COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD i HX00049727 RECAP RC20I VI tntlieCttpofl^tttjgork CoQege of 3^l)p6imn6 avib ^urseonK Uibrarp PRACTICAL CLOICAL LESSONS o:s[ SYPHILIS A2sB THE . GENITO-URI>TARY DISEASES VOL. I SYPHILIS Al^D OHAlsrOEOID BY FESSENDEN^ N. OTIS, M.D. CLINICAL PROFESSOR OP GEXITO-URINARY DISEASES IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK; SURGEON To CHARITY HOSPITAL; COXSULTINO SURGEON TO ST. ELIZABETH'S HOSPITAL, TO THE NEW YORK SKIN AND CANCER HOSPITAL, AND TO THE COLORED ORPHAN ASYLUM ; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE ; MEMBER OF THE BRITISH MEDICAL ASSOCIATION, ETC. NEW YORK BEEMINGIIAM & CO 1883 Copyright, 1883, by Bermingham & Co. TO WILLARD PAEKER, M.D., LL.D. EMERITUS PROFESSOR OF SURGERY IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. RENOWNED AS A TEACHER, DISTINGUISHED AS A SURGEON, EMINENT AS A CITIZEN, UNIVERSALLY BELOYED FOR HIS NOBLE NATURE AND HIS GENEROUS ACTS, @;i)is toork, WITH HIS CONSENT, IS GRATEFULLY AND AFFECTIONATELY DEDICATED BY ONE, AMONG THE MANY, OF HIS MEDICAL BRETHREN, WHO OWE TO HIM — NOW FULL OF YEARS AND HONOES — THE GREATEST MEASURE OF THEIR PROFESSIONAL SUCCESS. PREFACE. For a number of years it has been my Custom, to dis- tribute, from time to time, to the students of the Col- lege of Physicians and Surgeons, short papers, of a few pages each, which were entitled " Class-room Lessons." In these I endeavored to embody important principles, in the study of syphilis and the genito-urinary diseases. The lessons were intended to prevent errors, arising from inattention, or from misunderstanding of the state- ments made during the lectures in the college, and at Charity Hospital. This was rendered especially neces- sary, from the fact that my own views, on certain im- portant points, differed, essentially, from those embodied in the text-books in general use. In the first place, on the subject of syphilis : I had been unable to accept the statements of all authorities, that it was a mysterious, instantaneous, poisoning of the organism, in defiance of all known physiological and pathological laws. A care- ful study of the matter, in connection with modern dis- coveries in physiology and pathology, had convinced me, that an explanation of all the lesions and m.anifesta- tions of syphilis was possible, through known phj'siologi- cal and pathological processes, and that, the then uni- versally accepted view of the supernatural advent and behavior of syphilis, was incorrect. This position was taken, in my lectures in the college, in 1868. In 1870, it was presented to the medical profession, in a paper be- fore the Medical Society of the county of New York, and was followed by another paper, on the same subject, in 1871. Up to that time, no systematic effort had been made to explain the various manifestations of syphilis, on a scientific basis. In 1866, Beale had claimed, from his investigations of variola and the cattle disease, the 6 PREFACE. presence of a germinal cell, as a cause of syphilis. Bei- siadecki, of Krakow, had published, in 1867, the results of his microscopical examination of infecting chancre, in which he showed a localized proliferation of cell ele- ments in the lymphatic vessels, as a starting-point in syphilis, and claimed that this migJit afford an explana- tion, through which the general infection might be ex- plained. I took up the matter at this point, and through the results of pathological and histological researchcc of accepted authorities in pathology and histology, in other fields, succeeded, as I believed, in explaining the various' syphihtic phenomena throughout the entire course of the disease. A review of my papers, in the London Lancet of Nov. 9th, 1872, concluded with the statement that '' these new views on the physiology of syphilitic infection are not based upon the results of any experi- ments or new facts, or on the unravelling of observa- tions. They consist mainly of deductions drawn from a close and elaborate reasoning on the acknowledged features of syphilis in connection with the latest doc- trines and hypotheses of certain pathological teachers." Starting with the disease-germ, derived from the de- graded human germinal cell of Beale, supported by the microscopic examinations of Beisiadecki and Verson, as to the proliferation of new cell material at the site of syphilitic inoculation, and extending only in the hue lymph channels ; supported still farther by the clinical facts, in regard to gradual implication of lymph vessels and glands, by the known physiological processes in health, and under the influence of syphilitic infection, and also through the concurring testimony of such his- tological and pathological authorities as Chaveau, Beale, Schweiggerseidel, Strieker, KoUiker, Teichman, Kohn, Conhiem, Beisiadecki, and others, I was enabled to present a reasonable explanation of the course of syphihs, from its inception to its termination. It was scarcely to be expected, that such a radical departure from the views of the text-books, would be received without discussion; but the position taken was so amply supported by all known pysiological and patho- logical facts, that no opposing arguments were oifered. PREFACE. 7 The first authoritative publication in America which followed, practically adopted and supported the new views thus: (Bumstead and Taylor, N. Y., 1869, 4th ed. page 443) '' The secretions of syphilitic lesions are found to consist of a serous fluid containing numer- ous granules or molecules, which are masses of proto- plasm or germinal matter holding the contagious properties of syphilis. These microscopic bodies are probably taken into the circulation by the lymphatics, and con- veyed over the body. . . In the secondary period of syphilis these cells are very numerous, and the body may be covered with papules and tubercles composed of them. . . As the disease wanes . . the cells no longer have a tendency to reproduction which characterizes them in the early stages, but rather degenerate. Hence we consider the blood and the secretions in tertiary syphilis innocuous!' * The same views of syphilitic infection were presented in the second edition of Berkeley Hill's work, by Berk- eley Hill and Arthur Cooper, London, 1881 (p. 75), and erroneously attributed to Auspitz of Vienna (al- though in a foot-note the reader is referred, for further information on the subject, to my work on the Physio- logical Pathology and Treatment of Syphilis) thus : " The syphihtic virus enters the system by the absorb- ents. It first sets up plastic growth in the walls of the lymphatic vessels at the part where it is implanted. These walls thicken and throw off into their interior, cells which contain the virus ; as these cells float along they convey the virus still further inwards. But the infiltration of successive parts of the walls of the lym- phatic vessels also conducts the virus inwards. When a lymphatic gland is reached, the same proliferating pro- cess ensues in the gland, until the cells are sent off through the effersent ducts to other glands, and so on to the thoracic duct. Thence cells, containing the virus, are poured, direct into the circulation, by the veins, and are thus quickly carried to the several tissues of the body. Then appear the signs of general constitutional infection.'' * Italics my own. S PREFACE. Again, in the work of M. Cornil on syphilis (Paris, 1878), translated and edited by Profs. Simes and White, of the University of Penns34vania, '* with the consent and ap- proval of the author," and pubhshed in 1882, this same view of the mode of syphihtic infection, is extracted from my book, preceded by a statement (p. 21) of opinion that, " it presents fewer inconsistencies than any of the other the- ories /' and on page 23, " that it seems impossible, in the light of certain well-known facts, to deny that the syph- ilitic poison gains access to the general circulation, chief- ly, if not entirely, by the lymphatics ;" and again, page 25, "the action of mercury in relieving the early symp- toms, also becomes intelligible in the light of this the- ory, through its influence in hastening destructive met- amorphosis and bringing about fatty degeneration ; and its general undoubted tendency to relieve tissues encumbered with superfluous material. Small doses, most naturally, first influence newly-formed immature deposits, such as those due to syphilis, and hence the advantage of the modern treatment, which avoids sali- vation, due to the toxic action of the drug on the healthy tissues, and depends upon moderate, long-continued doses. The necessity for the use of iodide of potassium, in the later stages, with or without mercury, also becomes apparent, when it is remembered that iodine is the most powerful diffusible stimulant of the function of absorp. tion. with which we are acquainted, and that also, it has a certain established value, in hastening tissue change, especially in unhealthy formations." In view of the direct, or implied, approval of my posi- tion, by these recent eminent authorities in matters in- volving the nature, behavior, and treatment of syphilis, it has seemed proper that I should make use of every opportunity to advance these views, and to explain, on physiological and histological grounds, the various pomts in the diagnosis and treatment of cases of spyhi- lis and its sequelas, herewith presented. In the second place : Early in my clinical teaching, I had found myself unable to accept the conventional views, held by authorities on many important points in genito-urinary diseases. Especially as to the nature PREFACE. 9 and treatment of gonorrhoea and urethral stricture and the normal urethral calibre. As to the latter, I could not accept the standard universally taught, but claimed, from actual measurements, an individuality for every urethra, a proportionate relation, between the size of the urethra and the organ in which it is situated, and an average calibre, much greater than previously esti- mated. I also claimed, contrary to all previous teach- ing, a radical cure of urethral stricture, through com- plete division. These views, and others growing out of them, involving important questions in practice, sup- ported by several hundreds of practical examples, de- fended in written and in oral debate, against eminent authorities in this country and in Europe, made it es- pecially necessary for me to have a medium of com- munication with students, which could not be misin- terpreted or misunderstood. With an especial view to this, the second volume of this work was suggested. No attempt has been made to make it a systematic general exposition of genito - urinary diseases. The aim has been, chiefly, to present clinical cases, selected as typical and practical, which have been subjects of ob- servation and study, in my private practice, and in my cliniques, and such additional material illustrative of important practical points, and m}^ own experience in the treatment of such cases, as I could readily com- mand. When some learned and not too busy surgeon, in gathering, from every quarter, the material for a full and systematic treatise on genito-urinary troubles, meets the everyday experiences which have been pre- sented in the foregoing pages, it is my ambition, that some points may be found among them, which will be considered worthy of preservation, in more pretentious form. Meanwhile, I trust that many surgeons may find, in th.e cases recited, and in the principles and treatment advocated, a key which will help to explain much that has heretofore appeared obscure, and difficult of man- agement. F. N. Otis. New York, 108 West 34th Street, April 30, 1883. CONTENTS. LESSON I. PACK Nature of Gonorrhoea, Chancroid, and Syphilis — The Initial Lesion of Syphilis 17 LESSON IL The Initial Lesion of Syphilis — {Continued^ 27 LESSON in. The Initial Lesion of Syphilis — {Continued) 32 LESSON IV. Syphilis by Hereditary Transmission 42 LESSON V. Early Differential Diagnosis 50 LESSON VI. Progress of the Syphilitic Infection 56 LESSON VIL Varieties and Complications of the Initial Lesion of Syphilis 61 13 CONTENTS. LESSON VIII. FAQB Treatment of the Initial Lesion of Syphilis 66 LESSON IX. Early Constitutional Forms of Syphilis « 71 LESSON X. The Treatment of Syphilis in the Acute Stage 81 LESSON XL Clinical Cases, Illustrative of the Various Forms which the Initial Lesion may Present, and of the Various Lesions Associated with and Following the same 87 LESSON XIL Gangrenous Initial Lesion, or so-called Phagedenic Chancre 97 LESSON XIII. Polymorphous Character of Syphilis in some Cases and Absence of Characteristic Lesions in Others lOl LESSON XIV. Mucoid Form of the Initial Lesion 108 LESSON XV. Clinical Case Illustrative of the Results of Treatment 118 LESSON XVI. Results of Tresitment— {Continued) 124 CONTENTS. 13 LESSON XVII. PAca Sequelae of Syphilis 128 LESSON XVIII. Non-Contagiousness of the Late Lesions of Syphilis 167 LESSON XIX. Gummy Tumor of Bone, Loss of Substance without Caries — Syphi- litic Dactylitis 183 LESSOM XX. Syphilitic Sequelae Involving Nasal Bones, Vomer, and Vault of the Hard Palate 189 LESSON XXI. Gummy Tumor of Bone, Producing Brain Symptoms 193 LESSON XXII. Late Brain Lesions of Syphilis 199 LESSON XXIIL Syphilib of Infants and Hereditary Syphilis 204 LESSON XXIV. Chancroid: Its Nature and Treatment 207 LESSON XXV. Nature of Chancroid — Contimied) ». 217 14 CONTENTS. LESSON XXVI. PAQK Does Diagnosis of Chancroid rest upon Character of Lesion or upon its Source? 225 LESSON xxvn. Origin of the Chancroidal Abrasion ,.,.,,, 229 LESSON XXVIIL Chancroid Modified by Condition , 236 LESSON XXIX. Diagnosis and Treatment of Chancroid 240 LESSON XXX. Diagnosis and Treatment of Chancroidal Bubo and Bubonic Chan- croid 250 Remedies and Remedial Agents referred to in this Volume, and their Application , 258 PRACTICAL CLINICAL LESSONS ON Syphilis and the Genito-Urinary Diseases. LESSON I. Nature of Gonorrhoea — Of Chancroid — Of Syphilis — Infective Princi- ple of Syphilis a living Germinal Cell — Its History dating back over 2000 Years B.C. — Syphilis never of Spontaneous Origin — Always Ac- quired from a Human Being suffering with Syphilis — Always Requir- ing a Breach of Surface for its Introduction — The Virus of Syphilis not an Irritant — The so-called Incubation of Syphilis — Its Practical Importance — Admixture of Syphilitic Secretions with Vicious Uterine Secretion a common cause of error in Diagnosis — The Initial Lesion of Syphilis due to a Localized Cell Proliferation — Not Necessarily resulting in an open Lesion — Clinical Cases illustrative of the Devel- opment of the Initial Lesion of Syphilis — Treatment by Excision. Gentlemen : Through the light of modern teaching and experience, we recognize three separate and distinct contagious diseases resulting from venereal contact; viz., Gonorrhoea, Chancroid, Syphilis. 1st. GoNORRHCEA. — A vicious, non-specific inflamma- tion of mucous membrane, characterized by free puru- lent secretion without ulceration, chiefly occupying the urethra of the male, and the vagina and urethra of the female ; exceptionally, the mucous surfaces of the blad- der, the eye, the nares, the rectal and buccal cavities ; usually, though not necessarily, of venereal origin ; its contagious property transferred to sound mucous mem- brane without breach of tissue ; its action immediately following contact; its vicious principle incapable of f8 PRACTICAL CLINICAL LESSONS ON transmission through the general circulation; its occur- rence predisposing to subsequent attacks. 2d. Chancroid. — An acute, contagious ulcer of vene- real origin, whose contagious property is incapable of contaminating the blood, and hence can never estab- lish a constitutional disease, nor be acquired by hered- itary transmission ; is characterized by an acute ul- cerative action, with free suppuration ; is commonly initiated through a breach of surface, but possibly oc- curs upon sound tissue ; is usually multiple, and may occur repeatedly in the same individual. 3d. Syphilis. — A specific, contagious, constitutional disease, caused by the inoculation, upon any part of the human body, of a peculiar principle or contagium called the Syphilitic virus ^ which, after an indefinite period of apparent rest, or so-called incubation, produces, at the point of inoculation or entrance of the contagiiL7it^ a characteristic lesion; this followed by another period of apparent rest, to which succeeds a group of well-estab- lished evidences of the contamination of the general system. The characteristic initial lesion is usually soli- tary; sluggish, and non-suppurative in its development; inoculable with difficulty upon the person bearing it; and as a rule occurs but once in the same individual. During the course of clinical lessons which we inaug- urate to-day, I propose presenting to you cases of each one of the above-named diseases, under a variety of cir- cumstances and in different phases of their development. However ample the field from whence clinical cases are drawn, it is scarcely possible always to secure such a choice as will permit the pursuance of a rigidly sys- tematic arrangement in their presentation ; I shall, how- ever, endeavor to select the cases so as to show you the consecutive manifestations or lesions of each disease, as far as circumstances will allow. To-day I purpose presenting to you a number of persons exhibiting one or more phases of the most im- portant of the three diseases just mentioned, viz.. Syphi- lis. This disease is produced by the inoculation of a specific virus upon any part of the human body, as pre- viously stated. Of the origin, nature or composition of SYPHILIS AND THE GENITO-URINARY DISEASES. 19 this virus — vital, physical or chemical — we know prac- tically but little. The microscope has been brought into requisition by distinguished experts through the last quarter of a cen- tury, with the expectation of isolating and analyzing this so-called virus, but it has eluded all search. Simi- lar investigation as to the origin of such contagious dis- eases as variola, vaccinia, relapsing fever, and the cattle- plague,^ have resulted in establishing the fact that a de- generated, living, germinal cell contains the infective principle or contagium, the so-called virus, through which these diseases are communicated. Beale was the first to claim that a similar origin would be found for syphilis, but he failed to make the actual discovery. As we pro- ceed, however, it will be found that much valuable cir- cumstantial evidence will be met, in corroboration of Beale's view, and afford a possible interpretation of the syphilitic processes in harmony with recognized physio- logical and pathological laws. Of the history of syphilis so much has been written that I have not the time, if I had the inclination, even to epitomize the labors of syphilitic historians. I will briefly state that books have been written to fix its ori- gin at about the fifteenth century, attributing it to the effects of excesses in camp at the Siege of Naples, 1494 ; others to prove that it originated in America, and was carried to Europe by Columbus at about the same period ; others, again, and with more reason, assert that Moses, the great Jewish lawgiver, knew about it; and the dispute as to the bad eminence of having originated syphilis ran high, and higher, involving poets, historians and doctors, getting up no end of bad blood, until a re- cent time (1863), when a Frenchman, Capt. Dabry by name, in translating a very ancient record of Chinese medical lore, found this same syphilitic disease thor- oughly described in its various stages as existing and flourishing over two thousand years before the Chris- tian era. Its antiquity, and its prevalence to a greater or less * Bcalc on the Nature and Origin of Disease Germs. 20 PRACTICAL CLINICAL LESSONS ON extent in every known country, enable us safely to affirm that it has not been from lack of opportunities to study the development of syphilis that its constituent elements are unfamihar to us. On the contrary, it has been observed with probably moi'e care, with more scrupulous nicety, with more laborious and painstaking accuracy, than any other disease with which the human race are, or ever have been, afflicted. It has not only been studied and observed by the keenest, the most eru- dite, the most profound practitioners and philosophers the medical profession has ever produced, but it has been the altar upon which not a few have offered up their own bodies as subjects of scientific experiment, throwing health — even Hfe itself — into the investigation of this foulest and most terrible disease. With the great John Hunter heading the list, fully half a score of recorded names attest the courageous self-abnegation, the grand enthusiasm of our professional brethren in the past, whose labors and sufferings furnish us to-day with all-important and indisputable facts concerning the evolution and development of syphiUs. Through such earnest investigations, and by extended observa- tion of the disease as accidentally acquired, it has been accepted — I St. That syphilis is never of spontaneous origin; that no emanations from natural causes, no admixture of diseased conditions, no intermingling of necrotic ele- ments, no combination of vicious indulgence, is capable of establishing this disease de novo. It has always and invariably as a starting-point a human being suffering with syphilitic disease. Every syphilitic has contracted his syphilis from some antecedent syphilitic — has re- ceived into his blood a virus or contagium which has circulated in the blood of another suffering with syphi- litic disease. 2d. That for its introduction into the human system it requires a breach of surface — a solution of continuity ; that it is not absorbed through sound tissues; that it is not acquired through inhalation. An entrance of the syphi- litic principle always requires a pre-existing artificial port of entry. This may be accepted as an unvarying SVPlilLiS AND THE GEKlTO-tJRiNAkY DISEASES. 21 rule as regards the acquirement of syphilis. The child may contract the disease in utero from the diseased blood of the mother. The mother may, it is claimed (not proven), become infected through the child in her womb, diseased by the influence of the male parent. These possible exceptions do not invalidate the spirit of the law requiring a breach of continuity for the en- trance of the syphilitic virus into the human organism. Though the constituent elements of the syphilitic virus are not known, this much we do know, viz., that the secretion emanating from a certain well-recognized kind of sore, — which we call the chancre, or the initial lesion of syphilis, — when introduced, by the aid of a lan- cet, under the cuticle, or applied to an abraded surface anywhere upon a healthy individual, produces, after a definite period and with absolute certainty, a lesion presenting similar characteristics, and is followed by certain other evidences of a contamination of the system which cannot be produced by any other known agency. We know also that the aforesaid secretion in which the virus is hidden, when free from extraneous matters, is of a bland, unirritating nature in its local action upon living tissues ; that, introduced through an artificial puncture or an accidental abrasion, it gives no immedi- ate token of its power — it does not in any way interfere with the natural, rapid and complete healing of the wound. In this particular there exists a radical differ- ence between the syphilitic virus and that of the local contagious ulcer called the Chancroid, and of the puru- lent secretion of a Go7torrkcea ; both of which produce an immediate inflammatory action on the site of their initiation. Given, then, a case in which the syphilitic virus has been introduced into the system through a puncture or an abrasion and has been succeeded by a complete healing of the wounded part, let us consider what fol- lows. 1st. A period of incubation, so called, — a period of apparent rest ; a period during which the subject of the experiment is entirely free from the least evidence of the introduction of the poison into his economy, either S2 PRACTICAL CLINICAL LESSONS ON at the point of inoculation, or through any constitutional disturbance or internal or external sensation of any de- scription whatever. No feature in the development of syphilis is of more practical importance than this period of apparent incu- bation. A failure to appreciate it is fraught with dis- comfiture to both physician and patient. Lulled into a false security by the healing of a lesion following an illicit venereal contact — even assured of freedom from disease by his medical adviser — many an unfaithful benedict returns to his marital allegiance, only to realize the disaster after an innocent wife has been infected with syphilis, and through her the disease, it may be, trans- mitted to a luckless embryo. The period of apparent incubation, according to au- thorities, varies in different subjects from ten to seventy days. The causes of this variation are not well under- stood. It is supposed by some to depend upon the de- gree of activity of the particular specimen of virus in- oculated ; by others upon some pecuhar condition or idiosyncrasy of the subject. The fact, however, that in the great majority of cases of experimental inoculation of the virus, from whatever source, the results are much more uniform, being seldom less than eighteen nor more than thirty-five days, would lead to the belief that other influences than quality of the virus or peculiarity of the individual affects the term of apparent incuba- tion. Experiments in regard to the contagiousness of non-specific pus have demonstrated its erosive property under certain conditions. Secretions from a diseased uterus, and even from the Schneiderian membrane, are known to produce excoriation of sound mucous tissues and of integument, and even to set up a true ulcerative process. We may then easily admit the possibihty of admixture of the simple non-irritating secretion from an intra-vaginal syphilitic lesion with secretion from a diseased uterus, capable of effecting a solution of continuity in sound tissue ; the time required for such an effect varying with the degree of irritant power and the condition of the part to which it is applied. Thus, in the folds of integument upon the penis, SYPHILIS AND THE GENITO-URINARY DISEASES. 23 where heat and moisture are at the minimum, with even a decidedly vicious secretion, many days might elapse before the dry cuticle would be eroded sufficient- ly to afford entrance to the accompanying syphilitic poison ; or, on the contrary, should the secretion be applied to the moist delicate lining of the prepuce, the solution of continuity would be greatly facilitated. Again, in case of fracture of the skin or mucous mem- brane, ulcerative action might be, set up coincidently with the vicious contact; and yet in neither case Avould the lesion be due to or indicative of the presence of the syphilitic virus. And this fact, that the syphilitic virus may be associated in the same individual with vicious uterine secretions, and also with the specific secretions of chancroid capable of effecting a solu- tion of continuity in sound integument or mucous membrane, naturally leads to frequent errors in diag- nosis. There is, I repeat, absolutely nothing in the condition of the patient, at the point of entrance of the syphilitic poison, or at any other point, which can be considered a proof of syphilitic infection, until the termination of the (so-called) period of incuba- tion. And this time is announced by a peculiar change in the condition of the tissues at the point of entrance of the virus, and nowhere else; this change, too, occurring equally whether an abrasion or ulceration has been previously established at this point by other causes, or when the healing has immediately followed the intro- duction of the virus. An exudation or development of cellular and fibro-plastic material takes place in the tissue at the point of entrance of the contagiurn; and this pro- cess results in an iyiduration perceptible to the touch, and establishes a well-defined characteristic mark of syphili- tic infection. This, under the microscope, is found to consist of lymphoid or germinal cells apparently accu- mulated and proliferated in loco, as a direct result of the syphilitic inoculation. The excessive localized prolifer- ation of cell elements constitutes a marked feature in every stage of syphilis. Its first appearance at the site of entrance of the poison forms the initial lesion, or the first positive manifestation of the syphilitic influence. The 24 PRACTICAL CLINICAL LESSONS OM course and duration of the initial lesion varies in different subjects, in some cases appearing as a nodule covered by sound cuticle or mucous membrane, varying from a slight increase in thickness to a distinct cartilaginous nodule as large as a pea. It may remain stationary for a time, and then terminate in resolution — that is to say, undergoing fatty degeneration, become quietly ab- sorbed ; or it may take on a more active process, in- volving the destruction of the overlying tissue and an acute disintegration of its elements ; carrying away with them a certain limited amount of the original cellular tissue involved in its meshes, and producing an ulcer- like lesion, but which, however, is independent of true ulcerative action ; its secretion thin and serous, made up, not of pus, but of hastily generated cell material ; its natural course sluggish, and but little influenced by local treatment ; healing at last, over the induration, while the induration continues dense and characteristic, not unfrequently throughout the entire course of the constitutional disease. Some of the points of interest in regard to the incu- bation and induration of syphilis, which I have briefly set forth, will be apparent in the cases which are now before you. From the first, James- B., aged 23, we glean the history of an exposure about the 13th of August last, followed by a soreness of the " bridle*' or frenum, which lasted for two or three days, from which time nothing especial was observed until the second week in September, when he noticed a *' bunch" in the loose tissue of the frenum which became chafed about a week ago, and made a sore, and which grew gradually larger up to the present time. It is now, as you can see, about the size of a threepenny piece, shallow and smooth, presenting a fine granular surface with but httle moist- ure. As you pinch it up between your thumb and finger, the induration of which I have spoken may be distinctly felt ; and I present this case to illustrate the history of its origin, and which is classical for a single variety, and that you may test the induration, which is well marked. In Case II., George W., a baker, aged 19, presents SYPHILIS AND THE GENltO-URlNARY DISEASES. ^5 three points of apparent ulceration, one upon the side of the frenum about the size of a split pea, and two a little larger, in the furrow behind the glans penis. George has no distinct remembrance of the time after exposure when these sores first appeared, but thinks about a week or ten days ; has had them about a fort- night ; has been to a physician, *' who burned them with caustic" several times. The true syphilitic lesion is usually, though not al- ways, solitary, as in the case first presented. Here the existence of three points of lesion, and appearing within two days from exposure, militates against the idea of their syphilitic nature. You will also remember that the characteristic syphihtic lesion at the point of en- trance of the virus is seldom less than 1 5 or more days. There is, however, a distinct induration about the base of these sores, little if any less than that which you recognize in Case I. But when I tell you that simple sores and even incised wounds become indurated by irritant applications, and you recall the patient's state- ment that these have been " burned out with caustic," you will realize the difficulty of making a clear diagnosis at present. We will advise a simple water dressing, and if the induration is due to the application of the caustic it will soon disappear. Case III. We have here in a patient, 36 years of age, a mass of induration of the size of a hickory-nut, devel- oped in the tissue of the inferior portion of an elongated prepuce. Phymosis, or closure of the preputial orihce, has resulted, and is almost complete. He complains, from this cause, of much difficulty in passing his water. On pressure, a gray, serous-looking fluid exudes from the preputial orifice ; a shallow excoriation of its inner surface is observed when the prepuce is strained back. The glands of the groin are distinctly enlarged, but pain- less ; a distinct papular eruption covers his chest, arms and back. The history of this patient develops an ex- posure two months ago — not for a month previous, and not since. Three weeks after connection he noticed a " hardness," about the size of a pea, inside the prepuce, which has been growing ever since. He has had no 26 PRACTICAL CLINICAL LESSORS ON trouble from it except the pain in passing water. This case appears to me a clear one of syphilis. If the indu- ration and its history were not sufficient, we have posi- tive proof in the additional evidence furnished by the glandular swellings and the coppery papular eruption — the significance of which I shall have occasion to refer to on a future occasion. An operation is here called for, to remove the indurated mass on account of the phymo- sis which it has occasioned. I shall, therefore, proceed to remove the entire prepuce by the introduction of a director upon the superior surface of the glans, and back as far as the fossse ; then passing along it a curved bistoury, I bring it out over the fossae glandis, and, di- viding the intervening tissue, remove the redundant mass, including the induration, with a single cut on either side, completing the incisions at the frenum. You will observe that the hemorrhage here is very slight, no vessels of much size having been severed. Usually there is quite free bleeding from the vessels of the frenum, in such case requii'lng ligature. The op- eration will be completed by bringing the cut. surfaces into apposition with a very fine silk thread, by the glo- ver's' suture, which 1 invariably use in bringing the cut edges together after a circumcision. SYPHILIS AND THE GENlTO-URlNARY DISEASES. ^7 LESSON 11. Mon-Auto-inoculability of Chancre — Exceptional Cases — Prevention of Constitutional Infection through Excision of the Chancre Denied — Rapidity of Infection through Germinal Material in Proportion to the Rapidity of the Cell Proliferation and Size of Corpuscles Diminishing in same Ratio — Syphilis Characterized by Comparatively Slow Prolif- eration — Infective Cells in Syphilis not necessarily Differing greatly in Size from Normal Germinal Cells — Differing only in Amount, Pe^ culiar Aggregation, and Characteristic Infective Property — Gross Ap- pearances of the Excised Chancre — Microscopical Examination — Beisiadecki's Observations in Twenty Specimens — Confirmation of the Claim that the Initial Lesion is Formed by Cell Proliferation, iit loco, and not the Result of Inflammatory Action — The Open Lesion a Legiti- mate Result of Interference with the Vessels of Nutrition from Me^ chanical Pressure caused by the Cell Accumulation — Clinical Cases Illustrative of Characteristics of Chancroid. In briefly characterizing the initial lesion of syphilis, in the previous lesson, 1 spoke of it as non-inoculable upon the person bearing it. This may be laid down as a rule where the Chancre (as this lesion is usually termed) has not been subjected to irritation sufficient to set up a purulent discharge. When pus is present, however, inoculation may result in an ulcerative lesion. In Case III., previously cited (p. 25), the lesion was apparently free from this complication, so that its removal will not be liable to inoculate the cut surfaces. The effect of removal of indurated chancre by exci- sion has been the subject of controversy, some authori- ties claiming that early excision of the initial induration may wholly prevent systemic infection. Auspitz and Kolliker, of Vienna, the former in 1877 ^i^^ the latter in 1878, reported cases, in all numbering about 40, where such excision was believed to be effectual in preventing the occurrence of constitutional syphilis. It was even stated that in several of these cases enlargement of the inguinal glands was already well marked at the date of the operation. It is difficult to understand how such a claim can be seriously advanced when there is such 28 PRACTICAL CLINICAL LESSONS 0^ positive proof that the disease has already involved the l3^mphatic system beyond the site of the initial lesion ; and when we consider the fact that the inguinal glands are involved, as a rule to which there are few excep- tions, by the time the induration of the initial lesion is distinctly recognizable, we must deny, absolutely, even the possibility of the cure of syphilis through excision of the initial lesion alone. It is now beyond question that the infective principle of syphilis entering at a given point gradually invades the system — and as far as we are able to trace it by gross appearances and microscopic examination it is confined to the lympha- tic vessels and glands until it enters the blood through the great lymph channels. Its presence, as has been previously stated, is signalized by local cell accumula- tions, producing the characteristic enlargement and in- duration, first at the point of inoculation, then of the adjacent lymphatic glands, and subsequently of every recognized lesion of the active stage of the disease. Inoculation of all or any of the juices or secretions of these lesions upon healthy persons will surely communi- cate syphilis to such persons. Such secretions, under the microscope, are found laden with cell material: germ- inal matter analogous to that which has been demon- strated by Beale, Chauveau, Burdon-Sanderson and others to contain the infective principle of variola, re- lapsing fever, the cattle-plague,* etc., previously re- ferred to. The rapidity with which the infective ger- minal material is proliferated, would appear by the statements of the authorities just mentioned, to be in proportion to the malignity of the disease, and the size of the infective cells or corpuscles to diminish in the same proportion. It is not then remarkable that in a disease like syphilis, when its development is so gradual that months elapse before its climax is reached, the cell element should vary but little from the normal condi- tions. This would appear to be not improbable, for the closest microscopic investigations have failed to dis- * Disease Germs, their Nature and Origin. Lionel Beale. London, 1872. Page 143, etc. SYPHILIS AND THE GENITO-URINARY DISEASES. 