(Reprinted from "Pacific Medical Journal," May, 1892.) 
CASE OF A SMALL AND LARGE PAPULAR SYPHILIDE 
ASSOCIATED WITH MILIARY GUMMATA OF THE IRIS. 
By D. W. MONTGOMERY, M. D., 
Prof, of Pathology and Clinician for Diseases of the Skin, Medical Depart- 
ment of the University of California; Clinician for Diseases of the 
Skin, San Francisco Polyclinic. 
(Read before the San Francisco County Medical Society, March 8, 1892.) 
Members of the San Francisco County Medical Society:-I wish 
to show you to-night a very interesting case of a small and large 
papular syphilide of the integument associated with miliary 
gummata of the iris. 
W. H., a German, aged 45, married, acquired about ten 
months ago a sore on the left side of the mucous surface of the 
prepuce, where there is still a raised, pea-sized, flat-topped 
papule. He denies impure connection and is at loss to account 
for the source of contagion. 
There is at present a copious small papular syphilide of the 
trunk, of the lower limbs, and a few small papules on the dor- 
sum of the penis and on the glans penis, and a large and small 
papular syphilide on the upper extremities (principally on the 
flexor surfaces of the forearm), on the neck, and on the face. 
He says there have been some pimples on the scalp. Many of 
the lesions on the skin have a dusky, raw-ham color, and have 
glittering or slightly desquamating tops. The pimples are very 
numerous on the back, are grouped, but are not circinate. 
There are no subjective symptoms such as itching, headache, or 
malaise, but there is slight soreness of the mouth caused by 
mucous patches. There is one especially well marked mucous 
patch on the anterior surface of the soft palate. There is no 
sore throat. The epitrochlear, posterior cervical and inguinal 
lymphatic ganglia are enlarged. There are three well circum- 
scribed, miliary, yellow nodules on the pupillary margin (outer 
segment) of the right iris, accompanied by some injection of the 
neighboring blood vessels. He says the eye has been troubling 
him for the past four or five weeks. 
I am sorry that Dr, H. L. Wagner, who has charge of the 
lesion of the iris in this case, but who unfortunately is prevented 
from being here this evening, is not present to demonstrate this Papular Syphdide with Miliary Gumma'a of the Iris. 
2 
interesting disease of the eye, but you will see by a reference to 
Michel's description of the syphilitic granulation tumors of the 
iris, that this is a classic case. 
Michel 1 says that syphilitic granulation tumors of the eye 
occur most frequently in the iris, and principally on its pupillary 
border or in its neighborhood. At most there are two or three 
round, pin-head sized, or larger, nodules which are at first grey 
or reddish yellow, later on yellow. There is usually a good 
deal of congestion of the blood vessels in the vicinity. These 
granulomata occur very early in the course of syphilis, being 
frequently co-incident with an early integumentary manifesta- 
tion. 
The occurrence of gummata so early in syphilis is interesting, 
showing as it does that there is no well defined line between 
secondary and tertiary lesions, and that this division is princi- 
pally of value to teachers, but is liable to give rise to serious 
errors in clinical medicine. 
The prognosis is good as far as the iris itself is concerned. 
The small papular syphiloderms, however, yield but slowly to 
treatment, recur frequently, and at times initiate a marasmus 
which ends in death,2 and in this case the bad prognosis of the 
skin affection is, I should think, made still worse by the occur- 
rence of precocious gummata. 
1. Lehrbuch der Augenheilkunde, page 497, Von Dr. Julius Michel. 
2. Syphilis der Haut, von M. Kaposi, page 114.