On the Occurrence of Ulcers 
resulting from Spontaneous 
Gangrene of the Skin dur- 
ing the Later Stages of 
Syphilis, and then* Re- 
lation to Syphilis. 
BY 
HERMANN G. KLOTZ, M. D., 
ATTENDING PHYSICIAN TO THE GERMAN" HOSPITAL AND 
DISPENSARY OF NEW YORK. 
REPRINTED FROM 
Neto York iUeto'cal journal 
for October 8, 1887. Reprinted from the New York Medical Journal 
for October 8, 1887. 
ON TIIE OCCURRENCE OF 
ULCERS RESULTING FROM SPONTANEOUS 
GANGRENE OF THE SKIN 
DURING TIIE LATER STAGES OF SYPHILIS, 
AND THEIR RELATION TO SYPHILIS* S' 
ATTENDING PHYSICIAN TO THE GERMAN HOSPITAL AND DISPENSARY OF 
NEW YORK. 
HERMANN G. KLOTZ, M. D., 
Whenever we find an ulcer of round or oval shape, 
sharply cut as if punched out, with somewhat thickened 
abrupt edges, extending deeply into or through the entire 
thickness of the skin, with an uneven floor of a dark-green 
or yellow, dirty color, in a person known to be under the 
influence of syphilis in its later stages, such an ulcer we 
generally consider to be a syphilitic one-that is to say, to 
owe its origin to necrosis of some previously formed spe- 
cific tissue, most frequently to the breaking down of a gum- 
matous infiltration. An observation made several years ago 
rendered it more than probable to me that similar ulcers in 
syphilitic persons might directly result from circumscribed 
spontaneous gangrene of the skin, due to syphilitic arteritis 
or endarteritis obliterans. 
* Read before the section in Dermatology and Syphilography of the 
Ninth International Medical Congress. 2 
SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
Among the patients who came under my care when, on July 
1, 1879, I took charge of the out-door poor service of the Ger- 
man Society of New York, was Mrs. S., fifty-eight years of age, 
who, while otherwise in good health and strength and able to 
attend to her household duties, was, owing to a sore leg, pre- 
vented from leaving the house. Beginning directly below the 
knee, the right leg was considerably enlarged; on its upper two 
thirds the skin was congested and shining, showing numerous 
dilated blood-vessels, but was otherwise in good condition. 
From about the lower third of the leg to the middle of the dor- 
sal aspect of the foot, ulcers of irregular shape, at least one cen- 
timetre deep, with sharply cut, indurated edges, occupied nearly 
the entire circumference of the ankle. The floor of the ulcers 
showed an uneven surface of a dirty-green color, furnishing a 
copious watery discharge of very offensive odor. The foot, 
with the exception of the toes, was enormously enlarged in con- 
sequence of swelling of the soft parts, principally of the skin, 
which was partly smooth and glistening, partly uneven, owing 
to the formation of numerous aggregated wart-like elevations, 
and was constantly moist by a watery secretion. At first sight 
the case seemed to be one of simple chronic ulcers with ele- 
phantiasis of the leg; closer examination of the patient, how- 
ever, made it more than probable that syphilis was at the bot- 
tom of the disease. 
The patient being almost deaf and not of very bright intellect, 
it was with some difficulty that the following history was ex- 
tracted: Her husband is living, and does not show any signs of 
disease; she has two grown-up sons, both in good health; she 
herself was strong and healthy until eight years ago, when a 
tumor formed over the sternum, which, without ever causing 
much pain, broke and left an extensive ulcer, which finally 
healed. Soon after similar ulcers developed on the dorsal side 
of the right forearm, which likewise healed. Only a few weeks 
later ulcers made their appearance on the back of the right 
foot, laying bare the bones but gradually filling up again to 
about the present state, never healing, but attaining by degrees 
their present size. Extensive white, sharply defined scars, ad- 
herent on the sternum, confirmed the patient's report and left SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
3 
little doubt as to the syphilitic character, particularly of that 
over the sternal region, so favored a location of syphilis. 