2g tinguish the diseased from the healthy cell material, and it is only by its abnormal amount and peculiar ag- gregation, together with its infective property, that it can be differentiated from the most healthy germinal matter. I will now call 3^our attention to the gross physical characteristics of the initial lesion (Case III.) just removed by excision. It has exactly the appearance and feel of a mass of cartilage, and the sensation transmitted through the fingers as the knife is drawn through it is the same as if cartilaginous material were divided. There is no appearance of vascularity. The preputial tissue in which it is imbedded, and in which it is freely mova- ble, is apparently free from disease. The microscopi- cal examinations of such indurations show that they are made up of cell accumulations which involve even the walls 01 the blood-vessels, and bear out very strongly the claim that they are not the product of an inflamma- tory process, but of a local cell proliferation at this point. Alfred von Beisiadecki, of Krakow, has given us the results of a very exhaustive microscopical exami- nation of twenty specimens of this variety of indurated tissue."^ He says : " The induration consists in a cell in- filtration of the papillae of the corium and subcutane- ous connective tissue. The infiltrated cells are similar to those of dermatitis. They are round, have one or two nuclei, have a finely granular protoplasm, and separate the connective tissue equally. These fibres retain the normal size, are not infiltrated as in derma- titis ; they are apparently denser and more resistant to chemical reagents. But the arrangement of the cells differs from that in dermatitis. In those places where a rich cell proliferation has taken place, and in their vicinity still more, we find that the neighboring tis- sues of the vessels, as well as of their walls, are abund- antly infiltrated with cells. The walls of the capillary vessels of the papillae are thickened, have a shining and rigid appearance, and enclose Jiumerous nuclei, whicJi pro- ject even into the lumen of the vessels. The adventitia of * Archives of the Academy of Sciences of Vienna, i867, 30 PRACTICAL CLINICAL LESSONS ON the arteries and veins is three times its normal thick- ness, in consequence of the presence of numerous round, spindle-shaped and branched cells. The cahbre of the cells is diminished, but the vessels are permeable. If the induration still increases, we find in its vicinity an abundant proliferation in the adventitia of the vessels, and subsequently the adjoining connective-tissue cells enlarge and proliferate and anastomose with those situ- ated in the adventitia by means of their processes." " The induration is explained, however," he further remarks, " neither by the number of cells nor by their peculiar properties, but by the fact that while in derma- titis we have a proliferation of cells, and also a serous exudation which infiltrates the tissues and fibres, in the induration of syphilis we have a dry anseraic tissue, resistant connective-tissue fibres, considerably thick- ened walls of vessels. The dryness of the induration, which produces the hardness and also the anaemia, is caused by the proliferation in the walls of the vessels, which makes it difficult for the serum to leave the vessels, and also diminishes their calibre. And this," he says, ''explains why the S3^philitic induration breaks down into a molecular mass, and why resorption takes place so slowly." Now, in contrast with the indurated tissue associated with and characteristic of the initial lesion of syphilis, I wish to direct your attention to another patient. Case IV., who presents a sharply defined ulcer occupying the central portion of the fossse glandis, encroaching upon the glans and also upon the reflexion of the pre- puce. It is fully as large as a dime, and, as you see, something like a figure 8 in form. The history given by the patient is that a little over a month ago he had a suspicious connection, and within a few days — he is not quite certain, but not more than five — he observed "two small festers" (pustules), which soon discharged and grew until they formed a single sore. He has made repeated applications of "blue-stone" (cupri sulph.), and thought he was getting better, when, a few days since, his right groin began to be swollen and painful, and he has come to us for relief, SYPHILIS AND THE GENITO-URINARY DISEASES. 3 1 On pressing this ulcer between the thumb and finger it is found to be quite free from hardness, although the caustic treatment to which it has been subjected would be likely to develop more or less induration. The edges are abrupt, the floor is irregular and covered with a yellowish debris composed of pus and dis- organizing tissue ; the surrounding border is red and somewhat swollen, and also quite tender, as you can observe by the shrinking from our very careful manipu- lation. We have here, then, judging from the history and appearance and condition, a characteristic example of the contagious venereal ulcer, previously referred to as second among the contagious venereal disorders, and called chancroid. If there was still a doubt as to its nature, it is dispelled by the inflamed and swollen con- dition of the right groin. We recognize by gentle palpation a small abscess of one of the inguinal glands, a not uncommon result of the chancroidal action. Pus from the chancroid, gaining access by ulceration to the interior of a lymphatic vessel, passes at once into the gland in connection with it, and through its contagious and destructive property goes rapidly on to the pro- duction of a virulent abscess, the pus of which is con- tagious and destructive equally with that of the chancroid. The chief characteristic of the chancroid, you will observe, is its destructiveness. It begins as a pustule, resulting from necrosis of tissue, set up by con- tact of a molecule of chancroidal pus. Throughout its existence its secretion furnishes pus which, brought into contact with healthy tissue, sets up a destructive action of greater or less activity. It is simply, only and always destructive, and without the destructive prop- erty it cannot be chancroid. It is the antithesis of the initial lesion of syphilis, which in its inception is a process of growth instead of dissolution, and in which loss of tissue occurs not by any virulent agent, but by such an accumulation of new material as to embarrass and finally to arrest the processes of nutrition, and in this way result, in instances like that of Case III., in an open lesion. The microscopic examinations of Beisiadecki, which have been amply verified by Auspitz, Verspn, etc., prove this almost beyond question, 32 PRACTICAL CLINICAL LESSONS ON LESSON III. The Cell Accumulation of the Initial Lesion of Syphilis in Harmony with what is proved to occur in every Lesion during the Acute Stages of the Disease — Cell Proliferation, iit loco, always Sufficient to Explain Satisfactorily the Cause and Condition of the Lesion — Gradual Prog- ress of the Infected Cells through the Lymphatic System until the General Blood Current is Reached — Practical Denial of the Views of Instant Infection, with Corroborative Proofs — Incubation of Syphilis — Different Modes of Transference of Syphilis— Most frequent Locations of the Initial Lesion — Communication by Direct Contact through the Act of Kissing, through Surgical and Gynecological Operations, etc. — Communication of Syphilis through Mediate Contagion or through any Material which has been in Contact with the Secretion of any Lesion of Active Syphilis — Directions for the Prevention of such Acci- dents — Eight Cases Illustrative of this Mode of Acquiring Syphilis by Medical Men. The sig-nificance of the induration in the initial lesion of syphilis as thus explained is most important, and will be found to be in harmony with and typical of each and every manifestation or lesion throughout the active or acute stages of the disease. The cell accumulation which has been demonstrated to constitute this indura- tion has been found to occur in the lymphatic vessels in communication with it, not infrequently recognized, like knotted cords under the integument, running to the lymphatic glands into which they empty, which in turn become depots for the prohferative process, and enlarge in the manner shown in Case III. (see page 25), and are claimed and proven to be characteristic of the presence and advance of the syphihtic disease. The induration associated Avith the initial lesion of syphihs, then, is the result of a gradual invasion of the tissues, commencing at the point of inoculation or contact of the syphilitic principle, or so-called virus, with an open lesion of the integument, or mucous membrane. It is a most significant and important fact that, since the micro- scope has been applied to the investigation of syphi- litic disease, no lesion or manifestation of it has failed to present evidences of cell proKferation, in loco^ suf- SYPHILIS AND THE GENITO-URINARY DISEASES. 33 ficient in amount to explain, in a satisfactory way, the cause of the lesion. It has also in the same manner been demonstrated that this localized cell proliferation and accumulation occurs in a methodical way, progress- ing- steadily from its point of beginning, or first contact \vith the syphilitic virus or principle, gradually invading the lymphatic vessels and glands, until it reaches the great lymph reservoir, the receptaculum chyli, through which it reaches the general blood-current by the sub- clavian veins.* All this, it will at once be seen, is in direct opposition to the views formerly, and to a great extent still, held, viz., that the virus of syphilis enters the blood at the instant of inoculation, and that thus *' the entire organism is affected at once."'t' Such a claim is purely theoretical and unsupported by a single scientific proof, while the evidences of a gradual infection, through the lymphatic system, are not alone met in microscopical examinations by distinguished scientists, but are confirmed by the clinical observa- tions of every careful observer ; each succeeding lesion or manifestation from the initiation to the termi- nation of the disease adding corroborative proofs, not only by its physical characteristics, but by the date of its appearance. THE SO-CALLED INCUBATION OF SYPHILIS. This is a term usually applied to the period which elapses from the date of inoculation to the appearance of the characteristic initial lesion, and may vary in dif- ferent cases, according to different authorities, from one to seventy days, the usual time being from ten to twenty-five days. Strictly speaking, syphilis has no period of true incubation, inasmuch as the process of cell proliferation is undoubtedly established at the mo- ment the virus (disease cell or germ) comes in contact with the germinal or white blood cell of the human organism. * See Otis on the Physiology and Pathology of Syphilis. G. P. Put- nam's Sons. New York, 1881. f Billroth, Surgical Pathology. Am. ed., p. 386. 34 PRACTICAL CLINICAL LESSONS OK The immediate effect of such contact seems to be a rapid increase in the process of proliferation of such of the normal white blood cells as have become contami- mated or degraded by the influence of the disease germs (virus) of syphilis. Through accumulation of this de- graded product, the tissue (including the vessels of nu- trition) at the point of initiation of this process, becomes densely packed, forming a neoplasm of greater or less extent. The process of degradation or infection is con- fined to the immediate locality of the inoculation, until the degraded cells have gained access to the interior of a lymphatic vessel. Through this channel the diseased cells are carried to the nearest lymphatic gland (the gland of connection^ as it may be termed), and here are arrested, by the peculiar conformation of the gland structure, for a longer or shorter period (usually about six weeks), during which time there is no further evi- dence of constitutional infection. This period of appare7it rest is usually termed the second incubation of syphilis. Note. — It is probable that the interval between the date of inoculation and appreciable gland enlargement is dependent upon the facility or dif- ficulty with which the diseased cells gain access to the lymphatic vessel connecting the point of inoculation with the adjacent gland. Hence, at points where the distribution of lymphatic vessels is most liberal and most superficial we should expect to find the shortest interval between inoculation and gland implication. This view is supported by the clini- cal fact that, in cases when the shortest interval occurs, the initial lesion (in the male) is located at the frenum, or the anterior-inferior surface of the glans penis. From this point, chiefly, the superficial lymphatic ves- sels radiate, and are (according to Balaieff) ' ' most stiperficial, rising, in this especial locality, until they lie just underneath the epithelium" (see Otis on the Physiology, Pathology, and Treatment of Syphilis (Putnam Sons, i8So), pages 12 and 13, where it is shown that, by direct introduc- tion of the syphilitic element into the interior of a lymphatic vessel, dis- eased action, in the gland of connection, is inaugurated at once),, MODES OF TRANSFERENCE OF SYPHILIS FROM THE DISEASED TO THE HEALTHY. The modes of transference of syphilis from the dis- eased to the healthy are three : (i) By Direct Contact of the diseased surface with SYPHILIS AND THE GENITO-URINARY DISEASES. 35 an abrasion, or other breach of tissue, on a healthy per- son. (2) By Mediate Contagion. (3) By Hereditary Transmission. Communication of syphilis by Direct CONTACT fas under the circumstances peculiar to the venereal act) is the most frequent mode of the acquirement of syphilis. In the female, initial lesions from this source are most common in the vicinity of the ostium vagina ; especially so in the folds of mucous membrane about the foiirchette; between the greater and lesser labice; under the sheath of the clitoris ; upon, and even within, the meatus urina- rius. They are also found to occur, not unfrequently, about the amis; they are rarely found on the os uteris and still more rarely on the vaginal rugce. In the male, the most frequent sites are upon \h.Q glans penis and prepuce, occurring- with especial frequency in the sulci by the side of the frenum, at the meatus urina- rius, and in the fossce glandis, and occasionally on the integument of the penis. In both sexes the initial lesion is sometimes found upon either lip, in the angles of the mouth, or even within it, and also near, or within, the anus; all as a result of di- rect contagion. Communication of syphilis by direct contact, through the act of kissing, is an accident of oc- casional occurrence. There is also a danger that it may be transferred, through the act of nursing, from syphi- litic infants to healthy wet nurses, or from syphilitic nurses to healthy infants. Relations between nurses and children should never be entered into without a careful consideration of this fact. In these cases, the inoculating secretion may be furnished, either by an Initial Lesion, or by one of the common manifestations of active syphilis, known as the Mucous Patch. Initial lesions are also found in various other localities, as solutions of continuity, at any point, may become the accidental recipients of the syphilitic contagium. Usually, they are rare in proportion to their distance from the genitalia. Surgeons, accoucheurs, and gynecologists are especially exposed to the peril of an innocent inocu- lation of syphilis by direct contact. Within the circle 36 Practical clinical lessons on of my city acquaintance, at the present time, are three medical gentlemen who acquired syphiHs through an initial lesion on the right forefinger. In another case, a surgeon, also an acquaintance, received the syphilitic inoculation in the end of his right forefinger, through accidental puncture, by a spicula of bone, while ampu- tating the leg of a syphilitic subject. Inoculation of Syphilis through Mediate Con- tagion. — Cells diseased by the syphilitic influence (or what is usually termed the syphilitic virus) may cling to substances with which they are brought into contact. All degraded animal cells, or disease germs, have the power of maintaining their vitality for some time after removal from the organism in which they have been de- veloped. (Beale.) Any material, therefore, which has been in contact with the secretions of syphilitic lesions, or the blood of a syphihtic, during the active stage of syphilis, may prove the medium of communication of syphilis to a healthy person, provided, only, that the substance so contaminated is brought into contact with a lesion, however slight, of the skin or mucous mem- brane. The most common source of the contagium, in cases of Mediate Contagion, is the Mucous Patch, a consti- tutional syphihtic lesion, frequent upon the mucous membrane of the lips, mouth, and faucial region, in per- sons passing through the active stages of syphilis. The saliva is thus impregnated with the syphilitic disease germs, and, through it, a variety of domestic utensils have been the known medium of syphilitic inoculation, by contact with abrasions upon the lips of healthy per- sons, without regard to age or sex. In the same way, pipes passed from syphilitic mouths, cigars from syphi- litic cigar-makers, canes, pencils, and even sticks of candy, contaminated by syphihtic saliva, have effected a S37philitic inoculation. Within the last eighteen months I have met with four cases where there was un- doubted proof of the acquirement of syphilis through mediate contagion. One, of a young lady, with the initial lesion on the lower lip, acquired from her lover's kiss. The second, a physician, with the initial lesion SYPHILIS AND THE GENITO-URINARY DISEASES. 3/ just within the angle (on the right side) of the mouth, from a syphilitic friend's pipe. The third, in the same locality, appearing, characteristically, about three weeks after a morning spent in a dentist's chair. The fourth, a worthy merchant, with his initial lesion (well marked) on his lower hp, with mucous patches in his mouth, and an accompanying syphilitic iritis. In this latter case the only clue to the mode of acquirement of syphilis was the habit of passing among numerous clerks and occasionally transferring a lead pencil from their desks to his mouth. Well-marked constitutional syphilis, with complete absence of any genital lesion, was present in each case cited. The foregoing typical cases, illustrative of the modes through which syphilis may be contracted by Mediate Contagion (with the exception of the last), were seen in consultation with physicians from neighboring States. Such accidents, however, are of more likely occurrence in great cities, where moral restraint is least stringent and opportunity for acquiring venereal diseases most favorable. It becomes necessary, therefore, in connec- tion with cases of obscure disease, simulating syphiHs, to make a searching scrutiny of all incidents, conditions, and exposures which may, in the light of possible ac- cidents, point to opportunity of syphilitic infection through mediate contagion. The third case cited is of especial value, as conveying a lesson on the necessity of scrupulous care of instruments used in operations about the mouth. So simple a procedure as the depression of a patient's tongue with a spatula, in examinations of the mouth and throat, may easily become the means of carrying the syphilitic disease germ to an abraded surface in a healthy person. In all cases, therefore, where the same instruments are in use for different persons, after thorough cleans- ing, their passage through the flame of an alcohol lamp should be systematically practised after every opera- tion. The same procedure is equally indicated in re- gard to instruments used upon other mucous membranes, 38 PRACTICAL CLINICAL LESSONS ON as those lining the urethra, the bladder, the rectum, the eye. It is also essential in all instruments used in cut- tmg operations at any point. Not the least important among the modes of conveying syphilis by mediate con- tagion is that by vaccination. Numerous well-authenti- cated cases of this disaster may be found recorded in any modern systematic work on syphilis. Inoculation of syphilis by vaccination may be effected either by an impure virus or an unclean knife. Use of the bovine virus, by means of a clean instrument, relieves this benefi- cent operation from the stigma of being considered a possible means of communicating sj^philis. Extract from the Independent Practitioner. EIGHT CASES OF SYPHILIS OF THE FINGER IN MEDICAL MEN. REPORTED BY FESSENDEN N. OTIS, M.D. Case I. W. N., M.D., set. 26, was in good general health up to three weeks ago. In the latter part of September, 1881, he noticed a small, red papule on the superior surface of the forefinger, at the middle of the second phalanx. He had been for over a month on the venereal service of Charity Hospital. He had never noticed any previous abrasion at the point of appearance of the papule. He is not aware of having had any special exposure of this finger. He had been in the habit twice a week of making vaginal examinations of venereal patients. The papule was painless, had a pale red color and a slight boggy feel, but was without distinct induration. Thinking it might contain a splinter, an incision was made into it, but no splinter was found; no pus, only blood, escaped. This cut remained open and assumed the form of a small ulcer with sharply cut edges, y\ of an inch in diameter and y^g^ of an inch in depth, circular, with smooth, shiny, red floor. This exuded a secre- tion which accumulated, dried, and formed a scab which dropped off at the end of twenty-four hours, with an escape of 3 or 4 drops of sero- purulent fluid. It would exude, dry, and scab over again. I examined it about the loth of November, when exudation first commenced, and detected in connection with it an enlarged and somewhat tender gland in the axilla. Several days after I found an enlarged epitrochlear gland in the right arm. A deep red areola with a scaly border now surrounded the lesion. Patient's health was good up to three weeks ago (or six weeks after the discovery of the papule), when without apparent cause he began to suffer with headache and general malaise. Insomnia well marked; appetite pretty fair. He, however, kept about his work at the hospital; he had some febrile excitement; temperature about 100 in the evening. These symptoms all disappeared in about ten days, and he re- turned to his general health, and was feeling perfectly well, when on December 18, looking, as had for some time been his habit on retiring, he discovered on his body a distinct eruption which he described as papu- lar in character. Examination at the present time (about eleven weeks from the discoY' SYPHILIS AND THE GENITO-URINARY DISEASES. 39 ery of the original lesion) shows a discrete eruption of papules both fine and coarse, scattered over the body, most prominent on the chest and arms, and pale red in color; also distinctly indurated glands in cervical, epitrochlear, and inguinal regions, characteristically enlarged, and one also in right axilla enlarged and tender. The throat is congested, a single scab is found in the hair. The patient, who had been desirous of waiting until the diagnosis of syphilis was absolutely certain, was now put upon a systematic treatment for that disease. Case II. 1878, S. S. B. ; presented with a papule of the middle finger of right hand, about the size of a silver three-cent piece, just over the second joint, elevated and non-suppurating. It appeared as a red spot about two weeks previous, and has gradually become elevated, and with no distinct induration. About six days ago a dry scale appeared in the centre and a molecular necrosis started from that joint. He has poulticed it for the last week. There is no local tenderness but some pain in- the arm stretching up from the lesion as far as the elbow, A single en- larged gland is found in the corresponding axilla about the size of a fil- bert. The patient was advised that the lesion was probably syphilitic, and instructed to wait for signs at other points. In this case there was no positive induration about the lesion, only a boggy feel. The patient has no idea of any date of exposure. He attended a confinement on April 6, but had no suspicion of syphilis in the case. I lost sight of this patient until July, 1881, when I was informed by Dr. E. F. Ward, of New York, that he subsequently had roseola and a papular eruption developed, and that he was at this time suffering from hemiplegia, which had come on suddenly. Case III. In latter part of December, 1871, the patient, a physician, noticed a red spot upon the dorsal surface of the right index finger, near the base of the second phalanx. The spot when noticed was about an inch in diameter, and continued slowly to increase in circumference and to become raised, until within three weeks it reached nearly the size of a three-cent piece and looked precisely like a vaccine vesicle without a central depression. It soon became incrusted, but by the application of poultices the crust was removed, leaving a well-rounded ulcer about one- third of an inch in diameter, excavated, clean, without discharge, the edges raised and all of a deep red color and sluggish in appearance, neither inclining to heal itself nor to yield to treatment. The base was boggy and no induration whatever could be discovered, although searched ♦for by a distinguished surgeon in this city, and by him the lesion was confidently pronounced to be at most 2. simple chancre. Another surgeon familiar with syphilis was equally confident of its simple character. A third who saw it while a small papule regarded it with suspicion, and advised the patient to consult some surgeon who gave especial attention to such cases. The patient then came to me. My opinion was strongly in favor of a syphilitic origin for the lesion, but the patient desired to wait for further proof before commencing constitutional treatment. The ulcer showed no sign of improvement. The extended finger was bandaged to a splint, rendering the point immovable, and allowed to re- main so two weeks, but without improvement. I then advised the appli- cation of iodoform powder. Within forty-eight hours a decidedly favor- able change had taken place, and withm ten days the ulcer was perfectly healed. Once or twice afterward the skin was accidentally broken, but 40 PRACTICAL CLINICAL LESSONS ON on reapplying the iodoform it healed kindly. From the first appearance of the spot till the healing of the ulcer no pain or discomfort was felt. After some four months — that is to say, in the following April — the doctor called to inquire about an eruption which had made its appearance a week or two previously upon his breast and arm chiefly, sparsely on his face and head, which was quite bald. The eruption was of a dull red color, slightly elevated, and several papules were encircled by a line of exfoliating epidermis. They were free from itching, and were discovered by the accident of their appearance on the face and scalp, as they caused no sensation and were not preceded by any fever, headache, or other con- stitutional disturbance. Examination showed distinct gland enlarge- ments in the cervical, inguinal, and epitrochlear regions. He was then for the first time put on a regular mercurial course, viz., one pill of mass. Hydrarg., 2 gr. combined with i gr. of the exsiccated sulphate of iron, three times a day. At about this time this patient's wife began to complain of a profuse vaginal discharge, having been previously in good health, and free from any leucorrhoeal trouble. About three months subsequent to this, a characteristic papular eruption appeared on her face and body, general gland enlargements distinct and prominent in groin, neck, and epitrochlear regions. She too was then put on a system- atic mercurial course similar to that of her husband. Both were kept under treatment for about a year and a half, when no signs of syphilitic trouble having appeared for several months, it was discontinued. To- da}'-, Feb. 21, 1882, the doctor reporting by my request, states that now nearly ten years from the disappearance of the disease, and the cessation of all treatment, both he and his wife have been and are now free from any evidence of syphilis. Two other cases of the occurrence of syphilis in physicians where the initial lesion was situated on the right forefinger have been reported to me during the present winter, and in addition to these I am cognizant of three other cases in New York City, two gynecologists and one dis- tinguished surgeon, who have had syphilis through an initial lesion of the finger. The first point of interest in considering the foregoing cases is the dan- ger to which any physician who treats diseases of females or attends fe- males during the parturient condition is more or less exposed, and the necessity of using extraordinary precautions in examining or attending every case to which a suspicion of syphilis could possibly attach, and habits ually to protect by previous application of elastic collodion any cracks or abrasions about the nails or joints of the fingers, especially of the right forefinger, and to use a lotion of carbolic acid (i to 100) or of the liquor potassa permanganatis, i part to 40 of water, as a habit after all digital examinations of the female genital apparatus. It may be safely asserted that a pre-existent abrasion or fracture of the skin or mucous membrane is absolutely essential to the acquirement of syphilis; and that in any case when syphilis has been acquired without the recognition of a local initial lesion, it has been present, but over- looked. Destruction of tissue is not essential to the perfect initial lesion of syphilis. Healing of an abrasion may take place after an inoculation, just as promptly and as perfectly as if no inoculation had taken place, and the point of induration following may be so small and insensitive that it would easily escape observation. SYPHILIS AND THE GENITO-URINARY DISEASES. 4I In case of the wife of physician (Case III.), the initial lesion was not discovered. Her eruption was only preceded by a profuse vaginal dis- charge. There was never any recognized open lesion on the penis of her husband. It might be said of her that the inoculation had taken place through the iniluence of the semen. Mireir, of Marseilles, has made repeated experiments of inoculating the semen of a person in the active stage of syphilis, upon healthy persons, but without effect. It is more probable — in fact, almost a certainty — that the disease in this case was acquired from a syphilitic papule, of which there were at one time several on the penis. Abrasion occurring during coition coming in contact with an abrasion of the os or vaginal mucous membrane, might there establish the initial, lesion, resulting in the vaginal discharge, which preceded the syphilitic eruption, which Was the first recognized evidence of syphilis in the doctor's wife. The second point of interest is in the uniform and characteristic physi- cal appearances, presented in the initial lesion of syphilis of the finger, coming on always as a papule, coming soon to be of a deep red color, and presenting a superficial abrasion, becoming circular and deeper by a slow molecular necrosis; not by ulceration with formation of pus. The secretion thin and serous, and drying into a scab which is soon dis- placed by the fluid accumulating underneath. The entire absence of induration; in its place a slight, fiat, juicy-looking, boggy swelling or elevation about like a small peppermint in size and thickness — early appearance of an enlarged and somewhat tender gland in the axilla of the corresponding side. I would like to call attention to an interesting fact in regard to the efficacy of remedial measures, viz., that in five of the above-mentioned cases a careful systematic mercurial treatment was pursued during a period varying from one and a half to two and a half years. Eight healthy children have been born, and both they and the parents have continued free from any evidence of syphilis up to this date. 42 PRACTICAL CLINICAL LESSONS ON LESSON IV. Syphilis by Hereditary Transmission — Differences of Opinion in Regard to the Transmission of Syphilis through the Spermaiazoids — Evidence Furnished by the Cell Theory of Syphilis showing the Improbability of Infection in this Manner — The Onus of Hereditary Transmission Thrown Upon the Mother — The Previous Acquirement of Syphilis by the Mother Necessary to the Infection of the Foetus or an Embryo — Syphilis Transmitted only during the Active Period of the Disease; from One to Three Years — Reasons for this Statement — Cases Re- ported Claiming a Longer Period not well Substantiated — Without a Contagium there is no Syphilis — Errors Due to Acceptance of Imper- fect Evidence — Illustrative Case. SYPHILIS BY HEREDITARY TRANSMISSION. Heretofore, in considering the modes of transmission of syphilis, we have accepted the probable fact that this disease is communicated by contact of a diseased with a healthy human germinal cell. We have now to con- sider how diseased cells in the adult, male or female, suffering with syphilis, may be brought in contact with those of the embryo, or of the foetal organism. It is claimed that the foetus, through the natural processes of growth and development, may be built up from a syphilitic seminal animalculse {spermatozoids) furnished by the male, in conjunction with an ovum furnished by a healthy, or even by a syphilitic, female, and may thus come to comparative maturity. Much clinical material has been adduced to prove this. On the other hand it is claimed, with equal proof of a similar character, that this is never the case, but that the syphilitic influence is always furnished by th.Q female; presumedly communi- cated to the embryo or foetus through contact with the nutritive elements furnished by a mother in whose or- ganism the degraded cells or disease germs of syphilis are present. Like most important questions in which syphilis is in- volved, a solution of the foregoing, based on clinical evideace alone, is most difficult. The best proof of thi§ SYPHILIS AND THE GENITO-URINARY DISEASES. 43 statement is, that, on either side of all such questions, the most experienced and competent observers are ranged in nearly equal force. To constitute Hereditary syphihs either the embryo or the foetus must be infected. AH infection during- or subsequent to birth must be classed with one or other of the modes of transmission of syphilis previously considered. If we accept the syphilitic influence to be, as pre- viously claimed, a degraded formative cell, we may also accept, as a legitimate sequence, that, through this deg- radation, there is a loss of formative power — an inabil- ity to develop into any useful tissue. The contagion of syphilis, as claimed, is always ef- fected by contact of a degraded with a Jiealthy germinal cell. In a strict sense, therefore, it is always locahzed. Cells thus degraded are practically emasculated, their capacity for usefulness is lost. Of necessity, then, growth of living tissue occurring, it must take place through the normal cell elements, that is, through those which have escaped this degradation. It is thus plain that only a portion of the germinal material of a living organism can be affected by syphilis. Sufficient germi- nal material to carry on the processes of hfe and growth must escape, or growth would be at once arrested and life would cease. The possibility of involving in the syphilitic dyscrasia so infinitesimal a fraction of a sper- matic organism as would still enable it, in conjunction with the ovum, to play an efficient part in the growth and development of the human embryo, is scarcely con- ceivable. Especially difficult shall we find it to accept such a view when we consider that, once in connection with the ovum the syphilitic influence would be rapidly imparted to the germinal elements furnished by //. We may, then, consistently, throw the great improbabihty of continued growth (or indeed of any growth), under such an unfavorable influence, into the scale with the clinical claims of those who deny the possibility of the embryo or foetus being infected with syphilis by the spermatozoids. With this view of the subject, the onus of hereditary transmission of syphilis is necessarily thrown upon the Mother, under all, even under appar* 44 PRACTICAL CLINICAL LESSONS ON ently contradictory clinical circumstances. Hence, when an embryo or foetus is the subject of syphilitic infection, we may conclude that it is the result of contact of its normal formative or germinal cells, with cells degraded through the syphilitic influence, furnished by the nutri- tive fluids of the mother ; either directly through the circulation, or through degraded cells from her organ- ism, gaining access to that of the embryo or foetus by their amoeboid power. Hence, to make the syphilitic infection of an embryo or a foetus possible, the organism of the mother must first be infected with syphilis. The previous acquire- ment of S3^philis by the mother from the father, or through the secretion of a syphilitic lesion, or from the blood of one suffering from active syphilis (by direct or mediate contagion), is necessary to the syphilitic infection of a foetus or an embryo. . It is only during the active stages of syphiHs (primary and secondary periods) that the contagious element of the different lesions of syphilis and of the blood is pres- ent. Therefore hereditary transmission of this disease is only possible during this time (usually from one to three years). The sequelae of syphihs (tertiary and qua- ternary periods) contain no discovered elements of con tagion. The most careful microscopical examinations have failed to demonstrate in the products of Tertiary Syphilis (various forms of guinmata, including eruptions) anything besides the debris of normal germinal ele- ments. Repeated inoculations of these products have failed to disclose any contagious principle. Without contagium there is no syphilis. Hence we may reason- ably conclude that hereditary syphihs is only acquired during the active periods of the disease, and that in order to effect syphilitic contamination of the embryo or foetus the female organism must first be infected. With this view of the maternal influence in syphilitic infection of the foetus or embryo, cases reported, claim- ing such infection to have occurred through the sole agency of the father suffering with syphilis (the mother, up to this time, free from the disease), must be classed either among those instances where the characteristig SYPHILIS AND THE GEnITO-URINARY DISEASES. 