphilitic at all, but are simply 
 sequelae. Patients suffering with tertiary mani- 
 festations, may procreate healthy children, but do 
 
 *The possibility of such cases as those cited, being illustrations 
 of re-infection of subjects suffering from "sequelae" of a previous 
 attack, must be remembered, otherwise, they would seem to refute 
 the "physiological pathology." 
 
 
Lydston. 45 
 
 not always do so, and I think that in many cases 
 in which the children are fairly healthy, and can- 
 not be pronounced syphilitic, there will be some 
 slight manifestations of hereditary taint, such as 
 imperfect or irregular development of the teeth or 
 those different manifestations of faulty nutrition 
 which we are wont to accept as evidences of a 
 strumous diathesis. Hutchinson's ideas regarding 
 the efficacy of mercury and iodine in struma, have 
 probably a basis quite different from the supposed 
 " anti-strumous " action of these remedies. The 
 term " attenuated syphilis," would be fitting for 
 many cases of "scrofula." As a rule, however, 
 we may accept the statement that tertiary syphilis 
 is not transmissible. The later the period of the 
 disease, the less the liability to transmission, and 
 it is also probable that the male loses the power of 
 transmission before the female. None of the 
 physiological secretions, such as mucus, sweat, 
 urine, milk, and semen are inoculable, unless they 
 contain either syphilitic blood, or the secretion of 
 a syphilitic lesion. The saliva, so often the me- 
 dium of contagion, is innocuous unless mucous 
 patches or other lesions exist in the mouth, in 
 which case, it is contagious in the highest degree. 
 The syphilitic cell (bacillus?) must be present, or no 
 secretion, physiological or pathological, can trans- 
 mit syphilis. 
 
Lecture III. 
 
 Modes of conveying syphilis.— Constitutional syphilis always preceded 
 by chancre, save when foetus is infected by the mother, or vice versa. 
 —Explanation of the occasional apparent escape of mother, when 
 child is born syphilitic. — Escape of foetus when the mother is infected 
 after the seventh month of pregnancy —Impossibility of inoculation 
 with syphilis when the epithelium is intact.— Mediate and immediate 
 methods of transmission.— Danger of infection by kissing. — Danger 
 of infection of nurses by syphilitic children, and vice versa.— Colles' 
 law. — Example of infection of a number of persons by an hereditarily 
 syphilitic child. — Transmission of syphilis by a healthy woman. — 
 illustrations of mediate transmission. — Number, location and dura- 
 tion of chancre. —Varieties of chancre. — Urethral chancre. — Compli- 
 cations of chancre.— "Mixed sores." — Transformation of chancre. — 
 Treatment of chancre.— Syphilitic bubo. 
 
 Gentlemen: — At the conclusion of my last lec- 
 ture, I had finished the consideration of the various 
 secretions capable of transmitting syphilis, and this 
 morning we will devote a few moments to the dis- 
 cussion of the various modes of transmission of the 
 disease. As we have seen, the presence of the 
 syphilitic cell is all that is necessary to render any 
 secretion, whether physiological or pathological, 
 extremely contagious, and in the absence of this 
 cell no contagion can occur. Inasmuch as every 
 morbid secretion due to syphilitic lesions, contains 
 the syphilitic cell; and the lesions of syphilis are 
 many and various, occurring in any situation, we 
 can readily appreciate the fact that the opportuni- 
 ties for transmitting the disease, and the methods of 
 its contraction are very numerous. The contag- 
 
48 Lectures on Syphilis. 
 
 iousness of the blood of syphilitic subjects during 
 the active period of the disease, affords an additional 
 danger, as there are several ways in which it may 
 be accidentally inoculated. The initial lesion of 
 syphilis or chancre, may occur upon any portion of 
 the human body, the only essential requisites for 
 its production being a secretion containing the syphi- 
 litic cell, and a surface, integumentary or mucous, 
 which has been deprived of its epithelium, and is 
 consequently capable of absorption of extraneous 
 matter. 
 
 In every method of transmission of syphilis, with 
 the exception of two, the general disease is always 
 preceded by a chancre, and its existence may be 
 inferred, whether it has been detected or not. The 
 circumstances in which a chancre is never present 
 are, the infection of the child in utero, and the 
 infection of the mother through the medium of the 
 child. Under such circumstances, the syphilitic 
 cells enter the blood current directly, and not 
 through the medium of a localized process of pro- 
 liferation, followed by a round-about tour of the 
 lymphatics. Probably the same thing would occur 
 if the vsyphilitic virus were injected directly into a 
 large blood vessel. In case the father of the child 
 is syphilitic, and the mother healthy, the child may 
 escape infection, because the virus is temporarily 
 inactive in the father; either spontaneously, or from 
 
Lydston. 49 
 
 treatment, or the disease may be so far advanced in 
 the stage of sequelae that it ceases to be transmiss- 
 ible. Some authorities deny that the child can be 
 infected by the father directly, claiming that such 
 infection can only occur through the medium of 
 the mother, but it seems to me that this view can 
 hardly be correct, for syphilis is surely quite as 
 capable of being transmitted in this manner, as are 
 other morbid constitutional conditions. It may at 
 least be transmitted as a dyscrasia, if nothing more, 
 and I have seen instances apparently bearing out 
 both this assertion, and the possibility of transmis- 
 sion of syphilis proper.* When the mother is syph- 
 ilitic the child is invariably infected, unless a 
 thorough course of treatment be instituted during 
 the period of pregnancy, in which case it may pos- 
 sibly escape. Oftentimes, however, the children 
 of syphilitic women may not develop the disease 
 until late in life, thus leading to the supposition 
 that they have escaped the disease. In such in- 
 stances, the disease expends its violence upon the 
 maternal organism, and probably acts in a manner 
 somewhat analogous to vaccinia. When the mother 
 is infected after the seventh month of pregnancy, 
 the child usually escapes, a point in verification of 
 
 *Otis however, claims, and with reason, that the presence of the 
 syphilitic cell, would inevitably prove fatal to the vitality of the sper- 
 matozoa, and that consequently the child cannot become infected, 
 save through the maternal circulation. 
 
50 Lectures on Syphilis. 
 
 the views of the pathology of syphilis which I have 
 in part given you, and which we will shortly dilate 
 upon rather more fully. 
 
 The second mode of contracting syphilis without 
 the occurrence of a chancre, is the infection of the 
 mother through the medium of the child. This 
 too, is denied by many, but I believe it to occur, 
 although I am willing to admit that the mother 
 often apparently escapes the disease entirely or has 
 very mild symptoms. In explanation of this fact 
 also, w^e have the possible analogy of the foetal infec- 
 tion, to vaccination, first suggested I believe by 
 Hutchinson; syphilis in the mother being modified 
 greatly, or entirely prevented by the infection of the 
 child, in much the same manner that variola is mod- 
 ified or prevented by vaccination. The disease ex- 
 pends its violence upon the child in utero, thus ren- 
 dering the subsequent infection of the mother com 
 paratively mild, if indeed it occur at all. 
 
 I have stated that all that is necessary for the 
 transmission of syphilis, is the contact of a secretion 
 containing the syphilitic cell with an abraded sur- 
 face. Now, in many instances, no abrasion is 
 perceptible, but we infer that it must necesarily 
 have existed, inasmuch as the poison cannot be ab- 
 sorbed by the unbroken epithelial surface. Whether 
 the secretion containing the syphilitic virus may 
 
Lydston. 51 
 
 remain in contact with a sound surface of mucous 
 membrane, until maceration and removal of its epi- 
 thelium with subsequent absorption occurs, is not 
 positively known, but it is highly probable, and 
 may undoubtedly occur in the case of secretion 
 from a mixed sore, which is usually quite corrosive 
 in character. 
 
 The methods of contagion in syphilis are classi- 
 fied as mediate, and immediate. By the mediate 
 method we understand the transmission of the dis- 
 ease through the medium of infected drinking 
 utensils, tobacco pipes, towels, etc. Chancroid is 
 very rarely transmitted in this way, but syphilis is 
 quite often so transmitted on account of the 
 multiplicity of its lesions, which are apparently 
 so insignificant sometimes, but none the less infec- 
 tious. By the immediate method of contagion we 
 mean the direct contact of an abraded surface in a 
 healthy person, with a syphilitic lesion, or syphilitic 
 blood from a non-syphilitic lesion in a syphilitic sub- 
 ject. The type of this mode of contagion, is of 
 course, infection during sexual intercourse, but it 
 may be contracted in many other ways ; quite often 
 it is contracted by the physician or surgeon, in opera- 
 ting upon or examining syphilitic subjects. Some 
 of our prominent obstetricians and gynaecologists 
 have had sad experiences in this respect. Chancre 
 
52 Lectures on Syphilis. 
 
 is sometimes contracted in kissing, a little mucous 
 patch upon the lips or tongue of the diseased per- 
 son inoculating any slight fissure or abrasion upon 
 the lips of the healthy subject. I have known of 
 very sad examples of this method of contagion. 
 A short time since, I treated a young married man 
 for chancre of the tongue contracted in this man- 
 ner, and I have seen several probably innocent 
 women with labial chancre. Infants may contract 
 syphilitic chancre from the nipples of syphilitic 
 nurses, and on the other hand, a healthy nurse may 
 contract chancre of the nipple, from a syphilitic 
 infant. Colles' law, so-called, that a hereditarily 
 syphilitic infant, cannot infect its mother, depends 
 simply upon the fact that in many cases the mother 
 already has, or has had syphilis, or as already sug- 
 gested, the possible analogy to vaccinia may explain 
 it, the syphilization of the infant having afforded im- 
 munity for the mother. For my own part, I have 
 strong doubts as to the potency of this so-called 
 law of Abram Colles, and hold to the opinion that 
 a syphilitic infant should never be nursed by an 
 apparently healthy mother. My views upon this 
 subject will be presented hereafter. 
 
 As an illustration of the danger of immediate 
 contagion, in case one member of a family should 
 contract syphilis, I will mention an instance which 
 
Lydston. 53 
 
 I reported in the N. Y. Medical Record a few 
 months ago : A young married man contracted 
 syphilis, and communicated it to his wife, who was 
 then in the seventh month of pregnancy. The 
 child was born apparently healthy, and remained 
 so up to the age of three years, when it died of 
 some acute disease of the lungs, not supposed to be 
 of a syphilitic character. A second child was 
 born sixteen months later, which was unequivo- 
 cally syphilitic. From this child, its grandmother 
 and one aunt, contracted chancre of the mouth, and 
 the grandmother subsequently infected the grand- 
 father, after which the disease was diagnosed by 
 the family physician. Thus from the indiscretion 
 of one member of the family, five innocent persons 
 were infected with syphilis. The fact that the 
 first child apparently escaped, is important as bear- 
 ing out the assertion of Diday, that in case the 
 mother is infected after the seventh month of 
 utero-gestation, the foetus escapes the disease. 
 
 There are many interesting examples of the 
 mediate method of contracting syphilis. Instances 
 have been known in which a man with a long pre- 
 puce, has had intercourse with a syphilitic female, 
 and shortly afterward with his wife, infecting the 
 latter, while he himself escaped the disease, the 
 virus, having been retained beneath the prepuce and 
 
54 Lectures on Syphilis. 
 
 subsequently deposited in the healthy vagina. 
 Again, the syphilitic poison may be deposited in 
 the vagina of a female, by her lover, and her hus- 
 band, embracing her shortly afterward, receives the 
 souvenir the lover left him, while the woman herself 
 escapes. These facts must be borne in mind, for 
 they may be of service to you hereafter. Tobacco 
 pipes, drinking utensils, and the tubes used by 
 glass-blowers, are familiar media of syphilitic con- 
 tagion. There is an instance related, in which a 
 whole glass-blowing establishment became infected 
 by the blow pipe, as it was passed from mouth to 
 mouth. In this case, one of the workmen had a 
 few small mucous patches in his mouth, and from 
 this man, the whole party contracted syphilis. 
 Vaccination is also a familiar mode of contagion, 
 less frequently however, than is generally sup- 
 posed, for if the meanness ot generations past, 
 should happen to manifest itself at the time of the 
 vaccination, particularly if humanized virus is 
 used, the trouble is invariably laid at the door 
 of the dgctor. An interesting instance of the 
 wide dissemination of syphilis by mediate trans- 
 mission is that in which an entire community was 
 infected by an itinerant tattoo artist, who used his 
 own saliva in mixing his inks. The usual explana- 
 tion of mucous patches in the mouth, holds true in 
 this case. 
 
Lydstox. 55 
 
 The duration of syphilitic chancre is variable. 
 It ma} 7 last for a couple of weeks, and in the major- 
 ity of cases, an eruption appears prior to the disap- 
 pearance of the chancre. Chancre is generally 
 single, but may be multiple, according to the num- 
 ber of points primarily inoculated. It is usually 
 situated upon the genitals, and particularly behind 
 the corona glandis in the male, but its situation 
 may vaiy greatly, as may be readily seen upon 
 considering its numerous methods of contagion. 
 Chancres of the face, tongue and nipple are not so 
 very rare, and instances of chancre of the tonsil 
 have been reported. Urethral chancre is not un- 
 commonly seen. 
 
 I have already described to you, the various 
 forms of induration of chancre, but a further des- 
 cription of the sore, particularly of the ulceration, 
 may be of service. A chancre may consist of (1) 
 An erosion, (2) An ulceration, (3) A deep funnel- 
 shaped ulceration or (4) of a dry indurated papule.* 
 (1) Erosion is said to include about two-thirds of 
 chancres, and is usually situated upon mucous mem- 
 brane, very often inside the prepuce. In shape it 
 is oval or perhaps a trifle irregular, with a raw, 
 polished surface of a wine red color, and sometimes 
 a pultaceous base, but usually secreting a simple 
 
 * Vide Vanburen and Keyes, " Genito-Urinary Diseases with 
 Syphilis." 
 
56 Lectures on Syphilis. 
 
 thin, sanious fluid, devoid of pus, or at least con- 
 taining a very small amount of pus corpucles. 
 These erosions are flat and may surmount a thin 
 parchment induration, or may cap a hard lump as 
 large as a marble. (2) Superficial ulceration with 
 sloping edges is found with the parchment, or most 
 often with the split pea induration. (3) When this 
 ulceration caps a large mass of induration, it is 
 likely to be quite deep and funnel-shaped, consti- 
 tuting the so called "Hunterian chancre." The 
 secretion from a chancrous ulceration, is quite 
 likely to be of a sero-purulent character. (4) The 
 indurated papule, is usually seen upon the skin, or 
 upon the integument of the penis, or even upon 
 the prepuce when it is short and dry. Ulceration 
 of this form of induration might occur, if it were 
 kept moist, the conditions of warmth, moisture 
 and irritation combined, being especially favorable 
 to the production of ulceration. I think that the 
 parts upon which it develops, are not so rich in 
 lymphatic spaces as those tissues in which a chan- 
 cre is more likely to ulcerate, the collection of cells 
 being consequently smaller, and the tendency to 
 necrobiosis less marked. 
 
 The symptoms ot urethral chancre when too 
 deep to be seen, consist in a discharge coming on 
 after the usual period of incubation, this discharge 
 
Lydston. 57 
 
 being thin, and perhaps sanious, but sometimes 
 creamy and thick, and a painful spot in the urethra, 
 which is especially noticeable during micturition 
 and erection, with possibly a lump in the course of 
 the canal, which is plainly perceptible on palpation 
 with the thumb and finger, in some cases. By 
 means of the endoscope, an ulcer may be detected, 
 and in a short time the general enlargement of the 
 glands and other symptoms, clear up the diagnosis. 
 There are some complications of syphilitic chan- 
 cre that are worthy of attention : 1st. First and 
 simplest we have vegetations or warty growths — 
 the so-called venereal warts, which result from 
 local irritation, in combination with heat and moist- 
 ure, and are identical with those occurring under 
 other circumstances. Proper measures of cleanli- 
 ness will prevent their formation, but if they 
 appear in uncleanly persons, caustics or the scissors 
 are necessary for their removal. 2d. Inflamma- 
 tion of chancre sometimes occurs, giving rise to 
 considerable pain and profuse purulent secretion. 
 3d. Chancre may be complicated by chancroid, 
 constituting a " mixed sore," unless the two forms 
 of disease appear in different localities. When a 
 chancre becomes inoculated with chancroid, its 
 ulceration deepens, and it gradually assumes the 
 general characters of chancroid, but unless: phag- 
 
58 Lectures on Syphilis. 
 
 edaena occurs, induration still persists. When 
 chancroid develops primarily, it runs its usual 
 course, until the incubation period of syphilis has 
 elapsed, when induration occurs. The secretion of 
 the u mixed sore, "is auto-inoculable, and is capable 
 of transmitting either disease alone, or both 
 together, to a healthy person. In some cases chan- 
 croid appears and rapidly heals, or the incubation 
 period of syphilis is long, and we have induration 
 developing in the cicatrix of the chancroid, after it 
 has perfectly healed. The test for mixed chancre 
 is auto-inoculation : Any indurated sore, the secre- 
 tion of which is auto-inoculable, in the true sense 
 of the word, and which is followed by constitu- 
 tional syphilis, is a " mixed chancre" When we 
 use the term " auto-inoculable" we mean a sore, the 
 secretion of which, inoculated in a new situation in 
 the diseased individual, will produce chancroid. 
 The methods of contraction of mixed chancre are 
 two, viz : Both poisons may be contracted simul- 
 taneously, or either form of sore may develop pri- 
 marily, and subsequently become inoculated with 
 the other form of disease. 
 
 Typical syphilitic chancre, may undergo marked 
 transformations, e. g. a chancrous induration, par- 
 ticularly when situated in a moist locality, may lose 
 its hardness, and at the same time become trans- 
 
Lydston. 59 
 
 formed into a mucous patch, by becoming covered 
 with a characteristic whitish pellicle. In some 
 instances the sore acquires the form of the mucous 
 patch, and nevertheless retains its characteristic 
 induration. Phagedena may attack a true chancre, 
 and when it does so, is quite likely to be of the 
 gangrenous form. The pultaceous and serpiginous 
 varieties, are quite rarely seen under such circum- 
 stances. After phagedena has once invaded a 
 chancre, induration is no longer perceptible. If 
 the sore be of the mixed variety, we are then quite 
 likely to have the pultaceous or serpiginous form 
 of phagedena. Such authorities as Bassereau and 
 Diday think that the type of syphilis following 
 phagedenic chancre is apt to be exceptionally 
 severe. This is explicable by considering the fact 
 that phagedena is due to general debility, or a 
 peculiar diathesis, which lessens the resisting 
 power to any disease, and especially to syphilis, 
 rather than by any extraordinary intensity of 
 the syphilitic infection. 
 
 The treatment of syphilitic chancre is very sim- 
 ple, when no complications exist. The yellow or 
 black wash may be applied, and constitute the 
 best applications that can be used. According to 
 the new pharmacopcea, the lotio flava or yellow 
 wash, consists of 18 grains of the bichloride of mer- 
 
60 Lectures on Syphilis. 
 
 cury to 10 ounces of liq. calcis, and the lotio nigra 
 or black wash, of 30 grains of calomel to 10 ounces 
 of liq. calcis. These preparations should be well 
 shaken before being used, or very little of the salt 
 of mercury, which exists in the form of a precipi- 
 tate, will be applied. The mild chloride of mercury 
 with zinc oxide, forms a very efficient dressing. 
 Cauterization of simple hard chancre should never 
 be practiced, as it will simply cause painful inflam- 
 mation in an otherwise insignificant lesion. If, 
 however, the sore is of the mixed variety, its chan- 
 croidal property should be destroyed by cauteriza- 
 tion, after which iodoform in powder should be 
 applied. All sources of irritation should be care- 
 fully avoided, and perfect cleanliness insisted upon. 
 When phagedena occurs, mercury is essential to 
 counteract the debilitating influence of the consti- 
 tutional poison, and for my own part I believe that 
 the internal administration of mercury should be 
 begun, as soon as the diagnosis of syphilitic chan- 
 cre is perfectly clear, and by following this course, 
 I very seldom see any manifestations of the disease 
 other than a slight roseola, with perhaps a few 
 trifling mucous patches, during the entire course of 
 treatment. It is very essential to prevent eraptions, 
 upon the face especially. Whenever, on the other 
 hand, there is the slightest doubt as to the correct- 
 
Lydston. 61 
 
 ness of the diagnosis, no mercury should be given, 
 until the question is decided by the appearance of 
 symptoms unequivocally syphilitic. 
 
