Notes on Syphilis.—Syphiloma of the 
Nose of Unusual Form and Evolu- 
tion. The Diagnostic Value of 
Syphilitic Cicatrices. Extra-Geni- 
tal Chancres, Prognostic Signifi- 
cance of. Professional Syphilis. 
BY / 
Prince A. Morrow, M. I)., 
Surgeon to the City Hospital; Attending Physician 
to the New York Hospital, Department of 
Skin and Venereal Diseases. 
REPRINTED FROM THE 
Journal of Cutaneous and Genito-Urinary Diseases 
for April, 1896. [Reprinted from the Journal op Cutaneous and Genito-Urinary Diseases 
for April, 1896.] 
NOTES ON SYPHILIS.-SYPHILOMA OF THE NOSE OF UNUSUAL 
FORM AND EVOLUTION. THE DIAGNOSTIC VALUE OF SYPH 
ILITIC CICATRICES. EXTRA-GENITAL CHANCRES, PROGNOS- 
TIC SIGNIFICANCE OF. PROFESSIONAL SYPHILIS. 
By PRINCE a. MORROW, M. D., 
Surgeon to the City Hospital; Attending Physician to the New York Hospital, Department, 
of Skin and Venereal Diseases. 
I. Syphiloma of the Nose of Unusual Form and Evolution. 
TIIE patient with the lesions portrayed in Fig. 1 presented her- 
self at the New York Hospital, May, 1894, with the follow- 
ing history : She was twenty-one years old, had been mar- 
ried five years. The first child, three years and ten months old, 
is healthy ; the second died when about a month old ; the third preg- 
nancy resulted in a miscarriage. After the miscarriage the mother 
suffered from sores in the mouth and throat, with a generalized erup- 
tion of reddish spots. The scalp was so profusely studded with 
sores that she wTas compelled to cut off the hair. There has been no 
marked alopecia of the scalp, but the eyebrows and eyelashes were en- 
tirely lost. The eruption disappeared in about three months. 
In October, 1893, an eruption of large tumors appeared over va- 
rious parts of the body, many of which have undergone involution, 
leaving scars. These tumors have continued to appear since. At the 
present time there may be seen upon the arms a number of nut-sized 
globular tumors springing up from the skin like mushrooms and strik- 
ingly suggestive of the tumors of granuloma fungoides. The tumors 
Copyright, 1896, by D. Appleton and Company. 2 
Original Communications. 
are doughy in consistence, but not suppurative. The external aspect 
of the lower part of the right os humerus is occupied by five or six 
tumors surrounded by interrupted circles. On the right upper arm 
are seen tumors which have developed in cicatricial areas which mark 
Fig. 1. 
the site of former lesions. A cherry-sized gumma occupies the inner 
border of the left eyebrow. The tumor is soft, painless, and adherent 
to the skin. Notes on Syphilis. 
3 
The most interesting feature of this case, however, is the large, 
tumorlike infiltration which occupies the upper lip, blocking the 
aperture of the left nostril, and mounting upward on the left ala to 
the bony and cartilaginous junction. This infiltration does not extend 
upon the cheek, and is sharply demarcated from the healthy skin. 
The mass is surmounted and circumscribed above by a large, welt- 
like ring of infiltration which is exceedingly dense and hard to the feel. 
The lower part of the tumor is less resistant and softer in consistence. 
Under the influence of mixed treatment the tumors upon the arms 
and left eyebrow underwent rapid involution, but the lesion of the 
nose and lip was scarcely modified, although the constitutional treat- 
ment was re-enforced by the application of ung. hydrarg. and mercu- 
rial plaster. 
So peculiar was this lesion in its form and consistence and so re- 
fractory to specific treatment, that a suspicion of its representing a 
combination of syphilis and tuberculosis was entertained. The pa- 
tient was presented before the New York Dermatological Society. 