45 features of the disease are absent, or where they are so imperfectlj developed as to have escaped detection. The difficulty of instituting a thorough examination, under circumstances where it is necessary to avoid sus- picion of its object, the want of tact, care, and experi- ence in detecting obscure evidences of this disease, have, without doubt, too often led to the acceptance of syphi- lis acquired through the paternal influence, where, under other conditions and in other hands, infection of the mother would have been recognized. The following case will serve to indicate some of the various ways in which syphilis may be overlooked, and further, to show important variations in time and man- ner of development of syphihs from a similar source. Some three months since. Dr. W., a naval surgeon, con- sulted me in regard to a small nodule on X\\q fre?ium prepiitialis. An abrasion was discovered, after a sus- picious exposure, some four weeks previous. This healed at once, as if simple, and nothing further was noticed, until the nodule, about the size of a kernel of pearl-barley, was observed. Its surface was abraded, probably during a recent connection. Its scanty secre- tion was found under the microscope to consist chiefly of laminated epithehal scales. On account of the obe- sity of the patient, a satisfactory examination of the inguinal glands was impracticable. No enlargement could be felt. I advised excision of the neoplasm. This was done at once, and healing by first intention was complete in forty-eight hours. A few days ago (December 15th) the doctor called to say that the operation had evidently been efficacious in saving him from a general syphilitic infection ; that he had positive proof of having, himself, communicated syphilis to a young lady the night previous to the ex- cision. In her case an initial lesion followed, in due time after the connection, accompanied by inguinal gland enlargement and succeeded by general gland hyperplasia. She now had, in addition, a characteristic papular syphilide, and yet he claimed to be absolutely free from the least evidence of syphilis. A cursory examination appeared to confirm the doc- 46 I>RACTICAL CLINICAL LESSONS ON tor's statement. This, however, appeared so improb- able, that I at once instituted a more thorough exami- nation, which resulted in the discovery, under a deep layer of adipose, of small but characteristic gland en- largements in connection with the initial lesion. The cicatrix on its former site was slightly indurated. Glands at a distance — epitrochlean and post-cervical regions — perceptibly enlarged. Slight but positive congestion of the fauces, and a narrow but characteris- tic mucous patch hidden behind the anterior pillar on either side. These proofs of syphilitic infection had es- caped the anxious search and skill of the patient, also of a professional associate, who was a competent and experienced general surgeon. Through evidence furnished by clinical cases, it has been claimed that syphilis once acquired is never fully eliminated from the system, but that it exists as a pos- sible infecting agent, after the stages which furnish known contagious elements are past. During more than twenty years of observation and especial interest in regard to this point I had been unable to find a sin- gle undoubted example, where a person in the known Tertiary period of syphilis (and so demonstrated by the absence of the glandular enlargements characteristic of the active stages of the disease) had been the proven carrier of syphilis to a healthy person. I came to be- lieve fully, in regard to persons who had passed success- fully through the so-called p7'iviary and secondary periods, and so proven by complete absence of primary and sec- ondary hyperplasias that treatment was no longer neces- sary, that such persons might, if desirable, even be per- mitted to marry, with the assurance that, through them, transmission of syphilis to wife or child was impossible. This doctrine I had taught and practised for a very long period, when a case came under my observation which, but for a mere chance, had unsettled me on this vital point forever. The important lesson which it en- forced, namely, to distrust the value of purely clinical evi- dence, may be profitably transmitted by the brief extract from my note-book which follows: Mr. Q., a young lawyer, twenty-five years of age, had SYPHILIS AND THE GENlTO-URlNARY DISEASES. 47 acquired a well-marked initial lesion of syphilis on the glans penis. His gland enlargements in the epitroch- iean, cervical, and post-cervical regions were charac- teristic — his roseola escaped observation, but a classical papular syphilide appeared about the fourth month, and continued for several weeks. Ulcerations of the tonsils and mucous patches on the soft palate and inner surface of the cheeks followed, but yielded satisfactorily to treatment. The gentle but persistent use of mercury internally and by inunction had been pursued from the first and through a period of twelve months, occasionally com- bined with the iodide of potassium. At this time all glandular enlargements had disappeared, except a small one, the size of a pea, in the right post-cervical region. Treatment suspended for three months, when a thin diphtheric patch appeared on the right side of the tongue, with slight induration.* Treatment resumed, mercury, with iodide of potash. Patch on the tongue faded slowly out in about a month, but was replaced by another, on the opposite side, which continued about the same time, cervical gland not perceptibly changed. A series of mercurial baths, and a course of Zittman's decoction, covering nearly three months longer: gland now scarcely felt. Patient very anxious to marry, but was advised to wait a full year. The next six months passed without any new development. Gland very small, but still recognizable, when the patient, now in good general health, married on his own responsibility. One year after marriage the wife gave birth to a fine, healthy-looking boy. During the fifth month of lacta- tion, the wife had scrofulous abscess of the neck (in- herited tendency), which alarmed the husband (fearing syphilis) exceedingly. She recovered under simple treatment, and relief from nursing. Child healthy up * I have known patches similar in appearance to result, in certain cases, from the use of the iodide of potassitim, to pass off when the remedy was discontinued, and again to return when it was resumed, I have also seen patches of the same appearance in the mouths of persons habituated to the use of tobacco, where no history of syphilis could be ascertained. 48 PRACTICAL CLINICAL LESSONS ON to third year, when it died from tubercular meningitis, following scarlet fever. No salient evidences of syphi- litic taint. Fear that his old trouble had been in some way connected with his child's death made the hus- band very unhappy, and he frequently expressed the fear that he had contaminated or might yet contami- nate his wife, to whom he was tenderly attached. In November, 1870, Mr. Q. complained of some swelHng and soreness over the right tibia. A gummy tumor was found presenting, the size of half a horse chestnut. The nature of it explained, he was put on a mild mercurial, with large doses of the iodide of potas- sium, which resulted in its entire disappearance within a month. Both husband and wife continued healthy up to October, 1871, when one morning he called, in great distress, to say that his wife had some sores in her mouth, resembling those of his early syphilitic trouble. I did not hesitate to assure him that this was simply impossible; that his disease, if any trace of it remained, was beyond the fear of contagion. The spotless character and chaste deportment of his wife made me sure there could be no other danger, and I comforted him accordingly. What was my surprise, on seeing her, to find not only several characteristic mucous patches in her mouth, but, on further examination, to discover four or five mucous tubercles— one on the inner border of the thighs, and the others on the right labium. I was forced to acknowledge to the unhappy husband that he was right, and we could only conclude, contrary to all my assurance and behef, that his old taint had been the cause. Here was a dilemma. I could not suspect the wife. I could not accept the contagion from a source which stultified all my conclusions, teaching, and experience. I was wretched. The husband was wretched, but re- signed, desiring only, if the knowledge of it was not necessary to her recovery, that I should keep the secret from his wife. She zvas serene. After a few weeks' medication, and not unfrequent painful applications of caustic to the mucous tubercles, I thought she was too SYPtllLIS AND THE GENlTO-tfklNARY DISEASES. 49 serene. I asked and received permission from the hus- band to tell his wife what her trouble was, if I thought it best. My manner to her was changed ; from being sympathetic and considerate, it became brusque and reserved. An explanation was finally demanded. I evaded the issue. After a little dexterous fencing, the source of her troubles was flatly claimed. Ignorance of my meaning was feigned. I explained the only possible causes of her disease, and said she had been married too long to suspect her husband. She promptly replied that he was ''as pure as the sun." I then told her if she would give me her confidence, I would protect her — if not, would lay the matter before her husband (who was not supposed to be aware of the nature of the disease). Then came tears — reproaches — and finally, in a tempest of wo* manly indignation, she bade me leave, forever. I left, disheartened and in disgrace ; but, before I was well on my way downstairs, I was recalled, and amid tears and sobs she confessed. A yachting excursion ; an unexpected night at sea ; exposure with an old lover : and all this about three months before. A letter was subsequently received from him full of regret that he had discovered himself syphilitic, and inquiring if he had been so unfortunate as to have communicated the disease to her. The subsequent progress of this instructive case was not peculiar. The lady made an apparently complete recovery in about a year. After another year she again became pregnant — was delivered of a healthy child, now living — but died of puerperal fever the third week after her confinement. In carefully reviewing this history it will be observed that while it is seen to be no exception to the rule that tertiary lesions are not contagious, it will show how easily they may achieve the credit due to the active manifestations of syphilis. 50 PRACTICAL CLINICAL LESSONS ON LESSON V. Early Differential Diagnosis — The Earliest Recognizable Evidence of Syphilis in Local Cell Accumulation, and Progressing until Character- istic Nutritive Disturbances Occur — Neither Inflammation nor Ulcera- tion Essential Features in the Results of SyphiUtic Inoculation — Lesions of whatever Kind may Receive a Syphilitic Inoculation and Heal as Quickly and Perfectly as if no such Inoculation had Occurred — Immediate Decision in such Cases impossible — Delay until the long- est Interval of Known Latency between Exposure and Development of Syphilis has Occurred necessary to a Positive Opinion in Cases of Doubt — Induration of the Initial Lesion Non-inflammatory — Inflam- matory Induration Yields to Local Treatment which renders Specific Induration more Permanent— Physical Characteristics of Specific In- duration — Value of '■ Confrontation" in Cases of Doubt — Cases Illus- trative of Danger of Mistaken Diagnosis. EARLY DIFFERENTIAL DIAGNOSIS. The characteristic, and only constant, feature of all lesions, during the active stages of syphilis, is shown by microscopic examination to consist in a localized cell accumulation. Consideration of the nature and behavior of this ma- terial will afford intelligent aid, in a differential diag- nosis, between the initial lesion of syphilis, in its early period, and solutions of continuity from other causes. As far as shown, syphilis is primaril}^ a process of cell growth and accumulation, so rapid that it interferes with healthy tissue growth, by obstructing the processes of nutrition and development. Not of necessity inter- fering to the extent of causing death of tissue, but of impairing its vitality, and thus causing it to break down more rapidly under influences which favor so- lutions of continuity. Hence we have presenting, as characteristic initial lesions of sj^philis, either a neo- plasm, dense, insensitive, and covered with unbroken and apparently normal cuticle or mucous membrane, or, from the causes above mentioned, some one of the various characteristic solutions of continuity associated with the initial lesson of syphilis. SYPHILIS AND THE GENITO-URINARY DISEASES. ^1 In addition to the foregoing- characteristic lesions, we may also find early local disturbance, in various forms and from various causes, associated with the beginnings of syphilitic cell accumulation, but presenting no feat- ures characteristic of syphilitic inoculation. The known fact, however, that syphilitic infection not unfrequently follows a wound of inoculation, which heals promptly, and with no subsequent solution of continuity, is sufficient to prove that neither Inflam- mation nor Ulceration are essential features in the results of a syphilitic inoculation. Thus, wounds, abrasions, broken vesicles, pustules, or ulcers may receive a syphilitic inoculation, and pro- gress or heal as if no such inoculation had taken place. It is then evident that no positive differential diagnosis can be made at once between lesions which will be fol- lowed by syphilitic infection and those which will not. A positive decision cannot be rendered until after such interval, from latest exposure, as may be required to develop some characteristic cell accumulation, either on the site of the lesion or in the adjacent lymphatic channels and glands. This interval is recognized by all authorities as a clinical fact, and is characterized as ^''The Period of In- cubation of Syphilis.'' The term was invented in accordance with a belief (formerly prevalent) that the virus of syphilis was a mysterious impalpable influence. That this, having en- tered the system at a given point, instantly permeated the fluids and solids of the entire organism. It then accumulated by '' a kind of germination" until the point of " saturation^' or extreme limit of tolerance, was reached. This event was announced by a peculiar and characteristic action, at the point of entrance of the virus, which was termed the Chancre. It is plain, however, that such a view of syphilitic in- fection can have no support, if we accept the view of a cell degradation, and a systematic syphilitic infection, in accordance with known histological, physiological, and pathological laws. It is then to the local conditions, at the point of inocu- 52 PRACTICAL CLINICAL LESSONS ON lation, that we must look for the earHest evidences of syphilitic action. This is afforded, at first, through the microscope, by discovery of a densely packed non-inflam- matory cell accumulation which steadil}^ increases until it is appreciable to the ordinary touch. The same cell accumulation is also seen to occur in the lymphatic ves- sels connecting the initial lesion with the adjacent lym- phatic glands. These vessels are not unfrequently found obstructed and indurated, and, like knotted cords, the size of a crow's quill or larger, often easily traceable to their gland termination. The associated blood-vessels are never narrowed or interrupted from this cause.* The local induration of a suspected lesion, however, is r\ot positive evidence of syphilitic action. Cell accu- mulation sufficient in degree to produce well-pronounced induration may result from irritation of a simple lesion. Thus, an herpetic vesicle, or pustule, even a simple abra- :sion, through friction from clothes, or from applications •of caustics or astringents, may become indurated suffi- ciently to raise grave suspicions of syphilis. Induration in such cases is always the result of in- flammatory action. The induration of syphilis is essentially no7i-i7iflamma- tory. The differential diagnosis is aided by means used to combat the inflammatory condition. Under the influ- ence of rest and local sedatives the incidental induration is promptly dissipated; in the initial lesion of syphilis \kiQ induration is made more salient. Sometimes, though rarely, the induration is quite obscured by a slight local- ized serous effusion, which gives it a bluish appearance. This I have observed in several cases where the lesion was on a finger. The same condition quite frequently succeeds well-marked indurations near th.Q fossa glandis, and is so persistent as to become a valuable diagnostic mark. The induration may be said to be characteristic when * The only recognizable cell accumulation in syphilis is confined to the 15'^mphatic system. If, during the period of so-called incubation, the syphilitic influence has found access to the general circulation, no evi- dence of it has ever been discovered in the condition of blood-vessels, or of the blood, or in the conditions or sensations of the person so affected. SYPHILIS AND THE GENITO-URINARY DISEASES. 53 insensitive, dense, and resistant, like cartilage. If pressed between the thumb and finger it becomes ex- sanguinated, and hke in appearance to the tarsal carti- lage, when the eyelid is turned back. Even this most positive evidence of syphilis cannot be accepted as conclusive. The induration of a com- mencing epithelioma simulates it very perfectly, and, if an open lesion, its secretion under the microscope pre- sents appearances almost identical. In summing up the whole matter, we are forced to confess that a final decision in any given case is not warranted, until some other evidence is present besides the appearance and character of the local lesion. In all cases, where possible, the person from whom syphilis rnay have bee7i acquired should be carefully ex- amined. In making such examination, search not only for the initial lesion, but for each of the possible j^(;^;z^^rj/ mani- festations. Even when such are found, it must be borne in mind that a breach of surface on the person exposed is essential to the acquirement of syphilis, and that this surface must be brought into contact with the syphihtic secretion, either directly or mediately. So that while the presumptive evidence furnished by confrontation is often strong, it is not necessarily conclusive. The following cases will serve to illustrate the impor- tance of caution in arriving at conclusions in regard to the true nature of venereal lesions : Case I. Mr. T., aged twenty-three, on the fourteenth day after his first and only connection, noticed a sKght urethral discharge. Under the microscope this was found to be distinctly purulent. No pain on urination. Meatoscope showed the mucous lining of the urethra deeply congested for half an inch. Beyond this there was no purulent secretion ; appearances normal. The difficulty was, evidently, not go?torrhceal. A syphilitic inoculation was suspected. Examination of the woman with whom he had connection showed her to be passing through the active stages of syphilis. No initial lesion was found; but the inguinal, epitrochlean, and cervical glands were gbaracteristically enlarged. Several mucous 54 PRACTICAL CLINICAL LESSONS ON tubercles were discovered within the vulva ; one in the cervical sulcus, and three on the os tincce. Besides these there was a double row around the anus, eroded and secreting pus freely. In the presence of such evidences of syphilis, it seemed impossible that the young man could have escaped infection. The urethral discharge was probably caused by a syphiHtic inoculation which had not yet produced a well-defined initial lesion. Ingui- nal glands of both sides slightly enlarged. Treatment for syphilis deferred (much against the patient's wish) until evidence of syphilis should become more positive. The urethral discharge gradually declined and disappeared entirely in about a mo7ith. Up to the present time (four years from date of exposure) patient has not had the slightest evidence of syphilitic trouble. Case II. Mr. H., aged thirty, had a suspicious con- nection in May last. On the third day following he noticed several small pimples on his prepuce. Fearing venereal disease, he consulted his family physician, who at once pronounced the trouble a simple herpes. A mild lotion was recommended. Under its use all evidences of disease disappeared within a few days, and the patient was assured, in the most positive manner, that he was free from disease. June loth, four weeks after the sus- picious connection (and more than two after he had been pronounced free from disease), the patient was brought to me by his physician for an opinion in regard to a small, hard, eroded nodule on the former site of the herpes. Inguinal glands, on corresponding (right) side, characteristically enlarged. My belief that the nodule was an initial lesion of syphilis was strongly ex- pressed, and the gentleman was put upon a mercurial course. A month later he called, presenting a well- marked roseola, with the usual secondar}' gland enlarge- ments. His wife, who accompanied him, had an indu- rated initial lesion on the lower border of the meatus urinarius and well-marked inguinal enlargement. Case III. Mr. W. V. No unusual trouble until two and one half months ago, when ten days after a suspi- cious connection he noticed a small sore on the right side of the penis. He consulted a surgeon, by whom SYPHILIS AND THE GENITO-URINARY DISEASES. 55 he was informed that he had a ^^ soft chancre;'' that he would quickly destroy it by application of nitric acid, and further, that there needbeno fear of subsequent trouble. The cauterization was made, was repeated several times, at intervals of three or four days ; healing finally taking place in about three weeks. Patient had connection with his wife the night previous to receiving the sur- geon's opinion that he had a chancroid; no connection since. This gentleman called upon me to ascertain the cause of apapulo-pustular eruption which was confined to the face and neck. I at once recognized it as syphilitic ; examined the cicatrix of the so-called chancroid, and found it distinctly indurated. Gland enlargements of elbow and neck, all well pronounced and characteristic. In answer to an anxious inquiry as to the possible infection of the wife, I was obliged to admit the possi- bihty of such a calamity. He assured me that she had been, and was then, perfectly well in every respect — "■ except that she had some little sivellings in the right groin; 7iot the least pain.'' An examination of the lady on the following day disclosed characteristic gland enlarge- ments, not only in the groin, but in the arm and neck. No search was made for the initial lesion. She was put upon constitutional treatment for ^^ a forin of leucocy- themia," and remained in blissful ignorance as to the nature of her own and her husband's trouble. 56 PRACTICAL CLINICAL LESSONS ON LESSON VI. Progress of the Syphilitic Infection — Course of the Disease beyond the Point of Inoculation — Infecting Cells Following the Course of the Lymph Vessels Carried by the Lymph Current to the Lymphatic Glands — Detention in the Glands from Mechanical Causes — No Evi- dence yet of Constitutional Disease — Recent Painless Gland Enlarge- ments Strong Presumptive Evidence of Syphilitic Infection — Final Passage of the Diseased Cells or Germs into the Receptaculum Chyli, and from thence into the General Blood Current — The Period Inter- vening between the Inoculation and the Entrance of the Disease Germs into the General Circulation termed the Initiatory Period of Syphilis. PROGRESS OF THE SYPHILITIC INFECTION. The term Contagion has been used to designate the act by which, through cell contact, the syphihtic influ- ence is conveyed from a diseased to a heahhy person. By means of the influence thus communicated, pro- Hferation and accumulation of degraded cells, at the point of original contact (or inoculation), are claimed to result in the establishment of the initial lesion of syphilis, or cha^icre^ in its various forms. The course of the disease beyond this point is indi- cated, a priori, by the known fact^ that all integumen- tary and cellular tissue are pervaded by lymph spaces and channels, which lead more or less directly into lymphatic vessels, and that the lymph current is con- stantly flowing from the tissues toward the lymphatic vessels and the glands in which they terminate. Therefore a degraded germinal cell (syphilitic) intro- duced into the tissues (as by an inoculation), unless carried directly into the interior of a blood-vessel, must (itself, or its vitiated descendants) of necessity sooner or later be carried along by the lymph current to and * Strieker's Human and Comparative Histology, Sydenham ed., vol. i, pp. 307 et seq. SYPHILIS AND THE GENITO-URINARY DISEASES. 5/ into the gland of connection."^ All clinical observations confirm this view : first, in the discovery of indurated lymphatic vessels leading from the point of inoculation to the gland in connection ; second, by the subsequent enlargement and induration of such glands ; third, their acceptance as a necessary sequence of the inoculation, and as positive proof of the nature of the disease. The process through which the syphilitic influence thus gradually advances and finally invades the general system is termed the process of Syphilitic Infection. The progress of the syphilitic infection, from the date of its genesis at the point of inoculation to its charac- teristic appearance in the glands nearest the point of inoculation (the glands of connection), varies in different persons, from causes not thoroughly settled, but which are indicated in note on page 96. The degraded cell elements, then, effecting an en- trance into the substance of the lymphatic gland, are here detained by the peculiarities of the gland struc- ture, and perhaps by other inhibitory influences, for a period varying, in different instances, from twenty to sixty days. This period is recognized by all clinical observers, and has been described as the second incuba- tion of syphilis. It is certain, however, that no syphi- litic influence has yet been discovered in the general blood current during this period, and there is sufficient reason to suppose that the diseased elements are con- fined to the glands of connection, and those intervening more deeply between these and the thoracic duct.f * " The wandering red blood globules mostly again return into the cir- culation through the lymphatics. The wandering white blood corpuscles f)robably return into the circulation in the same way." — Wagner's Manual of General Pathology, Am. ed., p. 151. f A similar inhibitory influence, exerted by the lymphatic glands in cancerous diseases, is cited by Virchow, in his Cellular Pathology, Am. ed., p. 221, with the following explanation: "We can account for this by no other supposition than that the gland collects the hurtful ingredi- ents absorbed from the breast, and thereby for a time affords protection to the body." It has been suggested that if the disease were really so localized, prompt enucleation of the initial lesion and of the affected glands might prevent general infection. It must be remembered that the infective cells, each of which is potent to act as a starting-point for systemic infec 58 PRACTICAL CLINICAL LESSONS ON The glands of connection become gradually enlarged, apparently through the proliferation and accumulation of cells in their interior. When the initial lesion is located upon the genital apparatus, on the glands or on the body of the penis in the male, or on the labile or within the vulva in the female, the lymphatic glands of the groin become en- larged, so that, as a rule, several may be distinctly recognized by the touch, varying from the size of a small pea to that of a large bean. Sometimes these enlargements are apparently confined to the side cor- responding with the initial lesion — sometimes to the opposite side; usually, however, the glands of both sides are more or less enlarged. Hard, nearly or quite painless, and movable, their gradual accession within two or three weeks after a suspicious venereal exposure is strongly indicative of syphilitic origin, without regard to the character of the local lesion. If this is present and indurated, the syphilitic character of the trouble is no longer doubtful. It must, however, be borne in mind that glands enlarged through the influence of scrofula cannot be with certainty distinguished from those of syphilitic origin. They are found in the same locations, and, though usuall}' less positively indurated, are still sufficiently so to prevent certain diagnosis. When the initial lesion is on the lips or in the mouth, the submaxillary gland is affected. Wherever situated, it is always the glands of tion, are not only present in untold numbers at the point of inoculation, but that (as shown by Beisiadecki's microscopic researches) the walls of the intervening lymphatic vessels are lined if not packed with them. Hence any proposed surgical extirpation of the disease must imply the entire removal of all the lymphatic connections of the initial lesion and the glands of connection. A procedure not only without sufficient prom- ise of benefit at this stage of the infection, but even at the earliest date after inoculation, the necessary ignorance as to the degree of implication of the lymph spaces and vessels in the vicinity of the inoculation would in all probability render all such means of preventing the spread of the infective processes of uncertain value. Early excision of the initial lesion may, however, be found to modify the intensity of the subsequent general infection. My own experience in twelve cases of excision during the past eight years would warrant this inference. SYPHILIS AND THE GENITO-URINARY DISEASES. 59 connection {i.e., those nearest to the seat of inoculation) which are involved. Such enlargements are called syphilitic buboes. The complete freedom from true inflammatory action which has been shown to characterize the induration of the initial lesion of syphilis, and the lymphatic vessels in connection with it, is equally characteristic of the enlargement and induration of the associated lymphatic glands. When attaining sufficient size to interfere with freedom of motion of a part, or where from any cause they are subjected to undue pressure, a degree of ten- derness may result. From the same cause inflamma- tion and even suppuration may occur in highly scrof- ulous subjects. Such accidents, however, are excep- tional, and do not materially lessen the diagnostic value which attaches to recent and painless enlargement of lymphatic glands. The progress of the syphilitic infection, which has been steady and persistent from the moment of inoc- ulation to the engagement of the nearest lymphatic glands, appears now to be arrested. Gradual increase in their size and density alone indicates the activity of the infective process, until, after a period (varying in different instances from twenty to forty days), evidences of constitutional infection may appear. Access from the surface to the general blood current, through the lymphatic spaces and vessels, necessitates passage, ist, through the gland in immediate connec- tion; 2d, through any other glands or vessels which may intervene between them and the great lymph channels ; passage from thence into the general blood mass is immediate. Thus, the delay between appreciable implication of the glands of connection and earliest evidences of con- stitutional syphilis is explained in accordance with known histological and physiological laws. Hence, it is only after a time sufficient for the passage of the diseased elements through the natural barriers, the lymphatic glands, to the general blood channels that systemic infection can take place. With this view oi\\iQ, progress of the syphilitic infection^ 6o PRACTICAL CLINICAL LESSONS ON the interval between the date of inoculation and the introduction of the diseased elements into the general circulation may be appropriately termed the initiatory PERIOD OF SYPHILIS. SYPHILIS AND THE GENITO-URlNARY DISEASES. 6l Lesson vti. Varieties and Complications of the Initial Lesion of Svphilis— The Indu- ratedPapule-2. The Dry Scaling Patch-3. The Chancrous Abra<=ion -VThc Saucer-shaped Non-suppurating Chancre with Indurated Base and Edge-5. The Elevated, Moist. \ elvety Papule-Modmca- tions of the rSregoing-i. The Mucoid Chancre-2. The Inflamed or Suppurating Chancre-3. The Phagedenic or Gangrenous Chancre- Modifications of the Initial Lesion of Syphilis trom Implantation of Chancroid or other Secretions upon it. (i) The initial lesion of svphilis begins by a process of Undue Growth and ^Iultiplication of normal P-erminal cells, induced bv contact (through a lesion ot mucous membrane or integument;) with Diseased or Degraded cells derived from a person suffering Irom Svphilis. , , . , r h) Cells thus generated accumulate at the point ot initiation, in a circumscribed portion of the surrounding and underlving tissue, and also in the walls and interior of the blo6d and Ivmph vessels of the tissue so impli- cated, and thus form a characteristic neoplasm which is termed the Liifui/ Lesion of Syphilis— oi which there are live characteristic forms, namely : (i) The Indurated Papule. (2) The Drv Scahng Patch. ii) The Chancrous Abrasion. (4) The Saucer-Shaped Non-Suppurating Chancre, with indurated base and edge. (5) The Elevated, Moist, Velvety Papule. And as modifications — The Mucoid Form. The Inflamed or Suppurating. The Phagedenic or Gangrenous. Also modifications arising from implantation of the Virus of Chancroid or other Vicious Secretion, upon the Initial Lesion of Syphilis of any one of the above-named forms. , . J ^ The initial lesion of syphilis may be situated at any 62 PRACTICAL CLINICAL LESSONS ON point on the surface of the body, or it may be concealed within the orifice of the meatus urinarius, the anus, or the mouth. The differences in form of the initial lesion of syphilis are the legitimate and direct results of interference, to a greater or less degree, with the circulation of the tis- sues, at or beneath the point of initiation, of the abnor- mal cell-growth. Thus, in regard to the first-named form : (i) The indurated papule is a dense neoplasm in the cellular tissue, movable under the skin, and hence not materially impeding its functions. Complete absorp- tion of this morbid growth may take place, and the organism become thoroughly contaminated with syphi- lis, without the occurrence of any open lesion. (2) The dry scaling patch always occurs upon integu- ment, and the cell accumulation is diffused and quite superficial, producing an induration which to the touch is like parcJimeiit ; hence the term '■^parchment indura- tion'' applied to this lesion. Interference with the circulation in this case is not sufficient to prevent the evolution of the epidermis, but its development is im- peded, and layers of dry epidermic scales cling to its surface, giving it a characteristic scaly appearance. (3) The chancrous abrasion occurs upon an indurated papule, which by peripheral cell-growth has come to involve the circulation of the cutaneous or epithehal structures to the extent of rendering them friable and easily abraded. Imperfect evolution of the underlying cell elements results in a free shedding of the superficial layers from the moist surface of the lesion. Under the microscope these are seen to be like laminated epithelial scales, and constitute a significant mark of chancrous abrasion. (4) The saucer-shaped non-suppurating chanci*e, with indurated base and edge. In this form a characteristic loss of tissue has taken place (almost entirely at the expense of the adventitious cell-growth), through the continuance and extension of the causes which produce the chancrous abrasion; loss of tissue, as in that case, also occurring, not through the suppurative or ulcera- SYPHILIS AND THE GENITO-URINARY DISEASES. 