 We have already noted the glandular enlarge- 
 ments that succeed the appearance of the syphilitic 
 chancre. These are sometimes termed "syphilitic 
 bubo. " It may occur in any situation where there 
 are lymphatic glands in the vicinity of a chan- 
 cre, being naturally most often found in the groin. 
 The groups of glands involved, vary according to 
 the location of the chancre. In chancre of the 
 penis, uretha, groin, buttocks, anus, lower part of 
 the abdomen, scrotum, thighs, or rectum, the 
 inguinal or femoral glands, or both, are involved. 
 In chancre of the lips and mouth, the submaxillary 
 lymphatics, and in chancre of the face, the pre-au- 
 ral gland are involved. When the finger is inocu- 
 lated, we have enlargement of the glands in the 
 axilla. General glandular enlargement eventually 
 occurs, but the changes are first evident in the con- 
 tiguous glands, and they are always more mark- 
 edly enlarged than any of the others. When the 
 inguinal glands are implicated, they are grouped in 
 a peculiar fashion. This group, termed by Ricord, 
 the u pleiad, " consists usually of one large gland, 
 surrounded by from two or three, to six or eight of 
 smaller size. The enlargement is generally not 
 
62 Lectures on Syphilis. 
 
 very great, but is peculiar in some respects. There 
 is little or no pain or tenderness, and the glands 
 are freely movable under the skin, being distinctly 
 outlined and not matted together. As a rule they 
 have the hard, woody feel of the chancre, but 
 exceptionally they are softer and more elastic. 
 Enlargement of the glands begins usually about 
 the second week after the appearance of the chan- 
 cre, and Fournier remarks a case in which enlarge- 
 ment did not occur until the twenty-seventh day, as 
 unique. Instead of the peculiar group known as 
 the pleiad, we may have a single moderately 
 enlarged gland, or perhaps an enormously swollen 
 gland as large as a hen's egg, on one or both sides. 
 Such enlargements have been carefully studied by 
 Bassereau, and found to consist of small glands, 
 matted together with enlarged lymphatic vessels 
 and firm connective tissue. 
 
 The important practical point, to which I desire 
 to call your attention in connection with syphilitic 
 bubo, is that each indurated gland is but a repeti- 
 tion of the neoplastic formations of which the 
 chancre is the prototype. It is hard, and woody, 
 comparatively painless, perfectly circumscribed, 
 and not prone to suppuration, and all because of 
 those same characteristic microscopical features, 
 which we have studied in the chancre. Under the 
 
Lydstox. 63 
 
 microscope, we have the same collection of cells of 
 several forms, the large, round, multi-nucleated 
 granular cell being in the preponderance, and the 
 same proliferation of the surrounding connective 
 tissue, that we see in a section of a hard chancre. 
 Syphilitic bubo attains its full development in 
 from one to three weeks, and may then remain 
 stationary for some weeks or months, or perhaps 
 it may last for over a year. It is usually present, 
 and may suddenly increase in size when the early 
 eruptions appear, but in exceptional instances, it 
 may speedily disappear from unknown causes. 
 Suppuration rarely attacks syphilitic bubo, and 
 when it does occur, it is the result of inflammatory 
 irritation or of a strumous diathesis, and its pus is 
 not auto-inoculable. When pas from a btibo is 
 auto-inoculdble, the primary sore must necessarily 
 have been either a mixed sore, or imre chancroid. 
 Induration of the lymphatics is so rarely absent in 
 syphilitic chancre that practically it may be said 
 to always exist. It is likely to be absent in cases 
 of second infection, and according to Ricord, is not 
 present in phagedenic chancre. I have myself 
 seen several cases of phagedenic sloughing in hard 
 chancre, in which bubo did not appear, although 
 general adenopathy developed in connection with 
 the general symptoms. I can offer no explanation 
 
64 Lectures on Syphilis. 
 
 for this, and must confess that it does not enhance 
 the strength of the position which I have assumed 
 as to the pathology of the disease, and in which I 
 have adopted the views of Otis. Such cases would 
 naturally bring up a question to which I have 
 already alluded, viz : Whether there may not be 
 two elements in syphilization, one local, and the 
 other constitutional. In cases in which there is 
 considerable subcutaneous fat, bubo may not be 
 perceptible. As a rule syphilitic buboes gradually 
 attain their maximum development, and as grad- 
 ually disappear, either spontaneously, or as the 
 effect of administration of mercury, in the same 
 manner as the chancre itself eventually resolves. 
 Although as I have stated, they rarely suppurate, 
 these glandular enlargements are prone to caseous 
 degeneration, when the subject is of a strumous 
 diathesis. Virulent suppuration may, of course, 
 ensue in cases of mixed sore, or if the sore how- 
 ever innocent in appearance at its commencement, 
 should subsequently become irritated and inflamed. 
 In the former case, the pus is auto-inoculable, but 
 in the latter it is not. 
 
 The treatment of syphilitic bubo is that of gen- 
 eral syphilis, unless suppuration occurs, in which 
 case it must be treated upon ordinary surgical 
 principles. As I shall be unable to give you a 
 
L YD ST ON. 65 
 
 special lecture upon the treatment of bubo, I 
 should be pleased to have you refer to an article in 
 the Chicago Journal and Examiner, in which I 
 have presented my views. upon the subject.* We 
 leave the subject of syphilis at this point this morn- 
 ing, gentlemen, and in my next lecture I will 
 endeavor to give you an idea of the pathology of 
 " general syphilitic infection." 
 
 * Vide Chicago Journal and Examiner, May, 1883. 
 
Lecture IV. 
 
 General infection.— Importance of a knowledge of the site of the pri- 
 mary lesion. — Universal susceptibility of the tissues to the syphilitic 
 process. — Termination of the initiatory period and commencement of 
 general infection.— Progression of the syphilitic cells.— The periods 
 of quiescence not true periods of incubation.— Explanation of the 
 apparent periods of incubation. — First manifestation of constitu- 
 tional disease.— The roseola.— Occasional coincidence of febrile and 
 other symptoms with the roseola.— The roseola not due to prolifer- 
 ation of cells.— The so-called "syphilitic fever."— Explanation of 
 syphilitic sore throat.— The syphilitic papule. — Structure of papule 
 and explanation of its occurrence. — Syphilitic alopecia and onychia.— 
 Cause of ulceration and suppuration of papule.— Mucous patches, 
 tubercles, and condylomata. — Causes and structure of the "plaques 
 muqueuse."— Syphilitic iritis.— Osseous lesions of active period.— 
 Duration of the active period of syphilis. 
 
 Gextlemex : — TTe now come to the interesting 
 topic of " general syphilis" or the u period of gen- 
 eral infection and subsequent localized cell accu- 
 mulation".* The period covering the develop- 
 ment of the chancre with its attendant and consec- 
 utive lymphitis and adenitis, which we have termed 
 the initiatory period, or if we may use the expres- 
 sion " local syphilis," is also and more frequently 
 known as u primary syphilis." Inherited syphilis 
 has no primary period, being general from its very 
 commencement, but acquired syphilis has always a 
 primary stage. This is of great practical impor- 
 tance, for wherever we meet secondary syphilis, we 
 can positively affirm that there must necessarily 
 have heen a chancre somewhere, and this must have 
 
 *Vide Otis. 
 
68 Lectures on Syphilis. 
 
 been attended by adenitis, however obscure or 
 slight the symptoms may have been. Now it is 
 sometimes very important to decide where these 
 local changes were manifest. Only a few months 
 ago, I was consulted in regard to a young lady 
 suffering with active secondary syphilis, the origin 
 of which she professed to be entirely ignorant of. 
 Her relatives seemingly had no suspicion as to the 
 possible source of her trouble, and she was brought 
 to me by the gentleman to whom she was engaged 
 to be married. This gentleman had his own sus- 
 picions, but generously gave the woman the benefit 
 of a doubt existing in his own mind, as to the pos- 
 sibility of her having contracted some simple dis- 
 ease by kissing, he himself having a sore mouth at 
 the time. A careful investigation revealed the fact 
 that she had never had the slightest trouble with 
 her mouth or throat, until the late secondary 
 pharyngeal manifestations for which she consulted 
 me, appeared, and in addition, she innocently 
 stated that she had had about a year previous to 
 her consulting me, some little ; ' tender lumps " in 
 the groins. There had never been any " kernels " 
 as she termed them in the neck beneath the jaws. 
 These points settled the question as to the locality 
 primarily affected, and a candid statement of the 
 case saved the young man a mesalliance. The 
 
Lydston. 69 
 
 woman is probably congratulating herself upon 
 her success in duping me, but wondering at the 
 disappearance of her affianced, he having with- 
 drawn in the easiest manner possible by leaving 
 the city. 
 
 The initiatory period of syphilis terminates, when 
 the diseased cells have traversed the lymphatics 
 leading from the chancrous surface, have entered 
 the receptaculum chyli and from thence passed 
 into the blood, through the medium of which they 
 are disseminated throughout the system, giving 
 rise to the peculiar changes characteristic of syph- 
 ilis, in every tissue and organ in the body ; the 
 changes being more marked in some organs per- 
 haps than in others, in different cases, but there 
 being no tissue of the body which enjoys complete 
 immunity from the ravages of the disease. The 
 various bodily functions may be impaired, the 
 special senses and sexual appetite destroyed, par- 
 alyses may occur, and even the intellect itself may 
 be ruined by this terrible malady. 
 
 I will now direct your attention to the pathology 
 of the various manifestations of the period of 
 " general syphilitic infection." We have seen that 
 the period of local manifestations of syphilis is 
 preceded by a period of incubation, lasting on an 
 average twenty-one days. Following the initiatory 
 
70 Lectures on Syphilis. 
 
 period we have another apparent period of incuba- 
 tion, lasting on an average forty to forty-five days, 
 and followed by general syphilis. Now, gentle- 
 men, it would appear that these periods of quies- 
 cence are not true periods of incubation, but are 
 periods during which there is u an interference with 
 the progress of the diseased cells by normal anatom- 
 ical and physiological barriers." During the 
 second stage of incubation so-called, (this stage 
 we will shortly subdivide into several apparent 
 incubative periods) which as we have seen, lasts 
 on an average forty to forty -five days, the 
 syphilitic germinal cells are slowly traversing the 
 lymphatics, and gradually making their way to 
 the general blood current.* They are not ferment- 
 ing, and thus preparing for an explosion, hut are 
 slowly traveling on through the lymphatic system, 
 proliferating and multiplying by the way, and not 
 only changing themselves, but exciting propensities 
 for evil in the lymphatic and connective tissue 
 elements with which they come in contact, and to 
 which they impart their own infectious and other 
 morbid properties, particularly their morbid 
 activity and abnormal tendency to proliferation. 
 
 Generally we have only the chain of glands 
 intervening between the local induration, and the 
 lymphatic reservoir or receptaculum chyli, indura- 
 
 *Otis insists upon this point with especial emphasis. 
 
Lydston. 71 
 
 ted until just before, or at the time of the manifes- 
 tations of general syphilis, sometimes, however, 
 the general lymphatic system is involved prior to 
 the appearance of the eruption, and there is an 
 undoubted increase in size, coincident with the 
 eruption. Now why is it that we have an interval 
 between the appearance of the local induration, 
 and the enlargement of the nearest lymphatic 
 glands, another between this glandular enlarge- 
 ment and general glandular hyperplasia, and still 
 another sometimes, between the general glandular 
 enlargement and the appearance of the first erup- 
 tion ? I think that very good reasons can be 
 given for their occurrence : In the first place, 
 a certain length of time must elapse before the 
 diseased cells can leave the original focus of infec- 
 tion, viz. the chancre, traverse the intervening 
 lymphatic vessels, and arrive in the nearest lym- 
 phatic glands ; here the cells produce that charac- 
 teristic effects as evidenced by the development of 
 syphilitic bubo, and while the glands become en- 
 larged, the cells which have excited the morbid 
 changes, with others which have joined them and 
 become infected by the way, travel slowly on 
 toward the receptaculum chyli, and thence to the 
 general system by way of general circulation. 
 This requires a certain interval of time, for no 
 
72 Lectures on Syphilis. 
 
 morbid manifestations can occur until the cells 
 have reached their destination. Thus we have an 
 explanation of the second apparent period of incu- 
 bation which has been named. 
 
 As we have seen, the syphilitic germinal cells 
 eventually arrive at the receptaculum chyli, from 
 which they are carried to the general circulation, 
 and after entering the right heart, are finally dis- 
 seminated throughout the tissues generally, pro- 
 ducing their characteristic effects, a first evidence 
 of which may consist in a general glandular en- 
 largement sometimes seen prior to the eruption. 
 In cases in which the glands react prior to the 
 appearance of an eruption; — the possibility of this 
 is denied by some, good authorities claiming that 
 glandular enlargement is always coincident with, or 
 consecutive to the eruption; my own experience is 
 that they often become enlarged prior to the erup- 
 tion. — there is a consequent interval between gen- 
 eral adenitis and the syphilitic eruption. This is 
 due to the fact that, although the diseased cells ar- 
 rive in other tissues of the body through the medi- 
 um of the blood, quite as soon as in the lymphatics, 
 the latter are likely to be the first tissues to respond 
 to the morbid influence exerted by the cells. To 
 be sure the glands usually respond rather tardily, 
 and are not perceptibly enlarged until the eruption 
 
Lydston. 73 
 
 appears, but in my estimation many cases are ex- 
 ceptions to this rale. If the lymphatic glands are 
 already enlarged when the eruption appears, they 
 immediately still further increase in size, the pro- 
 liferation of cells being excited to renewed activity 
 at this time. We have thus, it seems, explained the 
 reasons for the three apparent periods of incuba- 
 tion, and have endeavored to demonstrate the fact 
 that they are not true periods of incubation or 
 quiescence at all, but are periods during which the 
 cells are still slowly marching on, and which are 
 necessary, in order that the cells may reach the 
 tissues which are successively involved. 
 
 The first period of incubation occurring in the 
 natural course of syphilis, I have not yet touched 
 upon, but we will now analyze it, and see if we 
 cannot explain it in a manner somewhat similar to 
 that involved in the explanations just given for the 
 other periods of quiescence. This first period of 
 incubation, is the most important of all the so- 
 called incubative periods, and as 1 shall endeavor 
 to show you, is like the others, in that it is apparent 
 and not real. Xow the question may arise, in the 
 minds of even those among you who are perfectly 
 willing to accept the statements as to the other 
 stages of quiescence being apparent and not real, 
 as to whether this first period, which intervenes be- 
 
74 Lectures on Syphilis. 
 
 tween the occurrence of inoculation with infectious 
 material, and the appearance of the initial indura- 
 tion, is not a stage of true incubation. Such a 
 question would be but natural, for it would certain- 
 ly appear from the long stage of quiescence, that 
 the virus of syphilis was undergoing a sort of 
 development or fermentive change, at the cul- 
 mination of which an explosion naturally followed, 
 in the form of a chancre. Now it is my own be- 
 lief, as formed from a careful survey of the inves- 
 tigations and teachings of Besiadecki, Baumler, 
 Otis and others, that local changes begin as soon as 
 the syphilitic virus has been absorbed. These 
 changes are very gradual, it is true, and probably 
 consist at first, of the incorporation of the syphilitic 
 germinal cell* (which as we have seen is a degraded 
 cell, and may be of a diameter of only 1-100,000 of 
 an inch), with the lymphatic elements of the infected 
 tissues. A certain length of time is necessary, be- 
 fore the degraded syphilitic cells reach the lymph 
 spaces, and again, some little time is necessary for 
 their incorporation with the lymph cells. 
 
 We now have a slow proliferation of the lym- 
 phatic elements, which are now syphilitic germinal 
 cells, and possessed of new T properties which are 
 morbid, as well as an intensification of their physi- 
 ological properties. The chief new and morbid 
 
 *Or bacillus of Lustgarten, if proven. 
 
Lydston. 75 
 
 property which they have acquired, is that of infec- 
 tiousness, and those normal properties already 
 existing but which now become intensified, are 
 those of amaeboicl activity, and power of prolifera- 
 tion. The multiplication of cells becomes more 
 active, the connective tissue elements of the blood- 
 vessels and lymphatic w r alls become involved, pro- 
 ducing as we have already seen, partial occlusion 
 of thuir lumen, and a consequent "anaemia of 
 tissue." The smaller lymphatic vessels are now 
 reached, and the accumulation of cells is so exten- 
 sive that a preceptible induration is noticed. This 
 area of induration increases in size until the cell 
 accumulation of which it is composed, has free 
 communication with the larger lymphatics, and the 
 smaller lymphatics regain their permeability. 
 From this time on, the cells are removed by the 
 lymphatics as fast as they are formed. Finally, 
 local proliferation having entirely ceased, the cells 
 composing the induration are entirely removed by 
 the absorbents, or undergo fatty degeneration and 
 resolution from the administration of mercury or 
 the iodide of potassium. 
 
 You will notice, gentlemen, that including the 
 primary stage of quiescence, I have described four 
 apparent stages of incubation, while ordinarily 
 there are described but two, one of which precedes 
 
76 Lectures on Syphilis. 
 
 the development of the chancre, and is termed a 
 period of true incubation, and the other deemed by 
 some a true, and by others an apparent period of 
 incubation, intervening between the primary and 
 secondary syphilitic manifestations. 1 think, how- 
 ever, that on careful consideration, the stages, or 
 rather intervals which I have described, will be 
 sufficiently plain. 
 
 At the end of about forty to forty-five days on 
 the average, after the development of the initial 
 lesion, the period of "general systemic infection 
 and localized cell accumulation" begins, the cells 
 having now reached their final destination.* The 
 first evidence of the general infection, consists in 
 the development of a peculiar eruption of rose 
 colored spots, termed the syphilitic roseola. Al- 
 though this eruption may escape observation, it is 
 probably constant, being always present in a greater 
 or less degree; in some cases lasting for a number 
 of weeks, probably from two to eight, while in 
 others it may last only a few hours. In its general 
 appearance, this eruption is not very unlike the 
 eruption of measles. The spots are of a dull rose 
 red hue and disappear on pressure, when recent, 
 but later on, leaving a coppery stain. Violent 
 exercise, as in running or dancing, is liable to 
 hasten or determine the eruption, as is the case 
 
 *Vide Otis "Class room lessons in Syphilis." 
 
Lydston. 77 
 
 with simple roseola. There is usually no pain or 
 other premonitory symptom with this eruption, al- 
 though such symptoms as a facial neuralgia, or 
 severe pain in the chest may be observed, and in 
 some cases general malaise, headache, and febrile 
 movement, may occur; these symptoms being sup- 
 posed by some, to be constant, and hence termed 
 •'the syphilitic fever." I have had recently a case 
 in which severe facial neuralgia attended the rose- 
 ola, and another in which all the subjective symp- 
 toms of an impending pneumonia were present, the 
 thoracic pain being especially severe, and these 
 symptoms being followed by the finest kind of a 
 roseola the next morning; as will be seen hereafter, 
 however, I believe these symptoms to have been 
 merely coincidental. Sometimes the eruption con- 
 sists of but a few pale spots, while in others it is 
 generally well marked, being occasionally slightly 
 elevated. 
 
 Now, the general idea prevails that the syphilitic 
 roseola is the result of local changes in the skin, 
 produced by the syphilitic poison, and reasoning a 
 priori from the line of argument which I have my- 
 self given you, you might be led to the conclusion 
 that it is due to a localized cell accumulation, the 
 product of which, collecting in the skin itself, con- 
 stitutes the exanthem. This is not the case, how- 
 
78 Lectures on Syphilis. 
 
 ever, and it is the only instance of the kind, 
 throughout the course of syphilis. The syphilitic 
 roseola is due to dilatation of the capillaries, with 
 subsequent stasis, and the exudation of leucocytes 
 and red blood corpuscles into the implicated integ- 
 umentary area.* The greater the degree of stasis, 
 the larger the number of extravasated red corpuscles, 
 and inasmuch as it is due to the changes in the blood 
 pigment that staining of the tissues occurs, the 
 greater the number of blood corpuscles extravasated, 
 the deeper and more persistent this staining is likely 
 to be. We find a similar staining in any lesion, 
 specific or simple, in which there exists long con- 
 tinued congestion. This is illustrated by the 
 changes in the tissues resulting from non-syphilitic 
 ulcers of the leg. Now it next remains to consider 
 the origin of this capillary dilatation, and inasmuch 
 as the contractility of the blood vessels is presided 
 over by the sympathetic system, or more properly, 
 by the vaso-motor system of the sympathetic, it 
 is evident that vascular dilatation in syphilis must 
 be due to some peculiar influence wrought upon 
 the sympathetic system, by the syphilitic cells, 
 which causes a suspension of the contractile power 
 of the vascular walls, and leads to dilatation and 
 stasis at the periphery. That the calibre of the 
 capillaries depends upon nervous currents from the 
 
 *Baiimler. 
 
Lydston. 79 
 
 sympathetic, is illustrated by the familiar physiolo- 
 gical demonstration, of section of the cervical sym- 
 pathetic, which gives rise to reddening and tume- 
 scence of the ear of the rabbit, as well as various 
 nutritive changes in the cornea of the eye, etc. It 
 is possible that the dilatation and stasis is a reflex 
 phenomenon, and due to the reflected local irrita- 
 tion produced by the syphilitic cells, but such an 
 explanation is hardly as rational as that involving 
 a direct influence upon the sympathetic centres, 
 analogous to that produced by various drugs, such 
 as quinine, belladonna and others, and to that pro- 
 duced by emotional disturbances. 
 
