HX64051480 
 RC201 .2 L1 7 1 91 1 Syphilis : its diagn 
 
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 HEALTH SCIENCES 
 LIBRARY 
 
THE BOSTOt ^ 
 JOURNAL- 
 
SYPHILIS 
 
 ITS DIAGNOSIS AND TREATMENT 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/syphilisitsdiagnOOIamb 
 
SYPHILIS 
 
 ITS DIAGNOSIS AND TREATMENT 
 
 F. J. LAMBKIN, Col. R.A.M.C. 
 
 yyy 
 
 LECTURER ON SY^HILOLOGY, ROYAL ARMY MEDICAL COLLEGE, LONDON 
 LATE SPECIALIST AT THE ARMY HEADQUARTERS, INDIA, ETC. 
 
 WITH PREFACE BY 
 
 SIR FREDERICK TREVES, Bart., G.C.V.O., C.B., LL.D. 
 
 NEW YORK 
 
 WILLIAM WOOD & COMPANY 
 
 MDCCCCXI 
 
I 
 
V. 
 
 >^ 
 
 
 PREFACE 
 
 PROBABLY no isolated disease has been the subject of 
 so extensive and contradictory a literature as syphilis. 
 
 The prevalence of the malady, the distressing symptoms 
 with which it is associated, and the lamentable results to 
 which it may lead in its later stages, serve to explain 
 the attention it has received from surgical writers. 
 
 A review of the literature of the subject reveals the 
 circumstance that it is upon the question of the treat- 
 ment of the disease that the most copious dissertations 
 have been bestowed. There is hardly a drug known 
 to medicine that has not, at some time or another, been 
 advocated as effective in the management of this 
 complaint. 
 
 At an early period one fact arose into prominence 
 out of the chaotic mass of dicta with which the treat- 
 ment of syphilis was confounded — the fact that mercury 
 had a beneficial effect upon the disease. This conviction, 
 carried into practice, led to some extravagance of action. 
 There soon came to be recorded two periods of extremes 
 in the use of the drug. At one period mercury was 
 administered in amounts so large as to deliberately 
 produce the phenomena of mercurial poisoning ; at the 
 •St other period the employment of the drug was condemned, 
 not only on the ground that it was useless, but on the 
 belief that it caused some of the grosser lesions with 
 which the late stages of the complaint were associated. 
 
 . - 
 
vi PREFACE 
 
 There are reasons to believe that a sound mean has 
 now been reached between these two diametrically opposed 
 positions. While no one would claim that an infallible 
 or perfect method of treating syphilis has been arrived 
 at, it must at least be owned that a course of treatment 
 has been evolved which gives better results than have 
 hitherto been attained, and which is attended with but 
 few drawbacks or objections. 
 
 In the treatment of syphilis by the intramuscular method 
 Colonel Lambkin's name has for long been conspicuously 
 associated. His opportunities for studying and treating 
 the disease have been probably unique, for he has been 
 engaged for a considerable period in the treatment of 
 syphilis in the army, both in England and in India, 
 and has, for some years past, been in charge of the chief 
 military hospital devoted exclusively to venereal affections. 
 He has worked patiently, cautiously, and with circum- 
 spection. 
 
 The army affords an unequalled opportunity for esti- 
 mating the value of any measure of treatment directed 
 against the disease. Syphilis is unfortunately common 
 among soldiers, while the treatment advised can be 
 carried out systematically and continuously, and the 
 patient can be watched from the time the disease is 
 recognised until he ultimately leaves the service. 
 
 Colonel Lambkin's experience has been so exceptional 
 that it may be claimed for him that in a department of 
 practice to which he has devoted the best years of his 
 life he speaks with an authority which cannot be lightly 
 put aside. 
 
 Frederick Treves. 
 
 July, 1910. 
 
CONTENTS 
 
 I. HISTORY .... 
 
 II. PATHOLOGY 
 
 III. CLINICAL COURSE : CHANCRE 
 
 IV. DIAGNOSIS AND PROGNOSIS 
 V. TREATMENT OF CHANCRE 
 
 VI. SECONDARY PERIOD 
 
 VII. TERTIARY SYPHILIS . 
 
 VIII. AFFECTIONS OF THE NERVOUS SYSTEM 
 
 IX. PARASYPHILIS OR QUATERNARY SYPHILIS 
 
 X. THE GENERAL TREATMENT OF SYPHILIS 
 
 XI. TREATMENT OF SYPHILIS {continued) — IN- 
 UNCTION ... . 
 
 XII. TREATMENT OF SYPHILIS {continued) — THE 
 INTRAMUSCULAR METHOD 
 
 XIII. TECHNIQUE OF THE INTRAMUSCULAR METHOD 
 
 XIV. ARYLARSONATE AND OTHER METHODS OF 
 
 TREATMENT 
 
 XV. MODERN AIDS IN THE DIAGNOSIS OF SYPHILIS 
 
 INDEX 
 
 vii 
 
 I 
 
 9 
 16 
 27 
 40 
 45 
 69 
 90 
 96 
 no 
 
 128 
 
 142 
 
 164 
 
 170 
 179 
 187 
 
SYPHILIS 
 
 ITS DIAGNOSIS AND TREATMENT 
 
 CHAPTER I 
 
 HISTORY 
 
 The history of Syphilis has for the purpose of con- 
 sideration been divided into : (i) its origin generally ; 
 (2) whether its existence is of prehistoric antiquity ; (3) its 
 first appearance and introduction into Europe; (4) its 
 first appearance and introduction into England. As to 
 its origin, although this is probably the most interesting 
 part of the whole question, and has formed the subject 
 for much controversy during the last century, more especi- 
 ally the last decade, it cannot be said that any definite 
 conclusion has resulted therefrom, other than that it is 
 now fairly settled that it has been known to have been 
 present in the West Indian Islands and Central America 
 from time immemorial ; but as to the direct origin of the 
 disease nothing is known. 
 
 With regard to its existence being of prehistoric 
 antiquity, this question has also been the theme for 
 much discussion, some holding that evidence points to 
 an affirmative answer being given, whereas others deny it 
 
 1 
 
2 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 and claim that it was quite unknown anywhere until the 
 close of the fifteenth century ; and even now it cannot be 
 said that the conclusion which has been arrived at, i.e. that 
 the disease has a prehistoric existence, has been abso- 
 lutely proved. The evidence in favour of the former is, 
 to say the least, doubtful, resting, as it does, on writings 
 which speak of the existence in prehistoric times of 
 certain ailments which are supposed to be descriptions of 
 syphilis, and also on the discovery of human bones bearing 
 the signs of syphilitic lesions. As regards the writings, 
 Hippocrates describes ulcers of the mouth and genital 
 organs, and Thucydides mentions diseases of the sexual 
 organs, hands, and feet occurring in the plague of Athens, 
 which is supposed to have been an epidemic of syphilis. 
 Lancereaux believes the " ficus " of the Romans and 
 "sykos" of the Greeks to have been syphilis. 
 
 From a collection of medical writings made in 1230 B.C. 
 by the Emperor Hoang-ti, it would appear that in those 
 far-off times the Chinese were fully acquainted with 
 syphilis, which they treated with mercury, and that they 
 recognised the hereditary transmission of the disease. 
 The veracity of this statement has recently been ques- 
 tioned by Okamura, a Japanese writer, who maintains 
 that, according to the old Japanese and Chinese authors, 
 syphilis was unheard of in either country until the middle 
 of the sixteenth century of our era. 
 
 It is asserted that syphilis was known in India 1000 B.C., 
 this assertion depending mainly on the descriptions of 
 certain diseases taken from the " Ayurvedas " of Susruta, 
 which are supposed to appertain to syphilis. 
 
HISTORY 3 
 
 Syphilis has also been supposed to have been known 
 to the Hebrews ; this is founded on scanty and uncertain 
 Biblical quotations, e.g. Lev. xiii., which gives an account of 
 leprosy, but which it is surmised was really syphilis. 
 
 The other evidence on which the prehistoric existence 
 of syphilis is founded, i.e. the discovery of human bones 
 showing signs of syphilitic lesions, is, to say the least, a 
 broken reed to depend upon, owing to the paucity of 
 bones which have been discovered in such a condition. 
 It would have been expected that, if the disease had 
 existed to any extent, innumerable skeletons showing 
 syphilitic signs would have been discovered in the Old 
 World. For instance, it might be thought that royal 
 Rome, with all the excesses of the Middle Ages, would 
 have furnished plenty of evidence in this direction ; but 
 this has not been the case. 
 
 The fact is that, in spite of the most painstaking 
 research among thousands of human skeletons of pre- 
 historic and ancient origin, there does not exist one bone 
 showing unequivocal signs of syphilis. The existence 
 of one bone in this condition, which at the same time 
 could be taken for certain to be of prehistoric origin, or 
 could be at least referred to a period prior to 1493, would 
 at once put an end to discussion as to the age and origin 
 of the complaint ; but unfortunately such is not the case, 
 for it is certain that no bone in this condition is found 
 either in German, English, or French collections or 
 museums. 
 
 As to the question of the antiquity of syphilis, and 
 whether it existed in prehistoric times, the evidence in 
 
4 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 favour is of too doubtful a character to enable a definite 
 conclusion to be come to regarding it ; at the same 
 time it is of a sufficiently stable kind to admit of the 
 probability of such being the case. 
 
 The first authentic appearance of syphilis in European 
 countries dates between 1493 an ^ 1500, which years are 
 more or less accurately mapped out as those which 
 saw the introduction of the disease. It has been 
 proved beyond doubt that it was brought into Spain 
 by sailors of Columbus returning from Haiti and Cen- 
 tral America in 1492, and that it spread to Italy from 
 Spain. 
 
 The campaign of Charles VIII. of France during 
 1494-5, as a result of which many mercenary bands, 
 accompanied by a great following of women, collected 
 in Italy, and there got in touch with each other, formed 
 the most favourable opportunity for the spread of the 
 disease ; and there can no longer be any doubt that the 
 latter first attracted attention in Europe when the French 
 under Charles sojourned in Italy, especially in Naples — 
 hence the dates between February and May 1495. Critics 
 are unanimous as to this, and also consider an invasion 
 from without as having occurred, for which they blame 
 the Spaniards. It is known that after the arrival of 
 Columbus in Barcelona, on his return from America and 
 the island of Haiti in 1494, syphilis spread there amongst 
 the inhabitants. The following year Charles VIII. of 
 France began preparations for his campaign, and attracted 
 mercenaries from neighbouring countries, amongst whom 
 were many Spaniards infected with syphilis. Thus it 
 
HISTORY 5 
 
 came about that the disease spread during the stay of 
 the French army in Italy. 
 
 Evidence goes to show that the followers of Columbus 
 first contracted the disease in the island of Haiti, and in 
 Central America. According to Diaz de Isla, a learned 
 physician of Barcelona, who himself witnessed the in- 
 vasion of syphilis in Spain, the disease had been known 
 in Haiti (Espafiole) from time immemorial, and Oviedo 
 completely concurs in this American origin of syphilis, 
 and declares it to be a specific disease of the Antilles 
 and Central America. According to Oviedo, syphilis was 
 communicated by the Indian women to the first Spaniards 
 who came there with Columbus, and brought by them 
 to Spain, whence it spread to the army of Charles VIII. 
 Amongst his informants, Oviedo includes both those who 
 accompanied Columbus upon his first voyage and those 
 who were with him on his second. Las Casas, a con- 
 temporary physician of the time, whose father was with 
 Columbus during the second voyage, and who himself 
 had lived in Haiti, testifies to the existence of syphilis 
 in the latter place before the advent of the Spaniards. 
 He says : " I took the trouble upon several occasions 
 to interrogate the Indians as to whether the disease 
 was of great antiquity, and they answered Yes, that 
 it dated from a period long before the arrival of 
 the Christians, its origin being beyond the memory of 
 man ; and it is an undoubted fact that all Spaniards 
 addicted to sexual excesses, and who did not observe 
 the virtue of continence, were attacked by the disease, 
 not one in a hundred escaping." Again, Oviedo, in his 
 
6 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 report to the Emperor Charles V., says : " Your Majesty 
 may take it for certain that this disease has originated 
 in the West Indies, where it is common amongst the 
 Indians, and in those regions it is not so dangerous as 
 with us." 
 
 Thus the reports of all these contemporaries are 
 unanimous as to syphilis being of American origin, and 
 that it was the syphilis of Haiti which eventually spread 
 through Europe and the Old World. Confirmation of 
 these narratives of Diaz de Isla, Oviedo and Las Casas 
 concerning the origin of syphilis in Europe, can easily 
 be obtained from documents and chronicles of contem- 
 porary Spanish and Italian writers, amongst whom was 
 Senarega, who states categorically, in his history of 
 Genoa, that syphilis had appeared in Spain two years 
 before the campaign of Charles VI II., i.e. in 1493, where 
 it had been introduced from the Far West ; and the 
 contemporary Italian physicians of the time declare that 
 syphilis came to Italy from Spain. 
 
 The conclusions arrived at are: (1) That syphilis was 
 unknown in Europe prior to the year 1493 '■> ( 2 ) That its 
 home is America, or, as far as Europe is concerned, the 
 island of Haiti, whence the crew of Columbus brought 
 it after the latter's first voyage. 
 
 Introduction into England 
 
 Everything points to syphilis as having been brought 
 to England by English soldiers, who were fighting in 
 Italy as mercenaries, and returning home took the disease 
 with them. All contemporary writers of the day are very 
 
HISTORY 7 
 
 explicit on this subject : the date of this would be the 
 end of the fifteenth century. 
 
 In Scotland it is first heard of in 1497, a decree being 
 published then by James IV. ordering all persons suffering 
 from syphilis to leave Edinburgh : they were to be taken 
 to an island opposite Leith and there treated. 
 
 The history of syphilis from the above date to 1767 
 was one of varying fortune, doubts being cast upon the 
 identity of the different venereal disorders, until the cele- 
 brated John Hunter made the mistake of his illustrious 
 career, an error which was destined to produce a period 
 of decay in syphilology that was to last for years. 
 
 Hunter's Mistake 
 
 In 1767 Hunter inoculated himself on the prepuce 
 with pus from a purulent gonorrhea, which produced a 
 chancre, followed by constitutional syphilis, from which 
 he concluded that the secretion of gonorrhea was capable 
 of producing gonorrhea, chancre, and syphilis, and that 
 all three were identically the same disease. He made 
 the further mistake of stating that the blood and secre- 
 tions of syphilitics were incapable of transmitting such 
 contagion. It may be imagined how these doctrines put 
 back the clock in the advancement of the knowledge of 
 syphilis ; there was no progress until the time of Ricord 
 (1800-89), who proved conclusively, by repeated inocu- 
 lations, that gonorrheal secretions pure and simple never 
 produced chancre or constitutional syphilis. He further 
 came to the following conclusions as regards syphilis : 
 
8 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 firstly, that during the primary stage, which consists 
 of the chancre, it was auto-inoculable, its induration being 
 the expression of the passage of the poison into the 
 organism ; secondly, he maintained that in its secondary 
 stage syphilis is not contagious, but is capable of trans- 
 mission to the offspring ; and thirdly he described the 
 encroachment of the poison upon the bones and viscera ; 
 during this, the third stage, he said that syphilis is 
 neither contagious nor is it transmissible to the offspring. 
 Ricord also differentiated between the hard and the soft 
 chancre ; the micro-organism of the latter was afterwards 
 discovered by Ducrey in 1889. 
 
 Undoubtedly to Ricord's teaching we owe the scientific 
 basis on which the future study of the disease was to 
 be grounded, and which eventually led to the formation 
 of the most important conclusions upon the nature and 
 cause of syphilis. In 1903 Metchnikoff and Roux made 
 the all-important discovery, that syphilis is transmissible 
 to monkeys, and in 1895 Schaudinn discovered that the 
 origin of the disease is due to a protozoon which he 
 named the " Spirochceta pallida" 
 
CHAPTER II 
 
 PATHOLOGY 
 
 ALL the lesions of syphilis consist of an interstitial in- 
 filtration of embryonic cells, constituting an inflammatory 
 neoplasm, which undergoes resolution in the case of the 
 chancre and secondary lesions, but tends to the formation 
 of fibrous tissue in the tertiary. A syphilitic neoplasm 
 consists of both round and giant cells ; an accumulation 
 of these (which can often be seen by the naked eye) is 
 called a miliary gumma, and a collection of the latter give 
 rise to gummata, which may attain to almost any size. 
 In the tertiary lesions a meshwork of fibrous bands can 
 be seen intersecting the whole or part of an organ, and in 
 these meshes gummata are found of various sizes, appear- 
 ing as yellow masses ; each gumma is surrounded by a 
 fibrous capsule, and in some of them the centre is seen 
 to be undergoing caseous degeneration, which is probably 
 due to either obliteration of vessels, overcrowding of cells, 
 or to the direct action of the syphilitic poison itself on 
 the cells. This latter supposition is now generally 
 accepted as correct, and is supported by Levaditi's dis- 
 covery of the Spirochceta pallida within the paren- 
 chymatous cells. The changes caused by syphilis consist 
 
 9 
 
io SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 of peri-arteritis, which leads to obliteration of vessels ; 
 inflammatory infiltrations, tending to interstitial fibrosis ; 
 and certain results due to the direct action of the poison 
 on the parenchymatous cells. Besides its direct action 
 on the blood and cells, which produces the ordinary 
 syphilitic symptoms, the virus of syphilis has a toxic 
 effect on the cells, which leads to degenerations re- 
 sulting in certain effects and sequelae, to which Fournier 
 has given the name of Parasyphilis, among these being : 
 leucoderma, tabes, general paralysis, epilepsy, leuco- 
 plakia, various muscular atrophies, diabetes, Bright's disease, 
 arterio-sclerosis, various osseous lesions, tuberculosis and 
 epithelioma ; add to these an hereditary parasyphilitic 
 affection caused by the arrest of development — both 
 physical and mental malformations, rickets, hydrocephalus, 
 meningitis, infantile general paralysis, tabes, etc. 
 
 Induration 
 
 The first lesion of syphilis is the indurated chancre 
 which constitutes primary syphilis, and the induration is 
 peculiar to it. As a rule the chancre appears as a 
 superficial erosion with no definite borders ; it is usually 
 circular in form, dark red in colour, becoming greyish later 
 on, and exuding a thin sanious fluid. Between the fifth 
 and tenth day after the first appearance its edges begin 
 to harden ; this hardening or indurating process goes on 
 around the original erosion up to about the twenty-fifth 
 day, when it ceases, and may then begin to be absorbed ; 
 it usually has disappeared at the end of two months. 
 The induration is not the result of inflammatory action, 
 
PATHOLOGY n 
 
 as can be seen by the absence of pain or itching, but 
 it is formed by a process of small-celled infiltration and 
 hyperplasia of connective tissue cells. Epithelial and giant 
 cells are also present, whilst the small arterioles and veins 
 are obliterated by peri-arteritis and endo-phlebitis. 
 
 The amount of induration varies in different chancres, 
 from slight hardening of the borders of the lesion, to the 
 extent of forming a hard lump the size of a hazel-nut. 
 
 Amount of Induration : what relation has it to the 
 progress of the disease ? 
 
 There is a general idea that the future of the syphilitic 
 attack depends much on the amount of induration which 
 develops at the site of the original point of infection — that 
 is, that the greater the induration the more severe will be 
 the after-symptoms and lesions, and vice versa. My personal 
 experience shows that it is not the amount but the per- 
 sistence, in spite of thorough treatment, of the induration , 
 which indicates a severe attack. 
 
 BACTERIOLOGY 
 
 The microbiology of syphilis dates back to a period 
 before that of microbiology itself. Before there existed 
 any idea of the part played by microbes in fermentation, 
 it was supposed that syphilis was caused by certain 
 minute organisms and, twenty years before the discovery 
 of lactic acid fermentation by Pasteur, discussions were 
 frequent as to the microbiology of syphilis. 
 
 When once micro-organisms had been discovered in 
 a whole heap of different infectious diseases, numbers 
 
12 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 of bacteriologists set to work to search for the supposed 
 organism of syphilis, amongst them being Weigert and 
 his pupil Lustgarten. The latter discovered a bacillus 
 in various syphilitic lesions, which eventually was to be 
 known as " Lustgarten's bacillus," and which for a time 
 was considered to be intimately connected with the cause 
 of syphilis, but was subsequently discarded. Then De 
 Lisle thought that he had discovered that syphilis was 
 caused by a certain large bacillus, but his theory could 
 not be confirmed. 
 
 Search for syphilitic bacteria having completely failed, 
 scientists began to believe that the microbe of syphilis 
 might be a protozoon, and soon Seigel published an essay 
 in which he described his discovery of a small protozoon 
 in syphilitic secretions ; this he believed to be the real 
 organism of the disease, and he named it " Cytoryctes 
 luis." 
 
 SpirocJicBta pallida was first seen by Schaudinn in some 
 papules round the vulva of a woman, who was suffering 
 from a hard chancre in the same region. 
 
 From further research Schaudinn was able to show that 
 in the genital organs two varieties of spirilla are to be 
 found. One of these may be found under both conditions, 
 whereas the other is only present in syphilitic lesions. 
 The former he called 6". refringens. It is larger than 
 S. pallida, and its spiral turns are fewer and much 
 better marked ; it is easily stained by any method, 
 especially by Giemsa's, and is much more intensely stained 
 than S. pallida. The latter is smaller, more delicate in 
 appearance, and its spiral turns are more numerous, and 
 
PATHOLOGY 13 
 
 not so well marked ; it stains with much difficulty by 
 any method. Schaudinn and Hoffmann were able to 
 prove definitely that 5. pallida is to be found only in 
 syphilitic affections ; further, that it is to be found not 
 only on the surface of syphilitic human papules and 
 chancres, but also in the deep tissues of the enlarged 
 syphilitic glands. At first these spirilla were only found 
 in primary and secondary lesions of the genital organs, 
 but with improved technique they were soon demonstrated 
 in secondary lesions far removed from this region— i.e. 
 in the blood, lymph, lymphatic vessels and glands, also 
 in the saliva and urine of syphilitic patients ; and, finally, 
 they were found by Spitza, in 1905, in gummata, also 
 by Schaudinn, who showed them in the peripheral layer 
 of a gumma of the liver of a syphilitic child. 
 
 In the vascular system Reuter found these organisms 
 in sections of the aorta of an old syphilitic who had 
 dropped dead — a fact which was confirmed by Schaudinn. 
 Soon it became an established fact that the specific 
 spirilla were to be found in the primary, secondary, and 
 tertiary lesions of syphilis, but up to the present they 
 have not been demonstrated in those affections known as 
 parasyphilitic. 
 
 As regards hereditary syphilis, the organisms were soon 
 found in almost all the tissues of new-born children 
 affected with the disease, especially in the liver and 
 in certain parts of the skeleton — i.e. the periosteum, 
 bones, etc. 
 
 Important as was the discovery of the 5. pallida, an 
 equally important one was the announcement by Metchnikoff 
 
14 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 and Roux in 1903 that syphilis is communicable to animals ; 
 they succeeded in conveying the disease from a human 
 syphilitic to a chimpanzee by inoculation, producing in 
 the latter a primary syphilitic chancre, which was after- 
 wards followed by a secondary train of symptoms. This 
 experiment they repeated over and over again in the 
 chimpanzee with similar results ; but monkeys of the lower 
 kind, such as macaques and papion, did not respond to 
 it so readily, syphilis being limited to a modified chancre, 
 which was not followed by secondaries. The chancre 
 produced was an cedematous nodule, which was followed 
 by desquamation, no ulceration taking place, nor was 
 induration or adenitis well marked, which points to the 
 resistance of these lower animals to syphilis. It has 
 been established that monkeys are more refractory to 
 syphilis the farther they are removed from the anthropoid, 
 and that the chancre of the macacus was really syphilis. 
 Metchnikoff and Roux, by producing the disease in a 
 chimpanzee they inoculated from it, proved it. 
 
 These researches led to various attempts being made 
 to prepare an antisyphilitic serum, but up to the present 
 all have failed. 
 
 With regard to the situation where the organism is 
 Best found, my own experience is that it is easier to 
 demonstrate it in hereditary lesions than in those of 
 acquired syphilis, and in early secondary rashes and 
 mucous lesions than in the chancre ; it is more abundant 
 in the deeper parts than superficially. Levaditi states 
 that, although present in the blood-vessels, the Spirochceta 
 pallida is rarely found in the blood itself, from which 
 
PATHOLOGY 15 
 
 fact it is now generally believed that the latter simply 
 acts as a conveying medium, but not as one in which 
 the organism is developed. 
 
 EXAMINATION 
 
 for Spirochseta pallida 
 
 Search for the Spirochceta pallida has been rendered 
 much easier by the introduction of the dark background. 
 The material should, when possible, be taken from the 
 deeper parts of a lesion, and having done so, it should 
 be placed on a cover-glass, spread out, a little normal 
 saline solution added to it, and there and then examined 
 under a -— in. immersion lens on a dark background. 
 The 5. pallida is a very delicate, mobile, spiral organism, 
 varying in length from 4 to 14 /x (about the size of a 
 red corpuscle), and about ^ fi in thickness. It differs 
 from the spirochete with which it is most likely to be 
 confounded in that the latter is generally found on the 
 surface of lesions, whereas the 6\ pallida inhabits the 
 deeper parts ; also the *S. pallida is smaller, is less 
 refractive, is harder to stain, has more numerous spiral 
 turns, and retains its spiral form both in motion and 
 at rest. It stains pink with Giemsa's stain, whilst other 
 spirochsetes stain blue. 
 
CHAPTER III 
 CLINICAL COURSE: CHANCRE 
 
 Clinical Course of Syphilis 
 
 THE clinical course of syphilis is divided into six 
 stages : 
 
 i. The stage of primary incubation, that between 
 exposure to infection and the appearance of the chancre. 
 
 2. The primary stage, during which the chancre develops 
 and glands enlarge. 
 
 3. The secondary incubation stage, that between the 
 appearance of the chancre and the stage of secondary 
 symptoms. 
 
 4. The secondary stage — the period during which fever, 
 neuralgic pains, and syphilis of the skin appear. 
 
 5. The intermediate stage, during which the patient 
 may be practically free from any signs. 
 
 6. The tertiary stage, which is characterised by the 
 formation of gummata, periostitis, osteitis, etc. 
 
 The Initial Lesion 
 
 The first lesion of syphilis is the chancre, which makes 
 
 16 
 
CLINICAL COURSE: CHANCRE 17 
 
 its appearance at the site of inoculation in from twenty- 
 five to thirty days after exposure ; this latter is a fair 
 average time, and as a rule it may generally be sur- 
 mised that a sore appearing after ten days from the 
 date of exposure is syphilitic. 
 
 The chancre is generally single, but is very often 
 multiple, and there may be as many as six, seven, or 
 even more initial lesions. 
 
 The chancre begins as a small, sharply-rounded, ex- 
 coriated spot, the surface of which is on a level with 
 the surrounding parts. It looks exactly like an erosion. 
 The colour is dull red, and later on may assume a coppery 
 hue. At first the primary lesion may cause little or no 
 disturbance, the patient's attention being generally called 
 to it by some itching. For the first five or six days 
 there is nothing very characteristic about it, but at the 
 end of that time induration may become perceptible 
 round its edges, and this increases and may become more 
 evident and pronounced up to the end of two or three 
 weeks after being first noticed. This induration is typical 
 of the syphilitic chancre. As regards the induration, 
 stress must be laid on the fact that at first it is not 
 present, and may not become sharply defined until the 
 tenth day, which fact has led to innumerable mistakes. 
 
 Induration is a peculiar hardness of the tissues around 
 and beneath the sore, and is formed without any inflam- 
 mation having taken place ; no pain, heat, or redness occurs 
 during its formation. It is peculiarly circumscribed, and 
 it remains after the chancre has healed, and may continue 
 to do so for weeks or months. 
 
 2 
 
1 8 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Nature of the Chancre 
 
 A chancre is formed of small-celled infiltration and 
 hyperplasia of the connective tissue cells, which is sup- 
 ported in a meshwork of thickened blood-vessels, some 
 of the latter being entirely obliterated by sclerosis. This 
 condition constitutes induration. 
 
 Chancrous Erosion 
 
 The chancrous erosion is by far the most common form 
 in which the primary lesion is found. It is most marked 
 on the inner side of the prepuce. In shape it is commonly 
 circular or ovoid, but sometimes of an irregular shape. Its 
 floor is but slightly, if at all excavated ; its surface, from 
 which a serous secretion oozes, is smooth and polished : 
 usually there is but one such lesion, but, as already stated, 
 there may be as many as five, six, or seven. Owing to the 
 absence of induration in the first stage of these chancres, 
 diagnosis may be difficult, but the absence of itching and 
 burning, their dark colour and chronicity, their late ap- 
 pearance after exposure, may help in distinguishing them 
 from herpes, with which they are likely to be confused. 
 
 Induration of Chancre 
 
 When the chancre remains superficial the induration is 
 spread out into a disc-like mass ; it is then called the 
 " parchment-like sore," and is mostly found on the integu- 
 ment of the penis and in the vulva. Indurated chancres 
 are generally found in the sulcus coronarius, near the 
 fraenum. , 
 
CLINICAL COURSE: CHANCRE 19 
 
 Varieties of Chancre 
 
 The chancre may assume various shapes, when it is 
 called by different names : the dry papule, ecthymatous 
 chancre, silvery spot, annular chancre, and mixed chancre. 
 
 Dry Papule 
 
 The dry papule is found mostly on the integument of 
 the penis at the base or pubic part As a rule it is 
 solitary, and appears, as its name implies, as a dry, hard 
 papule. It is a very characteristic form of the true chancre. 
 
 The Ecthymatous Chancre 
 
 This is simply a chancre which becomes covered with pus- 
 crusts, and may be developed from either a dry papule or 
 a chancrous erosion. It is simply a chancre whose surface 
 has become irritated, and ulceration has taken place, with 
 the consequent formation of pus. 
 
 The Annular Chancre 
 
 The name of " annular chancre " is given to those sores 
 in which the induration assumes a ring-like shape, and in 
 which the centre is less thickened and infiltrated. This 
 form of chancre is found generally on the internal surface 
 of the prepuce, sometimes on the glans, and very often on 
 the cutaneous surface of the penis. 
 
 The Silvery Spot 
 
 This was first described by Taylor, and is a rare condition. 
 Its site is generally the glans and about the meatus. At 
 first it looks like a pin-head spot which had been touched 
 
20 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 with carbolic acid : this lesion increases slowly, and is 
 subsequently raised up well above the surface by the 
 induration. It preserves the integrity of its surface until 
 it reaches an area of 2 mms., when it disappears, and is 
 replaced by a smooth, shiny surface on an indurated base. 
 
 Various other Chancres 
 
 Besides the above there are many other chancres which 
 go by various names : the inflamed, phagedenic, relapsing 
 (which may be true or false), and the mixed chancre. 
 
 The two former are what their names imply. 
 
 The Mixed Chancre. 
 
 It is possible for both simple chancre and syphilitic 
 chancre to co-exist at the same time, and either may 
 be inoculated on the other. If the virus of syphilis be 
 inoculated at the same time and at the same spot as the 
 simple chancre, a hard sore will develop in time at the 
 point formerly occupied by the soft sore. On the other 
 hand, a soft sore may be inoculated on the top of a 
 syphilitic chancre, resulting in an ulcerating sore situated 
 on an indurated base, thus constituting the mixed chancre. 
 {Seep. 26.) 
 
 Pain and Inflammation 
 
 Absence of pain and inflammation is common to all 
 uncomplicated chancres, the patient's attention being 
 generally first drawn to its presence by some degree of 
 itching ; but even this may be absent, and the chancre 
 fully developed before it is noticed. 
 
CLINICAL COURSE: CHANCRE 21 
 
 Recurring Chancre 
 
 Recurring chancres are of two kinds — false and true. 
 
 False Relapsing Chancre. — The former has generally been 
 described as a fresh induration appearing at, or perhaps 
 near, the site of an old sore. This induration may appear 
 without any apparent cause as to treatment or otherwise ; 
 and at almost any time, from a few weeks to ten or twelve 
 years after the healing of the original chancre. Usually 
 its surface remains intact, but may become ulcerated, and 
 then simulate a disintegrating gumma. 
 
 True Relapsing Chancre. — Having entirely disappeared 
 under treatment, the induration reappears at the site 
 of the old sore, and assumes exactly its previous con- 
 dition ; its surface may become broken, and to all intents 
 and purposes the old chancre may reappear, to be got 
 rid of again by specific treatment. This chancre, to the 
 writer's mind, is almost solely dependent on the line of 
 treatment which is adopted : should this be dropped too 
 early, then the induration is likely to reappear, and is 
 then, no doubt, a fresh nucleus for the Spirocluzta pallida. 
 
 SEATS OF CHANCRE 
 
 The primary lesion may be seated on any part of the 
 body which may have been exposed to infection ; hence 
 they occur more frequently on the genital region, which is 
 the generally exposed part. Chancres are divided into 
 genital and extragenital. 
 
22 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Genital Chancre 
 
 Two-thirds of all chancres are found on the mucous 
 membrane of the prepuce just behind the corona, or on the 
 surface of the glans penis, but they are found also at the 
 urinary meatus, within the urethra, at the base of the penis, 
 scrotum, groin, and anus, and these assume certain definite 
 characters according to the sites occupied : thus chancres 
 of the surface of the glans penis are generally flat at 
 first, becoming depressed later on, and surrounded by a 
 laminated layer of induration : chancres of the coronal 
 glans show a tendency to be raised above the surface, 
 induration is well marked, extensive, and nodular. 
 
 Chancres of the Urinary Meatus 
 
 In these chancres either one or both lips of the meatus 
 may be involved, but both are generally affected. The 
 mucous membrane is found thickened, and the lips are 
 glued together by a scanty viscid discharge. Induration 
 in these chancres, although limited, is well marked. 
 Needless to say that chancres of the meatus may be 
 mistaken for gonorrheal ulceration and vice versa, and 
 further that a correct diagnosis is rendered all the more 
 difficult when gonorrhea coexists. 
 
 Chancres of the Urethra 
 
 I believe these to be more common than is generally 
 supposed, and the reasons for this are obvious — they are 
 concealed from view, cause little disturbance, and are so 
 likely to be mistaken for gonorrhea that, in nine out of 
 ten cases, this latter happens, at least until things are 
 
CLINICAL COURSE: CHANCRE 23 
 
 well developed. Chancres attacking the urethra are met 
 with usually just within the meatus or in the fossa 
 naviculars, but may occur lower down the urethra. There 
 is pain on micturition ; slight thin yellow discharge and 
 hardness can be detected along the urethra in a circum- 
 scribed degree ; sometimes when the finger is passed 
 along the course of the canal it gives the sensation as if 
 there was " a piece of the stem of a clay pipe " in it. 
 These lesions can best be detected by means of internal 
 manipulation or seen through a meatus canula of a 
 urethroscope. 
 
 Chancre of Base of Penis 
 
 Occurs on the skin on or about the root of the penis. 
 When first seen it looks like a scratch or abrasion about 
 the size of a pea ; this enlarges slowly, becomes eroded, 
 flat or depressed, until it reaches the size of a sixpence, 
 or in some cases a shilling ; it is nearly always circular 
 in shape, edges markedly hard, and when taken between 
 the fingers laminated induration is well marked — in fact, it 
 is in these chancres that this form of induration is best 
 marked. 
 
 The surface of the chancre erodes and sometimes 
 ulcerates, but the latter is rare ; it is covered with a 
 whitish yellow false membrane, on the removal of which 
 a weeping surface is left. Sometimes the surface looks 
 like the top of a pepper caster. 
 
 Chancre of the Scrotum 
 Commences as a patch of circumscribed erythema. 
 The skin soon desquamates and leaves little cracks or 
 
24 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 fissures exuding a clear serum ; these cracks unite by 
 erosion, and a shallow ulcer, circular in shape, situated 
 on a hard base and with well-marked indurated edges, 
 remains. In other cases the surface of this form of chancre 
 is covered with brownish crusts of dried epithelium, which 
 keeps on re-forming as often as removed, or again the 
 syphilitic lesion in this locality may be in the form of a 
 tubercle. 
 
 Preputial Chancres 
 
 When placed at the end or termination of the prepuce, 
 these chancres are ragged, and give the end of the prepuce 
 the appearance of having been split in one or two 
 directions ; these splits look at first like scratches, the 
 edges of which are indurated or generally inflamed. The 
 prepuce in this situation is usually thickened. 
 