63 tive process, but by that which Virchow has termed a necrobiosis (death from altered life), that is, from a grad- ual obstruction to the processes of nutrition of the affected part. The secretion of this form of initial lesion is scanty, free from pus, and presents under the microscope the squamous epithelial elements found in the secretion of the chancrous abrasion. (5) The elevated, moist, velvety papule, is neither more nor less than the previously described lesion, " The saucer-shaped non-suppurating chancre, with indu- rated base and edge,'' upon which the granulation tis- sue of Billroth has been developed. This tissue is described in Billroth's " Pathology," Am. ed., p. 93, under the head of "'Proliferating fungus granulatio7isy He says, '' The most frequent cause of the development of such granulations is any local impediment to healing, such as rigidity of the surroimding ski7i, so that the con- traction of the cicatrix is difficult." This rigidity in the case of the moist velvety papule is caused b}^ the characteristic induration of syphilis, always associated with this form of initial lesion. We shall consider next the modifications to which the different forms of initial lesions are subject. (i) The mucoid chancre, is that modification of the moist velvety papule, which arises from the occurrence of a diphtheritic membrane, or deposit, upon its surface, giv- ing it the appearance of that secondary or constitutional manifestation of syphilis known as the mucous papule. This modification usually takes place coincidently with the appearance of mucous papules or patches in other localities. The induration associated with the initial lesion, thus modified, and its entire absence in the mu- cous papule, will constitute the distinguishing difference between these lesions. (2) The infiamed or suppurating chancre. In any of the open initial lesions subjected to persistent irri- tation from friction of clothes, repeated coition, appli- cation of caustics, alcoholic excess (especially in the scrofulous and debilitated), an inflammatory action may be set up. This soon results in pus formation, and a more or less active necrosis, so like in character to 64 PRACTICAL CLINICAL LESSONS ON that occurring in chancroid, that errors in diagnosis are easy. The, now purulent, secretion of the chancre is found to be contagious, producing by auto-inoculation a sore, identical with true chancroid, thus further ob- scuring the differential diagnosis. Previous history, and the induration more or less distinctly marked, will usually be sufficient to indicate the true character of this lesion. (3) The phagedenic or gangrenous chancre. In certain cases of the inflamed or suppurating initial lesion the indurated tissue becomes livid in color quite suddenly, and exhales a peculiar sickening odor, an- nouncing the occurrence of gangrene. This results from arrest of the vascular supply to the induration, through an aggravation of the causes which led to the antecedent necrobiosis. This view is sustained by the known influence of mercury in arresting the destruct- ive process thus set up in the initial lesion, while in any other form of gangrene the influence of this drug is known to be pernicious, and also from the fact that the loss of tissue is usually limited to the indu- ration. When the death of tissue occurs by molecular continuit}^ the lesion is said to be Phagedenic ; when the induration sloughs out en masse it is called GANGRE- NOUS. The influences which tend to convert the in- flamed or suppurating initial lesion into the phagedenic or gangrenous are predisposition to suppuration front any cause, constitutional dyscrasia, alcoholic excess, low, irregular life, etc. All forms of the initial lesion in syphilis may be modi- fied and more or less obscured by the occurrence of ulceration from any cause upon the site of syphilitic inoculation. No surface changes at the point of entry of the syphi- litic virus or principle can affect the course of the syphilitic infection after the disease germ has passed into lymph channels (spaces or vessels) below that sur- face. The characteristic local evidences of syphilitic infection may, however, be modified and more or less completely obscured by accidental lesions, such as her- pes, resulting from contact with vicious vaginal and SYPHILIS AND THE GENITO-URINARY DISEASES. 65 uterine secretions, or other causes, or by contact of the lesion of syphilitic inoculation with the virus of chan- croid. Such lesions pursue their course uninfluenced by the syphilitic cell-proliferation previously inaugurated, and may thus obscure diagnosis until evidences of constitu- tional infection are manifest. Hence, wherever the possibility of a syphilitic infec- tion is present, any breach of tissue, whether a simple abrasion or fracture of mucous membrane or integu- ment, or any vesicle or pustule, whether from general or venereal causes, whether healing as if simple or pur- suing the characteristic course of the chancroid, then in such case, opinions in regard to \h^ presence or absence of the contagiiiM of syphilis must be reserved until such time, from the date of latest exposure, as will equal t lie longest period knozvn to obtain between inoculation and syphilitic infection, as indicated by induration of the'local lesion and enlargement and induration of the adjacent lymphatic glands. This is not less than forty days. 66 PRACTICAL CLINICAL LESSONS ON LESSON VIIL Treatment of the Initial Lesion of Syphilis by Excision — Description of Operation and Subsequent Care — Constitutional Treatment also Es- sential^Local Measures where Excision is not Applicable — Relief from Accumulated Cell Material causing the Chancre occurs only through Fatty Metamorphosis — Mercury the most Efficient Agent both Locally and Internally — Forms, Doses, and Modes of Administrations — Treat- ment by Inunction — General Care — Treatment of Modifications — i. Mucoid Form — 2. Inflamed or Suppurating — 3. Gangrenous — Treat- ment of Concealed Initial Lesions — Treatment to be Continued after the Cure of the Initial Lesion — Increase or Diminution of the Induration a Barometer for Treatment — Enlargement and Induration of Lymphatic Glands nearest to Initial Lesion the First Positive Evidence of Progress of the Infection. TREATMENT OF THE INITIAL LESION OF SYPHILIS. First, by Excision. Whenever a well-determined initial lesion is situated in loose tissue (integument or folds of prepuce in males, or of the vulva in females) the earlier removal by excision is accomplished the better. Not with the expectation of preventmg constitutional infec- tion (which, as a rule, is inevitable before the local lesion is discovered), but as far as possible to remove a focus of dissemination for diseased elements, and to diminish the danger of conveying disease to others. The infective neoplasm, whether under sound skin or appearing in any one of the forms or modifications previously described (except the inflamed or suppurat- ing), should be removed entii-e. The resulting wound heals, as a rule, by first intention. Even when the in- duration is large, little if any deformity remains after cicatrization. Practically the indurated tissue is a for- eign body, and its thorough removal requires the sacri- fice of but little of the surrounding healthy structure. Favorably situated open initial lesions of long standing may be promptly cured in this way. For the performance of this operation first cleanse the parts thoroughly by gentle bathing in warm water. SYPHILIS AND THE GENITO-URINARY DISEASES. 6'] In all Open lesions apply a solution of carbolic acid of a strength of one part of the acid to forty parts of water, after which raise the mass of induration between the forefinger and thumb, and encircle it firmly at the base with a bit of fine silver or malleable iron wire. The in- durated part may be separated from the normal tissue in the same way by compression between the arms of a bent probe, being careful to include the entire indura- tion. Now with a narrow, sharp-pointed bistoury pierce the tissues at the centre beneath the compressing wire probe, and cut well under and out, including all the indurated and a little of the sound tissue of that side. This effected, from the place of beginning, cut out in the same way on the opposite side. Be assured by careful examination that every portion of the neoplasm is removed, then introduce interrupted sutures of silk or silver wire at intervals of a quarter of an inch or less. The patient should be kept in the recumbent position, the parts constantly wet with carbolated water, until the third day, when on removal of the sutures union by first intention will, as a rule, be found to have taken place. The resulting cicatrix may indurate, to a greater or less degree, but rarely, if ever, to the extent of inducing a solution of continuity. In no case does this procedure lessen the necessity for Constitutional Treatment. The indurated papule, when so located that excision is unadvisable (as on the glans penis, or involving the tissues of the corpora), may be subjected to applications of the oleate of mercury (six per cent solution), or any correspondingly mild mercurial ointment. When the mucous membrane or cuticle covering the finduration is abraded, or at any stage of simple necrobiosis, dusting the surface with dry calomel and protecting it with a thin layer of dry lint is then serviceable. Calomel, in combination with lime- water, in the proportion of a drachm to the pint {lotio nigra), or bichloride of mercury, half a drachm to the pint of lime-water (lotio flava), arc both much esteemed as applications to the open initial lesion. The tissue 68 PRACTICAL CLINICAL LESSONS OM metamorphosis and absorption, which are requisite for the removal of the syphilitic neoplasm, are most readily induced by the internal administration of some one of the various mercurial preparations. In all forms of the initial lesion the chief obstacle to resolution or healing is the mechanical interference to nutrition occasioned by accumulated cell-growth. Its removal must occur through the process known as fatty degeneration. The most active and reliable agent in effecting this and in promoting the necessary subsequent absorption and elimination, is mercury; hence the internal administra- tion of some mercurial preparation is essential in all well-determined initial lesions. The proto-iodide (so- called green iodzde) of mercury, in pill, one quarter grain to one grain, three times a day. The biniodide in one thirtieth to one twelfth. The bichloride in doses of from one thirtieth to one tw^elfth of a grain. The mass, hydrargyrum, from two to four grains, and may be judiciously combined with iron. A favorite formula, and one which I usually prescribe, consists of two grains mass, hvdrarg. with one of the exsiccated sulphate of iron. This ma}^ be made into a pill, and if intestinal irritation ensue one fourth grain of the watery extract of opium may be added. This pill was first suggested to me by the late Dr. Bumstead, and is sometimes i^nown as pil. Dzio or Duplex. Any of these forms of mercury may be administered (in suitable vehicles), in the dose deemed judicious for the presenting case, three times a day (increasing the dose if necessary to the limit as above indicated), until the constitutional influ- ence of the drug is manifested by a spongy and sensitive condition of the gums or a slight mercurial odor in the breath. In introduction of mercury into the system through inunction of the mild ointment of mercury, where this drug is not well borne by the digestive apparatus — a dram rubbed in morning and evening — changing locality each apphcation — thus, in right axilla in morning, left at night; then under left knee, then right; then right axilla again, and so on, until the desired effect on gums is SYPHILIS AND THE GENITO-URINARY DISEASES. 69 produced; then reduce amount so as to keep just below this point. The mercurial impression should be maintained as nearly as possible at this point luitil complete absorption of the local neoplasm has been effected, its further em- ployment will be considered in the Lessons on Treat- ment of General or Constitutional Syphilis. Cleanliness, freedom from friction and irritation from all other causes, simple diet, and abstinence from alco- holic stimuli, are necessary to the most favorable results in treatment of the Initial Lesion as well as all other forms of syphilis. In regard to the modifications of the initial lesion of syphilis : The mucoid form requires, in addition to the constitutional treatment previously described, the appli- cation of the solid argentum nitratis (or some other caustic), sufficient ojily to destroy and subsequently to repress the exuberant granulations. The inflamed or suppurating initial lesion, requires rest and opiate or sedative dressing, as the lotio plumbi et opii, in the pro- portion of five grains each to the ounce of water ; or the powdered iodoform, simple, or with an equal part of tannic acid, which seems to deodorize in some degree, and possibly increases the efficiency of the iodoform. In the gangrenous form the powdered iodoform is effi- cient as an antiseptic. Poultices of powdered charcoal are also of value, but the internal administration of mercury must not be neglected while the gangrenous action is limited to the in- duration. Passing beyond this point, prompt and thor- ough cauterization under ether, with the fuming nitric acid or the galvano or the gas cautery, should be done so as completelv to destroy the tissues involved in the destructive action. Opium is of great value in subdu- ing pain in these cases, as well as on account of its bra- cing effect on the nervous system. Occurring in debili- tated or highly scrofulous subjects, as is usually the case, attention should be given to general support, by generous diet, quinine, and iron. The potassio-tartrate of irouy in fifteen- to twenty-grain doses every three or 70 PRACTICAL CLINICAL LESSONS ON four hours (as recommended by Ricord), seems to exert a specific influence over gangrenous conditions. It must not be forgotten that healing and apparent cure of the initial lesion does not mean cure of syphilis. After disappearance, more or less complete, the indura- tion may return. Not unfrequently it may be observed to increase or diminish in apparent sympathy with the progress or abatement of the constitutional disease. From this fact the local induration has come to be con- sidered by some as a reliable barometer, by which the effect of general treatment may be appreciated. The duration of the initial lesion varies greatly in different cases, sometimes disappearing within a few weeks, and with it every trace of induration ; at others it continues as an induration, more or less distinctly marked, throughout the active stage of the constitutional infec- tion. Enlargement and induration of the lymphatic glands, nearest in connection with the initial lesion, constitute the first positive evidence of the progress of constitutional infection. Concealed initial lesions (as within the meatus uri- narius or the anus) may be treated with bougies or suppositories medicated with opium, salicylic acid, or iodoform. SYPHILIS AND THE GENITO-URINARY DISEASES. 7 1 LESSON IX. On the Early Manifestations of Syphilis — The Organism not Infected at once, but by a Gradual Process, through Normal Physiological Chan- nels — No Constitutional Evidence of the Disease at any Point until at least Thirty or Forty Days after Inoculation — Roseola of Syphilis — Clinical Case — Roseola of Syphilis shown to be the Result of Sympa- thetic Nerve Disturbance like Simple Roseolas, and not Caused by the Local Accumulation of Syphilitic Material — Pigmentation Due to Exudation of the Coloring Matter of the Blood and not to a Specific Material — Clinical Case Illustrating the Papular Eruption of Syphilis and its Comcomitants — Supernumerary Epitrochlear Gland — Mucous Patches Simulating Diphtheria — The Secretions of all Lesions of this Stage of Syphilis Inoculable — Note in Regard to the Contagion of Syphi- lis — Importance of Care to Prevent the Same — The Necessity of an Artificial Port of Entry a Great Security against the Acquirement of the Disease — Illustrative Cases, EARLY CONSTITUTIONAL FORMS OF SYPHILIS. The cases to which your attention is now invited are in illustration of the acute stages of syphilis, and these include all the manifestations of the disease during- which a contagious element pertains to it. The first manifestation, the " initial lesion' in its varied forms, has already been considered. The adjacent gland enlarge- ments, resulting from the same processes of cell prolife- ration and localized accumulation, have been seen to be an inseparable adjunct in every case, but they have been present without the least evidence of constitu- tional disturbance. No sensation of the patient, nor any recognized physical sign, suggests anything more than a local disease. Notwithstanding the claim of cer- tain authorities that syphilis is a constitutional disease at the moment of inoculation, and that, as Billroth puts it, the "organism is infected at once,""^ all the scientific research yet made, goes to prove that the disease pro- gresses by individual infection of germinal cells, from * Billroth's Surgical Pathology. Am. ed,, p. 386, 72 PRACTICAL CLINICAL LESSONS ON the point of inoculation, along the lymphatic channels, one of the chief offices of which, is to carry germinal material from the tissues into the general blood cur- rent. That their progress is slow and is obstructed by the lymphatic glands is made manifest, in every case, by the enlargement of all those immediately interposed between the point of inoculation and the great lym- phatic reservoir, the receptaculum cliyli, and by the fact that, until at least thirty or forty days after the inocu- lation, there is absolutely no evidence of the disease having reached the general blood current. In other words, it may be said, that, up to such time, the infection is confined to the locality of the inoculated point and the glands in immediate connection with it, and cannot yet be said to be a constitutional disease. At about the sixth week, however, an eruption presents, as the first evidence that the disease has found access to the system at large. This is well shown in the patient now before you. He has a history of suspicious venereal connec- tions — of one in particular about two months since. He accidentally noticed a small abrasion on the inside of his prepuce, near the " bridle" on the left side, which bothered him for several weeks, but was never of suf- ficient account to consult a surgeon about, and finally healed. Yesterday, after getting quite heated in a run- ning match, his face became spotted with red blotches, and, on going to bed, he found his body more or less covered with them. Here you have a fine specimen of the roseola of syphilis. Its history and advent are char- acteristic. There is a distinct thickening easily felt at the point referred to as the site of the abrasion. It is not as characteristic as in many cases you have seen, but is sufficient, when taken in connection with the history, the distinctly enlarged inguinal glands, and the roseola, to characterize the initial lesion of syphilis. The glands of the cervical region are also enlarged, so that we may accept the case as a classical one of early constitutional syphilis, which I have been accus- tomed to designate, on account of the tendency to localized accumulation in the glands at a distance from the point of inoculation, and in the skin at a later period, SYPHILIS AND THE GENITO-URINARY DISEASES, y^ as tke period of general infection and localized cell accumu- lation.'^ In its general appearance this exanthem is not un> like a slight eruption of measles. Pressure with the finger in the syphilitic roseola causes the color to dis- appear completely when the eruption is recent, as in the present instance, but when it has existed for some weeks a brownish or copper-colored stain is left. The longer the eruption remains, the more likely it is to- leave its characteristic trace, namely, a coppery stain,, unaffected by pressure. The color of this stain here,, as well as in other syphilitic eruptions, is usually con> sidered valuable as a diagnostic mark of syphilis. With this exception, however, it is not materially different from an idiopathic roseola. Like the latter, it appears suddenly, often during or following any exercise which gives a violent impetus to the circulation of the blood,, such as rowing, dancing, or running. Pain or other premonitory symptom is not necessarily associated with it. Sometimes it is slight, consisting only of a few pale spots; while again it is profuse and highly colored, and occasionally slightly elevated. But it never develops into any other form of lesion. Beyond a reddish blotch, it is never more than a copper-colored stain ; and even this stain, the only really salient point of difference between simple roseola and that which is thus seen to be associated with the advent of constitu- tional syphilis, will be shown to result from simple causes. It is true that this eruption is popularly accepted as syphilitic, in the sense that it is caused by the local presence of syphilitic material, and is to be gotten rid of through the same means by which the specific cell accumulations (forming papules in the skin and mucous membranes) at a later stage of the disease are eliminated. I believe, however, that this can be shown to be an error, and that this roseola, like all the other roseolas, is the result of a purely functional dis- turbance. Baumler says of it: ''In ever}^ syphilitic * For further information as to the causes of the " Roseola of Syphilis," see Otis on the Physiolocjy, Pathology, and Treatment of Syphilis, p. 17. New York: Putnam. i88r. 74 PRACTICAL CLINICAL LESSONS ON efflorescence there is a circumscribed dilatation of blood- vessels, together with a certain amount of exudation of white-blood cells into the sheaths of the vessels merely, and into the surrounding tissue. The greater the de- gree of stasis the more abundant will the exudation of red corpuscles be ; and it is the alteration of the coloring matter i7i these red globules which imparts to the color of the sypJiilides, after they have remained for some time, their yellowish or brownish shades. These shades are more distinct in proportion as the congestion of the vessels thereby occasioned recedes, and they are more pro- nounced the longer the stasis has continued. In the same way any efflorescence or its imamediate vicinity, or scars following ulcers on the lower extremities, not due to syphilis, may assume this color. Long-continued dilatation of capillaries and stasis of the blood are all that is necessary to produce pigmentation." Case 11. Here is another case presenting the charac- teristic developments of syphilis at a somewhat later period, and affords us an excellent opportunity of a further study of its leading features. The initial lesion is said to have occurred four months ago, and one month after the suspicious connection. It healed in a couple of weeks. During its presence the patient says it looked hke a simple sore, but there is still here a little knot of induration, situated in the loose tissue of the prepuce, indicating the character as well as the locality of the lesion. We find also Avell-marked enlargement of the lymphatic glands of the groins, and particularly below Poupart's ligament, on both sides, which latter is quite unusual at so early a period of the infection. You also observe very plainly an eruption on the forehead. It is papular in character, and is characteristic of the secondary eruption of syphilis, the first eruption being a roseola, which usually comes on at a period varying from six weeks to two months after the appearance of the initial lesion. Then, after another interval of about the same length of time, we get the second erup- tion, which is papular in character ; the first — the roseola — being macular, and occasionally slightly elevated. The second eruption has been described by authors as SYPHILIS AND THE GENITO-URINARY DISEASES. 75 of a raw-ham color or a coppery hue. It is rosy in color when it first makes its appearance, but grows darker and darker, until finally the papule passes away, leaving a distinct reddish or copper-colored stain. You will observe in this patient that the eruption is very prominent and wide-spread over the back. Some of the papules are surrounded by a little exfoliated epi- dermis, which is known as the " collarette of Biett," and is considered characteristic of a syphilitic lesion by some writers. It is simply an exfohation of the epidermis of the surface of the papule, seen most dis- tinctly at its base, and is dependent upon modified nutrition, caused by infiltration of the papules with cells. These interfere with the vascular supply of the part, and we get the exfoliation here exactly in the same way that we get it at the point of initial lesion — from accumu- lation and concentration of cells in that locality. When this exfohation is present on a papule, it affords an ad- ditional proof of the syphilitic character of the trouble. You will, however, see cases of psoriasis where the scales have been brushed off, which so nearly simulate the syphilitic papular eruption that it is impossible to distinguish between them ; and without other aid we are often obhged to wait further developments in order to make the diagnosis. Fortunately, however, for the diagnosis, but unfortunately for the patient, we nearly always have, at the time of the occurrence of this papular eruption, other lesions which aid us in making the diagnosis. The glandular enlargements in the groins, of the neck, and also in the epitrochlean spaces — sometimes one, sometimes all — ought to be well marked by this time. You will observe here on the neck a gland which can be seen at quite a distance — it is so much enlarged. There is a group of enlarged and indurated glands just behind the sterno-cleido-mas- toid muscle, and another farther back on either side. Here in the right epitrochlean space there is an en- larged gland about the size of a large pea, and what I do not remember to have ever found before, viz., an- other gland about two inches higher up, only a trifle smaller than the first. Quite often the epitrochlean 76 PRACTICAL CLINICAL LESSONS ON gland, instead of being in the little space above the in- ternal condyle of the humerus, is found an inch or two or three inches higher up, between the borders of the biceps and the triceps; but a supernumerary gland, as in the present instance, is very rare. By this tune also papules occur in the mucous membrane, and these are especially characteristic, there being nothing else which resembles them, unless possibly in psoriasis. When syphilitic papules occur in mucous membrane they usually soon become eroded and covered with a diph- theritic pellicle to greater or less extent. Mucous patches — really papules — in the mouth are characteristic of syphilis in its acute stage, and are present in a marked degree in this case. The mouth and the tongue are literally covered with them to an extent which you rarely see. These papules, which appear on the tongue, throat, and mouth, are superficial, and so fiat that they are scarcely if at all raised above the sur- rounding surface or spread over an area varying from the size of a pea to that of half a dollar or larger, hav- ing often a gray or pearl colored diphtheritic edge which occasionally festoons the edge of the soft palate, form- ing a very characteristic and unmistakable mark of syphilis. Some time ago I was called to see a man who \vas supposed to be suffering from diphtheria. I found him surrounded by his family, who were in great solicitude about him. On looking into his throat I saw this characteristic festooning of the palate, and did not hesitate a moment in making up my mind that the trouble was syphilitic. Soon having an opportunity to speak to the young man alone, I discovered that he had syphilis, although he had not before been aware of it. The mucous patch is also liable to occur between the toes or any place where there is habitual moisture. Just at the verge of the anus is a favorite seat for it ; and knowing this fact, examination of this locality will often help you out in the diagnosis of an obscure case. The mucous papule, from its prominence when on the skin or semi^mucous membrane about the anus, is usu- ally called a mucous tubercle, and is quite characteris- tic in this patient, as you see, SYPHILIS AND THE GENITO-URINARY DISEASES. "]*] You should bear in mind that the secretions of all lesions during this stage of the disease are inoculable, and one suffering from it may communicate the disease from the secretion of any open lesion upon the body or on the mucous membranes."^ You will understand, * The active period of syphilis, thus shown to be marked by exces- sive localized cell proliferation, is equally characterized by the contagious property attaching to cells thus generated. Inoculation of the blood, and of the secretion of all open lesions during the active period of syphilis, -has been found capable of communicating syphilis promptly to healthy persons. The physiolo ical secretions — milk, saliva, urine, perspiration, tears, and spermatic fluid — have not bee^i proven to be agents of syphiliiicinfectioji. Where apparently so, in many cases, syphilitic lesions of the mouth or breast have been found to account for the seeming inoculability of the saliva or of the milk. Repeated experiments* have been made by inocu- lation of the spermatic fluid of a person proven to be in the active stage of syphilis upon healthy persons, with absolutely negative results. In this we find confirmation of our position that the contagious property of syphilis is not an entity, an independent virus, pervading all the tissues and fluids of the organism, but that it is confined to the white-blood or tissue-building cells, and in this view we readily see how the physiologi- cal secretions above mentioned, which do not contain them, are found also to be free from the contagious property of syphilis. Thus far the only distinguishing feature which has been recognized between normal embryonal cells and cells which make up the accumula- tions characteristic of the active stage of syphilis is the possession by the latter of the contagious property ; in other words, a co7itagiu?n — the power of setting up in other cells, through simple contact, the same dis- position to rapid proliferation which the so-called syphilitic cells are known to possess. The direct result of this hasty proliferation, as far as we have yet been able to discover, is not a destructive actioji. It is simply and only what we should naturally expect from hastily generated normal material in excess of the necessities of growth and repair. In re resentative, uncomplicated cases it remains for a time obstructing the tissues by its presence, and then through purely normal processes, often of necessity set into operation by crowding of the newly formed cells, prolonged pressure, and consequent innutrition, and also from general causes it undergoes fatty degeneration, and is in this way finally elimi- nated from the affected organism. f Baumler virtually supports this view:]: when he says of the active stage of syphilis, " If there are only a few local deposits, the elimination of the virus may be so much in excess of its production that the organism is gradually freed from it. This takes place in the majority of cases, and at the expiration of eighteen months or two years the infection is entirely ex- hausted.^' * Dr. Mireur, of Marseilles. Annales de Dermatologie et de Syphilographie, No. 6, tome viii., 1877. t A fatty metamorphosis, entirely like that which occurs pathologically, occurs la the normal condition of the organism. Wagner, p. 305. %'P. 247 of Ziemssen's Cyclopaedia, Am. ed., vol. iii. 78 PRACTICAL CLINICAL LESSONS ON therefore, the importance of warning the patient having such lesion of the danger of communicating the disease to others by contact. A pencil, a pipe, a spoon, a knife, or other article introduced into the mouth where mu- cous patches are present, some of this secretion con- tained in the saliva drying upon it, and afterward coming in contact with an abrasion of the lips of an- other person, will communicate syphilis to that person as positively and certainly as would a syphilitic vene- real connection. From this you may see that syphihs is not necessarily a venereal disease, but any one ex- posed in the ways above referred to is liable to receive it, in which event it will follow the same course as if acquired by venereal connection. The great security which we all have against the accidental acquirement of syphilis is, that it requires an artificial port of en- trance — a fracture of the skin or of the mucous mem- Mr. Hutchinson, of London, in speaking of the contagious property which attaches to the emasculated white-blood cell, which we call pus, says, ^' All living pus is contagious. . . . I mean," he further says, "that all pus cells possess the power of setting up, when transferred to another home, if that home be a suitable one, a kind of inflammatory action similar to that from whence they themselves had originated." This, we know, results in the almost immediate death of cells in localities so contaminated. In the case of the germinal cells contaminated by con- tact with the syphilitic cells, however, this results only in a hasty genesis of cells, a too rapid production, which prevents their highest develop- ment; they fall by the way, are heaped up, undergo fatty degeneration, and are or may be eliminated. Nor is it alone in diseased cells that a contagious property is claimed to reside. Rindfleisch, an eminent Ger- man authority, in speaking of embryonal cells coming up from the tissue juices for the regeneration of mucous membranes, says of such cells that '''they become epithelial cells only by coining into coiitact with such. We must believe," he continues, " in a kind of epithelial infection." This, he says also, " must of course just as well obtain when embryonal forma- tive cells approach an existing epithelial stratum, as when, conversely, epithelial elements approach embryonal formative cells." If this be true, it at once becomes evident that the contagious property is not of necessity a virus ; and it must I think be suggested, in this view of the matter, as equally evident that the so-called virus of syphilis is simply a manifestation of that property or personal influence inherent in all cells, whether healthy or degraded, and which is as subtle and intangible, as incapable of material demonstration, as the influence which one mind exerts over another. Is it not then possible that the mischief which syphilis does is rather the result of an interference with the normal pro- cesses, through hasty development brought about by this influence, than of the action of a specific virus ? SYPHILIS AND THE GENlTO-URlNARY DISEASES. 7g bfane for its inoculation. Otherwise, sooner or later, we should all be likely to have it, for we could not come in contact with people who have syphilis without danger of getting it at every turn. But fortunately it requires an abrasion, an open port of entry. It is rarely through the ordinary affectionate relations between children and parents, brother and sisters, that communication of the disease takes place. If, however, an abrasion exist upon the lips of both parties the disease may be communi- cated from the one to the other by a kiss. I have often known this to occur in the venereal kiss, but never by the ordinary kiss of courtesy and family affection. But the liability to communicate the poison to an innocent person should be borne in mind by every one passing through the acute stage of syphilis. We must also bear in mind the fact that the disease may be transferred from a syphilitic to an innocent person, by the physi- cian, by the use of the spatula, carelessly laying it down after examining a syphilitic mouth, allowing the secre- tions to dry upon it, then introducing it into the mouth of another patient before properly cleansing it. This is especially liable to occur if the second patient be a child, as by its restlessness during the examination, a lesion of the mucous membrane of the mouth may be made by the instrument. All instruments in use about the mouth, throat, or teeth should be carefully cleansed and passed through the flame of an alcohol lamp imme- diately after use, and certainly before use upon another person, because syphilitic lesions may be present, although unrecognized. Several well-authenticated cases have come under my observation where syphilis has been contracted in the mouth from lack of proper care in this regard. Mucous papules are very often present in the vagina or on the os uteri of females suf- fering from acute syphilis. In the Independent Practi- tioner for March of this year may be found a report of no less than eight cases of syphilis of the finger, in medical men, acquired through vaginal examinations or attendance on syphilitic women during childbirth ; and since sending in that report I have seen two similar cases occurring in the resident medical staff of one of So PRACTICAL CLINICAL LESSONS ON the hospitals of this city. All of these cases were fol- lowed by constitutional evidences of syphilis. It is scarcely necessary to say that the early recognition and local treatment of mucous papules, patches, or tubercles, is one of the important duties attaching to the manage- ment of acute syphilis. Another characteristic lesion of the disease consists in the presence of scabs in the hair, as seen in this patient. The discovery of scabs, in this locality, sometimes enables us to make a positive diag- riosis, when otherwise we would be in doubt. Alopecia, or falling of the hair, is one of the common, though not constant, concomitants of this stage of the dis- ractical clinical lessons on irregularity in border of the iris becoming visible. This, however, soon gave way under a few repetitions of the atropine, at intervals of three or four hours, which also relieved the pain. The attack proved a very slight one, for no other treatment became necessary ; and after continuing the dilatation by atropine for a couple of weeks, and simply avoiding a strong light, all evidences of the trouble had disappeared. The initial lesion and the induration, never extensive, had quite disappeared. The papular eruption remained, and although the mer- curial was well borne, and an occasional sense of tender- ness of the gums announced the limit of endurance of the remedy. At the end of another month it had not entirely lost its salience, although it had quite lost its reddish color and assumed a deep coppery hue. Occasional papules showed an exfoliation of the epidermis at their base, which condition, resulting from the interference with nutrition through the cell accumulation causing the papule, constitutes a valuable point in diagnosis. With a steady continuance of the treatment, however, the spots gradually disappeared, having continued (from the date of their appearance until they could no longer be detected) fully three months. Nothing then occurred to interrupt the favorable course of the trouble in this case — throat trouble having gradually faded out : the gland enlargements almost gone. After nearly a year, however, the treatment in the period having been faith- fully pursued as initiated, small scaling papules ap- peared. These were flat, slightly thickened spots, rather than papules, about the size of a lead pencil top, with their silvery border of epidermal scales, when discov- ered, and, had it not been for previous histor}^, could not have been distinguished from spots of simple pso- riasis. There had been on each hand only a very few spots of the original papular eruption, say five or six, and had caused the chief discomfort of the patient at one time, as they constituted the only evidence of syphi- lis to a casual observer. On this account they had received quite a little local treatment by mild mercurial unguents, and with apparent success, as they passed off at least a month before those on the body. The SVPHILIS AND THE GENITO-URINA'RY DISEASES. 