 I have said something in reference to the so- 
 called syphilitic fever, but will say a few words 
 more upon that subject. Among the prodromata 
 which may be observed prior to the development 
 of the roseola, are malaise, headache, rheumatoid 
 pains, anorexia, nausea, prostration, sleeplessness, 
 and nervous irritability, and in some cases quite 
 sharp febrile movement, followed perhaps by per- 
 spiration. These are the symptoms several or all 
 of which may be included under the head of 
 "syphilitic fever" or as Didaymore correctly terms 
 them "syphilitic prodromes." On reviewing the 
 list of single symptoms which may occur, it will be 
 evident that they may be dependent upon so many 
 
80 Lectures on Syphilis. 
 
 and various coincident disturbances, that there can 
 be no great constancy or certainty about their oc- 
 currence in syphilis, and that the term "syphilitic 
 fever" is consequently inaccurate. M. Ricord de- 
 nies its relation to syphilis, and claims that in 
 every case, it can be traced to causes independent 
 of the roseola. Otis endorses this view, and from 
 my own personal experience I am inclined to agree 
 with it, for I have found that febrile disturbance is 
 exceptional, and that in my own practice my pa- 
 tients usually discover the roseola entirely by acci- 
 dent, or in their daily examination of the surface 
 of the body, and but rarely have the slightest con- 
 stitutional disturbance. Very often the roseola 
 escapes the patient's observation until I direct his 
 attention to it, and then he usually is much aston- 
 ished that he should feel perfectly well, with such a 
 prominent eruption. With this roseola or shortly 
 after it, in cases in which it has not occurred prior 
 to the appearance of the eruption, general enlarge- 
 ment of the lymphatic glands occurs, the cells at 
 this time not only having reached the general lym- 
 phatic system, which is extremely susceptible to 
 their morbific influence, but being moreover unus- 
 ually active. 
 
 Just about the time the roseola appears, some- 
 times shortly before or after it, we have the devel- 
 
Lydston. 81 
 
 opment of an inflammatory engorgement of the 
 tonsils, pharynx, and soft palate, involving usually 
 the whole faucial surface. Now, we must seek for 
 an explanation of this localization of the morbid 
 effects of syphilis, in the throat, and a simple one is 
 easily found. According to Frey, His, Eeckling- 
 hausen and Teichmann, the tonsil is a part of the 
 general lymphatic system, representing the simplest 
 form of lymphatic gland. There is no direct com- 
 munication between the tonsillar follicles and the 
 adjacent lymphatic vessels, but each follicle is seen 
 to be invested with an exceedingly dense network 
 of fine lymphatic vessels, which are dilated in a 
 peculiar fashion and cover in the follicle so com- 
 pletely, that but one small portion of its surface is 
 free, this being directed towards the mucous mem- 
 brane. The entire pharynx is exceedingly rich in 
 lymphatics, hence we might quite naturally expect 
 morbid changes in its structures, simultaneously 
 with those occurring in the general lymphatic sys- 
 tem. This arrangement of the lymphatics also 
 explains another phenomenon, viz., the occurrence 
 of those severe and often seriously destructive ul- 
 cerations, which occur in this situation in late 
 syphilis. These lymphatics are brought into much 
 more intimate relations with the contiguous blood 
 vessels, than are the lymphatics of a higher order, 
 
82 Lectures on Syphilis. 
 
 and are hence prone to true inflammation, and pro- 
 found nutritive disturbances, whenever they be- 
 come crowded with the syphilitic cells. 
 
 The next thing observable after the roseola, in 
 the natural course of syphilis, is the development 
 of an eruption of true papules. This may appear 
 when a roseola has not been noticed, or may even 
 be coincident with it, but generally follows it after 
 a variable interval, often some weeks or months. 
 The papules are usually most prominent about the 
 borders of the hair upon the forehead, forming a 
 peculiar appearance termed the "corona veneris," 
 or venereal crown, but may be scantily scattered 
 over the breast, back, and limbs. In still other 
 instances they may be thickly studded all over the 
 body. This eruption lasts longer than the roseola, 
 occasionally remaining prominent for a number of 
 months. It is at first of a tolerably bright reddish 
 hue, but this gradually fades, leaving the charac- 
 teristic ham color. The papules tend to exfoliate 
 epithelial scales, especially at their bases, forming 
 a peculiar appearance known as the collarette of 
 Biette, a sign which is supposed by some to be 
 pathognomonic of syphilis. It is undoubtedly char- 
 acteristic when present, but unfortunately it is 
 oftener absent. This shedding of epithelial cells 
 around the base of the papule of syphilis, is simply 
 
Lydston. 83 
 
 due to innutrition of the epithelial elements about 
 the base of the papule, produced by the morbid 
 cells within it. This process is precisely like that 
 which causes loss of tissue in the initial lesion, viz. 
 necrobiosis or anaemia of tissue, from the pressure of 
 abnormal cell infiltration. 
 
 We will now examine the syphilitic papule more 
 minutely: According to Kohn, the papule is com- 
 posed of a dense, circumscribed, cellular infiltration 
 into the papillae and corium. This accumulation 
 of cells is piled up in dense and regular layers 
 around the vessels, and in the meshes of the con- 
 nective tissue. These cells do not become perma- 
 nently organized, but tend to undergo granular 
 and fatty degeneration, and finally disappear en- 
 tirely, the detritus produced by their retrograde 
 metamorphosis, being removed by the absorbents, 
 to be eliminated by the various emunctories. Or, 
 the cells may become heaped together in large 
 amount, and form pus. On section of the papule, 
 we find two lines of cells in the corium and papil- 
 lary layer of the derma, which layers are glued 
 together quite firmly, the epidermis being tightly 
 stretched over them. The hardness of the papule 
 is due to the density and dryness of the accumu- 
 lated cells, and its color to capillary stasis, to any 
 effusion of coloring matter from the blood vessels, 
 
84 Lectures on Syphilis. 
 
 and possibly, to the color of the neoplasm itself. 
 You will observe gentlemen, that the structure of 
 a secondary papule, is essentially that of the initial 
 lesion and the primary glandular infiltrations. 
 Now, it remains to explain the cause of this cir- 
 cumscribed collection of cells, or the syphilitic 
 papule. 
 
 We have already stated that the initial lesion is 
 due to an accumulation of cells, which results from 
 a morbid impulse given to the normal leucocytes 
 by the degraded syphilitic cell, and it would seem 
 a very logical inference that we have here in the 
 papule a similar process, and such is in fact the 
 case. But why is it that these cell accumulations 
 occur in the papillae and cutis rather than in other 
 situations? By reviewing our anatomy and phy- 
 siology a little, we will be able to explain it. The 
 blood containing the nutrient pabulum upon which 
 the repair of the tissues depends, is distributed to 
 the various tissues of the body by the arteries, and 
 returns, loaded with the products of retrograde tis- 
 sue metamorphosis by way of the veins. There 
 must of necessity be a certain amount of nutritive 
 or germinal material taken to the tissues, over and 
 above the quantity necessary for their repair, and 
 there must be some physiological means of restor- 
 ing this to the blood. Such an arrangement does 
 
Lydston. 85 
 
 in fact exist, and we have interposed between the 
 arterial and venous systems, a system of fine ves- 
 sels termed lymphatics, the function of which is to 
 collect all surplus germinal material, and return it 
 to the circulation. The nearest points of contact 
 of the arterial, venous and lymphatic vessels are at 
 the superficies, or the periphery of the body, where 
 the capillaries of the general circulatory and lym- 
 phatic systems are in most intimate contact, and as 
 it is here that the vessels are smallest, it is natur- 
 ally in this situation that retardation of the circula- 
 tion is most likely to occur, or an interference with 
 the interchange of nutritive materials, result from 
 exciting causes of various kinds. It is here, there- 
 fore, that we should expect to find collections of 
 surplus germinal material which from any cause 
 had been forced to accumulate in the tissues, and 
 failed to find an entrance into the lymphatics. 
 Such is really the case. You are probably some- 
 what familiar with the structure of the papillae of 
 the cutis, and are aware that each one contains 
 capillary lymphatic and blood vessels. According 
 to V. Eindfleish, Teichmann, and others, the lym- 
 phatic plexus lies in the centre of the papilla, while 
 the capillary blood vessels, wind corkscrew fashion 
 around it until they reach the apex. Teichmann, 
 in particular, has called attention to this peculiar 
 
86 Lectures on Syphilis. 
 
 arrangement. These vessels vary in size from time 
 to time, and vary according to the degree of vascu- 
 lar or blood pressure. It is in the spaces hetween 
 these capillary loops and the central lymphatics, that 
 the accumulation of cells in the syphilitic papule 
 takes place. An extra number of cells is brought 
 to the part, and in addition, there is an increased 
 local proliferation which temporarily blocks up the 
 lymphatics, or overcomes their power to dispose of 
 surplus germinal material, and as a result, we have 
 a heaping up of cells, with all those attendant mor- 
 bid phenomena which we have seen in the initial 
 lesion. Sometimes the papules are very fine, but 
 they may become large, sometimes by fusion, or 
 may involve sebaceous and sudariparous glands, — 
 which have no lymphatics, — simply by matting 
 them into the general infiltration of a number of 
 papillae. As a result of this same cell process, we 
 may have at any time daring the period of general 
 syphilis, usually during the early months of the se- 
 condary period, often co-existent with the papular 
 eruption, falling of the hair, or alopecia. This re- 
 sults from a derangement of nutrition, produced by 
 a cellular infiltration of the hair follicles. As a re- 
 sult of spontaneous, or therapeutically induced fatty 
 degeneration, this cell accumulation may be re- 
 moved, and the hair again grow. The nails of the 
 
Lydston. 87 
 
 fingers and toes may become affected by this same 
 cellular infiltration, and become brittle and lustre- 
 less, or from very great infiltration and consequent 
 nutritive disturbances, the destructive lesion known 
 as syphilitic onychia may occur. I have already 
 stated that pustules or vesicles, may form during 
 the papular stage of syphilis. Ulcerations resem- 
 bling tertiary or late secondary lesions may also 
 occur. These changes apparently result from a 
 lack of formative power in the lymph, or a tendency 
 to liquefaction of the hyperplasic materials, due to 
 constitutional debility or lack of tone. 
 
 There are several peculiar lesions occurring dur- 
 ing the period of general syphilis which are both 
 important and interesting, but which are really 
 mere modifications of the syphilitic papule depend- 
 ent mainly upon the situation and surroundings of 
 the lesion. Mucous patches which appear upon 
 the various mucous surfaces or quasi mucous sur- 
 faces, where they are constantly subjected to irrita- 
 tion from friction, and to heat and moisture, are 
 examples. These lesions are elevated plaques of 
 a milky or grayish color, covered with a grayish 
 exudate, and are not greatly unlike the primary 
 superficial erosion sometimes seen upon the geni- 
 tals. When situated about the anus, upon the 
 scrotum, vulva, or between the digits, these 
 
88 Lectures on Syphilis. 
 
 "plaques muqueuse" tend to become hypertrophied, 
 forming broad papules or excrescences more or less 
 elevated, sometimes covered with a sort of diph- 
 theritic deposit, and usually secreting a foul-smell- 
 ing serous secretion. These modified mucous 
 patches are termed mucous tubercles, or condy- 
 lomata. The existence of local irritation often 
 determines the development of mucous patches, as 
 is seen in the mouth, from the contact of a pipe 
 stem, or from irritation of the mucous membrane 
 of the mouth or tongue by a broken tooth. Tobac- 
 co smoke from either pipe or cigars, and tobacco 
 juice, will also produce these patches, and it will 
 be found much easier to prevent them by remov- 
 ing sources of local irritation, than to remove them 
 when once they have formed. 
 
 During this period we often have ocular troubles, 
 which may prove of very serious import. An in- 
 filtration of cells into the iris and ciliary body 
 often sets up an iritis at this time, this inflamma- 
 tion being really in no way distinguishable from 
 that produced in the same situation by rheumatism, 
 trauma or other exciting causes. There is perhaps 
 a greater tendency to chronicity and plastic exu- 
 date, with the formation of adhesions or synechia, 
 and the iris is possibly a trifle more cloudy and 
 infiltrated than in the simple forms of iritis, but 
 
Lydston. 89 
 
 the differences if any exist, are too slight as a gen- 
 eral rule to be of very great practical importance 
 from a diagnostic stand-point. The local accumu- 
 lation of cells in these cases, sometimes forms a 
 distinct nodule or tumor often termed the "gummy 
 tumor of the iris," but which is in no wise different 
 in structure from the syphilitic papule. It is 
 especially apt to occur in late syphilis. Similar 
 plastic nodules may form in the choroid at this 
 period. Bone pains, usually localized, and localized 
 subperiosteal accumulations of cells termed nodes, 
 frequently occur during this time. The pain in 
 these instances is due to intra-osseous or sub-perios- 
 teal pressure, produced by the dense accumulations 
 of cells. 
 
 Now gentlemen, I think we have given sufficient 
 attention to the pathology of active or general 
 syphilis, to enable you to understand its various 
 phenomena pretty thoroughly, and to demonstrate 
 clearly to you this one important point, an accept- 
 ance of which will enable you to understand syph- 
 ilis under all forms, and in the greatest variety of 
 its pathological phenomena, viz: That all patho- 
 logical manifestations due to syphilis occurring' 
 during the active period of the disease, which lasts- 
 usually from six to eighteen months, are each and 
 every one due to a localized cell accumulation and 
 
90 Lectures on Syphilis. 
 
 proliferation, and to nothing else, and that an intel- 
 ligent appreciation of this fact will alone form a, 
 rational basis for the treatment of the disease, which 
 is alike in every case, and consists simply of all 
 those means, whether general or local, which tend to 
 produce fatty degeneration or retrograde metamor- 
 phosis in the hyperplastic materials and induce 
 their elimination from the body, while at the same 
 tims tending to improve the general health of the 
 patient. Quite a long proposition, but necessarily 
 so, for it contains the whole subject of syphilis 
 within a comparatively small space. The only 
 distinguishing characteristic of the syphilitic cell 
 as contrasted with the normal germinal cell, is its 
 contagiousness, which consists in its power of im- 
 parting to normal leucocytes, its own tendency to 
 proliferation, by which as we have seen it is charac- 
 acterized. This rapid proliferation does not usually 
 cause destruction of tissue, but gives rise to phe- 
 nomena which a priori we might expect from an 
 accumulation of surplus nutritive material. This 
 cell accumulation obstructs the tissues for a time, 
 in uncomplicated cases, and then from prolonged 
 pressure, innutrition and general causes, it under- 
 goes fatty metamorphosis and is finally eliminated 
 by the various emunctories. 
 
 According to Baiimler, the infection of syphilis 
 lasts from eighteen months to two years, after 
 
Lydston. 91 
 
 which it is exhausted. After the cessation of the 
 active period of syphilis, the blood and the secre- 
 tions of open lesions cease to be contagious, and it 
 may also be stated that in by far the greater pro- 
 portion of cases, especially if they have been pro . 
 perly treated, no further manifestations of syphilis 
 are ever experienced. Reasoning from these facts, 
 it is quite logical to infer that the so-called tertiary 
 period of syphilis to which I will hereafter call 
 your attention, is not a stage of the disease at all, 
 but is simply a period of generally unnecessary 
 sequelae, and indeed, such is now the teaching of 
 our best authorities upon the subject. Hutchin- 
 son, Lee, Lome, Baumler, Besiadecki, Otis, and 
 many others incline to this view. And for my 
 own part, I think that the list of cases of tertiary 
 syphilis or sequelae may be considerably narrowed, 
 if we remember that some of them may be suffering 
 from the excessive or injudicious action of mercury, 
 rather than from the sequelae of syphilis. 
 
Lecture V. 
 
 Period of sequelae, or so-called tertiary stage.— The tubercular syph- 
 ilide. — SyphUomatous lesions. — Structure of syphiloma.— Favorite 
 sites for development of syphilomata.— Tendency to necrosis and ul- 
 ceration of tertiary deposits. — Non-infectiousness of tertiary lesions. 
 —Normal character of the cells of gummy deposits. -Causes of gummy 
 deposits. — Lymphatic obstruction. — Cause of the tendency to recur- 
 rence during stage of sequelae.— Ordinary division of syphilis into 
 stages.— Precocious and malignant syphilis.— The syphilides; their 
 characteristics, nomenclature, andconcomit ant symptoms. -Syphilitic 
 ecthyma and rupia.— Syphilitic pigmentation and cicatrices.— Dura- 
 tion of syphilis as a whole. — Insidiousness of syphilis. — Probationary 
 period of syphilitics intending to many.- Bearing of hygienic sur- 
 roundings upon severity of syphilis. — Illustration of malignant 
 syphilis.— Character of early lesions influences prognosis.— A typical 
 case of syphilis. 
 
 Gentlemen: — Having finished our description 
 of the lesions of the secondary or active period of 
 syphilis, and having given the physio-pathological 
 explanation of the various phenomena presented 
 by that period of the disease during which we have 
 general constitutional infection and localized cell 
 accumulations, it only remains for us to consider 
 the period of sequelae, or the so-called "tertiary 
 stage." 
 
 One of the most frequent and important of the 
 tertiary lesions or sequelae, is the tubercular erup- 
 tion. This has been said to be due to a localized 
 accumulation of morbid material in the tissues, or 
 so-called "gummy infiltration," which is the basis 
 of all tertiary lesions. This gummy material is 
 
94 Lectures on Syphilis. 
 
 termed by Wagner "syphiloma," and is described 
 by him, as an infiltration of cells and nuclei, the 
 cells not being capable of differentiation from 
 the normal white blood cell or leucocyte, and the 
 nuclei themselves presenting no characteristic ap- 
 pearances. He states that their morbid effects are 
 due to a mere interference with the function and 
 nutrition of affected parts, by simple pressure. 
 Baiimler also claims that the histological elements 
 of syphilomata, lack specific microscopic charac- 
 ters. 
 
 The tubercular or gummy lesion may develop in 
 any situation, its favorite situations being the cell- 
 ular tissue, skin, bones, liver, testes, brain and 
 kidneys, and in children especially, the lungs. 
 This gummy material is a grayish red, homogene- 
 ous mass of greater or less consistency, which may 
 be found in the parenchyma of any organ or tissue 
 of the body, either as a diffused or circumscribed 
 infiltration, but never encapsulated. When this 
 accumulation of morbid material is superficial, and 
 exposed to unequal pressure, or when it is exces- 
 sive, or involves the walls of the blood-vessels, thus 
 giving rise to localized innutrition from pressure 
 or vascular obstruction, the whole mass is liable to 
 ulcerate, or break down into pus which may absorb 
 through fatty or granular degeneration without 
 ulceration. 
 
Lydston. 95 
 
 As we have already seen, the lesions now under 
 consideration have no specific inoculable properties, 
 this view being supported by Ricord, Diday, Bar- 
 ensprung and Baiimler. This is the only differ- 
 ence so far determined, between the histological 
 elements of the tertiary, and those of the secondary 
 lesions, save perhaps the greater tendency to 
 destruction of tissue in the former. Now, it has 
 been demonstrated that the longer the duration of 
 the secondary stage, and consequently the more 
 pronounced the changes in the lymphatic struc- 
 tures, produced by the lesions of the active stage, 
 the greater the liability to tertiary lesions of a 
 severe type. As the cells composing the gummata 
 are not infectious, and are less active than the 
 true syphilitic germinal cell, they are probably not 
 the result of the action of a virus or poison upon 
 the normal tissue elements, but are due to lym- 
 phatic obstruction, being no more nor less than an 
 accumulation of normal embryonal cells, which are 
 prone to undergo and produce various degenerative 
 changes through nutritive disturbances. The lym- 
 phatic obstruction giving rise to this accumulation 
 of embryonal cells, is the result of injury to the 
 absorbents produced by the lesions of the active 
 stage. Kindfleisch, who is unexcelled as an au- 
 thority on pathological questions, says: "Luxuri- 
 
96 Lectures on Syphilis. 
 
 ous new formations, catarrhs and surface secretions 
 of various kinds, must be produced when the 
 lymph conveyance is hindered." Now the results 
 of scientific investigation tend to show that the 
 new formations and surface secretions of tertiary 
 syphilis, are all due to an accumulation of normal 
 germinal material, and if this be true how else can 
 we account for it, except by the existence of lym- 
 phatic obstruction? A very important fact bear- 
 ing out this theory, is that the treatment of ter- 
 tiary lesions is the same throughout, whatever 
 the lesion, and consists in the administration 
 of mercury and the iodide of potassium. Ac- 
 cepting the view of the formation of the gum- 
 mata or syphilomata, which has been set forth, 
 the term " gummy period," applied by some, is 
 inaccurate, and the term " period of lymphatic 
 obstruction" suggested I believe, by Otis, is more 
 proper, as indicating the actual pathological con- 
 dition present, and the exact manner of its produc- 
 tion. 
 
 After the removal of the cells by fatty degenera- 
 tion, there is always a tendency to recurrence, 
 which explains the difficulty of curing the disease 
 at this period. This tendency is due to an increased 
 injury to the lymphatic structures, which were al- 
 ready greatly impaired by the lesions of the active 
 
Lydston. 97 
 
 stage of syphilis. This impairment consists in a 
 formation of fibrous tissue, as a result of low in- 
 flammatory action, mechanically set up by the 
 cells. This fibrous formation of course interferes 
 in a measure with tissue nutrition in different 
 localities, by producing changes in the vascular 
 walls, and it is claimed by some that a great deal 
 of the trouble in so-called tertiary syphilis, is due 
 to wide-spread fatty degeneration caused by this 
 same vascular contraction. In any event these 
 vascular changes do produce innutrition, and a 
 tendency to destructive changes in those parts sup- 
 plied by the affected vessels, and the nutrition of 
 which is still further impaired by local pressure from 
 accumulation of lymphatic elements. It is well- 
 known that fatty and purulent degeneration are 
 more likely to occur in some subjects than in others, 
 and are most likely to supervene in individuals 
 who are cachectic or debilitated from any cause. 
 Debility would of course be produced by a pro- 
 longed and severe active stage, and indeed, Hutch- 
 inson claims, "that the liability to, and severity of, 
 tertiary lesions, are in direct proportion to the 
 duration and severity of the secondary stage." 
 