Under appropriate, mostly specific treatment the swelling 
of the extremity was gradually reduced, the ulcers themselves 
presented a cleaner, healthier aspect, now and then good granu- 
lations cropped up, the edges had flattened down and softened 
visibly, when on one of my visits in November 1 was surprised 
to find the skin above the ankle affected at several new places, 
which before had been smooth and but little infiltrated. Be- 
ing interested in the patient, I had visited her at least once a 
week, and had watched the progress closely. I felt confident 
that on the localities of the recent affections no swelling, not 
even any discoloration, had previously existed. Now there ap- 
peared on several places dark-green, oval-shaped sloughs, of 
about the size of a small hen's egg, surrounded by well-defined 
borders, which were not more congested or swollen than the rest 
of the skin; their appearance was accompanied by considerable 
sharp pains. Gradually the tough, dry eschars began to sepa- 
rate from the surrounding tissues without losing their totality, 
showing an uneven floor throughout, the lower third of which 
was of semilunar shape, level and slightly elevated, and, like the 
rest, coated by a thin layer of yellowish detritus. After a while 
the ulcers thus formed took on the same appearance as the old 
ones, making but very slight progress toward improvement, with- 
out, however, evincing a tendency to increase in circumference. 
In September, 1880, the patient's left leg, which so far had 
remained intact, began to swell quite rapidly, exhibiting oedema 
of the soft parts with but slight congestion, when an inju- 
diciously applied liniment caused a dermatitis or artificial ecze- 
ma. This had subsided when, in October, without any previous 
induration or circumscribed swelling, similar sloughs as above 
described were formed on the back of the foot, followed in 
November by more extensive sloughing of the skin above the 
left ankle. Soon after, symptoms of blood-poisoning set in, 
which early in December terminated in death. 
Here I had a patient of whose syphilitic taint there could 
be no doubt, with ulcers closely resembling the typical so- 4 
SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
called gummatous ulcer of syphilis ; still I felt absolutely 
certain that in those localities where I had been able to 
watch their development there had been no symptoms of 
previous gummatous infiltration. There had been no red- 
dening of the surface, no spontaneous opening of a single 
aperture nor ulceration at several distinct points, no forma- 
tion of a small deep ulcer with a core underneath, and final 
extension until the entire neoplasm was destroyed ; no thick- 
ened edges and no hyperyemic areola. The blackish-green 
eschars had appeared at once, uniformly covering the whole 
area; they were closely adherent at first to the surrounding 
skin, which itself did not exhibit any changes from its for- 
mer condition ; they gradually separated in their totality- 
clearly spontaneous gangrene of the skin. In looking for 
the cause of the gangrene, there was no evidence of trauma, 
none of the influence of heat or cold or of caustic or irri- 
tating chemical action, none of a diathesis like diabetes or 
of an infectious disease, none of neurotic influences, none 
of ergotism, or any other cause except obstruction to the cir- 
culation. The patient exhibited no signs of endocarditis, 
no sclerosis of the arteries in other parts where it usually 
manifestsitself; therefore it seemed probable that syphilitic 
arteritis or endarteritis obliterans had led to the interrup- 
tion of circulation. This I stated to be my opinion when 
I presented the patient at a meeting of German physicians 
of New York in January, 1880. I shall try to show later 
on that such an assumption seems justified, even without 
direct anatomical proof. Still, I confess the case was not 
entirely convincing, especially in regard to the right ex- 
tremity, which was first affected. Here the whole leg was 
in such a condition that the obstruction of a blood-vessel 
could easily take place from various causes; not so, however, 
on the left leg, which had previously been in a normal state. 
Certainly my attention was sufficiently aroused to keep me SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
5 
on a sharp lookout for similar cases. Several years, how- 
ever, passed without furnishing further confirmation of my 
suspicion. A number of cases came under my observation 
which, indeed, somewhat resembled that of Mrs. S. In sev- 
eral instances I found the same dark-green sloughs, firmly 
adherent to their base and their periphery, occurring mostly 
at the malleolar region; sometimes I could watch the sepa- 
ration of these sloughs and the appearance of the deep, 
dirty, sharply cut ulcers, surrounded, at least at first, by rath- 
er normal skin, in persons known to be, or highly suspected 
of being, subjects of syphilis. At other times ulcers were 
seen, under similar conditions and in the same localities, 
which I felt convinced had been originated by the separa- 
tion of the same escharotic sloughs. They were generally 
of oval shape, uneven, very often deeper at one side than at 
the other, showing a flat semilunar elevation like the round 
ulcer of the stomach, with hard but sometimes inverted 
edges, furnishing a thin watery secretion and either exhibit- 
ing very little tendency to extend or to heal, or, after a very 
slow progress of healing, leaving a depressed scar that firm- 
ly adhered to the underlying tissue, even when not situated 
directly over a bone. Per contra, gummatous ulcers as a 
rule show a great tendency to heal under proper treatment 
with a slightly depressed, movable, and thin parchment-like 
scar. Naturally, such ulcers at first sight do not differ much 
from the common chronic ulcer of the leg, especially if left 
to themselves for some time, but on close observation some 
peculiarities can indeed be found. I have observed these 
so regularly in ulcers of the malleolar region that I always 
consider those as suspicious of syphilis, and but exception- 
ally has the suspicion failed of confirmation by the absence 
of a history or other manifestations of syphilis. All such 
cases, however, which I have seen, unfortunately belonged 
to dispensary practice, so that I was not able to trace their 6 
SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
history and development with sufficient accuracy. One case, 
however, occurring in private practice, offered a better op- 
portunity. 