Some of the members thought that there was probably a tuberculous 
element present, and suggested the removal of a piece, to be examined 
for tubercle bacilli. This proposition was not acceptable to the pa- 
tient, and she ceased her visits. I afterward learned that later she 
went to the A'anderbilt Clinic, and after some weeks of specific treat- 
ment the tumorlike mass on the side of the nose softened, broke down, 
and disappeared. I examined the patient January 29, 1896, and 
found that there was some infiltration of the upper lip, which, she 
states, becomes swollen and enlarged at each menstrual period. The 
left ala is somewhat contracted, showing at two or three points slight 
loss of substance. 
II. Diagnostic Value of Syphilitic Cicatrices. 
Syphilis possesses the peculiarity not only of manifesting itself dur- 
ing its active stage by lesions which are typical and characteristic, hut 
also of leaving indelible traces of its action upon the cutaneous surface 
in the shape of cicatrices. Another peculiarity of syphilis is its mys- 
terious uncertainty. ISA matter how mild or malignant its past, there 
is always the possibility of a formidable future. Long after the tires 
of the disease have apparently burned out, revealing in the scarred 
tissues the nature of the destructive process that has swept over them, 
they may break out anew upon the surface or be rekindled in some 
important central organ. So profound and permanent are the changes 
in the tissues wrought by syphilis that the exhumed bones of prehis- 4 
Original Communications. 
toric sepultures may preserve positive evidences of their syphilitic origin 
and nature. 
While the imprints of syphilis upon the cutaneous surface are not 
always so typical as to enable even the most practiced observer to de- 
cipher the nature of the process which has produced them, yet in many 
cases they have a positive value as a retrospective aid in diagnosis. It 
is not intended to assert that the cicatricial remains of syphilitic ulcer- 
ation present characters which are absolutely distinctive. Syphilitic 
scars taken singly may be exactly imitated by the scar following a 
burn, a traumatism, or the ulcerous process of some other disease. 
But when they are multiple, when they exhibit certain specific pecul- 
iarities in their circular or serpiginous outline, their grouping, their 
pigmentation, their localization, they may be just as characteristic of 
syphilis as were the lesions in their full stage of activity. 
Lupus or cutaneous tuberculosis may produce scars similar to those 
of syphilis, but they are distinguished by their limitation to certain re- 
gions and by their minute characters. The scars of tuberculosis are irreg- 
ular, uneven, and vicious, with a more livid pigmentation. The cica- 
trices of varicose ulcers of the leg may imitate closely those of syphilis 
in this locality, but they are generally limited to the lower third of the 
leg, while those of syphilis most often occupy the middle and upper 
third. The pigmentation of the former is more diffuse and permanent, 
often spreading over one half or more of the limb, while the pigmen- 
tation of syphilis almost invariably clears up, leaving white scars. The 
scars of zoster may be multiple and indistinguishable in their appear- 
ance from those of the small tubercular syphiloderm, but they are dif- 
ferentiated by their asymmetry and their localization along the course 
of certain nerves. 
In the picture presented in Fig. 2 we have an example of scars which 
are typical of syphilis, not only in their minute objective characters, 
but in their localization and general distribution. They are rounded 
or circular, more or less depressed, according to the depth of the ulcer- 
ative process, the older ones white, with a vanishing zone of pigmen- 
tation, the more recent ones red, encircled with a dark-brown, almost 
black area of pigmentation. These vestiges or marks of an antecedent 
syphilitic ulceration are typical and will remain so during the life- 
time of their bearer. Such stigmata would be of great value in the 
diagnosis of any obscure nervous or visceral complication in the 
future. 
All specialists are accustomed to have referred to them cases in 
which it is extremely difficult to differentiate between the late mani- 
festations of syphilis and other diseases. The late surface lesions of Notes on Syphilis. 
5 
syphilis may in most instances be diagnosticated by their optical char- 
acters ; the same is true of affections of the mouth, tongue, and throat. 
