DERMOCHROMES 
TEXT 
BY 
JEROME KINGSBURY, M.D. 
* »r 
ATTENDING PHYSICIAN NEW YORK SKIN AND CANCER HOSPITAL; PHYSICIAN FOR DISEASES 
OF THE SKIN TO THE PRESBYTERIAN HOSPITAL DISPENSARY J MEMBER OF THE 
AMERICAN DERMATOLOGICAL ASSOCIATION; MEMBER OF THE NEW 
YORK DERMATOLOGICAL SOCIETY, ETC. 
CHAPTERS ON SYPHILIS 
BY 
WILLIAM GAYNOR STATES, M.D. 
ASSISTANT SURGEON NEW YORK POLYCLINIC HOSPITAL; FORMERLY INSTRUCTOR IN GENITO- 
URINARY AND VENEREAL DISEASES J MEMBER OF THE AMERICAN MEDICAL 
ASSOCIATION; MEMBER OF STATE AND COUNTY MEDICAL SOCIETY 
OF NEW YORK, WEST SIDE CLINICAL SOCIETY, ETC. 
WITH TWO HUNDRED AND SIXTY-SIX COLORED ILLUSTRATIONS 
FROM THE FIFTH EDITION OF JACOBI'S ATLAS DER 
HAUTKRANKHEITEN AND SIX HALF-TONE FIGURES 
FROM ORIGINAL PHOTOGRAPHS 
Volume III 
NEW YORK 
REBMAN COMPANY 
HERALD SQUARE BUILDING 
141-145 West 36th Street Coptright, 1914, by 
REBMAN COMPANY 
New York 
All Rights reserved 
PRINTED IN AMERICA Tab. 110. 
No. 178. Carcinoma cutis cicatrisans. Carcinoma Cutis 
Plate 110, Fig. 178 
Cancer of the skin may appear in several different forms. It is 
usually secondary to carcinoma of some other organ, often the breast. 
It may occur in the form of multiple shot-like (lenticular) masses, in 
which ulceration frequently develops or as a diffuse carcinomatosis 
(cancer en cuirasse), in which the skin is hard and immovable. 
Another form of rare occurrence is when a carcinomatous change 
is dependent upon some precancerous state or when, as in Fig. 178, 
it develops in the apparently healed parts of one of those compara- 
tively benign rodent ulcers which tend to cicatrize in the centre and 
spread at the periphery. 
Fig. 178. Model in Neisser's Clinic in Breslau (Kroener). 
229 Tinea Favosa 
Synonym: Favus 
Plate 111, Figs. 179, 180 and 181; and Plate 112, Fig. 181 
This parasitic affection is most frequently seen in the scalps of 
children who are immigrants from certain European countries. It 
is eminently chronic and is one of the causes of early permanent bald- 
ness, the hair-follicles being destroyed outright. Favus, however, 
also attacks the smooth skin; and while the children mentioned sel- 
dom show more than a few cutaneous lesions from autoinoculation 
from the scalp, the disease may be generalized over a large portion 
of the integument. The parasitic cause of favus is a fungus having 
mycelium and spores, and its parasitism and pathology resemble 
those of the parasitic cause of ringworm. When studied on the 
smooth skin the fungus is seen to form peculiar sulphur-yellow crusts, 
from pinhead to pea size, which show a cuplike form and tend to 
coalesce in patches. On the integument the fungus causes super- 
ficial lesions, easily remedied; but on the hairy scalp the conditions 
are reversed. The same yellow cups are formed, encircling the hairs, 
and eventually patches are formed an inch and upward in breadth, 
which may involve the entire scalp. This process of crusting may 
be complicated by suppuration. The favus fungus, although it does 
not penetrate into the follicles like the tricophyton tonsurans, never- 
theless does far more damage to the hairs. This appears due to the 
fact that the cuplike disks formed by the fungus cause in time dys- 
trophic pressure effects on the hair papilla. The nutrition of the 
hairs is interfered with at an early period. They become lustreless 
and brittle, and are shed or break off. The growth of the favus 
crusts exerts pressure on the scalp and also favors pus formation, 
which in turn aids in detaching the crusts. In the patches of favus 
the slow destruction of the scalp begins in the centre, while at the 
periphery the disease is in its earlier stages, thus constituting a 
circinate process as seen in ordinary ringworm. In favus of the 
230 Tab. Ill 
No. 179. 180. Favus. Tab. 112. 
No. 181. Alopecia from favus. smooth skin a circinate lesion may also occur. The destruction of the 
hair-follicles and the accompanying atrophy of the scalp do not 
appear to be quite clear to authors. It is assumed, however, that it is 
purely a matter of pressure by the growing favus disks. 
Patients present themselves, young children as a rule, with mani- 
festations varying with the duration of the malady. In the earlier 
stages there is a crusted condition of the scalp, which is naturally 
of a yellow hue, but usually much darker from various impurities. 
There may be one or several patches. Upon inspection, it may be 
possible to see small cupped elevations, each transfixed by a hair. 
The latter are loose, and readily come away. There is a peculiar 
musty odor to favus crusts. 
At a more advanced stage, after the affection has persisted for 
years, the scalp, especially if it has been cleansed, has a peculiar 
worm-eaten appearance, due to irregular areas of baldness alternating 
with others which show normal hair-growth. In the bald areas the 
follicles are no longer visible, the scalp having also a cicatricial as- 
pect. Between these early and late manifestations there are all de- 
grees of transition. 
Etiology 
The parasitic cause is probably a group of closely related species 
of fungi which are derived originally from some of the domestic ani- 
mals. Young boys make up most of the victims. It is mildly con- 
tagious from one child to another. It is so exclusively a disease of 
the miserable that it is seldom encountered outside of a certain social 
stratum. Like all affections due to fungi, the general resistance is a 
factor of some importance. 
Diagnosis 
The peculiar cuplike crusts are made up chiefly of the fungus, and 
hence their nature is readily recognized. An epilated hair, previously 
treated with liquor potassae and glycerin, shows characteristic my- 
celium and spores. If isolated cutaneous lesions cause confusion, a 
study of the scalp will sometimes show that favus is present in that 
locality. 
Prognosis 
The disease, after years of persistence, may exhaust itself by 
using up all the suitable soil, the patient being left almost bald. 
There is no other type of self-limitation. With proper treatment a 
231 comparatively recent case is curable, but if treatment is neglected 
recurrence is common. 
Treatment 
The first indication in the management of this intractable disease 
is the removal of all crusts and scales; this can be accomplished with 
oily applications and soap and water washings. The next essential 
step is the removal of all the diseased hairs by means of epilation. 
The scalp is then ready for the remedial application, which may con- 
sist of an ointment containing any of the parasiticides, the most val- 
uable being sulphur, mercury, and chrysarobin. 
The X-rays are curative in this condition, and should always be 
used in extensive cases. Favus, unlike ringworm, frequently causes 
marked scarring and permanent alopecia, therefore in using the 
X-rays undue caution should not be allowed to conflict with their effi- 
cient application. So successful has been the employment of the rays 
that many authorities, particularly abroad, have discarded all other 
methods of treatment. While moderate cases do get well with other 
treatment, the fact remains, that in extensive cases, the X-rays in the 
hands of an expert have proved our best remedy for this disease. 
Favus of the body can be promptly cured by means of any parasiticide 
ointment or lotion. 
Fig. 179. Model in St. Louis Hospital in Paris, No. 548 (Baretta). 
Besnier's case. 
Fig. 180. Model in Neisser's Clinic in Breslau (Kroener). 
Fig. 181. Half-tone, Dr. Kingsbury, New York. 
232 Tab. 113. 
No. 182. Trichophytia capillitii (Mikrosporia). Tinea Trichophytina Capitis 
Plates 113 and 114, Figs. 182 and 183 
This affection is almost peculiar to children. Occurring in sub- 
jects with short or scanty hair and in young infants, in all of which it 
can be watched, it sufficiently resembles tinea circinata in its evolution. 
Sometimes it behaves exactly like the latter, in that scaly macules 
assume the form of rings, which are clear in the centre. Such a course 
naturally implies that at first the follicles are spared. In typical 
cases, however, after the first spot or spots appear, the follicles are 
invaded, so that instead of rings we have circular patches in which 
the scalp and follicles are continuously involved. The parasite enters 
the hair-shaft and the hairs then break off close to the scalp, pro- 
ducing an affection entirely characteristic. 