11^ statement (which the patient made quite confidently) that these spots had returned in the exact places occupied by the former eruption was noted. Similar carefully- observed cases which had been met, where a return of such an eruption over three years (in one instance) after the original papular eruption, and in the same places^ seemed to indicate that the later eruption might belong rather to the sequelae of syphilis than to the evidences of the active contagious disease. And the treatment was changed from the simple mercurial to the combina^ tion of mercury, with the iodid. of potass. (Mist, binio^ did. hydrarg., see page 259.) A few weeks of this treat- ment, added to ung. hydrarg. nit. and vaseline, equal parts, locally, caused entire disappearance of this, and after three months further treatment with the misturse biniodid. (3 three times a day), it was suspended from accidental causes for nearly a month, when the spots returned, and apparently 071 the exact sites of the former spots. Treatment resumed, with the addition of a fumi* gation thrice weekly, thirty grains of resublimed calo- mel, (this preparation, on account of its less irritant property, being preferred), and moderate inspiration of the vapor advised, if it could be borne without pro- ducing cough. Again, within a few weeks, the spots disappeared, and, as the gums became slightly tender, the fumigation was omitted, continuing the "Misturse Biniodid." alone. The patient then went on living very regularly, and taking his medicine as ordered, and with scrupulous care, as he was under engagement of marriage formed just pre- vious to his inoculation, and desirous of hastening his recovery in every possible way. After six months of this treatment, in order to test his condition, he omitted his medicines and the spots returned in less than a fort- night. This was the only evidence of the syphilitic dia- thesis now remaining, for the throat had long since ceased to show any unusual engorgement, and the glands in all localities, while still distinguishable, were no longer characteristic. Another six months, making fully two years from the date of his inoculation, and the patient presented very worried, stating that while he 114 PRACTICAL CLINICAL LESSONS ON was quite well in every other respect, and had no trouble of any sort when he took his medicine, as soon as he left off treatment, the scaly spots would return on his hands, and always in the same places. He was very anxious for some definite time to be set when it would be safe for him to marry. It became necessary to advise this patient that, in the present state of knowledge in regard to such a relapsing eruption following syphilis, it was uncertain whether or not any contagious element was still associated with it ; that the active stage of syphi- lis was one of steady progression, while the sequelae were prone to relapses. That the repeated recurrence of the scaling spots on the same sites were significant rather of organic change in the vessels of nutrition in the affected integument than of an infecting material free in the blood ; but inasmuch as there was not suffi- cient available experience to decide this point positively it would be necessary for him to postpone his marriage indefinitely, and go on with his treatment until the ces- sation of it, as tested from time to time, was not followed by a recurrence of the trouble. Then, according to best authorities, he should wait a full year, which, if passed without evidence of syphilitic trouble, he might venture to consider himself well, and marry. This pa- tient is now two and one-half years from the date of inoculation, and has passed nearly three months with- out treatment or any return of trouble. Remarks. — The occurrence of the syphilitic initial lesion on the lip is not very rare. In the foregoing case the contagion was undoubtedly direct, but this is the point, more than any other, where the initial lesion may be looked for as a result of mediate contagion, viz., con- tact as of the lips with any articles which have been in use by persons who have mucous patches on the lips or in the mouth or fauces. Hence, when syphilis is sus- pected, and the site of the initial lesion in doubt, this re- gion should be examined with great care. The presence of enlarged lymphatic glands in the vicinity is of great value in clearing up a diagnosis, for these are rarely, if ever, absent in sj^philis beyond the third or fourth week after inoculation, and may often be found at a much SYPHILIS AND THE GENITO-URINARY DISEASES. I15 earlier period. (For explanation of manner in which mucoid form of initial lesion is formed see page 108.) Various modifications of the papular eruption of syphilis will be met, no two cases presenting- exactly the same arrangement, locality, or degree of develop- ment. The miliary variety where the papules are about the size of a pin's head, sharply acuminated, and often into a little serous accumulation or a scale at the sum- mit, and thickly and irregularly distributed, or in groups (like that described in the female associated in the fore- going case), or arranged in circles or figures of 8. Again, the papules may be large and flat in groups, or thickly and generally distributed, or sparsely (as in the above case of A. W.), but to a certain extent always symmetri- cal on either side of the median line of the body — a fact which characterizes the early papular eruption as con- tra-distinguished from that sometimes occurring in groups and unsymmetrically at a later period, as towards the end of the first year of infection, or subsequently. Papules may be associated with pustules ; may all be more or less pustular ; may even begin apparently as pustules ; and thus a great variety of eruptions of a papu- lar or papulo-pustular character may be met in the early period, say from the third to the sixth month after in- fection. The presence of such eruptions, whether we designate them after authorities by the size or shape of the papules, or according to their real or supposed resemblance to simple diseases of the skin, as the lich- enoid, the lenticular, the scaling papular (syph. psoria- sis), the annular (syph. lepra), or the acneiform, the variola form, the impetigo form, or the ecthyma form, we must nevertheless bear constantly in mind the fact that one and all, if of syphilitic origin, are the result of the localized accumulation of cell material, hastily generated through the syphiUtic influence ; taking the different forms through constitutional idiosyncrasies or dyscrasias, and, according to the late microscopic re- searches of Kohn, Auspitz, Virchow, Neuman, Baum- ler, always beginning in a papillae cutis,* and that * See Otis on "Physiology, Pathology, and Treatment of Syphilis;" Putnams, 1881, p. 33. Il6 PRACTICAL CLINICAL LESSONS ON the treatment for all is the same, varied in degree only, to suit the constitutional peculiarities of each case. It is also proper to state that no eruption can be pro- nounced syphilitic from its appearance alone, but that, in order to warrant such opinion, gland enlargements must also be present more or less pronounced in the various localities where the superficial lymphatic glands are located, as in the cervical, inguinal, and epitrochlear regions. It will also be seldom that other evidences are not also present, one or more, such as congestion of the throat, ulceration of tonsils, mucous patches in the mouth, or between the toes, or at the anus. It is then evident that the form, color, size, or locality of an erup- tion is not the test as to its nature, but it must always be traced to a probable syphilitic origin before it is warrantable to pursue a systematic mercurial course. That, so traced, every variety of eruption of a papu- lar, pustular, or vesicular character, or any combination of these forms occurring between the second and seventh months after a syphilitic inoculation may be said to have its cause in a localized cell accumulation beginning in a papil^ cutis. For the elimination of this, a gentle persistent mercurial treatment is indicated not only as the result of clinical experience, but from the fact that it is *' the remedy, par excellence, for inducing the fatty metamorphosis : through zvhicJi alone the cell accumti- lations occurring during the acnte stage of syphilis can be re- moved!' Papular eruptions, and their variations, in the early stage are sometimes slow in reaching their full develop- ment, varying usually several days and sometimes as many weeks, but there are apparently no relapses, the new accessions appearing always at new points. The so-called relapses coming on soon after the disappear- ance of the first crop of papules, coming as they usually do in groups, would seem to be due to the setting free of infectious material stored in temporarily obstructed lymphatic glands. In other cases where the eruption recurs at same points (as in present case,) this would seem to be due to changes in the skin from previous damage, and may ultimately have to be classed among SYPHILIS AND THE GENITO-URINARY DISEASES. 11/ the sequelcE rather than among the manifestations of the active period of syphilis, or that in which a contagious element is still present in the blood and in the secre- tions of all lesions. Further observations on this point will be presented when considering the later periods of the disease. U8 PRACTICAL CLINICAL LESSONS ON LESSON XV. Clinical case — Hunterian Chancre — Treatment by excision — Mode of operation — Ulcerating papular eruption — Mucous patches and papules — Treatment — Unfavorable influence of tobacco and alcohol — Good effect of Syphilis on habits of patient — Treatment well borne — Length of time required to keep it up — Time when immunity from danger of communicating the disease arrives — Length of probationary period before marriage — Causes and conditions which occasion pustulation and ulceration in the papular eruptions of Syphilis. Case VIII. Initial lesion. Papulo- pustular eruption^ mucous patches^ and papules, etc. — G. M., aged i8; bar- tender ; presented with a characteristic specimen of the so-called Hunterian chancre on the superior aspect of a redundant prepuce. The open lesion was fully three- fourths of an inch in length by one-third of an inch in breadth, imbedded in a cartilaginous matrix about a quarter of an inch broader and longer, and moveable on the inner reflexion of the prepuce. This had been sev- eral months in coming to these dimensions — not quite certain as to time ; appearing first as a slight chafe and gradually increasing in size and density under a variety of local applications — caustic and sedative. No inter- nal treatment had been resorted to. Glands in groin and cervical regions enlarged and hard. No history of previous veneral disease. General health not very good, but no particular pain or trouble except, latterly, occasional headaches, sometimes in the day but chiefly at night. Examination shows a large, deep red papu- lar eruption rather thickly scattered on the back and breast chiefly, but on the thighs pustules were present about the size of a split pea, scabbed and surrounded by a slight inflammatory areola, while on the legs, es- pecially near the ankles, were several superficial ulcer- ations covered with brown scabs as large as a dime, looking very angry an4 sensitive. Also several points of superficial ulceration between the toes, the sur- rounding surface presenting a whitish sodden appear- SYPHILIS AND THE GENITO-URINARY DISEASES. II9 ance, the secretions very offensive (mucous patches). Besides these were several moist papules, quite ele- vated, and open pustules on the scrotum (mucous pa- pules and tubercles, simple and ulcerated). The throat was deeply congested, but neither this nor the mouth presented any localized lesion. Diagnosis: Syphilis, in the fourth or fifth month. Treatment : As the initial lesion was easily movable on the underlying cellular tissue, its enucleation was de- cided upon. After the parts had been thoroughly cleansed and bathed with a one to sixty solution of car- bolic acid, the indurated mass was tightly encircled by a small silver wire, and the tissues beneath it transfixed with a sharp pointed bistoury, cutting out first one half and then the other, thus removing the entire mass. Half-a-dozen turns of continuous suture of black thread closed the wound satisfactorily, and a simple wet bo- rated cotton dressing was applied. The mucous patches and tubercles were swept lightly over with the solid argenti nitras, and the patient was put on the usual mild mercurial treatment with an extra tonic. Thus, (Mass. Hyd. 2 grs., Ferri Exsic i gr., and pil. quin. bi- sulph. 2 grs.) one of each thrice daily, and in addition at the same time, a teaspoonful of a solution (made up fresh daily) of the sulphide of calcium (2 grs. to 2 i of water). Rest in bed or on a lounge until healing of the wound of operation ; simple but nutritious diet. On the third day, when the stitches were removed, healing was found to be complete. Under the local and internal treat- ment above indicated, touching the mucous patches and papular daily with the arg. nit., this, with the abstinence from tobacco to which the patient was addicted in all forms, resulted in prompt improvement, and in a short time the open lesions had entirely healed and returned to their original papular condition, and the sulphide of calcium was dropped. Through the indifference and want of sense in the patient the continuation of the mer- curial and tonic treatment was very irregular, and its effect was, moreover, much depreciated by occasional excesses in alcoholic stimulants and tobacco. While there was no return of ulceration in the papules, an 120 PRACTICAL CLINICAL LESSONS ON ulceration involving both tonsils occurred, requiring local treatment (application of acid nit. fort, at first, then soHd argent, nit.) for several weeks, and finally healing, leaving the whole pharynx congested, and at times quite sensitive. A saturated watery solution of the chlo- rate of potassa had been in daily use as a gargle and mouth-wash from the commencement of the mercurial course (as is usual in such cases), and was continued with occasional applications of a strong solution of tannin and glycerine, when the sensitiveness of the gums became manifest. The mercurial treatment was kept up more or less regularly, as originally com- menced, for about a year, only twice or thrice result- ing in any perceptible effect on the gums. The papu- lar eruption passed off the body, quite losing the sali- ence within two or three months ; but on the thighs, wherever a pustulation had occurred, a faint coppery stain was discernible at the year's end, and on the legs, where the ulceration was most marked, the stain was at that time of a deep coppery hue. The throat was no longer habitually congested, but still it was more easily affected by changes of weather than formerly, and the occasional necessity for his gargle was recog- nized. The general health of patient had not suffered during this long period of medication. He had become steadier in his ways, and had been for some time per- fectly regular in his treatment. The gland enlargements at all points were greatly decreased, but still readily dis- cernible. Of the initial lesion there was not a trace. Even the Hne of union of the cut surfaces was scarcely to be distinguished from the natural creases or wrinkles in this localit}^ and there was absolutely no more evi- dence of loss of tissue than if a simple foreign body had been removed. The patient now wishing to change his residence to a distant part of the country, desired specific instructions as to the length of time he still required to continue treatment, and what changes, if any, were to be made. He was informed that the present treatment, or its equivalent, should be pursued for still another year, always in such degree as not to affect the general health SYPHILIS AND THE GENITO-URINARY DISEASES. 121 unfavorably. Alternating it from time to time with the iodide of potassium (5 or 6 grs., three times a day), or taking that drug in combination with it — (Mist. Binio- did. Hydrarg.) He desired still further to inquire as to whether or not he was still capable of communicating the disease through ordinary contact, or otherwise, and, if so, when he would probably be free from such danger. In response to this he was informed that, although he had no open lesion, the contagious element of the disease was doubtless still in his system, and that the complete disappearance of the material evidences of the disease, which included gland enlargements, at all points, would be necessary before the incapacity to commu- nicate the disease could be reasonably claimed. That this, in a case like his, where early treatment had been neglected, and he had suffered from some of the severer lesions of the disease, immu7iity from danger of comniunu catirig syphilis could not confidently be expected in less than from two to three years from the date of its acquirement. That while lesions of syphilis certainly recognized as containing a contagious element, such as the true mu- cous patch, papule, or tubercle, were rarely, if ever seen, after the first year, but if the contagious element Avas still in the system, it might escape through an ordinary abrasion, or wound, or sore, of any description, and, if brought in contact with a fracture of skin or mucous membrane on a healthy person, it would communicate syphilis. Thus sexual contact was not without dan- ger of communicating syphilis in such cases, even when no recognized syphilitic le.sion was present at any point. Again, lastly, he desired to be informed as to whether or not he would, as a conscientious and upright man, be justified in looking forward to marriage within the next five years. This question, virtually identical with the previous one, yet embracing the assumption of a responsibility which, if assumed prematurely or in error, might inflict irreparable evil on a future wife and offspring, could only be fully answered after the probationary period of c^ year subsequent to the cessation of the treatment. 122 PRACTICAL CLINICAL LESSONS ON Provisionally, it might be stated that, after the pur- suance of a judicious, thorough, and well-borne mercu- rial course for at least one and a half to two years, and as long after (up to three years) as necessary to secure the complete disappearance of all gland enlargements due to syphilis aud all other evidences of the activity of the disease then if, for the full period of one more year, on care- ful scrutiny no evidence of the disease was manifest, consent to marriage would be justifiable as far as the question of conununicatioji of syphilis was concerned. But every person who has once suffered from syphilis, no matter in how light or how transient a form, is liable to suffer from trouble in various forms, known as the SequelcB of Syphilis. The earlier and more thorough the treatment the less the liability to these troubles. They might be very slight and pass off without recognition even, or be so grave as to threaten life. Such troubles, usually spoken of as Tertiary Syphilitic lesions, con- stituted a purely personal matter in every case, wholly lacking the contagious element. They are not a neces- sary part of syphilis, and, when occurring and recog- nized early, they are eminently amenable to treatment. As before stated, those cases of syphilis early, thor- oughly, and wisely treated, during the active period of the disease, escape as the rule. Yet every one once the subject of syphilis should never forget the possibility of such accident, and, whenever suffering from any serious or unusual difficulty, should always communicate the fact to the medical attendant in charge of the case. Remarks. — The foregoing case presents a good exam- ple of the causes and conditions which determine pustu- lation and ulceration in the papular eruptions of syphilis. 1. The debilitated condition of the patient favoring the suppurative process. 2. The character of his business requiring many hours daily in a standing position, producing additional ten- dency to congestion in the papules of the lower extremi- ties, and this increasing the suppurative action, result- ing in the ulcers about the legs and ankles ; papules also becoming mucous patches and ulcers in moist places. SYPHILIS AND THE GENITO-URINARY DISEASES. 1 23 Consideration of the causes which may affect any pre- senting eruption of syphilis from condition, locality, and business, etc., will suggest judicious modifications in the hygienic as well as the medicinal treatment, and make us hesitate in classifying eruptions of identical origin in a manner tending to obscure the real causes of differ- ence in appearance and amenability to treatment. 124 PRACTICAL CLINICAL LESSONS ON LESSON XVI. Length of time required for complete cure of Syphilis variable : gentle, steady influence of mercury from one and a half to three years — Popu- lar prejudice against mercury not well grounded — Testimony of all authorities in its favor — Destructive lesions of Syphilis belong to the late stage — Treatment not addressed chiefly to the accidents of the active stage, but to the prevention of so-called Tertiary accidents — The Sequelae of Syphilis — Unwarranted responsibility taken by those who claim safety after a brief period of treatment — Light form of early Syphilis no guarantee against grave late lesions — M, Fournier's views — Prolonged and judicious administration of mercury essential in every case of Syphilis — Exceptions where treatment is not well borne very few — Security against late troubles to be effected in no other way. General remarks. — The length of time usually required for the complete cure of syphilis will vary in different individuals from one and a half to three years, and dur- ing all this time the steady, gentle influence of the mer- curial in form, dose, and mode of administration as pre- viously stated (page 119) is required until all abnormal cell-accumulations dependent upon the syphilitic influ- ence have disappeared. When after a year and a half to two years all external evidences of the disease have passed away, and the ly^nphatic glands can no lo7iger be felt, or have returned to the condition in which they were found pre- vious to the constitutional stage of the disease, the treat- ment may be discontinued, but not before, unless there is some idiosyncrasy in the patie^it which contra-indicates its use. If the patients are faithful, sensible, and obedient, in by far the largest majority of cases, they will pass through the trouble easily and happily to a complete cure. A great weight of experience in the plan of treatment which I have indicated (including that of the most distinguished authorities in Europe and America), assures us of the truth of this, and the patients do not suffer from the long-continued treatment in any appre- ciable way, and that in consequence of it they have the greatest and the only security of escape from the so- palled tertiary, or late lesions — the sequelae of syphilis, SYPHILIS AND THE GENITO-URINARY DISEASES, 12$ I am quite aware that there is a great popular preju- dice against the use of mercury in syphilis, and this has arisen in great measure from the abuse of the drug in earlier times, but it has been kept up and intensified by quacks and the ignorant and the unworthy of our pro- fession, who, from causes and motives natural to these classes, refuse to accept the testimony of the learned and experienced authorities, who are now in complete accord in this matter, in every part of the world. With- out a show of evidence, or experience, entitled to respect, they deny the necessity of the mercurial treatment, and make the pretence, that syphilis may be as efficiently, and more safely, managed without it. They point to cases thus treated, apparently well of the disease, and claim them, as evidences of the truth of their statements. The very important fact, that syphilis, in its acute period, is a self-limited disease, and will pass away with any sort of treatment, or without treatment, is not made appar- ent. This is the fact, and while we claim and know, that a judicious mercurial treatment, will hasten the cure of the active lesions and stages of syphilis, it is not on this account, that the treatment is considered essentiaL It is because, more than any other known remedy, it prevents the sequelae of syphilis — the so-called tertiary and quarternary lesions — which result in destruction of important tissues and organs, vessels and bones. These accidents do not occur in the early or acute stages of syphilis. After the apparent disappearance of syphilis, in a few months, or a year or so, there comes a deceitful period of perfect health, perhaps. The disease is perhaps cured ; but in two, or three, or ten, or twenty years after, new trouble may arise, no longer contagious, as in the past syphilis, but destructive. It is this, that causes the really important damage. Deformity, disability of body or brain, or both, and, finally, in some cases, death. It is to avoid the danger, present in every case of syphilis, of such results, that the persistent and judicious use of mercury during the acute period of the disease is most important, and is, as we fully believe and know, abso- lutely essential. We do not urge the administration of mercurials, without a due consideration of the respon- 126 PRACTICAL CLINICAL LESSONS ON sibility we take in so doing, without a knowledge of all it has ever done, that is objectionable, or ever may do. It is because, without a systematic, judicious mercu- rial course, the patient who has once been a subject of syphilis, in no matter how light a form, or how shghtor short-lived the manifestation, is in jeopardy every hour, and that nothing but a course of simple mercurial treat- ment, continued systematically for at least a year, can afford any reliable security. This is the experience of all in our profession who have any title to a respectful hearing, on account of wisdom and experience, and in the present state of our knowledge of this matter it is sufficient to warrant you in insisting upon the necessity of such a course of treatment in every case of syphilis which in the future may present to you for care and treatment.* Do not understand me to say that every case shall be treated in the same manner, as to the size of the dose or the mode of administration, and without regard to the physical condition and circumstances. A judicious fol- lowing of the plan insisted on is necessary, i.e., such an amount and such a mode of administration as may be borne without disturbing the digestive apparatus, or materially interfering with the processes of nutrition. As a rule, if the medicine is judiciously administered, the patient will not only not be disturbed, but he will improve in both these respects. How much a more regular and exemplary mode of life, which a proper management of syphilis necessitates, has to do with the improved condition, I am not able exactly to state, but it is nevertheless a fact, that most young men are in * The distinguished French syphilographer, M. Fournier, says on this point: " Experience teaches us that syphilis, originally mild, may reveal itself sooner or later in serious symptoms, if it has not been submitted, like the more malignant forms, to a prolonged and severe treatment. One has seen, more than once, syphilis of this kind, negligently treated by reason of its apparent benignity, become, later, singularly dangerous in marriage in the double possibility of contagion and heredity. ... It is to-day proved, that the initial benignity of syphilis does not constitute in any degree an absolute guarantee for the future. Such syphilis which begins well, is not, for that reason, unexposed toabad end." ("Syphilis and Marriage," by M. Alfred Fournier. London Ed. 1881, pp. ill, 112.) SYPHILIS AND THE GENITO-URINARY DISEASES, I^; better health, after a judicious course of specific treat- ment for syphilis, than before its acquirement. 1 do not wish to be understood that no other medi- cines are necessary, or advisable, in any case of active syphilis. There are idiosyncrasies that must be re- spected — cases that will not bear the ordinary amount of mercurial without trouble of some sort. These are fortunately rare; but when they present, vou must use your ingenuity, so to select the particular form, and com- bine your most excellent remedy, that it may be borne. You may alternate it with the iodide of potassiumi, which is also an agent of much value in bringing about fatty degeneration of living tissue, or you may, if you can do better, rely upon this drug in combination with other means and measures which are known to favor fatty degeneration and elimination. You are likely to meet with cases that will try your temper and courage : that will call into fullest requisi- tion all your knowledge and your experience and your judgment, and, not least, all your common sense, and yet fail to obtain such a toleration of the mercurial as will enable you to prevent the occurrence of the sequelas of syphilis. These cases will, however, I am glad to say to you, be rare exceptions, and you may have the assurance of the rule, that such a plan of treatmentas I have sketched out for you will be well borne, and will not alone aid you, in carrying your patient with com- parative equanimity and comfort, through the acute stages of this disease, but, what is of infinitely greater importance, you will give him, the greatest possible se- curity, against an occurrence of the seqiielce or manifes- tations of so-called chronic or tertiary syphilis. 128 PRACtlCAI CLINICAL LESSONS OK LESSON XVIL Resume showing that the contagious property of sj^philis is not an in- dependent virus pervading all tissues, but is confined to tne white blood, or tissue-building cells, and that the only peculiarity of such cells is a contagious influence which is not distinguishable by microscopical examination. That its effect is to induce hasty proliferation of cell material, and that the result of this is not primarily destructive, but causes disturbance through mechanical interference with processes of nutrition. The property of contagion, inherent in normal cell develop- ment; all troubles occurring after the contagious period of syphilis, which clinical observation has shown to be limited — necessarily con- sidered as 0^^7/1?/^. Mr. Hutchinson's views on this point; the views of Mr. Henry Lee and Mr. Lane. The tubercular QxVi\^\\ox\ the first sequel of syphilis. lis characteristics and behavior. Syphilitic ecthyma; syphilitic rupia; no specific element in their composition. The lepra and psoriasis of ryphilis not distinguishable from, the simple forms ex- cept through effects of treatment, all caused by interference with natu- ral functions of tissues. Evidences of this interference confined to the lymphatic channels. This view supported by Rindfleisch, also by effects of treatment, all alike requiring mercury and the iodide of potas- sium. Proposal to substitute the term Period of Lymphatic Obstruc- tion for the old terms, Tertiary and Quarternary Syphilis^ Reasons for claiming that this syphilitic obstruction is due to damage to lymph channels during the active period of syphilis. THE SEQUELS OF SYPHILIS. Syn.: Chronic or Late Syphilis, Tertiary and Quater- nary Syphilis. — In following the natural history of S)^ph- ilis, as portrayed in the preceding pages, it will be seen, that, wherever the s}- philitic influence is recognized at a given point, culminating in a well-marked mani- festation of syphilis, this, on microscopic examination, has been found to differ from the health}' surrounding structures, only by an excessive local proliferation and accumulation of cells, in no way distinguishable from normal germinal cells. It will also be seen that this local proliferation and accumulation, is favored by anatom- ical conditions, in localities long recognized, clinically, as the favorite seat of such manifestations. The active period of syphihs, thus marked by exces- sive localized cell proliferation, was shown to be equally characterized by the contagious property attaching to SYPHILIS AND THE GENITO-URINARY DISEASES. 1 29 cells thus generated. Inoculation of the blood, and of the secretion of all open lesions, during the active period of syphilis, has been found capable of communicating syphilis promptly^ to healthy persons. The physiological secretions — milk, saliva, mucous, urine, perspiration, tears, and the spermatic fluid — have not been proven to be agents of syphilitic infection. Where apparently so, in many cases, syphilitic lesions of the mouth or breast have been found, to account for the seeming inoculability of the saliva or of the milk. Re- peated experiments have been made by inoculation of the spermatic fluid of a person proven to be in the active stage of syphihs, upon healthy persons, with absolutely negative results.^ In this we find confirmation of our position, that the contagious property of syphilis is not an entity, an independent virus, pervading all the tissues and fluids of the organism, but that it is confined to the white blood or tissue-building cells. In this view of the matter we readily see how the physiological secre- tions above mentioned, which do not contain formative cells, are found also to be free from the contagious property of syphilis. Thus far, the only distinguishing feature which has been recognized, between normal embryonal cells, and cells which make up the accumulations characteristic of the active stage of syphilis, is the possession, by the lat- ter, of the contagious property. In other words, a con- tagitim : the power of setting up in other cells, through simple contact, the same disposition to rapid prolifera- tion, which the so-called syphilitic cells are known to possess. The direct result of this hasty proliferation, as far as we have yet been able to discover, is not a de- structive action. It is, simply and only, what we should naturally expect from hastily generated normal material, in excess of the necessities of growth and repair. In representative, uncomplicated cases, it remains for a time, obstructing the tissues by its presence, and then through purely normal processes, (often of necessity set * Dr. Mireur, of Marseilles. Annales de Dermatologie et de Syphilo* graphic, No, 6, tome viii, 1877. 130 PRACTICAL CLINICAL LESSONS ON into operation by crowding of the newly-formed cells, prolonged pressure, and consequent innutrition, and also, from general causes), it undergoes fatty degeneration, and is in this way finally eliminated from the affected organism.