 Sub-preputial or Concealed Chancres 
 
 A chancre of the prepuce may be rendered invisible 
 owing to phimosis, either congenital or acquired, the latter 
 being the result of the inflammation caused by this very 
 chancre. 
 
 In this case, besides the phimosis, there will be a thin 
 yellowish discharge, which can be gently squeezed out ; 
 little or no pain on urinating, or other sign of gonorrhea. 
 Should an indurated sore be present beneath the foreskin, 
 this hardening can generally be felt by manipulating the 
 member with the fingers. But in any case the surgeon 
 ought seldom to be long in doubt, as means ought to be 
 taken to expose the sore at once. 
 
CLINICAL COURSE: CHANCRE 25 
 
 Chancres of the Anus 
 
 These may be situated at the margin of or entirely within 
 the anus. The former generally present a thickened, 
 fissured and ulcerated surface devoid of deep redness. 
 They are of a rose-red tint, and present a medium degree 
 of induration at their bases. Sometimes these chancres 
 assume the characters of fissures with pale, smooth margins 
 and pale-red surface. Their bases are resistant to the 
 touch, and they are far less tender than ordinary " fissure " 
 of the anus — an important point in diagnosis. 
 
 When situated within the anus the chancre will, of 
 course, be concealed. 
 
 Chancre of Groin 
 
 This chancre comes within the scope of perigenital 
 chancres. It may occur, a priori, from direct inoculation, 
 or as a secondary contagion to an open bubo. In the 
 first case it will appear like an indurated chancre of the 
 general integument, to be afterwards described. Should 
 an open bubo become infected with syphilitic virus, the 
 chancre will generally attack one or both lips of the 
 wound. The latter remains gaping, and a sore or nodule 
 appears on one of the lips. This slowly enlarges until 
 an ulcer is formed, which soon becomes planted on a 
 well-marked indurated base. The open bubo may con- 
 tinue to heal, all except the part at and about the 
 chancre, which remains open and indolent-looking. 
 
26 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Chancroid Inflammation 
 
 The chancroid virus may be implanted simultaneously 
 with or later than the syphilitic. In either case the 
 character of the syphilitic chancre will be modified in 
 appearance. Of course it would be quite possible for 
 the chancroid to heal up before the syphilitic virus took 
 effect, but this would be the exception. More commonly 
 the chancroid persists, the spreading, inflamed, punched- 
 out-looking ulcer becoming gradually enveloped in in- 
 duration as the full local development of the syphilitic 
 lesion is reached. In the other case, when the chancroid 
 virus is inoculated on the chancre, the result is chancroidal 
 ulceration, on the disappearance of which the induration 
 remains. Ulceration of a chancroid may cause sloughing 
 of an indurated mass — a result which leaves no local 
 indication of syphilis. 
 
 A sore of the above description is called a " mixed 
 chancre." 
 
CHAPTER IV 
 
 DIAGNOSIS AND PROGNOSIS 
 
 It is wise never to give a positive opinion as to the nature 
 of a chancre simply on the local examination of the lesion 
 itself, as although in most cases it may be an easy matter 
 to form a definite opinion from this alone, still it must 
 be remembered that it has no certain sign. 
 
 Signs of a Syphilitic Sore 
 
 i. Its incubation — a sore beginning in from ten days 
 to four weeks after exposure. 
 
 2. A sore beginning as a painless macule or slight 
 erosion, spreading slowly and becoming indurated, exuding 
 a thin scanty discharge from its surface, which latter may 
 be covered with crusts or false membrane. 
 
 3. Should it be followed by the neighbouring glands 
 becoming increased in size, without pain or inflammation, 
 forming a chain of little tumours, the evidence of the 
 syphilitic nature of the lesion is much strengthened. 
 
 4. Should the Spirochceta pallida be found in the secretion 
 from the sore, then a definite opinion may be given as 
 to its nature. 
 
 5. A positive reaction with Wasserman's test will of 
 course strengthen the evidence. 
 
 27 
 
28 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Difficulties of Diagnosis 
 
 The difficulties of diagnosis met with are : the history 
 of incubation may be vague and uncertain ; induration 
 absent, or marked, or so slight as to be indefinable ; en- 
 largement of neighbouring glands may be absent ; the 
 non-discovery of the Spirochata pallida in the sore — 
 always a difficult matter to find it in primary sores/ 
 
 Differential Diagnosis of Chancres 
 
 The character of a mixed chancre having already been 
 discussed, it suffices here to say that when a sore appears 
 later than ten days after exposure, followed by induration 
 which becomes inflamed and ulcerated, with consequent 
 destruction of the induration, which makes the lesion look 
 like a simple one, the probability is that it is a mixed 
 chancre ; being in other words a syphilitic chancre, which, 
 becoming infected by some septic matter, has taken on the 
 features of a soft sore from inflammation and ulceration. 
 
 It would thus lose the distinction of the induration, and 
 presenting only the features of the simple sore, the 
 probability is that it is a mixed chancre, which surmise 
 will be further strengthened should the lymphatic glands 
 in the neighbourhood become indolently enlarged. 
 
 DIAGNOSTIC POINTS BETWEEN A 
 CHANCRE AND CHANCROID 
 
 Chancre Chancroid (Soft Chancre) 
 
 Origin Origin 
 
 Due to inoculation from Due to inoculation from 
 
 syphilitic lesion, blood, or chancroidal discharge, 
 other syphilitic discharge. 
 
DIAGNOSIS AND PROGNOSIS 
 
 29 
 
 Incubation 
 Over ten days ; average 
 time, three to four weeks. 
 
 Com mencemen t 
 Erosion, papule or ulcer. 
 
 Number 
 Single, at times multiple 
 (exceptional). 
 
 Shape 
 Symmetrically irregular. 
 
 Depth 
 Superficial erosion, 
 scooped out, flat or ele- 
 vated. 
 
 Edges 
 
 Sloping. 
 
 Incubation 
 No definite period ; gener- 
 ally under five days. 
 
 Commencement 
 Pustule or open ulcer. 
 
 Number 
 As a rule multiple ; often 
 on opposing surfaces, from 
 auto-inoculation. 
 
 Shape 
 Round, oval. 
 
 Depth 
 Deep, perforating whole 
 thickness of skin and mu- 
 cous membrane. 
 
 Edges 
 Abrupt and sharply cut. 
 
 Floor 
 Whitish grey or yellow. 
 
 Floor 
 Red, livid, copper- 
 coloured ; often iridescent. 
 Sometimes covered with 
 false membrane. 
 
 Secretion Secretion 
 
 Scanty sanious serum. Abundant and purulent. 
 
 Not readily auto-inoculable, Readily auto-inoculable. 
 and only so during first ten 
 days of existence. 
 
3o SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Induration Induration 
 
 Exists as a rule: firm, car- No induration, as a rule; 
 tilaginous, circumscribed. if present, not circumscribed, 
 
 but shades off into adjacent 
 tissues. 
 
 Frequency in one Subject 
 One chancre affords pro- 
 tection in ninety-nine per 
 cent, of cases. 
 
 Frequency in one Subject 
 No protection. 
 
 Glandular enlargement 
 
 Neighbouring glands in- 
 dolently enlarged, firm, 
 movable, no inflammation. 
 When the sore is situated on enlarged 
 penis, glands of both groins 
 uniformly enlarged. No 
 pain. 
 
 Glandular enlargement 
 Inflamed, painful irregu- 
 lar suppuration. Glands on 
 both sides not uniformly 
 
 Micro-organism 
 Present : Spirochceta pal- 
 lida generally found. 
 
 Micro-organism 
 Spirockceta pallida never 
 present. Ducrey's bacillus 
 present. 
 
 Effects of Treatment. 
 Local treatment curative. 
 
 Effects of Treatment 
 Local treatment ineffec- 
 tual. 
 
 Auto-I noculation 
 It was formerly believed that the chancre was never 
 auto-inoculable ; it is now an established fact that during 
 at least the first fortnight of its existence it is auto- 
 
DIAGNOSIS AND PROGNOSIS 31 
 
 inoculable — that is, is capable of reproducing a like lesion 
 if inoculated in some other part of the body. Mercuralisa- 
 tion of the patient renders this impossible. 
 
 Syphilis and Yaws 
 
 The one other disease in which the Spirochceta pallida 
 was thought to have been found, is the one which 
 mostly resembles syphilis — namely, Yaws (parenga or 
 pian). The points of difference between them are : 
 
 Syphilis Yaws 
 
 1. Primary lesion. 1. No primary lesion. 
 
 2. Induration generally marked. 2. No induration. 
 
 3. Neighbouring glands en- 3. No glandular enlargements, 
 larged and nodular. 
 
 4. Auto-inoculable up to a 4. Always auto-inoculable. 
 certain time only. 
 
 5. Apes which have been in- 5. Apes capable of being in- 
 fected with syphilis unable to fected by inoculation and re- 
 transmit same to those already transmitting yaws to other apes, 
 suffering from syphilis. and to those suffering from 
 
 syphilis. 
 
 Castellani now differentiates between the Spirochceta pal- 
 lida and the organism which he believes to be the cause 
 of yaws, and which he calls Treponema pertenue. 
 
 Extragenital Chancres 
 
 Chancres may be situated on any part of the body, 
 but are found generally on those parts which are most 
 exposed to infection, such as the mouth, tongue, and tips 
 of fingers. 
 
32 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Modes of Conveyance 
 
 These may be either direct or mediate : by direct contact 
 with a syphilitic lesion, as by kissing ; or by mediate 
 contagion through contaminated spoons, forks, drinking 
 utensils, pipes, etc., etc., and again through the agency of 
 infected surgical or dentists' instruments. 
 
 Principal Extragenital Chancres 
 
 It will be necessary here to consider a few of the most 
 important extragenital chancres, as their diagnosis is 
 often rendered difficult owing to the position or locality 
 in which they are situated. 
 
 Chancre of the Lip 
 
 Begins as a chap or fissure. At first there is nothing 
 characteristic about it, but in time it becomes an indolent 
 ulcer with early marked " cartilaginous " induration ; later 
 on the submental glands become indolently and pain- 
 lessly enlarged. In appearance it is an indolent elevated 
 sore, papule or pustule ; its surface is smooth, and exudes 
 a scanty, glistening discharge. When taken between the 
 thumb and finger it feels like a lump of gristle. 
 
 The chief lesion that labial chancres may be mistaken 
 for is epithelioma, but the following points may serve 
 to differentiate between them : 
 
 Labial Chancre 
 
 Labial Epithelioma 
 
 Age 
 
 Age 
 
 Any. 
 
 Generally about middle 
 
 
 life. 
 
DIAGNOSIS AND PROGNOSIS 33 
 
 Site Site 
 
 Usually upper lip. Involves lower lip gener- 
 
 ally. 
 
 Sex 
 
 Both. 
 
 Local Symptoms 
 A painless papule, erosion 
 or ulcer. Regular outline, 
 surface smooth and has in- 
 durated edges ; discharge is 
 scanty and thin. 
 
 Course 
 Develops in a few weeks, 
 followed in about two weeks 
 by submaxillary glandular 
 enlargements. 
 
 Spirochceta pallida 
 Present. 
 
 Mercury 
 Causes disappearance. 
 
 Sex 
 Nearly always the male. 
 
 Local Symptoms 
 A painful, irregular, rugged 
 sore, bleeds easily; if indura- 
 tion be present it is irregular ; 
 discharge thick and offen- 
 sive. 
 
 Course 
 Develops very slowly, 
 taking as many months as 
 the chancre does weeks. 
 Glands not affected for 
 months after sore appears. 
 
 Spirochceta pallida 
 Not found. 
 
 Mercury 
 No effect. 
 
 Chancre of Tongue 
 
 Chancres of the tongue involve the anterior half, 
 dorsum, sides, or tip ; and may appear : 
 
 1. As a superficial erosion seated on an indurated base. 
 
 2. As a deep ulcer with sloping edges on a hard base. 
 
 3. As a dense sclerotic mass with unbroken surface. 
 
 3 
 
34 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Chancre of the tongue very often simulates an ulceration 
 caused by a carious tooth. 
 
 Chancre of Tonsil 
 
 This is rare, but may be mistaken for some ordinary throat 
 affection, from which it may be differentiated by its being 
 unilateral, indurated, persistent, and accompanied by in- 
 dolent glandular swellings under the sterno-cleido mastoid. 
 
 Chancre of the Eye 
 
 This may be palpebral or conjunctival. Contagion may 
 be carried by the fingers, by spitting, or by a contaminated 
 towel. The surgeon may become infected during ex- 
 amination of the throat or mouth of a syphilitic patient ; 
 one of the worst cases of syphilis I have seen occurred 
 in a surgeon who during an operation was infected by 
 some matter finding its way into the eye. 
 
 Appearance. — An ocular chancre usually begins as a 
 papule, which generally becomes indurated, then eroded, 
 and sometimes ulcerated, and is followed by indolent 
 enlargement of the glands in the vicinity of the ear and 
 angle of jaw. 
 
 Chancre of the palpebral margin may be mistaken for 
 a stye, an error which may be avoided by watching the 
 development of induration and the glandular swellings 
 which always accompany the former. 
 
 Conjunctival chancres may be found on the palpebral 
 or ocular conjunctiva, but more often on the former, in 
 which case the eyelid is everted, and there is conjunctivitis 
 
DIAGNOSIS AND PROGNOSIS 35 
 
 and chemosis. The chancre may be nodular, round, or 
 oval, or a simple hard erosion. 
 
 Facial Chancre 
 
 Facial Chancre may occur from kissing, spitting, or razor- 
 cuts, the latter being not uncommon. The cut, having 
 healed, reopens, and becomes covered with crusts and sur- 
 rounded by induration, and erosion and ulceration follow, 
 with indolent swellings of the submaxillary and parotid 
 glands. I have recently seen a chancre on the cheek of a 
 medical man, the result of a razor-cut becoming infected 
 whilst he was attending a midwifery case. These lesions 
 are generally well marked, and easy to diagnose, but have 
 been mistaken for sycosis and eczema. 
 
 Chancre of Finger 
 
 Of all extragenital chancres those of the fingers are 
 most common, occurring generally among medical men, 
 dentists, and midwives ; but they may arise in any one, 
 and have often occurred as the result of bites. They 
 usually are found at the edges or base of the nail ; they 
 are most commonly eroded, and often ulcerated, induration 
 being well marked and extensive. Oftentimes this class 
 of sore develops so insidiously and looks so innocent 
 that it goes unnoticed by the patient, and is apt to be 
 overlooked until later symptoms appear. On the other 
 hand, this chancre may develop into a large, hard, fleshy 
 mass, purplish in colour, of soft surface, with exuberant 
 vegetations on it. One type of sore resembles a whitlow ; 
 the terminal phalanx of the finger is red, swollen, painful 
 
36 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 and sensitive, whilst the surrounding tissue is indurated. 
 These chancres are remarkable for their long duration 
 and painful character ; the nail nearly always separates 
 from the finger, and very often the bone necroses. In 
 such sores the axillary and epitrochlear glands always 
 become indolently enlarged. 
 
 Vaccination Chancre 
 
 This is much rarer now compared with the days of 
 arm-to-arm vaccination. If the vaccination "takes," the 
 pustules run a normal course and heal up ; or healing may 
 be delayed, leaving an ulcer with smooth surface exuding 
 a scanty discharge. It is painless, and soon becomes 
 indurated ; and later the anatomically related glands 
 become enlarged and nodular. Should the revaccination 
 not " take," a characteristic chancre forms. 
 
 Chancre of the Breast 
 
 This is usually caused by a syphilitic infant nursed by a 
 healthy woman. The lesion appears either on or about 
 the nipple or on the mammary integument. It may begin 
 as a fissure, crack, or erosion without pain, exude a 
 scanty sanious discharge, and finally become indurated 
 and accompanied by indolently enlarged axillary glands. 
 
 Chancres of the General Integument 
 
 Chancres occur at any point of the body which 
 may have been exposed to infection — e.g. in the process 
 of tattooing. 
 
DIAGNOSIS AND PROGNOSIS 37 
 
 PROGNOSIS OF CHANCRE 
 
 From a local point of view this is always favourable ; 
 generally at the end of three or four weeks the chancre 
 becomes cicatrised and the induration disappears, leaving a 
 scar which is at first pigmented but eventually becomes 
 white. The healing of the sore will depend very much on 
 the constitutional treatment, but even without this it will 
 often ensue spontaneously. Ulceration from a syphilitic 
 chancre seldom leaves any deformity, owing to the fact 
 that any destruction of tissue is at the expense of the 
 infiltration ; deformity will, of course, result from phage- 
 dena. Chancres situated in certain parts will often give 
 rise to grave symptoms : for instance, on the tongue or 
 tonsil, causing difficulty of mastication and swallowing ; 
 or in the eye, leading to severe ophthalmia, and in the 
 urethra producing stricture. 
 
 Relation of Character of Chancre to Subsequent 
 Progress of the Disease 
 
 What relation, if any, exists between the source of 
 contagion and character of the chancre, and the subsequent 
 progress of the disease? This question has led to much 
 discussion, but the following deductions appear to be 
 justified : 
 
 i. It is impossible to predict the form of chancre which 
 will follow from a certain source of infection. 
 
 2. Many authorities think, and to a certain extent I 
 agree with them, that the severity of the constitutional 
 disease bears a relation to the character of the primary 
 
38 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 sore ; i.e. an ulcerating sore is more often the prelude to 
 one of the severer forms of eruption than an ordinary- 
 dry papule, and, generally speaking, the more marked the 
 induration the more likely are sclerotic lesions to follow. 
 3. A short primary or secondary incubation denotes 
 the probability of a severe case. Hallepeau maintains 
 that chancres situated on the prepuce or vulva and at 
 the anus are more often followed by severe symptoms 
 than those found elsewhere : the writer's experience is 
 that the worst forms of syphilis he has seen have followed 
 one of the extra-genital chancres. 
 
 Primary Lymphatic Enlargements 
 
 At the end of the first or second week after the 
 appearance of the chancre the lymphatic vessels leading 
 from it may be felt enlarged, like whipcord, though 
 there is no pain or inflammation ; at the same time 
 the glands associated with these vessels become pain- 
 lessly enlarged and hard. The glands thus affected 
 are those in the immediate vicinity of the chancre : the 
 inguinal in the case of genital chancres, the submaxillary 
 and submental in chancres of the tongue or lips, the 
 preauricular glands in chancres of the eyelid, and the 
 axillary in those of the fingers. These enlargements are 
 never great, hardly ever exceeding the size of a marble, 
 are hard, indolent, painless, and easily movable, and 
 scarcely ever suppurate. Rarely is it that a syphilitic 
 chancre is unaccompanied by these enlargements ; at the 
 same time it must be remembered that these vessels and 
 glands are also liable to become enlarged as the result 
 
DIAGNOSIS AND PROGNOSIS 39 
 
 of the presence of a chancroid, herpes, or any other local 
 irritation. The following points may help to differentiate 
 between the two conditions : 
 
 _ ._ _ , . . Inflammatory Lym- 
 
 Specific Lymphangitis phangitis 
 
 Hard and painless ; no Hard, painful, tender, and 
 inflammation; terminates in red ; overlying skin cedema- 
 resolution under specific tous; often ends in suppura- 
 treatment tion, not affected by specific 
 
 treatment. 
 
 The same points will also apply to the glands them- 
 selves. 
 
CHAPTER V 
 
 TREATMENT OF CHANCRE 
 
 Persistent efforts have been made from time to time 
 to set aside the possibility of syphilis by the destruction 
 of the primary lesion, either by excision, chemical means, 
 or by the actual cautery. Results have been disappointing, 
 as not only have the measures of destruction failed to 
 relieve the local symptoms, but also to prevent secondary 
 signs. In the face of these results the question arises, 
 ought excision of the primary lesion to be carried out? 
 If this lesion is looked on as but the local expression 
 of an intoxication generalised at the outset, common 
 sense would point to the uselessness of such a procedure. 
 On the other hand, if the view of probably the majority 
 of syphologists of to-day be adopted — that the initial 
 sore or lesion is the local point from which, after 
 multiplication, the microbe of the disease or its toxin 
 is swept through the system — then I should say that, 
 given certain conditions, the destruction, either by excision 
 or otherwise, of the sore should be done. But there is 
 only one class of case in which this abortive method is 
 applicable with any reasonable hope of success — in the 
 
 case of a very young chancre of a few hours' date, 
 
 40 
 
TREATMENT OF CHANCRE 41 
 
 without induration and without satellite glands. Un- 
 fortunately such conditions greatly restrict the applica- 
 bility of the proceeding, as ninety-nine out of a hundred 
 chancres seen have been in existence for days, and, in 
 fact, the chancre met with fulfilling the conditions indicated 
 must be a rare event. 
 
 Destruction of the Syphilitic Virus in Situ 
 
 The experimental work of Metchnikoff shows that the 
 syphilitic poison can easily be destroyed in the laboratory 
 by drying, cooling to a point below 50 F., or by heating 
 it to a temperature of 122 F. for half an hour. From this 
 fact he has endeavoured to destroy the Spirochceta pallida 
 in situ by thoroughly rubbing into the point of inoculation 
 an ointment consisting of calomel 10 gms., lanolin and 
 vaseline 30 gms., and is satisfied this will prevent infection 
 if done within eighteen hours of inoculation. He had the 
 advantage of proving this on the person of a student who 
 offered himself for such experiment, and in this case it 
 was a complete success. The same results have followed 
 in the case of innumerable monkeys, which were inoculated 
 with the virus and controlled. Without doubt it is a 
 procedure which should be preached broadcast. 
 
 As regards the local treatment of chancre, it is of the 
 utmost importance that no stimulating nor caustic applica- 
 tions should be made ; for, in the first place, should the 
 lesion be simple in nature, burning it with acids, etc., will 
 not destroy it, but will transform it into an inflammatory 
 nodule, and cause it to markedly resemble a hard chancre, 
 and thus doubt and uncertainty in diagnosis is the result. 
 
42 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 On the other hand, if the lesion is an incipient chancre, 
 cauterisation, however complete, cannot destroy it, but 
 may cause an oedema which may be troublesome to cure. 
 Any breach of surface, therefore, should be kept scrupu- 
 lously clean, and be covered with lint or absorbent cotton 
 moistened with boiled or distilled water, or a mild sub- 
 limate solution (i in 2,000), or very dilute carbolic lotion 
 applied ; peroxide of hydrogen, 1 in 6 of water, makes 
 a good application. As the chancre increases in size it 
 may be dressed with black or yellow wash. 
 
 Powders, such as boric acid, aristol, europhen, dermatol, 
 and last, but not least, iodoform, dusted on may be of 
 great benefit. The best of these is iodoform ; its odour 
 is certainly against it, but with care much of this incon- 
 venience may be obviated. It should be used sparingly, 
 and not allowed to fall on sound parts or upon clothes. 
 Should the sore be under the prepuce it may be kept at 
 a minimum by packing cotton in the preputial orifice. 
 It must be remembered that iodoform is applicable only 
 to unhealthy and necrotic surfaces, and should be dis- 
 continued when these cease. 
 
 In the case of chancres covered with a false membrane, 
 or those which have a tendency to ulcerate and become 
 destructive, it is important that a caustic effect should 
 be produced, and this is best done by washing the lesion 
 well with soap and water, and then irrigating it with 
 a 5 per cent, carbolic solution. It should be dried, and 
 a solution of cocaine applied to it, and then it should 
 be dried again. Better still, as a preparatory method, 
 is to mop the surface freely with peroxide of hydrogen, 
 
TREATMENT OF CHANCRE 43 
 
 equal parts with water, or with Merck's perhydrol ; apply 
 the cocaine, dry the parts, and then apply the caustic ; 
 for the latter nothing is better than fluid carbolic acid 
 or pure nitric acid. 
 
 Calomel very often acts promptly and efficiently on 
 chancres showing a disposition to destruction, and is 
 always a useful dry dressing in clean but indolent sores. 
 
 Bearing in mind that the indurated chancre is probably 
 the seat where the spirochastae multiply and the focus 
 from whence they spread throughout the system, it is 
 all-important that a specific action be brought to bear 
 on all chancres which show a tendency to become in- 
 durated. Having by proper means produced a healthy 
 surface, the chancre should be treated with mercurial 
 ointment. The surface having been washed and rendered 
 as nearly as possible aseptic, a layer of absorbent lint 
 well smeared with Ung. hydrarg. MetchnikofFs 30 per cent, 
 of calomel ointment, or oleate of mercury, 5 per cent, 
 should be placed upon it and kept in constant apposition, 
 and this dressing should be changed two or three times 
 a day. 
 
 As a rule, salves and ointments (other than mercurial) 
 should be avoided, exception being made when the dis- 
 charge is thick and sticky. 
 
 The Treatment of Phagedenic Chancres 
 
 The treatment of chancres complicated with phagedaena 
 is exceptional ; most to be depended on is continual 
 immersion in hot antiseptic solutions. In the case of 
 such a sore on the penis this can best be carried out 
 
44 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 by immersing the latter in hot water contained in such 
 a vessel as a bed-urinal, allowing it to remain there for 
 long periods : the water, of course, requires frequent 
 changing ; an ordinary-size bath may be used for the 
 same purpose. Should the phagedaenic action go on, 
 cauterisation, either by chemical means or the actual 
 cautery, must be undertaken. The best of the former 
 is crude chromic acid. The patient should be placed 
 under a general anaesthetic, or the parts rendered in- 
 sensible by a local one (I prefer the former) ; then the 
 sore having been thoroughly dried, the chromic acid is 
 applied to it ; a black slough remains, and this is detached 
 by charcoal poultices, leaving a healthy surface as a rule ; 
 however, a second application may be required. Instead 
 of chromic acid, strong nitric acid may be used. Some 
 cases of phagedena may require the actual cautery, and 
 all require watching, as they are rapid in their progress, 
 and require prompt recognition and treatment. 
 
CHAPTER VI 
 SECONDARY PERIOD 
 
 The Period of Secondary Incubation 
 
 The period of secondary incubation is the time between 
 the appearance of the chancre and the development of 
 secondary lesions, and this averages from forty to fifty 
 days, during which the chancres may have healed and 
 disappeared completely, and the disease, as far as any 
 constitutional symptoms are concerned, appear to be 
 quiescent. Undoubtedly during this time the virus is 
 becoming disseminated throughout the system. 
 
 The conditions influencing the length of this period 
 are the presence of malignant syphilis, or when the disease 
 attacks constitutions which are already undermined from 
 various causes. Then the period of secondary incubation 
 is shortened, whereas the contrary takes place when the 
 disease attacks those of robust constitution, or when it 
 is of a non-virulent kind. 
 
 The Evolution of Syphilis 
 
 After this comes the stage of secondary symptoms, 
 during which, to begin with, the virus manifests itself 
 
 45 
 
46 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 on the accessible lymphatic glands not anatomically con- 
 nected with the primary lesion. 
 
 Already it has been seen that within a week or so 
 after the appearance of the leison, those lymphatic vessels 
 and glands in its vicinity become enlarged and indurated ; 
 but care must be taken to differentiate between this and 
 the enlargement of the glands under consideration. The 
 glands which are most affected are those situated in 
 the neck, axilla, and groin, all of which become swollen 
 as a result of the essential hyperplastic process produced 
 by the virus. It is now generally recognised that the 
 changes in the deep glands are among the most frequent 
 and most constant of the effects of syphilis, either in 
 its secondary or tertiary stages ; in other words, they 
 are its constant accompaniment. The other glands most 
 frequently affected are the prevertebral, lumbar, iliac, and 
 femoral. Specific enlargement of the lymphatic vessels 
 and glands is characterised by three symptoms — indura- 
 tion, absence of inflammation, and persistency. During 
 the course of the disease this condition of the vessels 
 and glands may disappear, but more frequently they 
 remain enlarged for months, and even years, after all 
 other symptoms of the existence of the disease have 
 disappeared. Resolution without suppuration is almost the 
 constant termination, but suppuration may occur should 
 the chancre become infected with pyogenic microbes. 
 
 Treatment 
 
 Mercurial ointment should be well rubbed into the 
 skin over the enlarged glands daily. 
 
SECONDARY PERIOD 47 
 
 Course of the Disease 
 
 The general or constitutional symptoms which usher 
 in syphilis vary in different cases. In some there is 
 well-marked fever, especially towards evening, when it 
 may reach as high as 103 F. : in others this fever presents 
 a distinctly remittent type. Various neuralgic pains are 
 complained of, especially headache, which is nearly always 
 nocturnal, and which varies in degree from being quite 
 mild to one in which the patient's suffering is very great. 
 This headache generally affects the back of the head. 
 Other pains of a neuralgic kind may be present, attacking 
 mostly the fifth nerve, and may be seated in the inter- 
 costal, sciatic, or anterior crural nerves. Insomnia is 
 a symptom sometimes complained of. 
 
 Cachexia 
 
 Early in the secondary stage a condition known as 
 " syphilitic cachexia " takes place — loss of appetite and 
 strength, emaciation, and a pale sallow complexion, pulse 
 rapid, weak, and small — and the temperature runs up : 
 the patient is dejected, nervous, and apprehensive. This 
 condition may be postponed in some cases (especially 
 in those which undergo early mercurial treatment) to 
 quite late in the course of the disease. 
 
 The Osteotic Pains 
 
 Osteotic pains of different kinds are a frequent accom- 
 paniment in the early period, the bones affected mostly 
 being the cranium, ribs, sternum, and clavicle, and there 
 may be great tenderness ; these pains and this tenderness 
 are much worse at night. 
 
48 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Rheumatic Pains 
 
 Some of the most constant symptoms in the early- 
 period of syphilis are pains in the muscles, fascia, and 
 joints, the muscles affected being those of the extremities, 
 the fascia in the same part, and the joints engaged are 
 usually the larger ones — the hip, knee, and especially the 
 elbow — but often the wrist and phalanges are attacked. 
 
 Hyperemia of Pharynx and Tonsils 
 
 One of the points in which syphilis resembles the 
 acute exanthemata is its strong tendency to attack the 
 fauces. As a rule the throat suffers subsequent to 
 the appearance of cutaneous lesion, but frequently the 
 reverse occurs; very often it is affected without giving 
 any trouble, and is only discovered on inspection. 
 
 In many cases there is no superficial lesion other than 
 slight excoriation ; in others mucous patches may be 
 present. There is often a good deal of tonsillar swelling. 
 The follicles become enlarged and prominent ; or they 
 may rupture, giving rise to excoriations. In the more 
 chronic cases patches are present on the tonsils and 
 palatine arch ; or there may be yellow ulcers sharply 
 defined. One affection constantly seen on the fauces, 
 hard palate, inside of cheeks and lips, is scattered milk- 
 white spots called " plaques " ; they may be of any shape 
 and size, or they may run into each other so as to cover 
 a large space ; parts of their surface may be reddened, 
 showing only a little white opacity here and there. These 
 spots run a slow course, and may recur over and over 
 again during the first and second year of the disease. 
 
SECONDARY PERIOD 49 
 
 Albuminuria and Nephritis 
 
 About this time albuminuria may appear, and there is 
 no doubt that early, and sometimes rather late, in the 
 secondary stage, a mild or severe form of nephritis may 
 occur. 
 
 Some authors believe, and the writer is with them, that 
 syphilis causes the same condition in the kidneys as do 
 other infectious diseases. 
 
 The symptoms of this nephritis may be wanting, and 
 the condition only discovered by examination of the 
 urine ; on the other hand, it may give rise to oedema of 
 the lower extremities and face with lumbar pain. 
 
 The majority of these nephritic cases are benefited much 
 
 by antisyphilitic treatment, with, of course, strict attention 
 
 to diet. 
 
 Angina Pectoris 
 
 This condition, with all its classical symptoms, is seen 
 
 on rare occasions, both in the secondary and tertiary 
 
 periods. 
 
 SECONDARY ERUPTIONS 
 
 The next in sequence of events, as the case proceeds, 
 is the appearance of skin eruptions. Unlike all other 
 specific poisons, that of syphilis produces not one or two 
 definite cutaneous affections, but an immense variety 
 of them. They are known as syphilides or syphilo- 
 dermata. The early eruptions of the secondary stage of 
 syphilis are distributed symmetrically and generally over 
 the body, involving the superficial layers of the skin ; 
 the later ones, although symmetrical, are less copious, 
 
 4 
 
5o SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 and have a tendency to invade the deeper layers of the 
 skin. 
 
 As to the causes which influence the production of the 
 different forms of eruption, we are in ignorance. All that 
 can be said definitely on the subject is that a patient who 
 is in a bad state of health is more likely to develop 
 eruptions which suppurate and ulcerate than he would 
 otherwise have been if infected when in robust health ; 
 and that patients predisposed to certain non-syphilitic 
 skin diseases, such as ordinary psoriasis or lichen, are apt 
 to be affected with a squamous syphilide or with a papular 
 one. A phagedenic chancre is much more likely to be 
 followed by pustular eruptions than is the ordinary in- 
 durated sore. The fact is that pustular and rupial eruptions 
 and serpiginous syphilides are really the results of mixed 
 infections. 
 
 Features of Syphilides 
 
 To almost all syphilides certain features belong : 
 
 1. Colour and Pigmentation. — At first pinkish red, this 
 soon fades to a brownish colour, said to be coppery or to 
 resemble raw ham in appearance, the cause being prob- 
 ably some chemical change in disintegrating blood-discs 
 which have been extravasated into the tissues. At first 
 pressure dissipates the colour, but not so later on. 
 
 2. Absence of Pain and Itching. — They do not cause any 
 irritation to the skin. 
 
 3. Tendency to assume a Circular Form. — This is most 
 noticeable in the case of small papular rashes. 
 
 4. Polymorphism. — The circumstance of several varieties 
 
SECONDARY PERIOD 51 
 
 of lesions occurring in the same eruption is important. 
 Sometimes macular, papular, pustular, and scaly patches 
 
 are present together. 
 
 5. Peculiar Localisation. — Syphilitic eruptions are often 
 found in regions rarely the site of simple lesions. Syphilides 
 are irregular in their distribution, their favourite localities 
 being the forehead, the sides of the feet, and palms of 
 the hands. 
 
 Diagnosis of Syphilitic Eruptions 
 
 In most cases a correct diagnosis must be based not 
 so much upon the recognition of characters common to 
 all syphilides as upon an accurate acquaintance with each 
 of them individually. It is therefore essential that they 
 should be classified. Syphilides may be divided into 
 those which appear early and those that show themselves 
 late. The former seldom appear beyond the first twelve 
 months ; the latter rarely occur within the first year, and 
 their appearance may be postponed for several years. 
 
 Classification of Early Syphilides 
 
 I. Erythematous. 
 
 (Lichen. 
 Acne. 
 
 ((a) Psoriasis. 
 
 III. Papular (Lenticular^ , ,, ^ 
 
 * J \(b) Mucous Patches. 
 
 IV. Squamous. 
 V. Vesicular. 
 
 VI. Tertiary Syphilides. 
 
52 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 The Erythematous or Roseolar Syphilide 
 This is the earliest and most common of all syphilitic 
 skin eruptions, coming out about the same time that 
 the general lymphatic enlargements become apparent. 
 It consists of oval or round spots, with distinct or irregular 
 outlines ; their colour varies from a delicate rosy pink 
 to a decided red. It is probably present in all cases of 
 syphilis, but may escape notice on account of its extreme 
 faintness. It is usually seen on the front of the abdomen, 
 chest, sides and back of trunk ; sometimes, although rarely, 
 it invades the face and neck. It is also found on the 
 limbs on their flexor aspects ; it avoids the hands and 
 feet. It takes about a week coming out, but may develop 
 so rapidly as to be taken for measles. A pale, scanty 
 eruption of roseola often fades in a week or fortnight, 
 whereas a darker and more abundant one may be visible 
 for weeks, and then may assume a squamous or papular 
 character. This syphilide is apt to relapse, and may 
 occur at any time during the first year, and even in the 
 second. 
 
 The Follicular Syphilide 
 Of this there are two distinct varieties. One consists 
 of small, pointed, dry elevations or papules, generally 
 scaly at the summit, and their bases may be surrounded 
 by a white desquamating cuticle ; they may be irregu- 
 larly scattered, or in clusters. This rash is slow in its 
 course, developing itself by successive crops, and subsiding 
 after several weeks or even months. Sometimes the 
 little papules pass into pustules, and on disappearing 
 
SECONDARY PERIOD 53 
 
 always leave minute white cicatrices. The other variety 
 of this follicular eruption consists from the first of pustules 
 which are small and pointed, with swollen red bases ; they 
 may be present in immense numbers, not only on the 
 face, but also on the chest, trunk, and back. 
 