When a child presents itself with ringworm, we see one or sev- 
eral rounded areas upon the scalp which are more or less denuded of 
hairs. Some of these have fallen out while others are broken off. On 
passing the fingers over the patches the hair stumps are readily felt 
and also readily come away when pulled upon. The patches are the 
seat of considerable scurfy desquamation. There are usually two or 
three spots, and these may attain such dimensions as to cause a notable 
amount of alopecia from coalescence. In beginning lesions, where 
there is merely a small, itching, irritated focus, the testing of the 
hairs, not yet broken off, may reveal a loose one; if not at first, 
perhaps in a day or two afterward. A special clinical form, of infre- 
quent occurrence, is made up of a number of these spots. Whenever 
the hairs are broken flush off with the skin the stumps appear as black 
specks. Another unusual variety is characterized by the uniform 
shedding of the hair on the patches, producing a parasitic alopecia 
areata. Finally there is a deep-seated folliculitis analogous to the con- 
dition sometimes seen on the smooth skin, in which there is a great 
deal of infiltration of a soft boggy character. These lesions, known as 
kerion, may give exit to a good deal of discharge. The hairs come 
away and the severe reaction may prove curative. The fungi in this 
233 situation seem able to cause a granuloma, such as are produced by 
other fungi and other microorganisms. The kerion does not always 
discharge freely. In some cases the granulomata break down in their 
centres and form abscesses. 
Etiology 
In most cases tinea capitis is due to the microsporon Audouini, 
although the larger form is also pathogenic, and in some countries the 
chief cause. That in the United States the small spored fungus causes 
most of the tinea capitis, and the large spored kind, typical tinea cir- 
cinata readily explains why the two clinical forms so seldom coexist. 
It is probable, too, that the small spored parasite is limited to man- 
kind. / 
Diagnosis 
Although the clinical evidence is often conclusive, it is always the 
custom to examine some of the broken hairs under the microscope. If 
the patch is smooth, hairs over the border are tested, and if not yet 
loose, scrapings from the skin may reveal the parasite. Kerion has 
been confused with carbuncle, but is a thoroughly benign local con- 
dition. 
Prognosis 
The prognosis is favorable, because there is some natural tendency 
to recover, and because new hairs replace the shed ones. These may 
have some immunity. As the disease is peculiar to children, another 
prognostic feature is added. Naturally, when untreated, the outlook 
for immediate improvement is very poor, but with proper treatment, 
involving considerable time, it is good. The time required is from 
six weeks to six months or more. The obstinate character is often due 
to persistence at some one focus. And when this is cured another has 
appeared elsewhere. 
Treatment 
As a rule, but little attention is paid to the internal treatment of 
ringworm of the scalp, and wrongly so, for it is a clinical fact that the 
affection is always more stubborn in anemic and poorly nourished chil- 
dren than it is in the strong and robust. Tonics are always indicated 
when the child's general health and nutrition is not up to the stand- 
ard. Cod-liver oil and the hypophosphites are probably the most val- 
uable remedies. 
234 Tab. 114. 
No. 183. Trichophytia profunda capillitii (Kerion Celsi). In the external treatment, our efforts toward a cure should be di- 
rected into two channels, namely, general treatment of the scalp, to 
prevent the spread of the disease either in the same individual, or to 
others; and local treatment of the diseased areas. To prevent auto- 
inoculation, the hair must be clipped short, the scalp shampooed every 
other day with sapo viridis, containing some antiseptic, and a general 
daily inunction made of some parasiticide ointment, such as five per 
cent, ammoniated mercury. A cap of several thicknesses of gauze 
should be worn constantly. It should be either washed daily or de- 
stroyed. The child should sleep alone, and special attention should be 
paid to the towels and pillow-cases used by the patient. In the treat- 
ment of the diseased spots, it must be kept in mind that success is not 
attained through the use of any particular parasiticide, but is due en- 
tirely to the thoroughness of its application, it must be rubbed in, not 
applied. The rubbing-in process should take at least five minutes for 
each spot morning and night. The parasiticides recommended are 
legion, but the most effective are sulphur, iodine, chrysarobin and mer- 
cury. A salve frequently used at the New York Skin and Cancer Hos- 
pital is the following: 
I> Ungt. hydrargyri oxidi rub 5iss 
Ungt. sulphur 5iii 
Ungt. aquas rosas ad §i 
M. et ft. ungt. 
Jackson strongly recommends the tincture of iodine in goose- 
grease. Mercury in the form of the official ten per cent, white pre- 
cipitate ointment is very useful. Chrysarobin is applied as a saturated 
solution in chloroform. The area affected is painted with this solu- 
tion, the chloroform evaporates, leaving the film of chrysarobin in 
place. This is then covered with several layers of collodion. When 
the spots are small and few, epilation thoroughly done and carried 
well into the border of healthy hairs is an invaluable measure. Au 
artificial kerion may be induced by needling each follicle with croton 
oil, as recommended by Aldersmith. The method is a severe one, and 
should not be used in young children, or over a lesion larger than an 
inch in diameter. Larger patches can be treated at subsequent sit- 
tings. Kerion may be treated with applications of a ten per cent, 
ichthyol ointment or with wet dressings of bichloride solution. Care 
should be taken not to bring about too rapid a cure of the kerion, as 
the inflammatory process frequently proves destructive to the fungus. 
The use of the X-rays have supplanted all other measures in the 
235 hands of Sabouraud and Noire of Paris and Fox, Adamson and Se- 
queira of London. These workers have reported hundreds of cures. 
In this country, for various reasons, the results following radiotherapy 
have not been so uniformly favorable. The massive-dose method has 
its dangers, and it should be employed only by an expert. 
Fig. 182. Model in Freiburg Clinic (Vogelbacher). 
Fig. 183. Model in Neisser's Clinic in Breslau (Kroener). 
236 Tab. 115. 
No. 184. Trichophytia profunda nuchae. Tinea Trichophytina Corporis 
Synonyms: Tinea circinata, Ringworm of the body 
Plate 115, Fig. 184; and Plate 116, Figs. 185 and 186 
This affection represents the parasitism of the tricophyton upon 
the smooth skin, as distinguished from the scalp and bearded face. As 
a general proposition, whenever a patient, usually a child, presents a 
ringed eruption which shows no tendency to symmetry, and is sharply 
localized, the chances are that it is a ringworm in the popular sense of 
the term, due entirely to a cause operating from without. Other cir- 
cinate eruptions seem to be determined by causes chiefly internal, and 
show a tendency to symmetry. The lesions, however, do not begin as 
rings, but simply as flat, scaly spots, which clear up in the centre. They 
extend at the periphery, and at the same time clear up in the inner 
aspect. The ring shows some elevation, due to inflammatory infiltra- 
tion, and in extreme cases vesicopustules may be produced. There may 
be but a single lesion, but as a rule a small number of the rings occur 
side by side in some particular locality. There may, of course, be co- 
incidental lesions at some other focus, or associated lesions on the 
hairy portions, but this is quite exceptional. 
If it were common we would hardly be justified in making separate 
clinical affections of the three forms. The rings attain a variable 
growth limit, from half an inch up to three inches in diameter. After 
this they remain stationary and have some eventual tendency to spon- 
taneous recovery. As with all circinate affections, the rings may 
coalesce to form gyrate figures, and may even coalesce to form a con- 
tinuous sheet of inflammation. Both these phenomena are seen in the 
folds, notably in the inguino-scrotal, where the affection may appear as 
the so-called eczema marginatum, with a sinuous, sharply defined, 
parasitic border. Occasionally a new ring forms within an old one. 
The patients present themselves with what is evidently a localized 
affection. There should be one or more lesions seated somewhere on 
the hand or forearm, the face or neck. These are the classical loca- 
237 tions. The lesions will be found at some particular stage of develop- 
ment, and if there are a number the eruption should be multiform. The 
various stages would be first the macular, the spots being small and 
red with fine scaling; then a ring undergoing evolution, and finally a 
larger ring, better outlined and showing perhaps some infiltration. 
The lesions usually itch considerably. Exceptionally lesions appear 
about the feet, the genitals and buttocks. In some instances the para- 
site appears to be able to penetrate into the hair-follicles, whereupon, 
instead of a ring, a solid patch is formed, composed wholly of suppu- 
rating follicles. There is a great deal of thickening, and the numerous 
openings discharging pus suggest a carbuncle. These lesions do not 
differ radically from those normally present in tricophytosis of the 
hairy regions. 