 Now, gentlemen, the conclusion at which we may 
 arrive after a careful consideration of all the facts 
 which I have endeavored to present to you, is this: 
 
98 Lectures on Syphilis. 
 
 That the various lesions and different degrees of 
 severity of the lesions of the so-called "tertiary 
 stage of syphilis," depend upon, first, the amount 
 of damage produced by the lesions of the active 
 period of the disease, and its duration, and secondly, 
 upon the constitutional condition of the individual, 
 independently of any specific virus. 
 
 I have not yet given you the division ordinarily 
 made of syphilis, deeming it best to first give you 
 an idea of its "physiological pathology." As I 
 have already stated in a general way, syphilis is 
 ordinarily and somewhat arbitrarily divided into 
 the so-called "primary," "secondary" and "tertiary 
 stages," and by some an "intermediary" stage is 
 described which comprises the lull, or at most the 
 period of almost insignificant lesions following the 
 active period, and prior to the development of the 
 tertiary stage. "Primary syphilis" of course im- 
 plies the initial lesion with its attendant glandular 
 enlargements. ' 'Secondary syphilis" comprises the 
 earlier affections of the skin and mucous surfaces, 
 and many of the lighter changes in the eye, testis 
 and other glands, with some forms of nervous mani- 
 festations. "Tertiary syphilis" comprises the later 
 severe ulcerative skin lesions, the deeper lesions 
 of connective tissue, bone, muscle, cartilage and 
 the viscera, and all the severe lesions of the eye, 
 
Lydston. 99 
 
 testis, and brain; in short, all of those many and 
 various changes, characterized by the so-called 
 u gummy deposit." The line between the two 
 stages is not always clear, but in typical cases the 
 lesions, at first superficial, gradually increase in 
 severity to the destructive pathological changes of 
 the so-called tertiary stage or period of sequelae. 
 Some of the lesions properly belonging to the sec- 
 ondary group are liable to crop out with the ter- 
 tiary lesions, and rarely on the other hand, nodes 
 develop in the secondary stage. * In quite rare and 
 malignant cases, the secondary stage may appear 
 to be omitted entirely, destructive lesions ordinarily 
 characterizing the tertiary period, appearing in a 
 few months after the chancre. These varieties of 
 cases include or comprise the cases of so-called 
 irregular and malignant syphilis. 
 
 Secondary syphilis lasts often a year and some- 
 times two or more. I have already stated that the 
 active period of syphilis has a duration of from 
 eighteen months to two years, but there need not 
 necessarily be manifestations of the disease during 
 that time. You will understand, gentlemen, that 
 the division of the stages or periods of syphilis 
 involved in the physiological pathology that has 
 been given you, is based upon pathological changes 
 
 ♦Osseous and subperiosteal swellings do develop during the sec- 
 ondary stage, but characteristic nodes are exceptionally seen. 
 
100 Lectures on Syphilis. 
 
 altogether, and not upon mere symptomatology, as 
 is ordinarily done. You will thus appreciate the 
 fact that the so-called secondary stage, as ordinar- 
 ily given, is merely that portion of the " active 
 period" during which actual lesions are present. 
 The division of the disease into primary, secondary, 
 and tertiary stages, depends upon the form of the 
 lesions, and is therefore necessarily inaccurate and 
 unscientific, while the more rational division into 
 the " initial" and " active" periods and " period of 
 sequelae" is founded upon a knowledge of the 
 natural course of the disease in the tissues, the 
 lesions being dependent upon this natural course, 
 and not vice versa. Tertiary syphilis does not 
 commence until at least one year after the initial 
 sore, excepting in cases of malignant syphilis. As 
 I have endeavored to show you, it is not a neces- 
 sary stage of syphilis at all, and does not appear in 
 by far the largest number of cases. It may, how- 
 ever, appear after years of apparent good health. 
 The whole secondary stage is sometimes skipped, 
 especially under treatment, and no manifestations 
 of general syphilis appear until suddenly some 
 tertiary lesion of a greater or less severe type 
 develops. These cases are rare, and it must be 
 remembered that there is a possibility of even some 
 of these, being due to too much Doctor Hydrarg. I 
 
Lydston. 101 
 
 have seen quite recently two cases in which three 
 and nine years respectively had elapsed since the 
 primary sore, during which time no secondary 
 symptoms ever appeared, and in which true gummy 
 ulceration existed. 
 
 The most prominent of the manifestations of 
 syphilis are the eruptions of the skin, which are 
 termed "syphilides" or u syphilodermata." These 
 are many and various; but their classification may 
 be rendered quite simple, thus: if papules are the 
 most prominent lesion we term it a " papular syph- 
 ilide." In the same way we have the vesicular, 
 pustular, tubercular, scaly or squamous, and ulcer- 
 ative syphilides, and such combinations as papulo- 
 pustule, papulo-squamous syphilides, and so on. 
 Ulcerative syphilides may be designated as super- 
 ficial, deep, serpiginous, or perforative, as the case 
 may be. 
 
 The most important thing with reference to 
 syphilides is the consideration of their general 
 characteristics. They are: 1st, polymorphism of 
 the chancre; 2nd, rounded form of the eruptive 
 lesions and ulcers; 3rd, lividity or ham color, 
 becoming coppery, then grayish, and finally white 
 and shining; 4th, absence of pruritis and pain; 
 5th, symmetry, generalization and superficial 
 character of the early eruptions; 6th, tendency to 
 
102 Lectures on Syphilis. 
 
 grouping of later eruptions, which involve the 
 true skin and tend to scarring; 7th, scales 
 white, generally superficial and non-adherent; 
 8th, crusts irregular, thick and adherent, and 
 either of a greenish or black color; 9th, abrupt 
 edges of ulcerations, which are not undermined, 
 are sluggish, and bleed easily; 10th, the rounded, 
 depressed appearance of the cicatrix, which is thin, 
 movable upon the sublying tissues, pigmented at 
 first sometimes, but eventually becoming white and 
 shining.* In addition to these special characters 
 of the lesions of syphilis, we have attendant symp- 
 toms, such as the so-called syphilitic fever in some 
 cases, alopecia, headache, osteo-copic pains worse 
 at night, analgesia, anaesthesia, indolent lymphitis, 
 iritis, sore throat, and mucous patches. 
 
 We apply the term " polymorphous " to the 
 syphilides, for the reason that there is no form of 
 skin lesion which may not occur in syphilis, and 
 no single form or type of lesion is usually present, 
 e. g. a papular syphilide is rarely purely papular, 
 vesicles, pustules, or erythematous patches being 
 usually found at the same time, and the eruption 
 being named from the lesion whicn predominates. 
 
 The tendency of the syphilides to arrange them- 
 selves in a rounded form, is peculiar and well- 
 marked, the later syphilides being especially dis- 
 
 *Vide Van Buren and Keyes. 
 
Lydston. 103 
 
 posed to circular grouping. The color of the 
 syphilides is not an inflammatory red, but is a 
 vinous or purplish red, resembling the color of raw 
 ham, the color gradually passing by pigmentation 
 into a coppery hue, or more deeply to a brownish 
 or black color. The pigmentation may last for 
 years, but finally clears off gradually from the 
 center towards the periphery, the cicatrix or spot 
 becoming eventually white and shining. 
 
 Pain and pruritus are rarely present in uncompli- 
 cated syphilides, excepting when irritated or 
 inflamed. In dependent portions of the body, as 
 in the legs, or in such situations as the throat, 
 which are subjected to constant irritation, ulcera- 
 tions are liable to be quite painful. When an 
 eruption that is evidently syphilitic gives rise 
 to pain and itching, we can usually find some 
 cause of irritation independent of the syphilide. 
 The patient may, perhaps, have an irritable skin, 
 and a pruritus which constantly troubled him prior 
 to the development of syphilis. Contrary, how- 
 ever, to the general rule, the early eruptions of the 
 scalp are attended by pruritus. 
 
 The earlier syphilides are superficial, and leave 
 no cicatrices, and are symmetrical; appearing upon 
 the flanks and sides of the trunk, the sides of the 
 neck, forehead, etc. The later eruptions are 
 
104 Lectures on Syphilis. 
 
 grouped and not generalized, and are characterized 
 by destruction of tissue, as evidenced by the result- 
 ing cicatrices. They may leave scars, even if no 
 ulceration occurs, which is true of no other lesion 
 excepting the scrofulides, of which the lupus non- 
 exedens is an example, but which leaves an irreg- 
 ular burn-like scar. The scales of the squamous 
 syphilide are very thin and non-adherent, not at 
 all like the thick, imbricated scales of psoriasis. 
 The scabs of the ulcerative syphilides are thick, 
 rough, and adherent, dark, of a greenish black 
 color usually, but sometimes light, if the lesion be 
 simply pustular. In this connection I will call 
 your attention to two important varieties of syph- 
 ilide : The first is the syphilitic ecthyma, which 
 consists in an eruption of large pustules, which 
 soon scab over with a characteristic dark greenish 
 crust. On lifting this crust, a characteristic 
 sharply cut circular ulcer will be found. A step 
 fu rther, and we have the syphilitic rupia, in which 
 as the crusts form they are pushed up and replaced 
 by accumulations of material from beneath, and 
 the ulceration gradually extending at its periphery, 
 we soon have a peculiar appearance quite like an 
 oyster shell upon the surface. The crusts are piled 
 up in imbricated layers, which when lifted from 
 their bed, expose the results of tissue destruction, 
 
Lyjdston. 105 
 
 in the shape of extensive ulceration. These rupial 
 crusts may become very large, and when numer- 
 ous, form a most disgusting spectacle. 
 
 I have already stated that the ulcerations of 
 syphilis are round, clear cut, and not unlike chan- 
 chroid. They are sluggish like any chronic ulcer, 
 and are painless, unless greatly congested and 
 inflamed, or over a bone, the periosteum of which 
 is involved. Cicatrices remaining after destruction 
 of tissue by syphilides, whether there has been 
 ulceration or not, are usually rounded, thin, 
 depressed, and movable, not adherent. They are 
 at first pigmented, especially in brunettes, but 
 eventually clear up and become white and shining. 
 In strumous subjects, in whom the lesion is likely 
 to be a combination of struma and syphilis, the 
 resulting cicatrices are apt to be puckered and 
 irregular. 
 
 Now as for the duration of syphilis: There is 
 no disease, the duration and course of which are so 
 uncertain as those of syphilis It is impossible to 
 state, in any given case, that the disease has, or 
 has not terminated, and this is more especially true 
 when we consider that it may permanently modify 
 the constitution of the individual, even when no 
 actual manifestations of the disease appear after a 
 certain time. The disease may manifest itself as a 
 
106 Lectures on Syphilis. 
 
 series of mild secondary eruptions followed by 
 apparent recovery, or it may afford no evidence of 
 its presence after the initial sore, until late in life, 
 when suddenly tertiary lesions or sequelae crop 
 out. In a large number of cases, we must 
 acknowledge that syphilis causes a permanent 
 modification of the patients' constitution, still we 
 must believe that syphilis can be cured; and my 
 own opinion is, that it is a perfectly curable affec- 
 tion in by far the greater proportion of cases, pro- 
 viding the patient be intelligent and the doctor con- 
 scientious. We have proof of this in the cases of 
 second attacks, cited by reliable authorities, and we 
 have already seen that whatever the possibilities of 
 tertiary lesions, they are not necessary, and are 
 undoubtedly sequelae. We find that the patients 
 in the late tertiary period of syphilis may procreate 
 healthy children, and that the blood and secretions 
 of tertiary lesions are no longer inoculable. 
 
 As found among the better classes, syphilis is a 
 very insidious disorder, and we will meet with 
 innocent ladies complaining of various symptoms 
 which are vaguely described, and as vaguely treat- 
 ed, as neuralgic or rheumatic, which are no more 
 nor less than slight manifestations of old Proteus, 
 and by which they perhaps come honestly enough. 
 Children may have obscure symptoms which mis- 
 lead both parents and physician, and which are 
 
Lydston. 107 
 
 conveniently termed " scrofula" in some instances, 
 according to my own view of the heredity of scrof- 
 ulosis. The old gentleman forgets a u little sore" 
 he once had, and never dreams of attributing the 
 little troubles ot his wife and children, to those 
 dimly remembered, and as lightly weighed wild 
 oats that he once sowed. But whether remembered 
 or not, the harvest garnered as the fruit of that 
 sowing is none the less certain. 
 
 The practical question now arises: " When is it 
 safe for a person to marry after having had a chan- 
 cre?" On the average we may say three years, or 
 we might fix the period as eighteen months after 
 the disappearance of the last syphilitic lesion, 
 providing three years have elapsed, the patient 
 being meanwhile under careful treatment, which is 
 to be persisted in until after the birth of the first 
 child. During the three years named, symptoms 
 may crop out at any time, but under careful man- 
 agement, they are usually slight, and whether we 
 can call it a cure or not, the virulence of the disease 
 seems to be exhausted in cases of mild or moderate 
 severity so handled, in about three years. If a 
 patient be addicted to excesses of any sort, if he 
 does not take a steady and efficient course of treat- 
 ment, but treats himself — perhaps to excess — at 
 spasmodic intervals, his chances are of course not 
 very good. 
 
108 Lectures on Syphilis. 
 
 The severity of syphilis depends mainly upon the 
 constitution and hygienic condition of the patient. 
 As we have seen, we do not have at the present 
 day, such severe cases as a general rule, as in past 
 years, the reason for which I have already given. 
 In the better classes, it is a very mild disease by 
 comparison with the lower walks of life, in which 
 we may still meet with cases exemplifying the ser- 
 ious character of the disease. Even among persons 
 who are constitutionally and hygienically well cir- 
 cumstanced, we sometimes see cases of the most 
 malignant type. I well remember an instance in 
 illustration of this fact: During last Summer I was 
 consulted by a fine appearing, exceptionally well 
 nourished man; whose circumstances were the very 
 best that could be desired, in regard to a small 
 abrasion upon the glans penis. This had appeared 
 a day or two after a suspicious exposure, and had 
 probably resulted from friction during intercourse. 
 I told this gentleman that while the sore had noth- 
 ing at all alarming about it, yet it would bear close 
 watching, and dismissed him. In a few days — at 
 the end of two weeks from the date of exposure — 
 the sore became slightly indurated, constituting 
 the parchment variety of chancrous induration. 
 This chancre disappeared in a very short time, but 
 was followed by a most malignant course of syph- 
 ilis. True tubercular lesions appeared in various 
 
Lydston. 109 
 
 situations, and deep ulcerations developed and ran 
 their course inside of three months, the patient 
 barely escaping with his life. 
 
 We can never judge the severity of the syphil- 
 itic infection, by the character of the primary sore, 
 and this case serves as a very forcible illustration 
 of this statement. In private practice gentlemen, 
 you will seldom see cases of this sort, and only 
 those of you, who in the future are so fortunate as 
 to enjoy the privileges of some large hospital, 
 will be apt to realize the severity of syphilis in its 
 more marked and serious phases. 
 
 I have just stated that it is impossible to predict 
 the severity of syphilis by the character of the 
 primary sore, but this statement requires some 
 qualifications, e. g. , in cases of phagedaenic chan- 
 cre we can prognose a severe course of syphilis, 
 not because of any intrinsic severity of the infec- 
 tion, but because the constitution is at fault. 
 This constitutional defect will have the same influ- 
 ence upon the general symptoms, that it does upon 
 the primary lesion in inducing phagedaena. The 
 character of the earlier eruptions will influence the 
 prognosis, for the milder and more insignificant 
 these are, the milder the subsequent course of the 
 disease is apt to be, and vice versa. This is ex- 
 emplified incases of malignant syphilis, in which 
 the earlier lesions are deep and destructive. Ves- 
 
110 Lectures on Syphilis. 
 
 icular, and still more, pustular eruptions, indicate 
 a severer type of the disease than do the papular 
 and erythematous lesions. 
 
 Now gentlemen, I have given you all that I 
 think necessary or practical regarding the path- 
 ology and course of syphilis. Remember its phys- 
 io-pathological features, and you will have an all 
 powerful advantage over those physicians whose 
 ideas of syphilis are entirely bounded by the pro- 
 position that "Pox is syphilis, syphilis is pox, 
 the cause is venereal, and mercury and potash are 
 good for it. " Please don't look at the disease in 
 that way, for although such a course is broad and 
 simple enough, it is the pathway to imbecility as 
 far as the scientific study and treatment of syphilis 
 are concerned. 
 
 I will conclude this morning, by depicting in a 
 few words, a typical case of syphilis : A young 
 man exposes himself by a suspicious intercourse, 
 and during the performance of the act, causes a 
 little abrasion upon the glans penis — or possibly 
 he still further irritates or abrades a pre-existing 
 abrasion or patch of herpes. This abrasion may 
 heal in a day or two — or may escape his attention 
 entirely for that matter, — or it may persist. In 
 about two or three weeks a little hard lump or 
 nodule appears on the site of the abrasion. This 
 gradually enlarges until of the size perhaps of a 
 
Lydston. Ill 
 
 filbert. In a few days, say seven or eight, small 
 lines of hardness appear beneath the integument of 
 the penis leading from the induration and in a few 
 days more, small, hard and freely movable lumps 
 appear in the groins. What have we here ? 
 Syphilitic lymphitis and bubo. Mark how the 
 cells are slowdy traveling on. Now, we have an 
 interval of perhaps six weeks, after which we note 
 an enlargement of the cubital or epitrochlear 
 glands at the elbow over the internal condyle, 
 which is quite characteristic, and enlargement of 
 the general system of lymphatics. In a day or two 
 or more, or at the same time, we have an eruption 
 of macules or papules resembling measles, these 
 being scattered over the surface invariable amount; 
 — which eruption may appear simultaneously with 
 general adenopathy and a still further increase 
 in the size of the lymphatic glands. 
 
 A sore throat may now be complained of. After 
 a variable interval of some weeks or months, we 
 notice an eruption of papules, most prominent 
 about the roots of the hair on the forehead — the 
 venereal crown, — which papules may become vesic- 
 ular or pustular, according to the intensity of the 
 infection and the constitutional condition of the 
 patient. Sore throat is frequently experienced 
 shortly after the appearance of the roseola, or more 
 likely during the papular eruption, and syphilitic 
 
112 Lectures on Syphilis. 
 
 iritis is likely to occur at any time after the appear- 
 ance of the papules. - Late in the disease the iritic 
 inflammation takes on the so called " gummy" or 
 nodular form, when it is quite characteristic, but 
 the early syphilitic iritis is practically indis- 
 tinguishable from the rheumatic form. 
 
 During the latter part of the first year, bone 
 pains and nodes are apt to appear, but they may 
 appear earlier. Falling of the hair occurs usually 
 during the early months if at all, and in common 
 with the form of lesion known as the mucous 
 patch, is most likely to occur during the papular 
 eruption. 
 
 Pustular and ulcerative lesions begin to appear 
 during the latter part of the first year or eighteen 
 months, and are succeeded by ecthyma, rupia, 
 tubercular or gummy lesions of the bones, skin, 
 brain and other viscera, and various nervous 
 lesions, with destructive bone changes and other 
 lesions characteristic of the u tertiary " period or 
 period of sequelae. These latter severe lesions 
 may crop out from time to time during the life of 
 the patient, or may be delayed until very late in 
 life. The life of the patient may eventually be 
 destroyed by profound pathological changes in the 
 cerebro-spinal axis, or abdominal viscera. 
 
 At the next lecture gentlemen, we will consider 
 the treatment of syphilis. 
 
Lecture VI. 
 
 Treatment of Syphilis.— Simplicity of local treatment of chancre.— 
 Avoidance of caustics and ointments. — Excision of chancre. — Advan- 
 tages of excision.— Supposed antidotal effect of mercury in syph- 
 ilis.— Proper method of using.— Power of mercury to induce fatty 
 degeneration and elimination of morbid material. — Uniformity of all 
 successful methods of treatment, in producing fatty degeneration.— 
 Clevenger's theory of the mechanical action of mercury.— Probabil- 
 ity of mercury entering the system in both mechanical and chemical 
 conditions.— Action of mercury upon the blood.— Action varies 
 widely under different conditions. — Action of iodine in syphilis. — 
 When to begin the use of mercury.— Form of mercurial to be select- 
 ed.— Importance of protracted treatment.— Mercury by inunction 
 and fumigation. — Local use of mercurials. — Mercury by hypodermic 
 injection. 
 
 Gentlemen:— We now come to that portion of 
 our course, which you no doubt are much more 
 anxious to learn than the more abstruse and to 
 you perhaps, less practical topic of the pathology 
 of syphilis. Remember what I have already told 
 you, however, regarding the necessity for a good 
 idea of the pathology, in order that you may under- 
 stand the rationale of the therapeutics of the 
 disease. 
 