^ Baumler virtually supports this viewf when he says of the active stage of syphilis, " If there are only a few local deposits, the elimination of the virus may be so much in excess of its production that the organism is gradually freed from it. This takes place in the majority of cases, and, at the expiration of eighteen months or two years, the infection is entirely exhaiistedr Mr. Hutchinson, of London, in speaking of the con- tagious propert}^ which attaches to the emasculated white blood cell, which we call pus, says, '' All living pus is contagious. ... I mean," he further says, "that all pus cells possess the power of setting up, when transferred to another home, if that home be a suitable one, a kind of inflammatory action similar to that from whence they themselves had originated." J This, we know, results in the almost immediate death of cells in localities so contaminated. In the case of the germinal cells, contaminated by contact with the syphilitic cells, however, this results in a hasty genesis of cells, a too rapid production, which prevents their highest development ; they fall by the way, are heaped up, undergo fatty degeneration, and are, or may be, eliminated. Nor is it alone in diseased cells that a con- tagious property is claimed to reside. We have dis- tinguished authority for saying that, in the normal de- velopment of epithelial structures, the property of contagion is an essential feature. § If this be true, it at once becomes evident that the contagious property is not of necessity a virus ; and it must, I think, be sug- gested, in this view of the matter, as equally evident, * A fatty metamorphosis, entirely like that which occurs pathologically, occurs in the normal condition of the organism. Wagner, p. 305. f P. 247 of Ziemssen's Cyclopaedia, Am. ed. , vol. iii. %Lo7ido7i Lancet, September 18, 1875, p. 409. § Text-Book of Pathological Histology. Rindfleisch. Am. ed.. 1871, p. 100, § 83. SYPHILIS AND THE GENITO-URINARY DISEASES, I3I that the so-called virus of syphilis is simply the manifest- ation of a property or personal influence, inherent in all cells, whether healthy or degraded, and which is as subtle and intangible, as incapable of material dem- onstration, as the influence which one mind exerts over another. Is it not then possible, that the mischief which syphilis does, is rather the result of an interfer- ence with the normal processes, through hasty develop- ment, brought about by this influence, than of the action of a specific virus ? In any event this contagious property of syphilis ceases with the active period of the disease. After this has passed, the secretions of open lesions, and the blood, no longer contaminate. It may also be said, that, in by far the greater number of subjects of syphilis, (and more especially those who have been systemati- cally and judiciously treated), they remain free from any farther sign of the disease. If this be so, then we may legitimately claim, that, at the termination of the active period of syphilis, just described, all subsequent troubles must be looked upon as seqiielce, and not as a stage of syphilis, any more than we should look upon dropsy as a stage of scarlet fever, or stricture as a stage of gonorrhoea. Mr. Hutchinson, who is recognized as one of the most advanced of the English authorities on syphilis, says : " What are called tertiary symptoms, do not constitute a necessary stage, and are" rather to be regarded in the light of seqiielce, which may or may not show themselves." * Mr. Henry Lee (also a valued authority), in his Hunterian Lectures, delivered at the Royal College of Surgeons of England in 1875, pre- sents the same view of so-called tertiary or late syphilis, thus : " The pathological changes in this class, occasion- ally, according to Mr. Lane's view, present themselves in patients, who have passed through the primary and secondary stages of syphilis, but in whom the venereal poison no longer exists, and therefore cannot be traiis- mittedy This is, I know, quite at variance with the usual * London Lancet, p. 83, January 17, 1874. 132 PRACTICAL CLINICAL LESSONS ON teaching in this matter. The accidents following upon the active period of syphilis are usually representedj not as sequelse, but as the direct result of the syphi- litic virus, which had never been completely elimi- nated, but had remained in the system in a latent state. Authorities are quite agreed, however, in regard to the clinical fact, that, after a varying interval, of from one to forty or fifty years from the acquirement of sj'philis, a new variety of lesions appears in certain cases. These are often characteristic, although widely dif- ferent in localit}^, appearance, and results. Occurring only in a small proportion of the subjects of active syph- ilis, they are thus shown, not to constitute an essential stage of the disease, but the accident of it. Thus the so-called tubercular eruption, like the papular eruption of acute S3'philis, in some respects, is often mistaken for it, but differing, in that ist, it never "^ occurs in less than six months, and rarely under a year, from the acquirement of the initial lesion ; 2d, it is not symmetrical and generally distributed, but in patches, or groups, or single tubercles, * I am aware that ulcerati\'e lesions occur, though rarely, at the usual period for the papular eruption, that are accepted by some authorities as belonging to the later stages of the disease. I think, however, in all such cases, that the possible behavior of a papule or a lesion, resulting from the peculiar condition of the subject, will be sufficient to explain the nature of the accident without referring it to the so-called " tertiary stage;" or, if not, it will be found that the patient has had a previous at- tack of syphilis at a period sufficiently remote to account legitimately for the appearance of a tertiary lesion. The tubercle or its equivalent, viz., an accumulation of so-called ^z^w/«jj/ or germinal material, which is the result of a necessary previous stage, and lacks the contagious element, is the first of the accidents of the so-called tertiary stage — the sequel of syphilis. Notwithstanding that M. Cornil, in his recent^xcellent work on syphilis (p. 204), states that, " In the tubercles and gummata of the skin are seen the latest and deepest manifestations of cutaneous syphilis," yet he also states (p. 215) that "the very first symptoms of syphilis may be deep-generalized pustular or ulcerating eruptions," identical with those coming on after a period of many years (the seqiielce), ""following immediately after the chancre." — Cornil on Syphilis. Am. ed., Phila., 1882. I do not hesitate to claim that such cases, wherecritically analyzed, will be found to be as rare, as where, in nature, fruit has the precedence of the blossom.— F. N. O. SYPHILIS AND THE GENITO-URINARY DISEASES. 1 33 3d, of deeper color, it is also more elevated — more juicy in appearance, 4th, while frequently ulcerating (and often extensively), it not unfrequently passes off without ulceration, and yet leaving- well-marked cicatricial depressions on its site. This latter is the chief diagnostic point, independent of history or other associated lesion, of the tubercular eruption of syphilis. In other cases, under apparently the same conditions, an eruption, sero-pustular in charac- ter, may occur, the eruptive points varying from three to six or more millimetres in diameter, often sparsely scattered over the entire body, which soon become cov- ered with thick yellow laminated incrustations, and these, when removed, discover only superficial loss of integument. This is known as the SypJiilitic Ecthyma. And again, in still other individuals, one or many red spots may appear, which soon vesiculate and be- come covered with a dark sienna-colored scab, which accumulates in layers, and increasing in size, may reach even an inch or more in diameter, upon the re- moval of which sharply cut loss of tissue will be seen, not seldom involving the entire thickness of the integu- ment. This is termed by authors the Syphilitic Ritpia. Examination of all these lesions fails to discover any specific material or element in their composition. The microscope shows chiefly serum, lymph and pus cells, blood and epithehal debris. A depreciated condition of the general system, is alwaj^s the precursor of such symptoms, especially marked in the rupetic variety. And yet again, eruptions may occur presenting appear- ances similar to simple lepra, or psoriasis, or eczema, oftentimes so nearly identical in appearance that only the test of treatment enables even the expert derma- tologist to decide as to whether the disease is of simple or of syphilitic origin. Underneath the integument tumors sometimes occur, varying in size from a pea to a pullet's Qg^, in the cellular tissue, or in the sub- stance of the muscular structures ; often painless, seldom suppurating, except when subjected to prolonged and habitual pressure, often disappearing spontaneously and readily responding to suitable treatment. Tumors ia 134 PRACTICAL CLINICAL LESSONS ON the bones, called syphilitic nodes, are also possible, oc- curring, like the previously described lesions of the cu- taneous, cellular, and muscular structures, from accu- mulation of the so-called gummy material, at any time after a year or more from the occurrence of acute syphilis, and up to the latest years of life ; painless or painful according as the periosteum is more or less rapidly distended or pressed upon by overlying tissues. Chiefly occurring on the anterior surface of the long bones, especially of the tibiae, and on the external tables of the skull, occasionally involving the internal table and the diploe, and in such case sometimes disappearing spon- taneously without involving the scalp, and without a trace of necrosis, but leaving distinct evidences of loss of bony substance through the influence of pressure b}^ the material cause, the tumor. Similar tumors of bone may occur at any point throughout the bony system, pro- ducing disturbance by pressure on important structures. Tumors in the various organs of the body, occur apparently from similar causes, and in the same irregu- lar way in point of time, involving, in order of fre- quency, as follows : Testes, liver, kidneys, brain, lungs, heart, etc. In some cases walls of the blood-vessels are found infiltrated with the same material of which thetu mors of syphilitic origin are found to be composed, and become obstructed, as in the brain, often causing fatty degeneration of the structures to Avhich they are dis- tributed. In some cases, cicatricial bands are found to develop in organs the subject of syphilitic tumors, and b}' contraction and consequent constriction, destroy the secreting structures, notably seen in the liver and testes of subjects suffering from the later effects of the syphilitic influence in these organs. It will thus be seen that the diseased conditions, enumerated as char- acteristic of chronic syphilis (the tertiary and quater- nar}' syphilis of Lancereaux and other authors), are essentially different from true or acute syphilis, in date of appearance, mode and locality of development, and in the entire absence of the contagious syphilitic ele- ment. Microscopic examinations have brought to li^ht the very important and interesting fact, that all SYPHILIS AND THE GENITO-URINARY DISEASES. 1 35 the various sequelse of syphilis, are characterized by the presence of a peculiar material, which, from its physical properties, has received the name of " gummy material." This material has been proven, by repeated and exhaustive microscopical examinations, to be made up of gelatinous fluid, containing normal cells and nuclei, which do not differ in the least demonstrable de- gree, from the white blood cells and nuclei of a healthy person. Wagner, perhaps the most recent standard authority, says of this gummous material (which he terms syphiloma): ''Microscopically syphiloma con- sists of cells, or nuclei, or both at the same time, so that sometimes the former, sometimes the latter, exceed in number. Young syphilomata, as well as the periph- eral parts of the older ones, contain for the most part only nuclei, or nuclei and isolated cells ; the older syphilomata, not yet very atrophic, consist for the most part only of cells, or of cells with few nuclei. The nuclei offer nothing characteristic. They are from o.oi to 0.02 mm., large, round or rounded, or somewhat angular, and contain for the most part a distinct nucle- olus. The cells resemble most uninucleate colorless blood corpuscles ; their size varies, however, some- times, between 0.0 1 and 0.03 mm.; some are even still larger." * Again Wagner (page 436) says : '' The in- fluence of syphiloma, on the organism, depends upon the fact, that the affected portions of the membrane and parenchymata, are more or less incapable of fuiiction ; dependent partly on the deposit of cells, and especially of nuclei, upon compression or secondary atrophy of the gland cells, nerve fibres, ganglion cells," etc. Baumler, who fully adopts Wagner's views, says : '' From the fact of the close resemblance of the cells which pervade the tissues, or occur in the form of young tissue growths, with the blood-corpuscles, it is evident that, however much, they (authors) may characterize syphilitic new formations, they wholly lack specific microscopic char act ersT He also says : "■ Tumors of this sort (gummy), varying in consistency, * Wagner's Manual of General Pathology, Am. ed,, 1876, p. 435. 136 PRACTICAL CLINICAL LESSONS ON may develop in any organ in consequence of syphilis; but their favorite seats are in the subcutaneous cellular tissue, the skin, in and upon the bones, the liver, the testicles, the brain, the kidneys, and, especially in chil- dren, the lungs. According to Wagner's description," he further says, " they present the appearance of a rayish-red, soft, homogeneous mass, either without uid contents or else yielding a scanty juicy-like mucus. They may occur as infiltrations of microscopic size scattered throughout the parenchyma of an organ ; and even when they appear as sizable tumors, as large as a walnut or larger, they are not encysted nor sharply defined, but merge directly into the surrounding tis- sue." " The effects of a gummy tumor," says Baumler, " may extend to a great distance in case it has caused contraction of the calibre of some vessel, especially of a blood-vessel, which is particularly liable to occur when the tumor has its seat in the adventitia of a vessel. Fatty degeneration and wide-spread processes of softening may be the consequences of a tumor in itself insignificant, as occasionally happens in the brain. When situated in the skin, in the subcutaneous cellular tissue, upon mucous membranes and superficial bones, the gumma often makes its way to the surface, since in these situations it is not uniformly enclosed on all sides, but is exposed to unequal pressure. The entire infiltration then ulcerates." M. Cornil still later says of the histology of the ''gummata:" " All the pre-existing cellulo-vascular tissue is thus infiltrated and crowded with cells, the enormous quantity of which, stra7igles the normal tissue elements , and impairs the cir- culationy ^ It is reasonable to conclude, from the fore- going facts and views, that contraction of vessels, often plays an important part in causing the lesions of so-called tertiary syphilis : a purely mechanical matter quite independent of the influence of any virus. In passing, I desire also to call your attention to the statement of Baumler, " that gumma often makes its way * "Cornil on Syphilis," Am. ed., Henry C. Lea's Son & Co., Phila., 1883; p. 207. Ibid., at pp. 208 and 209, illustrations are given of the planner in which these cells obstruct and obliterate capillaries and vdng. SYPHILIS AND THE GENITO-URINARY DISEASES. 1 3/ to the surface." I hope to be able subsequently to show how this occurs — not making- its way, but pro- gressing, by natural forces, in line of the natural physio- logical channels. Ricord claims that tertiary lesions are not inoculable, and cannot be transmitted by hereditary descent. Bumstead states, in his last edition, after reviewing this matter, " Hence we consider the blood and the secretions in tertiary syphilis innocuous." * " Diday performed inoculations with the blood of persons in the tertiary stage of syphilis, and invariably with a negative result. Von Barensprung states that from observation as well as experiment he is persuaded that so soon as the syphilis has passed into the destructive forms of its tertiary stage, it ceases to generate an inoculable vi- rus," and, says Baumler, " chnical observation seems to confirm this view, both in respect to direct contagion and with reference to the inheritance of the disease." f These authorities, together with Lee, Hutchinson, Lancereaux, and many others of our best clinical and scientific observers, thus agree, fully, on this very im- portant point. What then, is there to show that the so-called "period of gummy products" (Lancereaux) is not simply a period of sequelae, when they are found, practically, by competent observers, to be free from the contagious property, and when by scientific investi- gators it is shown that they are capable of producing, without a vims, all the lesions, without exception, which ever occur in the so-called tertiary or gummy stage of syphilis ? — producing them, too, simply by interference with function of vessels and organs, not improbably through pressure, occasioned by th.Q presence of ab- normal, or excessive accumulations of material, which the most experienced and learned microscopists, cannot distinguish, from the normal elements of new forma- tions. If then we accept the lesions of the so-called tertiary stage (or the period of gummy products of Lancereaux) * Venereal Diseases, Bumstead and Taylor, p. 448. j" Ziem§sen's Cyclopaedia, Am. ed., iii. 57, 138 PRACTICAL CLINICAL LESSONS ON as sequelge, where shall we look for the causes of the undue accumulations of normal germinal material, at every point in the human organism, which are known to occur as a sequence of syphilis ? Naturally, it appears to me, in interferences with the lymphatic channels, through which, according to Rindfleisch, the nutritive material exuded into the tissues, in excessof the neces- sities of growth and repair, is returned to the general circulation."^ According to the same distinguished authority,f " Luxurious new formations, catarrhs, and surface secretions of all kinds, must be produced when the lymph conveyance is hindered, and," he further says, *' we will find this position in pathology very frequently confirmed." One thing is now admitted by all recent accepted authorities, namely, that all the surface secretions and new formations of the tertiary or gummy period, all the infiltrations and tumors, all the peccant elements which produce the varied lesions in the skin, in the cellular tissue, in the bones, in the viscera ; by whatever name characterized, are but the various forms of infiltration or deposit of gummy material. If this is, as it would appear by the results of scientific investigation to be, nothing more nor less than normal germinal elements, thus retained at various points, then the only legitimate way of accounting for this retention, would appear to be through ob- structions, " hindrances to the lymph conveyance," which, Rindfleisch insists, is of itself sufficient, inde- pendentty of an}^ question of sj^philis, to produce just such results as are known to occur in the so-called tertiary stage or period of gummy products. And yet another circumstance would favor this view : clinical experience has shown conclusively that whatever the form or locality or name of a lesion, whether in the skin as a scaling eruption, or as a tuber- cular eruption, or as a heaping up of gummy exudation in scabs, with or without ulceration, or as an ulcerative * Rindfleisch, Pathological History, Am. ed., 1871, p. 93. f Ibid., p. 93. SYPHILIS AND THE GENITO-URINARY DISEASES. 1 39 loss of tissue, or whether as a gummy tumor in the cellular tissue, in the bones, in the viscera, or in the brain and nervous system — one and the same treatment is adopted and found most efficacious and judicious for all, namely, the administration of mercury and the iodide of potassium. I have not heretofore objected to the term gummy period (so called only from the simi- larity of its products to the viscid material which it was believed to resemble), nor to the term tertiary, which is a purely arbitrary one ; but it appears to me that we may now venture to substitute for these the period of lymphatic obstruction, as more scientific, because ex- pressing the localization of lymphatic elements, which is proven to occur, and as suggesting the lymphatic canal system as among the possible causes of that localization. It appears to me that, inasmuch as it has been shown that the lymphatic spaces and vessels are primarily and chiefly affected and obstructed, during the active stage of syphilis, it is not unreasonable to infer that damage might have occurred to those spaces and vessels, during the active period of syphilis, which, if properly investi- gated, would lead to the true explanation of the failure of that system, to return to the general circulation, the germinal material exuded or developed in the tissues, in excess of the necessities of growth and repair, such as is practically demonstrated to have occurred in the so-called tertiary or gummy period of syphiHs. There are various known facts and analogies which afford strong presumptive and circumstantial evidence that this view is the correct one. Among these we have, first, the fact, generally recognized, that the more severe and prolonged the secondary or active stage of syphilis the more certain and severe are the so-called tertiary or gummous manifestations.*^ Second, the results of treatment show, that the difficulty is not simply an aggregation or infiltration of material, which, when removed, restores the patient permanently, but that the conditions for its reproduction remain, and relapses occur. * Hutchinson, London Lancet, January 31, 1874, p. 159. 140 PRACTICAL CLINICAL LESSONS ON Thus the iodide of potassium, is recognized as capable of most rapidly removing the gummous material, and thus of relieving symptoms ; but mercury is found requisite to produce permanent immunity. The iodide of potassium, acts readily in removing recent new for- mations and cell accumulations, probably through the iodine it contains. The fucus vesiculosus, a remedy in use for obesity, and popularly known as " antifat," owes its virtues to the same ingredient. But mercury is known not only to hasten dissolution and elimination of fatty matters and new formations : it is, besides, the only agent with which we can expect to disintegrate more or less long-standing fibrous obstructions. In the gummy accumulations of so-called tertiary syphilis, we are obliged to infer that some condition remains, after the removal of this material, which predisposes to, or causes subsequent reaccumulation. What is more likely, than that such condition, consists in obstruction of lymphatic vessels, the ofhce of which is to carry just such material as we find producing the difficulty? Vessels, too, that have been, more than any other structures, involved in recognized troubles during the active stage of the disease. More or less inflam- matory action, usually of a very low grade, is recog- nised at different superficial points in the lymphatic system during this period. The well-known tendency of all such action, is to the deposit of fibrous material — the very material through which cicatricial contractions of other tissues are brought about. Analogous, in a degree, are the conditions which result in stricture of the urethral canal, ten, twenty, or even forty years after the original inflammation : conditions which set in mo- tion a process which culminates, finally, in obstruction to the passage of urine. It has been claimed that much of the trouble, in so-called tertiary syphihs, may be the result of wide- spread fatty degeneration caused by obstruction of ves'sels. It is well known that fatty metamorphosis occurs more easily in some subjects than in others — that purulent degeneration is most readily set up in the SYPHILIS AND THE GENITO-URlNARY DISEASES, 14! debilitated and diseased. It is also claimed by Hutch- inson and others that the liability to, and severity of, the lesions of the so-called tertiary period of syphilis " is in proportion to the duration of the secondary stage." Hence we may conclude, that the varied degrees and forms of so-called tertiary manifestations, depend upon, first, the damage caused during the " duration of the secondary stage," and inferentially in consequence of it ; and, secondly, upon the condition of the individual affected, and this quite independently of any specific virus. Notwithstanding the variety in locality, physical characteristics, and date of appearance, the sequelae of syphilis practically call for the same remedial measures. Whether it be a superficial scaling or a tubercular erup- tion, an ulcerative lesion of the integument, an osseous swelling or a necrosis, a tumor in the cellular tissue or in the brain, or in any other organ or locahty ; whether it be a painless hypertrophy of the tongue or of the testi- cle, no matter how slight in degree or how destructive, all the lesions of this period are most efficiently treated by some form of mercurial, combined with the iodide of potassium. It is only necessary to know that the lesion presenting, is a legitimate sequel of syphilis, to deter- mine the character of the remedy to be used. The form, the size, and the frequency of dose will be suggested by the circumstances of each case ; but the agents through which Ave may expect the most rapid removal of the so-called "gummous material," upon the presence of which we are warranted in believing that all the trouble depends, are mercury and the iodide of potassium. It is the living material, obstructing nutrition of parts, which, in every instance, produces the destruction of tissue, as well as disturbances of function, that charac- terize the sequelae of syphilis. This is the inevitable conclusion to which we are led, by the published results of examinations, made by the most accomplished patholo- gists of modern times. Thei-e is no disagreement in re- gard to the presence of the so-called "gumma" of syphilis in all such cases. Destruction from the influence of syph- ilis may occur at any point where lymphatic vessels are 142 PRACTICAL CLINICAL LESSONS ON present — in other words, at any point to which nutritive material is carried ; not only to the skin, the cellular, muscular, bony, and even cartilaginous structures, but to every part of the brain and nervous system. It will also be found that the behavior of tissues and struc- tures, infiltrated with the so-called gummy material of syphilis, in all forms in which it presents a destructive result, shows nothing, either by inoculation or by any physical property, which proves it capable of acting otherwise than by the mechanical influence of its pres- ence, by interfei"ing with function and cutting off nutri- tion, through diminishing the calibre of blood-vessels, or possibly effecting their entire obliteration. The measures, theoreticall}^, most efficient in setting up a tissue metamorphosis in, and removing this gummy material, are those which, practically and clinically, are found most promptly serviceable in curing the late lesions of syphilis. In point of fact, it is so well under- stood that mercury and the iodide of potassium, when judiciously administered, have a specific influence in curing the sequelse of syphilis, of whatever form or degree, that whenever a case occurs in which the diagnosis is doubtful it is customary to test the charac- ter of the lesion in question, by use of these remedies : failure to relieve, constituting a positive evidence against the syphilitic origin of the trouble. The administration of mercury and the iodide of potassium, combined, is found most serviceable in the early syphilitic sequin, as for instance, in the tubercular eruptions which may appear before the contagious syphilitic principle has been eliminated from the affect- ed organism, that is to say, within the first two or three years from the date of the acquirement of the disease. These remedies, combined as in the following formula, are usually well borne : ]^ Biniodide of mercury gr. iii. Iodide of potassium 3 iii-vi. Tr. of orange peel Syrup of orange peel aa § i. Aquae ad, 5 viii, M. Sig. — A teaspoonful, thrice daily, after meals. SYPHILIS AND THE GENITO-URINARY DISEASES. I43 As the ordinary teaspoon holds somewhat more than a drachm, it will be found that the patient in the above prescription will get one sixteenth gr. of the biniodide, and about 4 to 8 grains of the iodide of potassium at a dose. The same may be judiciously used in every form, stage, and date of syphilitic sequelas. If, however, the lesion is one where destructive action is a prominent feat- ure, or the brain or nervous system is the seat of the affection, the iodide of potassium may be increased by the addition of a drop of the saturated solution, Iodide of potass 3 viii. Distilled water 3 viii. M. at every dose, in from a wineglass to a tumbler of milk or water (preferably the former), up to 60 or 80 drops, or until troublesome iodism results. The favorable effect of this treatment may be often seen within a few days, but occasionally no benefit will be observed until the dose of the iodide has reached a very high point, viz., a drachm at a dose, and in cases of cere- bral gummata this dose may require to be continued over a very long period — several months, or even longer. In the very largest majority of cases the foregoing plan may be successfully pursued, varying the amount of mercurial, or of the iodide, within the limits indicated, in proportion to the gravity and urgency of the case. The mercurial reaches its limit of efficiency when the constitution becomes slightly affected by it, as indicated by softening or tenderness of the gums and teeth, and should, at that limit, always be stayed. Should the iodide of potassium fail of toleration, the iodide of sodium may be substituted and better borne in the same doses. If still iodism quickly result, as in- dicated by irritation of mucous membrane of the dis- gestive tract, the tincture of iodine may be adminis- tered in doses of 10 to 40 drops in a wineglass of starch as prepared for laundry use, or what in my experience has often been a most serviceable and 144 PRACTICAL CLINICAL LESSONS ON agreeable substitute for the iodide of potassium and sodium, viz : ^ Iodine (crystals) gr. xviii. Iodide of potassium 3 i-iii Water q. s. Stuart's syrup or plain molasses to § viii. M. Let stand 12 hours. Sig. From a dessert to a tablespoonful, three or four times a day, after meals. Cod-Hver oil is always indicated in cases when any cachexia is present, from syphilitic influence, or debility from any other cause. The diet should be simple and nutritious, and adapted judiciously to the condition of the patient. Stimulants should be denied except in cases of especial urgency on account of habitual use and great debility — red wines may be permitted, at meals, in moderate quantity. The pursuance of the general plan just presented, covers all cases, as far as internal remedies are con- cerned. Mercurial fumigations may be, and often are, promptly serviceable, especially in the ulcerative le- sions, and may be substituted for the internal administra- tion of mercury. Twenty grains of resublimed calomel may be vaporized in a Lee's lamp, placed under a cane- bottom chair, and the patient covered in with a rubber cloak, or even an ordinary blanket, and this repeated three or four times a week — due care being used to pre- vent taking cold after the operation — and continued until the disappearance of the lesions, or the occurrence of the specific effect of the mercurial. In regard to local applications for the non-ulcerating forms of trouble, ointments containing a mercurial in- gredient, such as the ung. mas. h3^d., the ung. hyd. nitratis, or ung. hyd. prascip. alb., or a combination of the oleate of mercury (a 6 per cent solution), with an equal quantity of cosmoline or vaseline, is often service- able, especially in the scaling and non-ulcerating tuber- cular eruptions. For local apphcation to open ulcerations, or losses of tissue, through the influence of the so-called gummy in- SYPHILIS AND THE GENITO-URINARY DISEASES. 14$ filtration, especially when advancing, pointed, and pain- ful, the powdered iodoform is often promptly benenciaL In all forms of open lesion of syphiUtic origin this drug appears to be especially potent in its sedative, antiseptic, and healing properties; perhaps it is the most so of any. Throughout the treatment of the sequelae of syphilis the effort to appreciate the causes of any presenting trouble — the influences local and constitutional which may tend to modify, or aggravate, or interfere in any way with the favorable progress of recovery should be unremitting, and not to rely upon or seek after some drug or prescription which is vaunted for the cure of syphilis. Judicious attention to the general health, and to the idiosyncrasies of patients, often brings success in cases which would otherwise result disastrously. Many subjects of syphilitic sequels, suffer greatly from the apprehension of communicating the disease to others. They are entitled to the assurance that such troubles are not contagious, and are of purely personal interest after a lapse of four or five years from the occurrence of the initial lesion of syphilis, and this whether a sys- tematic course of treatment has been pursued in the in- terval or the patient has been quite neglected in this respect. It is quite true that many cases have been re- ported claiming communication of syphilis five, ten, and even twenty years after the acquirement of the disease, but a single well-observed, well-authenticated case, re- ported by a competent authority, has not yet come to my knowledge, nor have I ever known such an accident to occur after three years from the date of the initial lesion. CLINICAL CASES ILLUSTRATIVE OF THE VARIOUS SEQUELS OF SYPHILIS. Case I. W. W. ; 28, physician. In December, 1874, after repeated suspicious connections during many months, one day discovered a small sore on his penis. This was treated simply and only locally, and continu- ing in a sluggish way f()r a couple of months, when it was proved to be a true initial lesion of syphilis by the 146 PRACTICAL CLINICAL LESSONS ON appearance of a well-marked roseolous eruption and mucous patches in the throat. A systematic mercurial treatment was then initiated, bringing the system gently under its influence, and continuing at the point of easy toleration, occasionally pushing it up to sensi- tiveness of the gums or teeth. When this occurred the iodide of potassium was substituted until all evidences of the mercurialisra had disappeared, and then the mer- curial was resumed, either in the form of pil. duplex (mass, hydrarg., 2 grs.; ferri exsic, i gr.) or pil. pro- to-iodid. hydrarg. (-J gr.), three times daily. Under this treatment, borne satisfactorily for eighteen months, no further manifestations of syphiHs occurred. The glands in the groin and cervical regions, and also in the epitrochlear spaces, which were characteristically en- larged at the date of discovery of the roseola, had ap- parently become reduced more than one half in size. It was confidently asserted by the doctor that his glands were enlarged for years before the discovery of the initial lesion, and were now as small as he remem- bered ever to have seen them. In consequence of this statement, in connection with the entire absence of any congestion of the faucial mucous membrane or any ab- normal appearance at the site of the initial lesion or any evidence of syphihs at any other point, all treatment was suspended. After six months, during which there was no sign of trouble of any sort, local or general, atten- tion was called to a cluster of dark red papules (twenty to thirty), about the size of a small split pea, situated on the integument of the left temporal region. They were quite prominent, insensitive, and while firm to touch had a juicy, semi-transparent appearance at the centre. On examination another patch of similar erup- tions nearly as large as the hand was discovered under the left scapula. These clusters of apparent papules constituted a typical illustration of the simplest form of the tubercular syphilide, one of the most common and earliest of the sequelae of syphilis. Treatment by a combination of mercury and the iodide of potassium (mist, biniodid. hydrarg., No. , page ) was at once commenced, and continued steadily, the eruption for SYPHILIS AND THE GENlTO-URlNARY DISEASES. I47 a time increasing in prominence. At two points alone slight ulceration occurred, and a scab about the size of a five-cent piece was formed. After about four weeks the tubercles began to decline, Avith slight desquamation, and finally to sink below the surface, so that by the third month of treatment the only remaining evi- dence was a cicatricial depression on the site of each tubercle ; the intervening spaces between these points being of a faint coppery hue. Treatment discontinued, but, in a month, several tubercles had returned, and again disappeared under same treatment as before — mild mer- curial ointment (ung. hyd. nit. et vaseline, aa § ss) — applied locally for two months. Again, on remitting treatment, in a week or two, evidences of return of the trouble on the side of the forehead were visible ; several spots were simply reddened, while small scabs formed on others. The treatment was resumed, and re-enforced by fumigations with the re-sublimed calomel tri-weekly, and this continued steadily for three months, when, no evidence of the return of the trouble presenting, the cicatricial spots distinctly paler than the surrounding skin, and the coppery stain scarcely noticeable, the treatment was again discontinued. August, 1881, the doctor called with the statement that he was about to be married unless some important objection should be raised. The cicatricial depressions were still distinct in both locaUties and quite white, and no evidence of activity of the former trouble. Glands in the various localities were distinct, but not changed by time or treat- ment since the cessation of active medication, eighteen months after infection. Thus a period of five years had then elapsed since any sign of activity of the disease had been manifested, and it was concluded that there was no valid reason for postponing marriage, — always excepting the possibility of some future trouble of local character, but not suscep- tible of hereditary transmission. Now up to February, 1883, he has had no further trouble; has a wife and child, now eight months old, perfectly well. Remarks. — As recent painless enlargement and indura- tion of lymphatic glands (first, those directly connected 148 PRACTICAL CLINICAL LESSONS ON with the initial lesion of syphilis ; and second, groups of glands at characteristic points, such as the cervical and epitrochlear) are the most certain diagnostic signs of the presence of syphilis, in a given case, so their gradual subsidence is the most sure evidence of the effi- ciency of treatment, and their final and complete disap- pearance the most satisfactory proof of the complete cure of the disease. It is, however, necessary to mention that painless gland enlargements are present, in some persons, independent- ly of syphiHs, or of any distinct scrofulous antecedents or evidences of this or any other dyscrasia. Hence it becomes important to note the condition, in this respect of any person, presenting with known or suspected initial lesion of syphilis, not only for the diagnostic value attaching to recent painless gland enlargements, but as an aid in determining the proper duration of con- stitutional treatment. When the glands are in nor- mal condition at the time of inoculation of syphilis — i.e., not susceptible of recognition by the touch — a continua- tion of the treatment is necessary until their restoration to such condition. On the other hand, when apprecia- ble gland enlargements, are present before the system is invaded by the sj^philitic influence, there will be no such guide for the cessation of treatment, and a much longer period will be required, before the patient can be. assured of the propriety of discontinuing anti-syphilitic remedial measures. The administration of mercury by fumigation, as in the foregoing case, while not suitable for general sys- tematic treatment, is an excellent adjunct in certain cases. The necessity of a prolonged feeble mercurial influence is best met by its judicious internal adminis- tration, but in cases where this is not well borne, it may be supplemented by two or three fumigations a week — steadily, if practicable, or at intervals, when it appears desirable to produce the constitutional evidences of the mercurial influence. It is especially adapted to cases where eruptive and ulcerative troubles are present. The method of application is exceedingly simple. An ordi- nary tin basin set upon a couple of bricks, high enough SYPHILIS AND THE GENITO-URINARY DISEASES. 