Etiology 
Tinea circinata occurs chiefly in children or young adults, and is 
now known to be due to the ectothrix form of the trichophyton, or 
large-spored fungus, which is able to cause all the clinical types. The 
other type of the large-spored fungus and the small-spored forms do 
not form ringed lesions. The extent of their pathogenicity is the pro- 
duction of small, faintly colored scaly patches. The parasite, derived 
from another patient through toilet articles, etc., or from some animal, 
makes its abode in the horny layer of the epidermis, and exceptionally 
finds its way into the rete, corium and follicles, causing clinical varia- 
tions in the lesions. 
Diagnosis 
In spite of the sharply defined clinical characteristics, the diagnosis 
should always be made with the microscope. Scrapings of the skin or 
epilated hairs, should the follicles have been involved, will, when prop- 
erly prepared with liquor potassse and glycerin, show the presence of 
the trichophyton. 
Prognosis 
Ringworm of the smooth surface has a good prognosis, and might 
even terminate spontaneously in time. 
Treatment 
This is very simple, as the fungus is superficial and easily reached, 
any of the well-known antiseptic applications, in proper strength, 
proving efficacious. If the dark stain of tincture of iodine is not ob- 
238 Tab. 116. 
No. 185. Trichophytia annularis (iris). 
No. 186. Trichophytia profunda. jected to, it makes a very useful application. Sodium hyposulphite, 
one dram to the ounce, fresh sulphurous acid, and mercuric chlorid 
solution, 1/4 to of 1%, are all very useful. Ointments of ammo- 
niated mercury or sulphur can be used with success. Whatever 
remedial agent is used, care must be taken to apply it in weaker 
strengths at first, so as to avoid a dermatitis. It is surprising to see 
the rapid disappearance of the disease, which occurs at times, after the 
use of very mild local measures. The treatment of ringworm of the 
genitocrural region (eczema marginatum) is the same as that of the 
general surface, with the exception that at times it assumes an eczema- 
tous character, and requires at first mild soothing applications. The 
sodium hyposulphite solution and fresh sulphurous acid are the best 
local measures in this variety of ringworm. 
Fig. 184. Model in St. Louis Hospital in Paris, No. 1051. Vidal's case. 
Fig. 185. Model in Neisser's Clinic in Breslau (Kroener) 
Fig. 186. Model in Neisser's Clinic in Breslau (Kroener) 
289 Tinea Trichophytina Unguium 
Synonyms: Onychomycosis, Ringworm of the nails 
Plate 117, Fig. 187 
This affection is chiefly confined to a few of the finger nails, and 
is manifested first by changes in the nail itself, principally the free 
margins. The disease may or may not extend along the nail, and 
when it does there is an accumulation of debris beneath the same. 
The tendency with the advance of the disease is for the nail to be de- 
tached. The process may extend along the sides of the nail, and excep- 
tionally the fungus seems only to stimulate the overgrowth of the nails, 
which become thickened, discolored and horny. 
Etiology 
The various forms of the ringworm fungus may attack either the 
nail itself or the nail bed, they having a special affinity for the horny 
epidermal tissues. The nails may be the only structures involved, but 
may be the means of conveying the disease to other patients. That the 
trichophyton should gather and flourish in and about the nails is not 
surprising when we bear in mind that here is a favorite rallying-place 
for microbic life of all kinds. 
Diagnosis 
The direct diagnosis is made by products scraped or otherwise ob- 
tained from the nails. 
Prognosis 
Onychomycosis is an extremely obstinate affection, because the nail 
itself interposes an obstacle to remedies. There is no tendency for the 
disease to exhaust itself, as is seen elsewhere. Despite all pains, the 
affection has been known to persist for decades. 
Treatment 
The nails may be softened in various ways-by salicylic acid, caus- 
tic alkalies, soapsuds, etc., and as much as possible should be pared 
240 Tab. 117. 
No. 187. Trichophytia unguium. 
No. 188. Trichophytia profunda barbae. away. The nail may also be scrubbed with pumice stone or even 
avulsed under local anesthesia. Parasiticides should be used freely 
and alternated. Tincture of iodine is as efficacious as anything. Wet 
dressings may be applied under finger stalls, using bichloride of mer- 
cury, hyposulphite of sodium, etc. 
Fig. 187. Model in Lassar's Clinic in Berlin (Kasten). 
241 Tinea Barbae 
Plate 117, Fig. 188 
When this affection occurs on the bearded area of a man who 
shaves regularly and who is of cleanly habits it is clinically an insig- 
nificant affection so far as appearances go, although it may be very 
obstinate. It may behave much like tinea circinata; or it may give 
rise to hardly any symptoms beyond loosening of a few hairs (this 
behavior is common in cases which have received a good deal of treat- 
ment). On the other hand, when the beard is abundant or in persons 
who shave but seldom, the affection proceeds unchecked and the para- 
site sets up deep-seated folliculitis and perifolliculitis and the skin be- 
comes irregularly nodulated. As in folliculitis in the scalp and on 
the smooth skin, the openings may discharge freely, so that crusts are 
produced. Sometimes beneath the latter we find a raw granulating 
surface. 
In the superficial type already mentioned we may see multiple 
lesions-macules and rings-which differ but slightly from those of 
tinea circinata. The hairs loosen, but the same thing occurs to the 
lanugo hairs in the latter form. If the patient had been shaving him- 
self when the disease was contracted, he is compelled to discontinue 
the custom and so presents himself with a growth of heard. As soon 
as he is told to have it closely clipped, the phases of the disease may 
readily be studied. The hairs are by no means always involved at the 
outset, and it may be difficult to find a loose one for microscopic study. 
There is a steady tendency, however, to involve the follicles and de- 
velop the deep-seated phase of the disease. The latter usually develops 
from the superficial form and doubtless as a result of neglect. The 
subject, quite unable to shave, goes about with a beard of more or less 
growth, and the stubble on the face acts as a constant irritant. In a 
few cases only a sharply circumscribed patch of folliculitis is formed, 
the rest of the bearded face and neck being normal. As a rule, how- 
ever, a large part of the bearded area participates, and there may be 
a tract of nodules reaching from ear to ear. The deeper the follicles 
242 the larger the nodules; hence these may be relatively small above the 
jaw line and attain their greatest dimensions at the lower border of the 
beard. The latter becomes matted with dried secretion and a condi- 
tion results highly favorable to secondary infection. However, the 
•tendency of the hairs to loosen and come away acts as a corrective; 
and while spontaneous recovery is hardly possible, the unfavorable 
disposition is antagonized in this manner. 
Etiology 
This affection is limited to men, and its familiar name of barber's 
itch appears to be justified, as it is largely contracted from the com- 
mon shaving-brush. The large spored trichophyton which causes tinea 
circinata is usually responsible. There is no special mechanism in- 
volved, as kerion-like lesions occur in all localities. 
Diagnosis 
This, if not self-evident, is easily made with the microscope, 
Prognosis 
The prognosis is about the same as in tinea capitis, as several 
months may be required to eradicate the disease. 
Treatment 
Epilation of the affected hairs is of the greatest importance, and 
greatly shortens the duration of the disease. Frequent shaving should 
be practised, and the spread of the disease checked by the inunction of 
the salve used, in the non-affected as well as the diseased areas. Any 
of the parasiticide ointments are useful, but ammoniated mercury in 
from 5% to 10% strength, is by far the best local application. Precipi- 
tated sulphur in the form of a 10% ointment is also very useful. Nor- 
man Walker uses a 10% oleate of copper ointment. The parts should 
be frequently washed with soap and hot water. Whatever ointment 
is used should be well rubbed in twice daily, and more frequently in 
severer cases. The treatment should be persisted in for several weeks 
after apparent cure, as recurrences often occur. The X-rays are very 
seldom indicated, as the disease is much more amenable to treatment 
than is ringworm of the scalp. 
Fig. 188. Model in Neisser's Clinic in Breslau (Kroener). 