 We have studied the treatment of the primary 
 sore in connection with the description of its 
 pathological characters, but there are some points 
 which will bear repetition, and others to which I 
 have not yet alluded, but which appear to me very 
 important. In the first place, do not forget that 
 the chancre is to be coaxed, not driven, and that it 
 
114 Lectures on Syphilis. 
 
 will cause little annoyance if you give it half a 
 chance. Use the black or yellow wash, calomel or 
 iodoform powder, or even simple absorbent cotton 
 as a dressing, and let the induration take care of 
 itself. If you wish to see by contrast, the results 
 of meddlesome officiousness, try rubbing a hard 
 chancre with nitrate of silver, and then apply some 
 nasty, greasy ointment. You will have a fine mess 
 of it, and a condition of affairs which I often see 
 in patients who have been treated in this manner, 
 by physicians, drug clerks, or very often by them- 
 selves. Avoid grease and nitrate of silver, as an 
 abomination, if you would not lose your patients' 
 confidence. If, as in the case of a mixed sore, it 
 becomes necessary to cauterize, use a caustic, and 
 have done with it, and not an irritant like nitrate 
 of silver, which sears but does not destroy. Apply 
 carbolic acid followed by the fuming nitric, or bet- 
 ter still, use pure bromine or the actual cautery. 
 The form of caustic is not so important as the man- 
 ner of its use. Select your caustic early in prac- 
 tice, and stick to it until you know how to use it. 
 As a last injunction instruct your patient in the 
 matter of rest. Let him rest the affected member 
 by avoidance of sexuality in thought or action, by 
 taking very little exercise, and no stimulants, and 
 lastly by handling it as little as possible. The 
 
Lydston. 115 
 
 oftener he examines himself to note the progress of 
 the case, the worse he will eventually be. 
 
 There is one radical method of dealing with the 
 chancre, which I commend to your attention, and 
 which is often a wise thing to do. I refer to 
 the treatment by excision. It is claimed by some 
 advocates of this method, that by it the general 
 symptoms are modified and in some instances pre- 
 vented entirely, not even the indolent glandular 
 changes being perceptible. Theoretically, if the 
 views of the pathology of the disease which I have 
 called to your attention, be correct, excision of the 
 initial induration ought to prevent general infec- 
 tion completely, but unfortunately this has as yet 
 to be proven to be the case in actual practice. As 
 for myself, I am performing excision whenever 
 the patient will consent, and am trying to arrive at 
 a definite conclusion in regard to the matter, from 
 actual observation. I have already studied ten 
 cases in this way, and have become pretty thor- 
 oughly convinced that the operation is of benefit. 
 I have not yet omitted the administration of mer- 
 cury, but am positive that excision followed by 
 the exhibition of the drug is productive of better 
 results on the whole, than the treatment of mer- 
 cury alone. There are several considerations which 
 may be advanced and which are in the main indor- 
 
116 Lectukes on Syphilis. 
 
 sed by Otis, in favor of the operation, in which 
 nearly all will agree, viz. : We thereby remove a 
 constant focus of infection, which is present as long 
 as the induration persists. 2d. We at once remove 
 a large mass of syphilized cells which would other- 
 wise only be removed by the slower process of 
 fatty degeneration, absorption and elimination. 3d. 
 We obviate the possibility of the transmission of 
 the disease to others by means of the initial lesion, 
 a point of great importance to married persons. 
 4th. We lesson the danger of suppurating bubo, 
 in case the chancre should inflame. 5th. We re- 
 move a constant source of irritation, and lessen the 
 danger of phagedena and inflammation which 
 might disable the patient. 6th. The patient is able 
 to resume his marital relations at once, after the 
 incision has cicatrized perfectly. Why it is that 
 we cannot prevent constitutional syphilis, by 
 excision of the chancre prior to local glandular 
 changes, is not clearly explicable, if we accept the 
 view that the disease is practically local primarily. 
 It is probable that a morbid impression has been 
 made upon the tissues by the syphilitic poison, 
 which began the moment infection occurred, and 
 which has extended far beyond the limits of the 
 initial lesion before its appearance. Excision of 
 the chancre should be preceded by washing the 
 
Lydston. 117 
 
 parts in a solution of bichloride of mere my 1-1000. 
 The ulceration if any exist, should then be cauter- 
 ized, and dusted with calomel. The chancre should 
 now be transfixed with a tenaculum, raised from 
 its bed, and the mass of induration quickly 
 removed with a sharp scalpel or curved scissors. 
 The parts should be sutured with fine catgut or 
 silk, and the parts kept at rest for a few days with 
 cold water dressings. Within forty-eight hours as 
 a rule, the wound will have united, and the 
 stitches may be removed. In a few days, if no 
 lesion be present, the patient may resume his mar- 
 ital relations. 
 
 The constitutional treatment of syphilis, is 
 naturally a subject of paramount importance. 
 Errors, more serious in their effects than the dis- 
 ease itself, are often committed by those whose 
 practice is not founded upon a sound pathological 
 basis. The disease has long been treated upon the 
 principle that there is present a constitutional 
 poison, which must be antidoted, and mercury has 
 appeared to be the antidote. Hutchinson has 
 taught that this drug has the property of neutral- 
 izing the specific virus upon which syphilis is 
 supposed to depend. This theory of the antidotal 
 effect of mercury, has been accepted by some of 
 our best syphilographers. They, however, in 
 
118 Lectures on Syphilis. 
 
 thus accepting the antidotal doctrine, have seemed 
 to consider it all-sufficient, and have failed to ex- 
 plain the the physiological action of the drug, and 
 have given it solely because experience has proven 
 that it is curative in syphilis. Now, we find that 
 even when the system has been completely satur- 
 ated with mercury, even to the extent of producing 
 severe ptyalism, the disease returns directly the 
 drug is withdrawn, thus showing that the syphilis 
 has in no sense been antidoted. On the contrary, 
 the case is usually worse than ever. On the other 
 hand, ive find that the sloiv, continuous and moder- 
 ate use of mercury, for a period corresponding to 
 the maximum time of the normal duration of the 
 disease as nearly as may he, and without at any 
 time producing its full physiological effects, will 
 bring about a cure, ichich can be accomplished in no 
 other way. 
 
 It is well know r n that mercury has the power of 
 inducing fatty degeneration, and elimination of 
 inflammatory products, or in other words, ' ' of 
 relieving tissues encumbered with superfluous and 
 obstructive material. " This condition of the 
 tissues is precisely what we have in syphilis, and 
 as mercury is the best remedy we have for such a 
 pathological state, irrespective of causation, we 
 administer it throughout the natural course of the 
 
L YD ST OX. 119 
 
 disease, not to antidote a poison, hut to remove the 
 morbid results produced by it, as fast as they are 
 formed, until finally the syphilitic impression upon 
 the organism has naturally exhausted itself. We 
 have already seen that the " virus " of syphilis is 
 not a material substance, but practically consists 
 in an influence which a degraded cell has over 
 another which is healthy, causing rapid prolifer- 
 ation and obstructive accumulation of the cells so 
 influenced. It is a rather peculiar fact, that every 
 method of treatment for syphilis that has been 
 advocated for the last two or three centuries, has 
 comprised such measures as tend to produce rapid 
 tissue change. The sweating cure, the use of hot 
 baths as at the Hot Springs of Arkansas, the purga- 
 tion and starvation cures, Boeck's method of 
 syphilization, and the treatment by pustulation 
 with tartar emetic, all of which have been recom- 
 mended by various authorities at different times, 
 are chiefly active through their power of inducing 
 fatty changes in the tissues. 
 
 The action of mercury upon the system has 
 been the subject of considerable controversy, 
 particularly as regards the form in which it 
 enters the blood. A very ingenious theory was 
 promulgated a few T years ago by Prof. S. V. 
 Clevenger, of Chicago. The professor has en- 
 
120 Lectures on Syphilis. 
 
 deavored to show that mercury does not enter 
 the system as a chemical compound, but as me- 
 tallic mercury in an exceedingly fine state of 
 subdivision, and that it acts upon disease — particu- 
 larly syphilis — in a purely mechanical manner, by 
 pushing the syphilized cells through the fine 
 capillaries, and eventually into the various elimin- 
 ative areas of the body, from which they are re- 
 moved as is other excrementitious matter. 
 
 Clevenger has found by examination of the tis- 
 sues after the use of mercury by inunction, that 
 they are filled with minute globules of the metal, 
 thus showing that it does, in that instance at least, 
 enter the blood in a state of fine subdivision. 
 Another argument is the fact that free 
 mercury is to be found in the tissues of 
 patients who have been taking the drug for 
 sometime . 
 
 The prevailing view has been, that mercury 
 enters the system as a chemical compound, and 
 brings about an antidotal effect, or produces a 
 fatty metamorphosis of the diseased cells. 
 
 My own idea is that mercury may enter the 
 blood in either form. When it enters as a chem- 
 ical compound , it may split up so as to liberate 
 a certain amou nt of the pure metal, or entering 
 as metallic mercury , it may undergo chemical 
 
Lydston. 121 
 
 changes in the tissues, these effects varying in dif- 
 ferent cases. Certain it is that finely subdivided 
 mercury introduced into the great physiological 
 chemical laboratory of the body, is quite likely to 
 undergo chemical changes. Should it be demon- 
 strated that mercury cannot exist in the body as a 
 chemical compound, and that it cannot act in any 
 but a mechanical manner, I should still be in- 
 clined to doubt its alleged ferret-like properties 
 of chasing and pushing the diseased cells out of 
 the back doors and chimneys of the economy, and 
 should be inclined to believe that it acted by 
 blocking up the vessels leading to the syphilitic 
 neoplasia, and thus enhancing their own intrinsic 
 tendency to fatty degeneration. Practically, I am 
 firmly convinced that the drug acts by inducing 
 fatty degeneration, but whether by a mechanical 
 or chemical action, or by a combination of both — 
 which is highly probable — does not seem to be of 
 any great moment. 
 
 The action of mercury upon the blood is of 
 great practical interest, inasmuch as by its use 
 two diametrically opposite effects may be pro- 
 duced, according to : 1st. The dose used; 2d. 
 The duration of its administration; 3d. The con- 
 stitutional condition of the patient; and 4th, the 
 stage of the disease. If the drug be given in full 
 doses for a few days, or in frequently repeated 
 
122 Lectures on Syphilis. 
 
 small doses for twenty-four to thirty-six hours, 
 severe stomatitis and ptyalism may be produced. 
 If it be given in a less vigorous fashion for a longer 
 period, we may have pallor and debility, due to a 
 depreciation in the quantity and quality of the red 
 blood corpuscles, to defibrination of the blood 
 plasma, and increased tissue* waste. A certain 
 degree of these effects is necessary in the treat- 
 ment of syphilis, but it is our chief aim to keep 
 them within bounds, and to avoid the danger of 
 producing permanently injurious effects. Such 
 effects as great pallor, wasting, and debility, pus- 
 tular or vesicular eruptions with fever known as 
 the "mercurial fever," and marked tremors, may 
 result from the action of mercury, and that too, 
 without the occurrence of ptyalism. On the other 
 hand, small doses of mercury, in various cachectic 
 or ansemic conditions, particularly during the 
 sequels of syphilis, will rapidly and markedly 
 increase the quantity, and improve the quality of 
 the red corpuscles and fibrine, thus lessening 
 hydremia. This statement is based upon the 
 experiments of Prof. Keyes with the hsematome- 
 ter, and moreover, upon personal observation of 
 the action of the drug. 
 
 There is another remedy which experience has 
 shown to be curative in syphilis, and which is 
 second only to mercury. I refer to iodine, which 
 
Lydstox. 123 
 
 in the form of the iodides is exceedingly useful, 
 especially in late syphilis. The iodides, — of which 
 potassic iodide is the type — act in two ways in the 
 cure of syphilis : viz, first, by their own intrinsic 
 power of producing fatty degeneration, and elim- 
 ination of morbid products, and second, by liberat- 
 ing and exciting to renewed activity the mercury 
 which may be stored up in the tissues, thus assist- 
 ing: its action. It is evident that the first of these 
 effects is the most important, for the iodides have 
 a most powerful effect in resolving the products of 
 inflammatory changes, or of adventitious deposits, 
 irrespective of their cause. I make this assertion 
 in the face of the argument that iodine can cure 
 syphilis, only by liberating mercury from the 
 tissues, and that it is the mercury and not the 
 iodides that produces the curative effects. That 
 this is incorrect is shown by the benefiicial effects 
 of iodide of potassium in cases of late syphilis in 
 which mercury has never been administered. * 
 
 Having decided upon the administration of mer- 
 cury in the constitutional management of syphilis, 
 when shall we begin its use ? It is claimed by some, 
 that it is not good practice to begin treatment 
 until the secondary symptoms develop, until, in 
 short, the case is matured, as mercury will have 
 
 * In the British and Foreign Medical Review for Oct., 1845, Hassing, 
 of Copenhagen, reported 195 cases of syphilis, TO of which were cured 
 by the iodide of potassium alone, without mercury at any stage. 
 
124 Lectures on Syphilis. 
 
 little effect prior to that time. Now I believe that it 
 is our duty to begin treatment just as soon as we are 
 positive of the diagnosis, as we thereby shorten the 
 duration of the initial lesion, and modify or even 
 prevent, secondary symptoms. To save the 
 patient from lesions upon the body or face, which 
 "he who runs may read," is very desirable, and 
 is only to be accomplished by early treatment. It 
 must be acknowledged however, that those cases 
 in which treatment is not begun until pronounced 
 eruptions appear, sometimes seem to respond more 
 readily to therapeutic measures, and to give rather 
 less annoyance during the active period, than those 
 in which mercury is given as soon as the chancre 
 develops. Whether the prospect of a permanent 
 cure is brighter, is questionable. 
 
 Having determined upon the administration of 
 mercury, it remains to select an eligible prepara- 
 tion. The mildest and least irritating form of the 
 drug, is the protiodide, or as it is sometimes 
 termed, the green iodide. It is best given in 
 pill form, in doses of on the average, one-fifth of 
 a grain, thrice daily. This dose is to be continued 
 for several days, and then increased one pill per 
 day until the gums become somewhat tender, or 
 the stomach and bowels are disturbed. I generally 
 give the drug until the gums are slightly affected, 
 
Lydston. 125 
 
 and then gradually lessen the dose until the 
 patient is taking about half the amount necessary 
 to produce slight physiological effects. This, as 
 Dr. Keyes terms it, is the patient's average dose, 
 and is usually from two to four pills of the strength 
 mentioned, daily. It is generally continued 
 throughout the course of treatment. It is well to 
 bear in mind the possibility of injurious effects 
 from the cumulative action of the drug, and also 
 the fact that it is apt to lose its effect upon the dis- 
 ease after a time. A good plan is to omit the 
 protiodide at intervals of two or three months, 
 and give potassic iodide pretty freely for about four 
 weeks. In this way any mercury which may be 
 stored up in the tissues, is liberated, rendered 
 active, and eliminated, and the system again 
 rendered susceptible to its action by the time the 
 pills are resumed. By proceeding in this manner, 
 you will always avoid the possibility of injuring 
 your patient with mercury. 
 
 It is always a matter of great difficulty to induce 
 our patients to take medicine for a sufficient length 
 of time to effect a cure. They are prone to find 
 fault with us if we are honest with them, and to 
 suspect us of sordid motives if we attempt to 
 coerce them into prolonged treatment. It is a 
 solemn fact gentlemen, that people try desperately 
 
126 Lectures on Syphilis. 
 
 to compel the physician to be dishonest. They 
 mistake honesty for lack of skill, and will more 
 readily pay the quack huge fees for false promises 
 and blatant pretenses, than the scientific physician 
 a moderate amount for skillful treatment. They 
 have always at their tongue's end a long list of 
 their friends who were cured of a bad case of syph- 
 ilis (?) by Dr. So-and-So, in three months. In spite 
 of this perverseness of human nature, however, it 
 is your duty to tell j^our patient that if he wants 
 to get well, he must take medicine for at least two 
 years, and if any doubt exists at the end of that 
 time he had better add another year, especially if 
 he has matrimonial intentions. Allow no syphilitic 
 patient to marry under three years from the 
 appearance of the chancre, if you would have clear 
 consciences. 
 
 Another difficult item in the management of 
 most cases of syphilis, is convincing the patient 
 that it is absolutely necessary for him to avoid 
 the use of liquor and tobacco for an extended 
 period, and that he must abstain from the various 
 dissipations and excesses to which he has been 
 accustomed. This point must be insisted upon 
 however, and with good conduct upon the part of 
 the patient assured, half the battle will have been 
 gained. 
 
Lydston. 127 
 
 In some cases you will find that your patient 
 does not tolerate mercury well, and that a diarrhoea 
 or gastric disturbance follows the slightest attempt 
 to crowd the drug. In this event, one-eighth 
 grain of ext. hyoscyanius should be added to each 
 pill. A good plan too, is to give the patient a few 
 five grain powders of bismuth subnitrate, with 
 instructions to take one whenever the stomach or 
 bowels become troublesome. In other cases, the 
 patient will stand a large amount of mercury, and 
 I have repeatedly given several grains of the pro- 
 tiodide daily for some w^eeks, without affecting the 
 gunis or the digestive tract in the slightest 
 degree. In such cases the large doses should be 
 kept up for a few weeks, and then diminished to 
 about four or five pills daily. In some cases you 
 will find the pil. duo. introduced by Dr. Bum- 
 stead to be an excellent preparation, especially 
 when the patient is amemic and debilitated. The 
 pil. duo. contains gr. ii. of pil. hydrarg. and gr. i. 
 of ferri sulph. exsiccat. It should be given pre- 
 cisely like the protiodide. It usually produces 
 constipation, hence an occasional dose of hunyadi 
 or bitter water may be necessary. 
 
 When a patient fails to respond readily to the 
 internal administration of mercury, or when gas- 
 trointestinal irritation is marked, the drug may be 
 
128 Lectures on Syphilis. 
 
 used by inunction. The oleate is the best prepa- 
 ration, although too expensive for some patients. 
 The twenty per cent, solution should be used, and 
 about 3i rubbed into the axilla morning and 
 night. As the axilla become irritated, the rubbing 
 may be done at the flexures of the joints, where 
 the skin is thin and absorption readily occurs. 
 The mercurial ointment, though less elegant, may 
 be used as a substitute for the oleate. It may be 
 rubbed in, or spread upon a white flannel band in 
 contact with the abdomen, the band being shifted 
 about occasionally, and the skin kept clean by 
 daily washing. Another good plan in hospital 
 practice, is to rub the ointment upon the soles of 
 the feet, and have the patient wear heavy woolen 
 socks. 
 
 In some cases inunctions or baths must be 
 wholly depended upon, and it may be said in this 
 connection, that they are very efficacious in obsti- 
 nate skin lesions. Frictions of the oleate are use- 
 ful in rupia, and will also assist in removing the 
 induration of the primary sore unless ulceration 
 exists, in which case it produces irritation. 
 
 A simple method of giving a mercurial bath, is as 
 follows : A small tin plate supported by a tripod, 
 an alcohol lamp, and a pan of boiling water, are 
 all that is necessary. The patient being stripped, 
 
Lydston. 129 
 
 seats himself in a cane bottomed chair, and wraps 
 the chair and his body thoroughly in blankets. 
 About twenty grains of the mercurous chloride is 
 placed upon the plate, the lamp is lighted, and 
 the whole apparatus is placed under the chair. In 
 a few minutes the calomel is vaporized, and with 
 the steam from the boiling water, is deposited 
 upon the skin of the patient. In fifteen minutes 
 the lamp may be extinguished, and after ten min- 
 utes more, the patient should wrap himself in a 
 dry blanket and go to bed. In the morning he 
 may rub himself with dry towels, the mercury 
 having become in great part absorbed. About 
 three baths per week are necessary. Calomel is 
 the best preparation for fumigation, because of its 
 freedom from irritating properties, and the readi- 
 ness with which it volatilizes without reduction to 
 the metallic condition. The red oxide also vola- 
 tilizes readily, but its fumes are more irritating to 
 the respiratory tract. 
 
 It is sometimes necessary to bring a patient 
 under the influence of mercury very rapidly, e. g. , 
 in cases of syphilitic iritis, in which a few hours 
 delay might be fatal to the integrity of the eyes. 
 In such an event calomel in doses of T V gr. every 
 hour, will accomplish the desired result; and if 
 necessary, ptyalism can be produced in this man- 
 
130 Lectures on Sypilis. 
 
 ner within twenty -four to forty-eight hours. 
 Another method of rapid and efficacious introduc- 
 tion of mercury, is by Lewin's method of hypo- 
 dermic injection.'* From T V to ^ of a grain of the 
 bichloride, in combination with -£$ gr. of morphia 
 and a small quantity of sodium chloride, are dis- 
 solved in fifteen minims of distilled water, and 
 injected into the cellular tissue, preferably of the 
 back, once or twice daily, f There is a vast differ- 
 ence in the susceptibility of different patients to 
 these injections. I have never seen an abscess 
 produced by them, but some patients complain 
 bitterly of the pain following their administration. 
 In others, hard and painful indurations follow their 
 use. If the precaution is taken however, of intro- 
 ducing the needle well into the cellular tissue 
 before injecting the fluid, very little trouble will 
 be caused in the majority of cases. It is probably 
 the best treatment for syphilis, in a large number 
 of cases, if you can get your patients to attend 
 strictly to treatment. As an adjunct to internal 
 treatment, the injections are excellent, and I am at 
 present giving them in most of my cases. There 
 is one point to which I desire to call attention, viz: 
 the bichloride makes the needle very brittle, and 
 unless you change it frequently, you are quite like- 
 
 *Lewin, "Behandlung der Syphilis, mit Subcntaner Sublimat— 
 injection," Berlin, 1869. 
 
 tStern, Progres Medicale, Paris, 1878. 
 
Lydston. 131 
 
 ly to break it off in the tissues, an accident which 
 the patient is quite liable to criticise. For the aver- 
 age patient in the hands of the general practitioner, 
 it is probable that Lewin's method is inferior to 
 the internal use of the mild iodide. 
 