Lesions of the testicle, bones, and joints may also often be distin- 
Fig. 2. 6 
Original Communications. 
guished by objective characters peculiar to syphilis, but in the pres- 
ence of syphilitic affections of the internal organs, and especially in 
obscure diseases of the nervous system, the symptoms do not differ es- 
sentially from the symptoms of other diseases affecting these organs. 
Any sign which would lead to the identification of sypliilis as the seti- 
ological factor in such cases is of the utmost importance. While rec- 
ognizing the value of the patient’s history in throwing light upon the 
nature of obscure affections, we find that many syphilitics are unwilling 
to own up to an avowal which they consider an impeachment of their 
morals and respectability. They will fence with the examiner, and, 
in answering questions, conveniently forget any circumstance which 
might indicate the syphilitic origin of their trouble. Especially is this 
the case with women. In such cases the discovery of characteristic 
syphilitic scars may furnish the connecting link between doubtful 
symptoms and syphilis. Such a discovery is most fortunate for the 
patient, as, thanks to the wonderful efficacy of specific treatment, it 
carries with it in many cases an almost certain assurance of cure. 
III. Extra-Genital Chancres. 
During the past three years twenty cases of extra-genital chancre 
have occurred in my public practice. Fifteen of these cases came un- 
der my observation at the New York Hospital, and five were seen in 
my service in the City Hospital. 
In my private practice within the same period ten physicians have 
consulted me for chancres of the hand or fingers contracted in the exer- 
cise of their professional work. To speak with absolute accuracy, only 
nine of these were seen by me; the tenth came to consult me last sum- 
mer, during my absence from the city, and was seen by my assistant, 
Dr. Johnston, who took notes of the case. 
I am well aware that extra-genital chancres are by no means rare 
in the practice of specialists. My object in reporting these cases is not 
to illustrate new and interesting clinical features, but simply to utilize 
them as a basis for certain deductions of practical importance. The 
clinical appearances and course of extra-genital chancres are so famil- 
iar that a detailed description of each individual case is unnecessary. 
Certain points in relation to their location and aetiology may, how- 
ever, be of interest. In the twenty cases seen in public practice there 
were: 
Chancres of the upper lip 3 
“ “ lower lip 5 
“ chin : 3 
“ “ gum 1 Notes on Syphilis. 
7 
Chancres of the tongue 1 
“ “ hard palate 1 
“ “ soft palate 1 
“ “ pharynx 1 
“ cheek 1 
“ fingers 2 
“ anus 1 
It will be seen that this series embraces seventeen cephalic chancres, 
two digital, and one of the anus. 
The chancre of the hard palate merits especial mention, from the 
exceeding rarity of the initial lesion in this location. It was deemed 
of sufficient interest to present the patient before the New York Der- 
matological Society. In this case the lesion was situated to the left of 
the median line, and presented the appearance of an ulcerated gumma. 
The submaxillary glands of the left side were enormously tumefied, 
obliterating the lines between the jaw and the neck. Any possible 
doubt as to the nature of the lesion was removed by the appearance of 
a maculo-papular eruption six weeks after the sore. Concerning the 
mode of infection no definite information could be gained. 
The chancre of the gum may also be noted for its comparative 
rarity. It was situated on the right of the median line, and occupied a 
surface corresponding to the lateral incisor, the canine, and bicuspid 
teeth. It presented the appearance of a semilunar erosion of the gum, 
which was red and slightly tumefied. The epithelium was detached 
from the center. The chancre did not heal until after the appearance 
of secondary accidents. In attempting to trace the aetiology of the 
disease, the patient absolutely denied any lascivious contact. He was 
a barkeeper by occupation, and ascribed the contagion to a rather 
curious cause. lie was accustomed to use his mouth as a receptacle 
for the coins which he took from customers until he found it conven- 
ient to deposit them in the cash drawer, and he thought himself in- 
fected by this means. 