243 Tinea Versicolor 
Synonyms: Pityriasis versicolor; Chromophytosis 
Plate 118, Fig. 189 
This parasitic disease is one of the most typical local derma- 
toses because of its tendency to begin over the thorax, and especially 
in front, and its characteristic range of colors, which vary from yel- 
low to brown. As it seldom produces sensations, it is often over- 
looked, especially among those who have little opportunity to undress 
or see themselves in the glass. The affection thus often has the op- 
portunity of extending down the arms or down the trunk to its 
lower limits. The lower extremities are usually exempt, as is also 
the face. The lesions are originally macules, small and very irregu- 
lar as to size and shape. The latter, however, is almost invariably 
polyhedral or angular. Unlike most parasitic affections, there is ab- 
solutely no tendency here to form rings. These initial blotches quickly 
join together to form sheets, in which all semblance of the originals 
is lost. This feature is chiefly in evidence in the region of selection, 
to wit, the anterior thorax. All the outlying territory is occupied 
by the separate blotches, which, however, communicate in part, leav- 
ing a reticulum, the meshes of which are represented by normal in- 
tegument. There is more or less desquamation of the branny sort, 
hence the synonym pityriasis versicolor-two terms which have a 
diagnostic significance. The disease has a marked tendency to attain 
a certain degree of growth, but none whatever to spontaneous retro- 
gression. 
Etiology 
This disease simply represents the parasitism of a fungus, the 
microsporon furfur, which is easily seen through microscopes of low 
powers. Aside from neglect of its presence by the patient, which is 
decidedly contributory to its progress, certain predisposing factors no 
244 Tab. 118. 
No. 189. Pityriasis versicolor. doubt exist. It presumably flourishes more readily on consumptives 
on account of their night-sweats. It is mildly contagious. 
Diagnosis 
This is readily made with the microscope. Skin-scrapings should 
be mounted in a mixture of equal parts of liquor potassae and 
glycerin, and after a brief interval the mycelium and spores are 
readily seen. In the absence of a microscopic test, it must be remem- 
bered that chloasma and vitiligo may be simulated by the disease 
when it appears on the forearm and hands. Mistakes of this sort are 
always prevented if the patients disrobe. 
Prognosis and Treatment 
These are the same for both tinea versicolor and its congener 
erythrasma; for the two may be said to form a group disease. With 
no tendency whatever to recover spontaneously, both are readily 
amenable to treatment, which, however, must be persistent if a per- 
manent cure is expected. The parasite is readily destroyed by a 
number of mild preparations; and, as in the case of scabies, it is the 
technique rather than the particular remedy which counts. The in- 
tegument should first be prepared by a warm bath and soap fric- 
tions; after which a white precipitate, sulphur or naphthol ointment 
should be rubbed thoroughly into the skin. Bulkley regards hypo- 
sulphite of soda in water (5i-5ii to §i) as one of the best remedies 
for this affection. It may be well to use the same measures to pre- 
vent reinfection as obtain in scabies; also, to rectify any constitu- 
tional peculiarity. 
Fig. 189. Model in Dermatological Department of the Municipal Hospital 
in Cologne on Rhine. Prof. Zinsser. 
245 Erythrasma 
Plate 119, Fig. 190 
This is an obscure parasitic disease, which is limited largely to 
the genitocrural folds and axillae. It may, of course, be simulated 
by a variety of affections which attack the same localities; and as the 
parasite which has been isolated from its lesions is difficult to rec- 
ognize and as its status when found is by no means fixed, it is read- 
ily apparent that a positive diagnosis of erythrasma is not always 
made. Some experienced men have never seen a case in which they 
felt called upon to make such a diagnosis, although several other 
affections when fading out may answer the description of erythrasma. 
The disease has been known since 1859, but years elapsed before 
it became universally recognized as an entity; and even now a few 
authorities regard it as an aberrant local form of one of the more 
prevalent parasitic diseases. 
At its very outset the disease presents a unique appearance, so 
that if seen early the diagnosis might present no obscurity. Thus 
copper-colored or orange spots begin to appear in the selective areas, 
which greatly resemble, save in the tint, the earliest manifestations of 
tinea versicolor. These soon fuse together, producing a continuous 
discoloration. In certain cases the eruption extends from the original 
foci upon the trunk; but as a rule separate plaques do not appear in 
the outlying area. Instead, the entire patch at the armpits or in- 
guino pubic border extends en masse. This is somewhat unusual, 
and adds to the difficulty of diagnosis. The parasite of the disease 
seems to settle down to life upon its host; for while the eruption 
reaches a certain limit there is no tendency whatever toward resolu- 
tion. The same behavior is also seen in other parasitic diseases. 
Etiology 
There appears to be no doubt that this affection represents the 
parasitism of the microsporon minutissimum, whose nearest congener 
is the parasitic cause of tinea versicolor. Its status is much less as- 
246 Tab. 119. 
No. 191. Pityriasis rosea 
No. 190. Erythrasma sured, however, than that of the more familiar fungi. It is also 
alleged that the minutissimum may exist in the epidermis as a mere 
saprophyte. 
Diagnosis 
Two classes of affections have to be borne in mind in diagnosis: 
first, those due to other fungi, and second, affections which elect the 
same localities as erythrasma. Among the former, tinea versicolor 
alone need be considered. It is quite conceivable that the two affec- 
tions could simulate each other, and as a matter of fact they have 
done so. The presence or absence of the fungus of tinea versicolor 
should determine the diagnosis. On the other hand, a half-cured 
ringworm of the body or seborrheic dermatitis readily simulate ery- 
thrasma. If a satisfactory history cannot be obtained, it might not 
be possible to make a diagnosis, as the fungus of erythrasma is gen- 
erally demonstrated with considerable difficulty. 
Prognosis and Treatment 
These coincide so thoroughly with those of tinea versicolor that 
a separate account will not be necessary. 
Fig. 190. Model in Riehl's Clinic in Vienna {Henning}. 
247 Pityriasis Rosea 
Synonyms: Gibert's disease, Pityriasis maculata et circinata 
Plate 119, Fig. 191 
This somewhat rare affection possesses a well-marked clinical in- 
dividuality, but there has always been a doubt as to whether it is an 
independent affection. First isolated, described and named by Gibert 
in 1860, it was pronounced by Hebra to be only a mitigated form of 
ringworm, herpes tonsurans maculosus, in which the parasite, for 
some reason, eludes discovery. Bazin emphasized the fact that it 
occurs in two principal types of efflorescence, and termed it pityriasis 
maculata et circinata. It is assumed that the rings develop from the 
macules. In more recent years a close resemblance has been noted 
in this and other respects to seborrheic dermatitis. The element of 
uncertainty about pityriasis rosea lies wholly in the fact that a num- 
ber of superficial dermatoses may either regularly or incidentally ap- 
pear in the double form of macules and rings. 
In order to be entitled to the name pityriasis, the affection neces- 
sarily appears as a superficial reddish area, which affords a fine 
branny desquamation. So slight is the erythema that the lesions are 
usually of a pink or rose hue, such as is presented by some eruptions 
when they first appear or before their disappearance. This peculiar 
shade serves largely to characterize the affection. Aside from a fawn 
tint seen as the lesions pale out, and which is also characteristic, there 
is little of the play of colors shown at times in the majority of der- 
matoses. 
The affection begins as a macular or maculopapular efflorescence 
over the body, which may be thickly or sparsely disseminated, and 
either generalized or limited to certain members. Some observers 
have noted a slight constitutional reaction in advance of the efflores- 
cence-slight fever, malaise-and during the evolution of the disease 
the superficial lymph-nodes may become enlarged and tender. This 
does not necessarily imply that the eruption is an expression of a 
constitutional or internal affection. 
248 In rare instances the eruption may remain macular throughout. 
Under these circumstances some lesions may sometimes attain a di- 
ameter of three-fourths of an inch, and may pale out without any at- 
tempt to clear up in the centre, although a few rings may be discov- 
ered. The affection may even appear almost wholly as small ma- 
culopapular lesions, in which case attempts at diagnosis will prove 
disconcerting. 
In the great majority of cases the macules, as they broaden, 
promptly assume the circinate form, so that the efflorescence consists 
chiefly of rings. These are at first small, but, like other circinate 
lesions, tend to increase at the periphery as they undergo an involution 
within. The limit of growth attained is seldom over an inch in di- 
ameter. The ring, upon attaining its growth, undergoes involution, 
paling out immediately or after first breaking up into macules. Rings 
frequently coalesce, forming gyrate figures, which in turn pale out. 
As the pink lesions undergo involution, a fawn color appears before 
the normal hue of the skin is restored. 
The clinical picture is much complicated by the fact that, as a rule, 
the efflorescences appear in crops, so that all the forms of early and 
late lesions may be seen side by side. 