 The Papular Syphilide 
 
 is known as the " Lenticular Syphilide," and consists of 
 red, shiny elevations, which feel hard and shotty, and 
 vary in size from a millet seed to the size of a split 
 pea. They develop rapidly, coming out in a few days, 
 and develop in crops ; they are generally scattered irregu- 
 larly over the body, are sometimes numerous on the 
 forehead and neck, and occasionally appear profusely on 
 the face. These papules remain for a long time, some- 
 times for months, when they gradually decline ; at other 
 times their surface or summit softens and becomes 
 covered with a brown crust. 
 
 This eruption is of two kinds : the small fiat papular 
 syphilides, and the large flat papules. The former begin 
 as minute red spots, which rapidly increase in size until 
 they reach a diameter of perhaps one-fourth of an inch. 
 They are round or oval. The papules are first seen 
 about the shoulders, neck, and sides of chest, and later 
 on they appear on the forehead at the margin of the 
 scalp, and on the face, chiefly about the nose, mouth, 
 and chin, and eventually they may invade the trunk 
 generally. 
 
 The large fiat papules are either round or oval, having 
 a diameter of an inch in some cases. Their surface is 
 
54 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 flat and covered with a few adherent scales; colour red, 
 becoming coppery ; they are very chronic, and cause 
 neither pain nor itching. 
 
 On thick cuticle, like that of the palms and soles, the 
 spots are not raised into papules, but form round, horny 
 plates with copper-coloured margins. After a time these 
 plates become detached, and their place is taken by thick 
 crusts or scales, or an ulcer is formed, and this is the 
 condition which constitutes " syphilitic palmar or plantar 
 psoriasis." The early appearance of this syphilide is sup- 
 posed to be the herald of a severe form of syphilis. 
 
 The Squamous Syphilide 
 
 Generally known as " Syphilitic Lepra," these lesions are 
 flat and hardly raised above the surface ; they are covered 
 with silvery scales, underneath which is a coppery 
 glistening base. The scales are easily detached, but ac- 
 cumulate over and over again. This eruption is rather a 
 late one ; the spots are always scattered, few, and confined 
 to one particular region : for instance, they may be limited 
 altogether to the thighs or palms of the hands or soles 
 of the feet. 
 
 The Circinate Syphilide 
 
 A particular variety of this eruption is the " Circinate 
 Syphilide," which is fairly common. It assumes the shape 
 of rings, and resembles very much Tinea Circinata ; but 
 the exfoliation of the margin is generally profuse, and 
 the silvery scales become easily detached ; the rings are 
 few and scattered, their favourite site being the front of 
 
SECONDARY PERIOD 55 
 
 the thighs, but they may appear anywhere from the 
 forehead and face downwards. This eruption is very 
 prone to relapse, coming out as late as the fifth year. 
 
 The Vesicular Syphilide 
 
 This is a rare variety ; the vesicles are, as a rule, small.. 
 They may come out profusely all over the body, or in 
 groups, the face and genitals being usually the selected, 
 spots ; these vesicles are filled with a clear fluid, which 
 generally dries up, but sometimes they become pustular. 
 
 The Pustular Syphilide 
 
 These syphilides constitute an important group, which, 
 though less common than the erythematous or papular 
 form, may appear in the earlier stages of syphilis at any 
 time, and late in its tertiary period. They consist of 
 pustules of all sizes, each of which is seated on a firm 
 base ; they may be present in immense numbers, especially 
 in the face and trunk ; they come out rapidly and in suc- 
 cessive crops, accompanied by much febrile disturbance ; 
 they relapse even after a year. They dry up into brown 
 or black scabs, and leave large stains, which ultimately 
 pass into shallow, flat cicatrices. In other cases the 
 inflamed bases continue to spread long after the summits 
 have scabbed over ; thus, as the crusts increase in size 
 the older parts are continually being pushed up by the 
 collection of fresh material underneath, so that they 
 assume a conical shape and look like shells, whilst others 
 acquire enormous sizes. This variety of eruption is 
 called " Rupia." 
 
56 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Some Special Varieties of Syphilide 
 
 Besides those described, other forms of syphilides are 
 common — viz. pigmentary, acneform, and malignant pre- 
 cocious syphilides. 
 
 The Pigmentary Syphilide 
 
 This is seen in two distinct forms — viz. in spots or 
 patches of various sizes, or as a diffuse pigmentation which, 
 later on, becomes the seat of leucoderma ; this latter is the 
 retiform pigmentary syphilide. 
 
 The evolution of this syphilide may occur as early as 
 the third month, but it usually appears about the sixth, or 
 towards the end of the first year, and often is postponed 
 until the second or third year of infection. It occurs 
 generally in women. The parts of predilection are the 
 lateral surfaces of the neck, face, or forehead. 
 
 The first variety of the pigmentary syphilide consists 
 of round or oval plaques, which may have sharply defined 
 borders, and their colour is light brown. 
 
 The second form — the lace form — is much more common 
 than the former ; slowly or rapidly the neck becomes 
 discoloured, the tint being cafe-au-lait. Scattered irregu- 
 larly over the pigmented surface are irregular or oval 
 white spots, which gradually enlarge and increase in 
 numbers until the neck is covered with them and the skin 
 assumes a lace-like character — hence the name. 
 
 Other Early Secondary Symptoms 
 
 An&mic alteration in the blood. — Anaemia is generally 
 a marked symptom, for even before the enlargement of 
 
SECONDARY PERIOD 57 
 
 the lymphatic glands the patient becomes pale, listless, 
 and loses weight, and is evidently gravely debilitated ; 
 there is a general " impress " about him which is very 
 apparent to the expert. Examination of the blood shows 
 deficiency in haemoglobin and red cells with some increase 
 of the white. These changes become more marked 
 as the case proceeds, and vary in intensity with the 
 severity of the disease. 
 
 SYPHILITIC AFFECTIONS OF THE VARIOUS 
 MUCOUS MEMBRANES 
 
 Erythema of the mucous membranes is usually con- 
 fined to the neighbourhood of the fauces and to that 
 of the outlets of mucous canals, especially around the 
 genital organs and anus and the mucous membrane of 
 the mouth. The most common syphilitic lesions of the 
 mouth are mucous patches, which consist of greyish white 
 areas termed " opaline patches." Their site is generally 
 the angles of the mouth, inner surface of the cheeks and 
 dorsum of the tongue. They occur most often in the 
 mouths of inveterate smokers, and are due to proliferations 
 of the epithelium ; they are sometimes fissured or eroded, 
 are very obstinate, and persist long after all signs of 
 the infection have apparently passed away. 
 
 Superficial Affections of the Tongue 
 
 The mucous membrane of the tongue may also become 
 hyperaemic either in whole or parts ; when the latter is the 
 case, white oval patches of erythema are scattered over the 
 
58 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 dorsum. From these the epithelium may be removed, 
 leaving an eroded or perfectly smooth surface forming the 
 well-known " plaques." 
 
 Mucous patches of the tongue are very frequent, their 
 usual position being the top and sides of the organ. 
 Smokers are particularly liable to them. Sometimes the 
 tongue becomes extensively fissured as the result of the 
 erythema. Mucous patches have been called psoriasis of 
 the tongue and leucoplakia. They are usually early 
 visitors, but also occur in the secondary stage as well as 
 in the tertiary, and when late in the latter belong rather 
 to the parasyphilitic affections than to lesions which are 
 the outcome of direct syphilitic infection. These lesions 
 are very prone to lead to epithelioma. 
 
 Treatment of Mucous Patches 
 
 Patients must be warned as to the danger they are 
 to others when suffering from these lesions. Smoking 
 is to be prohibited altogether ; the morbid spots are to 
 be sprayed two or three times a day with a solution of 
 perhydrol I in 4, or nitrate of silver 5 grains to 1 ounce. 
 They should also be touched daily with a solution of 
 chromic acid 5 grs. to the ounce, and if this does not 
 improve them, one of 20 grs. to the ounce, or with pure 
 carbolic acid. The mucous membrane of the mouth 
 should be kept as healthy as possible by means of mouth 
 washes of chlorate of potash, borax, perhydrol or carbolic 
 I in 40. The application of the stronger solutions should 
 only be made at intervals of two or three days. 
 
 Curetting may be necessary. 
 
SECONDARY PERIOD 59 
 
 Syphilitic Affections of the NOSE 
 
 The nasal mucous membrane may be the seat of 
 erythematous inflammation with consequent ulceration, 
 leading very often to increase of adenoid tissue, which 
 latter tends to blocking up the nasal passages and causes 
 much suffering. 
 
 Treatment. — Strong stimulating applications should as 
 a rule be avoided ; spraying frequently with mild 
 solutions of boric acid, peroxide of hydrogen or per- 
 hydrol ; insufflation of equal parts of iodoform and boric 
 acid. 
 
 Mucous Patches of Genital Organs 
 
 The favourite seat of these is the anus and perinaeum, 
 but similar patches occur near the angles of the 
 mouth, and between the toes. The most frequent form 
 they assume about the anus is that known as con- 
 dylomata, which consist of broad raised patches, edges 
 well defined, surface sometimes dry, but much oftener 
 moist and coated with a dirty grey secretion which gives 
 off a sickly smell. The lesions consist of cell-infiltration 
 of the cutis, with the addition of overgrowth of the 
 papillae ; they sometimes become confluent, and then a 
 large portion of skin is involved ; and occasionally large 
 cauliflower-like excrescences are formed, which are called 
 vegetating papules. 
 
 Treatment. — Absolute cleanliness of the parts, with dry- 
 ness, which is best obtained by the interposition of some 
 absorbent material; black or yellow wash is very efficacious. 
 
60 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 In the case of condylomata these lesions should be destroyed 
 with fuming nitric acid (nothing is better), acid nitrate 
 of mercury, or pure carbolic acid. After cauterisation the 
 surfaces should be well cleansed and dried, and dusted 
 over with some powder such as starch, boric acid, resorcin, 
 or calomel. 
 
 Affections of the LARYNX 
 
 Erythema of the larynx may be so slight as to cause 
 no other symptoms than slight huskiness with moderate 
 catarrh. It occurs in patches, which give the mucous 
 membrane a mottled appearance, or it may cause diffuse 
 redness. Chronic inflammation of the larynx is common 
 in the later stages. Early laryngitis usually disappears 
 rapidly with specific treatment ; but locally sprayings of 
 nitrate of silver 3 grs. to 3 ij are good. Should ulceration 
 be present, insufflation of iodoform and boric acid will be 
 found excellent. 
 
 Affections of the HAIR 
 
 Alopecia is a common and early symptom of syphilis : 
 there may be either total or partial loss of hair. The 
 former consists of a general shedding of the hair, causing 
 total baldness, but this is rare : more commonly the shed- 
 ding is irregular, and hair comes out in patches, leaving 
 circular bare spots ; this alopecia may attack the 
 moustache and beard. As a rule the hair grows again 
 rapidly, unless there be destruction of the papillae, when 
 there will be permanent baldness. 
 
 Treatment. — Hair to be cut quite close or shaved ; daily 
 
SECOND AR Y PERIOD 6 1 
 
 the scalp should be well rubbed with an ointment of white 
 precipitate (30 grs.), cold cream (1 oz.) ; parts to be 
 thoroughly washed each morning with soap and bran- 
 water ; a lotion of bichloride of mercury (1 in 1000) to be 
 applied twice or three times during the day. 
 
 Secondary Affections of NAILS 
 
 Onychia — Secondary affections of the nails are of two 
 varieties — Onychia and Paronychia. In the case of the 
 former the nail becomes dry, brittle, and breaks on little 
 pressure ; its surface is rough, and presents longitudinal 
 fissures and minute depressions in which dirt collects, and 
 gives the nail a speckled appearance. The epidermis 
 under the free margin is usually thickened and scaly. 
 
 Paronychia — Of Paronychia there are three forms : 
 ulcerative, indolent, and diffuse. The ulcerative form may 
 begin as a papule ; ulceration of this takes place, and extends 
 along the sulcus at the attached border of the nail ; the nail 
 loses its lustre and becomes detached, and from beneath 
 it offensive pus exudes ; gradually the nail is undermined 
 and destroyed. In the non-ulcerative variety the border 
 of the nail is thickened and infiltrated, and there is a 
 papular ring round it : the colour is dead red and the 
 surface may be scaly. The nail usually loosens and drops 
 off. The diffuse form begins as an inflammation or rather 
 hyperaemia of the tissue surrounding the nail. At first 
 there is no pain, and the colour is dull red, which as the 
 case proceeds becomes coppery, and the parts become 
 swollen and bulbous ; eventually the nail itself becomes 
 engaged, and is then destroyed. 
 
62 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Treatment. — In the case of Onychia, the affected finger 
 should be soaked frequently in a solution of bichloride of 
 mercury (i in iooo), and the nails kept carefully trimmed. 
 In ulcerative Paronychia the diseased surface should be 
 exposed as soon as possible and cauterised with nitric 
 or chromic acid, and water dressings applied, followed by 
 the application of iodoform. Prolonged immersion of the 
 hand in a warm solution of bichloride of mercury is very 
 beneficial. 
 
 Secondary affections of the nails generally appear within 
 the first ten years, but may occur very much later. 
 
 Secondary Affections of the EYE 
 
 Iritis. — Among the early secondary affections of the 
 eye iritis takes first place, and it is of two kinds — simple 
 plastic iritis and parenchymatous zritis. Plastic iritis often 
 occurs about the second month, and is characterised by 
 severe supra-orbital pain, worse at night, and by con- 
 tracted and sluggish pupils ; the iris is discoloured and 
 adherent to the lens, and there is vascular injection of the 
 cornea. Parenchymatous iritis presents yellowish brown 
 nodules on the pupillary border of the inflamed iris. 
 The nodules are very distinct, and together with the 
 ordinary signs of iritis go to form true syphilitic iritis. 
 This variety of iritis may appear like the plastic in the 
 early months, but may be delayed to a much later 
 period. 
 
 Treatment. — The local treatment of iritis consists mainly 
 in the free use of atropine, a solution of which (gr. v to 5 j) 
 should be dropped into the eye every second hour until 
 
SECONDARY PERIOD 63 
 
 good dilatation is brought about. Pain may be relieved 
 by hot compresses over the eyes and the application of 
 leeches to the temple. Subconjunctival injections of 
 bichloride of mercury may be necessary in obstinate cases. 
 Atropine is essential in the treatment of iritis. It should 
 be ordered at the beginning and persevered with during 
 the continuance of the attack, the object being to keep 
 the pupil dilated, and by so doing to break through any 
 adhesions which may have formed between it and the 
 capsule of the lens. Also it always relieves irritation, 
 and by paralysing accommodation places the eye in a 
 state of rest. Should the pupil become closed by the 
 effusion of lymph on to the pupillary margin of the lens, 
 an iridectomy should be done when inflammation has 
 subsided, for the purpose of making an artificial pupil 
 and preventing a recurrence of iritis. 
 
 Other Secondary Affections of the Eye 
 
 Other affections to which the eye is exposed in syphilis 
 are cyclitis, choroiditis, irido-choroiditis, and retinitis ; but 
 these are not common, and occur generally in the later 
 stages. 
 
 Secondary Affections of the Nervous System 
 
 The secondary nervous affections are : neuralgia, 
 cephalalgia, paralysis (especially of the muscles of the 
 eye and face), hemiplegia, paraplegia, and chorea. 
 
 One of the earliest symptoms of secondary syphilis is 
 neuralgia, affecting the superficial nerves of the scalp, 
 and producing the well-known phenomenon of " nocturnal 
 
64 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 headache," which consists of a dull pain, beginning, 
 especially towards sundown, in the back of the neck, 
 running to the top of the head and perhaps lasting for 
 hours. 
 
 Cephalalgia is more a feeling of tension than of actual 
 pain. It is generally located in the occiput, and nocturnal 
 exacerbations are marked. 
 
 Motor paralysis of t/ie muscles of the eye and face are 
 common even early in syphilis, and are usually the 
 result of compression of the nerve-trunk by periostitis in 
 the early stages and gumma in the later. 
 
 Although hemiplegia and paraplegia are generally 
 classed as belonging almost exclusively to the tertiary 
 period, that they occur quite early in the secondary 
 stage oftener than is thought is the writer's belief. He 
 has met with two cases where they took place in the third 
 month, another in the fourth, and several occurred in the 
 sixth to the eighth month after infection. 
 
 K. G , aged fifty-two, a medical man, noticed a small 
 
 papule on one of his fingers in or about the first week 
 in February 1907 ; this persisted for about a month, 
 when it passed away. The question as to its being 
 syphilitic or not was considered, but it was pronounced 
 to be not. Six weeks later the glands in the axilla 
 and neck became enlarged, but no rash appeared. At 
 the end of two months he began to take " grey powder " 
 daily. He was apparently quite well until the morning 
 of April 25, when, endeavouring to reach out of bed to 
 get his watch, he found he could not move his arm 
 (right), and the leg of the same side was in a similar 
 
SECONDARY PERIOD 65 
 
 condition. This patient, under energetic specific treatment, 
 made a good recovery, regaining the full use of both 
 limbs. 
 
 E. T , a soldier, contracted the disease in March 1908. 
 
 Hard sore, with subsequent adenitis and a roseolar eruption. 
 Had but a modified treatment, as he deserted, and was 
 found in the street by the police unable to walk. He 
 stated to me that he had not suffered from any pre- 
 monitory symptoms, but that after a drinking bout he 
 found himself in the street unable to walk. This occurred 
 at the end of June, three months after infection. Under 
 treatment this man regained complete use of his legs, 
 and is still serving. 
 
 H. C , a soldier, contracted the disease in October 
 
 1908. The primary lesion was considered to be a "soft 
 sore," and he had no specific treatment. On waking one 
 morning in February 1909, he found he could not move his 
 right arm or either leg ; he passed his urine and fsces 
 involuntarily. Under calomel injections he made a 
 wonderful recovery, and is still serving. Practically all 
 the cases of hemiplegia and paraplegia which have come 
 under the author's notice had received either no specific 
 treatment or a very modified form of it. 
 
 Hemiplegia is due to endarteritis or thrombosis of the 
 middle meningeal artery, whilst paraplegia results from 
 meningitis of the membranes of the cord. 
 
 A variety of phenomena depending on the extent of 
 the lesions may accompany syphilitic hemiplegia, such 
 as paralysis of various nerves, aphasia, optic neuritis, and 
 epilepsy ; mental depression is constant. 
 
 5 
 
66 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Prognosis and Treatment 
 
 The prognosis is better in syphilitic hemiplegia or 
 paraplegia than in the simple form, much depending on 
 the amount of specific treatment already given, and on 
 the energetic way it is carried out after the onset of the 
 paralytic symptoms. 
 
 Secondary Visceral Affections 
 
 There may be albuminuria due to syphilitic nephritis, 
 pleural effusion from pleuritis, and congestion of the liver 
 causing jaundice. 
 
 The osseous system is often one of the earliest attacked 
 by syphilis. It begins as a simple periostitis, running 
 on sometimes to inflammation of the bone itself. The 
 tibia, clavicle, sternum, bones of the cranium and the ribs 
 are mostly attacked, and in the order named. 
 
 Periostitis 
 
 This is often a very early secondary, coming on 
 sometimes before the appearance of any rash, etc., but it 
 is more often seen between the sixth and ninth month. 
 It is a subacute affection ; it appears as a swelling over 
 one of the bones already quoted, which is elastic, tender, 
 and painful. The pain is sometimes intense, especially 
 at night-time. Under treatment this lesion will generally 
 subside, leaving no trace behind it ; but often the bone 
 itself becomes engaged, when the inflammation is some- 
 times followed by suppuration. In any case bony 
 nodules called osteophytes remain at the seat of attack. 
 
SECONDARY PERIOD 67 
 
 Secondary Affections of the Joints 
 
 The secondary lesions as far as joints go are of two 
 kinds — acute and subacute. The acute generally attacks 
 the elbow joints both at the same time. There is slight 
 swelling accompanied by severe pain, which is always 
 intensified at night-time, and there is usually a marked 
 rise of bodily temperature, which may reach 104 F. 
 The subacute variety, which is far more common than 
 the former, very often attacks one knee only. There 
 appears a swelling of the joint which is unaccompanied 
 by pain, or if the latter does exist it is only slight ; 
 bodily disturbance and pyrexia are insignificant, and it 
 generally ends in resolution ; the amount of fluid secreted 
 is usually small. A peculiar feature of this variety is 
 the intermittent character of the effusion. 
 
 Rheumatoid Pains of Secondary Syphilis 
 
 Some of the most constant symptoms in the early 
 months of syphilitic infection are pains in the muscles, 
 bones, and joints. The muscles attacked are chiefly those 
 of the extremities, whilst the joints affected are the ankle, 
 elbow, wrist, and phalanges. These pains begin at sun- 
 down, and get gradually worse at night. 
 
 Secondary Affections of the Tendons 
 
 Teno-synovitis may come on at an early stage, and is 
 characterised by effusion, tenderness, and swelling along 
 the course of a tendon. Sometimes it is limited to one, 
 such as the tendo Achillis, more rarely it attacks several 
 
68 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 at the same time, and there may be severe pain and 
 tenderness over them. 
 
 Treatment. — Little can be done locally for these affections ; 
 everything depends on constitutional treatment Pain 
 can, of course, be assuaged by the usual methods, and 
 when very severe morphia hypodermically is indicated. 
 
 Secondary Affections of the Epididymis and Testicle 
 
 As secondary affections these are not common. When 
 the epididymis is attacked the lesion appears as an acute 
 inflammation, which readily subsides in resolution under 
 treatment. Inflammation of the testicle itself is very 
 rare in early syphilis, and when it does occur it follows 
 the course of ordinary acute orchitis, resolution being 
 generally the result. 
 
 Specific Treatment 
 
 In speaking of the treatment of all secondary affections 
 it is presumed that specific treatment is strictly adhered 
 to in all, as no local measures will avail in its absence. 
 
CHAPTER VII 
 
 TERTIARY SYPHILIS 
 
 WHEN not exterminated in its secondary stage syphilis 
 passes into a chronic condition, when it is called tertiary. 
 
 Tertiary syphilitic affections present many differences 
 from those of the secondary stage : they are of deep 
 development, of compact structure, and slow growth ; 
 they are less numerous and more isolated than secondary 
 lesions, irregular in their course, and much more deeply 
 seated and destructive in their tendency. Secondary 
 affections have a tendency towards resolution, tertiary 
 ones favour progression. The viscera are rarely attacked 
 in secondary syphilis, whereas in the tertiary stage they 
 suffer deeply from a chronic infiltration which produces 
 nodules and tumours called gummata. 
 
 It is almost impossible to write a clear and defined 
 description of tertiary syphilis, as each case differs so 
 much in the mode of onset and progression. In some 
 cases what we know as tertiary lesions make their appear- 
 ance as early as the third or fourth month, while the 
 roseolar rash is still present. The patient appears suddenly 
 to change for the worse ; any skin lesions present ulcer- 
 ate and suppurate, these ulcers spread over the body, 
 
70 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 and the patient becomes weak and cachectic. In other 
 cases tertiary syphilis manifests itself in hemiplegia, 
 paraplegia, and other nervous lesions, and generally these 
 cases are rapid and severe. The majority of tertiary 
 syphilis cases occur in the third or fourth year and on- 
 wards from the date of infection. The following tissues 
 and organs are attacked in sequence : the skin, nervous 
 system, osseous system, mucous membranes, and viscera. 
 
 Some authorities believe that tertiary syphilis is not 
 true syphilis, but that it is a chronic condition left behind 
 by the active disease ; seeing that the tertiary lesions 
 may co-exist with the secondary, this belief seems illogical. 
 The discovery of Spirochceta pallida in tertiary lesions points 
 to these being due to the same condition as secondary 
 syphilis, modified no doubt by the attenuation of the virus. 
 It has been proved that syphilis can be reproduced by 
 inoculation with matter taken from gummata and other 
 tertiary lesions. 
 
 The chief causes of tertiary syphilis are inadequate 
 treatment, overwork, enervating climates, excesses of all 
 kinds, more especially alcoholism. Malaria is also a very 
 special adjunct to tertiary syphilis. 
 
 Cutaneous and Subcutaneous Affections 
 
 Gummatous syphilides are typical of tertiary syphilis. 
 The perivascular cell infiltration forms an inflammatory 
 neoplasm in the skin, which has a tendency to soften 
 and to ulcerate. Some of these syphilides become 
 ulcerated almost from the commencement, whilst others 
 ulcerate at one part and heal at another. 
 
TERTIARY SYPHILIS 71 
 
 Simple Gummatous Syphilides 
 
 The gummatous syphilide is of two kinds : simple and 
 ulcerative. The first is formed by dark red, copper- 
 coloured nodules of slow evolution ; the extending margin 
 of this syphilide is circinate or serpiginous. After healing, 
 a brown macule is left, followed by a depressed cicatrix, 
 and there is destruction of tissue without ulceration. 
 
 Ulcerative Gummatous Syphilides 
 These syphilides may consist of a number of nodules, 
 which eventually coalesce, or of a single large nodule with 
 extensive serpiginous ulceration. Progress is slow and pain- 
 less, and inflammatory reaction absent. The nodule may 
 undergo resolution without any treatment ; but, on the 
 other hand, it may persist for years. Generally specific 
 treatment has a marked effect. Under this it heals 
 rapidly, leaving a cicatrix which, at first pigmented, ulti- 
 mately becomes a white depression circular or annular 
 in shape. 
 
 Subcutaneous Gummata 
 These appear as nodules in the hypodermic tissue. They 
 are hard, painless, and freely movable at first. Later on 
 they become caseated and adherent to the skin, which 
 they perforate, and form an ulcer with the characteristics 
 already described. When they have healed depressed 
 pigmented cicatrices remain. 
 
 Treatment of Gummatous Syphilides 
 
 Specific treatment is, of course, absolutely necessary, 
 but much can be done locally for ulceration. Dressings 
 
72 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 of iodoform, mercurial ointments (red and yellow oxide 
 or white precipitate) are very good ; also perhydrol 
 (Merck), in a concentrated solution, applied two or three 
 times a day, or calomel applied in powder or fumigation. 
 It is in these gummatous syphilides that iodide of potas- 
 sium is so useful. Iodipin given by intramuscular or 
 subcutaneous injection is of much benefit. 
 
 THE ALIMENTARY SYSTEM 
 
 Tertiary lesions of the lips are not common, but they 
 are important owing to their liability to being mistaken 
 for cancer, and vice versd. They may appear as a 
 tubercular formation or as a gumma. The former is very 
 apt to relapse. In shape it is usually circinate, and may 
 extend so as to involve most of the lip. It may appear 
 as diffuse infiltration, the mucous membrane of the lip 
 becoming swollen and red. In other cases this lesion 
 assumes the character of a hard circumscribed gumma in 
 the substance of the lip. This may be taken for cancer, 
 but in the gumma the lymphatic glands are not enlarged ; 
 the skin over this gumma may ulcerate, and then it may 
 be mistaken for a chancre. 
 
 The Tongue 
 
 Gummatous inflammation attacks the tongue with great 
 frequency, in numerous forms, and at any time. 
 
 Superficial Glossitis 
 
 This sometimes arises in habitual smokers. On exami- 
 nation the tongue is found to be swollen, bright red, and 
 
TERTIARY SYPHILIS 73 
 
 indented at its edges with marks of the teeth. The dorsal 
 surface is devoid of fur, and the papillae may have dis- 
 appeared over a large surface. The tongue itself is freely 
 movable, and can be protruded to its normal extent. 
 Its surface is moist, tender and painful. There is little 
 induration. 
 
 In other cases the lesion consists of patches of round 
 or oval shape and deep red colour; they are slightly 
 raised and indurated, and when healed leave milk-white 
 patches. They run a very chronic course, and are painless 
 throughout ; sometimes they soften and give rise to ulcers, 
 fissures, or erosions. 
 
 Sclerosing Glossitis 
 
 This is characterised by swelling, most marked on the 
 dorsal surface of the tongue, the central part being most 
 frequently affected. Disappearance of the papillae gives a 
 smooth appearance to the mucous membrane covering 
 the affected parts. Fissures and ulcers are produced, 
 the former radiating outwards from the central raph6. 
 The course of this lesion is also very chronic. The 
 lymphatic glands seldom enlarge. 
 
 Gummatous Glossitis 
 
 This occurs about four to six years after infection, and 
 the gummata may be either superficial or deep. The 
 former are usually situated on the dorsum of the tongue. 
 They are small nodules projecting into the mucous mem- 
 brane, where they can be felt as hard bodies, not always very 
 well defined. Unaffected at first, the mucous membrane 
 
74 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 covering a nodule eventually softens, and an ulcer is 
 formed, with a typical " washleather " slough as its floor. 
 The deep gummata may lie at any depth in the tongue's 
 substance. They occur at any age, and are often found 
 in children, but generally appear in middle age. They 
 form painless indolent swellings, with the mucous mem- 
 brane covering them unaltered. They are not, as a rule, 
 tender. Sooner or later they soften, the mucous mem- 
 brane gives way, and ulceration takes place. Needless 
 to say, this is a very chronic and obstinate affection. 
 
 Differential Diagnosis 
 
 Gummata of the tongue may be mistaken for either 
 innocent or malignant tumours. The points of distinction 
 between innocent tutnours and gummata are these. The 
 former are often polypoid, the latter never ; innocent 
 tumours are, as a rule, well defined, whilst gummata 
 are not ; the former are generally single, gummata more 
 often multiple ; innocent tumours are often, gummata 
 never, lobulated. 
 
 The diagnosis between gummata of the tongue and 
 cancer turns upon the following differences : Cancer is 
 nearly always single, gumma often multiple. The former 
 tends to attack the borders of the tongue, the latter as 
 often the middle. Cancer often forms opposite a carious 
 tooth, whereas gumma has no connection therewith. 
 Cancer is usually a disease occurring in patients past 
 middle life ; gumma is found in those between twenty- 
 five and thirty years of age. The tongue in gumma is 
 freely movable, whilst its mobility is impaired in cancer. 
 
TERTIARY SYPHILIS 75 
 
 The microscope and history will also furnish help in 
 differentiating between the two affections. 
 
 Fissures and Ulcers of the Tongue 
 
 may occur both in early and in late syphilis. The latter 
 are very often found in the dorsum, and are caused by 
 softening of the gummata. Ulceration begins as a small 
 hole, which quickly enlarges by the giving way of the 
 infiltrated tissue surrounding the tumour. A cavity is 
 formed with sharply cut, ragged undermined borders 
 and sloughy floor. Symptoms are usually singularly 
 slight, considering the condition ; the patient suffers in 
 many cases little inconvenience other than a feeling of 
 thickness of the tongue, pain being practically absent 
 at first, though sometimes troublesome while ulceration 
 is proceeding. 
 
 Treatment of Tertiary Affections of the Tongue 
 
 One thing is very certain, i.e. that smokers suffer much 
 more often from these affections than non-smokers ; hence 
 smoking should be forbidden altogether, or at least much 
 curtailed, and in fact all irritation or anything likely to 
 facilitate it should be avoided, hence spirits and hot 
 condiments should be forbidden. The dentist should be 
 visited, to have the teeth examined and put right when 
 required, all tartar being scraped off. It goes without 
 saying that specific treatment is all-important in these 
 affections ; the writer has found calomel by injection 
 most useful, and the arylarsonates especially beneficial. 
 Iodide of potash is also essential. 
 
76 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Cracks and fissures should be well dried, and then 
 painted with a solution of either chromic acid (gr. x to 3J) 
 or of perhydrol or peroxide of hydrogen. When there 
 is much inflammation of the parts the following application 
 
 a 
 
 de to the ulcers : 
 Iod 
 
 grs. ij = 
 
 grm. 
 
 0.41 
 
 Potassi iodidi 
 
 grs. xx = 
 
 grm. 
 
 1-37 
 
 Tinct opii 
 
 TtlV = 
 
 grm. 
 
 0.31 
 
 01. menth. pip. 
 
 mv = 
 
 grm. 
 
 0.31 
 
 Glycerini 
 
 ad si = 
 
 c.c. 
 
 •3° 
 
 Solve et Misce 
 
 
 
 
 The Palate 
 
 Gummatous infiltration affects both the hard and the 
 soft palate as well in acquired as in inherited syphilis. 
 It begins either as a local gummatous mass or as a 
 diffuse infiltration. In the former case it projects from 
 the soft palate as a flattened tumour, which is at first 
 hard and elastic, but eventually softens and breaks down, 
 leaving a gummatous ulcer behind. The diffuse variety 
 is much oftener seen. The soft palate becomes thickened 
 and congested ; this may be limited to a part, or it may 
 involve the whole arch of the soft palate. Later on 
 softening of this infiltration and ulceration takes place, 
 and the ulceration may extend to the velum palati, the 
 uvula, and pillars of the fauces, and through the entire 
 thickness of the soft palate, so that perforation is the 
 result. Perforation causes the voice to become nasal, 
 and fluids regurgitate through the nose. When the per- 
 foration is small, it may close by granulation ; when it 
 cicatrises, the palate is left scarred and deformed. 
 
TERTIARY SYPHILIS 77 
 
 Differential Diagnoses 
 
 Differential Diagnoses will have to be made between 
 gummatous infiltration of the palate and lupus, tubercle 
 and cancer. 
 
 Lupus runs a much more chronic course, and creeps 
 over the surface of the palate, whereas the syphilitic 
 affection begins in the deeper tissues. Lupus does not 
 affect the bone, whereas gumma does. 
 
 Tubercular ulceration is shallower than syphilitic ; it is 
 more limited in extent, and has sharply-cut edges, whilst 
 its base is red and more granular. The lymphatic glands 
 in its neighbourhood are often enlarged in tuberculous 
 ulceration, but are seldom so in syphilis. Tubercle 
 very rarely leads to perforation, the contrary being the 
 case with syphilis. Tuberculous ulceration is unaffected 
 by specific treatment or potassium iodide. 
 
 Treatment 
 
 Treatment consists in arresting the ulceration by specific 
 treatment and iodide of potassium. Locally the palate 
 should be frequently sprayed with dilute solutions of 
 iodine or perhydrol, and kept as clean as possible. No 
 surgical procedure should be undertaken until all ulceration 
 has ceased. 
 
 Tertiary Affections of the Pharynx 
 
 The pharynx is liable to the same syphilitic mani- 
 festations as the mouth. In some cases the entire soft 
 palate is destroyed by ulceration : necrosis of the hard 
 palate occurs, the mouth, nose, and pharynx being con- 
 verted into one cavity. In others the ulcerative process 
 
78 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 is limited to the border of the velum and pharyngeal 
 wall ; adhesions form, and divide the cavity of the pharynx 
 into two distinct chambers, one communicating with the 
 posterior nares, the other with the mouth. 
 
 Tertiary Affections of the Larynx 
 
 These consistof chronic inflammation leading to thicken- 
 ing or hypertrophy of the mucous membrane, and accom- 
 panied by superficial ulcers from which spring vegetations. 
 These vegetations may be of such a size as to impede 
 respiration. The cords may also become much thickened, 
 causing in some cases complete aphonia. Later on deep 
 ulceration may occur, the epiglottis and aryteno-epiglottic 
 ligaments being destroyed. These ulcerations are liable 
 to be mistaken for malignant disease, from which they 
 differ by being of slower growth, non-painful ; and 
 whereas in cancer the submaxillary glands are from an 
 early date infiltrated, they are not so in syphilis. Gum- 
 matous tumours may also occur as a tertiary lesion in 
 the larynx. 
 
 The Trachea 
 
 In tertiary syphilis the trachea is subject to gummatous 
 infiltration and connective tissue proliferation. The 
 former leads to ulceration and necrosis of cartilage. 
 The healing of the ulcers may leave cicatricial contraction, 
 which may lead to either complete or partial contraction 
 of the trachea. 
 
 The Lungs 
 
 The morbid processes of syphilis in the lungs consist 
 of indurations and gummata, which occur in either the 
 
TERTIARY SYPHILIS 79 
 
 middle or lower lobes rather than at the apices. Fibrous 
 bands enclosing islets of lung tissue are formed. The 
 bronchi in relation with these are flattened and the 
 alveoli are filled with exudation containing leucocytes 
 and desquamated epithelial cells. The pleura is often 
 thickened and adherent about these areas. The surface 
 of the lung is puckered and furrowed. 
 