Mrs. B., then about fifty years of age, had contracted syphi- 
lis in August, 1880. Although rationally treated from the start 
by her physician, the disease soon developed a very malignant 
character, partly in consequence of irregularity of treatment 
owing to the miserable state of the patient's digestion, partly of 
constant family trouble and excitement. I first saw her about 
a year after the infection, when she presented superficial ulcera- 
tions of the forehead, scars of ulcers on the legs, and gummata 
of the thighs and arms, and ever since have had her under ob- 
servation. During these six years Mrs. B. hardly ever has been 
entirely free from symptoms of syphilis, consisting mostly of 
ulcers of different parts of the body. In March, 1884, two 
gummata of the size of a small walnut made their appearance 
on the lower third of the right leg, breaking down in the usual 
way and leaving two deep ulcers in an area of considerably in- 
filtrated and congested skin. These ulcers, after various periods 
of improvement and aggravation, presented, about the end of 
June a clean granulating surface, giving promise of a speedy 
healing. Early in September I found these ulcers healed with 
a smooth, thin scar; the leg, which had repeatedly shown differ- 
ent degrees of cedema, was of natural size, but below the mal- 
leolus internus two dark-green, firmly adherent sloughs, about 
the size and shape of peach-stones, were visible, separated by a 
band of slightly oedematous skin and causing no particular in- 
convenience. Four weeks later the sloughs had come off, leav- 
ing tolerably clean, shallow defects, with sharply cut, uninfil- 
trated edges. These two ulcers have never entirely healed 
since; they have not materially increased in size, but have been 
constantly changing in depth. At one time in January, 1885, 
the greater part of them had been transformed into a depressed 
adherent .scar, showing several transverse, ridge-like elevations 
and causing then considerable pain, but since that time the 
ulcers have increased in depth again and do not undergo much 
change, neither healing nor extending, although the patient is 
keeping very quiet and is not obliged to use her legs much. SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
7 
So far my own experience. In literature not much is 
to be found. Some of the features of syphilitic ulcers in 
the chronic state are found described in the hand-books, 
for instance, by Bumstead and Taylor,* where the chronic 
swelling resembling elephantiasis Arabum,as in my first case, 
is especially mentioned, but the original formation of a 
slough without previous gummatous infiltration I have not 
found distinctly recognized. Some of the malignant pre- 
cocious syphilides, described originally by French authors, 
often rapidly lead to sloughing, but never without a neo- 
plasm being previously visible, differing from my cases by 
their early appearance. We find the closest resemblance to 
spontaneous gangrene, however, in a description recently 
given by Fournier f of what he calls gangrene primitive, 
and to which, he says, Bazin has given the name of tuber- 
culo-gangrenous syphilide. I have tried to find the origi- 
nal of Bazin, which Fournier has not indicated, but have 
not succeeded, so that I cite the latter author: 
" Here the tuberculous infiltration, as soon as it has been 
formed, takes a livid color in the center and a chocolate 
color in the peripheral portions, with insensibility of the 
diseased part; for in reality the formation of an eschar 
takes place under which the mortified, insensible, sloughy 
tissues are found, no external occasional cause being recog- 
nizable. The mortified parts take on the appearance of gan- 
grene, they become detached, and underneath the syphilitic 
ulcer is found at last. The symptoms perfectly bear the 
character of spontaneous primary gangrene.'' 