The areas of preference to be involved are the anterior aspect of 
the trunk, especially the abdomen, the sides of the neck and the but- 
tocks. It may occur on the arms and thighs, but is almost never seen 
on the exposed parts or on the lower legs and feet. It seldom runs 
its course in less than a fortnight, and may last for weeks and even 
months, depending on the number of crops of eruption. The affection, 
rare though it be, has even occurred a second time. Practically there 
is no itching, so that scratch lesions are absent. The spots some- 
times show a deeper hue, suggestive of irritation. 
Etiology 
No parasite has ever been found, and until one is isolated we 
cannot feel sure of the nature of the affection. The evidences of parasit- 
ism are, aside from its grosser clinical features, first, an alleged initial 
plaque, a mother lesion, said by some authors to occur low down upon 
the abdomen. The existence of this is open to dispute. Second, occa- 
sional multiple incidence in families. Third, the reported claims that 
cases diagnosticated as pityriasis rosea might have been called with 
equal propriety mild forms of ringworm or seborrheic dermatitis. This 
confusion is much more likely to arise in sharply localized forms; and it 
has even arisen between pityriasis rosea and eczema marginatum, the 
249 latter a form of ringworm. On the other hand, there is, in the widely 
disseminated form, especially when maculopapular throughout, a con- 
siderable resemblance to erythema multiforme of the mildest type. 
The microscope reveals only a very slight inflammation of the skin, 
not even severe enough to cause transudation, and hardly more than a 
hyperemia. It is therefore at present almost impossible to formulate 
any theory of the nature and causation of the disease. 
Diagnosis 
Despite the above-mentioned confusion as to the nature of the dis- 
ease, its diagnosis is very easy, and its great benignity makes an in- 
fallible diagnosis of no practical value. Like any affection of its type, 
it could be mistaken, as it sometimes is, for syphilis. Its absence 
from the face and hands, and the absence of other evidences of syphi- 
lis, should prove conclusive, and its extremely superficial character 
should differentiate it not only from syphilis, but from psoriasis, 
seborrhea, and ringworm. Failure to find a fungus does not abso- 
lutely exclude the latter. 
Treatment 
In a self-limited disease, which presents neither disfigurement nor 
itching, there is little interference called for. If it continue to reap- 
pear in successive crops only constitutional treatment will be indi- 
cated. None has ever been suggested, save antirheumatic remedies 
used in erythema multiforme. The usual management for a pro- 
nounced case is an alkaline or antiseptic bath, followed by salicylic 
ointment dressings, the success of which in some cases suggests a 
parasitic factor. 
Fig. 191. Model in Neisser's Clinic in Breslau (Kroener). 
250 Tab. 120. 
No. 193. Actinomycosis. 
No. 192. Anthrax (Pustula maligna). Anthrax 
Synonym: Pustula maligna 
Plate 120, Fig. 192 
This affection must be carefully distinguished from ordinary car- 
buncle. Both are termed anthrax and carbuncle, and both can be 
malignant. Malignant pustule is one of the local expressions of a 
general disease-which, however, is localized at first-caused by the 
anthrax bacillus. The pustule, which results from direct inoculation, 
is usually single, but if the abraded surface which becomes inoculated 
is extensive, a number of pustules may result. The lesion is at first 
a papule or tubercle and undergoes central necrosis, a bleb forming 
at the apex. An indurated areola forms about the pustule, and the 
central necrosis may increase in size. New vesicles may form at the 
periphery. The classic descriptions of a mature malignant pustule 
have mentioned a depressed black gangrenous centre surrounded by 
a ring of bullae, and beyond this an inflamed indurated zone. The 
lymphatics and nearest lymph-nodes are involved, and there is often a 
marked constitutional reaction. This lesion, however, represents an 
extreme type, and in some cases the pustules are relatively small, 
the gangrenous centre is not marked, there is no systemic reaction, and 
the general appearance does not differ greatly from that of an ery- 
thema pustule or boil. 
Etiology 
The affection is enumerated among the diseases of occupation- 
wool sorters, dealers and handlers of hides, butchers, etc. The occu- 
pation is often an aid to diagnosis. The disease is either self-trans- 
mitted by the contaminated fingers or is inoculated by insects. The 
pustules usually appear on the exposed regions, and in most cases the 
affection remains localized. General infection may be due to the bacil- 
lus anthracis, or perhaps also to the germs of ordinary septicemia. The 
bacillus, however, sets up other forms of disease without reference 
251 to the pustule. One is malignant edema, which affects exposed parts 
and tends to become gangrenous. The other is splenic fever, the 
results of general infection from within. The pustular form may 
pass quickly into malignant edema before the pustule can develop. 
Prognosis 
It was formerly taught that this affection was highly fatal. At 
present we know that the reverse is true. Most cases, perhaps, recover, 
even irrespective of the treatment used. It is probable that the older 
writers knew only the more malignant forms. 
Diagnosis 
The milder and initial forms naturally may escape diagnosis, which 
if not evident from the history and occupation (the incubation period 
is very brief, one to three days) may be clinched by a bacteriologic 
study of the serum of the blebs. 
Treatment 
It was once believed that heroic measures were imperative, such as 
free incision with immediate application of pure carbolic acid or 
injections of strong antiseptics or the free use of the thermocautery. 
At present excellent results are obtained with constitutional measures 
and mild antiseptic dressings. The internal remedies are much the 
same as those used in erysipelas and gangrene. 
Fig. 192. Model in Neisser's Clinic in Breslau (Kroener). The patient 
was a shepherd, whose case was published in full by Dr. Hermann in 
the Arch. f. Dermatol., vol. Ixii, No. 213. Eight days before the erup- 
tion appeared he had scratched his skin on a piece of bone while cut- 
ting up a dead cow. Most of the pustules corresponded to the scratch- 
mark. There was extreme swelling of the axillary gland. He died in 
3 days. 
252 Actinomycosis Cutis 
Plate 120, Fig. 193 
The ray fungus, which enters the system through the mouth and 
may cause deposits in almost every region of the body, commonly 
produces its manifestations about the lower jaw, face and neck, due to 
the fact that it lodges in carious teeth. In this cervicofacial area there 
may be cutaneous lesions, usually associated with and secondary to 
lesions in the more deeply seated structures. Even when superficial, 
the deposits which form are really subcutaneous, and the skin proper 
is not involved until softening, rupture and discharge have occurred. 
Firm, nodular formations appear beneath the skin, which becomes 
red or livid. After a time the lumps show softening, the skin is broken, 
and a purulent discharge begins, and this may often be seen to contain 
masses of fungi, even with the naked eye. In the meantime new 
nodules continue to appear, new openings result, and sometimes ex- 
uberant granulations are produced. Considerable loss of substance 
may occur as ulcers and sinuses. Some authors distinguish two clin- 
ical types of the mature disease, one of which resembles a carbuncle 
in having a number of small openings, while the other tends to ulcera- 
tion and fungoid proliferation. 
Authors mention no tendency to spontaneous recovery, although 
the area finally involved may attain only a limited size. 
Etiology 
The ray fungus is believed to come from grain, hay, straw, etc., 
so that the affection it causes is, roughly speaking, an occupational 
disease which occurs in stablemen, bakers, millers and the like. Cattle 
and horses are much more frequently attacked than man, from obvi- 
ous reasons. Since the fungus must lurk in the mouth, at times it is 
possible that it may be transferred by kissing, or by pipes, etc. 
Diagnosis 
Actinomycosis naturally resembles malignant growths and granu- 
253 lomata, but the external conditions, location and presence of the fungus 
should be sufficient to prevent confusion. 
Prognosis 
Aside from having no tendency to self cure, the disease may ter- 
minate in pyemia from secondary pyogenic infection. 
Treatment 
Iodide of potassium with symptomatic surgical treatment sums 
up the management. The drug is believed to be surely curative only 
in pure cases; should the lesions become infected with pyogenic cocci, 
not much should be expected of it. 
Fig. 193. Model in Neisser's Clinic in Breslau (Kroener). 
254 Tab. 121. 
No. 194. 195. Sporotrichosis. Sporotrichosis 
Plate 121, Figs. 194 and 195; Plate 122, Figs. 196 and 197 
This parasitic granulomatous disease occurs both in mankind and 
domestic animals, and in the horse is known by some as pseudo-farcy. 