 Gumma of the lung is more common than the above 
 condition. The gumma may be deposited in any part 
 of the organ, but is mostly found in the lower lobes. 
 Softening takes place in the centre of the mass. The 
 parts around may be thickened by proliferation of cells, 
 and around the whole mass there is always a zone of 
 indurated tissue. The degeneration of the centres leads 
 to liquefaction and evacuation of the fluid, which is the 
 cause of much irritation to the bronchi. Cough, dyspnoea, 
 haemoptysis, and muco-purulent sputum may all be 
 present, but the tubercle bacilli are absent from the latter. 
 In all lung lesions beginning in the lower lobes, and slowly 
 progressing without fever, syphilis should be suspected. 
 
 The Liver 
 
 Of all the abdominal viscera, the liver is the most 
 frequently attacked by tertiary syphilis, the conditions 
 produced being (1) amyloid degeneration, (2) perihepatitis, 
 and (3) hepatitis, either diffuse or gummatous. The first 
 is the result of cachexia. In perihepatitis there is thicken- 
 ing of the capsule with adhesions to surrounding parts. 
 In hepatitis there is great increase in the connective tissue, 
 accompanied by shrinking and the formation of fibrous 
 
80 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 bands ; by the contraction of these bands the liver be- 
 comes lobulated and nodular on the surface, so that a 
 " ploughed-up " appearance is caused. Gummata are 
 frequently found in the liver, and consist of a central 
 zone of yellow matter, a middle zone of fibrous tissue, 
 and an outer of dense hepatic tissue. The yellow matter 
 in the central zone is often absorbed j when it is replaced 
 by a mass of fibrous tissue, which causes puckering of the 
 surface of the organ. 
 
 Symptoms 
 
 The liver may be enlarged, irregular, and nodular. 
 Pain in the hepatic region is common, and may be sharp 
 or dull and persistent. In perihepatitis the pain may be 
 very severe. As a result of pressure ascites may occur. 
 Marasmus is often present, accompanied by albuminuria 
 and persistent jaundice. On the whole the symptoms in 
 tertiary syphilis of the liver are mild and not at all 
 distinct, so that the disease may be entirely overlooked. 
 
 Tertiary Affections of the Spleen 
 
 These may consist of infiltrations, either interstitial or 
 gummatous. The former begin around the blood-vessels, 
 producing a diffuse connective tissue which presses on 
 the splenic pulp and causes contraction of the organ. 
 Gummata occurring in the spleen are small, and are 
 sometimes found single, whilst at other times they may 
 be numerous. When freshly formed the gummata have 
 a reddish-grey colour ; when old they are dry and of a 
 yellow colour. They cause contraction of the splenic 
 capsule. 
 
TERTIARY SYPHILIS 81 
 
 The Stomach and the Rectum 
 
 Tertiary affections of the stomach are very rare, and 
 there are no regular symptoms which are pathognomonic 
 of them. When they do occur they consist of gummatous 
 infiltration of the walls. 
 
 The rectum may be attacked in tertiary syphilis in 
 three ways : by ulceration, by gumma formation, or by 
 the development and contraction of fibrous tissues. All 
 these varieties may lead to stricture of the gut. Indurating 
 oedema complicates all three ; the process extends to and 
 surrounds the anus ; the walls of the rectum become 
 thickened and ulcerated, a condition which ends in 
 stricture. Ulceration of the mucous membrane on the 
 surface of the indurating mass very often leads to abscess 
 and fistula. 
 
 The Kidney 
 
 The kidney is liable to be attacked in three ways — by 
 gummata, by interstitial nephritis, and by amyloid disease. 
 Gummatous infiltration of the kidney is rare, and is usually 
 associated with the same condition of other organs, such 
 as the liver and spleen. Nephritis is of the chronic 
 interstitial variety, and leads to the granular contracted 
 kidney presenting the usual symptoms of that condition. 
 Amyloid disease is the commonest renal result of tertiary 
 syphilis, and is also nearly always associated with amyloid 
 degeneration of the liver and spleen. 
 
 Treatment. — In these affections of the kidneys mercury 
 must be given cautiously, but at the same time specific 
 
 6 
 
82 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 treatment must be carried out by injection either of the 
 soluble salts or of one of the amylarsonate preparations, 
 the latter being very applicable in such cases. 
 
 The Muscles and Tendons 
 
 Myositis occurs as the result of tertiary syphilis in three 
 forms : the hyperaemic, the chronic infiltrative, and the 
 gummatous nodular. Myositis, when chronic, tends to 
 more or less contraction ; pain is usually of a dull, aching 
 character. One or more muscles may be attacked at the 
 same time ; those most frequently involved are the flexors 
 of the upper extremity, especially the biceps. 
 
 Globular, fusiform, or flat gummatous tumours may 
 occur in the muscle. When superficial they become 
 adherent to the aponeurosis, which becomes inflamed and 
 hypertrophies. They are best detected when the muscle is 
 relaxed. They excite little pain, their chief inconvenience 
 being interference with motion. These tumours may 
 undergo softening, break down and form deep ulcers. 
 
 Tertiary lesions of tendons take the shape of teno- 
 synovitis, with hyperaemia of the sheath and serous effusion. 
 They form elastic, often fluctuating tumours, and may be 
 painful. Gummata sometimes form in tendons. 
 
 Tertiary Affections of the Bursas 
 
 In tertiary syphilis the patellar bursas are frequently 
 attacked by painless gummatous infiltration, elastic to 
 the feel. It very often becomes inflamed, softens and 
 breaks down, and then is very tedious. 
 
TERTIARY SYPHILIS 83 
 
 Tertiary Affections of the Bones 
 
 The tertiary affections of the bones consist of osteo- 
 periostitis, exostoses, and gummatous infiltration. The 
 bones most frequently attacked in osteo-periostitis are 
 the tibia, ulna, clavicle and sternum, also the bones of 
 the cranium. The signs of this lesion are ill-defined 
 tumours of different sizes, adherent to the osseous tissue ; 
 they are very tender to pressure and very painful, especi- 
 ally towards evening. As a rule they end in absorption 
 and undergo resolution ; in other cases inflammation takes 
 place ; the skin becomes adherent to the tumour, is 
 reddened and thinned ; softening takes place, and an 
 opening is formed ; eventually the superficial portion of 
 the bone becomes necrosed and comes away. 
 
 Exostoses are the result of eburnation of bony tissue ; 
 when this takes place resolution is not possible ; the node 
 or tumour remains stationary. As a rule these lesions 
 give little trouble, but sometimes, when situated on the 
 internal surface of the cranial bones, they may cause 
 convulsions, epilepsy, and various forms of paralysis. 
 
 Gummatous Osteo-Periostitis 
 
 The bones most frequently attacked are those of the 
 cranium, where one or more nodes are developed ; the 
 bones of the face are also very liable to be attacked, 
 especially the malar, superior and inferior maxillary bones ; 
 the first symptoms are swelling and pain, and very often 
 the whole bone is destroyed. The vertebra may be the 
 seat of gummatous osteitis, when a condition called " syphi- 
 litic spondylitis " is formed. This gives rise to various 
 
84 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 symptoms, according to its localisation : when the vertebra 
 in the cervical region are attacked, paralysis of all four 
 limbs may take place ; when in the dorso-lumbar, paralysis 
 is limited to the lower limbs. Syphilitic disease of the 
 vertebrae differs from tuberculosis in not causing destruc- 
 tion of the whole body of the vertebra, hence in the 
 former there is generally an absence of angular curvature. 
 
 Joint Affections 
 
 {a) Synovitis, subacute and chronic ; {b) Gummatous 
 deposits in the synovial membranes ; (c) Gummatous 
 changes primarily in the bones ; (d) Spreading to the 
 joint from the surrounding parts ; (e) Ankyloses. 
 
 Synovitis of the tertiary period is markedly subacute ; 
 there is but slight pain or impairment of movement ; 
 the effusion into the cavity takes place slowly and is 
 never very great. A marked feature is the tendency of 
 this affection to become stationary. There is seldom any 
 suppuration or any other degeneration, in marked contrast 
 to tubercular affections of the same parts. 
 
 Gummatous arthritis generally attacks the knee-joint. 
 It begins in an insidious manner, there being but slight 
 pain and but little effusion. It may set up acute arthritis, 
 ending in complete destruction of the joint and leading 
 to ankylosis. 
 
 When the gummatous disease begins in the bones, 
 osteitis affects both the epiphysis and the diaphysis, 
 causing enlargement of the bone near the joint. It 
 is frequently preceded by nocturnal pains, though later 
 on pain is but slight. 
 
TERTIARY SYPHILIS 85 
 
 The Fingers and Toes 
 
 Dactylitis syphilitica is a condition due to gummatous 
 deposit, which may begin in the bones and periosteum, 
 eventually implicating the joints ; or it may commence 
 in the subcutaneous tissue of the fingers and toes, and 
 also may extend to the joints. 
 
 In the former case the disease develops slowly as an 
 enlargement of one of the fingers or toes. The skin over 
 it becomes stretched and swollen ; pain is slight, and may 
 be completely absent. Only one phalanx may be attacked 
 at a time, but usually two or more, and eventually the 
 whole finger or toe becomes implicated. The fingers are 
 attacked more often than the toes. The swellings may 
 remain in the same indolent condition for a long time, 
 and then the gummatous deposit is either absorbed or 
 softened and discharged through a sinus. The bone is 
 generally left permanently deformed, and may be partly 
 absorbed and shortened or thickened. 
 
 The Testes 
 
 Affections of these organs consist of chronic hyperplastic 
 processes of the body of the testis alone or of its cover- 
 ings as well. This lesion begins without inflammation or 
 pain. The organ is uniformly enlarged, hard, firm, and 
 less sensitive than in its normal state. There may be an 
 accompanying hydrocele. The testicle may sometimes be 
 found to contain masses of induration, which form projec- 
 tions on its surface; the latter may coalesce and form a 
 
86 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 hard resistant mass which may remain for years, or soften- 
 ing and breaking down may take place and an abscess 
 cavity be left. 
 
 Treatment. — Specific treatment of course is necessary, 
 and without it little can be attained locally. Strapping the 
 testicle with mercurial plaster and tapping a hydrocele 
 when present, may be used as adjuvants. 
 
 THE CIRCULATORY SYSTEM 
 
 Lesions in the arterial system, inside or outside the 
 cranium, are invariably present, and constitute the most 
 important pathological element in all cases of syphilis, 
 endarteritis, panarteritis, peri-arteritis and endoperi- 
 arteritis, all being constantly found, sometimes in the same 
 subject. The arterial changes may, in rare cases, manifest 
 themselves before the end of the first year, especially in 
 the neighbourhood of the base of the brain, but usually 
 they are delayed till after the third year, and often they 
 do not give rise to symptoms till a much later period, when 
 they may end in atheroma of the aorta, aneurysms, or 
 aortic regurgitation. 
 
 Several types of syphilitic arteritis are recognised, the 
 best marked being the obliterative, in which the most 
 advanced changes are seen in the inner coat of the vessel, 
 constituting the condition known as "Endarteritis ob- 
 literans." The intima is thickened sometimes more on 
 one side than the other ; the internal elastic lamina usually 
 remains intact, but it may be absorbed. The tunica 
 adventitia is generally found infiltrated with round cells 
 
TERTIARY SYPHILIS 87 
 
 and the vasa vasorum thickened. The tunica media is 
 sometimes also affected, and when this takes place the 
 muscle cells are atrophied. The wall of the artery, being 
 deprived of its elastic and muscular elements, offers less 
 resistance to the blood pressure, bulging takes place, and 
 an aneurysm is formed. Thickening of the intima causes 
 anaemia of the parts supplied by the affected vessel. The 
 result will depend on the localisation of the latter, and 
 much will depend on whether it is a terminal artery, or 
 if there is collateral circulation. In the latter case there 
 will be loss of or diminished function. If the vessel is 
 situated in a lower limb the latter will be weakened. 
 Should it be the coronary arteries which are engaged, 
 angina pectoris may result ; should the affected vessel be 
 in the brain, dizziness, etc. will follow. Obliteration of a 
 terminal artery will cause arrest of function, and in the 
 case of the cerebral arteries, softening of the brain. 
 
 Endarteritis obliterans is characterised by a prolifera- 
 tion of the endothelial tissue, and the media and adventitia 
 are infiltrated with small cells. In gummatous periarteritis 
 nodular gummata may develop in the adventitia, produc- 
 ing globular swellings which may attain considerable size. 
 These swellings are not infrequently found in the cerebral 
 arteries. Endarteritis obliterans, when it attacks the 
 vessels of the limbs, may cause gangrene, the signs of 
 which consist of pain lasting over a long period with 
 perhaps no other symptom but oedema. Charcot de- 
 scribes a peculiar gait, which he says is a sure sign of 
 arterial constriction, — when walking there is a sudden 
 attack of numbness and weakness accompanied by pain 
 
88 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 and cramp in the limb. In two cases which occurred 
 in the author's practice, the first symptoms took place 
 in the cricket field : the patient was about to deliver a 
 ball in bowling when he experienced a numbness in the 
 calf of one of his legs, and this was followed by sharp pain ; 
 these passed away, but it was the beginning of endar- 
 teritis obliterans, which eventually resulted in loss of the 
 limb. The second case happened to a tennis player, who, 
 whilst serving, suddenly experienced pain and numbness 
 in the right arm, which recurred fairly frequently after 
 this, and was put down as a " tennis elbow " ; this case also 
 ended in amputation of the limb about two years later. 
 In endarteritis obliterans the calibre of the artery is 
 slowly but progressively occluded, until it is completely 
 so, when gangrene sets in, resulting in the loss of the 
 affected limb or part of it. The process may attack one 
 limb after another, and the writer remembers one case in 
 which both arms and both legs had been amputated for 
 endarteritis obliterans. 
 
 Atheroma 
 
 Atheroma is a secondary degeneration of the coats of an 
 artery brought about by endarteritis of its vasa vasorum, 
 causing defective nutrition of the walls of the vessel, and 
 by the toxic effects of the syphilitic virus itself on the 
 vessel. This leads to what is known as atheroma and to 
 endarteritis deformans. Of the many causes of atheroma 
 syphilis is the most important There is a local syphilitic 
 arteritis most commonly seen in the aota — aortitis which 
 is a prime factor in the production of aneurysm ; and 
 
TERTIARY SYPHILIS 89 
 
 there is a late diffuse change, comparable to the para- 
 syphilitic lesions of the nervous system. 
 
 Aneurysm 
 
 As a cause of aneurysm syphilis stands pre-eminent ; 
 the arguments in favour of this being the case are : — the 
 frequent coexistence of aneurysm with other syphilitic 
 lesions such as cerebral arteritis, the number of cases of 
 aneurysm with histories of syphilis, and the frequency of 
 aneurysm in locomotor ataxy, which is now known to be 
 almost solely of syphilitic origin. 
 
CHAPTER VIII 
 
 AFFECTIONS OF THE NERVOUS SYSTEM 
 
 The nervous system in tertiary syphilis is nearly as 
 
 frequently attacked as the skin and mucous membranes 
 
 taken together. Nearly three-fourths of all spinal-cord 
 
 diseases are due to it, as are those of brain disease. 
 
 Syphilitic nerve affections may be developed as early as 
 
 the fourth month, and as late as the twentieth year after 
 
 infection. Fournier's figures show that in about one-ninth 
 
 of all cases of ordinary cerebral syphilis the symptoms 
 
 of hemiplegia occur during the first year of the disease, 
 
 and a much larger percentage of spinal cases occurs 
 
 before the expiration of this early period. In rare cases 
 
 described as " malignant," cerebral and spinal affections 
 
 have been recognised before the disappearance of the 
 
 primary induration at the site of infection. Nervous 
 
 symptoms are especially likely to appear in individuals 
 
 of the neurotic type, and chorea, migraine, neuralgia, etc., 
 
 are common in the history of such persons. Mental 
 
 anxiety and strain, sexual and alcoholic excesses are 
 
 certainly predisposing causes, and last, although not least, 
 
 90 
 
AFFECTIONS OF THE NERVOUS SYSTEM 91 
 
 comes " insufficient treatment," which is indeed one of 
 the main factors in tertiarism. 
 
 The following figures speak for themselves : 
 
 Fournier's statistics of 100 cases of cerebral syphilis of which the 
 previous history of treatment was known 
 
 After thorough treatment 
 After modified but insufficient treatment 
 After seven to eighteen months' treatment 
 After one to six months' treatment . 
 
 After no treatment 
 
 After treatment by iodides exclusively . 
 
 5 
 
 6 
 
 10 
 
 70 
 
 4 
 
 5 
 
 100 
 
 The above shows that 5 P er cent, only occurred after 
 thorough treatment, as against 95 per cent, after insuffi- 
 cient treatment 
 
 In tertiary syphilis of the nervous system, the latter 
 may be affected by the syphilitic virus, by its causing 
 inflammation of the membranes or blood-vessels with 
 subsequent occlusion of the latter ; by gumma of various 
 parts of the brain ; by its lowering the vitality of the cells, 
 laying them open to parasyphilitic affections — general 
 paralysis, tabes and epilepsy. Inflammation of the mem- 
 branes (meningitis), generally affects the base of the brain 
 and may extend down the membranes of the cord ; 
 gummatous deposits nearly always originate in the mem- 
 branes — they are generally small, and are scattered round 
 the vessels, and are of a greyish red colour ; when 
 occurring in the substance of the brain they are usually 
 an extension from the meninges. At other times the 
 gummata may be single and large, in which case they are 
 
92 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 mostly found at the base of the brain ; they are greyish 
 yellow in colour. Adhesions form between them and the 
 dura mater, which may be much thickened. The chief 
 lesion in cerebral syphilis is endarteritis, which causes 
 narrowing of the lumen of the affected vessels, and con- 
 sequently deficient blood supply to the parts of the brain 
 dependent on them ; should they become completely 
 occluded, softening of the brain surface takes place. The 
 symptoms of cerebral syphilis will vary according to the 
 part of the brain which is engaged, thus, when the lesion 
 is situated in the convexity of the brain it may lead to 
 epilepsy, disorders of the mind, and paralysis ; whereas, 
 when on the base, paralysis will follow from implication 
 of the nerves at the base of the brain. There are no 
 symptoms which can be described as pathognomonic of 
 syphilis of the brain, but the following are suggestive 
 of it :— 
 
 Epilepsy occurring at middle or adult life without loss 
 of consciousness ; aphasia ; paralysis of certain muscles 
 (ocular), paralysis, mental disorders, more especially loss 
 of memory, hemiplegia, and general loss of health. Of 
 these hemiplegia is perhaps the most common, and is 
 due to endarteritis of the middle cerebral artery, but 
 sometimes to the pressure of gummata. Syphilitic 
 hemiplegia as a rule sets in suddenly, although it may 
 have been preceded by headaches, numbness, and transient 
 paresis of the ocular muscles ; sensation is generally 
 unimpaired, and it may or may not be associated with 
 mental disorder. 
 
AFFECTIONS OF THE NERVOUS SYSTEM 93 
 
 Tertiary Syphilitic Affections of the Spinal Cord 
 
 The spinal cord is one of the most favourite sites of 
 tertiary syphilis ; the lesions produced being the result 
 of inflammation and some degeneration, probably caused 
 by endarteritis. Tertiary syphilis attacks the cord in a 
 very irregular manner, and is not limited, as in locomotor 
 ataxy, to the posterior columns, but may attack any other 
 part, or all the systems at the same time, and is very often 
 associated with syphilis of the brain. 
 
 As in the brain, so in the cord, tertiary syphilis may 
 affect the membranes alone, the cord itself, or both 
 together, the latter being most often the case ; all three 
 membranes are usually affected together, and when the 
 cord is engaged its posterior columns are the favourite 
 sites. 
 
 The symptoms of spinal syphilis vary much owing to 
 the irregular distribution of the lesions, and consist chiefly 
 of pain along the spine — girdle pain — accompanied by 
 motor, sensory, and trophic symptoms. Later on paraplegia 
 sets in, with affections of the bladder and rectum. 
 
 The principal lesions of tertiary syphilis of the spinal 
 system are meningitis, myelitis, and meningo-myelitis. 
 Meningitis is very often an early affection. Myelitis may 
 be acute or chronic ; the former sets in suddenly, 
 with acute and severe pain somewhere about the dorso- 
 lumbar region, followed in a few days by paraplegia; 
 both lower limbs become totally paralysed, and a fatal 
 termination very often is the result. Chronic myelitis 
 is the commonest syphilitic affection of the cord, and 
 
94 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 commences with sensations of numbness and tingling of 
 the feet, followed after a long period by affections of the 
 bladder and rectum. Sometimes incontinence takes place, 
 at others retention is the rule. The disease is slow in its 
 progress, but eventually the lower limbs become partially 
 paralysed. Knee-jerks are irregular, being more marked 
 on one side than the other, and there may be anaesthesia 
 or hyperesthesia in irregular patches. Cramps in the legs 
 are also, as a rule, a great trouble. The disease may be 
 arrested in its progress, but such cases are rare ; the 
 majority, in the absence of early treatment, becoming 
 hopeless paralytics. 
 
 Leucocytosis of the Cerebro-spinal Fluid 
 
 Widal and Ravant discovered that lymphocytosis of the 
 cerebro-spinal fluid always accompanies organic disease 
 of the nervous system, more especially tuberculous and 
 syphilitic meningitis, as well as tabes and general paralysis, 
 but that it is absent in functional diseases. Hence they 
 advocate lumbar puncture in all cases of syphilis with 
 nervous symptoms ; the presence of lymphocytosis being 
 an indication for energetic treatment. Undoubtedly this 
 is a valuable means of diagnosis. 
 
 Treatment of Cerebro-spinal Syphilis 
 
 The treatment of cerebro-spinal syphilis must be com- 
 menced as soon as the diagnosis has been made. To be 
 of use treatment must be of an intensive character, 
 mercury being, as usual, our sheet-anchor ; by far the 
 best form to administer it in these cases is by calomel 
 
AFFECTIONS OF THE NERVOUS SYSTEM 95 
 
 injections. Oral administration under such conditions is 
 practically useless. Failing calomel injections, inunction 
 a l'Aachen (Aix-la-Chapelle) is the best. I have seen 
 many cases of cerebro-spinal syphilis make wonderful 
 recoveries under these injections. My plan is to give 
 gr. I of calomel by intramuscular injection twice a week 
 for four weeks, then to suspend the treatment for a period 
 of two weeks, and then repeat the course, at the same 
 time being guided by the symptoms, etc., as to continuing 
 it further. During the intervals iodide of potassium ought 
 to be given in not smaller doses than gr. xv three times 
 a day, and for not longer than ten days at a time ; the 
 dose being gradually increased to gr. xxx. three times 
 a day. 
 
CHAPTER IX 
 
 PARASYPHILIS OR QUATERNARY SYPHILIS 
 
 MANY years, it may be, from the primary sore and from 
 any active manifestations, certain diseases may follow, 
 not directly syphilitic, but dependent in some way upon 
 its poison, and hence termed parasyphilitic affections, the 
 chief of which are locomotor ataxia, general paralysis, and 
 epilepsy. Of these, Fournier and Mott maintain that 
 tabes and general paralysis are pathogenically identical, 
 and only different aspects of the same disease. Both are 
 caused by syphilis, and appear about the same time after 
 infection ; — Argyll " Robertson pupil " and lymphocytosis 
 of the cerebro-spinal fluid are common to both. These 
 authorities also say that the primary lesion in both tabes 
 and general paralysis is the same, being a dystrophy of 
 the neurones, the sclerosis and thickening of the mem- 
 branes being a secondary result of degeneration. 
 
 Tabes or Locomotor Ataxia 
 
 Tabes, tabes dorsalis, or locomotor ataxia, is an 
 
 affection characterised clinically by sensory disturbances, 
 
 incoordination, trophic changes and involvement of special 
 
 96 
 
PARASYPHILIS OR QUATERNARY SYPHILIS 97 
 
 organs, particularly the eye. Anatomically there are 
 found degenerations of the root fibres of the dorsal 
 columns of the cord, of the dorsal roots, and at times of 
 the spinal ganglia and peripheral nerves. At the present 
 time tabes is looked on as essentially a syphilitic disease. 
 Moebius says, " The longer I reflect upon it, the more 
 firmly I believe that tabes never originates without 
 syphilis." Erb, Fournier, and Gowers show that in from 
 50 to 90 per cent, of all cases of tabes there is a syphilitic 
 history, and Erb's latest figures show that of three hundred 
 cases of tabes 89 per cent, had a history of this disease. 
 
 The importance of the role played by syphilis in the 
 production of tabes and general paralysis becomes more 
 and more evident as time goes on. Collins in a series of 
 140 cases of tabes obtained a definite history of syphilis in 
 70 per cent, of them, whereas out of 140 cases of nervous 
 diseases other than tabes or general paralysis only 8' 5 
 had had syphilis. Additional proof of the syphilitic 
 origin of tabes and general paralysis is afforded by the 
 results of cyto-diagnoses of the cerebro-spinal fluid by 
 lumbar puncture. Widal, Sicard, and Ravant found 
 distinct lymphocytosis in 36 out of 37 cases. Lympho- 
 cytosis is often distinct in the very earliest stage, even 
 preceding " Argyll-Robertson pupil " or loss of knee-jerks. 
 
 Exciting Causes. — Excessive fatigue, over-exertion, 
 injury, exposure to cold and wet, all no doubt contribute 
 to the development of tabes. 
 
 A good many cases are on record of the existence of 
 the disease in both husband and wife, and a few where 
 children were also affected. 
 
 7 
 
98 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Theories as regards Actual Lesion. — Maries and 
 Guillain believe in a " lympho-angiotic " theory — that 
 tabes is due to a syphilitic affection of the posterior 
 lymphatic system of the cord. 
 
 Magrath maintains that it is due to the spread of a 
 chronic syphilitic meningitis to the posterior roots. 
 
 Ferrier comes to the conclusion concerning tabes that 
 the most feasible hypothesis is that its essential lesion is 
 a dystrophy, probably toxic in origin, affecting the sensory 
 protoneurones as a whole, manifesting in degeneration 
 of its intraspinal prolongations, and that the toxin in 
 tabes is generated by the syphilitic virus. The toxin of 
 syphilis differs from others inasmuch as the disease is a 
 progressive one, and does not tend to come to a standstill, 
 as in other toxin-produced degenerations. 
 
 Purves Stewart shows that lymphocytosis of the 
 cerebro-spinal fluid is constantly present both in tabes 
 and general paralysis from the very start, and is un- 
 influenced by the most energetic anti-syphilitic treat- 
 ment, unlike other lesions of the central nervous 
 system. 
 
 Ford Robertson's Theory. — Another theory concerning 
 tabes is that of Ford Robertson, who says : " We have 
 found that bacilli of the diphtheroid group can be found 
 to be invading the tissues in all cases of advancing tabes 
 and general paralysis ; the chief seats of invasion are the 
 naso-pharyngeal and oral mucosae in cases of general 
 paralysis and the genito-urinary tract in tabes." He has 
 named the bacillus — bacillus paralyticans. He further 
 states that he has seen cases of general paralysis and tabes 
 
PARASYPHILIS OR QUATERNARY SYPHILIS 99 
 
 much benefited by anti-bacterial serum prepared in the 
 sheep by immunisation with these special diphtheroidal 
 cells. 
 
 Symptoms. — In typical cases there are three stages of 
 the disease — the pre-ataxic, the ataxic, and the paralytic 
 stages. In the pre-ataxic stage the chief symptoms are 
 pains, ocular symptoms, bladder symptoms, trophic dis- 
 turbances, and loss of deep reflexes. 
 
 Pains, usually of a sharp, stabbing character — hence 
 the term " lightning pains." They last only a second or 
 two, and are most common in the legs or about the trunk ; 
 they dart from place to place. At times they are of a 
 burning character, and when they disappear leave the areas 
 they occupied tender to pressure. They occur at irregular 
 intervals, and are prone to follow excesses of all kinds, 
 exposure to cold and damp, and to come on when the 
 health is impaired. In rare cases, as pointed out by 
 Gowers, these pains may constitute the only symptom 
 of the disease. 
 
 Recently the writer has had experience of three cases 
 of tabes where lightning pains and " Argyll-Robertson 
 pupil " had been the only symptoms in periods varying 
 from ten to seventeen years. 
 
 Ocular Symptoms consist of — (a) optic atrophy ; (b) 
 ptosis ; (c) paralysis of the external muscles of the eye ; 
 id) " Argyll-Robertson pupil," in which there is loss of 
 the iris reflex to light ; but the power of contraction is 
 demonstrated when a patient looks at a near object — 
 accommodation. The pupils are generally contracted, 
 sometimes to a pin-point. 
 
ioo SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Bladder Symptoms, — The first warning of the onset 
 of the disease may be a certain difficulty in emptying 
 the bladder. In many cases of tabes the sexual desire 
 is very often increased early in the disease, but rapidly 
 becomes diminished, and later on is totally abolished. 
 
 Trophic symptoms, although belonging mostly to the 
 later stages, very often occur in this, the incipient stage, 
 when it is not uncommon to find a perforating ulcer 
 of the foot. 
 
 Loss of Deep Reflexes. — One of the most reliable 
 signs of tabes is diminution or absence of the knee-jerks 
 (Westphal's sign), and this early and most important 
 symptom may occur years before ataxia appears ; also loss 
 of ankle jerks. The combination of loss of either of these 
 with one or more of the symptoms mentioned above, 
 especially with lightning pains or "Argyll-Robertson 
 pupil," is practically diagnostic. 
 
 Tabes may never progress beyond this stage. A 
 peculiarity is that when optic atrophy comes on early, 
 ataxia rarely supervenes. 
 
 Ataxic Stage. — Ataxia develops gradually ; one of the 
 first indications of it is the patient's inability to get about 
 in the dark, or to maintain his equilibrium when washing 
 his face with his eyes shut. 
 
 When the patient stands with the feet together and the 
 eyes closed, he sways and loses his balance (Romberg's 
 sign). He cannot stand on one leg, and is unable to 
 start off promptly at the word of command. On turning 
 quickly he is apt to fall. Gradually the characteristic 
 gait of ataxia comes on : the patient starts unsteadily, 
 
PARASYPHILIS OR QUATERNARY SYPHILIS 101 
 
 with his legs somewhat apart, lifting his foot too high 
 and jerking out the limb, which comes down with a 
 sudden stamp caused by the entire sole striking the ground 
 at once. The incoordination is not limited to walking, but 
 extends to the performance of other movements : if the 
 patient, whilst in the recumbent position, is asked to touch 
 one knee with the other foot, the irregularity of the 
 movement is very marked. Incoordination, although less 
 observable in the upper limbs, is very often evident, as 
 instanced by the difficulty which the patient experiences 
 in buttoning his coat or collar. There is no paralysis, 
 and the muscle-reactions are normal ; but the subject of 
 ataxia is unable to co-ordinate his muscles harmoniously. 
 
 Sensory symptoms increase as the case goes on ; the 
 lightning pains come on oftener and persist longer. Other 
 symptoms are tingling and " pins and needles " in the 
 feet, with areas of anaesthesia and hyperesthesia ; a feeling 
 as if a layer of cotton wool were interposed between the 
 soles of the feet and the ground ; " pins and needles " in 
 the arms and hands. A frequent and constant symptom 
 is a feeling of " bands " about the chest and waist, giving 
 the sensation of something heavy tied round the chest. 
 A well-marked phenomenon is the loss of ability to 
 localise pain : if the patient is pricked in one limb he 
 may say he feels it in the other. Reflexes diminish still 
 further in this stage, and the eye symptoms become more 
 marked ; at the same time ataxia is very rare when 
 optic atrophy exists. 
 
 In this stage the visceral symptoms are most remarkable, 
 and consist of what are called tabetic crises, severe 
 
102 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 paroxysms of pain referred to various viscera — laryngeal, 
 gastric, nephritic, rectal, and urethral. Gastric crisis is 
 the most common, there is intense pain in the stomach 
 and vomiting of acid gastric juice ; the attack may 
 come on suddenly and last for some days. Paroxysms 
 of pain in the rectum, accompanied or not by tenesmus, 
 are common. 
 
 Trophic Symptoms. — Trophic changes are marked : 
 sweating, shedding of the nails and teeth, herpes, and 
 cedema. The perforating ulcer of the foot is a most 
 characteristic phenomenon, commencing as a suppurating 
 corn under the prominence of the first or fifth toe. The 
 ulcer gradually eats its way through to the dorsum of 
 the foot. It is in this stage that the condition known 
 as Charcot's joint is to be seen : a huge painless swelling 
 suddenly appears about the joint, such as the hip or knee, 
 and in a few days may have altogether disappeared or 
 suppuration taken place, with total disorganisation of the 
 joint ; this affection is very like chronic arthritis deformans. 
 
 The Third or Paralytic Stage. — In this all the 
 symptoms deepen ; progress is very slow as a rule. 
 Ataxia becomes so marked that the patient is unable to 
 stand, and later on he becomes quite bed-ridden. Incon- 
 tinence or retention of urine sets up bladder or kidney 
 mischief, which very often carries him off if pneumonia 
 or cerebral apoplexy are not beforehand. The courses of 
 the symptoms and duration of tabes are most variable : 
 one patient may become hopelessly ataxic in a twelve- 
 month, whereas another may be able to walk about and 
 attend to his business for twenty or thirty years. 
 
PARASYPHILIS OR QUATERNARY SYPHILIS 103 
 
 Diagnosis. — The presence of lightning pains when 
 combined with any of the other signs is very distinctive, 
 and the combination of any of the following signs is 
 almost pathognomonic of tabes — i.e. absence of knee-jerk, 
 " Argyll-Robertson pupil," lightning pains, visceral crises, 
 atrophy of the optic disc, and Romberg's sign, and last, 
 although not least, a history of syphilis. Wasserman's 
 reaction test, together with cyto-diagnosis, may be of 
 great value in doubtful cases. 
 
 Prognosis. — Complete recovery cannot be expected, 
 but arrest of the process, with a marked amelioration of 
 symptoms, is frequent. On the whole the prognosis of 
 tabes is bad. 
 
 Treatment. — In treating tabes our object ought to be 
 to arrest its progress and relieve symptoms, as we can 
 never hope to restore to their normal condition the 
 degenerated columns of the cord. For this purpose anti- 
 syphilitic remedies are all-important ; the treatment should 
 be intensive, and for this purpose nothing is better than 
 intramuscular injections of calomel, next to which comes 
 inunction of mercury a V Aix. Iodides given in inter- 
 mittent courses in not less than 50 grains per day, and 
 continued for not longer than ten days at a time, are 
 very often very beneficial. Lightning and other pains 
 are best relieved by phenacetin, antiebrine, or antipyrine ; 
 and gastric and other crises by hypodermic injections 
 of morphia. 
 
 Bladder symptoms require constant care ; when the 
 organ cannot be perfectly emptied the catheter should 
 be used. 
 
104 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 GENERAL PARALYSIS 
 
 Like tabes, general paralysis is undoubtedly due to 
 syphilis in at least 90 per cent, of cases. It occurs usually 
 about the ages of thirty to thirty-five, and among those 
 who live an active, busy life — hence is particularly liable 
 to occur among active business men in large cities. 
 Fournier maintains that the chief factor in the causation 
 of general paralysis is insufficient treatment of syphilis. 
 The predisposing causes are over-exertion and alcoholic 
 and sexual excesses. 
 
 Symptoms. — These vary very much ; in some cases the 
 mental and in others the motor-spinal or motor-cerebral 
 symptoms predominate. The disease has been divided 
 into certain stages, but these are ill defined, as the 
 symptoms supposed to be peculiar to a particular stage 
 may appear at any period of the malady. The im- 
 portance of recognising the very earliest signs cannot 
 be exaggerated. 
 
 Prodromata. — There may be some slight change in 
 character which is often in the nature of an exaggeration 
 of some peculiarity present in the individual : if he has 
 been always quick in his temper he now shows unusual 
 irritability ; his power of concentration may be weakened, 
 or some feebleness may be noticed in his will. His 
 affections may undergo some change, and moral perver- 
 sions of various kinds may be noticed by his performance 
 of acts which he formerly regarded as discourteous, dis- 
 honest, or indecent in others. Such acts may be first 
 observed to occur after a dose of alcohol which formerly 
 
PARASYPHILIS OR QUATERNARY SYPHILIS 105 
 
 had no effect upon his mental equilibrium. These fore- 
 shadowings deepen into the symptoms of the real disease, 
 any of which latter may also appear as the first warning 
 to his immediate friends : thus his premonitory symptoms 
 may be those of an abnormal idea of his own importance, 
 wealth, and station ; or indifference to business. Motor 
 symptoms or restlessness, slight tremors of the lips and 
 hands, difficulty in articulation or in letter-writing, may 
 precede the mental warnings ; pupillary rigidity or an 
 unsteadiness in his gait may be the first sign that anything 
 is wrong. 
 