149 to admit a small alcohol lamp to be placed under the basin. From fifteen to thirty grains of pure calomel (re- sublimed to carry off the free hydrochloric acid, which is very irritating to the respiratory apparatus) is placed in the basin over the lamp. This under a cane-bottomed or open-worked chair. The patient sits on this naked, and is then enveloped closely in an ordinary blanket — the lamp is lighted, and in the course of from ten to twenty minutes the calomel is vaporized, and deposited to a greater or, less extent on the surface of the body. Still wrapped in the blanket, or slipping on a flannel night-dress, the patient gets at once into bed, and re- mains through the night. During the fumigation the vapor may be inhaled from time to time to advantage, especially if there are open lesions of the mouth or throat, or if a prompt mercurial effect is desired. If an irritative cough results, inhalation should be very limited, or suspended entirely. Where it is available, the fumigation lamp invented by Mr. Henry Lee of London, and in general use under the name of Lee's lamp, is preferable. In this a small amount of water is evaporated with the calomel. An ample water-proof garment in place of the blanket is also an improvement, but the results are fully much the same as with the simpler apparatus. There is no more danger of taking cold after a mercurial bath or fumigation than after a simple warm bath, but it is desirable to secure a tem- perature in the room of about 70° F,, and to have the patient clad habitually in flannels, light or heavy accord- ing to the season, throughout the period during which the baths are administered. When the mercurial fumi- gation is relied upon alone, and the patient is robust, it may be used nightly, using ten to sixteen grains, and continued for months without producing the apparent constitutional effects. If, however, signs of the mercu- rial influence appear in the mouth and breath, the fumi- gations should be promptly suspended. The incon- veniences attendant on this mode of treatment are such, that except it is manifestly the only way the mercurial can be efficiently introduced, the treatment by innunc- 150 PRACTICAL CLINICAL LESSONS ON _ ^ tion, or through internal remedies will be found greatly preferable. Case II. June loth, 1874, N. L., 46, naval officer, pre- sented with a general and quite profuse, large, ham- colored, papular eruption, slightly scaling at borders, of some papules, chiefly on body and legs and arms, none on face. Mucous patches in the mouth ; well-marked gland enlargements in the cervical region, viz. along the posterior border of the sterno-cleido-mastoid muscle and of the trapezius, also in the epitrochlear and in the inguinal regions. On further examination, an indurated lump, the size of a pea, was found in the tissues of the prepuce on the left side. This was said to have come with a small sore some six months previously. Had con- sulted several surgeons, who thought his sore a simple one. It finally healed, after several weeks' continuance, through simple applications alone, but left a hard kernel on its site. No more attention was paid to the matter until the appearance of the eruption, some three weeks previously, when he was suffering from a supposed malarial attack. Having now some suspicions that his trouble was syphilitic, and not then desirous of confiding in the medical officer of his ship, he waited without treatment until his arrival in port. The case was one of undoubted syphilis in full bloom, and was at once put upon a systematic mercurial treatment. This was car- ried on now under the care of another surgeon — a most accomplished medical man — for about a year. During this time several consultations wei"e held. The eruption, and all other external lesions, passed off satisfactorily. The chief difficulty experienced was a failure to produce the constitutional effect of mercury by the ordinary means. Three at first, then four, five, and even six pil. duplex (each 2 grs. mass, hydrarg. and i of exsic- cated sulph, of iron), were given daily, without appar- ent effect either on the gums or on the digestive appara- tus. Patient's general health excellent. Small doses of calomel (^ gr. every two hours) were given then in addition until gums responded, and at the same time a bilious diarrhoea set in and continued for several days. When this and the other evidences of mercurial action SYPHILIS AND THE GEXITO-URIXARY DISEASES. 151 had completely disappeared, the patient resumed the mercurial in the form of pil. proto-iodid. h^xlrarg., three J-gr. pills, three times a day. The treatment was pursued steadily, for about three months, making about twenty months since the acquirement of the disease, and over a year of full and systematic treat- ment. This course was remarkably well borne, in every respect, and the patient was in excellent general health and spirits. There was now no external evidence of syphilis, and the glands in the various regions were no longer characteristically enlarged. Leaving home for a three months' cruise, the patient returned presenting a thickly studded tubercular patch about the size of his hand, under the left scapula : tubercles size of a grape- seed, and of a pale purphsh-red color — with neither itch- ing nor tenderness to touch. Another group, chiefly of large tubercles, covered with brown serous scabs, ranging in size from a pea to a five-cent piece, arranged in a horse- shoe form four or five inches in diameter, appeared on the left thigh ; while several small tubercles were scattered irregularly over the buttocks, — thus presenting a well- marked specimen of the so-called tubercular syphilide in its several characteristic forms: ist. The simple tu- bercular under the scapula, in an irregular patch, with each tubercle distinct, and of pale purplish hue, with no tendency to ulceration or exudation of serum ; this kind disappearing slowly by absorption of the material com- posing; the tubercle, and leaving a distinct depressed cicatrix to mark the site of each. 2d. The tubercles coalescing and extending by a superficial ulceration, exuding serum and forming brownish scabs with a ten- dency to the horseshoe shape. In the arrangement of this lesion, the scabs, often quite thick, on removal presented a superficial surface of large florid granula- tions scantily bathed in serum, and bleeding at slight touch. The so-called impetigenous \AxhQTQv\\?^x syphilide. 3d. Tubercles from size of a grain of pearl-barley to a pea, varying in color from pale red to purple, irregularly scattered about; also some larger, quite pustular in ap- pearance, some with yellow and others with scabs of quite a dark brown color. 152 PRACTICAL CLINICAL LESSONS ON All these had come on so insidiously, so entirely with- out pain or even itching, that they had only been discovered by the patient to be more than accidental pimples a week or so previously, but had evidently been present a month or more. The treatment was changed from the pil. proto-iodid. hyd. to the mist, biniodid. hy drarg.,^ a teaspoonful thrice daily. Scabs poulticed off, and an ointment composed of nitrate of mercury ung. and vasehne, equal parts, applied morning and night. Improvement followed, especially in the open lesions ; but after a couple of months, when the first crop had almost disappeared, others appeared on the right calf. Treatment changed to nightly mercurial fumigations (20 grs. calomel), and increase in the iodide of potas- sium—increasing from eight grains three times a da}', a drop for each dose, up to sixty, and taken in a tum- bler of milk. After several months, taking from fifteen to twenty fumigations a month, and keeping the iodide at about sixty grains thrice daily, the eruption entirely disappeared, leaving slight, pale, depressed, and corru- gated cicatrices on the body, and deep coppery stains on the extremities. The treatment Avas then omitted, the patient still being in good general health. Capsules of cod-liver oil and iron (Mathey Caylus), adminis- tered. After a month or so, other crops, chiefly pustular, came to the surface, apparently on the site of the former eruptions, and came and went for the next six months, getting better in one place and then cropping out in groups of half a dozen or so in another, and this under a systematic treatment as before mentioned, car- ried out with as much regularity and persistence as was possible under the circumstances. Relaxing it, for even a few days, was followed by more or less return of the trouble, and it was fully two years after the appearance of the first tubercular eruption before the trouble entirely ceased to recur. During this time no points were at- tacked except those first mentioned — under the scapula, and on the thigh and buttocks, and soon after on the right calf ; after this the recurrences were in the same * See formula, p. 92. SYPHILIS AND THE GENITO-URINARY DISEASES. 153 points or in their immediate vicinity. During the entire period covered by the treatment the patient was most of his time at sea, under favorable hygienic conditions, and living a temperate and regular life. Within the last year (1882) the above-mentioned person was seen in consultation for what was supposed to be a malarial neuralgia. There was no history of any recurrence of trouble which could be reasonably attributed to the syphilitic influence for the previous five years. The neuralgia, which was chiefly in the muscles of the spine, after resisting treatment by the iodide for several weeks, finally passed away under the influence of a month's so- journ in the tropics. Remarks. — The chief interest involved in the appear- ance of an eruption, after the eighth or tenth month of syphilis, is as to whether it is to be accounted as a se- quel of the active disease, or is an evidence of the active presence of syphilitic cell material in the organism. After the first general papular eruption, which, as a rule, appears between the third and the seventh month, and is more or less symmetrical in its distribution, groups of papules may develop on the shoulder or arm or back or forehead, which, although usually darker and more likely to assume an annular or crescentic form, may pre- sent all the physical characteristics of the papules of the earlier general eruption. These are known as the recur- ring papular syphilides, and are supposed to be the result of a release of accidentally imprisoned infective cell ma- terial from lymphatic glands, in the immediate vicinity of the eruption, and to indicate a continued activity of the contagious element.* It is quite impossible, in the present state of our knowl- edge of this matter, to make a positive diagnosis in cases of doubt, until sufficient time has passed to observe the * "The secretions of syphilitic lesions are found to consist of a serous fluid containing numerous shining granules or molecules, which are masses of protoplasm or germinal matter holding the contagious proper- ties of syphilis. These microscopic bodies are probably taken into the circulation by the lyi7iphatics and conveyed over the body." (Bumstead and Taylor on the Venereal Diseases, fourth edition. Henry C. Lea, Phila., 1879. P- 443-) 154 PRACTICAL CLINICAL LESSONS ON manner in which the tissues occupied by the eruption, are affected by the presence and the final absorption of the material causing it. Thus the papule, having its origin in an accumulation (proliferation in loco?) of germinal cells (commencing, according to Kohn and others, always in a papilla cutis), has several character- istic points. I St. In certains cases the cells thus crowded together ''are not destined to become permanently or- ganized, as they degenerate and disappear, or assume a dull granular appearance, undergo fatty degeneration and are absorbed. Or they may become heaped to- gether in the form of detritus and form pus." * Thus they either '' undergo fatty degeneration and become absorbed," leaving no loss of tissue to mark their site, or they become pustules. The tubercle, on the other hand, is made up of the so-called ''gummy' or germinal material, identical with that found in the lymph channels ; arrested by localized obstruction of such channels; this localized accumulation causing absorption of the tissue in which it is located, finally itself undergoing fatty degener- ation and absorption, a depression or cicatrix is left which is a sure diagnostic mark of the uncomplicated syphilitic tubercle. f These so-called " gummy exudations," char- acterizing as they do all the sequelae of syphilis (the secretions of which are non-contagious), form the dis- tinguishing feature between syphilis, as a contagious disease, and its sequelae. Their occurrence, in what- ever locality or form, calls for change or modification in the treatment. Iodine and the iodide of potassium having been found to possess a peculiar power in caus- ing the fatt}^ degeneration and elimination of the so-called gummy material is then found promptly efficacious in aiding in the cure.:}: * Caracteres cliniques et histologiques des Syphilis, par Moritz Kohn, Wiener Woc^enschrift. Caracteres, 1870. No, 55, Archives Ghi^rales de M^decitie, March, 1872. f See Van Buren and Keyes. Genito-Urinary Diseases, with Syphilis, page 583. Appleton & Co., New York, 1874, f As these processes are quite distinct in their origin they may be pres- ent at one and the same time, and thus it may occur that although the tubercular eruption — a sequel of syphilis — is present, the contagious ma- terial represented by the papule may still exist in the organism ; the SYPHILIS AND THE GENITO-URINARY DISEASES. 1 55 The punctate form of the tubercular syphilide, as first described, is usually the earUest of the syphilitic se- quelge, and rarely appears after the third year. The su- perficial ulceration, with a tendency to the crescentic, or horseshoe arrangement, is next in order, and, is occasion- ally associated with it, as in the foregoing- case, but may occur as late as the tenth and even the twentieth year after infection, and is likely to be especially severe and extensive in cases of chronic alcoholism. Tubercles occasionally appear singly, or in small groups, on the face, especially on the alae nasi, and, ulcer- ating superficially, become scabbed over and pursue a very sluggish course, often for many months, and are not unfrequently mistaken for simple lupus. Under favorable hygienic conditions, all these forms yield promptly to treatment : locally, by iodoform, or the ung. hydrarg. nitratis and vaseline ; and internally by com- bination of mercury and the iodide of potassium, as in the misturge biniodid., and additional iodide of potas- sium in doses increasing by one drop at each dose up to 60, thrice daily, if well borne, always taken well di- luted — in half a tumbler, and finally a tumbler of fluid, preferably of milk. In this way the stomach is rarely rebeUious to the maximum dose. It is a fact well understood by all who have experi- ence in the tubercular forms of sj^philis, that local meas- ures, while apparently hastening the cure, are almost wholly useless, except in combination with mercury and the iodide of potassium. It is also equally appre- ciated that while prompt benefit, is almost certain to follow the use of the iodide of potassium, recurrences of the trouble are much more frequent, than when this limit of contagion in acute syphilis having been ascertained in the very- greatest majority of cases not to exceed three years. Bearing this in mind, it may then be said that although the presenting lesion being tuber- cular and by its origin illustrating the non-contagious stage of syphilis, yet it cannot be claimed as free from virulence {i.e., power of contagion) until two or more years have passed and all gland enlargements depen- dent upon syphilis have disappeared ; but that after such proof of the ter- mination of the acute stage of the disease, the presence of such tubercular eruption would not indicate a power to transmit syphilis by direct con- tact or through heredity. 156 PRACTICAL CLIXICAL LESSONS OX remedy is used in combination with a mild mercurial treatment, either internally oi* by innunction or fumiga- tion. Such behavior, which is recocrnized as a clinical fact, is most significant of the conditions which demand treatment. The accumulations of the arrested germinal material, or so-called gumma, as the immediate recog- nized cause of the local lesions, are readily acted uj)on by the iodide of potassium, (the weaker agent in pro- ducing tissue metamorphosisX while the permanence of results is better secured by the mercurial, which has the greater power to cause a modification, if not a complete metamorphosis of the material causing the obstruction. In the absence of absolute proof, as to the degree and quality of the obstruction in the lymph channels, it may be possible, that this is due, in some cases, to actual clo- sure by cicatricial deposit, such as is seen constricting the parenchymatous structure of the liver, the tes- ticle, etc. If this is the fact, removal of such obstruc- tive material by anv sort of treatment is scarcely prob- able. This would account for the repeated recurrences of trouble, temporarily relieved b}' treatment, and con- stituting a form of what is termed a syphihtic dyscrasia. It may also be possible, that, where such cicatricial ob- literation of lymph channels is not extensive, the circu- lation is temporarilv relieved by elimination of the excess through treatment, or through fatt}' metamorph- osis, sua spo7ite, until the dilatation of adjoining or sub- sidiary efferent channels shall afford permanent relief. It is a clinical fact that, as in the foregoing case, relapses continue to occur for vears even, and the case is at last permanently cured by efficient treatment: while in others, the troubles, with or without treatment, remain until the termination of the hfe of the patient, notwith- standing the most judicious care.^ * However mnch the explanation of gmnmons collections may need absolute microscopical demonstration, it is conceded by all modem patho- looi.5ts: I St. That the so-called gommoos material constitutes in some way the sum and substance of all the tertiary and qoartemay lesions: in other words, the sequel/z cf syphilis. 2d. That this material does not differ mi- croscopicaHv in any appreciable way from the normal germinal elements, such as are found in all the lymphatic gland, channels, and spaces in the human organism. If, then, this material present to a cer^un d^[cee in all SYPHILIS And the genito-urinary diseases. 157 Case 111. W. McN. ; merchant ; 42. Temperate, or- dinarily healthy ; had a well-marked open initial lesion of syphilis at 25 years of age. This was followed by a general papular eruption, at about the fifth month. Treat- ment desultory, until the appearance of the eruption, when he came under my observation, and was put upon pil. duplex (mass, hydrarg. et ferri). This treatment was well borne, and continued for a year and a hall very steadily; occasional intermissions of a few days only, when slight evidences of mercurialism occurred. With the exception of several mucous patches in the mouth, and slight ulcerationof the tonsils,during the sixth month, there were no open lesions of any sort. General and local gland enlargements had declined satisfactorily. The patient at this point was put upon the mist, biniodid. hyd. (potas. iodid. 8 grs., hydrarg. biniodid. -^V^' '^ teaspoon- full thrice daily, and it was faithfully continued for the following six months. During this time the patient was apparently in perfect health. At its close, the only evi- dence of syphilitic trouble, was the abnormal, but not greatly enlarged, lymphatic glands, at all characteristic points. As these glands had not diminished, appreciably, during the last six months of treatment, it was concluded, in the absence of knowledge of their condition before the accession of syphilis, that they had no longer any pathological signihcance, and all treatment was sus- pended. During the following two years, no evidence of syphilis having been manifest, permission to marry was accorded. Child born a year after ; mother and the tissues — for all tissues are supplied with lymphatic spaces or channels — becomes localized in excess at certain given points, this can logically only occur by the obstruction of such channels or spaces. Whether we can yet demonstrate this microscoi/ically or not. It is within the last ten years that even the existence of lymphatic vessels in the most im[)ortant pans of the body — as, in the eye, in the bones, etc. — has been denied liy leading and accepted authorities. But since then it has been proven by Thin. Ludwig, Schvveigger-Seidel, anil others, that there is not alone a gen- erous supply of lymphatic vessels to the eye and the bones, etc., but even cartilages are abutulantly furnished with them. Accepting thus a legiti- mate deduction from known facts, whch furnish logical reasons for the plan and measure of treatment, we may wait hopefully for the microscop- ical ailvances which shall scieruifically establish our kiunvledge of the exact mechanism of the late lesions of syphilis. 158 PRACTICAL CLINICAL LESSONS ON child healthy — and so continued. Two years subsequent to the birth of the child, and thus six years from the ac- quirement of syphilis, patient presented with a swelling over the lower portion of the sternum, about the size of half a lemon ; quite firm ; slightly tender on pres- sure. First noticed, about half its present size, about a month previous. Diagnosis : gummy tumor — a sequel of former syphilis. Treatment : iodide of potassium 8 grs., biniodid. of mercury one sixteenth, three times a day. As the patient was otherwise in good health, noth- ing further was prescribed. Without any local applica- tion, under the above-mentioned treatment, the tumor declined rapidl}^ and at the end of three months every evidence of it had completely disappeared, and all treatment was discontinued. A little more than ten 3"ears have passed, and no further trouble of syphilitic nature has occurred, either to the patient, his wife, or his children, of which latter he has several. Remarks on Case III. — Claims for the non-contagious character of syphilitic sequelae, find corroboration in this case. Prompt effects of the specific treatment re- move any possible doubt as to syphilitic origin of the trouble. The cessation of treatment on the entire disappearance of the tumor, is in accordance with the usual practice in such cases, but it must not be for- gotten that such tumors are likely to return, or that similar accumulations may occur at other points. And while, as in this case, a prolonged immunit}' may be ac- quired, even escape from any further syphilitic sequelae, yet such an accident, indicating failure of treatment dur- ing the active stages of syphilis to completely efface the damage then done, must make the patient and his phy- sician anxious and watchful for possible similar develop- ments in other localities. Especially should this be borne in mind when obscure troubles of nutrition or of the motor or sensory apparatus are recognized. GUMMA OF THE TESTICLE. Case IV. J. V., 65 ; lawyer, in good general health. Presented with an enlargement of the left testicle. SYPHILIS AND THE GENITO-URINARY DISEASES. 159 It had a few weeks previously attracted his attention by its weight, and not from any pain in it. The size of the organ, which was ovoid in shape, was four inches in its vertical and three in its horizontal diameter, quite firm and insensitive to the touch. A small amount of fiuid was recognized in the tunica vaginalis. There was no history of any urethral disease or any mechanical injury either to the testicle or the sur- rounding parts ; but there was a tolerably clear history of syphilis at the age of 24, viz.: a sore coming on the penis fully three weeks after a suspicious connection, which remained for some time, finally healing under the internal administration of mercury. He married a few years after ; had several children ; also grandchildren ; not one of whom had ever any recognized signs of syphilis. No recognized sign of syphilis had appeared in the patient from the date of the healing of his sore, to the occurrence of the swelling of his testicle, forty years after. The tumor, both as to its accession and its physical characteristics, was like a sequel of syphilis. Freedom from pain, and from irregularities in shape ; freely movable under the scrotum : unconnected with any tubercular or cancerous antecedents. About four drams of serum were drawn from the tunica vagi- nalis and the smooth surface of the tumor, and com- plete freedom from fluctuation was made more manifest. Treatment by the mist, biniodid. internally, was com- menced, together with ung. hydrarg. mit. externally. Subsidence of the tumor commenced within a fort- night, and at the end of six months the testicle had re- sumed, nearly or quite, its original size. Remarks. — The absence of all recognized manifesta- tions of syphilis, as in the foregoing case, is not without precedent. Early constitutional syphilis varies in its intensity as much as any other known disease. The roseola, even if present, may readily escape observation. The papular eruption may be confined to half-a-dozen points, or even a single spot on the body, or a single mu- cous patch or tubercle, which shall pass away without treatment or recognition, and yet syphilitic sequelae may l6o PRACTICAL CLINICAL LESSONS ON occur, the effects of which may prove as grave as when every phase of the active period presents the typical manifestations. Once recognized as syphihtic, no matter how slight the lesions of the initiatory period or that of general infection, the treatment should be as system- atic, as thoroughly considered and carried out, as when well-marked in all respects. It is only in this way that we gain the great security against the occur- rence of sequelas, and if occurring, secure the lightest forms of trouble. Unfortunately, relief from the im- mediate and appreciable accumulations constituting sequelse (the so-called gummy tumors of syphilis) does not always mean cure : recurrences, especially of the accumulations in the testes, are not uncommon, as in the following : Case V. P. P. S. This patient gave a clear his- tory of the characteristic eruptions of active syphilis occurring twenty years ago. Good health up to five years, when his right testicle became enlarged to the size of his fist. He stated that under occasional treat- ment of iodide of potassium the testicle grew very much smaller; in fact, he thought his difficulty almost cured, when the swelling returned. On examination, a large quantity of fluid was found in the tunica vagina- lis. Four ounces being drawn off, it became evident that the tumor remaining, while not larger than a nor- mal testicle, was irregular in shape — nodulated — espec- ially at the lower portion, where it was of cartilaginous hardness. The upper portion alone was sensitive to pressure. It thus became evident that a fibrous de- generation of the entire inferior portion of the testicle had taken place, and that its secretory structure was almost entirely destroyed ; the sensitiveness to pres- sure indicating the portion which had thus far escaped. Remarks on Case V. — In the post-mortem exami- nation of similar cases, it is found that two forms of trouble frequently (and always in long-standing cases) unite in the so-called chronic orchitis of late syphilis, the one usually earliest to manifest itself being gen- eral infiltration or a localized tumor at one or more SYPHILIS AND THE GENITO-URINARY DISEASES. l6l points in the substance of the or^an. This accumu- lation is found to be made up of materials charac- teristic of the ^' gummy tumor' occurring in other localities. Subsequently to the occurrence of these tumors a marked growth of fibrous tissue is found to take place, apparently commencing in the lobular spaces^ and gradually encroaching upon the seminal lobules until they are destroyed. The elements of new forma- tion, traversing in this same way the substance of the entire organ with a cicatricial net-Avork, the contrac- tion which naturally follows often results in the total destruction and almost complete disappearance of the organ. This explains what we find in the present in- stance. The history points to a general so-called gummy infiltration, involving, probably, the epididymis and the body of the testicle, and a later development of fibrous tissue, which has, by its subsequent contrac- tion, reduced the organ to its present indurated and atrophied condition. It is interesting here to recall the fact, made prominent by all authorities on syphilis, that cicatricial deposit and its subsequent contraction and strangulation of the parenchyma of the testicle, resulting in true atrophy, is characteristic of the influ- ence of late syphilis, and occurs not alone in the testi- cle, but notably also in the liver and the kidneys. The tendency to formation of fibrous tissue has also been recognized (from apparently the same causes) at other points, as in the larynx, intestine, etc. Ranvier and Cornil significantly remark"^ that all profound syphilitic lesions of the mucous membrane occasion a prolifera- tion and a production of connective tissue usually much greater than in diseases due to other causes. It is a .veil ascertained clinical fact that gummy infiltration precedes the stage of cicatricial deposit, and that while both the gummy tumor and cicatricial atrophy, are often met with m the same testicle, general enlarge- ment first occurs; then comes the recognition of local- ized deposits of gummy material, and later, often sev- eral years after, compression, due to contraction of * "Fatholog. Histol.," page 399, 1880. l62 PRACTICAL CLINICAL LESSONS ON cicatricial deposit, finally takes place, and atrophy of the testicle results. The clinical evidences are strongly in favor of considering the gummy exudation as the basis of the cicatricial deposit, and the different subse- quent conditions, as but stages of the same pathological process, terminating finally in atrophy, through cica- tricial contraction. In favor also of this view, and as affording a possible explanation of the cause and mode of formation of the cicatricial deposits in other organs, due to late syphilis, we may recall the statement of Rindfleisch in regard to the most favorable conditions for the development of new cell formations, namely, " Contact with tissue and relative rest of the emigrant cells induces them first to essay their amoeboid mobility, and then to division."^ But absolute x^^i, stasis oi s\xq\\ cells, or of any cells, is necessary for their developmeiit into tissue. All fibrous or connective tissue is said to be made up of the spindle-shaped or connective-tissue cells and fi-brillse which are simply a higher stage of development of the lymphoid cells and corpuscles, evolved from and circulating in and through the lym- phatic organs, spaces, and vessels. This is exactly the essential material of which cicatricial tissue, wherever found, is made up, and this is exactly the sort of tissue which has caused the mischief in this testicle, and which by authorities is accepted simply as one of the many mysterious phases of the so-called tertiary period of the disease. Only a single condition is lacking, how- ever, in order to place this cicatricial deposit, due to syphilis, in the line of ordinary pathological conditions, and that is, one which will account satisfactorily for the presence and quantity of embryonal or formative cells in the localities where the cicatricial tissue is subse- quently developed, and the causes of their enforced accumulation and stasis in those localities, during a period sufficient for the formation of such tissue. Ludwig and Thomsa \ claim to have demonstrated a * Rindfleisch, "Path. Hist.," p. 94, sec 77. f Strieker, " Human and Comparative Histology," Sydenham ed.i vol, i.,p. 311, et seq. SYPHILIS AND THE GENITO-URINARY DISEASES. 163 very generous distribution of lymphatic channels in the testicle, the liver, and the kidneys, organs in which the cicatricial contraction due to the influence of late syphilis is chiefly found. Especially are the lymphatics claimed to be numerous and ample in the testicle, where injections performed upon dogs have shown that lobular spaces are simply lymph sacs or lacunae. In point of fact, the seminal lobules are literally inclosed in lymph chambers, and the reticulation of lymph channels not only surrounds, but permeates, every por- tion of the testicle and its appendages. The same rich distribution is shown also in the liver and kidneys. Having, then, the material necessary for the formation of cicatricial tissue, and in localities where it is known to develop, the essential condition to produce it, is an enforced stasis of cell elements, through interference with the lymph circulation of these organs ; in short, obstruction of the lymph channels at various points. GUMMY TUMORS OF THE INTEGUMENT AND CELLULAR TISSUE. Case VI. W. W.; 49. Presented three large, sharp- ly cut, apparent ulcerations on the inner aspect of the right leg just below the knee ; two about two inches each in diameter, quite circular, and a third about two inches in length, formed by the union of two about an inch in diameter. All had penetrated the integument completely; the surrounding integument was only slight- ly inflamed. Two small tumors just under the integu- ment on the outer side of the right thigh, movable under the skin, painless, and another nearer the knee, attached to the integument, and distinctly fluctuating. Here were, then, three characteristic stages in the progress of gummy lesions of the integument. There was a clear history of syphilis irregularly treated about fifteen years previously. Alleged occurrence, four or five years previous,, of large sores with heavy black scabs upon them, chiefly on the legs and arms, which were cured by iodide or potassium. Cicatrices paler than the sur- roundings skin were found corroborating the statement, 164 PRACTICAL CLINICAL LESSONS ON This patient was in low general condition from dissipa- tion, insufficient nutrition, and bad hygiene. He was given nutritious diet, with cod liver oil. A course of iodide potassium with biniodide hydrarg., the former to be gradually increased by the addition of a gi'ain at a dose, taken largely diluted with milk, up to sixty grains. Under this treatment and care, with local appli- cations of iodoform in powder to the ulcerations, marked improvement at once took place, and in about two months healing of the open lesions was com- plete, and the tumors were apparently absorbed. Remarks on Case VI. — As a rule, to which excep- tions are rare, the ulcerative forms of syphilitic sequelae occur in those cases which have either been imperfectly treated or not treated at all in the early active form of the disease. It is also true that, while the gravest acci- dent maj occur to those who have had the hghtest forms of early manifestations, the destructive sequelae are usually associated with a history of profuse and re- curring eruptions in the early stages of the disease. It will be found that whatever the form or locality of the lesion of late syphilis, the ability to assimilate large doses of the iodide of potassium without inter- fering with the digestion, is a guarantee of rapid bene- fit from its use. Very great care, then, is necessary to introduce this potent remedy so gradually and so well diluted with milk or some agreeable tonic diluent, that the digestive apparatus may be educated to tolerate the drug. Fortunately, in cases where it is required, iodism rarely occurs in any troublesome degree when sufficient care has been exercised in this respect. The substitution of pure iodine in plain molasses, or with starch, has been previously suggested, when the iodide of potassium is not tolerated. PSORIASIS OF TONGUE, P^OLLOWING SYPHILIS. Case. N. M. W.; 30. At 22 had an initial lesion of syphilis, which remained unhealed under local applica- tions up to the fourth month after infection. It was then excised. Healing took place by first intention; SYPHILIS AND THE GENITO-URlNARY DISEASES. 