Belonging as it does to the infectious granulomata, it bears consider- 
able resemblance to other members of the group, notably tuberculosis 
and syphilis. The affection has only been isolated since 1898, but is 
undoubtedly old, and hitherto described erroneously under some other 
name. In so far as it has been contracted by stablemen, it may 
have imposed itself as farcy. We have the assurance of veterinarians 
that in the horse it frequently passes for farcy. The fact that it re- 
sponds to potassium iodide would readily cause it to be recorded as 
syphilis. It is potentially at least a general affection, attacking many 
kinds of tissue. Over one hundred cases have been described, and as 
these show a high degree of polymorphism, attempts have been made 
to group them into types. Of these the first to be named is the local- 
ized type. This begins as a local inoculation lesion comparable with 
a chancre, but often too slight to be visible. The characteristic lesion 
of this type is a nodular lymphangitis in which the lymph vessel be- 
comes the seat of a series of subcutaneous nodules. The lymph nodes 
participate but slightly. The initial lesion may appear on the hand, 
or some less exposed locality. A single dermic nodule may appear, 
and may or may not undergo softening and ulceration; in some cases 
the initial lesion may be multiple, consisting of a group of small 
nodules. In other cases, as when an inoculation wound has been made, 
the latter heals up as usual so that no local lesion develops. The 
first evidence of the disease is now a subcutaneous nodule on the 
forearm. In numerous cases in which inoculation has doubtless oc- 
curred no trace of a lesion or port of entry is found. The lymphatic 
vessels usually show induration to the touch. In reference to the 
nodules which appear along the lymphatic vessel or vessels, these 
succeed one another until a series of two, three, four, five or more 
have formed. While as a rule these are not large and show some 
uniformity in size, in certain cases one or more of the nodules may 
255 grow to a notable size, forming large tumors. Either these nodules 
do not soften or they behave much like cold abscesses. This local type 
is evidently only an abortive phase of the disease. In most cases 
the affection is disseminated over the limbs and trunk in such a manner 
that the process of distribution is obscure. In the exceptions it seems 
to have originated in some particular locality from which it becomes 
generalized. 
There appear to be two, perhaps three separate types of the dis- 
seminated form, one of which may be regarded as a combination of 
the other two. In the first there is no ulceration, which implies that 
the lesions are very indolent and relatively deep-seated. The nodules 
are developed in the course of the lymphatics. In the second or ulcer- 
ated type, the lesions may be both superficial and deep, the granu- 
lomatous infiltration involving the skin alone or in association with 
the subcutaneous tissues. When ulceration appears there results a 
great polymorphism of lesion, due largely to the depth of the process. 
The most superficial may be no more than vesicopustules suggesting 
ringworm; next in severity come ecthyma-like lesions, then superficial 
ulcerated gummata and deep ulcers. In some cases there is an acute 
element present-an erysipelatous lymphangitis, hot abscesses instead 
of cold ones, and in very rare cases burrowing abscesses. It is this 
location in the lymph vessels, with occasional implication of the skin 
and subcutaneous tissues, which agrees so closely with farcy. The 
mixed form is simply the association of the non-ulcerous and ulcerous 
forms. In rare cases there are lesions of the mucosae, bones and 
viscera. 
In addition to what has already been said of the manifestations, it 
may be stated that the average patient presents himself with multiple 
ulcerated nodules scattered well over the surface to a number which 
may be as high as fifty and upwards, but in the earlier stages may be 
much less. The ulcers depend upon the size of the nodules and repre- 
sent the softened centres; there is no constant tendency to spread nor 
to heal, but in certain cases, corresponding to what we see in syphilis 
and tubercle, the ulcers may be undermined or fungating. If the 
affection is known to have begun as a particular lesion in the hand, 
for example, this lesion may present a vegetating surface, and when 
this occurs the secondary ulcers may show a similar tendency. 
A certain number of ulcers seem able to cicatrize, while others 
undergo a certain amount of involution, but are unable to cicatrize. 
Despite the great polymorphism of lesions and the atypical forms, all 
authors agree that the disease as a whole is of unusual uniformity. 
256 Tab. 122. 
No. 196. Sporotrichosis verrucosa. 
No. 197. Sporotrichosis epidermica. Etiology 
The disease is known to be caused by the parasitism of a sporo- 
thrix. The lesions contain both spores and mycelium, which after an 
incubation period of from six to twelve days in the host produces 
typical tissue of infectious granuloma. The fungus is known to exist 
on fruits and vegetables, and since it attacks many species of animals 
it may be transmitted from them directly or through the medium of 
insects. It is quite likely that eating uncooked fruit, etc., may cause 
general infection. Those with diminished general resistance are more 
likely to be attacked than the robust. 
Diagnosis 
A large number of lesions in a subject in fairly good health should 
suggest the possibility of sporotrichosis. A narrow ulcer in a rela- 
tively large amount of granulomatous tissue is mentioned as a diag- 
nostic criterion; also a double ulcer in a single nodule-for the bridge 
between the two does not melt away as in some similar affections. It 
is also stated that the pus is readily inoculable. Since a living cause 
is actually known to exist, it is incumbent to demonstrate its presence, 
which may be done both by culture and sero-diagnosis. The latter 
is an agglutinating test. Both these methods are trustworthy and 
check each other. 
Prognosis 
In but two in over one hundred cases have patients died of the 
disease, which in its most virulent form is fatal. But there is abso- 
lutely no tendency to spontaneous recovery at any stage. Despite the 
fact that patients are not usually robust when attacked, their general 
health does not seem to suffer much. 
Treatment 
This may be summed up in one word, iodine, an excellent example 
perhaps of selective chemotropic action of an element upon a parasite, 
or upon the tissues which it attacks. Iodide of potassium is given 
internally in full doses, while the ulcers are treated with the tincture 
of iodine. 
Figs. 194 and 195. Models in the St. Louis Hospital in Paris (Baretta). 
Nos. 2531 and 2557. De Beurmann's case. 
Figs. 196 and 197. Models in St. Louis Hospital in Paris (Baretta). No. 
2589. De Beurmann and Gougerot's case. 
257 Scabies 
Plate 123, Fig. 198; Plate 124, Figs. 199 and 200 
This affection represents the effects of the parasitism of the itch 
mite (acarus scabiei), and is highly transmissible. The essential le- 
sions are due to the burrowing of the parasite, which causes papules 
and vesicles, and to these are added all the consequences of scratching, 
including secondary infections. The distribution of the lesions does 
not seem to be due to any decided preference on the part of the 
acarus, which is equally at home on any part of the surface save the 
head and face, but rather to the fact that it is passively carried by 
the patient on his clothing from one region to another. The burrows 
first appear as a rule on the hands, fingers and wrists, and from this 
locality are carried to others, and also to other individuals. Thus 
if an infected woman has a young baby, the eruption may first appear 
about its feet and nates, the exposed parts which come most in contact 
with the mother's hands as she carries it. The hands of patients 
readily transfer the parasite to the penis, nipple and other parts regu- 
larly handled, and also to towels and various utensils from which 
others are contaminated. These and similar acts of transmission, 
however, are usually overshadowed by the fact that in a majority 
of cases transmission appears to have occurred from sleeping on in- 
fected bedding or with infected subjects. As a result, lesions are 
equally prone to appear on the lower portion of the body, the but- 
tocks, thighs, feet and ankles. The common occurrence of lesions on 
the elbows and anterior folds of the axillae is not so readily explained, 
but as already implied there appears to be no evidence that the para- 
site deliberately seeks out particular localities for breeding. 
There is no predisposition to scabies, but the habits and status of 
the patient answer in this respect. In very uncleanly subjects the 
parasitism flourishes unchecked, for the organism puts up no defense. 
The more cleanly the patient and the oftener the clothing and bedding 
are changed the smaller the inroads of the disease. In anesthetic 
258 Tab. 123 
No. 198. Scabies lepers who cannot itch the latter is said to make far greater headway 
than in any other class of individuals, so that the patients may be 
literally covered with lesions and the skin completely riddled with 
burrows. This would seem to show that the incessant scratching of 
the ordinary subject and the resulting reaction do exert considerable 
influence in holding the eruption in check. The mites on the surface 
are brushed off, burrows torn open, etc. 
In ordinary scabies reinfection is constantly going on from the 
bedding and clothing. Were it not for this fact, ordinary care and 
cleanliness might prevent the parasite from gaining a foothold. The 
reinfection explains why patients are seldom or never able to cure 
themselves with proprietary applications or remedies furnished by 
apothecaries for the itching. 