 Mental Symptoms of the Established Disease. — 
 These consist of the exaggeration of the " warning 
 symptoms " ; the character of the patient becomes rapidly 
 changed, he gets heartless and careless about his family 
 and home duties, neglects his business — though his mind 
 may be filled with schemes for making colossal fortunes — 
 and he may take to the spending of money lavishly, and 
 may at the same time not scruple as to how he obtains 
 more. His will-power is markedly weakened ; memory 
 fails early, especially for recent events ; he becomes 
 unable to calculate, and may soon cease to remember 
 the day of the week or the number of the year. Rest- 
 lessness is marked, and there is a liability to violent 
 outbursts of anger and jealousy, or to the performance 
 of some indecent act. 
 
 As the mental deterioration increases towards dementia, 
 delusions are common, the most characteristic type of 
 which is the " grandiose," the patient fancying himself 
 God, a king, or the possessor of boundless wealth : on 
 
106 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 the other hand these grandiose ideas may be replaced 
 by depression of spirits and melancholia ; the patient 
 often has the delusion that all food is poison, or else 
 that it will " block up " his intestines. 
 
 Motor Symptoms. — The facial muscles are generally 
 the first to show the serious nature of the disease. The 
 face is flabby and expressionless, giving the idea of 
 stolidity ; in speaking there is a marked tremulous con- 
 dition of the muscles, which show want of control ; 
 the lips and tongue are the seat of marked tremor ; the 
 tongue is protruded with difficulty and only with ataxic 
 jerkings, and later on it is completely paralysed. 
 Speech is markedly affected ; it becomes halting, slow 
 and drawling. The prominence of the cheeks is often 
 noticed. 
 
 Handwriting. — Letters are unevenly formed, the strokes 
 showing shakiness and unequal degrees of length and 
 strength ; but the most characteristic feature is the 
 omission of letters, syllables, or complete words. 
 
 " Argyll-Robertson pupil " is marked in almost every 
 case. The knee-jerks are also affected, being either 
 exaggerated or the reverse. The movements of the 
 limbs may be abnormal ; the gait becomes unsteady, and 
 may be typically tabetic, at other times it may be spastic. 
 
 In general paralysis there is a liability to paralytic 
 seizures, which have a tendency to recur at short intervals, 
 the patient being left hemiplegic, monoplegic, or aphasic. 
 These paralytic symptoms usually pass off in a few 
 hours, but each succeeding attack leaves a deepening of 
 the mental weakness and muscular feebleness. 
 
PARASYPHILIS OR QUATERNARY SYPHILIS 107 
 
 Sensory Symptoms. — These may consist of partial 
 or total blindness, whilst the senses of smell and taste 
 may also be lost ; illusions and hallucinations, such as 
 seeing faces or hearing noises, are common. Symptoms 
 pointing to the connection between general paralysis 
 and tabes are frequent — e.g. Charcot's joint affection, 
 perforating ulcer, and spontaneous fracture of bones. 
 Many authorities regard the essential features of tabes 
 and general paralysis as identical, depending altogether 
 on whether it be the cord or brain which is the seat of 
 the process of degeneration. 
 
 Course and Duration. — The general average of cases 
 run their course towards total dementia and death within a 
 period of three years, and in rare cases a couple of months. 
 The ordinary course is that as the patient proceeds to- 
 wards complete dementia the paralytic symptoms deepen, 
 he becomes bed-ridden, and is unable to articulate, the 
 sphincters fail, and huge bed-sores form ; he usually 
 succumbs to some intercurrent affection, such as cystitis, 
 diarrhoea, or general inanition. 
 
 ./Etiology. — The same theories as to the pathogeny 
 of tabes are held concerning general paralysis ; the most 
 likely being that the syphilitic toxin has so diminished 
 the natural vitality or resistance of the entire nerve 
 system that, certain tracts being exposed to "over- 
 exertion," their nerve elements succumb to degeneration — 
 a view which is supported by the fact that the disease is 
 always more advanced in the cortex of the frontal lobes. 
 
 Prognosis. — The prognosis of general paralysis is bad ; 
 indeed, the affection may be looked on as incurable. 
 
108 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Treatment. — Nothing really can be done either to 
 arrest or cure general paralysis, although if recognised 
 very early anti-syphilitic measures should undoubtedly 
 be given a chance. 
 
 EPILEPSY 
 
 The third parasyphilitic affection to be considered is 
 epilepsy, which is of frequent occurrence in cerebral 
 syphilis, and, like the non-specific variety, presents two 
 forms — the " grand mal " and the " petit mal." Headache, 
 increasing in severity, always precedes an attack of 
 syphilitic epilepsy. The epileptic aura and cry are 
 absent as a rule. The attacks occur at intervals, and 
 frequently with regularity every ten days or once a 
 month. In some cases consciousness returns in a few 
 minutes, whilst in others the patient remains in a 
 stupid condition for hours and may remain so for 
 some days. It is stated that the longer the prodromal 
 stage the more severe will be the seizure, and vice versa. 
 
 In " petit mal " the paroxysm may begin either with a 
 twitching of one side of the face, a turning of the tongue 
 to one side, extreme giddiness, or cramps in the limbs ; 
 loss of consciousness and a slight convulsion follow. In a 
 great number of cases there is no convulsion, but the 
 patient, whilst talking or performing some act, becomes 
 unconscious, and is seen to stare vacantly ; if sitting he 
 becomes motionless, and if conversing suddenly silent, and 
 fails to comprehend questions addressed to him. 
 
 From simple epilepsy the specific form may be dis- 
 tinguished by the history of the case ; simple epilepsy is 
 
PARASYPHILIS OR QUATERNARY SYPHILIS 109 
 
 generally developed before puberty, whereas the specific 
 form begins usually between twenty and thirty. The simple 
 seizures are uninfluenced by mercury or the arylarsonates, 
 whereas the specific forms respond to both. 
 
 Treatment of syphilitic epilepsy consists of mercury, 
 arylarsonates, iodides, and of course bromides. 
 
CHAPTER X 
 
 THE GENERAL TREATMENT OF SYPHILIS 
 
 UNTIL quite recently mercury was recognised as the only 
 specific for syphilis, but now there is reason to believe 
 that in the arylarsonates we are in possession of a second ; 
 indeed, this is certain as far as concerns their power of 
 preventing the occurrence of syphilitic symptoms and of 
 causing their disappearance ; but whether they are capable 
 of effecting an eventual permanent cure remains an open 
 question, which can only be determined by time and 
 further experience. At one time the iodides were sup- 
 posed to be specific in their action, but for many years 
 past they have been looked on as adjuncts only to 
 mercury, and as possessing no specific power. 
 
 Abortive Treatment. — Many attempts have been made 
 by cauterisation and excision of the primary lesion to 
 prevent constitutional infection, but have invariably failed. 
 Metchnikoff has endeavoured to destroy in situ the Spiro- 
 chceta pallida by the application of a 30 per cent, calomel 
 ointment, with a certain amount of success ; his experiments 
 on monkeys proved successful in preventing the develop- 
 ment of the disease when applied to the point of inoculation 
 within an hour or two of infection, as also in the case of 
 
THE GENERAL TREATMENT OF SYPHILIS in 
 
 the medical student already quoted, in whose case in- 
 unction at the point of inoculation prevented further 
 developments. Neisser says : " There is no doubt that 
 by the application of strong mercurial ointments very 
 many syphilitic infections could be avoided, and I hold it 
 to be the duty of every doctor to publish this fact when- 
 ever he can, and to advise this individual prophylaxis." 
 This question may, at present, be considered to be sub 
 judice. 
 
 Specific Medication. — Many drugs have been used in 
 the treatment of syphilis ; among others sarsaparilla, 
 guaiacum, sassafras, sulphur, arsenic, gold, silver, platinum, 
 and many vegetable preparations ; iodide of potassium, and 
 last, but needless to say not least, mercury, and, as already 
 mentioned, the arylarsonates. But most of these have 
 long ago ceased to be employed in the treatment of 
 syphilis. Sarsaparilla proves of benefit in syphilis under 
 certain circumstances ; but this is probably due more to 
 its tonic and depurative effects than to any specific action. 
 At one time iodide of potassium was believed to be a true 
 specific in syphilis, but it has long ago been relegated to 
 a position as a mere adjunct to the real specifics — mercury, 
 and now the arylarsonates. 
 
 Mercury. — With the possible exception of quinine in 
 malaria, no other drug is more worthy of the name 
 " specific " than is mercury in its action upon syphilis ; 
 nevertheless it has had its ups and downs, at one time 
 it was considered to be indispensable for the cure of the 
 disease, at others it was looked on as useless, and at one 
 period it fell into utter disrepute, as not only being useless, 
 
112 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 but was accused of being the cause of half the misfortunes 
 which had hitherto been attributed to syphilis itself. No 
 doubt this was partially true, owing to the barbarous and 
 unscientific way mercury was administered. It was during 
 the Peninsular War that this state of things was first brought 
 forward, principally by Guthrie ; the position of mercury 
 was seriously threatened, until it was in danger of being 
 removed altogether from the category of syphilitic remedies. 
 The situation was saved by William Ferguson, who calmly 
 and lucidly explained the true position of affairs, and 
 advocated the employment of mercury in doses sufficient 
 to bring about its physiological effects short of the 
 salivation which had previously been the custom. 
 
 It was many years before mercury recovered its good 
 name, or rather lost its bad reputation ; and even to this 
 day it is a drug which is hated and detested by the 
 general public as being the cause of unheard-of woes ; 
 and many a case of syphilis has been allowed to have 
 its full swing owing to the refusal of the patient to undergo 
 mercurial treatment through dread of its effects. 
 
 There is little cause for fear of mercury if administered 
 properly and in therapeutic doses ; at the same time there 
 are undoubtedly certain dangers attaching to it — (i) saliva- 
 tion, (2) gastro-intestinal symptoms, (3) cutaneous erup- 
 tions, (4) disorders of nutrition. 
 
 Salivation. — The stomatitis seen to-day is generally of 
 a mild type, and does not damage the teeth or jaws ; 
 but sometimes even now severe cases occur, varying in 
 degree from slight swelling of the gums to intense inflam- 
 mation of the whole buccal mucous membrane, accom- 
 
THE GENERAL TREATMENT OF SYPHILIS 113 
 
 panied by deep ulcerations, local gangrene, necrosis of 
 the jaw, and loss of teeth. Salivation of this sort is 
 nearly always the result of faulty methods of admini- 
 stration, or of neglect of buccal hygiene. A few cases, 
 however, are due to some peculiar intolerance to mercury 
 on the part of the patient. 
 
 Before beginning a course of mercury all old stumps 
 should be extracted, and teeth freed from tartar and 
 regulated as far as possible. Clear and concise rules 
 should be given to the patient about the care of his 
 teeth and gums whilst he is undergoing treatment by 
 mercury ; he should be warned as to the necessity of 
 washing his teeth after each meal, and advised to use 
 some mouth wash frequently during the day, such as 
 chlorate of potash (5 grs. to the ounce), or better — 
 
 R 1. 2. 
 
 Plumbi acetatis . 3" j. Aluminis sulph. . 3" j. 
 
 Aquam, ad . . 3" v. Aquam, ad . . 5 v - 
 
 1 and 2 to be mixed and filtered. 
 
 Or the gums may be painted two or three times a day 
 with a solution of peroxide of hydrogen, or perhydrol, 
 which is a 50 per cent, solution of peroxide of hydrogen, 
 but which is quite non-irritating and most beneficial in 
 keeping the gums healthy. Another excellent application 
 in cases showing any tendency to pyorrhoea is powdered 
 sulphate of copper applied to the roots of the teeth by 
 means of a pointed stick or match. Should stomatitis of 
 any severity occur, all mercury must be stopped, saline 
 aperients freely administered, and a mixture of chlorate 
 of potash (gr. xv) should be given three times a day. 
 
114 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Sweating should be induced by means of hot air or 
 Turkish baths, and the patient kept as much as possible 
 in the open air. The greatest attention must be paid 
 to the teeth and gums in such cases, which latter ought 
 to be painted frequently during the day with either per- 
 hydrol, solutions of chromic acid, or sulphate of copper. 
 Gastro-intestinal complications consist of pains in 
 the stomach, colic, and diarrhoea ; later on of dyspepsia 
 and loss of appetite. Diarrhoea, although at first slight, 
 may at times become very severe and assume dysenteric 
 characters, with the passage of blood, slime, and mucus. 
 A fatal result may follow. The gastro-intestinal dis- 
 turbance is followed by anaemia, want of appetite, and 
 emaciation. 
 
 METHODS OF ADMINISTERING MERCURY 
 
 Mercury is introduced into the system by different 
 methods, the principal being — (i) by the internal or 
 ingestion method ; (2) by inunction ; (3) by intramuscular 
 injections. It is also administered by intravenous injec- 
 tion, by fumigation, by suppositories, and by inhalation 
 with the aid of Wailender's bag. 
 
 The points to be considered in a choice of method are : 
 
 1. Convenience of the patient. — Which can be employed 
 with the greatest convenience to the patient ? 
 
 2. Suitability to prolonged use. — Which of them will 
 best enable us to carry out the treatment over the 
 lengthened period we know to be necessary to effect 
 an eventual cure, or with a view to preventing future 
 ravages of the disease ? 
 
THE GENERAL TREATMENT OF SYPHILIS 115 
 
 3. Regularity of treatment. — Which of them will best 
 ensure regularity of treatment ? 
 
 4. Rapidity of action in urgent cases. — Which to adopt 
 in severe cases of syphilis with urgent symptoms? 
 
 The Ingestion Method.— By the ingestion or internal 
 method is meant the giving of mercury by the mouth, 
 depending on the stomach and intestines for its absorption. 
 It is the plan which even to this day is usually employed 
 in British practice generally. 
 
 Before considering the technique of this method it will 
 be well to see what are its advantages and disadvantages. 
 First it is claimed that it is the easiest and most convenient 
 method for the patient to carry out. Second, that it is 
 free from certain dangers and inconveniences which are 
 inherent in other methods — i.e. that it is much less likely 
 to be followed by stomatitis, and that the latter when it 
 does occur is far less severe than when produced by any 
 of the other methods. 
 
 With regard to its being the easiest and most con- 
 venient method for the patient to carry out, in the writer's 
 opinion, this will not hold ground at least with the plan 
 of introducing mercury by intramuscular injections : surely 
 an injection once a week is far preferable to being obliged 
 to take medicine three, four, or perhaps five times a day 
 for weeks and months at a time. As to stomatitis, this 
 may be less severe than when it is produced by inunction 
 or intramuscular injection, but it is none the less frequent 
 — certainly not when compared with the intramuscular 
 method. 
 
 The disadvantages of the ingestion method are : Firstly, 
 
n6 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 given in this manner there is no guarantee as to how- 
 much, if any, of the mercury is absorbed. Many cases 
 are on record in which it has been shown that mercurial 
 pills were passed through the intestinal tract unchanged 
 in any way. One case is within the knowledge of the 
 author of a patient taking grs. x of blue pill daily 
 for a period of three months without any physiological 
 effects having been produced. It was discovered later 
 that the pills were regularly voided in the same condition 
 in which they had been taken. 
 
 Secondly, sooner or later, in the majority of cases, 
 mercury introduced by the internal method is more or 
 less certain to produce gastric or gastro-intestinal irritation 
 with all the concomitant effects — i.e. diarrhoea, debility, and 
 anaemia. The mercury has to be withheld, and then the 
 syphilitic virus gets the chance of reasserting itself. The 
 third objection to the internal method is uncertainty as 
 to its being carried out with anything like regularity, and 
 this to the author's mind is the chief objection to the 
 method. 
 
 The uncertainty as to regular administration may be 
 due either to the patient's absentmindedness in forgetting 
 to take his medicine, or, on the other hand, to his de- 
 liberately giving it up on the disappearance of active 
 symptoms. To put the matter plainly, it is easy for the 
 medical man to sit down and write a prescription for 
 mixtures, pills, or powders, with instructions to his patient 
 to take one of them three or four times a day for months 
 at a time ; but it is quite another thing to expect these 
 instructions to be carried out with anything like regularity. 
 
THE GENERAL TREATMENT OF SYPHILIS 117 
 
 The conscientious patient, with the best intentions possible 
 of adhering strictly to his instructions, places his medicine 
 each morning in his pocket with the intention of taking 
 it during the day ; how often, when the end of the week 
 comes, can he look back and say he has taken it regularly 
 during every day of the week ? Yet to be of any use 
 we know that regularity in taking the mercury is an 
 absolute necessity. On the other hand, the ordinary 
 patient approaches the matter in a different spirit, and 
 deliberately gives up his mercury as soon as the activity 
 of the disease has ceased for any time. 
 
 Technique of the Ingestion Method. — In considering 
 the technique of the internal method it is needless to say 
 that the preparations of mercury used are innumerable. 
 Here it will suffice to mention the chief of these mercurial 
 compounds : 
 
 1. Metallic mercury, which is administered in different 
 ways, and enters into some of the most famous prepara- 
 tions — i.e. " blue pill " : 
 
 R Purified mercury .... 5 grins. 
 
 Powdered liquorice . . . i\ „ 
 Confection of roses . . . "j\ „ 
 
 Divide into 100 pills, each containing 5 centigrams 
 of mercury. 
 
 " Sedillot's pills " : 
 
 & Mercurial ointment . . .30 grms. 
 
 Powdered soap . . . . 20 „ 
 Powdered liquorice . . . 10 „ 
 
 Misce et div. in pil. xx. 
 
n8 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 English "grey powder": 
 
 R Mercury I part. 
 
 Powdered chalk ... .3 parts. 
 
 This last is of all preparations of mercury the favourite 
 one in England in the treatment of syphilis. 
 
 2. Calomel is not used very extensively internally, owing 
 to its liability to bring on diarrhoea and stomatitis ; it is 
 chiefly given in the form of "Plummer's pills." 
 
 3. Biniodide of mercury is a very toxic agent, but is 
 sometimes employed in conjunction with iodide of 
 potassium. 
 
 4. Tannate of mercury "is not a definite compound," 
 and in spite of the advantages claimed for it is not to 
 be recommended. 
 
 5. Salicylate of mercury. 
 
 6. Proto-iodide and sublimate have proved the best and 
 most reliable of all mercurial remedies given internally. 
 Perchloride of mercury (corrosive sublimate) has been 
 and is most popular in England. Among other celebrated 
 preparations of which it is the basis Dupuytren's pills are 
 perhaps the most famous. The formula is as follows : 
 
 R Perchloride of mercury . . . eg. j (gr. \) 
 
 Ext. of opium eg. ij (gr. I) 
 
 Ext. of guaiacum . . . . eg. iv (gr. §) 
 
 It also enters into a very celebrated French preparation 
 which is still extensively used in that country — viz. Van 
 Swieten's liquor. 
 
 R Bichloride of mercury 1 grm. 
 
 Alcohol (90 per cent.) . . . .100 grms. 
 Distilled water 9°° » 
 
THE GENERAL TREATMENT OF SYPHILIS 
 
 119 
 
 The strength is 1 in 1,000, so that each tablespoon 
 contains exactly \\ eg. of corrosive sublimate. This 
 preparation ought to be taken well diluted, and is best 
 given in milk. 
 
 Van Swieten's liquor has not the same formula in all 
 countries. Thus the French liquor is stronger than that 
 of the Spanish pharmacopoeia, and weaker than the 
 English. 
 
 Sublimate also forms the basis of various other prepara- 
 tions : e.g. Hoffman's pills, which are composed of subli- 
 mate, distilled water, and breadcrumbs ; Chomel's pills, 
 consisting of equal parts of sublimate and extract of 
 opium (| eg. in each pill) ; and Baron Larrey's syrup, 
 composed as follows : — 
 
 B Sarsaparilla 
 
 Guaiacum 
 Sassafras 
 Senna 
 
 Chiretta root . 
 Elder 
 
 Bichloride of mercury 
 Ext. opii liq. . 
 Hydrochlorate of ammonia 
 
 • 500 grm. 
 
 ^aa eg. xxv. 
 
 Fournier suggests the following modification of Dupuy- 
 tren's pills : — 
 
 B Bichloride of mercury 
 
 Ext. of opium . 
 
 ' jaa eg. j (gr, J) 
 
 for one pill, as containing less opium. These pills 
 are best taken during or before meals. 
 
 Proto-iodide of mercury is a salt of greenish yellow 
 colour, changing with the light, almost insoluble in water, 
 
l2o SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 and insoluble in alcohol. It was introduced into thera- 
 peutics by Biett, and popularised by Ricord, whose 
 celebrated pills have the following formula : — 
 
 Proto-iodide of mercury 
 
 . grm. iij 
 
 Ext. of thebain . 
 
 5 > J 
 
 Theriaca .... 
 
 „ iij 
 
 Confection of roses 
 
 „ V J 
 
 Misce et div. in pil. Ix. 
 
 
 Each pill contains -^ grm. of the proto-iodide. 
 
 There can be no doubt that for ingestion purposes 
 corrosive sublimate and the proto-iodide are the best 
 mercurial preparations to use. In France the proto-iodide 
 is the most popular, whereas the perchloride is given the 
 preference in England. 
 
 Both sublimate and the proto-iodide are excellent in 
 their way, but one or the other may be more suitable 
 under certain conditions : thus, proto-iodide is more 
 likely to be followed by salivation than sublimate, which 
 is probably the result of the proportionally larger dose 
 of the former which is necessary in order to bring about 
 physiological effects than is required in the case of 
 sublimate. 
 
 Thus proto-iodide must be considered a salivating 
 remedy, with a view to guarding against the occurrence 
 of affections of the mouth which may result from it. 
 No doubt it is less salivating than calomel, and also than 
 mercurial inunctions ; but it is salivating to a certain 
 extent, which is the principal objection to its use, and 
 it will be of the greatest importance to arrive at a more 
 or less definite conclusion as to what is the buccal 
 
THE GENERAL TREATMENT OF SYPHILIS 121 
 
 tolerance dose of this remedy. With regard to the degree 
 of buccal tolerance, excluding individuals with idiosyn- 
 crasies towards intolerance, there is a marked difference 
 in the two sexes : a woman's mouth tolerates the proto- 
 iodide much less than a man's. 
 
 For men we may say that a daily dose of f gr. is 
 absolutely inoffensive, and that in nine cases out of ten 
 a dose of if gr. is tolerated without evil effect, provided 
 that the mouth is in good order and is kept so during 
 treatment. 
 
 It may be considered that a daily dose of if gr. of 
 proto-iodide is the average dose of buccal toleration in 
 men. Of course, much larger doses, up to 3 grs., are 
 sometimes well tolerated. 
 
 As regards the other sex, there are few women in whom 
 the mouth tolerates without irritation a dose of if gr., 
 with which dose stomatitis is nearly always imminent, 
 and seldom fails to occur if treatment is continued. The 
 average dose of buccal toleration can be put down as 
 1 gr. of the proto-iodide. 
 
 Action on the Digestive Organs. — In this respect 
 there are notable differences between the two preparations 
 under consideration. 
 
 In therapeutic doses sublimate affects the stomach 
 rather than the intestine, rarely producing diarrhoea, 
 whilst, even in moderate doses, it often disturbs the 
 stomach, causing cramps, pains, and strange sensations, 
 often of such severity that treatment has to be suspended 
 for a time at least. These pains are known as " sublimate 
 gastralgia." Women suffer in this respect much more 
 
122 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 than men — so much so that it is questionable if some 
 other preparation of mercury should not always be pre- 
 ferred to the sublimate in the case of women. 
 
 Sublimate is tolerated by the stomach if care be taken 
 not to prescribe too large doses of it, and not to continue 
 it for too long a period, for even when well tolerated 
 by the stomach, this is only for a time, after which it 
 causes harm. Clinical experience taught me that from 
 three to four weeks was the limit of this period, hence 
 I made a rule never to prescribe sublimate for longer 
 than a month at a time. 
 
 The proto-iodide seldom or never affects the stomach 
 in any way, but in nearly every case proto-iodide is 
 followed by slight attacks of colic and diarrhoea when 
 first given : this is called " premonitory diarrhoea " ; it 
 soon passes off, and no further trouble may be caused 
 during a long course of the salt. On the other hand, 
 some patients are troubled with sudden attacks of diarrhoea 
 varying in intensity from those lasting a few hours to 
 those resembling dysentery, and threatening to become 
 permanent. If we desire to produce therapeutic effects 
 of any intensity the proto-iodide is far preferable to 
 sublimate, because to bring about the same results with 
 the latter it would be necessary to raise its dose to a 
 dangerous degree. 
 
 Sublimate hardly ever affects the intestine or brings on 
 diarrhoea. 
 
 From what has been seen as regards these two salts, it 
 is hard to give preference to one over the other. They 
 are both excellent remedies, each having its advantages 
 
THE GENERAL TREATMENT OF SYPHILIS 123 
 
 and disadvantages. All that can be affirmed with regard 
 to the choice of either of them is that, as a rule, the proto- 
 iodide ought to be given in the early secondary, and 
 sublimate kept for the later secondary and tertiary stages. 
 Sublimate administered in the first stage of the disease 
 only exercises on secondary lesions an incomplete action — 
 that is, it only brings them to an end slowly, and often 
 allows them to be reproduced. An undoubted advantage 
 that proto-iodide has over sublimate is that it can be 
 continued over a much longer period without causing any 
 trouble. On the other hand, sublimate is preferable to 
 proto-iodide in the later stages owing to its undoubted 
 greater influence over the late lesions, also owing to its 
 combining better with iodide of potassium, which is of 
 importance. 
 
 The pros and cons as regards the employment of these 
 two salts may be summarised as follows : 
 
 1. With sublimate there is little salivation, but gastric 
 intolerance is very frequent. 
 
 2. Gastric disturbances are infrequent with proto-iodide, 
 but stomatitis and intestinal troubles are often caused 
 by it. 
 
 It is needless to observe that the choice of either of 
 these salts will depend a great deal on the nature and 
 condition of the case. Thus for patients with bad teeth 
 sublimate should be the chosen salt ; whereas in those 
 inclined to suffer from dyspepsia and gastric troubles 
 proto-iodide should be selected. 
 
 As to the best forms to order : sublimate is usually 
 prescribed in solutions or in pills. A favourite solution, 
 
124 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 especially in France, has been and is Van Swieten's liquor, 
 whilst in pill form Dupuytren's pills (p. 118) are much in 
 favour. As an improvement on that formula Fournier 
 suggests the following : 
 
 R Bichloride of mercury . ."|_ 
 
 Extract of opium . . f 1 *^* 
 
 As a mixture, sublimate is generally ordered either in 
 water or some tonic infusion. A stock mixture, which is 
 a favourite one in English practice, is one containing liq. 
 hydrarg. perchl. and iodide of potassium, and this is given 
 for unlimited periods ; but the less said about such a 
 practice the better, except to condemn it freely. 
 
 Owing to its insolubility the proto-iodide can only be 
 ordered in the form of pills, those of Ricord being still 
 ever popular ; but here again as an improvement Fournier 
 suggests the following : 
 
 R: Proto-iodide of mercury . . 5 eg. (| gr.) 
 
 Extract of opium . . •!»(£,») 
 
 as containing less opium than the original, and as affording 
 greater scope for increasing or lessening the dose. A draw- 
 back to both Dupuytren's and Ricord's pills is that they 
 contain opium, which is to my mind a mistake. Since 
 opium has no curative action, what advantage is there 
 in systematically combining it with mercury, and very 
 often for the whole duration of the treatment ? Personally 
 I think it should only be added when required. 
 
 Dosage. — With regard to dosage it may be taken for 
 granted that the dose of mercury ordered is, in nine cases 
 
THE GENERAL TREATMENT OF SYPHILIS 125 
 
 out of ten, lower than that consistent with the physio- 
 logical effects which are necessary. This is generally the 
 result of timidity — in other words, having to keep on the 
 right side, which leads to insufficient treatment. It be- 
 comes all the more needful, then, for each individual case 
 of syphilis to be studied separately, with a view, if possible* 
 of arriving at some idea as to what dose can be ordered 
 with safety — a dose which at the same time will be large 
 enough to exert its full therapeutic effects. It may truly 
 be said that no two cases of syphilis stand mercury alike, 
 more especially when given by the internal method. It 
 is almost impossible to lay down a rule as to what is the 
 dose of either the bichloride or proto-iodide ; it can only 
 be surmised. As regards sublimate it can be considered 
 as gr. \ daily for a man and gr. \ for a woman ; the dose 
 of proto-iodide, as already stated, is gr. i| daily for a man 
 and gr. 1 for a woman. These are the average doses, but 
 the average dose is not always the most efficacious : not 
 all manifestations of syphilis are equally influenced by 
 the same dose of mercury. There are some which dis- 
 appear with small doses, such as roseola or any of the 
 generalised syphilides, while the same doses would have no 
 effect whatever, on, for instance, cerebral syphilis. Again, 
 it must ever be remembered that subjects respond differ- 
 ently to mercury, some to doses of the drug which would 
 be too small to have the slightest effect on others, so that 
 in giving mercury it behoves us to find out what is the 
 " dose for the patient." 
 
 Remarks on the Internal Method. — Personally, my 
 experience of treating syphilis by the ingestion plan ex- 
 
126 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 tended over a good many years, during which time I made 
 use of most of the preparations above described. I found 
 that, in the majority of cases thus treated, after mercury 
 had been administered for a period of, say, a month or 
 six weeks, it began to disagree in one way or the other. 
 In some cases stomatitis appeared, the digestive system 
 became impaired, and as a consequence the general 
 condition of health began to suffer, a condition of 
 malnutrition resulted, and the disease either remained 
 in statu quo, or else further and worse outbreaks of it 
 occurred ; and in either case the drug had to be dis- 
 continued for a time at least. This same series of events 
 went on, the patient gradually drifting into a chronic 
 syphilitic state ; he never got a chance of anything like 
 a continued treatment, and consequently never got cured. 
 Another lesson I learnt — that with this plan of treatment 
 there was no certainty of the patient getting his medicine 
 with any regularity ; on the contrary, I had reason to 
 suspect, and afterwards found' out, that in the majority 
 of instances this was the case, and in a great many the 
 medicine was dropped altogether. The fact is, that as 
 the taking of the medicine depends absolutely on the 
 patient himself, he at times inadvertently forgot to take 
 it ; and if by chance he happened to be careless, he 
 dropped it altogether when no urgent symptoms were 
 present. This objection seemed to me to be so serious 
 and insurmountable, as to be quite sufficient to put the 
 ingestion plan of giving mercury out of court. 
 
 A third objection is that years ago clinical observation 
 led me to suspect that in a great many cases treated by 
 
THE GENERAL TREATMENT OF SYPHILIS 127 
 
 this method, after the mercury had been taken for any 
 length of time, the organism became as it were inured 
 to it, and the drug apparently lost all its physiological 
 effects ; while in other cases it undoubtedly passed 
 through the system unabsorbed. 
 
CHAPTER XI 
 
 TREATMENT OF SYPHILIS {continued) 
 INUNCTION 
 
 The External or Inunction Method. — This is the 
 oldest known method of administering mercury. It was 
 employed in the fifteenth century against the ravages of 
 what was called " mal francais," or the " new disease," and 
 is mentioned by Fracastor in his poem on syphilis. 
 Popular before all other methods of giving mercury, the 
 inunction plan, through the reckless manner in which it 
 was carried out, gradually lost caste, and eventually died 
 out. The reaction against it reached its highest point 
 during the Peninsular War. Gaspard Torella, writing in 
 1497, says, " Avoid, like the plague, these murderous 
 ointments which already have made so many victims ; it is 
 they that killed Cardinal Segube, whose brother also owes 
 his death to these ointments." 
 
 The old plan of inunction consisted not only in a series 
 
 of rubbings with mercurial ointment, but in addition 
 
 purgation, bleeding, overheating, and dieting to the 
 
 point of inanition ; these conditions were supposed to 
 
 be absolutely necessary, as also was the production of 
 
 stomatitis. 
 
 128 
 
TREATMENT OF SYPHILIS— INUNCTION 129 
 
 Here is a description of the inunction method as then 
 carried out, in the words of Ulrich van Hutten (1488 — 
 1523): "Some used these anointings once a day, some 
 twice, others three times and four times ; the patient 
 being shut up in a stove with continual and fervent heat 
 some twenty, some thirty whole days ; some laying in 
 bed within the stove with many clothes, being compelled 
 to sweat. Part at the second anointing began to faint ; 
 yet was the ointment of such strength that whatsoever dis- 
 temper was in the upper parts it drew into the stomach 
 and thence to the brain ; and so the disease was voided 
 both by the nose and mouth, and put the patient to such 
 great pain that except they took good heed their teeth 
 fell out, and their throats, their lungs, with the roofs of 
 their mouths were full of sores ; their jaws did swell, 
 their teeth became loosened, and a stinking matter 
 continually was voided from these places. What part so- 
 ever it touched the same was strait corrupted thereby., 
 so that not only their lips but the inside of their 
 cheeks were grievously pained, and made the place where 
 they were stink abominably ; which sort of cure was 
 indeed so terrible that many chose rather to die than to 
 be eased thus of their sickness. Howbeit scarce one 
 sick person in a hundred could be cured in this way, 
 but quickly after relapsed, so that the cure held out 
 but for a few days." 
 
 And in a later period Syme says as regards this form 
 of administering mercury, " And the solitude of the 
 syphilitic ward was only broken by the noise caused 
 when the last tooth of one of the patients fell upon 
 
 9 
 
130 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 the floor." The patients undergoing treatment as above 
 described soon became debilitated and emaciated ; some 
 were reduced to a state of syncope, which, however, was 
 regarded as a favourable sign ; they were advised " not 
 to become discouraged, and to look forward to an early 
 cure." 
 
 Such treatment naturally caused severe salivation, but 
 this was looked upon as being necessary, and the more 
 profuse the salivation the better the outlook was ; it was 
 believed that the disease was evacuated by the mouth. 
 
 Fracastor exhorted his patients thus : " A truce to the 
 disgust which this medication may inspire in you, for 
 this is the price of your cure. Therefore spread this 
 ointment on your body, and cover the whole skin, except 
 the head and the region of the heart, with it. Bear this 
 ordeal for ten days, the benefit of which will soon be 
 felt. Soon, in fact, an infallible omen will announce the 
 hour of your deliverance. You will soon feel the ferments 
 of the disease dissolve in your mouth by an unclean 
 slime, and you will see the virus evacuated at your feet 
 in the saliva." The amount of salivation thought to be 
 necessary was one which produced five or six pounds of 
 saliva in twenty-four days, but the famous Dutch physician 
 Boerhaave considered that a hundred pounds should be 
 produced in thirty days. 
 
 Is it surprising, then, that under the above circumstances 
 the inunction method became unpopular and fell into 
 disrepute? It died out altogether, to rise again under 
 happier auspices, and to become re-established in popu- 
 larity. The methods of inunction to-day are very different 
 
TREATMENT OF SYPHILIS— INUNCTION 131 
 
 from those of yore. They simply consist of a certain amount 
 of rubbings with a mercurial ointment of a known strength, 
 combined with mild diaphoresis, good diet and hygiene, 
 with a total absence of the purging, bleeding, and profuse 
 sweating and salivation which had hitherto been con- 
 sidered necessary. However, popular as the inunction 
 method became on the continent of Europe, it never 
 appears to have attained the same repute in England even 
 down to the present day, and this in the face of the teachings 
 of some of her most famous syphilogists, notably John 
 Hunter, who says : " When mercury can be thrown into 
 the constitution by the external method it is preferable 
 to the internal, as the skin is not nearly so essential to 
 life as the stomach." 
 
 The main reason why the plan never became popular 
 in England was, I believe, due to the ignorance that 
 existed as regards its necessary technique ; and it has 
 always been an enigma to me why England has not 
 taken example in this matter from Aachen (Aix-la- 
 Chapelle), for there during the last century and a half 
 the inunction method has flourished in the most successful 
 way. Every nation has benefited more or less by it — 
 none more so than England, for from this country 
 syphilitic patients have gone to this place year after 
 year, cases in which home treatment had signally failed, 
 to return after a sojourn of a couple of months much 
 improved. 
 