 In the case of females with very weak stomachs, 
 or in infantile syphilis, the gray powder or hy- 
 drarg. cum creta, is an excellent mercurial prepar- 
 ation. If you have to crowd the mercurial, do so 
 by superadding fumigations or inunctions, rather 
 than by increasing the internal dose. A prepar- 
 ation recently extolled abroad, is the tannate of 
 mercury, which is claimed to be perfectly un- 
 irritating. The peptonate is another fanciful 
 preparation used by our French confreres. At my 
 next lecture gentlemen, I will mention the evil 
 effects of mercury. 
 
Lecture VII. 
 
 Necessity for appreciating the evil effects of rnercury when improp- 
 erly given.— Prejudice against its use. — Depression from mercury. — 
 Mercurial ptyalisrn and stomatitis. — Care of the teeth during a 
 mercurial course, to prevent ptyalisrn.— Causes of salivation. — 
 Treatment of salivation and stomatitis.— Rheumatoid pains as an 
 indication of excessive use of mercury. — Pain in the heels and soles 
 of the feet from mercury. — Possibility of some of the alleged late 
 lesions being due to mercury. — Action of iodine preparations. — 
 Iodides in precocious svphilis — Methods of using iodine and its 
 preparations.— Large doses of the iodides in destructive and nervous 
 lesions. — Unpleasant and injurious effects of the iodides in excessive 
 doses.— Iodism and its treatment. — Iodine eruptions. — Tendency to 
 the use of questionable preparations in syphilis. — Mistura alterans, 
 (Mc. Dade's), Tayuga, Potassium bichromate, Coca, Iodoform 
 and iron.— Local management of certain syphilitic lesions.— Necro- 
 sis of bones in late syphilis. 
 
 Gentlemen: — There is a strong tendency upon 
 the part of most teachers upon the subject of ther- 
 apeutics, to speak only of the good effects which 
 are claimed to result from the administration of 
 various drugs, and to avoid the discussion of 
 those evil effects which are likely to occur at the 
 hands of the inexperienced or careless practitioner. 
 This I believe to be wrong, and I will therefore 
 state with reference to mercury, that it is a drug 
 which must be used with great circumspection. 
 You will meet with a very firm, and it must be 
 confessed, fairly well grounded prejudice against 
 its use, existing in the minds of the laity. We 
 must of course, take into consideration the fact 
 that many of the alleged evil results of mercury 
 
134 Lectures on Syphilis. 
 
 are due to the fact that its use has not been faith- 
 fully persisted in for a sufficient length of time, 
 but with all this, there is undoubtedly a certain 
 proportion of cases in which serious injury to the 
 system of the patient may be justly laid at the door 
 of this remedy. With proper care, however, I ven- 
 ture to assert that there is no drug which is safer 
 or more reliable, and I have yet to see a single 
 case of permanent injury resulting from the drug, 
 when properly used. 
 
 We occasionally meet with cases in which mer- 
 cury has a very unsalutary effect upon the patient, 
 in the form of intense mental and emotional 
 depression, even when very moderate doses are 
 given. In such cases it may be necessary to give 
 tonics and even stimulants, in order to counteract 
 this condition. Or it may even be necessary to 
 stop the mercury entirely, and depend upon potas- 
 sium iodide. Coca will be found useful in such 
 cases. 
 
 One of the most frequent of the injurious 
 effects produced by mercury is ptyalism. Saliva- 
 tion in any marked degree is always injurious, and 
 no greater effect should be produced than a slight 
 redness and tenderness of the gums, with a slight 
 increase in the salivary secretion, a coppery 
 taste in the mouth, and what is often a good 
 
Lydston. 135 
 
 indication to diminish the amount of mercury-, a 
 sensation as if the teeth were too long. To this lat- 
 ter symptom I desire to call especial attention. 
 Ulceration of the cheeks or gums sometimes occurs 
 without previous salivation, but this is quite rare. 
 To prevent these annoyances, the mouth and teeth 
 ought to be thoroughly put in order by the dentist, 
 prior to beginning treatment. Tartar should be 
 removed and the teeth cleaned, and all those which 
 are decayed, either extracted or filled. 
 
 The causes of salivation are, iodiosyncrasy with 
 moderate doses of mercury, or large doses without 
 idiosyncrasy. Diseases of the mouth and gums 
 predispose to it, and sometimes exposure to cold 
 and wet during a mercurial course will bring it 
 on. When salivation occurs, it requires treatment. 
 Of course the first thing to do is to stop the mer- 
 curial. The chlorate of potassium may be given 
 internally, and a mouth wash used, composed 
 of the chloride of potassium and tincture of 
 myrrh, in the proportion of 3i. of the potass, 
 chloride and %i. of tr. of myrrh to giv. of 
 water. Glycerine may be added if desired. 
 Remember to specify the chloride, and not the 
 chlorate in this mixture. In some severe cases of 
 salivation, the patient cannot swallow solid food, 
 and whether this be the case or not, fluid aliment 
 
136 Lectures on Syphilis. 
 
 is indicated. I hope that you may see a case of 
 mercurial salivation sometime, in the practice of 
 somebody else, as a sort of warning to you regard- 
 ing the abuse of a really excellent drug. The fetor 
 of the breath in these cases is something horrible, 
 and is due to the presence of decomposing fat in 
 the saliva, produced by the action of mercury upon 
 the tissues and eliminated by the salivary glands. 
 In some cases of mercurial stomatitis, the cheeks, 
 tongue and lips are fearfully swollen, perhaps 
 ulcerated, and covered with a yellowish pultaceous 
 deposit, which is eminently characteristic. 
 
 You will find in certain instances chronic pains 
 of a rheumatic character, muscular and articular, 
 resulting from mercury, and I have learned by 
 experience, that when a patient who is taking much 
 mercury, begins to complain of vague pains in the 
 forearms and legs, it is time to drop mercury, and 
 give iodine. There is one peculiar fact which I 
 must mention, and that is, that some patients com- 
 plain bitterly of pain "in the heels, and sometimes 
 the soles of the feet, similar to that which occurs 
 in gonorrhoeal rheumatism. This I firmly believe 
 to be due to mercury. When your patient com- 
 plains of his feet being tender, lessen the amount 
 of mercury, and give the iodides, if you would 
 save yourself trouble . There is a serious question 
 
Lydston. 137 
 
 in my mind whether some of the ulcerations of the 
 mouth and tongue in the later periods of syphilis, 
 may not be due to mercury. I see many such 
 cases in which the continued use of the drug ap- 
 pears to make matters w r orse, and I find that 
 when iodides are substituted, improvement at once 
 occurs. This might be attributed to the action of 
 the iodine in liberating and revivifying, so to speak, 
 the latent mercury, but I doubt it being the cor- 
 rect explanation. 
 
 The use of the iodides in syphilis requires some 
 special notice. The active element in the iodides, 
 is supposed to be the free iodine which is liberated 
 in the system, but there seems to be some differ- 
 ence in the degree of effect exerted by the various 
 salts. The potassic iodide is the most powerful, 
 but is the most liable to produce gastro-intestinal 
 irritation. This does not however, impair its use- 
 fulness to a great extent, for it is the most gener- 
 ally used of all the preparations of iodine. The 
 sodic salt is milder, and is a useful substitute for 
 the potassic iodide, where the patient has a feeble 
 or irritable digestive apparatus. The iodides are 
 often and successfully used in combination, the 
 ammonium iodide being combined with the iodides 
 of potassium and sodium. Pure iodine is useful, 
 but often too irritating. 
 
188 Lectures on Syphilis. 
 
 It is the custom with most practitioners, to use 
 iodine and its preparations only in the late 
 periods of the disease, and chiefly in tertiary 
 lesions, but it will be found that many cases of 
 obstinate secondary lesions will not yield until 
 the iodides are given. As I have already stated, 
 it is well to give a few weeks' course of the iodides 
 from time to time, throughout the course of 
 mercurial treatment. A small amount of the bin- 
 iodide may be given at the same time if thought 
 best. In cases of precocious syphilis, in which 
 destructive lesions or nervous changes come on 
 early in the disease, the iodides are our chief reli- 
 ance. It is in late syphilis however, that the 
 iodides will be found most reliable, especially if 
 combined with mercury in the form of ' ' mixed 
 treatment." Gummy lesions require an excess of 
 the iodides, but in all cases, after the serious les- 
 ions are under control, a prolonged mild mercurial 
 course should be instituted. This is the proper 
 method of treating the deeper lesions of the brain, 
 spinal cord, bones, viscera, testicle, etc., the tub- 
 ercular lesions of various kinds, the various scaly 
 eruptions, and those later syphilides which tend to 
 aggregate themselves in groups, or to become par- 
 ticularly obstinate. As an example of the formu- 
 lae for the mixed treatment, I will give you a quite 
 popular combination: 
 
Lydston. 139 
 
 R Hydrarg. bichloridi gr. iv 
 
 Ammon. iodidi 3 "i 
 
 Kalii iodidi Z v Ji 
 
 Tr. cinchonae Co. or Syr. Sarsap. Co g viii 
 
 ]y[ # sig. — 3 ii in wineglassful of water after each meal. 
 
 Prof. Grunn's " three-eights " mixture is an 
 excellent one for the administration of iodine. It 
 is as follows: 
 
 ft Iodinii Resubl gr. viii 
 
 Potass, iodidi £ viii 
 
 Syr. Sarsap. Co § viii 
 
 M. Sig. — 5 i dose. 
 
 Always instruct your patients to dilute these 
 preparations well before taking, as they are all 
 more or less irritating to the stomach, and as far as 
 possible, to take them after meals. In some in- 
 stances however, in which the patient's digestive 
 organs are not very sensitive, the iodides may be 
 taken with advantage while fasting, especially if 
 combined with a vegetable bitter, like quassia or 
 cinchona. In the formula which I have given you 
 for the mixed treatment, you are likely to criticise 
 the combination of incompatibles and the admin- 
 istration of the irritating bichloride, but if you 
 reflect, you will see that the ingredients are ration- 
 ally compatible, although not chemically so. We 
 have a chemical reaction in the mixture, which 
 results in the formation of the biniodide, w T hich is 
 very active by virtue of its being in the nascent 
 
140 Lectures on Syphilis. 
 
 condition. When it is necessary to push the dose 
 of the iodides, do so by adding a saturated solution 
 of sodic or potassic iodide, to be taken in doses of 
 five drops thrice daily to begin with, and to be 
 subsequently increased one drop daily at each dose, 
 until the limit of tolerance has been reached, or 
 until the symptoms yield, when the. dose may be 
 reduced, the favorable result meanwhile continu- 
 ing. It is sometimes necessary to use mercurial 
 inunctions in addition to the iodides, and the local 
 application of the oleate sometimes assists in the 
 cure of the lesions amazingly. 
 
 The deep-seated ulcerations, — especially those of 
 the throat, — syphilis of the bones, and syphilis of 
 the brain and cord, often require enormous doses 
 of the iodides before they exhibit any signs of 
 yielding. In the venereal wards of the New York 
 Charity Hospital, a daily dose of two or three 
 hundred grains of potassic iodide was nothing un- 
 usual, and Van Buren relates a case in which nine 
 hundred grains were given daily for eleven days. 
 In my own service we had several cases in which 
 the drug was increased to a daily allowance of four 
 hundred grains. I must acknowledge, however, 
 that I was never fully satisfied as to the purity of 
 our hospital drugs, and Van Buren himself told me 
 that he did not believe it possible for a patient to 
 
Lydston. 141 
 
 tolerate the amount of iodide which we so common- 
 ly gave at the hospital, if the drug were pure. It 
 would seem that a pair of kidneys would be rather 
 worthless, after eleven days work at the daily elim- 
 ination of two ounces of the iodide. Making due 
 allowance for adulterations however, the doses 
 which some patients will tolerate, are amazing. I 
 have one patient who has taken three hundred 
 grains daily for nearly three weeks, and I am cer- 
 tain that the drug is perfectly pure. On the 
 other hand we meet cases which will not tolerate 
 even small doses of the iodides. 
 
 Like the unpleasant effects of mercury, those of 
 iodine require more than casual attention. In the 
 first place, the iodides may cause sudden and 
 severe ptyalism in patients who have been taking 
 mercury freely, simply by suddenly liberating and 
 rendering active the latter drug. On this account, 
 caution should be exercised in the use of the 
 iodides in such cases as have been under a pro- 
 longed course of mercurials. You will find in 
 every case, that the iodine has a special action 
 upon the salivary glands, whether the patient has 
 been taking mercury or not. If you will take a 
 ten grain dose of the iodide of potassium, you will 
 find that you can taste the iodine most distinctly 
 in a very short time, and that your saliva, and the 
 
143 Lectures on Syphilis, 
 
 mucus from your nasal passages, will exhibit a 
 decidedly yellowish tinge. The nasal mucus 
 especially, will be greatly increased in amount. 
 
 The most important of the evils which may be 
 caused by the iodides is the condition known as 
 " iodism, " This consists in a feeling of depres- 
 sion and malaise, nervous irritability, tinnitus 
 aurium, neuralgic or rheumatic pains in various 
 situations, especially in the bones and muscles, and 
 irritation of the various mucous surfaces, especial- 
 ly those of the eyes and nose. The latter symptom 
 may be merely a mild coryza or may amount to 
 a very severe inflammatory oedema of the conjunc- 
 tiva, nasal and lachrymal apparatuses. Severe 
 diarrhoea and vomiting, with severe griping pain, 
 may occur from the irritant action of the drug, 
 and may necessitate its complete suspension for a 
 time. Often, however, the treatment may be con- 
 tinued by substituting the sodium for the potas- 
 sium salt, limiting the diet to rice and milk, and 
 giving large doses of the subnitrate of bismuth. 
 When given as I have already suggested, by begin- 
 ning with small doses and gradually increasing 
 until the limit of tolerance is reached, there is 
 usually little difficulty in administering large doses 
 of the iodides. 
 
 Eruptions of the skin are liable to occur from 
 the iodides, and some patients appear to have an 
 
Lydston. 143 
 
 idiosyncrasy which renders them peculiarly liable 
 to the occurrence of eruptive phenomena, even 
 when quite small doses are given. I have a patient 
 at the present time who cannot take the iodide in 
 ten grain doses for a day, without the development 
 of red painful swellings upon his limbs. In the 
 same way we find patients who are liable to extreme 
 iodism, from very small doses. A professional 
 gentlemen of my acquaintance cannot tolerate the 
 drug in doses of two or three grains without the 
 development of a severe coryza in a few hours. 
 
 There are three principal forms of eruption which 
 may result from iodine and the iodides, viz: acne, 
 erythema, and purpura. Of these eruptions, acne 
 is the most frequent, and may be slight or quite 
 extensive, the pustules varying from the size of 
 the head of a pin, to quite extensive phlegmonoid 
 abscesses. Erythema when it occurs, is usually 
 situated upon the nose, cheeks, or forehead, and is 
 followed by branny desquamation. It may how- 
 ever, run into eczema. Any of these forms of erup- 
 tion may be attended by considerable heat and 
 itching. 
 
 Severe and well-marked purpura hemorrhagica, 
 is occasionally noted in cases of tertiary syphilis 
 treated by large doses of the iodide of potassium. 
 In such cases we have the combined evil pro- 
 
144 Lectures on Syphilis. 
 
 pensities of the syphilitic cachexia, and large 
 doses of iodine, to explain the profound blood 
 changes to which the purpuric extravasations are 
 attributable. 
 
 All of the evil effects of the iodides, rapidly 
 disappear upon the cessation of the drug, and the 
 administration of such tonics as quinine, iron, 
 and cod liver oil, with free doses of such diuretics 
 as the citrate or acetate of potassium. The cause 
 of the evil phenomena described, is usually defec- 
 tive action of the kidneys, hence the advisability 
 of promoting free diuresis during a course of the 
 iodides. Acne, in certain special cases of idio- 
 syncrasy, may be prevented by the administra- 
 tion of Fowler's solution of arsenic, conjointly 
 with the iodides. 
 
 There is a great tendency on the part of the pro- 
 fession, to recommend various new and questiona- 
 ble preparations in the treatment of syphilis. Cer- 
 tain vegetable preparations have enjoyed a more 
 or less long-lived popularity in this respect. Sar- 
 saparilla was long thought to be a specific. Among 
 the new preparations are cascara amarga, berberis 
 aquafolium, stillingia and other drugs, alone or in 
 combination. I advise you to try these things, in 
 the firm belief that you will soon discover their 
 fallacies, and come back to our reliable friends, 
 
Lydston. 145 
 
 iodine and mercury. As bitter tonics they are all 
 more or less useful, but as specifics they are arrant 
 humbugs. A certain quasi patent medicine, known 
 as "Mc. Dade's mixture," and composed of various 
 vegetable ingredients, was introduced a short time 
 ago, and I am sorry to say, was fathered by no 
 less a man than Marion Sims, and indorsed by 
 some other very good men, who must feel proud 
 of the distinction of having attached their testi- 
 monials to a remedy which is now heralded in 
 every newspaper, as the popular remedy for syph- 
 ilis. As a matter of fact, it is on a par with its 
 quite as respectable contemporary, the three S's, 
 as a therapeutic agent. Tayuga is another remedy 
 of doubtful origin which was recommended some 
 years ago, and which Dr. J. Nevins Hyde, of this 
 city, gave a fair trial in syphilis, with, he claims, 
 negative results. The bichromate of potassium 
 has been recently recommended, but I have had 
 no experience with it. It is best to be liberal, and 
 give different remedies a fair trial, irrespective of 
 their origin, and such has been my custom, but I 
 think that you will find that the proportion of cases 
 of syphilis which is curable by the judicious use of 
 mercury and iodine, is so large, and so gratifying, 
 that you will waste no unnecessary time upon new 
 and strange drugs. * In conclusion I will mention 
 
 * Bumstead and Taylor estimate the proportion of cures at about 
 95 per cent. , but this is somewhat exaggerated. 
 
146 Lectures on Syphilis. 
 
 two remedies which are decidedly beneficial as a 
 tonic in syphilis, viz., the fl. extract of coca, 
 and iodoform. Coca is an excellent tonic when 
 used conjointly with strictly anti-syphilitic treat- 
 ment, and tends decidedly to relieve the nervous 
 depression from which most syphilitics suffer. 
 Iodoform will be found most useful in cases which 
 do not tolerate mercury and iodine well, and should 
 be combined with the exsiccated sulphate of iron 
 or the iron by hydrogen, the latter perhaps being 
 the most useful and convenient. 
 
 Before leaving the subject of the treatment of 
 syphilis, I desire to call your particular attention 
 to several little items in the local management of 
 the disease, which may prove of great service to 
 you. There is nothing of importance to add to 
 what I have already said, regarding the treatment 
 of the chancre itself, but some of the secondary 
 lesions require attention. Mucous patches some- 
 times gives great annoyance, and refuse to yield to 
 purely constitutional treatment, becoming sluggish 
 and indolent. In such an event, the pure acid ni- 
 trate of mercury will be found to be the best appli- 
 cation. Before applying it, the lesion should be 
 dried with a piece of bibulous paper or absorbent 
 cotton. The surface should then be thoroughly 
 cauterized, after which it is again dried. The ni- 
 
Lydston. 147 
 
 trate of silver may be used in the same manner. 
 Sometimes cauterization is not tolerated, the sore 
 becoming inflamed and irritable. In such cases 
 the tr. benzoin co. will be found most effectual. 
 It coats the lesion with a deposit of the gum ben- 
 zoin, and in addition to its mildly stimulant 
 and antiseptic action, protects the surface from 
 irritation. When mucous patches hypertrophy, 
 and form tubercles or condylomata, an application 
 of hydrarg. bichlor. in collodion in a strength of 
 four to twenty grains to the ounce, will be found 
 to remove them very rapidly. Calomel, zinc 
 oxide, salicylic acid and iodoform are also all quite 
 useful applications. Washing the parts in salt and 
 water followed by the application of calomel is 
 also of service, as nascent bichloride is formed 
 and acts very powerfully upon the lesions. In case 
 of secondary or even tertiary lesions upon the face 
 which are non-ulcerative, the solution of bichlo- 
 ride in collodion will be found to remove them 
 quite rapidly. Be careful however, not to cause 
 severe blistering of the skin by too powerful or 
 too frequent applications. In case of ecthymatous 
 or rupial ulcerations, frictions with the oleate are 
 beneficial. Gummy ulceration, especially when 
 situated in the mouth or pharynx, will be best 
 treated by the application of benzoin. Although 
 
148 Lectures on Syphilis. 
 
 iodoform is also quite effectual, it is far more un- 
 pleasant, for most people do not like to have such 
 an odorous application, in so close proximity to 
 their nasal and digestive organs. 
 
 We sometimes meet with cases of necrosis of 
 the bones in various situations in late syphilis, or 
 more properly speaking, the period of sequelae. 
 Try and determine whether the osseous troubles 
 are due to syphilis or to mercury, and then treat 
 them upon general principles. Remember that 
 tonics are always indicated in these cases, and that 
 the iodides are our main reliance, mercury if giv- 
 en at all, being indicated only in tonic doses. As 
 a parting injunction in the treatment of syphilis, I 
 wish you to remember that cleanliness is nowhere 
 productive of better results than in this disease. 
 The Turkish or Russian bath once or twice weekly, 
 has an excellent general as well as local effect, 
 and where possible, recommend them to all your 
 patients. 
 