Etiology 
The cause of the affection is single, there being but one known 
species of parasite. As already stated there is no natural predisposi- 
tion or immunity. Other species of acari from domestic animals 
sometimes gain access to the human skin, but do not thrive therein. 
The female is the only parasite, although males are of course hatched 
in the burrows. The latter are made by the female to deposit her ova 
which is done throughout the act of burrowing. When the process is 
complete the female dies. The mite simply penetrates the horny layer 
and does not go through the rete. Its presence sets up intense itching 
and independently of any scratch lesions there occurs an inflammatory 
reaction usually expressed as a vesicle or small bleb which readily 
becomes purulent. The ova first deposited hatch first; a larval stage 
is reached in less than a week and about two weeks more are requisite 
before the young females are able to leave the burrows and begin new 
ones. 
Scabies has an epidemiology whenever men are closely crowded 
together into sleeping quarters. Barracks and camps readily become 
infected, and local designations are sometimes applied to these small 
pandemics. 
Diagnosis 
Many diagnostic features have already been touched upon. The 
burrow, which in theory should be conspicuous and pathognomonic, is, 
as a matter of fact very seldom encountered. The individual burrow 
may not exhibit any inflammatory reaction and when one is present 
it is in the wake of the parasite. If no vesicles or pustules form in 
259 its course the burrow has nothing to render it visible save the feces 
of the mite, which appear as dark dots, and perhaps some specks of 
dirt adherent to the roughened epidermis. The burrow varies greatly 
in length. Some present one of a quarter of an inch, but it is not 
common to see them much longer. As a rule they present a broken 
or wavy line. That so few burrows are seen is due chiefly because 
scratching tears them open while the vesicles and pustules tend to 
efface them. 
In practice the eruption of scabies is highly polymorphous, resem- 
bling a scratched eczema, especially on the hands, where it may greatly 
resemble some trade eczema. On stripping the patient the tendency 
to be localized in certain areas is unmistakable-the folds of the 
wrists, webs of the fingers (elbows, front folds of axillae, nipples), 
dorsum penis, buttocks-especially the cleft,-ankles, etc. In very 
mild and very severe cases alike the diagnosis may be somewhat diffi- 
cult. A few isolated papulo-vesicular formations on the hands, with 
some other preferred location and the occupation (actor, commercial 
traveller, etc.), or history of sleeping in a strange, unclean bed will at 
once suggest scabies. In the absence of absolute proof (recognition of 
burrows, etc.) the effects of treatment which should cure scabies in a 
few days, will leave no possible doubt as to the nature of the affection. 
In a very severe case in a careless subject, in which large flattened 
crusts of dried pus, resembling impetigo contagiosa, may be present, 
with stains of older lesions, it may be necessary to exclude a variety 
of affections, including syphilis, which of course may coexist. 
When authorities speak of making diagnosis from the presence 
of the burrows, they state an ideal rather than that which actually 
occurs in practice. After the diagnosis has been made from the dis- 
tribution, etc., a search may be made for burrows for the sake of com- 
pleteness; but in the majority of cases no typical ones are found- 
only dubious remnants. Failure to find them does not weaken the 
diagnosis. 
Prognosis 
Despite the familiar expression, "seven years' itch," scabies has 
no tendency to spontaneous recovery. When intelligently treated the 
prognosis is of the best. It is not known that any cases have ever 
refused to recover promptly under proper treatment and prophylaxis. 
Treatment 
Under ideal conditions it is possible to cure scabies in twenty-four 
260 Tab. 124, 
No. 199. 200. Scabies. hours, although a somewhat longer time should perhaps be devoted 
to the task even under the most favorable conditions. Treatment of 
this sort can only be carried out in hospitals with the aid of trained 
nurses and attendants. The patient enters the hospital, taking with 
him clean underclothing. He is stripped and bathed and scrubbed 
from head to foot with hot soapsuds, which soften the cuticle. Green 
soap is often used for this purpose and common kitchen or laundry 
soap answers well. Simple mechanical treatment of the skin is of 
great value, for it aids in breaking up the burrows. This is carried 
out with the flesh brush. After this preliminary treatment, which in 
itself may suffice for cure, a parasiticide is applied, usually a sulphur 
ointment, which is rubbed into every portion of the surface, even if 
no lesions or itching are present, with the exception of the head and 
face. A second treatment is usually given on the following day, despite 
the fact that the first session is sufficient to cure most cases. In very 
old, obstinate, extensive cases, or when for any reason the treatment 
cannot be carried out with necessary rigor, the treatment is repeated 
a third or fourth time. Throughout the period of treatment, the pa- 
tient wears a special suit of underwear, day and night, removing it 
only for treatment. This prevents reinfection from the bedding 
and clothing. The benefit is first apparent in the cessation of itch- 
ing. The eruption cannot show any improvement, and may even ap- 
pear to be aggravated if secondary eczema is present, while sulphur 
itself may set up a slight dermatitis. Hence it is sometimes advisable 
to apply soothing measures suitable to eczema and dermatitis as soon 
as the necessity for sulphur is past. 
All treatment of scabies when these favorable conditions do not 
obtain must be an approximation of the preceding. A patient who 
must be treated at home will first seek to prevent reinfection by pro- 
viding special bedding and underwear. The applications he can make 
himself or have made by a relative or attendant. To make up for the 
technical shortcomings, he can eke out the treatment by taking sulphur 
baths at home. Or he can have one or more sulphur vapor baths, 
preferably at a regular medicated bath establishment. 
If conveniences or opportunities to use them are wanting, or if 
the case is a very mild one, it may be necessary or advisable to depend 
on ointments. In such cases it is best to use some parasiticide other 
than sulphur, which is by no means the most effective but is used 
largely because expedient. Storax, Peruvian balsam and betanaphthol 
are all serviceable for the purpose and may be given alone or in 
combination. 
261 Here is the formula for the Ungt. Contra Scabiem used at the New 
York Skin and Cancer Hospital: 
Styracis 5iv 
Saponis viridis 5iv 
Ungt. picis 5ii 
Zinci oxidi 5ii 
Cerae 5iii 
Sulphuris sublim 3v 
Cretae preparatae 3iv 
Adipis §iiss 
M. et ft. ungt. 
Sherwell recommends the employment of powdered sulphur and 
directs his patients, after taking a warm bath, to distribute a spoonful 
of flowers of sulphur between the bed sheets. This treatment is con- 
venient, cleanly, and in certain cases quite effective. 
Fig. 198. Model in Freiburg Clinic (Vogelbacher). Extraordinary, 
numerous and very characteristic burrows in a child, five years of age. 
Typical pustules in children's itch. 
Figs. 199 and 200. Models in Freiburg Clinic (Johnsen) 
262 Tab. 125. 
No. 202. Pediculosis vestimentorum. 
No. 201. Pediculosis capitis; Eczema impetiginosum. Pediculosis Capitis 
Synonym: Phthisiasis capitis 
Plate 125, Fig. 201 
The parasitism of the head louse may exhibit nothing more than 
pediculi and nits in the hair, itching and perhaps scratch marks. This 
may be termed the mild form of the disease; the severer types, however, 
are quite different. Very often we see especially in children a grouping 
of lesions, at the occiput especially and a secondary infection of the 
scratch marks with ordinary cocci of suppuration which leads to the 
formation of thick crusts at the occiput and nuchal region, and enlarge- 
ment of cutaneous lymph nodes. Both these forms are sufficiently 
common. There is however a third form, seen only where overcrowd- 
ing, misery and absence of all sanitation are coexistent. This type of 
pediculosis is, at times, hardly recognizable as such even though it be 
the most cumulative form. The hairs may be saturated with serum 
or pus and the condition of long hair, matted into a sort of straight 
half rigid queue and abounding with lice and nits has been known for 
ages as plica polonica. 
Etiology 
It is enough to know that a special type of pediculi is parasitic in 
the human head hair upon which it breeds, its ova being found on the 
hairs while the louse travels over the scalp and readily passes, directly 
or indirectly, to the scalp of others. The subject of the phylogeny of 
the head louse has not been much studied; we do not know why it is 
parasitic to the scalp-hair only. It may be found in the hair or head- 
covering of any subject, however select in their habits and associations. 
Diagnosis 
Suspects are readily recognized-usually young girls or young 
women. Diagnosis must be proved by finding lice or nits in the back 
of the head or behind the ears. The former will be attached to hairs at 
263 considerable distance, perhaps, from the roots. The lens must at times 
be used freely to distinguish lice from epithelial products. 