132 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 MODERN TECHNIQUE OF THE EXTERNAL 
 METHOD 
 
 This can best be given by describing the manner in 
 which it is carried out at Aix-la-Chapelle, for there, as 
 already said, it has been done for the last century and a 
 half in such a thorough way as to make the place famous 
 throughout the world as a resort for the successful treat- 
 ment of syphilis, and to have led to hundreds of patients 
 flocking there to receive that alleviation from their 
 disease which they had before failed to obtain from 
 perhaps one or two years of sporadic courses of treat- 
 ment by the internal method. The routine treatment 
 at Aix-la-Chapelle (Aachen) is as follows : 
 
 (i) A visit to a physician, who examines, weighs, and 
 records case. 
 
 (2) The patient rises early each morning, goes to one 
 of the mineral springs, where he partakes of one or two 
 glasses of the sulphur water. 
 
 (3) Breakfast, consisting perhaps of one egg, bread, 
 butter, and coffee. 
 
 (4) One or two hours later the patient proceeds to one 
 of the many baths, and there has his bath, which consists 
 of the natural sulphur water at a temperature of 39 C. 
 In this he remains from twenty-five to thirty minutes ; 
 when he leaves it he is well dried. 
 
 (5) Half an hour afterwards a professional rubber rubs 
 into the patient's skin 75 grains of a mercurial ointment 
 about the same strength as our Ung. hydrarg. (B.P.). Each 
 rubbing lasts from fifteen to twenty minutes. To avoid 
 
TREATMENT OF SYPHILIS— INUNCTION 
 
 133 
 
 the effects of the friction caused by these rubbings, such 
 as dermatitis, etc., the parts so rubbed are changed daily : 
 
 1 st day, the arms ; 
 
 2nd day, the forearms ; 
 
 3rd day, the chest ; 
 
 4th day, the back ; 
 
 5th day, the thighs ; 
 
 6th day, the legs ; 
 
 7th day, the sides of the chest and loins ; 
 and on the eighth day the arms again, and so on, in 
 rotation. 
 
 Composition of the Aachen Water.— The water from 
 the Aachen springs contains from 22 to 28 grammes of 
 chloride of sodium, 4 to 5 grammes of sulphates, and 8 
 to 12 grammes of carbonates in 10,000 c.cm., and their 
 range of temperature for therapeutical purposes is from 
 38 C. to 72 C. 
 Gaseous Constituents. — Gases absorbed in water : 
 
 Nitrogen 
 Carbonic acid 
 Carburetted hydrogen 
 Sulphuretted hydrogen 
 Oxygen 
 
 9"oo 
 39'4 
 0-37 
 
 1 "23 
 
 Nitrogen 
 
 Carbonic acid 
 
 Carburetted hydrogen 
 
 Oxygen 
 
 Sulphuretted hydrogen 
 
 66-98 
 
 30-89 
 
 1-82 
 
 Q'3^ 
 
 IOO'OO 
 
 Total volume of absorbed carbonic acid, free and partly combined 
 carbonic acid, 251-5. 
 
134 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 The advantages claimed for these waters are that, since 
 in the administration of mercury, remedies are required 
 which will influence the whole organism as well as its 
 individual parts, and thereby favour the general nutrition, 
 the circulation, and the glandular activity, the water 
 of Aachen fulfils these requirements in every way. In 
 the first place, the drinking of 800 to 1,000 grammes of 
 the sulphur water daily improves the appetite, increases the 
 excretion of the kidneys, and regulates the bowels. The 
 regular action of the bowels is maintained in almost every 
 case, thus inflammation of the intestines consequent on 
 the use of mercury is avoided. 
 
 The warm baths, on account of the quantity of soda 
 which they contain, greatly facilitate the proper cleansing 
 of the skin from excessive or diseased deposits from the 
 epidermis and glands. By its warmth the water makes 
 the skin pliable, opens its pores, and increases its normal 
 action by stimulating the circulation. As a result, 
 absorption and chemical transformation of the mercury 
 in the ointment are facilitated. 
 
 Mode of Action of Inunction : How does Mercury 
 penetrate the System? — The fact of absorption of 
 mercury by the skin is proved in three ways: (1) by the 
 appearance of mercury in the urine ; (2) by the occurrence 
 of the physiological effects of mercury, especially stoma- 
 titis ; (3) by the production of therapeutic effects, which 
 are often intense. 
 
 There are four theories as to the manner in which 
 mercury penetrates the organism : (1) mechanical pene- 
 tration in a state of fine division ; (2) absorption in the 
 
TREATMENT OF SYPHILIS— INUNCTION 135 
 
 form of vapour ; (3) absorption by the hair follicles and 
 sweat glands ; (4) some authorities maintain that mercury- 
 does not penetrate the skin at all, but is inhaled after 
 volatilisation on the skin. 
 
 The majority of observers nowadays agree that most 
 of the metal penetrates through the skin, only a small 
 amount entering by the lungs. The idea that the 
 curative action of inunction is due to the volatilisation of 
 the mercury and its absorption by the lungs is based 
 on the fact that mercury is much more volatile than 
 was formerly supposed. However, if the mercury were 
 absorbed by inhalation, hospital patients who are not 
 taking mercury, and most certainly rubbers, would be 
 mercurialised ; but this is not the case. It may be taken 
 for granted that the amount of mercury which is absorbed 
 by inhalation is but a negligible quantity. 
 
 Mercurial Ointments for Inunction. — In Aachen, 
 generally speaking, the ointment used is the Ung. hydrarg. 
 (G.P.). 
 
 Sometimes mercurial soaps are used, but these have 
 the disadvantage of requiring a considerable time for 
 absorption. On the other hand, they are said to be 
 cleaner and also less irritating. 
 
 At the Military Hospital, Rochester Row, the following 
 is the ointment used : 
 
 r> 
 
 Ung. hydrarg 50 grs. 
 
 Lanolin hydro. . . . . . 25 „ 
 
 Adipis benzoin. . . .... 25 „ 
 
 Divide into two parts, and wrap in waxed paper. 
 
136 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Dosage. — No rules can be laid down as to the actual dose 
 of ointment, as this depends on various factors, chief among 
 them being the degree of tolerance of the patient. The 
 average dose for an adult is 5J, and this can be increased 
 to 5 ij, according to the tolerance of the patient. A 
 somewhat smaller dose should suffice for a woman ; in 
 the case of an infant 15 to 30 grs. may be considered 
 a safe dose. 
 
 The best time for inunction is the morning, as the 
 movements caused by exercise favour absorption. 
 
 Mode of Rubbing. — The part rubbed on one day is 
 not scrubbed until the morning prior to its being again 
 utilised. The rubbing should, when possible, be carried 
 out by trained rubbers ; the rubbing should be done 
 slowly, evenly, and with a good deal of pressure. The 
 part, after being rubbed, if properly done, ought to look 
 as if blacklead had been used — shiny, but not greasy. 
 Each rubbing should last from fifteen to twenty minutes. 
 
 Effect on Rubbers. — It would be expected that the 
 rubbers might be injuriously affected from inhalation or 
 absorption of mercury, yet this is not the case ; the writer 
 has never seen any ill results to rubbers, although 
 following the custom at Aachen, where no artificial pro- 
 tection to the hands is used. At Wiesbaden and other 
 places glass balls and slabs are used in rubbing, but the 
 experience at Aix, which coincides with that of the 
 author, is that the rubbing can be done much more 
 efficiently with the bare hand. 
 
 Number of Rubbings. — A course of rubbings at Aix 
 lasts generally six weeks, during which period some forty 
 
TREATMENT OF SYPHILIS— INUNCTION 137 
 
 rubbings are administered ; but in England I think that 
 thirty ought to be the maximum number, the greater 
 number being permissible in the former case owing 
 to the tolerance which is brought about by the use of 
 the natural water, which of course is unobtainable for 
 bathing purposes away from Aix. In my opinion all 
 rubbings ought to cease after a maximum of thirty, 
 followed by a rest of at least two months prior to a fresh 
 course being commenced. 
 
 Necessary Precautions. — During a course of in- 
 unction, and for some time after, the greatest attention 
 should be given to the hygiene of the mouth : the patient 
 must be instructed to look to the state of his gums and 
 the cleanliness of his teeth, and the latter should be well 
 brushed after each meal with a fairly soft tooth-brush ; as 
 a matter of routine some astringent mouth-wash should 
 be used frequently during the day : a favourite one which 
 is used at Rochester Row is — 
 
 Aluminis sulph. . 1 ]. Plumbi acetas . % j. 
 
 Aqua . . . 1 v. Aqua . . 3 v. 
 
 Mix and filter. 
 
 Should the gums show any tendency to soreness they 
 may be painted two or three times a day with perhydrol 
 or a solution of peroxide of hydrogen. 
 
 Diet. — The diet should be generous, the patient being 
 told to live well and to drink freely of new milk. Spirits 
 should be forbidden, but beer, claret, and hock allowed in 
 moderation. 
 
138 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Exercise. — Exercise in the open air is to be very much 
 encouraged ; patients undergoing inunction should live 
 and sleep in large, well-ventilated rooms. 
 
 Advantages of Inunction. — The advantages claimed 
 for the inunction method are : 
 
 i. Therapeutic effects are far more marked than when 
 the drug is given by the mouth. Undoubtedly in many 
 cases inunction brings about a cure in which other 
 methods failed ; especially is it useful in all syphilitic 
 sclerotic affections, such as the primary induration, 
 sclerotic glossitis, and tabes, etc., in which cases, although 
 the usual dose of the mercurial ointment may have to 
 be raised, it very often proves most beneficial. 
 
 2. It does not affect the alimentary system. There is no 
 doubt that mercury when administered by the skin, very 
 rarely affects the digestive system, at any rate not nearly 
 so frequently as when introduced by the ingestive plan. 
 Valuable as this is in any case, it is much more so in the 
 case of dyspeptic subjects, in those liable to diarrhoea, in 
 subjects in whom it is important to support the general 
 condition, and in infants and young children. 
 
 3. It leaves the stomach free for the administration 
 of other remedies. This is certainly a great boon, for 
 whilst the specific treatment is going on other remedies 
 may be used, such as iodide of potassium, cod liver oil, 
 tonics, etc. 
 
 Disadvantages of Inunction. — 1. Treatment by the 
 inunction method can only be of a very intermittent 
 kind, which is opposed to our judgment as regards 
 ultimate cure and prevention. What is meant by this 
 
TREATMENT OF SYPHILIS— INUNCTION 139 
 
 is that the courses of rubbings cannot be continued long 
 enough, nor resorted to frequently enough, to enable us 
 to carry out the chronic intermittent treatment. 
 
 2. It is very frequently followed by severe stomatitis, 
 and often by diarrhoea and dermatitis. Although as a 
 rule mercury when administered by the skin does not 
 affect the alimentary canal, still at times it does so, causing- 
 pain, colic, and diarrhoea. Dermatitis is more common, 
 and is usually limited to the sites of the inunction : it is 
 in most cases the result of local irritation on a delicate 
 skin, and in a few to some idiosyncrasy. In the former 
 it generally occurs in the form of an erythema, either 
 circumscribed or diffuse, whilst in the latter it may appear 
 as an eczema, which consists in a deep red area of 
 erythema covered with vesicles full of clear fluid which 
 later on becomes turbid ; this is accompanied by inflam- 
 mation and swelling of the skin with heat and pruritus. 
 
 Stomatitis is far more common than diarrhoea or 
 dermatitis ; and it is certainly one of the chief objections 
 to the inunction method that of all modes of introducing 
 mercury into the system inunction is the most likely to 
 cause stomatitis : some of the worst cases of this which 
 the author remembers having seen occurred, either at 
 Aachen or elsewhere, in patients whilst undergoing 
 inunction. Moreover, the form of stomatitis resulting 
 from inunction differs considerably from that produced by 
 ingestion of mercury : it comes on more suddenly, without 
 any warning ; instead of beginning at some particular spot 
 and spreading gradually, it is general and extensive from 
 the first ; it is more intense, salivation is considerable 
 
140 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 and swelling of the salivary glands and ulceration of the 
 gums are common. 
 
 4. It is dirty, inconvenient, and very difficult to have 
 carried out with anything like efficiency under ordinary 
 circumstances. That it is dirty goes without saying ; also 
 it is undoubtedly inconvenient from two points — first 
 because it necessitates the patient giving up at least an 
 hour a day to it, and secondly it is compromising, as it 
 stains linen, and servants and washerwomen soon get to 
 know what is going on. These last objections may 
 appear trivial, but they are not, as one soon finds out 
 that for the efficient carrying out of the treatment the 
 patient's feelings form an important factor. That it is 
 difficult to have properly carried out is only too true, 
 depending as it does on the capability and willingness of 
 the rubber. 
 
 Conclusion. — Until recently I looked on the inunction 
 plan as the most efficacious in removing certain signs 
 and symptoms, and employed it extensively in cases such 
 as for the removal of persistent induration at the site of 
 infection, in all cases of syphilitic sclerosis, and in cerebro- 
 spinal syphilis ; but at the present time intramuscular 
 injections of calomel have quite taken the place of inunc- 
 tion in my practice when dealing with such cases, owing 
 to its more rapid and intensive action. 
 
 The question to be considered is, whether the inunction 
 method is suitable as a routine form of treatment, or 
 whether it should be reserved for special cases ? As a 
 routine treatment it is contra-indicated first because the 
 treatment of syphilis is not a symptomatic one, but it 
 
TREATMENT OF SYPHILIS— INUNCTION 141 
 
 aims at extinguishing the virus both as a diathesis and 
 as a possible source of future mishaps, which can only 
 be realised by a treatment of long duration. It is obvious 
 that the inunction method is not suitable for this purpose 
 for certain reasons — i.e. it is open to accidents, as already 
 seen, and is a method which is not easily carried out or 
 agreeable to patients. For a treatment of long duration 
 personal and social necessities must be taken into account, 
 and from this point of view the inunction method is the 
 most inconvenient. Undoubtedly if the patient tolerated 
 inunction, and carried it out faithfully and regularly and 
 for the whole of the necessary time, I am certain the 
 result would leave nothing to be desired ; but how often 
 is such a patient to be found ? As a routine practice the 
 inunction method is to be condemned : it runs a very 
 good chance of being badly performed ; it may cause 
 severe stomatitis ; it is repugnant to the patient ; it may 
 end by discouraging and disquieting the patient with the 
 treatment, and cause him to give up specific treatment 
 altogether. 
 
 To my mind the inunction method should be reserved 
 for particular cases : cerebral and spinal syphilis, cases 
 which have proved refractory to other methods, cases 
 of syphilis in the young ; but, with the exception of the 
 last, as already stated, even in these cases injections of 
 calomel have taken its place. 
 
CHAPTER XII 
 
 TREATMENT OF SYPHILIS (continued)— THE 
 INTRAMUSCULAR METHOD 
 
 This method consists of injecting certain mercurial 
 preparations into the muscles, with the view to their 
 being absorbed by the circulatory system. 
 
 It was first suggested by Scarenzio, and was actively 
 practised for a certain time : owing to certain accidents 
 which appear to have almost invariably attended it, it 
 had to be abandoned. The history of this method 
 may be divided into three periods: (i) the period of 
 Scarenzio ; (2) the period of Smirnoff ; (3) the period of 
 Balzer. 
 
 The first period dates from 1864, when the treatment 
 of syphilis by subcutaneous injections of calomel was 
 introduced by Scarenzio, a professor in the University 
 of Pavia. At first Scarenzio used yellow oxide of 
 mercury, and later on, calomel ; as an excipient gly- 
 cerine was first employed, but being irritating, gum- 
 water was afterwards substituted for it. He records 
 having given eight subcutaneous injections of this, each 
 of which was followed by an abscess. Ambrosoli of 
 Milan published a series of sixteen cases, all treated by 
 
 142 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 143 
 
 the method recommended by Scarenzio, thirteen of which 
 were followed by an abscess after each injection. Among 
 the opponents of this method we find Professor Profeta, 
 who writes of it : " I should never have recourse to the 
 method unless all others failed, owing to the constant 
 occurrence of abscesses at the site of injection." In spite 
 of these accidents the method continued to be used in 
 most of the capitals on the Continent, with varying fortunes 
 in each country. In Italy, although it had some very 
 enthusiastic exponents, its detractors numbered many 
 men ; among them, as already seen, was Profeta. Opinions 
 concerning it were divided in France. At the St. Louis 
 Hospital it was practised with much success by Hardy ; 
 and Liegois, substituting sublimate for calomel, was 
 equally successful. On the other hand, Jullien was a 
 strong opponent of the method. In England the system 
 does not seem to have been practised at this period to 
 any extent ; indeed, there is little proof of its having been 
 tried at all. In Germany and Austria opinions differed 
 concerning it: we find Stork describing it as a "detest- 
 able" treatment, whilst Kolliker appears to have been in 
 favour of it. 
 
 In three or four years the method had gradually died out, 
 and we hear little of it until it was reintroduced by Smir- 
 noff in 1882, in an interesting essay on the subject which 
 was published in that year, in which he showed that with 
 the help of antiseptic precautions, which by this time had 
 become much better understood, injections could be given 
 without the occurrence of abscesses. Smirnoff succeeded 
 in reviving the subcutaneous method for a time ; and 
 
144 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 although abscesses became much rarer than formerly, still 
 they were frequent enough to be the cause of the method 
 becoming once more discredited. 
 
 For a third time it was reviewed : Balzer being the 
 means of doing this in a paper which he read before 
 the Societe des Hopitaux on May n, 1888, entitled 
 " Injections of Yellow Oxide of Mercury and Calomel in 
 the Treatment of Syphilis," in which he explained that 
 the chief causes of abscesses following the injections were 
 because the latter were given into the subcutaneous tissue 
 instead of into the deep tissues ; secondly, owing to the 
 unsuitability of the vehicles which had hitherto been in 
 use. To remedy these defects he advocated deep injections 
 into the muscles and the substitution of liquid paraffin 
 as a vehicle for the mercury in place of gum-water, 
 glycerine, and olive oil. These suggestions were followed 
 by the best results, abscesses became rarer as time 
 went on, and the intramuscular method became established 
 in popular favour day by day until the present time, 
 when it is certainly on the Continent the most popular 
 mode of treating syphilis. Curiously it never seems to 
 have been taken up in this country to any extent, and 
 even in England to-day and in her world-wide Empire 
 it is little known certainly amongst the civil medical 
 profession. On the other hand, nowhere is the intra- 
 muscular treatment more popular than in the army, into 
 which it was introduced in 1889, since which time it 
 has been steadily gaining in favour among army surgeons. 
 Brilliant results have attended its use, especially in India, 
 where in the army the rates of invaliding iand death from 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 145 
 
 syphilis have declined to about two-fifths of what they 
 were prior to the introduction of the intramuscular 
 method. 
 
 Advantages of the Intramuscular Method. — Like 
 other methods of administering mercury, the intramuscular 
 has its advantages and disadvantages, which must be 
 carefully considered. Taking its advantages first, the 
 following is a fairly complete list : 
 
 1. Convenience to the patient. 
 
 2. It insures regularity of treatment. 
 
 3. It leaves the stomach free for the reception of other 
 remedies. 
 
 4. It ensures more accurate doses. 
 
 5. The absorption of mercury is much more certain. 
 
 6. It does not interfere with the gastro-intestinal system. 
 
 7. Less chance of toxic symptoms — stomatitis. 
 
 8. Both therapeutic intensity and physiological effects 
 are much more marked and lasting. 
 
 9. It does not exaggerate the moral effect of the 
 presence of syphilis upon the mind of the patient. 
 
 As regards convenience, I think it must be admitted that 
 the only inconvenience which the intramuscular method 
 entails is the occasional visit of the patient to his medical 
 adviser to receive his injection ; in the case where insoluble 
 salts are used, there is an interval of at least a week and 
 very often a fortnight : compare this with his having to 
 take medicine three, four, or five times a day for months 
 at a time, or with his being obliged to give up an hour 
 or so a day for the purpose of inunction for periods 
 varying from a month to six weeks. 
 
 10 
 
146 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 There can be no question but that with the intra- 
 muscular method regularity and certainty of treatment 
 is assured, and with it there is no fear of patients eluding 
 such. This is a most important consideration, especially 
 among hospital patients, who, owing to their horror of 
 mercury, often do everything to try to avoid swallow- 
 ing it. 
 
 The third advantage claimed for the intramuscular 
 method — i.e. leaving the stomach free for the reception 
 of other remedies and not irritating the digestive organs — 
 is true ; but the first part, avoiding the stomach, is not 
 peculiar to it, as it is shared by the inunction method. 
 
 As regards accuracy of dosage, this is more apparent 
 than real, for it assumes that the dose absorbed is always 
 the same as that injected ; and although I believe that 
 in the majority of cases this is true, still it may sometimes 
 be different — for instance, when the mercurial deposit 
 becomes surrounded by inflammatory tissue, which pre- 
 vents its absorption. Speaking generally, it will be 
 allowed that, although not quite so accurate as is believed, 
 the dosage of mercury given by injection can be gauged 
 far more accurately than that given by either ingestion 
 or inunction, for the reason that in the former case the 
 dose of mercury which can reasonably be expected to 
 be absorbed is known, whereas it is quite unknown in 
 the case of ingestion or inunction. Absorption of mercury 
 in a definite manner is ensured by the intramuscular 
 method. Already we have seen that in the case of 
 ingestion very little and sometimes no mercury may be 
 absorbed ; and by the inunction plan the amount of 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 147 
 
 absorption must of necessity be very uncertain, depending 
 as it does, to a great extent, on the way the rubbing is 
 done. 
 
 I have no hesitation in saying that the dangers of 
 toxic effects are far less with the intramuscular method 
 than with other plans, especially as regards stomatitis, 
 provided the ordinary precautions are adhered to. I 
 do not mean to assert that this never occurs ; on the 
 contrary, I have seen cases of very severe stomatitis 
 following this method, although very rarely, and in 
 my opinion in this respect it undoubtedly compares 
 most favourably with the methods of ingestion and 
 inunction. 
 
 All authorities, even those who oppose the intramuscular 
 plan of giving mercury, are agreed as to its superiority 
 in its therapeutic intensity and physiological effects on 
 the symptoms of the disease. In this respect it has 
 undoubtedly realised expectations ; it is acknowledged 
 on all hands to be a powerful form of mercurialisation, 
 having an energetic action on most ot the manifestations 
 ot syphilis. 
 
 With regard to the last advantage which I claim for 
 the intramuscular method — i.e. its not emphasising the 
 moral effect of the presence of syphilis on the mind of 
 the patient — I would say that the mental condition ought 
 to have a foremost place in our consideration. Those of 
 highly-strung disposition are liable to suffer much from 
 depression of spirits ; the mere knowledge that they are 
 infected induces in them a state of melancholy bordering 
 on a condition known as syphilophobia, and this, in my 
 
148 SYPHILIS: ITS DIAGNOSIS AND TREATMEN1 
 
 experience, is one of the greatest difficulties met with in 
 treating syphilitic patients, especially among the educated 
 and well-to-do classes. 
 
 The first thing to be done in such cases is to endeavour 
 to divert the mind from the exciting cause. This we 
 certainly do not do when treating the disease by either 
 the method of ingestion or inunction, for when a patient 
 has to take a pill, powder, or medicine three or four times 
 a day, or to be daily rubbed, he is reminded each time of 
 the " skeleton in his cupboard," whereas, whilst undergoing 
 the intramuscular treatment, this reminder need only be 
 given once a week, or even fortnight. This advantage 
 may sound a trivial one, but I cannot lay too much 
 stress on it, and I feel convinced that it has helped me 
 over many difficulties; for with the mind depressed 
 treatment of any kind is rendered all the harder to carry 
 out to a successful issue. 
 
 The Disadvantages of the Intramuscular Method. — 
 The disadvantages of the intramuscular method are said 
 to be the following : 
 
 i. Pain at the site of injection. 
 
 2. Nodosities and abscesses. 
 
 3. The occurrence of embolism. 
 
 Pain at the site of injection varies in different subjects 
 and with the preparation of mercury used ; it is, in 
 fact, usually present when the soluble salts are employed ; 
 whereas, with the newer preparations of the insoluble 
 salts, even calomel, it does not exist to any extent. I 
 have met with two or three patients who complained of 
 severe pain after injection, but those were neurasthenic 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 149 
 
 subjects, who would probably make a similar fuss if 
 ordered to take medicine internally for any length of 
 time. A few cases complain of slight, dull, aching pain, 
 with some stiffness, lasting for one or two days ; but the 
 majority assert that pain either does not exist at all or 
 is so slight as to be insignificant. 
 
 Nodosities and abscesses are things of the past, owing, 
 no doubt, to improved technique. The former may cer- 
 tainly be sometimes seen even now, although very rarely. 
 In former years I used to see them fairly often, but now 
 they are very rare, this latter circumstance coinciding with 
 the time I first began to use boiling oil as a steriliser 
 for needles and syringes. In my opinion the occurrence 
 of abscesses is due entirely to some neglect in carrying 
 out the technique. As regards embolism, although cases 
 are reported from time to time, I have never seen one 
 in my long experience of this method. 
 
 The Two Methods of Intramuscular Injection. — The 
 intramuscular methods are of two kinds — the frequent 
 injection of soluble salts, and the infrequent injection of 
 insoluble salts. 
 
 The method of frequent injections consists in a series 
 of mercurial injections practised daily for five or six 
 weeks. The preparations used for this purpose are nearly 
 all soluble. The list of these preparations is innumerable, 
 too long to produce here, also unnecessary ; it will be 
 sufficient to mention the principal : 
 
 Sublimate. 
 
 Double chloride of mercury and ammonium. 
 
 Peptonate of mercury. 
 
150 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Tannate of mercury. 
 
 Cyanide of mercury. 
 
 Biniodide of mercury 
 
 Lactate of mercury. 
 
 Urate of mercury. 
 
 Benzoate of mercury. 
 
 Acetate of mercury. 
 
 Sozoiodolate of mercury. 
 
 Succinimide of mercury. 
 
 Chloro-albuminate of mercury. 
 
 Alaniate of mercury. 
 All the above are mercury served up under different 
 names, and from such a list of remedies it might be 
 difficult to make a choice. However, the following are 
 the forms in which they are generally prescribed : 
 
 R Hydrarg. perchloridi . . . grs. iij 
 
 Aquae §j 
 
 20 minims as a dose, by injection. 
 
 R Hydrarg. perchloridi . ■ . . grs. xxxij 
 
 Ammon. chloridi .... grs. xij 
 
 Aquas gj 
 
 Dose, 10 minims for an injection. 
 
 B= Hydrarg. succinimate . . . grs. ij 
 
 Cocainas hydrochloridi . . . grs. iij 
 
 Aquas 3 ij 
 
 Dose, 10 minims for an injection. 
 
 R Hydrarg. cyanidi . . . . gr. j 
 
 Cocainas hydrochloridi . . . gr. j 
 
 Aquae destil n\ 10 
 
 Dose, 10 minims for an injection. 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 151 
 
 Peptonate of mercury is a solution in glycerine and 
 water of a mixture of peptone, sublimate, and chloride of 
 ammonium ; it contains about one centigramme of bichloride 
 in a centimetre of distilled water, and is said to be better 
 tolerated than sublimate. 
 
 Benzoate of mercury is rendered soluble by chloride 
 of sodium, and is prescribed thus for daily injection: 
 
 R Hydrarg. benzoat. 1 _ 
 
 . , > aa gr. f 
 
 Ammon. benzoat. ) 
 
 Aquae destil 5 i ss 
 
 Biniodide of mercury oil was introduced by Panas : 
 
 R Hydrarg. Biniodide. 
 Olei (sterilised). 
 
 One c.c. contains tV grain of the biniodide. 
 
 Biniodide is an active and safe remedy, is well tolerated 
 as an injection, and causes little pain or local trouble. 
 Although an active remedy, it is one of only medium 
 intensity, and in this respect cannot compare with either 
 calomel or metallic mercury. The dose recommended 
 {i.e. T V grain) is too small to produce therapeutic effects, 
 for which purpose at least \ grain ought to be injected. 
 The injections of biniodide should not be too concen- 
 trated ; if so they are liable to produce much pain and 
 nodosities. 
 
 Sozoiodolate of mercury is greatly prescribed for in- 
 jection purposes, thus : 
 
 R Sod. iodi grs. x. 
 
 Hydrarg. sozoiodol grs. v. 
 
 Aquae TT^ cc 
 
 1^ x to TT^ xii as an injection four or five times a week. 
 
152 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Like many of these preparations, when first introduced its 
 praises were sung very loudly ; it was said to be a " perfect " 
 remedy, free from any semblance of pain, and possessing 
 rapid and powerful action in syphilis. When I was 
 accustomed to use the soluble salts, I found it inferior 
 to almost any of the other salts. Its therapeutic intensity 
 appeared to be of the mildest kind. 
 
 Succinimide of mercury has also been highly recom- 
 mended, and, indeed, it is freely used even now : 
 
 & Hydrarg. succinim grs. ij. 
 
 Cocain. hydrochl grs. iij. 
 
 Aquae ^ ij. 
 
 T)| x as an injection once daily. 
 
 Advantages and Disadvantages of Injection of the 
 Soluble Salts. — Although at one time opinions were 
 equally divided as to the merits of injection of the 
 soluble salts of mercury and the insoluble, I think there 
 can be little doubt that at the present time the advocates 
 for the employment of the former are very few in com- 
 parison with those in favour of the insoluble salts. At 
 the same time it cannot be denied that the daily injec- 
 tions of the soluble salts, especially of bichloride or 
 biniodide, have a powerful anti-syphilitic action ; but there 
 they end, as from the author's experience their curative 
 or preventive action is very little. In other words, the 
 soluble salts injected daily will remove the ordinary 
 active early symptoms of syphilis, but have very little 
 effect on lesions of the advanced stages ; and although 
 one must never forget that recurrences may take place 
 after the very best treatment, still it is an undoubted fact 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 153 
 
 that they are far more common after a course of the 
 soluble salts than after one of inunction or injections of 
 the insoluble salts. The real disadvantages of the method 
 of frequent injections of the soluble salts are : 
 
 1. The injections are always more or less painful. 
 
 2. They are absorbed too rapidly, and, worse still, 
 eliminated too quickly. 
 
 3. They require to be injected daily, or nearly so. 
 With regard to the pain, although this is never very 
 
 great, still it is much more so than when the insoluble 
 salts are used, and when I was accustomed to use these 
 soluble salts I found that the pain they caused was a very 
 great obstacle. As already seen, it has been claimed 
 for some of these preparations that they cause little or 
 no pain ; but this is not my experience, and I think I 
 have employed most of them. That their absorption 
 and elimination are far too rapid to have any lasting 
 effect on the disease goes without saying, and this has 
 become all the more apparent since the discovery of the 
 Spiroch&ta pallida, which makes its reappearance very 
 soon after the discontinuance of the injections. 
 
 The third disadvantage of the soluble salts is that to 
 be effective at all they have of necessity to be injected 
 daily, or very nearly so. From a practical point of view 
 this is a great obstacle : in the first place, the patient 
 not being able to give an injection to himself, it neces- 
 sitates a daily visit to his medical adviser, which of itself 
 is enough to condemn the method ; in any case, the vast 
 majority of patients will object strongly to having an 
 intramuscular injection daily. 
 
154 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 In conclusion, I would say that, although formerly I 
 believed that the frequent injections of the soluble salts 
 were as good as, if not superior to, the insoluble salts in 
 some few cases, time and experience have taught me that 
 I was wrong, and I can honestly say that I do not know 
 of any case in which they are not infinitely inferior to 
 the latter, and that as a method of routine treatment 
 they cannot be put on the same level. 
 
 THE METHOD OF INFREQUENT INJECTIONS 
 OF INSOLUBLE SALTS 
 
 This method consists in a series of injections of insoluble 
 salts of mercury at more or less long intervals. The 
 rationale of such a method is based on our knowledge 
 that, with a view to prevention and cure, syphilis is a 
 disease which requires the administration of mercury for 
 a period of at least two years intermittently, but in such 
 a manner that the patient during the whole period is 
 continuously under the action of mercury. Owing to 
 their slow absorption and elimination, the insoluble salts 
 are selected for this purpose. 
 
 Forms of Insoluble Salts used. — The two chief 
 preparations of mercury which are used for carrying out 
 the method of infrequent injections are metallic mercury 
 itself and calomel, besides which, although not nearly so 
 frequently employed, is salicylate of mercury. The in- 
 soluble salt originally used was the yellow oxide, which 
 has long been superseded. 
 
 Metallic Mercury. — Metallic mercury for the treatment 
 of syphilis by intramuscular injection was first intro- 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 155 
 
 duced by Lang, of Vienna. He brought it forward in the 
 form of grey oil (oleum cinereum), which is a mercurial 
 preparation consisting of mercury in a state of fine 
 division, suspended in a liquid fat : it is a kind of liquid 
 ointment, and contains 40 per cent, of mercury. 
 
 During the last five-and-twenty years the author has 
 used metallic mercury in preference to all the other salts 
 of the metal, such a preference being arrived at after 
 ample opportunities of judging them side by side ; and 
 as years have gone on, and with increased experience, his 
 faith has grown stronger than ever in it. To-day he main- 
 tains that, although its therapeutical intensity is certainly 
 not so great as is that of calomel, its curative and preventive 
 effects are far greater, and, as a consequence, that it easily 
 holds premier place among the remedies for syphilis. 
 
 The Advantages of Metallic Mercury. — The advan- 
 tages of metallic mercury are : 
 
 1. It is practically painless. 
 
 2. It is slowly absorbed and very slowly excreted. 
 
 3. It is less likely to produce stomatitis than other 
 preparations. 
 
 4. It requires to be injected only at long intervals. 
 
 5. Therapeutic effects are far more lasting than those 
 of any other preparation. 
 
 There is little doubt but that injections of metallic 
 mercury are peculiarly free from pain as compared with 
 those of other salts. 
 
 It is owing to the slowness of its absorption and elimina- 
 tion that metallic mercury is so superior in its lasting 
 effects to the other preparations of mercury in the treat- 
 
156 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 ment of syphilis ; as a general rule it may be said that 
 the preparations which are quickly absorbed are quickly 
 eliminated. The rate of absorption of mercury given 
 per os is uncertain ; soluble salts of mercury given by 
 injection are quickly absorbed and eliminated ; salicylate 
 of mercury is quickly absorbed and eliminated ; calomel 
 is slowly but powerfully absorbed, and eliminated fairly 
 quickly ; metallic mercury is very slowly absorbed and 
 excreted. 
 
 The conclusion come to as regards the lasting effects 
 of metallic mercury, has been further strengthened by 
 observing the behaviour of the Spirochceta pallida under its 
 influence. At the Military Hospital, Rochester Row, it 
 was found that, although those organisms disappeared 
 with about the same rapidity under almost any form of 
 mercurial injection, they reappeared at a much longer 
 interval after the discontinuance of the metallic prepara- 
 tions than was the case under a similar discontinuance 
 of any other form of mercury. This, needless to say, is a 
 very important and significant fact, and a strong argument 
 in favour of the metal itself in the treatment of syphilis. 
 
 Gagniere has studied the modifications in the blood 
 caused by injections of metallic mercury, and has demon- 
 strated that the corpuscles and the haemoglobin increase 
 after the second injection, and generally diminish after 
 the fifth. It is accordingly indicated by him, not to give 
 more than five consecutive injections. 
 
 With the single exception of calomel the therapeutic 
 intensity of metallic mercury is greater than that of any 
 other mercurial preparation ; and, although inferior in this 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 157 
 
 respect to calomel, it is not only far better tolerated 
 than that salt, but is far better than it as regards curative 
 and preventive effects, which applies equally to all other 
 preparations of mercury. 
 
 Clinical experience taught us that metallic mercury, by 
 its slow absorption and elimination, is vastly superior to 
 all other mercurial remedies in its lasting influence over 
 syphilis — a lesson which the microscope and other bacterio- 
 logical researches have confirmed. 
 
 It is needless to point out the very great advantage the 
 insoluble salts have over the soluble — i.e. that it is only 
 necessary to give injections of them at comparatively long 
 intervals — at the most not oftener than once a week. 
 This makes the plan less objectionable to the patient. 
 