Here you have an exact description of what I have 
stated to have observed, only that Bazin insists on the previ- 
ous formation of a neoplasm that begins to disintegrate as 
soon as it is formed. It is true, the syphilitic newly formed 
* Bumstead and Taylor, "Venereal Diseases," fifth ed., p. 601. 
j- " Gaz. d. hopitaux," 1887, Nos. 37 and 40. 8 
SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
tissue is perhaps the most short lived, but not so ephemeral 
as Bazin's description would lead us to believe; only in 
phagedenism do we meet with so rapid a decay, yet Bazin 
does not identify his tuberculo-gangrenous syphilide with 
phagedenism. Has this new formation not been assumed 
perhaps in conformity with the usual experience that syphi- 
litic ulcers always result from the disintegration of a specific 
product ? And has not the bona fide acceptance of such a 
new formation been the cause that the gangrenous ulcer 
has never been distinguished from the gummatous one ? It 
seems to me that it is not necessary to resort to such an ex- 
planation ; the sudden occlusion of a small terminal branch 
of an artery would more satisfactorily account for the al- 
most instantaneous appearance of such a spontaneous gan- 
grene. It has been satisfactorily shown that in every stage 
of syphilis its virus exerts its action most constantly on and 
around the blood-vessels. To changes in the blood-vessels, 
therefore, particularly to endarteritis obliterans, we must 
look for an explanation, if we can exclude other external or 
internal causes of gangrene. Endarteritis in syphilitic per- 
sons is an established fact; it does not detract from its im- 
portance that this arteritis is really not a specifically syphi- 
litic process; that it owes its origin to syphilis in a great 
many cases is generally conceded. Such an origin would at 
the same time explain the inefficacy of antisyphilitic treat- 
ment in such cases. The product of endarteritis of the 
skin will no more be influenced by the same than the nerve 
or ganglion that was destroyed by cerebral haemorrhage due 
to specific endarteritis. The mischief is done by syphilis, 
but its- result ceases to be syphilis. Lang, who, in his lec- 
tures on the pathology and treatment of syphilis,* has de- 
voted an entire lecture to the syphilitic affections of the cir- 
culatory system, has paid more attention to this question 
* Wiesbaden, 1884-86. SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
9 
than other authors. He speaks first of arteritis of the larger 
blood-vessels, leading in some cases to gangrene of entire 
extremities or portions thereof. Besides an observation of 
his own, he cites cases of Zeissl and Lomikowsky, to which 
others of Nicoladoni,* Billroth, f PodresJ (cited by Bum- 
stead and Taylor), and Cabot and Warren * might be added. 
The latter report gangrene of the two lower thirds of the 
right leg, and a gangrenous spot three to four inches in di- 
ameter on the inner side of the right thigh. I observed 
the following case of endarteritis of the popliteal artery or 
one of its branches, which, like Lang'a case, took a favorable 
course under specific treatment. 
Mr. R., who had contracted syphilis in 1874, consulted me 
in June, 1882, for a thickening of the epidermis between the 
toes and on the sole of the left foot. On August 16th this 
thickened epidermis was found to be detached, covering a su- 
perficial, irregularly shaped, serpiginous ulcer, which under 
local applications and mixed treatment had healed about Sep- 
tember 3d. After continued treatment, on October 13th the 
sole appeared smooth but for several small scaling spots beneath 
the first phala iges of the toes, but the whole leg, which had 
been slightly oedematous before, appeared considerably swollen 
from the knee downward to the toes; the skin was pale, cool 
to the touch, and not sensitive on pressure except at the lower 
part of the tibia. Under the use of iodide of sodium within 
the next days the swelling somewhat subsided; on removal, 
however, of the scales from the sole, ulcers were again found. 
On October 19th the treatment was changed to hypodermic in- 
jections of a one-per-cent, solution of the bicyanide of mer- 
cury, and soon the swelling began to diminish steadily; on the 
25th the toes were smaller, and on the 28th, when nine injec- 
* "Wiener med. Wochenschrift," 1881, p. 231, No. 8. 
f "Wiener med. Woch.," 1879, No. 51. 
f " Centralblatt f. Chirurgie," 1876, No. 33. 
* "Boston Med. Journal," 1880, ii, No. 7. 10 
SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
tions had been administered, the ulcers of the sole had healed, 
the fourth and fifth toes were of normal size, while the second 
and third and the inner half of the great toe were still en- 
larged, and on the sole the interdigital spaces between the first, 
second, and third toes were nearly obliterated by a pad-like 
protuberance of the soft parts. The dorsal aspect of the foot 
still showed moderate swelling over the tibio-tarsal joint; on 
the leg the outlines of the tibia were still concealed by oedema 
of the soft parts, which on both sides of the bone gave a pecul- 
iar elastic sensation; the front aspect of the tibia seemed to be 
thickened by periosteal new formation, but was not sensitive. 