In another case—chancre of the tongue—curiously enough, the con- 
tagion was ascribed to paper money. The patient, a young woman 
twenty-six years old, presented herself at the New York Hospital with 
a corneous syphilide of the palms and a general papular eruption. She 
denied most indignantly that she had exposed herself to contagion 
in the usual way, and her claim of virginity was confirmed by an ex- 
amination. There was no trace of enlarged glands in the groin. She 
stated that her occupation as cashier in a large establishment required 
her to count a great deal of currency every evening. In counting over 
the rolls of bills she was accustomed to moisten her finger by placing 8 
Original Communications. 
it on the right side of the tongue. Some three or four mon ths ago she 
observed that this part of the tongue became quite sore, so that she 
had to moisten her finger by touching the tip of the tongue. The side 
of the tongue continued sore, and soon afterward the glands of the 
right side became enlarged, followed later by patches on the tonsils 
and an eruption on the cutaneous surface. Examination disclosed on 
the side of the tongue at the point she indicated a slight cicatricial de- 
pression, which in all probability marked the site of the initial lesion. 
The most minute examina- 
tion failed to discover any 
other probable seat of the 
chancre. 
One of the three cases ot 
chancre of the chin was dis- 
tinguished by its enormous 
dimension. It occupied 
nearly the entire surface of 
the chin, extending from the 
edge of the lip to the mental 
border. was ul- 
cerated, the elevated, 
hard, and everted, presenting 
the appearance of an ulcer- 
ated epithelioma. As a mat- 
ter of fact, the patient’s phy- 
sician had made this diagno- 
sis, and he had been sent to 
the New York Hospital to 
have the “ cancer cut out.” 
Before operating, the house 
surgeon referred the case to 
me for an opinion. The diag- 
nosis of epithelioma was contraindicated by the age of the patient, 
the optical features of the lesion, its rapid development, and the 
precocious implication of the glands. Any possible doubt as to its 
specific nature was set at rest by the appearance of a macular eruption 
on the chest and other signs of constitutional syphilis. Notwithstand- 
ing the enormous volume of the lesion, there was scarcely any appre- 
ciable cicatrix left after its involution. 
One of the cases of chancre of the upper lip was also remarkable 
for its elephantine proportions. The entire upper lip Avas enormously 
tumefied, everted, with a fungating, easily bleeding surface. The 
Fig. 3, Notes on Syphilis. 
9 
inflammatory induration was so marked as to almost completely im- 
mobilize the lip. The other lip chancres presented nothing in their 
appearance or mode of evolution to call for special description. The 
aetiology was variously referred to kissing, contact with pipes, etc. In 
one case a chancre of the lower lip in an infant had been contracted 
from a syphilitic nurse. 
The chancre of the anus was the result of unnatural practices, to 
which the patient confessed. The chancre over the malar portion of 
the left cheek was the result of a blow received in a fight with a 
drunken man. The cases of chancre of the finger, both of which were 
seen in the City Hospital, were ascribed to bites received in drunken 
brawls. In one of these cases, some months after the chancres had 
healed, the entire integument of the index finger presented a dusky- 
red appearance. 
In this connection I may present the picture of a chancre over the 
knuckle of the right hand (Fig. 3) sent to me by the late Dr. E. R. 
Palmer. It resulted from a blow which the patient administered to a 
drunken tramp. The skin was broken by the force of the blow. A 
few weeks afterward the lesion depicted appeared, and was followed 
by a characteristic eruption. 
In the ten cases of professional syphilis the location of the chancres 
was as follows: 
Chancre of terminal phalanx of index finger 5 
“ “ “ middle finger 1 
“ “ “ little finger 1 
“ “ thumb 1 
“ distal extremity of first metacarpal bone 1 
“ outer border of wrist 1 
As regards the location of chancres of the hand and fingers, Four- 
nier’s statistics, embracing eighty-eight cases, give only one case of 
•chancre of the wrist, while the thumb and the little finger were only 
very exceptionally its seat. Chancre of the middle linger, according 
to Fournier, is most often the result of contamination in venereal 
dalliance. 