 Preparations of Metallic Mercury. — As regards the 
 preparations of either metallic mercury or of calomel, 
 they must be homogeneous and capable of being injected, 
 whilst at the same time they should be of such a con- 
 sistence as to be able to hold the mercury in suspension. 
 They should be non-caustic, unirritating, and sterile ; they 
 should not enter the organism as a foreign body, and 
 should be chemically pure. 
 
 The preparations of metallic mercury which have been 
 introduced from time to time have been numerous. Lang 
 has modified the formula of his original " oleum cinereum " 
 several times, the latest being : 
 
 R 
 
 Metallic mercury ...... 2 parts 
 
 Sterilised anhydrous lanolin . . . . 1 part 
 
 Sterilised liq. paraffin 1 „ 
 
 50 per cent, of mercury. Dose gr. § of mercury. 
 
158 SYPHILIS; ITS DIAGNOSIS AND TREATMENT 
 Lafay's formula : 
 
 ■ Metallic mercury 40 parts 
 
 Sterilised anhydrous lanolin . . . . 12 „ 
 Sterilised white vaseline . . . 13 „ 
 
 Sterilised oil of vaseline . . . . 35 „ 
 
 40 per cent, of mercury. Dose gr. 1 to 2 grs. of mercury. 
 
 Author's (original formula) : 
 
 Pure metallic mercury 3 j 
 
 Anhydrous lanolin . . . . . % iv 
 
 Liquid paraffin (carbol. 2 %) ad . . . 3" x 
 By volume 10 per cent, of mercury. Dose 10 to 15 minims. 
 
 The last is the mercurial cream which has been in use 
 throughout the British Army both at home and abroad 
 during the past ten years ; and although, generally speaking, 
 it has given great satisfaction and has yielded brilliant 
 results, I have always been conscious of a grave objection 
 to which it, as well as all other preparations of the insoluble 
 salts, was liable : it is, that, owing to the substances which 
 have been employed in them as vehicles for the suspension 
 of the mercury being insoluble in the organism, they 
 entered the circulation as foreign bodies^ and as such 
 might possibly produce nodosities, abscesses and embolism. 
 To overcome this grave objection had for years been my 
 endeavour, until I eventually attained my object by sub- 
 stituting " palmitin " as the vehicle in place of lanolin. 
 
 Palmitin * is a neutral fat derived from palm oil, having 
 
 1 In Stirling's work on Physiology, p. 29, it is stated that neutra 
 fats of adipose tissues of the body generally consist of a mixture 
 of stearin, olein, and palmitin. Prof. Halliburton, in " Essentials 
 of Chemical Physiology," p. 15, states that the fat cells are composed 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 159 
 
 the same chemical composition as the palmitin of the 
 human system. It is an ether glycerine of palmitic acid, 
 is therefore easily saponified in the fluids of the organism, 
 being converted into a soluble alkaline palmitate and 
 glycerine, and thus it enters the circulation not as a 
 foreign body, like all substances hitherto employed as 
 vehicles. The advantages claimed for palmitin as a 
 vehicle are : 
 
 1. It is non-irritant and non-toxic. 
 
 2. It is not so easily oxidised as the other compounds 
 of human fat. 
 
 3. Being already a normal constituent of the human 
 organism, it is easily saponified and soluble therein, and 
 does not enter the circulation as a foreign body. 
 
 4. As a vehicle it makes a more homogeneous prepara- 
 tion for injection purposes than any other. 
 
 5. Its melting-point can be raised or lowered with the 
 greatest facility. 
 
 Pure palmitin (which is the only preparation used) is a 
 snowy-white flocculent powder, and great care is necessary 
 to get it pure. 
 
 Analgesia. — The question of pain, although never 
 amounting to anything serious so far as metallic mercury 
 is concerned, still has been sufficient to constitute a grave 
 objection to the practice of intramuscular injections of 
 mercury, and is apt to bring about, what Fournier terms 
 
 of three different fats called palmitin, stearin and olein. Charles, 
 " Physiology and Pathology," p. 84, says, palmitin is more abundant 
 than stearin in human fats, and is the chief component of most 
 animal fats. 
 
160 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 " fear of the needle," with consequent desertion and non- 
 attendance for further injections on the part of patients ; 
 in the case of calomel pain used to be the chief objection 
 to its use for injection purposes. 
 
 With a view, if possible, to abolish pain altogether after 
 injections, various substances have been introduced from 
 time to time into the mercurial preparations used for that 
 purpose — i.e. morphia, cocaine, /3-cocaine, etc. ; these, 
 acting as they do almost at once, will assuage any pain 
 which may follow immediately after the injection. But 
 unfortunately, this is not the kind of drawback we have as 
 a rule to deal with, as the pain which troubles us is one 
 which comes on the second or third day after the injection, 
 when all local anaesthetics like the above are useless. This 
 is a very serious matter, but more so as regards injections 
 of calomel, for the pain is most marked and severe with 
 this drug. The consequence was that hitherto, not being 
 able to cope with it, injection of calomel had to be 
 abandoned and only resorted to in some grave case where 
 pain was a matter of secondary consideration ; thus per- 
 haps our strongest weapon for dealing with syphilis was 
 practically lost to us. 
 
 To obviate this pain, I added to my latest mercurial 
 preparation equal parts of absolute creosote and camphoric 
 acid — a combination which has proved altogether a com- 
 plete success, as it renders the injections even of calomel 
 quite painless. This combination of creosote and cam- 
 phoric acid possesses other attributes : i.e. it is non-toxic, 
 strongly antiseptic, and, being viscid, is a valuable adjuvant 
 to the palmitin in making up a homogeneous vehicle. 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 161 
 The following is the formula for the metallic cream : 
 
 & Hydrarg. pur io grms. 
 
 Creo-camph. 1 ..... 20 c.c. 
 Palmitin bases ad 100 c.c. 
 
 T(\_ x contain 1 grain of metallic mercury. 
 
 The greatest care ought to be exercised in seeing that 
 the cream is of proper consistence. It should be kept in 
 wide-mouthed glass bottles, and only removed from them 
 when required for injection purposes. No attempt should 
 be made to sterilise the cream, as it is already sterile; 2 
 before use it should be well stirred up with a glass rod. 
 In cold climates the cream is liable to become semi-solid, 
 and it may require slight heating in a warm-water bath ; 
 in the tropics the reverse occurs, and there the bottle con- 
 taining the cream should always be kept in an ice-chest 
 until it is required for use, when it can be transferred 
 to some crushed ice. 
 
 It is advisable that the melting-point of this cream 
 should be regulated to suit the climate. In the case of 
 the cream used in England at present, we find 35 centi- 
 grade the best ; in the creams sent to the tropics, it is 
 raised by 3 centigrade. 
 
 Disadvantage. — Metallic mercury has only one real 
 disadvantage, which is, that should salivation take place 
 after an injection it is a difficult matter to prevent matters 
 getting worse, unless the mercury can be removed by 
 
 1 Equal parts of absolute creosote and camphoric acid. 
 
 2 Leishman reports that "this preparation is sterile and bacteria 
 will not grow in it." 
 
 II 
 
r62 SYPHIUS: ITS DIAGNOSIS AND TREATMENT 
 
 operation. I have never seen a case requiring so severe 
 a measure, and cannot help thinking that the reported 
 cases were the victims of too large a dose ; so long as 
 the latter does not exceed ih gr. per week these cases 
 will not occur. 
 
 Calomel. — Calomel has long ago proved itself to be 
 the most potent salt of mercury in its power over syphilis 
 in all its stages. It is more active and energetic than 
 any other preparation of mercury, acting promptly in 
 acute cases, as well as clearing up old-standing ones. 
 
 In spite of this, as already stated, owing to the pain 
 which followed calomel injections, it has been limited to 
 the treatment of certain special cases. 
 
 This pain at times was almost intolerable, and at one 
 period I used to give injections of calomel with much 
 hesitation, reserving them for exceptional cases where 
 symptoms were of such urgency that pain could not be 
 taken into account. However, by the help of the com- 
 bination of creosote and camphoric acid (already described) 
 the pain has been entirely overcome, and for the past 
 three years I have been using calomel with impunity. 
 
 The following is the formula for calomel cream : 
 
 R Calomel purified 5 grms. 
 
 " Creo-camph." ' 20 c.c. 
 
 Palmitin bases ad 100 c.c. 
 
 V[ x equals calomel \ gr. Dose 17^ x t0 xv P er wee k. 
 
 Calomel and Metallic Mercury. — It has been observed 
 long ago by others, as well as by the author, that the 
 action of calomel on syphilis, although remarkably 
 1 See footnote, p. 161. 
 
INTRAMUSCULAR TREATMENT OF SYPHILIS 163 
 
 energetic and rapid, is short-lived when compared with 
 that of metallic mercury. Hence it will never take the 
 place of the latter in the routine treatment of the disease, 
 but will be reserved more for dispersing early symptoms 
 and signs of the disease, and for those cases where 
 symptoms call for rapid action, i.e. cerebral and spinal 
 syphilis, etc. Even in such cases metallic mercury will 
 have to be reverted to, to effect a permanent alleviation. 
 
CHAPTER XIII 
 
 TECHNIQUE OF THE INTRAMUSCULAR 
 METHOD 
 
 The technique of the intramuscular method of introducing 
 mercury into the organism is simple, but the following 
 rules concerning it, although some may appear too insigni- 
 ficant to be remembered, are all of the greatest importance, 
 and should be strictly adhered to. 
 
 Instruments. — i. The syringe should be all glass, so 
 that it can be sterilised throughout. 
 
 2. The needles must be of either platino-iridium or gold : 
 maximum length i£ in. 
 
 3. The points of the needles to be kept as keen as 
 possible, to facilitate penetration and thus lessen pain. 
 
 4. Steel needles not to be used, as they are apt to 
 snap. 
 
 5. Both needles and syringe to be thoroughly sterilised 
 in oil heated to 160 F. 
 
 6. " Injections to be given into the muscles," and not 
 subcutaneously. 
 
 7. The skin over the site of injection to be swabbed 
 over with some antiseptic solution prior to puncture. 
 
 8. A cloth, wrung out of carbolic acid solution 1 in 20, 
 
 to be spread on a table to lay the syringe on. 
 
 164 
 
TECHNIQUE OF THE INTRAMUSCULAR METHOD 165 
 
 9. No cotton wool or anything " fluffy " to be brought near 
 or used to wipe the needles, pieces of sterilised linen or 
 gauze being used for this purpose. 
 
 10. The best sites for injection are (1) npper third of 
 buttock ; (2) the retro-trochanteric fossa ; (3) the lumbar 
 muscles. 
 
 11. The operation of injection to be completed in one 
 stage. 
 
 12. In the case of the insoluble salts of mercury 
 injections should be given at most once a week. 
 
 Salicylate of Mercury. — The salicylate of mercury is 
 used on a large scale on the Continent, especially in 
 Germany. For some time I employed it fairly extensively, 
 giving \ gr. suspended in liquor paraffin, twice a week, 
 but on the whole found it very inferior to either mercury 
 or calomel. 
 
 SOME POINTS TO BE CONSIDERED IN 
 THE TREATMENT OF SYPHILIS BY THE 
 INTRAMUSCULAR METHOD 
 
 As to dosage, no definite rule can be laid down, for, 
 as already pointed out, each patient tolerates mercury to 
 a different degree. What the latter is can only be arrived 
 at by a personal study of each individual case ; hence 
 the great necessity of treating cases on their merits. 
 
 The following circumstances govern, to a great extent, 
 the dosage : — 
 
 1. The type of syphilis: as pointed out, the dose of 
 mercury which will dissipate an ordinary roseolar rash 
 
166 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 will probably have no effect on a papular or pustular 
 eruption. 
 
 2. The condition of the patient : a strong, healthy 
 individual will, as a rule, require a larger dose than a 
 weakly one. 
 
 3. Cases of "malignant" or "virulent" syphilis require 
 smaller doses than ordinary ones. 
 
 Maximum Dose. — Of the metallic mercurial, I find 
 that the maximum dose should not exceed ij gr., or 
 r\. xv of the cream. I get far better results using this 
 reduced dose than I formerly did when employing the 
 larger ones. The fact is, that under large doses of mercury 
 the blood after a time deteriorates, but that when smaller 
 doses are given the metal acts as a blood tonic. 
 
 The maximum dose of calomel which I give is f gr. 
 (v\ xv of the calomel cream) ; this is given once a week, 
 and is seldom continued longer than the fourth injection, 
 when metallic cream is resorted to. 
 
 Treatment should be of an intermittent character — 
 that is, injections should be given in courses, with certain 
 intervals when none are given ; these " rest-intervals " 
 being gradually increased in length as the case goes on. 
 
 Although no arbitrary rule can be laid down as to 
 dose, intervals between injections, intervals of rest and 
 length of treatment, it is a safe and prudent proceeding 
 to have a certain plan to follow, and this is my own. 
 
 PLAN 
 
 1. A course of six weeks' treatment, which involves 
 six mercurial injections (four of which are calomel). 
 
TECHNIQUE OF THE INTRAMUSCULAR METHOD 167 
 
 2. Two months' interval without injections. 
 
 3. Two months' treatment: eight mercurial injections 
 (metallic). 
 
 4. Four months' period of rest 
 
 5. Two months' treatment : eight mercurial injections 
 (metallic). 
 
 6. Six months' period of rest. 
 
 7. One month's treatment : four mercurial injections. 
 
 8. Four months' period of rest. 
 
 9. Two months' treatment : eight mercurial injections. 
 In giving this tabular statement it cannot be too 
 
 strongly impressed on the reader that it is absolutely 
 impossible to lay down any stock plan of dealing with 
 a disease like syphilis. 
 
 In former years it was my custom to begin treatment 
 with inunction of mercury (30 rubbings a l'Aix) ; but 
 now that I am enabled to use calomel with impunity 
 I begin the treatment with it in preference to inunction, 
 as there is no comparison between the two as regards 
 rapidity and energy of action ; after four injections of 
 calomel I resort to metallic mercury, which is probably 
 employed during the remainder of the treatment. 
 
 How Long should Treatment be continued? — Al- 
 though one can never say for certain how long treat- 
 ment should be continued, or when a patient can be 
 considered cured of his disease, still treatment cannot 
 go on for ever, and a decision will most certainly be 
 asked for and will have to be given sooner or later. 
 Up to recent years the only means we had to enable 
 us to form a definite opinion on this subject was 
 
1 68 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 long experience of treatment and observation of numbers 
 of cases ; however, the introduction of Wassermann's 
 reaction test bids fair to put us in a far stronger and 
 better position in coming to a definite decision as to 
 whether a case may be considered cured or not : and 
 I think we have every right to believe that a case which 
 has had two years' thorough treatment, and which at the 
 end of that time gives repeated negative reactions with 
 Wassermann's test, is one which, to say the least, needs no 
 further treatment. As regards this test, one cannot help 
 feeling that its importance in solving the questions of 
 " how long should treatment be continued," or " when the 
 patient may be considered cured " cannot be exaggerated. 
 
 Precaution. — It is unnecessary to say that before the 
 injection of mercury is given all the precautions as 
 regards the hygiene of the mouth and teeth, as already 
 described (p. 113), should be rigidly adhered to. 
 
 Contra-indications to Mercury. 
 
 Albuminuria. — Many cases of syphilis exhibit albu- 
 minuria in their early stages, due probably to tubal 
 nephritis of a syphilitic nature, which will disappear 
 under mercury. On the other hand, the metal must 
 be given carefully and in reduced doses where organic 
 disease of the kidneys is due to some other cause. 
 
 Malaria adds very much to the seriousness of an 
 attack of syphilis, as patients suffering from it stand 
 mercury badly and become easily salivated. Before being 
 subjected to mercury such patients should have a thorough 
 course of quinine. 
 
TECHNIQUE OF THE INTRAMUSCULAR METHOD 169 
 
 OTHER METHODS OF ADMINISTERING 
 MERCURY 
 
 Fumigation was used frequently in days of yore, but 
 fell into disrepute for many years until it was partially 
 revived by Henry Lee. It is little practised now, as it 
 often produces salivation, anaemia, and general debility. 
 
 Intravenous Injection, introduced by Baccelli in 1893, 
 consists of the introduction of mercury into the circu- 
 lation through a vein ; the advantages claimed being 
 that it is painless, and that physiological effects are 
 brought about much quicker than when other methods 
 are employed. The objections to it are difficulties of 
 technique, thrombosis, embolism, and phlebitis. 
 
 Zittmanri s Treatment consists of treating chronic and 
 refractory cases of syphilis by eliminating the poison from 
 the system by sweating, purging, and the administration 
 of mercury in infinitesimal doses, the latter being com- 
 bined with tonic decoctions. The course of treatment 
 lasts fourteen days, during which time the patient is 
 kept in a temperature of 8o° F. 
 
CHAPTER XIV 
 
 FURTHER DEVELOPMENTS IN THE TREAT- 
 MENT OF SYPHILIS, INCLUDING THE 
 " EHRLICH-HATA-No. 606 PREPARATION " 
 
 As a result of the beneficial effects which had been 
 obtained from the use of " Atoxyl" in Sleeping Sickness, 
 and from his own researches as regards its action in fowl 
 spirillosis, Uhlenhuth suggested that the same drug might 
 be useful in Syphilis, the latter being, like Trypanosomiasis, 
 a protozoal disease. Hallopeau and Salmon in France 
 and the author in England made experiments according to 
 this suggestion with much success, other observers also 
 reporting favourably on it. On the other hand, from 
 different sources came records showing symptoms of 
 toxicity from its use — i.e. gastro-intestinal pains, malaise, 
 nausea, and vomiting, and more serious still, of total blind- 
 ness from optic atrophy. These adverse reports resulted 
 n Atoxyl being dropped ; in England in its place a 
 preparation of arsenic named Soamin (para-amino-phenyl- 
 arsonate) was adopted ; this is analogous to Atoxyl, but is 
 a known staple preparation. It had one great disadvantage 
 — i.e. that its solutions decomposed on keeping, and were 
 
 thus rendered dangerous. 
 
 170 
 
FURTHER DEVELOPMENTS IN THE TREATMENT 171 
 
 Dose. — Given by intramuscular injection, I gave 10 grs. 
 every other day until a total of 100 grs. had been given, 
 and the course was repeated in a month's time with this 
 preparation. I had much success in the early stages of 
 syphilis, more especially in cases with mouth and throat 
 lesions. 
 
 " Arsacetin " 
 
 The next Arylarsonate preparation used was "Ar- 
 sacetin," introduced by Ehrlich. This was spoken of 
 very highly by Neisser before the Dermatological Clinic 
 at Breslau. Arsacetin is described as Sodium Acetyl- 
 phenyl-arsonate. Of this Neisser says, "In accordance with 
 this experience gained with animals, we have now for some 
 months treated the greater number of our syphilis patients 
 with Arsacetin, and I believe that I can recommend it as a 
 very useful preparation." In the writer's hands it proved 
 a great success in some two hundred cases of both early 
 and late syphilis. 
 
 Dose. — Given intramuscularly in 10 per cent and 15 per 
 cent solutions in courses of 100 grs., like Soamin. Its 
 great advantage is that its solutions never decompose. 
 
 Arseno-phenyl-glycin 
 
 Another preparation, also introduced by Ehrlich, is 
 Arseno-phenyl-glycin. This preparation was proved to be 
 the most highly trypanocidal of all Arylarsonates, and it 
 was hoped that it would prove equally so to the SpirochcBta 
 pallidum. These hopes have not been fulfilled, and in 
 
172 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 the author's estimation it is not nearly so efficacious as 
 Arsacetin ; besides, it has the great disadvantage that 
 exposure to air causes decomposition, when the drug 
 becomes poisonous. 
 
 Conclusions as regards Arylarsonates 
 
 That the Arylarsonates have a distinct specific effect 
 in clearing up syphilitic symptoms, both in early and 
 late syphilis, there can be no doubt whatever, and up 
 to within eighteen months ago one had much hope of 
 their being able to effect a final cure ; however, since 
 Wasserman's reaction test became more familiar to us, 
 this assumption, to say the least, has become doubtful. 
 It is found that whereas in many cases they do not 
 appear to affect the reaction at all, in others a negative 
 one is brought about much more slowly when they are 
 used than is the case when mercury is employed, and 
 what is of still more significance is that a positive reaction 
 returns very quickly after their discontinuance. 
 
 " Hata," or No. 606 
 
 Ehrlich, who has been the foremost worker for years 
 in the study of the curative values of innumerable syn- 
 thetic organic bodies, observes " that it is not an unusual 
 phenomenon that a substance which is inimical to an 
 organism in a large dose is favourable to its growth in 
 a small one, and in those instances in which a ' contrary 
 effect ' is observed, the quantity of the chemical reagent 
 
FURTHER DEVELOPMENTS IN THE TREATMENT 173 
 
 which the parasite fixes is so small that it is sufficient 
 to stimulate it, but not to destroy it." Ehrlich therefore 
 inclines to his " Therapia magna sterilans." He would 
 introduce into the body one, and only one, massive dose 
 of the parasitotropic chemical substance, which would 
 free it, once and for all, from its invading parasitic foes." 
 With this object in view he has introduced the now 
 well-known preparation dioxy-diamido-arseno-benzol ; this 
 has been investigated by Hata, hence it is called by his 
 name, or by the number 606, for which the following is 
 the formula : 
 
 Oh/ )As = As/^ \0H 
 NH 2 NH 2 
 
 " Hata " appears as a yellowish powder, and each dose 
 is contained in a glass capsule sealed in vacuo. Before 
 commencing treatment by No. 606 the patient should 
 be kept in bed, a pulse and temperature chart kept, and 
 every means taken to ascertain whether the patient is 
 free from degeneration of liver and kidney. 
 
 Method of Administering the Drug 
 
 The method adopted for the preparation of the emulsion 
 of " Hata " at the Military Hospital, Rochester Row, 
 London, is as follows : 0'6 gramme of the powder is 
 shaken into 30 c.c. of sterile water heated to 50 C. con- 
 tained in a sterile vessel. Solution is effected with the 
 
 N 
 aid of a glass rod ; 6 c.c. of — , NaOH are slowly added 
 
174A SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 — a lumpy precipitate falls, which re-dissolves in the excess 
 
 N 
 of the alkali. — acetic acid (prepared by mixing I c.c. of 
 
 glacial acetic acid with i6'6 c.c. of sterile water) is dropped 
 in until neutrality is restored ; 3*25 c.c. is the theoretical 
 
 N 
 amount of — acid required. The " Hata " salt is again 
 
 precipitated, but this time in a very fine form, which can 
 pass with ease through the needle of the syringe. By 
 using the exact quantities given above, the " 606 " be- 
 comes suspended in a solution of sodium chloride and 
 acetate, which is isotonic with physiological saline fluid — 
 pain is thereby avoided. The whole is then injected 
 either into the glutei or subcutaneously beneath the 
 scapula. The pain of the injection is trifling at the time, 
 but shortly afterwards may be severe. On the third or 
 fourth day it may be aggravated by the infiltration 
 which is produced ; this may be relieved by warm baths 
 and fomentations, but morphia is sometimes required. 
 
 The temperature as a general rule rises to ioo° F. on 
 the night of the injection, to become normal after 48 hours. 
 In a number of cases induration remains for some time at 
 the site of injection. 
 
 With regard to " Hata " in the treatment of syphilis, 
 Neisser has given the following pronouncement : — 
 
 "I have injected 'Hata' in 126 cases, and find that 
 the preparation is very highly spirochsetetropic. In almost 
 every instance where manifest lesions existed, the lesions 
 subsided in a startling manner. Primary sores lost their 
 hardness and healed, whilst the Treponemata in Chancre 
 
FURTHER DEVELOPMENTS IN THE TREATMENT 174B 
 
 and Condylomata disappeared in twenty-four hours. Mus- 
 cular and papular eruptions became stains in a day or so. 
 Mucous patches went ; shotty glands subsided ; gummata 
 melted away ; tertiary ulcers of malignant syphilis cleaned 
 and cicatrised in a few days ; the paralyses and pains of 
 cerebral syphilis disappeared sometimes in an hour or so." 
 
 Action in the Wasserman Reaction. 
 
 As to the influence of the new remedy in changing 
 a positive Wasserman reaction into a negative, Neisser 
 observed this in 44 per cent of his cases. Gerome found 
 negative reactions in 60 per cent of his ; Schruber in 
 80 to 90 per cent ; and Wechselmann in 100 per cent of 
 his. In 270 cases treated with "Hata" by Lange, 57 
 per cent reacted negatively four or five weeks after the 
 treatment. 
 
 McDonald reporting on 20 cases treated by " Hata " 
 says : " Beyond the improvement observed by the naked 
 eye, I was very much struck by the extraordinary change 
 for the better in almost every patient's general condition ; 
 they not only appeared brighter, but felt ever so much 
 better and put on weight." 
 
 Toxicity. — Neisser states that 2,500 patients have been 
 treated with " 606 " without any toxic effects, and disorders 
 of vision and optic atrophy have never been observed. 
 
 Final Remarks. — At the Frankfort Congress of the 
 German Dermatological Society in 1907, Ehrlich when 
 introducing " Arsacetin " as an improved remedy for 
 Syphilis, remarked thus : 
 
I74-C SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 " But even if this material should prove unsuitable for 
 human use, we must not throw up the cards and abandon 
 hope of something better. Then must we advance further 
 along the road which now stretches clear before us." 
 
 True to this advice, Ehrlich has continued the hard fight 
 until he is about to reap his reward by producing " Hata " 
 or " No. 606," which apparently has a wonderful future 
 before it in the treatment of Syphilis. ' 
 
ARYLARSONATE AND OTHER METHODS 175 
 
 AUXILIARY MEANS OF TREATMENT 
 
 Although mercury and the arylarsonates form the main 
 part of the treatment of syphilis, there are auxiliary means 
 which are also very necessary — viz. hydrotherapy, iodide 
 of potassium, and various tonics ; besides these care in 
 living and dieting is most desirable. 
 
 Second only to specific medication do I consider hydro- 
 therapy, for hot baths of all kinds favour the elimination 
 of mercury, and, what is of greater importance, increase 
 and maintain metabolism generally. Hot-air baths are 
 best, then Turkish baths, and last hot-water baths. At 
 Rochester Row every patient undergoing either mercurial 
 or arylarsonate treatment for syphilis sits in a hot-air 
 bath at a temperature of 300 ° daily for ten minutes. 
 
 Iodide of Potassium. — Iodide of potassium at one 
 time was supposed to have a specific action on syphilis ; 
 but for many years it has been regarded not as a specific, 
 but as a valuable adjunct to mercury. In the early stages 
 of the disease it is of little value, its therapeutic efficiency 
 increasing in direct ratio with the age of the disease. 
 It acts by promoting fatty degeneration and absorption 
 of the imperfectly organised exudates. 
 
 As a rule, iodide of potassium is unnecessary in the 
 early stages, except to relieve nocturnal headaches and 
 periosteal pains generally. In such cases it is most suc- 
 cessful, given in 5-grain doses three times a day. 
 
 In the later stages iodide of potassium, either given 
 alone after a thorough course of mercury, or in combination 
 with the latter, produces results which are sometimes 
 
176 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 marvellous. On the other hand, when given in an un- 
 scientific manner the iodides lead to grave consequences. 
 They act on the system as depressants, lowering it to 
 such an extent that it is left an easy prey to the further 
 ravages of syphilis. At other times iodism is produced, 
 represented by gastro-intestinal irritation, coryza, pustular 
 and other forms of skin eruptions, various forms of neuritis, 
 and acute oedema of the larynx. 
 
 In ordinary doses most patients will exhibit no symptoms 
 whatever from the use of the iodides. A small propor- 
 tion may suffer from a coppery taste in the mouth, coryza, 
 and perhaps some gastro-intestinal catarrh. A still smaller 
 proportion may be entirely intolerant of iodide of potas- 
 sium, and will suffer from swelling of the mucous mem- 
 branes, especially of the larynx and pharynx. 
 
 Rules for giving Iodide of Potassium. 
 
 1. The drug ought to be given well diluted. 
 
 2. Excipients facilitate absorption. 
 
 3. It should be given about an hour after meals. 
 
 4. It should be given in intermittent courses of in- 
 creasing doses, never for longer than ten days at a time, 
 after which there should be a week's interval before it is 
 resumed. 
 
 Dosage. — In the early stages, if required, the average 
 dose is gr. v three times a day ; in the later stages gr. x 
 three times a day, increasing up to gr. xxx three times 
 a day ; so that by the end of a course of ten or fourteen 
 days the patient will be taking 5 ij per day : as much as 
 3 ij three times a day may be found necessary in some 
 cases. 
 
ARYLARSONATE AND OTHER METHODS 177 
 
 Manner of Giving Iodides. — They may be given in 
 the form of a saturated solution, one drop of which re- 
 presents approximately gr. j of iodide of potassium : 
 
 & Iodide of potassium 5 V 
 
 Aquas ad 5 J 
 
 Dose : 17\ v to V\ x in a glass of milk and water three times a day. 
 
 If this disagrees, 5 to 10 grains of pepsin may be 
 added. 
 
 The great thing to remember in giving iodide of 
 potassium internally, is to give it well diluted. It can 
 be taken in milk, beer, wine, or in any liquid. 
 
 The drug can be given by enema when necessary. 
 When thus administered the intestine should first be 
 evacuated by a simple enema. Then an enema of iodide 
 of potassium, gr. xxx to gr. xl dissolved in 3 ij of water 
 with a few drops of laudanum, may be given. 
 
 Hypodermic Injection. — Hypodermic injection of potas- 
 sium iodide is sometimes resorted to. This mode cannot 
 be recommended owing to the frequent occurrence of 
 abscesses and sloughing. 
 
 lodipin. — Iodipin is a combination of iodine and sesame 
 oil, and is prepared in two strengths, i.e. 10 °/ Q and 20 °/ Q , 
 the former for internal medication, the latter for injection 
 purposes. Although the desired therapeutic effects can 
 be brought about by giving it internally, this manner is 
 not recommended, as it is apt to bring on dyspepsia. 
 Given hypodermically and intramuscularly, the dose is : 
 from c.c. x to c.c. xx for ten consecutive days. The 
 syringe should be capable of holding at least 10 c.c. 
 The needle should be 2\ in. long, and have a large bore. 
 
 12 
 
178 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Injections are best given in the loose tissues of the 
 loins. Iodipin is a viscid fluid, and requires heating to 
 at least body temperature to bring it to the proper 
 consistence for injection purposes. The advantages 
 claimed for iodipin over iodide of potassium are that it 
 is more slowly absorbed and excreted than the latter ; 
 that it is non-depressent, and does not interfere with the 
 digestion. I have used iodipin very extensively, and can 
 recommend it as a substitute for potassium iodide in all 
 cases where the latter is inadmissible. It has one ob- 
 jection— i.e. the large bulk it is necessary to inject at a 
 sitting. 
 
 Iodism. — The treatment of iodism will depend on the 
 severity or otherwise of the symptoms. When these are 
 mild, and it is important to continue the drug, the iodide 
 may be given in increased doses ; but when severe, dis- 
 continuance of the drug is imperative. 
 
 The character of the iodide rash is important : 
 
 i. Rapidity of invasion. 
 
 2. Begins as a vesicle, and runs speedily through a 
 pustular stage. 
 
 3. The margins are inflamed with a bright red areola. 
 
 4. The base is soft. 
 
 5. The suppression of the drug causes the disappearance 
 of the rash. 
 
CHAPTER XV 
 
 MODERN AIDS IN THE DIAGNOSIS OF 
 SYPHILIS 
 
 SCHAUDINN in 1905 discovered the Spirochceta pallida, 
 
 and from various experiments was led to believe that this 
 
 spirochete was the true cause of syphilis — a belief soon 
 
 to be fully confirmed by some of the greatest pathologists 
 
 of the day, notably Metchnikoff, Levaditi, Roux and 
 
 Koch, and to-day it is the generally accepted fact. 
 
 Since a positive diagnosis can only be obtained by 
 
 finding the Spirochceta pallida, the importance of this 
 
 discovery of Schaudinn can easily be imagined. It is 
 
 of greater value in the primary stage of syphilis than at 
 
 any other. In no stage of the disease is diagnosis so 
 
 important. Seen early, some chancres defy the most 
 
 experienced in coming to a conclusion as to their real 
 
 nature, with the result that one of two courses is usually 
 
 adopted — either the patient is given mercury with a three 
 
 or four years' treatment to look forward to, and the 
 
 constant thought of suffering from a disease of which 
 
 he may be entirely innocent, or he is given no treatment 
 
 until the whole system is infected and secondaries are 
 
 obvious. Thus the most valuable time for grappling with 
 
 179 
 
180 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 the disease is lost, for it is an undoubted fact that the 
 earlier treatment is begun, and the more vigorously it 
 is carried out in the primary stage, so much the sooner 
 may a cure be looked for and further developments 
 prevented. 
 
 To demonstrate the Spirochceta pallida the specimen 
 should be examined by the "dark ground illumination." 
 This latter is obtained by using a condenser, which allows 
 no rays of light to reach the eye except those reflected 
 by certain objects, such as the Spirochceta pallida, which 
 appears as a delicate, attenuated, brightly illuminated 
 silvery corkscrew standing out in beautiful contrast on 
 a dark or intensely black field. The necessary apparatus 
 for the " dark ground illumination " can be adapted to 
 any microscope at a comparatively small cost, and the 
 technique for setting up the specimen is extremely simple. 
 By its means a diagnosis can be established in the case 
 of an untreated syphilitic sore in a very few minutes. 
 
 It is of course necessary for the observer to familiarise 
 himself with the appearances of the various spirochaetes 
 under this method of examination, but when the 
 characteristic appearance of the Spirochceta pallida has 
 been once mentally fixed, no mistake should occur. In 
 lesions of the genital organs the spirochaetes which are 
 likely to cause confusion at first are the finer forms of 
 Spirochceta refringens, amongst which, without com- 
 mitting oneself to any definite opinion as regards their 
 relationship to the form originally named by Schaudinn 
 and Hoffman as 6". refringens, may be mentioned 6". 
 balanitidis and the spirochaetes of ulcerating cancers and 
 
MODERN AIDS IN THE DIAGNOSIS OF SYPHILIS 181 
 
 papillomata. In general these differ from the 6". pallida 
 by their greater thickness, irregularity of undulations 
 and the wider spacing of the latter, while they are to be 
 found on the surface rather than in the depths of the 
 sore, and in the ulcerated area rather than the indurated 
 margin. 
 
 The beginner at this method of examination is strongly 
 urged to make himself familiar — by taking specimens from 
 the surface of syphilitic sores, from the deeper layers of 
 epithelium at the indurated margin, from the secretion of 
 cases of balanitis, and from other than syphilitic lesions — 
 with the appearance of the various spirochetes found in 
 these conditions. He will find half an hour's work in 
 this direction of more value than pages of description. 
 
 Burri's Method 1 consists of demonstrating the 
 Spirochceta pallida by means of Chinese ink. A platinum 
 loopful of secretion from a sore is placed upon a slide, 
 surrounded by seven or eight loopfuls of distilled water 
 and the same quantity of a solution of Chinese ink. 
 The whole is mixed and spread out upon a slide, or a 
 blood film is made, allowed to dry, and examined with an 
 oil-immersion lens. The ink produces a dark background, 
 and the objects under examination stand out white. 
 
 Giemsa's Stain. — At one time it was believed 
 that, whereas all other spirochetes stained blue with 
 Giemsa's stain, the Spirochceta pallida stained pink ; but 
 now it is known that the latter sometimes stains blue, 
 so that staining is not really a very strong point. 
 
 1 The Journal of Clinical Research^ May 1910, p. 59, has a note on 
 this method. — [Ed.] 
 
1 82 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Excision of Chancres. — Neisser's experiments on the 
 infectivity of organs of syphilised monkeys at different 
 periods after inoculation, show that by the time the 
 chancre has appeared (in fact long before), the spirochete 
 has already established itself in the hemopoietic organs 
 and blood, so that excision of the chancre is theoretically 
 not sound. Levaditi and Koch condemn it. 
 
 The Spirochaeta Pallida. — That the Spirochceta pallida 
 is the true organism of syphilis has been established beyond 
 a doubt from the following : 
 
 It is found only in syphilitic lesions. 
 
 It has been found in the blood of syphilitics. 
 
 It has been found in the blood and viscera of syphilitic 
 infants. 
 
 Metchnikoff and Roux found it in lesions in monkeys 
 caused by inoculation from syphilitic men and monkeys. 
 