On November 13th the swelling had still more subsided, but, 
owing to my protracted sickness, I did not see the patient again 
until the following May, when the leg was in perfectly normal 
condition except slight periosteal thickening of the upper and 
lower third of the tibia. The extremity at all times had been 
cool, pale, and almost free from pain ; at no time could I detect 
a thickened, hard, or enlarged blood vessel, like in Lang's case, 
still I can not think of another cause for the apparent obstruc- 
tion of the circulation but of endarteritis obliterans. 
To return to Lang, he then proceeds to the considera- 
tion of the affections of the medium-sized and small arte- 
ries, dwelling particularly on the importance of the endar- 
teritis of the smaller cerebral vessels, which was first stud- 
ied by Heubner and confirmed by other authors; Birch- 
Hirschfeld's and Schuetz's observations of endarteritis in 
hereditary syphilis, and Huber's of calcification of blood- 
vessels, are then mentioned. I here wish to call your atten- 
tion to the publication of Galliard* on the occurrence in 
syphilitic persons of the round ulcer of the stomach, to the 
similarity of which with the gangrenous ulcers of the skin 
I have repeatedly alluded, and on the probable connection 
of the same with endarteritis. 
* " Archives gen6rales de medecine," janvier 1886. " Syphilis gas- 
trique et ulcere simple de 1'estomac." SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
11 
Lang then continues: * 
"Naturally, the symptoms which follow an affection of the 
blood-vessels will vary a good deal according to the nature and 
extent of the pathological process, to the size of the affected 
vessel, and in smaller ones according to the dignity of the 
organ the vascular supply of which is the seat of the affection. 
Either dilatation or narrowing and. obliteration may result; 
therefore we must expect in due time either an aneurysm or 
such phenomena as usually follow obliteration of blood-vessels. 
The constringing and obliterating arteritis will be the less pro- 
nounced the smaller the area supplied by the affected vessel, 
the less important its physiological function, and the more fa- 
vorable the circumstances for the establishment of a collateral 
circulation, which in the slow development of the arteritis may 
be effected with hardly any disturbance. But if terminal or a 
larger number of blood-vessels are the seat of the affection, an 
insufficient or entirely interrupted circulation and consequent 
diminished nutrition and necrobiosis are inevitable. Death of 
the foetus in consequence of affections of the umbilical or pla- 
cental vessels, circumscribed softening of the brain or of the 
heart, ulcerations of the skin and of the mucous membranes, 
have to be looked for as the natural consequences of arteritis." 
The probability that arteritis may begin in small periph- 
eral vessels and spread to larger trunks has been distinctly 
insisted upon by Jonathan Hutchinson in a paper published 
in 1884,f which seems to have escaped Lang; its title is "A 
Case of Syphilis in which the Fingers of One Hand became 
Cold and Livid-Suspected Arteritis." 
The case had been under Hutchinson's observation twenty 
years ago, but had not been published because no satisfactory 
conjecture as regards diagnosis could then be offered. "Only 
in reading over the notes again, it occurred to me," Hutchinson 
says, " that the cause of the symptoms must have been inflam- 
matory occlusion of the arteries of the hand. Lividity, coldness, 
* Loc. cit., p. 305. 
f l> Med. Tinies and Gazette," 1884, i, p. 374. 12 
SYPHILITIC GANGRENOUS ULCERS OF THE SKIN. 
and pain were indicative rather of disturbance of nutrition and 
circulation than of nervous influence. It will be seen," further 
on Mr. Hutchinson says, " that, although the finger-tips never 
actually went into gangrene, they were very near it. Since this 
occurrence I have seen several cases favoring the belief that 
arteritis may begin in the small peripheral vessels and may travel 
to large trunks." 
I am well aware that it will require the anatomical proof 
that changes in an artery leading to a gangrenous portion 
of the skin must actually be shown to exist to establish as 
an irrefutable fact what I have maintained. This, I confess, 
I have not been able to do thus far, nor can I hope to find 
the opportunity myself in the future. To awaken the in- 
of such an investigation, I have taken leave to bring my ob- 
servations before this assembly and to submit to your pres- 
ent and future consideration the following conclusions : 
1. Ulcers resembling the so-called gummatous syphilitic 
ulcer may occasionally result from circumscribed spontane- 
ous gangrene of the skin without the previous formation of 
a syphilitic neoplasm. 
2. Such ulcers may be distinguished by several pecul- 
iarities in shape, formation of the floor, and course. 
3. They are not at all or but very little affected by anti- 
syphilitic treatment. 
4. The spontaneous gangrene in such cases is probably 
due to endarteritis obliterans. 
222 East Nineteenth Street, New York. REASONS WHY 
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