Lectuke VIII. 
 
 Congenital Syphilis.— Acquired syphilis of children, —Methods of 
 acquiring the disease. — Methods of contracting the disease by 
 hereditary transmision.— Necessity of caution in differentiating the 
 acquired and congenital forms of syphilis in children. — Intra- uter- 
 ine syphilis. — Syphilitic abortion. — Treatment of syphilitic abor- 
 tion.— Occasional masquerading of congenital syphilis as " scrof^ 
 ulosis."— Peculiar appearance of the hereditarily syphilitic child.— 
 Congenital syphilitic lesions of the skin and mucous membranes, 
 nails, hair, bones, and viscera. — Apoplectic effusions.— Sudden 
 death of syphilitic children. — Hydrocephalus from congenital 
 syphilis.— Predisposition to tuberculosis. — Hutchinson's descrip- 
 tion of the teeth in hereditary syphilis.— The syphilitic counten- 
 ance.— Prognosis and treatment of congenital syphilis. 
 
 Gentlemen: I have thought it advisable before 
 leaving the subject of syphilis, to devote an hour 
 to the discussion of the congenital form of the 
 disease. I believe that this is a topic of practical 
 importance, and one which although not entirely 
 neglected by the more systematic works upon 
 syphilis, has not often been presented in a practical 
 manner. I have used the term congenital syphilis, 
 in preference to "infantile syphilis," for the reason 
 that children may acquire syphilis in a number of 
 ways independently of hereditary transmission. 
 When thus acquired, the course and various phe- 
 nomena of syphilis are in no wise different from 
 the same affection in the adult. A child may 
 become inoculated with syphilis by kissing persons 
 with oral or labial syphilides, such as mucous 
 
150 Lectures on Syphilis. 
 
 patches, fissures and ulcers, or it may acquire it 
 from nursing its syphilitic mother or nurse. 
 The possibility of acquiring the disease by vacci- 
 nation must also be remembered, although at the 
 present day, when non-humanized virus is almost 
 exclusively used, such an accident can only occur 
 through the most gross and culpable carelessness. 
 
 There is also the possibility of contamination 
 through attempts at sexual congress, by both male 
 and female examples of depravity. I have myself 
 seen two cases of syphilis in children, acquired in 
 this manner. These instances have, however, no 
 bearing upon congenital syphilis, excepting that 
 great care is to be exercised in differentiating the 
 two. An error here, might seriously compromise 
 an innocent person on the one hand, or allow a 
 guilty one to escape upon the other. 
 
 In the case of alleged vaccinal syphilis, care 
 should be taken, else an innocent operator may be 
 held responsible for the sins of the child's parents. 
 Remember gentlemen, that a diagnosis is difficult 
 without a knowledge of the natural course of syph- 
 ilis, and that a more or less typical course of syph- 
 ilitic phenomena, following a pre-existing chancre, 
 is the only positive proof of acquired syphilis, he 
 the subject old or young. 
 
 The methods of acquiring syphilis by heredity, 
 we have already studied to some extent. It is 
 
Lydston. 151 
 
 probable that either parent may transmit syphilis 
 to the child, although as far as the father is con- 
 cerned, the question of his power to procreate a 
 syphilitic child, without first infecting the mother, 
 is still sub-judice. Otis claims that the presence 
 of the syphilitic cell, is incompatible with life in 
 the spermatozoa, but it would be necessary to 
 demonstrate the cell as an entity, before it could 
 be admitted as a necessity in this particular 
 method of transmission. The probable truth is, 
 that while the presence of the syphilitic germinal 
 cell is necessary in order that the semen should be 
 inoculable, its presence is unnecessary in order 
 that the father should infect the foetus. This 
 results from the fact that the spermatozoa of a man 
 who is in the flower of syphilis, have been so modi- 
 fied that they are incapable in some instances of 
 generating a healthy child. The child need not 
 necessarily be affected by the ordinary phenomena 
 of syphilis, but may present certain perversions of 
 growth and nutrition, which are not ordinarily con- 
 sidered to be syphilitic. That syphilis may so 
 impress the spermatozoa, that the child may be 
 cachectic and ill nourished, if not actually syphil- 
 itic, is probably true. It is almost beyond doubt, 
 that the syphilitic impress is liable to masquerade as 
 rickets or scrofulosis in the child. Independently 
 
152 Lectures on Syphilis. 
 
 of theoretical reasoning, it is a positive fact that 
 the children of apparently healthy mothers, by 
 syphilitic fathers, are often affected by certain con- 
 ditions of mal-nutrition which are singularly bene- 
 fitted by anti-syphilitic treatment, and which are 
 probably "attenuated syphilis." That the mothers 
 are not really syphilitic, is of course an open ques- 
 tion, but in a large proportion of cases, the evi- 
 dence is in their favor. 
 
 It is an undisputable fact, that when the mother 
 is syphilitic, the offspring rarely escapes. Her 
 power of transmitting the disease lasts much longer 
 than that of the father, as may be readily explained, 
 if we stop to consider the intimate anatomical and 
 physiological relations which exist between the 
 foetus in utero and its mother. v The exception of 
 the mother who becomes pregnant while healthy, 
 and does not become infected with syphilis until 
 the seventh month, is to be borne in mind in con- 
 sidering the probability of the mother infecting her 
 child. * It has been demonstrated that the female 
 may procreate syphilitic children, long after she 
 has lost the power of infecting a healthy man. 
 
 As a matter of practical importance it had best 
 be remembered, that while it remains to be positive- 
 ly shown, that either parent may infect the child 
 independently of the other, cases have occurrred 
 
 *Diday, " De la Syphilis des Nonveaux-nes." 
 
Lydston. 153 
 
 which seem to prove its truth, and until the ques- 
 tion is absolutely settled, it is best to be cautious, 
 and remain upon the safe side. 
 
 The changes in the foetus which result from the 
 syphilitic infection or impression, are of vital im- 
 portance, and often decide the question as to the 
 birth of a living syphilitic child. The ovum may 
 be blighted early in the course of utero-gestation 
 and be cast off, or absorbed, or it may develop to a 
 greater or less extent, according to the severity 
 with which the syphilitic infection manifests itself. 
 The disease may manifest itself in several ways, 
 and sometimes in a rather obscure fashion. A 
 general shriveling or dwarfing of the structure of 
 the foetus may occur, with resulting death, and a 
 consequent abortion. Serious visceral lesions 
 sometimes occur, and destroy life, e. g. , I recall a 
 case in which a woman miscarried and was de- 
 livered of a still-born child, whose liver was so 
 enormously hypertrophied as to cause serious 
 difficulty in delivery. Intra-uterine hydrocephalus 
 is an occasional result of syphilis, and I once saw 
 Dr. Munde perform craniotomy upon a case of 
 this kind, in the New York Maternity Hospital. 
 
 Disease and malformation of the osseous system 
 are frequent results of syphilis, and it is my own 
 conviction that many congenital deformities de- 
 
154 Lectures on Syphilis. 
 
 pend upon imperfect development, resulting from 
 intra-uterine syphilis. These however, are the 
 more obscure manifestations of the disease. 
 
 Apoplectic effusions often occur in the syphilitic 
 foetus, and if all aborted syphilitic children were 
 examined critically, much light might be shed 
 upon the effects of syphilis upon the vascular sys- 
 tem. 
 
 Well marked eruptions are apt to occur upon 
 the foetus in utero, and most syphilitic foetuses will 
 present some unmistakable external lesion. 
 
 It is exceptional that a woman in full syphilis, 
 succeeds in carrying a child to term, even when 
 under quite active treatment. Abortion usually 
 occurs, and is perhaps most often due to death of 
 the foetus, which then acts as a foreign body, 
 and is cast off. It is not unusual however, for the 
 abortion to occur as a result of placental changes. 
 Placentitis hemorrhagica, fatty and waxy changes 
 in the placenta, all interfere with its uterine attach- 
 ments primarily, and secondarily affect the vital- 
 ity of the foetus by interfering with the interchange 
 of nutritive material, necessary for its sustenance. 
 Placental apoplexy is especially apt to bring on 
 abortion, particularly when the blood extravasates 
 upon its attached surface. When the hemorrhage 
 is parenchymatous, abortion is not so likely to 
 occur. 
 
Lydston. 155 
 
 Syphilis is one of the most potent causes of 
 abortion, and when a female, however healthy, 
 aborts frequently, a suspicion of syphilitic taint is 
 justifiable. 
 
 The treatment of syphilitic abortion is of neces- 
 sity the administration of mild mercurials through- 
 out the course of pregnancy. It by no means fol- 
 lows, that because a woman aborts as a result 
 of syphilis, she must necessarily give birth to a 
 syphilitic child, hence it is always just and consci- 
 entious to try to carry the pregnancy to full term. 
 The better the apparent health of the mother, and 
 the later the period of the disease, the more emi- 
 nently proper such a course becomes. 
 
 When a syphilitic child goes on to full term, 
 which often occurs, it may be born apparently 
 healthy and well nourished, but as a rule it devel- 
 ops symptoms of inherited syphilis within a few 
 weeks. In the majority of instances, syphilis de- 
 velops before the child is three months old. In 
 some cases however, some years elapse before 
 symptoms develop, and then they are more or less 
 marked. Cases have been related in which lesions 
 of the pharynx, viscera and bones occurred in 
 adult life for the first time, the childhood of the 
 patient having been apparently healthy. It is 
 probable moreover, that a generation may be 
 
156 Lectures on Syphilis. 
 
 skipped before the syphilitic impression manifests 
 itself. 
 
 As has been already asserted, many of the cases 
 of disturbed nutrition termed struma or scrofulo- 
 sis, are probably syphilitic. Hutchinson and Ast- 
 ley Cooper, both tacitly admitted this in their day, 
 and Cooper's favorite remedy for scrofula, consist- 
 ed of bichloride of mercury in Huxham's tincture 
 of cinchona bark. 
 
 In the majority of instances, a syphilitic child is 
 indelibly stamped with the hereditary impress. 
 It is as a rule, remarkable for its pinched, shrivelled 
 appearance, due probably to a lack of fatty tissue 
 from malnutrition. The new born baby has the 
 look of an old man, and if it lives long enough, it 
 has often the most supernatural look of intelli- 
 gence that could well be imagined. This wise 
 little old man is as remorseless as fate, in divulging 
 the sins of his parents. He says little, but ex- 
 presses much, and he is a burden greater than the 
 "Old Man of the Sea" as long as he lives. 
 
 If not present at birth, lesions of various kinds 
 develop from time to time. I have seen a child 
 born with a well marked roseola. Chaps and ex- 
 coriations of the quasi-mucous surfaces about the 
 genitals, anus and mouth, are apt to develop, and 
 may form true plaques muquease or even condy- 
 
Lydston. 157 
 
 lomata. A scalded appearance of the anus, is quite 
 characteristic. Snuffles develop after a time, and 
 the nares become so clogged up, that respiration and 
 nursing are interfered with, and nutrition still 
 farther impaired. This ozoena may lead to necrosis 
 of the nasal cartilages. 
 
 A livid macular eruption is sometimes seen, and 
 ulcerations may form about the mucous orifices. 
 Papular and pustular lesions are not infrequent, 
 and quite characteristically affect the palms and 
 soles in certain instances. Subcutaneous tuber- 
 cular lesions may be seen in some few cases. 
 
 A very peculiar eruption is sometimes seen in 
 syphilitic children, which is quite identical in its 
 physical characteristics with ordinary pemphigus 
 in the adult. This "infantile pemphigus" is an 
 unmistakable evidence of syphilis. It consists of 
 an eruption of bullae or blebs, sparsely distributed 
 over the skin. Sometimes but one or two bullae 
 are present. It is especially apt to affect the palms 
 of the hands and soles of the feet. The blebs are 
 filled with fluid which varies in its physical char- 
 acters from slightly turbid serum to pus. When 
 the cuticle yields, the fluid dries into a greenish 
 crust, and ulceration occurs beneath, precisely as 
 in syphilitic ecthyma or rupia. 
 
 It has been claimed that infantile pemphigus 
 may result from simple cachexia, but this is not 
 
158 Lectures on Syphilis. 
 
 probable, and it may generally be accepted as an 
 evidence of syphilis. When a syphilitic child 
 develops pemphigus, a bad type of disease is evi- 
 denced, and the case is usually hopeless. 
 
 Another almost pathognomonic indication of 
 syphilis, may occur in the form of keratitis. This 
 is often attributed to scrofula. 
 
 The epithelial appendages of the body, such as 
 the hair and nails, are not so likely to become 
 affected in congenital syphilis as in the adult, but 
 a brittle, lustreless condition of the nails is occa- 
 sionally noted. As Hutchinson has shown, the 
 nails may be repeatedly shed, or they may split 
 and become ragged in appearance. They may 
 even become affected by suppuration of the matrix, 
 or onychia.* 
 
 It has been generally accepted that the osseous 
 lesions of children are insignificant as compared 
 with the same changes in the adult syphilitic. 
 This is however a mistake, and in my own exper- 
 ience I have been able to observe a considerable 
 number of bone lesions in children. In fact, one 
 of the most frequent lesions observed in the cases 
 of congenital syphilis at the N. Y. Charity Hos- 
 pital was syphilitic inflammation of the bones. It 
 was the exception rather than the rule, that serious 
 visceral lesions were unaccompanied by osseous 
 
 *Hutehinson. "Patholog. trans." XII. 259. 
 
Lydston. 159 
 
 troubles. Taylor has called especial attention to 
 the lesions of the bones in congenital syphilis.* 
 This eminent authority has shown that the most 
 frequent seat of the osseous lesions is at the 
 diaphyso-epiphyseal junction of the long bones, 
 certain bones however, being affected with especial 
 frequency. This is explained by the fact that the 
 processes of growth and nutrition, are most active 
 at the junction of the diaphysis and epiphysis of a 
 bone in any situation. 
 
 Most frequently the bone is more or less uni- 
 formly enlarged, although in certain instances the 
 periosteum seems chiefly affected. Suppuration is 
 infrequent, but is described by Bouchut as a result 
 of softening of the cartilages of the epiphysis. + 
 Necrosis is not very frequent. 
 
 The most important of all the manifestations of 
 hereditary syphilis are the lesions of the viscera. 
 The processes of growth and nutrition in the in- 
 fant are very active, and constructive changes are 
 especially favored. These circumstances are par- 
 ticularly conducive to the proliferation of young 
 connective tissue, in the parenchyma of the viscera. 
 When present, these interstitial proliferations 
 are usually diffuse, circumscribed gummy 
 changes being exceptional. Such cases however, 
 
 * R. W. Taylor, "Bone Syphilis in Children." 
 
 t Bouchut, "Maladies des Enfans Nouveaux-nes," 1861. 
 
160 Lectures on Syphilis. 
 
 are related. Any or all of the viscera may be in- 
 volved, the connective tissue changes being espec- 
 ially apt to affect the liver, spleen and kidneys. 
 
 There is hi syphilitic new-born children, a 
 marked tendency to apoplectic effusions in various 
 situations, particularly in the meninges of the 
 brain, and probably also the cord. The condition 
 known as cephal-hsematoma is most apt to occur in 
 syphilitic children, in whom the vessels seem to be 
 characterized by great tenuity. If the labor be at 
 all difficult, or if forceps be used, there is great 
 danger of intra-cranial or sub-peri cranial effusions. 
 I have noted three cases of meningeal hemorrhage 
 in new born syphilitic children, and four cases of 
 cephal-haeiiiatoma, three of which were undoubt- 
 edly syphilitic. In one case the child developed 
 a cephal-hsematoma soon after birth, which ab- 
 sorbed in a few weeks. During the fourth week 
 the child developed convulsions and died. On 
 autopsy extensive changes in all the viscera were 
 noted, and upon the surface of the brain, a large 
 clot from a ruptured meningeal vessel was found. 
 In one of the cases of meningeal hemorrhage 
 which I have seen, the child was found dead by its 
 mother's side, and a suspicion of foul play was 
 entertained. The autopsy however, showed an 
 extensive meningeal hemorrhage. 
 
Lydston. 161 
 
 Cases of sudden death in syphilitic children, have 
 been occasionally noted by other observers, but 
 there seems to have been no autopsy in the majority 
 of instances, at least no explanation for these cases 
 has been given, as far as I am aware. It is prob- 
 able that some of them have been due to menin- 
 geal hemorrhage. 
 
 Children are apt to develop hydrocephalus, as a 
 result of syphilitic inheritance. I recall to mind 
 a family in which two children died of this disease, 
 as a result of congenital syphilis. The so-called 
 rachitic appearance of the skull is often a manifes- 
 tation of syphilis. 
 
 It is probable that congenital syphilis, has a 
 more or less marked influence in the causation of 
 tubercular meningitis. It may not give positive 
 evidence of its presence by a development of une- 
 quivocal syphilitic disease, and yet may so impair 
 nutrition as to develop a deposit of tubercle. The 
 syphilitic soil, is one in which the tubercular pro- 
 cess will flourish. 
 
 The most accurate description of the symptoms 
 of hereditary syphilis that has ever been given, is 
 that of Mr. Jonathan Hutchinson. The syphilitic 
 countenance as described by him is quite charac- 
 teristic, and his description of the teeth, in heredi- 
 tary syphilis, is classical. The evidences given by 
 
162 Lectures on Syphilis. 
 
 the teeth are not pathognomonic, nor are they al- 
 ways present, even when positive signs of syphilis 
 exist, but in general they are very valuable. 
 
 The permanent teeth, instead of being regular, 
 and symmetrically developed, are irregular, 
 notched and pegged in appearance, and the confor- 
 mation of the alveolar arch is imperfect. The two 
 upper central incisors are the "test teeth." They 
 are short, vertically notched, narrow and rounded 
 at their corners. 
 
 "Next in value to the malformation of the teeth," 
 says Hutchinson, "are the state of the patient's 
 skin, the formation of his nose, and the contour of 
 his forehead; the skin is almost always thick, 
 pasty, and opaque It also shows pits and scars, 
 the relics of former eruptions, and at the angles of 
 the mouth are radiating linear scars, running out 
 into the cheeks. The bridge of the nose is almost 
 always low, and broader than usual, often it is 
 remarkably sunken and expanded. The forehead 
 is usually large and protuberant in the region of 
 the frontal eminences; often there is a well marked 
 broad depression a little above the eyebrows. The 
 hair is usually dry and thin, and now and then the 
 nails are broken and splitting into layers. " Inter- 
 stitial keratitis is pathognomonic of inherited 
 taint, and when co-incident with the syphilitic 
 type of teeth, the diagnosis is beyond a doubt. 
 
Lydstox. 163 
 
 The prognosis of congenital syphilis, is of course 
 very unfavorable. The earlier the eruptions or 
 other symptoms appear, the greater the danger. 
 Marked eruptions occurring shortly after birth, 
 indicate a fatal prognosis. Severe and early 
 ozcena, in badly nourished children, is of like im- 
 port. Marked visceral lesions and apoplectic 
 effusions, are always fatal. Lesions of the bones, if 
 unaccompanied by marked visceral changes, are 
 not so unfavorable. In cases of enteritis syphilitica, 
 a lesion described by Lancereaux, there is no hope 
 of saving the child. 
 
 In the face of the unfavorable prognosis of 
 hereditary syphilis, it is some consolation to know 
 that as a rule, a syphilitic child is better dead, for 
 it is a constant danger to its friends, and its life is 
 at best but a miserable one. Sometimes, however, 
 a syphilitic child becomes fat and healthy, under 
 proper treatment. 
 
 The treatment of congenital syphilis, is to be 
 carried out in two ways, viz. : by direct medication, 
 and indirectly, through the system of the mother. 
 
 The best internal remedy for the child, is the 
 hydrarg. cum creta or gray powder. This may 
 be given in doses of from one, to three or four 
 grains three times daily. In very young children, 
 inunctions of the ung. hydrarg. or hydrarg. oleatis 
 
164 Lectures on Syphilis. 
 
 must be depended upon. A good plan is to spread 
 a piece of blue ointment the size of a large filbert, 
 upon the flannel binder once daily. The delicate 
 skin of the child absorbs this quite readily. Daily 
 cleansing with soap and water, and frequent shift- 
 ing of the position of the band, are necessary to 
 avoid irritation. The soles of the feet, axillae, and 
 flexures of the joints, are also eligible situations 
 for inunctions. 
 
 In older children, the bichloride of mercury may 
 be given in small doses, in combination with some 
 vegetable bitter, like Huxham's tincture. Parvules 
 of the hydrarg.cum cretse, protiodide, or mild chlor- 
 ide are also useful. 
 
 The general condition is always to be borne in 
 mind in treating congenital syphilis, and cod liver 
 oil and iron will always be of benefit. The syrup 
 of the iodide of iron is the best preparation. 
 Young children absorb cod liver oil readily, when 
 given by inunction. The oleate of mercury may 
 be combined with the oil. Good and sufficient nour- 
 ishment is always required, but the child should 
 not nurse from its mother, unless it is positive that 
 she not only has, or has had syphilis, but is in fair 
 general health. A syphilitic child should never be 
 reared by a healthy nurse, that is, one who has not 
 had syphilis. In general, good cow's milk is the 
 
Lydston. 165 
 
 best for the child. I will say something with refer- 
 ence to the nursing of syphilitic children, in the 
 next lecture. 
 