In none of these eight cases of digital chancre was the lesion hyper- 
trophic or fungating. Two of them were examples of the panaris type, 
while the others were of the superficial erosive or slightly ulcerous 
type, with a brownish or dusky-red elevated and indurated base. 
The accompanying picture (Fig. 4) of chancre of the forefinger in one 
•of these cases was taken after the lesion was in process of healing. 
All were accompanied with epitrochlear and axillary adenopathy, with 10 
Original Communications. 
one exception. In this case I could not detect the slightest trace of 
glandular enlargement. To be clear upon this point, I wrote to the 
patient recently, who replied : “ I have never had an enlarged gland ; 
the only symptoms of syphilis I have had were the first eruption and the 
throat lesions a year later, which you saw and treated.” 
Fig. 4. 
In regard to the {etiology of these cases, seven ascribed their infec- 
tion to digital examinations or manipulation in obstetrical or gynaeco- 
logical work; three, to contamination in the course of surgical work. 
Two of the latter were infected at the same time in performing a peri- 
neal section in a syphilitic patient—the operator through a hangnail on 
the little linger; his assistant by an accidental prick on the wrist by 
the knife used in making the section. Some weeks later the operator, 
alarmed by the long persistence of the sore on his little linger, came to- 
consult me as to its nature. In the absence of any glandular enlarge- 
ment, I gave a tentative diagnosis of syphilis, which was confirmed ten 
days later by the appearance of a characteristic eruption. Some two> JVotes on Syphilis. 
11 
weeks afterward the surgeon who had assisted at the operation came to 
consult me. The chancre on the wrist had practically healed, but there 
wTas a generalized papular eruption. 
As before intimated, these cases are presented not so much for their 
intrinsic interest as a basis for some general reflections. 
The Prognostic Significance of Extra-genital Chancres. As is 
well known, there is a tradition or belief in the profession that extra- 
genital chancres are not only more apt to be severe in their local pro- 
cesses, but more liable to be followed by a grave syphilis. Chancres of 
the fingers, especially, are thought to portend a bad type of syphilis. 
As the French phrase it, “ It is a misfortune for a man to catch the pox; 
it is a much greater misfortune for him to take it in any other way 
than by the genital way.’’ This conception that the gravity of a con- 
stitutional infection may be modified by the seat of inoculation receives 
support, it is claimed, from analogy with other infectious diseases. 
Thus, for example, there has been observed a marked difference in the 
relative mortality of mad-dog bites according to the region in which 
the virus is implanted. The mortality of rabies is four times greater 
from wounds of the face and neck than from wounds of the lower ex- 
tremities. This difference may, however, be explained partly on the 
ground that as the lower members are habitually clothed, the virus is 
often absorbed by the clothing, while the richer lymphatic and vascular 
supply of the face furnishes more favorable conditions for successful 
inoculation. In the case of syphilis, however, it is difficult to believe 
that the constitutional effects of the syphilitic virus are materially mod- 
ified by its port of entry into the system. So far as the local effects are 
concerned, we can readily understand why their severity may be influ- 
enced by the accident of location. 
Chancres of the fingers, especially those of the panaris type, are 
proverbially painful and apt to be attended with severe glandular com- 
plications. The pain is readily explicable from the character of the 
tissues involved, the structures being compact, dense, and resisting, and 
the nail bed endowed with the most excjuisite sensibility. Sympathetic 
irritation, no doubt, enters as a factor in the production of adenitis 
Again, the digital chancre is subject to numberless causes of irritation 
from pressure, painful contacts, and knocks, etc., besides being exposed 
to secondary infection from pyogenic germs; the septic process thus set 
up is not infrequently attended with severe lymphangitis, pyaemia, and 
other complications. 