165 several small mucous patches were then present in the mouth and on the tongue; the superficial lymphatic glands were enlarged and indurated at all usual locali- ties. The patient was put upon pil. duplex (hjd. mass. 2 gr., ferri sulph, exsic. i gr.) thrice daily, and this was continued, somewhat irregularly — omitting several times for several weeks, whenever some tenderness of the gums appeared — for a year and a half. No inter- current lesions during this time. Glands still some- what enlarged ; mist, biniodid. hyd. (potas. lod. 8 grs., hyd. biniodid. -^q), a teaspoonful as a rule thrice daily, but not seldom neglecting it, for the following six months, when no further evidences of syphilis having developed — the patient in excellent health — treatment was suspended. Not the least sign of syphilis for the next four years, when slight soreness of the right side of the tongue appeared, chiefly along the edge. This was attributed to the excessive use of cigarettes, to which the patient was addicted. On ceasing this there was immediate improvement in regard to the soreness, but a pale, thin pellicle, appeared in two spots on the tongue, about the size of a split pea, a thin film along the edge, and a patch of the same, as large as a dime, on the inferior surface of the same side, and all within a few days. The patient was put again upon the binio- dide m'ixture, and took it faithfully for several weeks, making appKcations locally with a saturated solution of nitrate of silver, every day or two, without any very decided benefit. In point of fact, the spots on the tongue became slightly elevated and whiter, apparently from accumulated epithelium, giving the characteristic appearance of a simple psoriasis of the tongue. An application to these spots with Paquehn's gas cautery, the platinum point at a white heat, was carefully made, and the internal treatment continued. The result was an immediate improvement in the appearance of the spots, and after the second application, about a week after the first, the patches were quite freed from the pellicle. The patch under the tongue was then treated in the same manner, carrying the cauterization as far as possible through the thickness of the pellicle, subse- l66 PRACTICAL CLINICAL LESSONS ON quently simply brushing the platinum point quickly over the surface. Altogether, half-a-dozen apphcations were made in the course of four weeks, at the end of which time there was complete disappearance of the pellicle, and scarcely a trace of the lesion remained. The internal treatment was suspended, and at the end of three months, there was no indication of return of trouble. Syphilis and the genito-urinary diseases. 167 LESSON XVIII. Significance of psoriasis of the tongue, following syphilis; often mistaken for mucous patches of the active stage of syphilis, and when occurring after the first or second year, called chronic mucous patches. All lesions of late syphilis, of the same significance, as to their contagious property. All caused by accumulations of so-called gummy material, or non-con- contagious lymphatic matter. So-called chronic mucous patches of tongue usually caused by use of tobacco. The authority of M. Four- nier, favoring the view of their capacity for contagion. Case quoted by him in illustration. Analysis of M. Fournier's case, and arguments to show its failure in proving the inoculability of late chronic lesions of the tongue, and also from Fournier's work and other valued authori- ties to show, that no form of syphilitic lesion, is contagious after the fourth year. This position supported by the teachings and experi- ence of M. Fournier, in his work on syphilis and marriage. Marriage proper after a certain period. Strong statements of M. Fournier to this effect. Syphilis constitutes only a temporary bar to marriage. Fournier adduces eighty-seven cases in proof of this. Tertiary lesions shown not to be capable of transmitting syphilis. Exceptions claimed, lacking authentic proof. Fournier's case, cited to prove infec- tion from lesions present after three or four years, inadmissible. An- alysis of evidence. Case adduced in rebuttal. Case cited to illustrate sources of error. What is needed is a guide, as to time, when syphilitic patient may be considered free from danger of communicating the dis- ease. Facts and arguments to show that this time, is not necessarily more than three or four years. Sources of error in claiming infection beyond this time. Cases in illustration. Remarks. — The foregoing case would, I think, be best characterized as a psoriasis, induced by tobacco, causing irritation of a surface predisposed to such action, by the previous occurrence of local syphilitic lesions at this vicinity, during the active period of the disease. It has been in my experience to see quite a number of such cases, with or without superficial ulcera- tive lesions, and which had been classed, by previous medical attendants, as chronic mucous patches, with the distinct understanding that they possessed the power of communicating syphilis. It should be understood that mucous patches, are simply papules, occurring on mu- cous membrane, and cannot exist as specific lesions after the active stage of svphilis has passed. It may, I think, be safely stated, that, after the third, and at I68 PRACTICAL CLINICAL LESSONS ON farthest after the fourth year, lesions of the mouth of whatever character, — either superficial glossitis, which is recognized b}^ oval or circular, small or large patches, or tubercles of thickened sub-mucous cellular tissue ; or the deep glossitis, which causes a general hyperthropic thickening, — are due to accumulations of gummy mate- rial, so-called; and, whether accompanied by ulcera- tions, superficial or deep, are of the same nature as all the other lesions of so-called tertiary or late syphilis, which have been incontestably proven to be free from the contagium of syphilis. The occurrence of super- ficial erosions of the tongue, from a few to many years after the termination of the active stage of syphilis, is not infrequent. The habitual excessive use of tobacco, has seemed to me more likely to produce superficial ulcerative lesions, than where syphilis has not been ex- perienced, especially where the lesions of the active disease have occurred in the mouth. Often, in such cases, simple abstinence from tobacco, will cause such ulcerations to heal, without further trouble. In other cases, the iodide of potassium acts quickly to relieve, but, in all, the apprehension of communicating syph- ilis is an ever-present horror, and when, as is some- times the case, such ulcerations, either from vices in the digestive processes, or from permanent cicatricial dis- turbances of the affected tissues, continue for years, the condition of such patients is sometimes, indeed, pitiable. It is true that we have the weight of an authority, so great as M. Fournier, in support of the possibility, nay, the probability, of infection of syphi- lis for many years, or, indeed, indefinitely in such cases, as is shown in the following, quoted from his popular work on ''Syphilis and Marriage."* "These lesions are always superficial, limited, and mild. They are readily cured by cauterization, aided by some local care ; but they are only cured to be reproduced, — to re- new themselves incessantly. In themselves they are of * "Syphilis et Mariag-e." Legons Professees a I'Hopital Saint Louis. Par Alfred Fournier, Professeur a la Facuite de Medecine de Paris, Medecin de I'Hopital Saint Louis, Membre de I'Academie de M6decine. Paris, 1880. Page 122. SYPHILIS AND THE GENITO-URINARY DISEASES. 169 no importance, but they become only the more danger- ous in respect to contagion. Such, for example, is the case of a patient whom I treated some time ago. This young man had been infected with a syphilis, five years before, which one could fairly call mild, since the initial chancre was only followed by a roseola, a palmar syphi- lide of slight intensity, and a sore throat. He treated it almost from the beginning sufficiently well ; several times he submitted, under my advice, to a strong mer- curialization (15 to 20 centigrammes of proto-iodide daily). Well, in spite of this treatment, and in spite of all my efforts, the patient (who, by the way, is a smoker : a circumstance essential to note) has not ceased to be affected, during a period of five years, with lingual syphi- hdes almost continuously. I cured him of one breaking out ; one or two months later a new one attacked the tongue; then came a new treatment, followed by a new cure ; then reappearance of the malady, and so on. To be brief, I always cured him, and ' it always began again,' to use his own expression. Now that he has completely given up tobacco, at my earnest solicitation, the eruptions become less frequent, but have not alto- gether ceased ; and quite lately I have again seen him with syphilis coming on the back part of his tongue. Now, what would have happened if, relying on the mild nature of his disease, and satisfied as to the treat- ment followed, I had allowed the patient to marry be- tween the two outbreaks of such symptoms? What would have happened, I need not predict theoretically, because I have had a practical demonstration. This young man took as a mistress, last year, a woman who, till then, was perfectly healthy : exempt from every venereal symptom. Some weeks later he brought her to me, affected by an indurated labial chancre, mani- festly received from the lingual syphilides of the patient." This case is presented as a typical one, to illus- trate the possible -persistence of contagious lesions after many years, notwithstanding the disease is of mild form, and has been systematicall}^ persistently, and efficiently treated from ** almost from the begin- ning." 1^0 PkACttCAL CLINICAL LESSONS ON It will at once be seen, that, as such lesions of the mouth may appear, several years after the apparent cure of syphilis, no real guarantee against the dan- ger of communicating syphilis, for a very long period of years, can ever be given, and if such guarantee can- not be given, no man, it appears to int\ has ever a right to advise, or even to consent to, marriage of a person who has once had syphilis. It becomes a matter of vital importance to know, whether or not, there is a form of late lesion of syphilis, which, unlike all other late lesions, still retains the power of infection. M. Cornil says (p. 34, Am. ed. 1882): ''The inocula- tions made by Diday render it probable that the tertiary lesions are not inocitlable, and consequently not contagions^ Bumstead & Taylor (ed., 1879, P- 443)- '''Hence we con- sider the blood and the secretions in tertiary syphilis in- nocuous'' Hill & Cooper (London, 1881, p. 11), say: ^^ All attempts to propagate the disease zvith secretions taken at this period have failed!' Baumler says of the cessation of the innoculable stage of syphilis : " This takes place in the majority of cases, and at the expira- tion of eighteen mo7itJis or two years the infection is en- tirely exhausted." (Ziemssens's '' Encyclop2edia/' Am. edition). The most complete and irrefragable evidence, in favor of the view that the injective power of syphilis is self-limited, and does not extend over a period of more than three or four years, is that presented by M. Fournier, in his recent work on " Syphilis and Marriage," adduced to justify his previous statement of opinion, that persons having had syphilis under certain circumstances may marry. The statement, a very strong one, appears on page 18 of his work, thus : *' Then, yes ; a hundred times, yes : one may marry after having had syphilis, and the results of such a marriage, contracted under these conditions, may end absolutely happily, medically speaking. This I affirm, and fear- lessly proclaim from the house-tops, after having con- cientiously studied this grave question, both clinically and socially, and after having religiously consulted num- bers of observations of m}^ own and others. It is for me an absolute fact, an undeniable truth ;" and at page SYPHILIS AND THE GENITO-URINARY DISEASES. I^t t5, ibid.: "The truth is that, with some very rare ex- ceptions, syphilis only constitutes a temporary bar to marriage." In support of this positive opinion he says,* " For my part alone, I have in my hands, to speak only of written facts, eighty-seven observations relative to syphilitic subjects, undoubtedly syphilitic, who, having married, have never conimunicated to their wives the least suspicious phenomenon ; and, moreover, these eighty-seven have produced among them a total of one hundred and fifty-six absolutely healthy ^ children." In examining the clinical records of these eighty- seven cases, given at page 231, et seq., of his work, we find that thirty-six out of this number of men who were thus proven free from any power to transmit syphihs, either by direct contact or by heredity, were subjects of late or tertiary lesions of syphilis after marriage — some before and some after the birth of children. These lesions comprise almost all the accidents of late sj'philis, thus : gumma of penis, palmar psoriasis, dry tubercular syphilide, gumma of velum paluli, cerebral syphilis, papulo-tubercular syphilide, and costal perios- tosis, cerebro-spinal symptoms (evidently of specific origin), diplopia, passing attacks of hemiplegia, nasal RACT1CAL CLINICAL LESSONS ON LESSON XXX. DIAGNOSIS AND TREATMENT OF CHANCROIDAL BUBO AND BUBONIC CHANCROID. Manner in which these lesions occur. Definition. Usual teachings in regard to the chancroidal or virulent bubo. All buboes, not syphilitic, which do not suppurate, claimed as sympathetic or scrofulous. Phage- denic buboes. All sores which give rise to suppurating buboes not necessarily chancroidal. Early treatment of gland swelling associated with chancroid. Calcium sulphide an efficient agent in arresting the suppurative process. Statistics in proof of this. Later treatment. Rest in bed important. Danger of extension of trouble through for- mation of sinuses. Signs of such accident. Treatment necessary to their arrest and subsequent cure. Chancroids of the anus and rectum. Usual m.ode of advent. Aids to diagnosis. Modes of treatment. Chancroids of anus and rectum. Mode of origin. Aids to diagnosis. Modifications of treatment to meet varied conditions. General reme- dial measures when local remedies prove inefficient. The exulcerous form of chancroid the mildest type. Mode of treatment. The ulcus elevatum not a true chancroid. Mode of treatment. Modifications re- sulting from the union of the contagia of chancre and chancroid. Syph- ilitic disease more likely to be associated with the milder forms of chancroid. Frequency of this accident. The term mixed chancre a misnomer. No mixing possible. Each disease always independent of the other, and always of necessity antagonistic. Possible development of the initial lesion of syphilis after the healing of a chancroid. Inflammation of lymphatic glands in connection with chancroid is not uncommon. The tumors, thus occur- ring, are termed chancroidal buboes. The inflammation is set up in such glands through the passage of the pus of the chanchroid through a l3^mphatic vessel. Inflam- mation is immmediately set up in the substance of the gland, which soon swells and becomes painful. Swel- ling of a lymphatic gland, from any cause, is usually called a bubo. Painful swelling of a Ij^mphatic gland with inflammation, finally extending to the integument covering it, is termed an inflammatory bubo. When the inflammation is set up by inoculation, through the lym- phatic vessels in connection with chancroid, it is termed a chancroidal or virulent bubo. When an inoculation is thus effected, suppurative ac- tion is set up which (it has been taught as a rule to SYPHILIS AND THE GENITO-tJRlNARY DISEASES. 2^t which there is no exception) goes on to the formation of an abscess, and steadily progressing, in the course of two or three weeks, sometimes longer, finally finds its way through the parenchyma of the gland and the overlying integument. When this is effected, the lesion is called an open chancroidal bubo, or a bubonic chan- croid. The purulent product of this lesion is, if not identical, analogous, in character, to that of the original chancroid. This accident may be initiated at any period in the course of the chancroid, from its first appearance as a small suppurative point, throughout its existence. This is a strong argument in favor of the early and thor- ough destruction of chancroid. The activity of the suppurative process in the gland, bears a tolerably defi- nite relation to that of the lesion from which it origi- nates. When the source of the pus is active, virulent, it is not probable that any course of treatment, local or general, will prevent its termination in open bubo or chancroid. Where glands, associated with chancroid, inflame and yet do not go on to formation of abscess, or when abscess is thus formed and its contents are ab- sorbed through treatment, local or general, it may be claimed that the chancroid, from which it is derived, is of mild type. It is, however, the habit of surgeons to classify all buboes (not syphilitic) which do not sup- purate, as sympathetic or scrofulous. Those resulting from irritation and not from inocula- tion, are termed sympathetic buboes. Whenever, through suppurative process, or by surgical intefer- ence, the chancroidal bubo is open, it goes on to ex- hibit the diagnostic appearances of the original chan- croid. Pus secreted by it, when inoculated at other points, or on another individual, produces the charac- teristic chancroid. When the lesion from which it is derived, assumes the phagedenic form, the danger of extension of phage- denic action, to the bubonic chancroid, is imminent. Phagedenic action may also be set up in a bubonic chancroid after the original chancroid has healed. In such case the treatment should be the same as that pre- ^52 PRACTICAL CLINICAL LESSONS ON viously directed (p. 244) for the phagedenic chanc- roid. The earlier the destruction of a chancroid is effected, the less the danger of a complication through medium of the connecting lymphatic vessels. This accident sel- dom affects more than a single gland, and that usually in the groin, corresponding to the side on which the chancroid is situated. Occasionally, however, through intercommunication of lymph canals, it may appear in the opposite groin, even in both groins. A sore of very mild type may give rise to a bubo which may go on to suppuration. AH sores which give rise to abscess of lymph glands are not necessarily of chancroidal ori- gin. It is only by the activity of the contagium and of the inflammatory and destructive processes, exhibited in the inguinal lesion, that we can decide in what grade to place it. It is safe, at first, to treat all imflammatory gland swellings in connection with chancroid, as if the}^ were of simple origin, that is, by rest in the recumbent posi- tion, by local sedative apphcations, and at once to begin the use of the sulphide of calcium internally, giving par- vules-jL- gr. every hour or two, or using a solution made fresh every day — ■^ Calx Sulphurata grs. 2. M. Aq 3iv. A teaspoonful every hour or two. Also using pressure (when it is well borne), by means of a compressed sponge, retained by a spica bandage, and moistened with the lotio pluinbi et opii. If pressure is productive of pain, and this continues after it has been on for a lit- tle time, cold applications, even the ice bag, will usu- ally give comfort, and, later, allow the pressure. If the feelings of the patient permit, the cold may be main- tained and in some cases abort the bubo. Tincture of iodine painted on morning and night is also valuable, if the patient cannot take the rest required for other treatment. It has the advantage of being easily kept in place, and the popular credit of favoring abortion where this is possible, and when this cannot be hoped SYPHILIS AND THE GENITO-URINARY DISEASES. 253 for, of favoring suppuration. The early evacuation of the resulting- abscess is usually advised. My habit, formerly, was to introduce a bistoury and make a free incision parallel to the long axis of the tumor at the earliest recognition of positive fluctuation. My later experience with the sulphide of calcium, administered internally, has caused me to delay operative interfer- ence until inefficiency of the sulphide of calcium has been fairly demonstrated.* Once the bubo has been laid open by an incision, ex- tending through its long diameter, it will be usually sufficient to pack the cavity with cotton or lint saturated with the ordinary tincture of iodine. This is a good styptic and has sufficient cauterant property to destroy * If suppuration, going on to the production of an open lesion, is in- evitable, undoubtedly it is wise to encourage it, to evacuate the virulent product at the earliest moment, and thus afferd access for efficient treat- ment for the destruction of this new formed chancroid. For this reason I had been an earnest advocate for early incision into suppurating bu- boes associated with chancroid. My experience in the few cases a'.ove alluded to, however, made me incline to the belief that a thorough and extended trial of the sulphide of calcium, in cases of inflammatory buboes associated with chancroid, might give such results as to make its use imperative in every such case. In order to gain further light on this important matter, a systematic use of the calcium sulphide was made, in my service at Charity Hospi- tal, in eighteen consecutive cases of inflammatory bubo occuring with, or as the immediate sequel of, well-pronounced chancroid. All the facts, considered of importance, were noted by myself and under my direction by Dr. Johnson, my House Surgeon. Out of eighteen cases of inflammatory bubo presenting the rational evidences of chancroidal origin, and treated systematically by the use of small doses of the sulphide of calcium, resolution occurred in fifteen, and in only three cases was incision ultimately required. Applications of tincture of iodine and systematic compression were also employed in every case. If we apply to these cases the usual rule that chancroidal buboes al- ways eventuate in chanchroidal abscesses, always suppurate and require evacuation by natural means or surgical procedure, then we must hold that only three out of fifteen cases of inflammatory buboes associated with chancroid were the result of transference of the suppurative process from the chancroid to the adjacent lymphatic gland. It is just possible, however, that the influence of the sulphide of calcium may, in arresting suppuration, extend to the true ciiancroidal bubo. The apparent suc- cessful use of this drug in the series of cases herewith presented, at least .suggests, and invites, a trial of its efficacy in all instances of threatened glandular suppuration, whether of purely sympathetic origin or asso- ciated with chancroid. 254 PRACTICAL CLINICAL LESSONS ON the chancroidal contagium and stimulate the abscess cavity to heahhy granulation. Iodoform maj be sub- stituted if the iodine is objected to on account of pain ; the pain caused by it, however, is very commonly tran- sitory. Rest in bed is essential after the opening of the bubo, and until healing is well advanced, on account of the tendency to burrow, which abscesses in the region of the groin are wont to exhibit. The announcement of such an accident, is often, through a sharp rise of pulse and temperature, while the pain in the vicinity of the burrowing may be very slight. Whenever fever suddenly starts up in a patient suffering from an ingui- nal abscess or sinus, even when nearly healed, it is an almost certain sign of the formation or extension of a sinus, usually at the most dependent portion. In this event, after ascertaining its full extent by probing, in exGry case slip in a grooved director to the very bot- tom of the sinus, and if its direction is such as to make it surgically a proper thing to do, pass in a blunt curved bistoury and cut out — being careful not to leave a lit- tle pocket at the bottom. Injection of tincture of iodine may be made to advantage when cutting is not con- sidered feasible. For the same purpose, a silver probe, dipped in nitric acid, (which forms a coating of ni- trate of silver), may be conveniently applied by inser- tion of the probe. When possible, in cases where it is not considered judicious to lay it open throghout, the sinus should be drained b}^ a counter opening, and, if suppuration is extensive, drainage effected by small perforated, rubber tubes, or carbolated threads. If not treated with promptness, extensive sinuses may form, requiring months to heal. DIAGNOSIS AND TREATMENT OF THE URETHRAL* CHAN- CROID. A slight smarting on urination, or purulent discharge, appearing at the urethral orihce, six or eight days after impure connection, is suggestive chancroid of the mea- tus. Especially is a little blood in the discharge valu- able as a diag;nostic point — careful examination should SYPHILIS AND THE GENITO-URINARY DISEASES. 255 be made at once. This form is quite common, and is usually slow in its progress. If the tissues at the lower part of the contracted orifice are very thin, as is often the case, snipping- them with a pair of blunt scissors will sometimes permit free application to the lesion without greatly increasing the surface thus exposed to inoculation. The use of a meatoscope, or a Toynbees ear speculum, will be of service in making examination and application beyond the orifice where, fortunately, chancroids are seldom met. If seen early, and the meatus is of sufficient size to expose it wholly, after cleansing with a weak carbolic lotion, and the part made properly dry, it should be thoroughly destroyed with nitric acid (after the manner described for small chancroids in other localities), subsequently dressing with a little thin linen wetted with a sedative lotion, or by small suppositories composed of equal parts of iodoform and cocoa butter. If the entire surface of the lesion cannot be exposed, treatment by iodoform suppositories will be best, using frequent hot water soakage, and in- sisting upon absolute rest. DIAGNOSIS AND TREATMENT OF CHANCROIDS OF THE ANUS AND RECTUM. These may occur as a result of connection a posteri- ori, or from inoculation. This accident, through chan- croids previously existing in the vicinity, is suggested by pain in defecation and purulent discharge. The in- troduction of the finger may be sufficient to make out a diagnosis, but the short rectal bivalve speculum, with narrow blades, will give access, when required, for diagnosis and treatment. But Httle especial treatment will be required, beyond that already suggested for other varieties. Cauterization to be made use of when called for; and absolute cleanliness insisted on. If great difficulty and pain are experienced in intro- duction of necessary instruments and dressings, or if the lesion is penetrating the tissues rapidly, or is rebel- lious to treatment, the external sphincter may be divided through the lesion^ and the cut surface treated, together 256 PRACTICAL CLINICAL LESSONS ON with the chancroid, by application of iodoform and tan- nin suppositories, subsequently using nitric acid if nec- essary to arrest the disintegrating process, and then resuming the iodoform suppositories, until healing is complete. The use of the vaginal speculum, in treat- ing chancroid of the ostium vaginas and parts beyond, is absolutely essential, not alone for the security of reaching the full extent of the lesions, but for occasional examinations beyond the site of existing lesions, and to insure against insidious development of new points. The healthy tissues adjacent to contagious surfaces, should be kept constantly separate by thin layers of carbolated or iodoform dressing ; and by occasional soakage in hot water, secure absolute cleanliness, and relief to inflammatory conditions. In all cases of chancroid, which, when judiciously cared for, are still rebellious to treatment — particularly those where ulcerations and sinuses have occurred, the general condition of the patient should receive especial attention. In cases of scrofulous habit, cod liver oil, iron, etc., are often of service in hastening the healing of a sluggish chancroid. The case cited page 223, where all measures failed, until a change of cHmate and a sea voyage wrought a prompt cure, is significant. The Exulcerous Form of Chancroid, described as existing without perceptible loss of tissue, being either on a level or slightly above the surrounding sur- face, and hence not characterized by the usual marks of chancroidal action — must be classed as of the mildest form, and amenable usually to local astringent sedative applications. The sulphate of iron as a lotion — 10 grs. to § I of water — is often promptly curative. The Ulcus Elevatum, a lesion of the same type, is scarcely to be classed among chancroids, as it lacks wholly the characteristic features of such lesions. It is usually not larger than a flattened pea, and found on the borders of a prepuce, which is bathed in secretions more or less vitiated. It partakes more of the nature of a papilliary hypertrophy, and a local treatment adapt- ed to such overgrowth should be employed, viz. : re- moving first the source of the irritant secretion, then SYPHILIS AND THE GENITO-URlNARY DISEASES. 25f apply the powdered persulphate of iron, or if necessary, to touch, lightly, with pure chromic acid. MODIFICATIONS RESULTING FROM DEVELOPMENT OF SYPHILITIC ELEMENTS, IMPLANTED ON THE SITE OF A CHANCROIDAL LESION. The milder the form of chancroid, the more likely to develop a syphilitic complication, after syphilitic ex- posure. Active chancroidal action, is doubtless as de- structive of the syphilitic contagium, as of healthy tis- sue, but when, as is sometimes the case, the contagia of both chancre and chancroid are implanted on the same abrasion, at about the same time, the chances are, that the syphilitic disease germ, will find its way into a lymph space, and out of the reach of harm, before con- tact with the destructive chancroidal cell. This latter, going steadily on in its characteristic destructive action, while the prohferation of the syphilitic disease germs is progressing underneath. So it often happens, that, while the chancroid is in full typical action, the tissues underlying and surrounding, become gradually stiffened and indurated, until a sore presents, equally character- istic of both chancroid and the initial lesion of syphilis. This is known as the "■ mixed chancre!' It will be at once seen that there is not, and never can be, any mixing of the contagion of chancroid and syphihs, one representing the destruction and the other the growth of tissue elements. Necessity for the treat- ment of the chancroid, is the same as before, but the complication requires the constitutional treatment ap- propriate for syphilis, at the first moment, when, through development of other characteristic syphiHtic lesions, the diagnosis can be definitely settled. The development of induration of syphilis, after the healing of a chancroid (the tissues about which have remained supple throughout its existence) is also not uncommon, The possibihty of such an occurrence must be borne prommently in mind, for several weeks after the heal- ing of any lesion resulting from a suspicious sexual contact. 258 PRACTICAL CLINICAL LESSONSi Remedies and Remedial Agents Referred to in this Volume, Aki) THEIR Application. For Local Application to the Initial Lesion of Syphilis. in the non-ulcerative forms; the indurated papule, and the dry scaling patch. No. I. White precipitate ointment, vaseline; equal parts; or, No, 2. The mild mercural ointment; or, No. 3. The oleate of mercury, 6 per cent solution, with vaseline; equal parts. Apply by gently rubbing in a small quantity morning and night. In all Uncomplicated Open Initial Lesions. No. 4. Calomel pure, dusted on and protected by a thin film of bof- ated cotton; or soaking the cotton with the following solution, and apply; or, No. 5, Calomel, 20grs. ; lime water, 4 ounces; mix; or, No. 6. Corrosive sublimate, logrs. ; lime water, 6 ounces; mix. For the Inflamed Initial Lesion. Diluted solution of sub-acetate of lead, 4 ounces. No. 7. Aqueous ext, opium, 10 grs. ; or, No. 8. Iodoform, 30 grs.; glycerine, i ounce; oil of roses, I drop; mix; apply on lint. For the Phagedenic or Gangrenous Form. No. 9. Iodoform, a sufficient quantity; i drop of the oil of roses to 30 grs.; applied freely. Internal Remedies for Treatment of Syphilis, from date of Initiation, for at least 12 Months. No. 10. Blue mass., 60 grs.; exsicated sulphate of iron, 30 grs. ; make 30 pills (pil. duplex), one three times a day; or. No. II. Protoiodide of mercury, exsicated sulphate of iron, 40 grs.; aqueous extract of opium, 4 grs.; mix, make 40 pills; one three times a day. External Applications for Innunction. No. 12. The mild mercurial ointment; a piece as large as a filbert rubbed in thoroughly, morning and night; or, No. 13. Oleate of mercury, 10 per cent solution; vaseline an equal quantity; a teaspoonful rubbed in, morning and night, always in a fresh and protected place. For Mercurial Fumigation, or the Mercurial Bath. No. 14. Calomel, (resublimed) 15 to 30 grs.; nightly, or every two or three nights, until its specific effect is obtained. Further directions on page. SYPHILIS AND THE GENITO-URINARY DISEASES. 259 After the Twelfth Month, the Mixture of the Biniodide OF Mercury and the Iodide of Potassium. No. 15, Biniodide of mercury, 3 grs. ; iodide of potassium, 120 grs. ; tincture of orange peel, l-^ ounces; syrup of orange peel, i^ ounces; distilled water, up to 8 ounces; mix; a teaspoonful three times a day, or if gastric or intestinal irritation ensues — No. 16. Biniodide of mercury, 3 grs.; iodide of potassium, 120 grs ; fluid extract of thuja, 8 ounces; mix; a teaspoonful three times a day. In addition to the foregoing, During the Sequels of Syphilis. No. 17. Iodide of potassium, i ounce; distilled water, 6 drams; mix. Beginning with 5 drops in a small glass of water, or preferably of milk, increasing by a drop for each dose, gradually increasing the diluent to a tumblerful, until sixty drops are taken, equivalent to 60 grains of the iodide of potassium, three times daily, after meals, unless iodism occurs. In this case begin again with the minimum dose, and increase as before up to 40 drops, and then increase by i drop, until 60 grains is again reached. If decided benefit does not take place, the quantity may be even farther increased up to twice that amount, in grave cases, and con- tinued, if well borne, until all signs of the disease have disappeared. If the iodide of potassium is not tolerated, the following may be administered. No. 18. Iodine, 24 grains; distilled water, 2 ounces; iodine of potas- sium, 48 grains; dissolve and add common molasses, or Stuart's syrup, 8 ounces; let it stand 12 hours. Administer from a dessertspoonful, gradually increased to a tablespoonful, thrice daily after meals. In the Alopecia of Syphilis. The following lotions will be found serviceable: No. ig Bi-chloride of mercury, 3 grains; hydrochloric acid, 30 min- ims; distilled water, 8 ounces; then add, spirits of cologne, i ounce; rose water, i ounce; glycerine, -|- ounce; mix; or No. 20. Castor oil, i^ ounces; rectified spirit, i| ounces; spirits of cologne, I ounce; tincture of cantharides, 2 drams; mix, apply nightly, washing the hair every morning with castile soap. For Local Applications in the Treatment of Chancroid in the Slowly Destructive Forms. No. 21. Sulphate of iron, 10 grains; aqueous extract of opium, 10 grains; aistilled water to i ounce. No. 22. Carbolic acid, 5 to 10 grains; solution of morphia, (U. S. P., containing i grain of morphia), i ounce. If the secretion is profuse, No. 23. Iodoform and tannic acid, equal parts, dusted on; mix; in the more acute forms, No. 24. Iodoform, 60 grains; vaseline. 60 grains; oil of roses, idrop; or, No. 25. Iodoform, 60 grains; oil of roses, i drop; apply in powder; or, No. 26. Iodoform, i dram; carbolic acid, i minim; oil of peppermint, 6 minims; mix. 26o PRACTICAL CLINICAL LESSONS. For Destruction of the Chancroid, or PhactEdenic CoNDiTioNS. Nitric acid, pure; galvano cautery, or the thermo cautery. For Sluggish Conditions. No. 27. Permanganate of potassa, 2 grains; distilled water, I ounce. No. 28. Carbolic acid, pure; applied daily; or, No. 29. Carbolic acid, 10 grains; glycerine, 2 drams; distilled water, 6 drams; mix; apply on a thin film of cotton. For Application to Bubonic Ulcers, and Sinuses. No. 30. Tincture of iodine, pure; and, for arrest of suppuration in any case. No. 31. Sulphate of calcium, i grain; distilled water, 2 ounces; a tea spoonful every hour, solution to be freshly made every day; or, Parvules, ^ grs. each. For Applications to the Phagedenic Chancroid. No. 32. Hot water immersion, temperature 100° F. ; actual cautery; charcoal poultices Internally, (Ricords formula). No. 33. Poiassio tartrate of iron, ^ ounce; distilled water, 3 ounces; syrup, 3 ounces; mix; a dessertspoonful to a tablespoonful three every six hours, preferably after meals. COLUMBIA UNIVERSITY LIBRARY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28(239)M10O RC201 Obis Practical clinical lessons on syphilis. 0t4 v.l