 When the child is nursed by its mother or by a 
 nurse, it may be treated through the medium of 
 the breast milk, by the iodide of potassium. This 
 drug is eliminated in great part by the mammary 
 glands, and this physiological fact is therefore of 
 therapeutical service in hereditary syphilis. From 
 five to ten grains may be given four or five times 
 daily, care being exercised in regard to the pro- 
 duction of gastro-enteric irritation in both mother 
 and child. 
 
 The local management of congenital syphilis is 
 often of importance. Perfect cleanliness is a par- 
 amount indication. Ulcers and excoriations should 
 be kept clean and dry, and dusted with calomel or 
 oxide of zinc. Condylomata are to be treated as 
 in the adult. Ozaena requires local treatment, and 
 a nasal douche of some antiseptic solution is use- 
 ful. The preparation known as Listerine is useful 
 for this purpose. It should be diluted with about 
 three or four parts of water, and used three times 
 daily. Be careful not to use harsh applications in 
 syphilitic lesions of children, as their delicate skins 
 are very intolerant of such measures. 
 
Lecture IX. 
 
 The nursing of syphilitic children. — Possibility of a healthy child being 
 born of syphilitic mother, and of a syphilitic child being born of ap- 
 parently healthy mother — Attenuation of virus by passing through 
 the system of foetus. — Belief of Hutchinson in the primary infection 
 of the foetus.— Analogy of syphilization of foetus to inoculation with 
 virus of variola. Escape of the child from infection after 7th month 
 of pregnancy. --In dividual insusceptibility to infection — Analogy of 
 syphilization to vaccination.— Danger of infection of child by syphil- 
 itic mother, and vice versa. — A desirability of artificial feeding. 
 
 Gentlemen : In accordance with a promise 
 which I made you some time ago, I desire to 
 say a few words this morning regarding the nurs- 
 ing of syphilitic children, a subject of quite prac- 
 tical interest and importance. 
 
 The question of the management of infants who 
 are the subjects of hereditary syphilis, or who are 
 the children of syphilitic mothers, and in whom 
 the disease is likely to develop, has received com- 
 paratively little attention at the hands of syphil- 
 ographers, Fournier having perhaps given the sub- 
 iect more attention than the majority of observers. 
 The conclusions to which his studies in this direc- 
 tion have led him, are, first, that the child of a 
 syphilitic mother should be given to her to nurse, 
 even if it present no evidences of syphilis, as it will 
 almost inevitably exhibit the disease, and would 
 run the risk of infecting a non-syphilitic nurse. 
 
168 Lectures on Syphilis. 
 
 Second, that if the child be syphilitic and the 
 mother apparently healthy, it should still be nursed 
 by her, as there is no danger of maternal infection 
 by the infant. The consideration of the manage- 
 ment of the infant, in case both mother and child 
 have apparently escaped, but the father is in the 
 active stage of syphilis, is passed by with the asser- 
 tion that there is absolutely no danger to either 
 mother or child, if maternal nursing be allowed. 
 The question of nursing an infant born free trom 
 syphilis, although its mother has the disease, and 
 it having escaped as the result of a mercurial 
 course administered to the woman during gesta- 
 tion, is not dwelt upon. 
 
 It is a practical fact that in the cases ot children 
 who have inherited syphilis, but in which the 
 mother has apparently escaped the disease, no 
 clearly defined instances have been reported of the 
 infection of the mother by the infant, and this fact 
 affords the foundation for " Colles law," so called, 
 viz., that a child born syphilitic will not infect the 
 mother. The reverse is also held to be true, viz., 
 that a syphilitic mother is in no danger of infect- 
 ing her child, it being apparently healthy, unless 
 her disease has been contracted subsequent to de- 
 livery, in which case she is ultra-contagious to it. 
 This has been variously explained. One very 
 
Lydston. 169 
 
 plausifc e argument is that the mother already has, 
 or has had syphilis, contracted either before, or 
 during the pregnancy in question. 
 
 This would imply, that it is impossible for a 
 syphilitic child to be born of a healthy mother, or in 
 other words that it is absolutely impossible, for the 
 father to transmit syphilis to his child, without the 
 mother being secondarily infected. Others deny 
 the possibility of the child inheriting the syphilitic 
 taint from the father, excepting secondarily, 
 through the medium of the mother. 
 
 If these views be correct, then the disease must 
 exist in the mother when she appears to remain 
 healthy, in an exceedingly mild form; so mild in 
 fact, that its manifestations escape observation, or 
 it must remain latent for a longer or shorter time, 
 and finally manifest itself by some of the lesions 
 characteristic of the late period of syphilis. This 
 might result from the fact that the disease expends 
 its violence upon the child in utero, thus rendering 
 the infection of the mother comparatively mild, or 
 the secondary period of the disease might be repre- 
 sented and replaced by the manifestations- which 
 occur in the foetus, thus exempting the mother 
 from affections of a secondary character, but 
 rendering her none the less liable to the tertiary 
 forms. In the first instance, the changes in the 
 
170 Lectures on Syphilis. 
 
 fcetus v could be said to produce an attenuation of 
 the specific principle, just as the virus of other in- 
 fectious diseases may become attenuated by succes- 
 sive inoculations. 
 
 Hutchinson believes the explanation to be in the 
 manner of the introduction of the " virus" into the 
 maternal system, using as an analogy, the result 
 of inoculation with the virus of variola, which pro- 
 duces a comparatively mild form of the disease, 
 while inhalation of the same materies morbi, 
 causes variola of the severest type. This implies 
 that the syphilitic poison is modified ill some 
 peculiar manner by its passage through the fcetal 
 circulation.* Fournier is undecided upon this 
 point, and does not advance any very definite 
 views, but unites with the majority of authorities, 
 in advocating the indiscriminate nursing of the 
 hereditarily syphilitic infant, by the mother, 
 whether she herself appears to suffer from the 
 disease or not. 
 
 None of the authorities quoted, state that it is 
 absolutely impossible for the mother to be infected 
 by the infant in such cases, but they simply ad- 
 vance the clinical fact that such infection has not 
 occurred. Facts have been recorded by many 
 observers, to show that it is possible for the 
 
 *Thus it is assumed by Hutchinson, that the foetus may be infected 
 with active syphilis primarily, and without the intervention of the 
 maternal circulation. This is a mooted point. 
 
Lydston. 171 
 
 mother to contract syphilis during pregnancy, 
 without necessarily transmitting the disease to the 
 child, this being especially true in case of her in- 
 fection after the seventh month, in which instance, 
 according to Diday, the child always escapes. This 
 would appear to be a powerful argument against 
 the mother nursing the infant, as long as it presents 
 no manifestations of the disease, although she her- 
 self is affected by it, the lesions having shown 
 themselves either shortly before, or immediately 
 subsequent to delivery. The cases in which the 
 infant escapes the disease, when it has existed in 
 the mother for any length of time before delivery, 
 must be exceedingly rare. Fournier thinks that 
 he has seen a certain number. The instance may 
 however occur, especially if the mother be brought 
 under the influence of mercury sufficiently early. 
 
 If the mother be infected shortly before delivery, 
 and secondary symptoms do not appear until after 
 the birth of the child, it stands an excellent chance 
 of escaping the disease, as far as heredity is con- 
 cerned, although it is possible that it is in no wise 
 insusceptible to infection by inoculation, either 
 through the medium of the lesions present in the 
 mother, or by a syphilitic nurse, if such be ob- 
 tained; and the latter contingency may occur 
 from the fact that syphilitic nurses are intentionally 
 
1 72 Lectures on Syphilis. 
 
 procured in some instances in which the mother is 
 syphilitic but the child apparently healthy, the 
 belief being that syphilis will necessarily develop 
 in the latter, and that it cannot by any possibility 
 escape. The same plan is also advocated when the 
 child presents unmistakable evidences of the 
 disease. 
 
 It is undoubtedly true, that certain persons are 
 insusceptible to syphilis and that the susceptibility 
 of different persons varies greatly, as in the case 
 of other contagious affections. It would appear 
 then, more rational to infer, in certain of the cases 
 of children born syphilitic, and in which the 
 mother apparently escapes, that she was primarily 
 insusceptible to infection, or that she exhibited a 
 certain power of resistance to it, than to explain 
 the circumstance by "some occult and indiscernible 
 change in the maternal system." Might not the 
 mother have a sufficient power of resistance, to 
 enable her to escape infection through the foetus 
 in utero, and yet remain susceptible to inoculation? 
 It is possible too, that she may have been insuscep- 
 tible to syphilitic infection or inoculation during 
 gestation, and yet might at any time become sus- 
 ceptible, the degree of susceptibility varying at 
 different times, as is true of other infectious dis- 
 eases. 
 
Lydston. 173 
 
 In case the mother was primarily insusceptible 
 to both infection and inoculation, there is evidently 
 no danger of her contamination by the infant, but 
 it is of course impossible to determine this. Under 
 any of the other circumstances mentioned, there is 
 evidently an element of danger. 
 
 Another consideration, is the possible analogy 
 between the effects of the infection of the foetus, 
 upon the mother, and vaccinia, there being a certain 
 degree of immunity from syphilis resulting, which 
 lasts for a variable length of time. In this event, 
 the mother may become susceptible at any time 
 daring lactation, and contract the disease from the 
 infant. It is possible that in the same way, the 
 infant may enjoy a certain amount of protection 
 from infection, it being born healthy and its moth- 
 er being syphilitic, although it may at any time 
 contract the disease by inoculation. 
 
 If the mother and child have both apparently 
 escaped syphilis, although it is present in an active 
 form in the father, it is evident that one or both of 
 them may be syphilitic, and lesions develop at 
 any time, with a consequent danger of infection in 
 the act of nursing, for it is impossible to say in 
 some cases, exactly when the mother becomes in- 
 fected. I would consequently strenuously object 
 to maternal nursing under any of the circumstan- 
 
174 Lectures on Syphilis. 
 
 ces I have mentioned, believing that there is a cer- 
 tain amount of danger in the practice, be that dan- 
 ger ever so slight. If however, the mother and 
 child are both undoubtedly diseased, and the phys- 
 ical condition of the mother be such that she is 
 able to nurse her infant, and her milk is of a fair 
 quality, nursing should be allowed. It is evident 
 that if the mother is not permitted to nurse the 
 child for the reasons I have stated, an artificial 
 substitute for mother's milk must be given. The 
 same rules should guide us, as in the ordinary 
 management of artificial infant feeding. Although 
 there is a possibility of a child born of a syphilitic 
 mother, escaping the manifestations of the disease 
 during childhood, only to become the subject of its 
 lesions later in life, I still think that in all cases it 
 should have the benefit of the doubt, and should be 
 reared by artificial feeding. 
 
 The mother, if syphilitic, is often in a condition 
 of extreme malnutrition, thus rendering nursing 
 not only injurious to the child, from the compara- 
 tively inferior quality of the lacteal secretion, 
 especially if it be entirely depended upon for its 
 support, but also injurious to her, by causing a still 
 further drain upon her fund of vitality in the per- 
 formance of the function of lactation. But it may 
 be objected that "the child, if syphilitic, will 
 
Lydston. 175 
 
 not thrive upon artificial nourishment, inas- 
 much as it is already the subject of a cachexia, 
 with its concomitant impairment of nutrition." 
 Now it is true, that in case the mother is 
 in good condition and apparently free from syph- 
 ilis, her milk is usually far the best food for the 
 child, and gives the best possible prospects of rear- 
 ing it; but this fact does not weigh very heavily 
 in the balance when we reflect that the mother 
 may have escaped syphilitic infection, and may pos- 
 sibly be infected by her syphilitic child in case it 
 be allowed to nurse. The chance of the ultimate 
 survival of the syphilitic infant, is small at best, 
 and as for the difference between the prospective 
 usefulness of the syphilitic child, and the possibly 
 non-syphilitic mother, it is sufficiently obvious. 
 We must also consider the fact that the child, even 
 if syphilitic, may attain an age sufficient to enable 
 it to withstand the tardy lesions of the disease, and 
 that this possibility is greatly enhanced by the 
 proper performance of its nutritive functions, which 
 depends almost entirely upon good and sufficient 
 nourishment, which it cannot obtain from a cach- 
 ectic mother. In case a woman has been brought 
 under the influence of mercury before delivery, 
 and the child be born and remain for some weeks 
 free from syphilis, there is a possibility of its escap- 
 
176 Lectures on Syphilis. 
 
 ing the disease entirely, unless it receives it from 
 its mother by inoculation, and inoculable lesions 
 may occur upon her at any time. In such a case 
 the possible danger of contagion should warrant us 
 in interdicting nursing, and in the substitution of 
 artificial food. 
 
 The practice of employing a syphilitic nurse to 
 care for a syphilitic, or possibly non-syphilitic in- 
 fant, requires but little comment, as there are few 
 circumstances which would warrant it. If the 
 child present unequi vocable evidences of syphilis; 
 if we have positive evidence that the nurse has had, 
 or has the disease, and she is in good condition, her 
 milk being of good quality, she may be employed. 
 Under all other circumstances, I should most em- 
 phatically protest against nursing, and should ad- 
 vise an artificial substitute for the mother's milk. 
 
APPENDIX. 
 
APPENDIX. 
 
 As there are very few formulae given in the preceding lec- 
 tures, it has been thought advisable to append a list of some 
 of the more useful prescriptions for the treatment of syphilis. 
 
 IN SECONDARY SYPHILIS. 
 
 ft Pil. Hydrarg. Protiod 1-5 gr. q. s. 
 
 (Gamier et Lamoreux.) 
 gjg. — Begin with one pill t. d. and cautiously increase until 
 physiological effects are produced. 
 
 ft Hydrarg. Protiod gr. xx 
 
 Ext. Taraxici q. s. 
 
 M. Ft. pil. No. C. 
 
 Sig. — From three to eight pills daily in divided doses. 
 
 ft Hydrarg. Protiod gr. xx 
 
 Ext. Hy oscy ami gr. x 
 
 Sacch. Lac gi 
 
 M. Trit. subtilis et ft. chart, No. C. 
 
 Sig. — One to six powders daily at regular intervals. Opium 
 may be added in lieu of the hyoscyamus, should gastro-intesti- 
 nal irritation be a source of annoyance. 
 
 ft Hydrarg. Biniod , gr. iv 
 
 Ext. Hyoscyami gr. x 
 
 M. Ft. pil. No. lx. 
 
 Sig. — One pill three or four times daily. To be used only 
 when the stomach is extremely tolerant. 
 
180 Appendix. 
 
 R Pil. Hydrarg gr. c 
 
 Ferri. Sulph. Exsiccat gr. 1 
 
 M. Ft. pil. No. 1. 
 
 Sig. — One to eight pills daily. Bumstead's pil. duo. espec- 
 ially useful in anaemic patients, and as a tonic in late syphilis. 
 
 R Hydrarg. Tannat gr. x 
 
 Ext. Lactuc gr. xxx 
 
 M. Ft. pil. No. xxx. 
 
 Sig. — One to five pills daily. Especially recommended as 
 unlikely to produce gastro-intestinal disturbance. 
 
 R Hydrarg Bichlor gr. iv 
 
 Kalii Iod 3 vi 
 
 Elix. Simp g iv 
 
 M. Sig. — 31 in water after each meal. The "mixed treatment" 
 for late secondary lesions and the period of sequelae, and to 
 alternate with mercury during the entire course of syphilis. 
 
 R Hydrarg. Bichlor gr. iv 
 
 Sodii Chloridi jii 
 
 Aquae Dest 3 xiii 
 
 M. Sig. — For hypodermic use. Dose mxxx.* 
 
 R Hydrarg. Bichlor gr. ix 
 
 Sodii Chloridi gr. xl 
 
 Aquae Dest ^ iv 
 
 M. — Add the albumen of one egg and filter. Dose M. xv 
 hypodermically. f 
 
 N. B. — It should be remembered that the bichloride cor- 
 rodes the needles and makes them brittle, hence care is neces- 
 sary not to break them off in the tissues. They should be 
 kept well oiled, to prevent corrosion. 
 
 * Stern. Progres Medicale, Paris, 1878. 
 
 t Staub. " Treatment of syphilis by hypodermic injections of the 
 chloro-albuminate of mercury," Paris, 1872. This mixture decom- 
 poses readily and tends to become cloudy. It must be freshly pre- 
 pared, and carefully filtered. 
 
Appendix. 181 
 
 for late secondary, malignant or precocious syphi- 
 lis, and the period of sequelae. 
 
 ft Kalii Iod 3 vji 
 
 Hydrarg. Bichlor . . gr. ii 
 
 Tr. Quassias § iv 
 
 M. Sig. — Dose 3I well diluted. 
 
 ft Aramonii Carbonat 3 i ss 
 
 Kalii Iod 3 iii 
 
 Syr. Sarsas Comp. 
 
 Aquas Dest aa . . § ii ss 
 
 M. Sig. — gi three or four times daily. 
 
 Prof. Gunn's "three -eights" mixture. 
 
 ft Iodinii Resub gr. viii 
 
 Kalii Iod 3 viii 
 
 Syr. Sarsae Co . . : § viii 
 
 M. Sig. — £i three or four times daily. 
 
 FOR INFANTILE SYPHILIS. 
 
 ft Sodii Bicarb gr. xx 
 
 Hydrargyri cum. cretaa gr. xl 
 
 M. Ft. chart, No. xx. 
 
 Sig. — One four times daily. 
 
 ft Hydrargyri Chlor. Mit gr. ii 
 
 Sacchari Lac ....... gr. xx 
 
 M. Trit. subtilis et ft. chart, No. xx. 
 Sig, — One four times daily. 
 
 N. B. — In children who are old enough to take them, the 
 parvules of mercury with chalk, and of calomel, which are sold 
 in the shops, are an excellent form for administration. 
 
182 Appendix. 
 
 tonics for the syphilitic cachexia and late syphilis. 
 
 ft Hydrarg. Bichlor gr. ss 
 
 Fl. Ext. Berberis Aq. 
 
 Tr. Cinchon. Co aa. . ^ ii 
 
 M. Sig. — ^ii after each meal. 
 
 ft Hydrarg. Bichlor gr. ss 
 
 Fl. Ext. Rumicis Crisp. 
 
 Fl. Ext. Cascarae Sag aa . . § ii 
 
 M. Sig. — gii after each meal. 
 
 ft Liq. Arsen. et Hydrarg. Iod £ iss 
 
 Tr. Cinchon. Co g iv 
 
 M. Sig.— £i after each meal. 
 
 ft Iodof ormi gr. xx 
 
 Ferri Sulph. Exsic gr. xl 
 
 M. Ft. pil. No. xx. 
 
 Sig. — One four times daily. 
 
 LOCAL TREATMENT OP SYPHILIS. 
 
 FOR THE CHANCRE. 
 
 LOTIO FLAVA. 
 
 ft Hydrarg. Bichlor gr. xviii 
 
 Aquae Calcis g x 
 
 M. Sig. — Lotion. 
 
 LOTIO NIGRA. 
 
 ft Hydrarg. Chlor. Mit gr. xxx 
 
 Aquae Calcis 3 x 
 
 M. Sig. — Lotion. 
 
 ft Ferri et Pot. Tart gr. xx 
 
 Aquae § iv 
 
 M. Sig. — Lotion. In phagedenic chancre. 
 
Appendix. 183 
 
 R Hydrarg. Oleat 10%. g i 
 
 Vaselinae § i 
 
 M. Sig. — Ungt. For application to non-ulcerated indurations. 
 
 R Hydrarg. Chlor. Mit 3 ii 
 
 Zinci - Oxide 3 ii 
 
 M. Trit. Subtil. Sig. — Apply twice daily, after drying the 
 surface with bibulous paper. 
 
 FOR THE SYPHILIDES. 
 
 R Hydrarg. Oleat 20%. . g i 
 
 Cerati Simp ^ i 
 
 M. Sig.— Ungt. 
 
 R Hydrarg. Bichlor gr. iv 
 
 Tr. Benzoini Co § ii 
 
 M. Sig. — Apply with brush once daily. Especially useful in 
 sluggish ulcerations. 
 
 R Hydrarg. Bichlor gr. iv 
 
 Tr. Myrrh %i 
 
 M. Sig. — Apply with brush once daily. 
 
 R Hydrarg. Bichlor gr. xx 
 
 Collodionis ^ i 
 
 M. Sig. — Apply every second day until skin shows signs of 
 irritation, or lesions yield. Especially useful in condylomata 
 and scaly lesions. 
 
 FOR MUCOUS PATCHES AND BUCCAL ULCERATIONS. 
 
 R Acid Chromici gr. x 
 
 Aquae Dest ^ i 
 
 M. Sig. — Apply with brush several times daily. 
 
 R Liq. Hydrarg. Nitrat q. s 
 
 Sig. — To be applied with glass rod, after careful drying of 
 the surface. 
 
184 Appendix. 
 
 in laryngeal syphilis. 
 
 ft Iodoform! 3 ii 
 
 G-lycerinae § i 
 
 M. Sig. — Apply daily with sponge probang. 
 
 ft Iodof ormi • • 3 i 
 
 ^Ether Sulph g i 
 
 M. Sig.- -Apply daily with sponge probang. 
 
 FOR BONE AND JOINT LESIONS IN LATE SYPHILIS, AND TU- 
 BERCULAR SYPHILIDES. 
 
 R Hydrarg. Oleatis 10% 
 
 Ung. Iodinii Comp aa. . J i 
 
 M. Sig. — Apply at bed-time. 
 

 
 Wmm 
 
 r^i 
 
 m 
 
KS1 
 
 M