Likewise, chancres of the lips, tongue, and pharynx are exposed to 
multitudinous causes of irritation from contact with food, spices, hot 
liquids, etc., while the constant movement of the parts in talking and 12 
Original Communications. 
swallowing interferes with the rest necessary to prompt healing. Chan- 
cres of the tonsil especially have a had reputation. The structure of 
the tonsil is favorable to syphilitic infiltration, while its crypts and 
anfractuosities constitute favorable breeding places for pyogenic cocci. 
The malaise, fever, and other signs of constitutional disturbance are 
doubtless due, in many cases, to secondary infection. Some time ago 
I had a case of chancre of the tonsil in private practice which had been 
previously treated for four weeks as a case of diphtheria under the care 
of two physicians and a trained nurse. The identical aspect of the false 
membrane of chancre of the tonsil with that of diphtheria would ex- 
tenuate but not excuse the mistake in diagnosis. 
As regards the local process, it may be conceded that extra-genital 
chancres are more apt to be severe, but this increased severity is due 
to peculiarities of anatomical structure of the parts and local causes of 
irritation. But, advancing a step further, do we find that the accident 
of location influences the ulterior evolution of the disease—in other 
words, is syphilis contracted extra-gen itally more grave in type than 
syphilis received in the ordinary way? 
So far as my observation of these cases would throw any light upon 
the determination of this question, it must be answered in the nega- 
tive. In none of them was the gravity of the resulting syphilis more 
pronounced than in the average run of patients. Of the dispensary 
cases the majority have been under my observation for variable peri- 
ods—some of them constantly for more than two years. Most of them 
have attended with the intermittent regularity which characterizes pa- 
tients of the dispensary class; they would continue to come until the 
disappearence of existing accidents, and then cease their visits until the 
recurrence of another outbreak of symptoms. 
Of the ten physicians who figure in the above category, four still 
continue under my personal care; two of them, who live at a distance, 
I hear of from time to time; the remaining four passed from my ob- 
servation as soon as the diagnosis was definitely established. Notwith- 
standing the fact that physicians are notoriously bad patients, in all 
these six cases the constitutional symptoms have thus far been of mild 
or medium severity. 
It is evident, however, that conclusions based upon the observa- 
tion of syphilis during the secondary stage have a comparative rather 
than an absolute value, because, except in malignant precocious syph- 
ilis, the elements of gravity are only manifest at a later stage. 
This question has been studied by Prof. Fournier in his usual care- 
ful and scientific manner. In a recent lecture upon the u Comparative 
'Gravity of Extra-genital and Genital Chancres,” he has analyzed a Notes on Syphilis. 
13 
large number of personal statistics, covering long periods, which- 
directly bear upon the determination of this question. Starting with 
the general proposition that statistics of ten thousand cases of chan- 
cre show that ninety-three per cent are genital and seven per cent are 
extra-genital, he has considered the criteria upon which the gravity of 
syphilis may be based. 
1. The occurrence of tertiary accidents he regards as one of the best 
criteria of the gravity of syphilis. In twelve hundred cases of tertiary 
syphilis he found that in six or seven per cent it originated in extra- 
genital chancres, and in ninety-three to ninety-four per cent it had for 
its point of departure genital chancres. The second criterion is the 
occurrence of 
2. Malignant precocious syphilis. In two hundred and forty-two 
cases of malignant precocious syphilis genital chancres were respon- 
sible for ninety-two per cent, and extra-genital chancres for seven per 
cent of the cases. 
3. The occurrence of cerebral syphilis, which is accepted as the 
most formidable accident of syphilis, he takes as the third criterion of 
gravity. In seven hundred and seven cases of cerebral syphilis ninety- 
live per cent made their debut by genital chancres, and only five per 
cent resulted from extra-genital chancres. These statistics, which 
were taken impartially without knowing where they would lead, 
would seem to prove that so far as cerebral syphilis is concerned it 
would more likely result from a genital than an extra-genital 
chancre. 