 Wassermann's Serum Reaction Test. 1 — Of recent 
 advances in medicine none can claim to be of so much 
 importance as the serum diagnosis of syphilis, a test based 
 on what is known as the Bordet-Gengou reaction. The 
 latter is a binding of the complement which takes place 
 when an antigen meets with its homologous inactive 
 immune serum, erythrocytes and hemolytic serum (which 
 has been inactivated in order to rob it of its complement). 
 No hemolysis can occur if the complement has become 
 bound, because the hemolysin has no free complement. 
 Founded on this, Wassermann discovered that a positive 
 
 1 A useful article on " The Serum of Diagnosis of Syphilis " will be 
 found in The Practitioner, September 1909 [Ed.], also see E. Merck's 
 Annual Report, Vol. XXII. 
 
MODERN AIDS IN THE DIAGNOSIS OF SYPHILIS 183 
 
 reaction could be obtained by the bringing together of 
 bacterial extracts and immune serum, and later on proved 
 that extracts of organs behaved as the antigen, and that in 
 the serum of apes, which had been treated with syphilitic 
 extract, substances appeared which brought about fixation 
 of the complement. Finally he found the same substances 
 in serum of human syphilitics. 
 
 In Wassermann's test the antigen is obtained from the 
 liver or spleen of an hereditary syphilitic infant ; the anti- 
 serum from the blood of the patient ; the complement from 
 guinea-pig serum ; the erythrocytes from sheep's blood ; 
 and the hemolytic serum from an immunised rabbit. 
 
 The technique of Wassermann's test is certainly very 
 intricate, and can only be satisfactorily carried out in a 
 well-equipped laboratory and by an expert, and, as at 
 present instituted, can never come within the range of the 
 general practitioner. Of late years many workers have 
 endeavoured to modify and simplify the test, but have 
 not succeeded, and at the present moment Wassermann's 
 original method still holds its ground as the most approved 
 and most reliable of all. 
 
 The value of Wassermann's reaction varies according to 
 the stage of the disease. In the primary stage a positive 
 result is not obtained in more than 40 per cent, of cases. 
 In the secondary stage a positive reaction is obtained 
 in 85 per cent, of all cases, whether showing secondary 
 manifestations or not, and where the patient is under- 
 going treatment. When there are secondary signs present, 
 such as rash, and where the patient has not yet had any 
 mercury, 97 per cent, give a positive Wassermann. 
 
1 84 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 Treatment, of course, influences the results of Wasser- 
 mann's test. Directly after a course or courses of inter- 
 mittent treatment the reaction is usually negative, but 
 when the mercury becomes eliminated the reaction result- 
 ing is positive. The greater the number of courses the 
 more likelihood there is of a negative result, which in 
 time may become permanent ; and herein lies a most 
 important point in connection with the Wassermann test. 
 Should a case which has undergone a thorough treat- 
 ment give a negative reaction three, six, or nine months 
 after the cessation of all treatment, is it then justifiable 
 to give an opinion that a cure has been established ? This 
 would indeed be a great advance ; but at present the 
 reaction is not certain enough to justify such an opinion ; 
 time and further experience of the test can alone tell us. 
 
 Two facts which Wassermann's test has taught us are : 
 the enormous benefit which arises from an early and 
 vigorous treatment ; and the advantage of injections and 
 inunction over the oral administration of mercury. 
 
 Whatever time may tell us as to the value of Wassermann's 
 test in enabling a definite opinion to be given as to cure 
 or not, there can be no doubt as to its present-day value 
 to the clinician, in not only enabling him to diagnose 
 syphilis, but also to differentiate between it and other 
 diseases. 
 
 i. Take a very common instance — that of a patient who 
 gives a history of a sore which appeared a few days after 
 connection, and disappeared within ten days to a fortnight. 
 No notice is taken at the time, but some months later 
 a few spots appear on the body, and a medical opinion 
 
MODERN AIDS IN THE DIAGNOSIS OF SYPHILIS 185 
 
 is sought, but no definite conclusion can be arrived at. 
 With such a history and a " positive " Wassermann there 
 cannot be any doubt as to the nature of the disease, and 
 treatment should be commenced forthwith. 
 
 2. Differential diagnoses between various ulcers and 
 syphilitic ones. 
 
 3. Gummatous periostitis and sarcoma. 
 
 4. Gummata of the testes, tubercle, and new growth. 
 
 5. Gumma and malignant growth of the liver. 
 
 6. Syphilitic ulceration of the tongue and epithelioma. 
 The author had a case which was under orders to have ex- 
 cision of the tongue for cancer. There was no evidence of 
 acquired syphilis, but slight of hereditary disease. Wasser- 
 mann's test gave an undoubted positive reaction. The 
 patient was put on atoxylate of mercury injections, which 
 cleared up the local affection at once. 
 
 7. Between general paralysis of the insane and other 
 cerebral affections, 100 per cent, of cases of genera 
 paralysis give a positive reaction. 
 
 8. Tabes, in which 70 per cent, of the cases give a 
 positive reaction. 
 
 9. In cases of repeated abortions. 
 
 10. Between cases of hereditary syphilis and tubercle. 
 
 11. Syphilitic affections of the eye, and those due to 
 some other cause. 
 
 Some two years ago a case was sent to the author, 
 the patient a male, aged fifty-five, who had suffered for 
 thirty years from rheumatic arthritis and periodic attacks 
 of what was considered rheumatic iritis. The oculist 
 who sent the case wanted to see how these attacks 
 
186 SYPHILIS: ITS DIAGNOSIS AND TREATMENT 
 
 behaved under metallic mercurial injections. Although 
 there was no history nor sign whatsoever of either acquired 
 or hereditary syphilis, the patient's blood when sub- 
 jected to Wassermann's test gave an undoubted positive 
 result. The case was treated accordingly, since which 
 time there has been no recurrence of iritis, and now the 
 reaction has been negative for the last four months. 
 
 Conclusion. — The value of these two discoveries — i.e. 
 of the Spirochczta pallida by Schaudinn, and the serum 
 reaction test by Wassermann — have opened up a new era 
 in the clinical study and treatment of syphilis. Their 
 importance cannot be exaggerated. The former enables 
 us to give a definite opinion as to the character of 
 the primary lesion, which in itself is a tremendous ad- 
 vantage ; whilst Wassermann's reaction test has been 
 proved by experience in several thousands of cases all 
 over the world to be one which is practically specific 
 for syphilis. It is therefore an addition to the diagnostic 
 armament of the very highest value. Apart from its 
 value as an aid to diagnosis in obscure cases, I believe 
 there is reason to hope that by it we may gain some 
 knowledge as to the progress which treatment is making 
 against the disease. Though the reaction is of too recent 
 date to enable one to make any definite statement on 
 this question, it seems to be undoubted that efficient 
 treatment does tend to convert a " positive " reaction into 
 a " negative " one ; and in the great majority of cases the 
 occurrence of a negative reaction in cases of syphilis after 
 efficient treatment appears to be the more frequent as 
 the clinical signs indicate a return to health. Whether it 
 
MODERN AIDS IN THE DIAGNOSIS OF SYPHILIS 187 
 
 will eventually be possible to determine from a succession 
 of negative reactions that treatment has effected its 
 purpose and can be discontinued is a question which 
 can only be determined after the lapse of many years, when 
 the history of the cases whose blood has already been 
 tested and found to be persistently " negative " has been 
 followed out to the end. 
 
INDEX 
 
 {Authorities in Italics) 
 
 >,n+V,. A a + 
 
 I Arteritis rerphral Rc\ 
 
 ERRATA TO INDEX 
 Omit — 
 
 Arsonates, 170 
 Glossitis, sclerotic, 173 
 Leucoplakia, 172 
 
 Add— 
 
 Arseno-phenyl-glycin, 171 
 Dioxy-diamido-arseno-benzol, 173 
 " Ehrlich-Hata-No. 606," 172 
 Sodium acetyl-phenyl-arsonate, 171 
 Wasseiman's Reaction, 172-174B 
 
 Antigen, 102 
 
 
 mmucuue ui uiciuuiy, no 
 
 Antipyrin, 103 
 
 
 Black wash, 42, 60 
 
 Antiquity of syphilis, 4 
 
 
 Blood, changes caused in, bymercury, 
 
 Anti-serum, 183 
 
 
 156 
 
 Anti-syphilitic serum, 14 
 
 
 Blue pill, 117 
 
 Anus, chancres of, 25 
 
 
 Boerhaave, 130 
 
 Aortic regurgitation, 86 
 
 
 Bones, secondary affections of, 66 
 
 Aphasia, 66 
 
 
 — tertiary affections of, 83 
 
 Aphonia, 78 
 
 
 Borax, 58 
 
 Argyll- Robertson pupil, 96 
 
 99, 106 
 
 Bordet-Gengou reaction, 182 
 
 Aristol, 42 
 
 
 Boric acid, 42, 59, 60 
 
 Arsacetin, 171 
 
 
 Breast, chancre of, 36 
 
 Arsenic, 1 1 1 
 
 
 Bromides, 109 
 
 Arsonates, 170 
 
 
 Buccal hygiene, 131, 137 
 
 Arsonic acid, 170 
 
 
 — tolerance, sex differences, 121 
 
 Arterial system, tertiary 
 
 affections 
 
 Burri's method (Chinese ink), 181 
 
 of, 86 
 
 
 Bursas, secondary affections of, 67 
 
 Arteritis, 86 
 
 
 — tertiary affections of, 82 
 
INDEX 
 
 (Authorities in Italics) 
 
 Aachen, method at, 131, 132 
 
 — water, composition, 133 
 
 Acid, chromic, 44, 58, 62, 76, 114 
 
 — nitrate of mercurj', 60 
 
 Acne, 51 
 
 Aix-la-Chapelle, see Aachen. 
 
 Albuminuria, 49, 66, 80, 168 
 
 Alcohol, rules during inunction, 137 
 
 Alimentary system, tertiary affec- 
 tions of, 72 
 
 Alopecia, 60 
 
 Alphyl, 170 
 
 Ambrosoli, of Milan, 142 
 
 American origin of syphilis, 5 
 
 Ammonium chloride, 150 
 
 Amyloid degeneration of kidne} 7 , 81 
 
 of liver, 79 
 
 Anasmia, 56 
 
 Analgesia, 159 
 
 Aneurysm, 86, 89 
 
 Angina pectoris, 49 
 
 Aniline, i7r 
 
 Ankylosis, 84 
 
 Annular chancre, 19 
 
 Antifebrin, 103 
 
 Antigen, 182 
 
 Antipyrin, r03 
 
 Antiquity of syphilis, 4 
 
 Anti-serum, 183 
 
 Anti-syphilitic serum, 14 
 
 Anus, chancres of, 25 
 
 Aortic regurgitation, 86 
 
 Aphasia, 66 
 
 Aphonia, 78 
 
 Argyll- Robertson pupil, 96, 99, 106 
 
 Aristol, 42 
 
 Arsacetin, 171 
 
 Arsenic, in 
 
 Arsonates, 170 
 
 Arsonic acid, 170 
 
 Arterial system, tertiary affections 
 of, 86 
 
 Arteritis, 86 
 
 Arteritis, cerebral, 89 
 Arthritis, gummatous, 84 
 
 — secondary, 67 
 
 — tertiary, 84 
 Arylarsonates, 75, 109, no 
 
 — treatment by, 170 
 Ascites, 80 
 Atheroma, 88 
 
 — of aorta, 86 
 Atoxyl, 170, 172 
 Atoxylate of mercury, 173, 185 
 Atropine, 63 
 Auto-inoculation, 30 
 
 Auxiliary means of treatment, 175 
 "Ayurvedas," 2 
 
 /3-cocaine, 160 
 
 Baccelli, 169 
 
 Bacillus paralyticans, 98 
 
 Bacteriology of syphilis, n 
 
 Balzer, 144 
 
 Baron Larrey's syrup, 119 
 
 Baths, hot-air, 114, 175 
 
 — Turkish, 114, 175 
 Biett, 120 
 
 Biniodide of mercury, 118 
 
 Black wash, 42, 60 
 
 Blood, changes caused in, by mercury, 
 
 156 
 Blue pill, 117 
 Boerhaave, 130 
 Bones, secondary affections of, 66 
 
 — tertiary affections of, 83 
 Borax, 58 
 
 Bordet-Gengou reaction, 182 
 Boric acid, 42, 59, 60 
 Breast, chancre of, 36 
 Bromides, 109 
 
 Buccal hygiene, 131, 137 
 
 — tolerance, sex differences, 121 
 Burri's method (Chinese ink), 181 
 Bursas, secondary affections of, 67 
 
 — tertiary affections of, 82 
 
 189 
 
190 
 
 INDEX 
 
 Cachexia, syphilitic, 47 
 Calomel, dry dressing, 43 
 
 — dusting powder, 60 
 
 — injections, 75, 95, 103, 144, 156, 
 162 
 
 formula for, 162 
 
 pain after, 160 
 
 — ointment (Metchnikoff), 43 
 Camphoric acid, 160 
 Cancer of lip, 32 
 
 — of tongue, 74 
 Carbolic acid, 43, 58, 60, 
 
 — lotion, 42 
 Castellani, 31 
 Cautery, actual, 44 
 Central America, 1, 4 
 Cephalalgia, 64 
 
 Cerebral syphilis, statistics, 91 
 Cerebro-spinal fluid, leucocytosis of, 
 94, 96 
 
 — syphilis, 94 
 Chancre, description of, 17 
 
 — indurated, 10 
 
 — prognosis of, 37 
 
 — seats of, 21 
 anus, 25 
 
 base of penis, 23 
 
 breast, 36 
 
 concealed, 24 
 
 extragenital, 32 
 
 eye, 34 
 
 face, 35 
 
 finger, 35 
 
 general integument, 36 
 
 genital, 22 
 
 groin, 25 
 
 lip, 32 
 
 preputial, 24 
 
 scrotum, 2 3 
 
 sub-preputial, 24 
 
 tongue, 33 
 
 tonsil, 34 
 
 urethra, 22 
 
 urinary meatus, 22 
 
 — structure of, 18 
 
 — treatment of, 40 
 
 — varieties of, 19 
 
 annular, 19 
 
 ecthymatous, 19 
 
 dry papule, 19 
 
 false relapsing, 21 
 
 mixed, 20 
 
 phagedenic, 43 
 
 recurring, 20 
 
 silvery spot, 19 
 
 true relapsing, 21 
 
 vaccination, 36 
 
 Chancroid inflammation, 26 
 Chancrous erosion, 18 
 Charcoal poultices, 44 
 Charcot's gait, 87 
 
 — joint, 102, 107 
 Charles (Physiology), 159 
 
 — V., Emperor, 6 
 
 Charles VIII. of France, 4, 6 
 Chimpanzee, inoculation of, 14 
 Chinese ink method, 181 
 — knowledge of syphilis, 2 
 Chlorate of potash, 58, 113 
 Chomel's pills, 119 
 Chorea, 90 
 Choroiditis, 63 
 
 Chromic acid, 44, 58, 62, 76, 114 
 Circinate syphilide, 54 
 Circulatory system, tertiary affec- 
 tions of, 86 
 Cocain hydrochlorat., 150, 160 
 Collins, 97 
 
 Columbus, sailors of, 4 
 Concealed chancres, 24 
 Condylomata, 59 
 Conjunctival chancre, 34 
 Copper, sulphate of, 113, 114 
 Coryza, 176 
 Creo-camph., 161, 162 
 Creosote, 160 
 Cyclitis, 63 
 Cyto-diagnosis, 103 
 Cytoryctes luis, 12 
 
 Dactylitis syphilitica, 85 
 Dark-ground illumination, 180 
 De Lisle, 12 
 
 Depression, mental, 66 
 Dermatitis during inunction, 139 
 
 — secondary, 49 
 
 — tertiary, 70 
 Dermatol, 42 
 
 Destruction of syphilitic virus, 41 
 Diagnosis, differential, 28, 184 
 
 — of chancre, 27 
 
 — modern aids to, 179 
 Diarrhoea, 139 
 
 Diaz de Isla, 5, 6 
 
 Diet during inunction, 137 
 
 Diffuse paronychia, 61 
 
 Digestive organs, action of mercury 
 
 preparations on, 121 
 Dosage of mercury, 124 
 Dose, maximum for injection, 
 
 166 
 Dry papule, the, 19 
 Ducrey, 8 
 
 Dupuytren's pills, 118, 124 
 Fournier's modification of, 119, 
 
 124 
 Duration of treatment, 167 
 Dystrophy of the neurones, 96 
 
 Eburnation of bony tissue, 83 
 Ecthymatous chancre, the, 19 
 Eczema, 35 
 
 Edinburgh, syphilis in, 7 
 Ehrlich, of Frankfort, 171 
 Embolism, 148 
 Endarteritis obliterans, 86 
 Endoperiarteritis, 86 
 Enema of potass, iodid., 177 
 
INDEX 
 
 191 
 
 England, introduction of syphilis 
 
 into, 6 
 Epididymis, secondary affections of, 68 
 Epilepsy, 66, 108 
 Epithelioma, diagnosis of, 32 
 Erb, 97 
 Eruptions, secondary, 49 
 
 — tertiary, 70 
 Erythema of larynx, 60 
 Erythematous syphilides, 51, 52 
 Europhen, 42 
 
 Exercise during inunction, 138 
 Exostoses, 83 
 External method, 128 
 Extragenital chancres, 31 
 Eye, chancre of, 34 
 
 — secondary affections of, 62 
 
 Facial chancre, 35 
 
 False relapsing chancre, 21 
 
 Ferguson, William, 112 
 
 Ferrier, 98 
 
 " Ficus," of the Romans, 2 
 
 Finger, chancre of, 35 
 
 — tertiary affections of, 85 
 Follicular syphilides, 51, 52 
 Fournier, 10, 90, 96, 97, 160 
 Fournier's modification of Dupuy- 
 
 tren's pill, 119, 124 
 Fracture, spontaneous, 107 
 Fumigation, 169 
 
 Gagniere, 156 
 
 Gaseous constituents of Aachen 
 
 water, 133 
 Gastro-intestinal irritation, 176 
 General paralysis, 104 
 Genital chancre, 22 
 
 — organs, mucous patches of, 59 
 Giemsa's stain, 12, 15, 181 
 Girdle pain, 93 
 
 Glands, enlargement of, 46 
 Glossitis, gummatous, 73 
 
 — sclerosing, 73 
 
 — sclerotic, 173 
 
 — superficial, 72 
 Glycerin, 144 
 Gold, in 
 Gowers, 97, 99 
 
 " Grand mal," 108 
 Grandiose delusions, 105 
 Grey oil, 155 
 
 — powder, 118 
 Groin, chancre of; 25 
 Guaiacum, in 
 Guillain, 98 
 
 Gumma, structure of, 9 
 Gummata, subcutaneous, 71 
 Gummatous syphilides, 71 
 Gum-water, 144 
 Guthrie, 112 
 
 Hemolytic serum, 183 
 Haemoptysis, 79 
 
 Hair, affections of the, 60 
 
 Haiti, 4, 5, 6 
 
 Halliburton, 158 
 
 Hallopeau, 170, 171 
 
 Hardy, 143 
 
 Headache, nocturnal, 64, 175 
 
 Hebrew knowledge of syphilis, 3 
 
 Hemiplegia, early, 64 
 
 — syphilitic, 92 
 Hepatitis, 79 
 Hippocrates, 2 
 Hoang-ti, Emperor, 2 
 Hoffmann, 13, 180 
 Hoffmann's pills, 119 
 Hot-air baths, 175 
 Hot compresses, 63 
 Hot-water baths, 175 
 Hunter, John, 7, 131 
 
 experiment of, 7 
 
 Hutten, Ulrich van, 129 
 Hydrocele, 85 
 
 — , tapping, 86 
 Hydrotherapy, 175 
 Hydroxyl group, 170 
 Hygiene of mouth, 113, 137 
 Hyperasmia of pharynx, 48 
 
 — of tonsils, 48 
 
 Hypodermic injection of potass. 
 iodid., 177 
 
 India, syphilis in, 2 
 Indian (W.), source of syphilis, 5 
 Indolent paronychia, 61 
 Indurated chancre, 10 
 Induration, description of, 17 
 Injection, intramuscular, 142 
 
 — sites for, 165 
 
 — intravenous, 169 
 
 Insoluble salts, injection of, 154 
 Internal method, remarks on, 125 
 Interstitial nephritis, 81 
 Intramuscular method, 142 
 
 advantages of, 145 
 
 disadvantages of, 148 
 
 points in, 165 
 
 stomatitis after, 147 
 
 success of, 144 
 
 technique of, 164 
 
 Intravenous injection, 169 
 Inunction, cases for, 141 
 
 — diet during, 137 
 
 — disadvantages of, 138 
 
 — exercise during, 137 
 
 — mercurial, 95 
 
 — method, 128 
 
 — mode of action, 134 
 
 — ointments for, 135 
 
 Iodide of potassium, 72, 75, 175 
 
 manner of giving, 177 
 
 rash, 178 
 
 Iodine, solutions of, yj 
 Iodipin, 72, 177 
 Iodism, 176, 178 
 Iodoform, 42, 59, 60, 62, 72 
 
ig-2 
 
 INDEX 
 
 Iridectomy, 63 
 Irido- choroiditis, 63 
 Iritis, 62 
 
 James IV. of Scotland, 7 
 Japanese knowledge of syphilis, 2 
 Jaundice, 66, 80 
 
 Joints, secondary affections of the, 
 67 
 
 — tertiary affections of the, 84 
 Jullien, 143 
 
 Kidney, amyloid disease of, 81 
 
 — granular contracted, 81 
 
 — secondary affections of, 49 
 
 — tertiary affections of, 81 
 Knee-jerks, 100 
 
 Koch, 171, 179, 182 
 Kolliker, 143 
 
 Labial chancre, 32 
 
 — epithelioma, 33 
 Lafay's formula, 158 
 Lambkin's original formula, 158 
 Lancereaux, 2 
 
 Lang, of Vienna, 154, 157 
 Larrey's syrup, 119 
 Laryngitis, early, 60 
 Larynx, affections of, 60 
 
 — erythema of, 60 
 
 — oedema of, 176 
 
 — tertiary affections of, 78 
 Las Casas, 5, 6 
 
 Lee, Henry, 169 
 
 Leeches, 63 
 
 Leishman, 161 
 
 Lenticular syphilides, 51, 53 
 
 Lepra, syphilitic, 54 
 
 Leprosy, Biblical account of, 3 
 
 Leucocytosis of cerebrospinal fluid, 
 
 94, 96 
 Leucoderma, 56 
 Leucoplakia, 58, 172 
 Levaditi, 9, 14, 179, 182 
 Lichen, 50 
 Liegois, 143 
 Lightning pains, 99 
 Lips, chancre of, 32 
 
 — tertiary lesions of, 72 
 Liver, congestion of, 66 
 
 — tertiary affections of, 79 
 Locomotor ataxia, 96 
 
 Lungs, tertiary affections of, 78 
 Lupus, differential diagnosis, 77 
 Lustgarten's bacillus, 12 
 Lymphangitis, inflammatory, 39 
 
 — specific, 39 
 
 Lympho-angiotic theory of tabes, 98 
 Lymphocytosis, 97 
 
 Magrath, 98 
 " Mai francais," 128 
 Malaria, 168 
 Maries, 98 
 
 Melting-point of mercurial cream, 
 
 161 
 Meningitis, 91 
 
 — spinal, 93 
 Meningo-myelitis, 93 
 Mental depression, 66 
 Mercurial cream, 158 
 
 — ointment, 46, 72 
 
 — plaster, 86 
 
 — soaps, 135 
 Mercury, in 
 
 — acetate of, 150 
 
 — acid nitrate of, 60 
 
 — alaniate of, 150 
 
 — and ammonium, double chloride 
 of, 149 
 
 — atoxylate of, 173, 185 
 
 — benzoate of, 150 
 
 — bichloride, 61-3, 152 
 
 — biniodide, 118, 150 
 oil, 151 
 
 — chloro- albumin ate of, 150 
 
 — contra-indications, 168 
 
 — cyanide of, 150 
 
 — dosage of, 124 
 
 — ingestion method, 115 
 
 — intramuscular method, 142 
 
 — lactate of, 150 
 
 — metallic, 154 
 
 advantages of, 155 
 
 disadvantages of, 161 
 
 — methods of administering, 114 
 
 — oleate of, 43 
 
 — peptonate of, 149, 151 
 
 — perchloride, 118: see bichloride 
 
 — preparations of, 157 
 
 — proto-iodide, 119 
 
 — salicylate, 118, 154, 156, 165 
 
 — sozoiodolate of, 150, 151 
 
 — succinimate of, 150, 152 
 
 — tannate of, 118, 150 
 
 — urate of, 150 
 
 — yellow oxide of, 144, 154 
 Metchnikoff, 8, 14, 41, no, 179, 182 
 
 — ointment, 41, 43, no 
 Methods, ingestion, 115 
 
 — intramuscular, 142 
 
 — intravenous, 169 
 
 — inunction, 128 
 Microbiology of syphilis, 11 
 Migraine, 90 
 
 Mixed chancre, 20, 26 
 Modern aids in diagnosis, 179 
 Moebius, 97 
 
 Monkeys, inoculation of, 14 
 Morphia, 160 
 
 — hypodermic, 68, 103 
 Motor paralysis, 64 
 Mott, 96 
 
 Mouth, hygiene of, 113, 137 
 
 — wash, 137 
 
 Mucous membranes, secondary affec- 
 tions of, 57 
 
 — patches, 58 
 
INDEX 
 
 193 
 
 Mucous membranes, patches of 
 
 genital organs, 59 
 Muscles, tertiary diseases of, 82 
 Myelitis, 93 
 Myositis, chronic infiltrative, 82 
 
 — gummatous nodular, 82 
 
 — hyperasmic, 82 
 
 Nails, secondary affections of, 61 
 " Needle, fear of the," 160 
 Needles, 164 
 Neisser, in, 172 
 
 — experiment, 181 
 Nephritis, 49 
 
 — interstitial, 81 
 
 Nervous system, secondary affec- 
 tions of, 64 
 
 — tertiary affections of, 90 
 Neuralgia, 64 
 
 Neuritis, optic, 66 
 Neurones, dystrophy of, 96 
 Nitrate of silver, 58, 60 
 Nitric acid, 43, 44, 60, 62 
 Nocturnal headaches, 64, 175 
 Nose, syphilitic affections of, 59 
 
 Ocular chancre, 34 
 Ointment, mercurial, 46, 72 
 Metchnikoff's, 41, 43, no 
 
 — white precipitate, 61 
 Okamura, 2 
 
 Oleate of mercury, 43 
 
 Olein, 158 
 
 Oleum cinereum, 155, 157 
 
 Olive oil, 144 
 
 Onychia, 61 
 
 Opaline patches, 57 
 
 Optic atrophy, 103 
 
 — neuritis, 66 
 Orchitis, 68 
 Osteoperiostitis, 83 
 Osteotic pains, 47 
 Oviedo, 5, 6 
 
 Pain after injection, 148, 152, 155, 
 
 159 
 Pains, neuralgic, 47 
 
 — osteotic, 47 
 
 — periosteal, 175 
 
 — rheumatic, 48 
 
 — rheumatoid, 67 
 Palate, gumma of, 76 
 Palmitin, 158, 159 
 Palpebral chancre, 34 
 Panarteritis, 86 
 Panas, 151 
 
 Papular syphilides, 51, 53 
 Paraffin, liquid, 144 
 Paralysis, general, 104 
 
 — motor, eye and face, 64 
 Paraplegia, 92, 93 
 
 — early, 64 
 Parasyphilis, 10, 96 
 Parchment-like sore, 18 
 
 Parenchymatous iritis, 62 
 
 Parenga (Yaws), 31 
 
 Paronychia, 61 
 
 Pasteur, n 
 
 Patellar bursa?, 82 
 
 Pathology of syphilis, 9 
 
 Peninsular War, 112, 128 
 
 Penis, chancres of, 23 
 
 Perforating ulcer, 107 
 
 Perhydrol (Merck), 43, 58, 72, 76, 
 
 77, 113, 114 
 Peri- arteritis, 10, 86 
 Perihepatitis, 79 
 Periosteal pains, 175 
 Periostitis, 66 
 Peroxide of hydrogen, 59, 76, 113 
 
 lotion, 42 
 
 " Petit Mai," 108 
 Phagedasnic chancres, 43 
 Pharynx, hyperemia of, 48 
 
 — tertiary affections of, 77 
 Phenacetin, 103 
 
 Pian (Yaws), 31 
 Pigmentary syphilides, 56 
 
 retiform, 56 
 
 Plan of treatment, 166 
 
 " Plaques," 48, 58 
 
 Plastic iritis, 62 
 
 Platinum, in 
 
 Pleural effusion, 66 
 
 Plummer's pill, 58 
 
 Potassium, chlorate of, 58, 113 
 
 — iodide, 95, 103, 109, in, 175 
 rules for, 176 
 
 Prehistoric existence of syphilis, 2, 3 
 Prepuce, chancres of, 24 
 Prescriptions, 76, 113, 117, 118, 150, 
 
 151, 157, 158, 161, 162 
 Profeta, 143 
 
 Proto- iodide of mercury, 118, 119 
 Psoriasis, 50 
 
 — of the tongue, 58 
 
 Pupil, Argyll- Robertson, 96, 99, 106 
 Pustular syphilides, 55 
 
 Quaternary syphilis, 96 
 Quinine, 168 
 
 Ravant, 94, 97 
 
 Rectum, tertiary affections of, 81 
 
 Recurring chancre, 20 
 
 Relapsing chancre, 21 
 
 Resorcin, 60 
 
 Retiform pigmentary syphilide, 56 
 
 Retinitis, 63 
 
 Reuter, 13 
 
 Rheumatic pains, 48 
 
 Rheumatoid pains, 67 
 
 Ricord, 7 
 
 Ricord's pills, 120 
 
 Fournier's modification of, 124 
 
 Robertson, Argyll-, pupil, 96, 99, 
 
 106 
 Robertson, Ford, 98 
 
 13 
 
194 
 
 INDEX 
 
 Rochester Row, formulae at, 135, 137 
 
 Romberg's sign, 100 
 
 Roseolar syphilides, 52 
 
 Roux, 8, 14, 179, 182 
 
 Rubbing, mode of, 136 
 
 Rupia, 55 
 
 Salicylate of mercury, 118, 165 
 Salivation, 112, 129 
 Salmon, 1J0 
 Sarsaparilla, in 
 Sassafras, in 
 Scarenzio of Pavia, 142 
 Schaudinn, 8, 12, 13, 179 
 Scotland, syphilis in, 7 
 Scrotum, chancre of, 23 
 Secondary period affections, 45 
 
 albuminuria, 49 
 
 angina pectoris, 49 
 
 cachexia, 47 
 
 eruptions, 49 
 
 eye, 62 
 
 glandular, 46 
 
 hair, 60 
 
 joint, 67 
 
 laryngeal, 60 
 
 mucous patches, 59 
 
 nerve, 64 
 
 nose, 59 
 
 onychia, 61 
 
 orchitis, 68 
 
 paronychia, 61 
 
 periostitis, 66 
 
 syphilides, 49 
 
 tenosynovitis, 68 
 
 tongue, 57 
 
 tonsils, 48 
 
 visceral, 66 
 Sedillot's pill, 117 
 Seigel, 12 
 Senarega, 6 
 
 Serum, anti-syphilitic, 14 
 Sicard, 97 
 Silver, in 
 Silvery spot, the, 19 
 Sites for injection, 165 
 Sleeping sickness, 170 
 Smirnoff, 143 
 Soamin, 171 
 Sodium chloride, 151 
 
 — iodide, 151 
 
 — paraminophenylarsonate, 171 
 Soft chancre, diagnosis of, 28 
 Soluble salts, injection of, 152 
 Spinal cord, tertiary syphilis of, 93 
 Spirochseta balantiditis, 180 
 
 — pallida, 8, 12, 14, 27, 70, no, 180 
 examination for, 15 
 
 — refringens, 12, 180 
 Spitza, 13 
 
 Spleen, tertiary affections of, 80 
 Spondylitis, syphilitic, 83 
 Spontaneous fracture, 107 
 Squamous syphilides, 51, 54 
 
 Starch, 60 
 Stark, 143 
 
 Statistics, cerebral syphilis, 91 
 Stearin, 158 
 Stewart, Purves, 98 
 Stirling, 158 
 
 Stomach, tertiary affections of, 81 
 Stomatitis, 112, 129 
 Stricture of rectum, 81 
 Sublimate, 118, 149, {see Mercury 
 bichlor.) 
 
 — gastralgia, 121 
 
 — solution, 42 
 Sub-preputial chancres, 24 
 Sulphur, in 
 
 Susrutas, 2 
 
 Sycosis, 35 
 
 " Sykos " of the Greeks, 2 
 
 Syme, 129 
 
 Synovitis, secondary, 68 
 
 — tertiary, 84 
 Syphilides, 49 
 Syphilis, history of, 1 
 
 — pathology of, 9 
 
 — prehistoric, 3 
 Syphilo-dermata, 49 
 Syphilophobia, 147 
 
 Tannate of mercury, 118 
 Tattooing, infection by, 36 
 Taylor, 19 
 
 Technique of the external method, 
 132 
 
 — of the intramuscular method, 164 
 Tendons, secondary affections of, 68 
 
 — tertiary diseases of, 82 
 Teno-synovitis, 68, 82 
 Tertiary affections : 
 
 alimentary system, 72 
 
 arteries, 86 
 
 bones, 83 
 
 bursae, 82 
 
 circulatory system, 86 
 
 fingers, 85 
 
 joints, 84 
 
 kidneys, 81 
 
 larynx, 78 
 
 lips, 72 
 
 liver, 79 
 
 lungs, 78 
 
 muscles, 82 
 
 nervous system, 90 
 
 palate, 76 
 
 pharynx, 77 
 
 rectum, 81 
 
 skin, 70 
 
 spinal cord, 93 
 
 spleen, 80 
 
 stomach, 81 
 
 tendons, 82 
 
 testes, 85 
 
 toes, 85 
 
 tongue, 72 
 
 trachea, 78 
 
INDEX 
 
 195 
 
 Tertiary syphilis, 69 
 
 Testicle, secondary affections of, 68 
 
 — strapping, 86 
 
 — tertiary affections of, 85 
 Thucydides, 2 
 
 Tinea circinata, 54 
 
 Toes, tertiary affections of, 85 
 
 Tongue, cancer of, 74 
 
 — chancre of, 33 
 
 — fissures of, 75 
 
 — gummata of, 74 
 
 — superficial affections of, 57 
 
 — tertiary affections of, 72 
 
 — ulcers of, 75 
 Tonsils, chancre of, 34 
 
 — hyperaemia of, 48 
 Torella, Gaspard, 128 
 Trachea, tertiary affections of, 78 
 Treatment, duration of, 167 
 
 — plan of, 166 
 
 — Zittmann's, 169 
 Treponema pertenue, 31 
 True relapsing chancre, 21 
 Tubercle, differential diagnosis, 77 
 Turkish baths, 114, 175 
 
 Uhlenhuth, 170 
 
 Ulcerative gummatous syphilides, 71 
 
 Ulcerative paronychia, 61 
 Ulcers of tongue, 75 
 Unguentum hydrarg., 43 
 — G.P., 135 
 Urethra, chancres of, 22 
 Urinary meatus, chancres of, 22 
 
 Vaccination chancre, 36 
 Van Swieten's liquor, 118, 124 
 Vegetating papules, 59 
 Vesicular syphilides, 51, 55 
 Visceral affections, secondary, 66 
 tertiary, 79 
 
 Wallender's bag, 114 
 
 Ward, Major, 170, 173 
 
 Wassermann's reaction, 103, 182 
 
 Weigert, 12 
 
 West Indian Islands, 1, 5 
 
 Westphal's sign, 100 
 
 White precipitate ointment, 61 
 
 Whitlow, 35 
 
 Widal, 94, 97 
 
 Yaws, 31 
 
 Yellow wash, 42, 60 
 
 Zittmann's treatment, 169 
 
 Bailliire, Tindall & Cox, 8 Henrietta Street, Covent Garden. 
 
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Lambkin 
 Syphilis, 
 
 RC201.2 
 
 L17 
 
 1911 
 
 COLUMBIA UNIVERSITY LIBRARIES (hsl stx) 
 
 RC 201.2 L17 1911 C.1 
 
 Syphilis : 
 
 2002059746