Notwithstanding these statistics, Fournier still insists that the digi- 
tal chancre is grave, not because of its location but because of the soil 
in which it generally develops. It occurs, as a rule, upon the physi- 
cian who is generally run down and fatigued. The moral effect is, 
moreover, depressing, since the physician, knowing the dangers of the 
disease, lives in a state of great anxiety. Finally, physicians do not 
take care of themselves. Some have a therapeutic skepticism, some 
treat themselves, while others consult a great number of their confreres, 
and continually change their medication. 
Upon this point the opinion of another distinguished authority 
may be quoted. Mauriac, in his recent work (1895) on the Treat- 
ment of Syphilis, says : “ Chancres of the fingers have a bad reputation, 
and it is merited. In the first place, they are often grave in them- 
selves, especially when they are large, ulcerated, and fungous, and 
when they become complicated with an inflammatory panaris, with 
pain, necrosis, etc. But they are especially dangerous and almost im- 
pressed with malignity in their consequences as to general infection.. 14 
Original Communications. 
All authorities are united upon this point. It is incontestable that 
syphilis from a digital chancre is a dangerous syphilis, and turns easily 
to tertiarism. This fact is difficult to explain.” 
Professional Syphilis. 
Without further discussing this aspect of the question, it may be 
said that chancres of the fingers possess a peculiar interest for physi- 
cians, who from their occupation are most exposed to contract syphilis 
through this medium. While medical men can not claim an exclu- 
sive monopoly of digital chancres, yet they are immeasurably more 
common among accoucheurs and surgeons. In Fournier’s statistics of 
forty-nine cases, thirty occurred in physicians. These facts emphasize 
the following points : 
1. The Personal Risks of the Physician.—Medical men, especially 
those engaged in obstetrical and surgical work, can not be too strongly 
impressed with a recognition of the risks incurred. Professional syphi- 
lis is much more common than is generally supposed, and for obvious 
reasons. Syphilis is not a disease which reflects credit upon its pos- 
sessor, and the unfortunate victim is not eager to proclaim himself a 
syphilitic. On the contrary, he is disposed to carefully conceal the 
nature of his disease, not only from motives of delicacy, but because 
of the injury to his professional interests which a knowledge of the 
fact would carry with it. In years past I have seen a great number of 
cases of professional syphilis, and know of at least two recent cases 
among my colleagues of the City Hospital which have not been included 
in the above category. Forewarned is forearmed, and the recognition 
of the danger would lead to greater care in the protection of the fingers, 
and greater circumspection, not only in the examination of known 
syphilitics, but of patients of whose history and antecedents nothing is 
known. It is a noteworthy fact that specialists in venereal diseases 
who are most exposed to constant contact with syphilis are rarely con- 
taminated. This is because they recognize the danger and take greater 
precautions to guard against infection. 
2. The Risk to Others.—The important fact must not be lost sight 
of that the dangers of professional syphilis are not purely personal; 
they are not to be measured alone by the risks of contagion to the 
patient’s family and intimates. A digital chancre involves serious 
danger to those with whom its bearer comes into professional relations. 
The many well-attested local epidemics of syphilis which have origi- 
nated from a chancre on the finger of an accoucheur, besides numerous 
scattered cases where one or more women, and through them their 
families, have been contaminated injtlie same way, furnish a large Notes on Syphilis. 
15 
■contingent of cases in the literature of syphilis insontium. I might 
refer to the historical epidemic of St. Euphemie, originating from a 
chancre on the linger of a midwife, where fifty women were the imme- 
diate victims; to the epidemic of Brives (1874), reported by Bardinet, 
when thirty-one cases of syphilis, with four deaths, were traced to a 
midwifery chancre, etc. Enough has been said to show that a chancre 
on the hand of any one engaged in obstetrical work may be a prolific 
cause of syphilitic infection. 
These facts suggest an ethical question of great practical impor- 
tance, viz., whether a physician is justified in continuing his profes- 
sional work while he bears upon his hands such an active source of 
contagion. The surgeon, or the physician in general practice, may be 
able to render himself innocuous to his patients by a suitable protective 
dressing—such as a rubber stall, for example. Where the chancre is 
inflamed and very painful, the pressure of such an appliance would 
render its use impossible. So far as the accoucheur is concerned, there 
can be no doubt as to his manifest obligation to discontinue his work 
until the chancre is healed. The fact that he can ill afford to give up 
his work during this long period does not affect the moral aspect of 
the question. One of the physicians who came to consult me had a 
very large obstetrical practice in this city, and he had continued to 
attend to his work for several weeks after the chancre appeared. To 
my question as to how many women he had exposed to possible con- 
tagion during this period he was unwilling to reply. He assured me, 
however, that not even a suspicion of the syphilitic nature of the sore 
had crossed his mind until the eruption appeared. This brings us to 
the consideration of 
3. The Importance of an Early Diagnosis of the Digital Chancre. 
—I have been more than once surprised at the invincible repugnance 
on the part of the bearer of such a lesion to recognize its true nature. 
Almost all of them maintain that it must be a simple sore, a felon, a 
septic infection, or something else, and they cherish this delusion until 
their perceptions are quickened by the appearance of unmistakable 
constitutional symptoms. One of my patients, acting on the advice 
of his confreres, that his chancre was an infected wound, had it scraped 
and cauterized, and the entire chain of glands, including the axillary, 
extirpated. This procedure delayed somewhat, but did not prevent, 
the evolution of the disease. A more general recognition of the fre- 
quency of this mode of infection on the part of the profession would 
more readily awaken suspicion as to the possible syphilitic character 
of any suspicious sore which develops on the fingers. In fact, it would 
be a safe rule for any physician bearing upon his hand or fingers an 16 
Original Communications. 
indolent ulcer, which in its appearance and sluggish evolution does 
not correspond to ordinary lesions in this locality, to at once suspect 
its possible syphilitic nature. 
4. The prophylactic precepts which the study of these facts impose 
are to preserve intact, as far as possible, the integrity of the epidermis 
of the hands and fingers, and to use great circumspection in making 
vaginal examinations, and in operations on syphilitic subjects. Obser- 
vation shows that digital chancres are most often contracted from mucous 
patches of the vulva, or from masked or concealed lesions in persons 
not known to be syphilitic. Many physicians, called to a woman in 
labor, are accustomed to make a digital examination without inspec- 
tion of the genital parts, or without any knowledge of the condition 
of the patient’s health. 
So far as we know, a sound and unbroken epidermis affords a per- 
fect safeguard against inoculation. Cuts, pricks, abrasions, fissures, 
hangnails, eczematous eruptions—any break of the epidermis from 
whatever cause—may be a port of entry for the syphilitic virus. Le- 
sions of continuity may be so microscopic as to escape ocular detection, 
but exposure of the hands to the vapor of ammonia may reveal the ex- 
istence of unsuspected breaks in the epidermis. It is hardly necessary 
to insist that the hands should be thoroughly washed immediately after 
examination of any syphilitic, whether they come in contact with 
syphilitic lesions or not. For this purpose the free use of soap and hot 
water is better than the strong mercurial or carbolic washes employed 
by many surgeons. As a matter of fact, the latter often cause a 
chapped condition of the skin, thus affording a favorable surface for 
inoculation. Moreover, the free use of sublimate or other aseptic 
washes immediately after contact with the secretions or blood of a 
syphilitic is deceptive as a prophylactic against inoculation. Jullien 
reports the case of a medical man who was called upon to examine a 
sore on the glans penis of a patient. He carefully lifted up the organ 
between the thumb and index finger, but in doing so his middle finger, 
upon which there was an abrasion, accidentally came in contact with 
a mucous patch of the scrotum which had not been observed. The 
contact was but momentary and the part was immediately washed in a 
strong antiseptic solution ; nevertheless, a chancre developed on the fin- 
ger, followed by severe constitutional infection.