Treatment 
All pediculi and ova must be destroyed or removed en masse. Sim- 
ple cleansing alone does not suffice. Some agent must be employed 
which is directly a parasiticide. "White precipitate ointment, solution of 
bichloride of mercury, larkspur, or kerosene oil are all effective. If 
the latter is used it should be diluted with linseed oil and the head thor- 
oughly soaked with it two or three times during the day and left 
wrapped in a towel for at least twenty-four hours. The head should 
then be washed and the crusts removed. For excoriations of the scalp 
a boric acid ointment may be used. An important part of the treat- 
ment is the removal of the nits. Acetic acid should first be applied to 
the hair, as this dissolves the glutinous material fixing the nit to the 
hair. When no longer adherent, the nits are readily removed with a 
fine tooth comb. The hair should be held by the ends and combed 
toward the scalp. In severe cases, especially in institutions, it is best 
to have the hair clipped close to the scalp. 
Fig. 201. Model in Freiburg Clinic (Johnsen). 
264 Tab. 126. 
No. 203. Melanodermia e pediculis vestimentorum. 
No. 204. Maculae caeruleae (Ulcus molle elevatum, Bubo inguinalis). Pediculosis Vestimentorum 
Synonym: Vagabond's disease 
Plate 126, Figs. 202 and 203 
This affection, also but not correctly termed pediculosis corporis 
(for pediculosis pubis also occurs on the body at times), is a form of 
parasitism in which the lice live and breed in the clothing, from which 
they go forth to feed on the skin. But for the fact that exceptionally 
pediculi lay their ova among the fine hairs of the body, they might 
almost be classed among parasites which do not dwell upon the same. 
Their relationship to the clothes is apparent in every connection- 
etiology, pathology, diagnosis, prognosis and treatment, especially in 
prophylaxis. 
The pediculi live in the clothing, especially about the seams, where 
their ova are deposited. They first affect by preference the skin under 
the upper margin of the undershirt, or whatever garment comes near- 
est the skin. Hence the itching caused by the parasite is located on the 
upper portion of the back and shoulders. Next in order comes the 
region of the waist, where the lice or ova may be found in the seams 
in that region. Third in order come the extensor surfaces of the 
limbs. It is not entirely apparent just why the clothes-louse first 
attacks certain localities. 
As long as we find the lice located in certain sites we can form 
some idea of how the affection was acquired. But in dirty and neg- 
lected subjects the disease may quickly spread over the body (the 
hands and face alone being exempt). The seams and other regions of 
the clothing continue to be the breeding-places, but the number of lice 
which must feed upon the subject is much greater, and the number of 
lesions formed correspondingly increased. But the amount of derma- 
titis, the latter being chiefly the result of scratching, is not an inevitable 
index of the number of lice present. The sole primary injury caused 
by the parasite is a hemorrhagic red dot, generally held to be due to 
the fact that the proboscis of the louse enters a cutaneous follicle and 
sucks out blood, without causing an actual wound. This little act of 
265 feeding causes a most intense itching. It is not always easy to deter- 
mine whether the louse or the scratching causes the urticaria papulosa 
which follows; but at least the latter is of a type not usually encoun- 
tered under other circumstances. An entire area of skin may, as a 
result of scratching, become the seat of numerous, closely aggregated 
wheals. Isolated urticarial papules are, however, the rule, and these 
soon become more or less stable, scratched lesions. Some of these be- 
come pustules from infection. Many accessory nail-marks occur with- 
out any connection with actual lesions. These, too, may become in- 
fected. It is sufficient to state that the clothes louse may cause at times 
one of the severest types of artificial dermatitis. 
The changes which occur in the skins of vagabonds and the like, 
after years of pediculosis vestimentorum, are so peculiar clinically 
as to constitute almost a special affection; the more so because all other 
evidence of pediculosis may have vanished. The secondary lesions con- 
sist of pigmentation and a sort of atrophy of the skin, the latter due in 
part to precocious senile changes. 
There is naturally a period during which the discoloration reveals 
the original papules and nail-marks in the sites of predilection of the 
disease. Such cases are readily recognized as a rule. At a later pe- 
riod, however, not only have some of these detached stains coalesced to 
form wide sheets of pigment, extending perhaps beyond the scratch 
area, but pigmentation entirely separate from the scratched areas- 
even at times on mucous membranes-has been noted. 
Prognosis 
In a condition due purely to the operations of the clothes-louse, 
removal of the latter should in theory at least cause the disappearance 
of the disease picture. 
Treatment 
All of the patient's clothing should be destroyed outright, but if 
this is impracticable the garments may be disinfected by baking in an 
oven at a temperature of 212°. An antiseptic bath is next in order, and 
following this boric acid ointment may be applied to hasten the heal- 
ing of excoriations and infected lesions. It has been observed at the 
City Hospital on Blackwell's Island that after the bath these patients 
will often develop a fever with a rise of temperature of from two to 
four degrees. Authors do not mention any resources for promoting 
the absorption of the pigment. Fortunately, however, the patients with 
this affection seldom look for cosmetic results. 
Figs. 202 and 203. Models in Neisser's Clinic in Breslau (Kroener). 
266 Maculae Caeruleae 
Plate 126, Fig. 204 
Maculae caeruleae represent an artificial pigmentation caused by the 
pediculus pubis or crab louse. The condition is a transitory one, which 
disappears spontaneously after removal of the parasite. Its chief 
practical significance lies in the fact that it has been mistaken for seri- 
ous affections, for example, the roseola of typhoid, or syphilis, which 
may give rise to pigment anomalies. 
Although the pediculus pubis has been known for centuries, the 
blue spots were first mentioned by Morrison in 1868. Their nature 
was not understood until 1880, when Duguet found that the pigment 
was derived from the body of the parasite. The only conceivable way 
in which the pigment can be introduced would appear to be the act of 
feeding, but this supposition throws no light on the peculiar size, shape 
and distributon of the spots; nor is it at all apparent why they de- 
velop on only a certain proportion of patients. 
The spots vary in size from pea to finger-nail, and, despite their 
designation, are not blue but steel gray. They are perfectly flat, and 
in some the stain is deeply placed. They are said to occur most com- 
monly in fair skins and also in cases in which scratch marks and der- 
matitis are largely absent. The assertion has therefore been made 
that the pigment has an anesthetic effect on the skin. 
The spots, if they occur there, are not visible on the hairy areas, 
but in the outlying localities-abdomen and thighs. They may be 
encountered on the sides of the thorax and arms. 
Diagnosis 
The pigmentation implies that the patient has pediculosis pubis, 
or has recently recovered from it. In exceptional cases the patient 
may not have lice in the pubic area-these may have been destroyed- 
but they will be found in hair on the abdomen or thorax. The para- 
sites appear as dark spots, flat on the skin or even partly beneath it. 
They are sometimes in motion, but usually grasp the base of the hair 
267 shafts, with heads buried in the follicles. With the lens, ova may be 
recognized attached to the hairs, while the excrement is sometimes 
visible as minute dark spots. 
Treatment 
The only management required is destruction of the parasite, for 
the discoloration will then vanish of itself. The number of familiar 
parasiticides is considerable. Nearly any essential oil will answer the 
purpose. The blue ointment so extensively used may set up mercurial 
dermatitis, but an ointment containing hydrarg. ammon., half a dram 
to the ounce, is equally as effective and seldom irritates the skin. If 
not too numerous, the parasites may be removed bodily with forceps, 
and the ova destroyed by washing with a weak solution of acetic acid. 
Fig. 204. Model in Freiburg Clinic (Johnsen). The patient was also suf- 
fering from an Ulcus molle elevatum and Bubo inguinalis. 
268 Tab. 127 
No. 206. Onychogryphosis. 
No. 205. Myiasis linearis. Myiasis Linearis 
Plate 127, Fig. 205 
This affection, which presents some analogy with scabies, is due 
to the burrowing of a larva-probably one of the oestridae or gadflies 
-in the epidermis. But while the acarus will simply make for itself 
a short burrow, which serves as its nest, the larva burrows on in- 
definitely, and has, therefore, been likened to a mole. A red line or 
narrow ridge results, the direction of which may be straight, curved, 
broken, or exquisitely sinuous. A burrow may intersect itself over 
and over. One line may traverse the greater portion of the integu- 
ment. 
The condition was first described by Lee in 1874, under the name 
11 creeping eruption, ' ' and at a later period Crocker applied the term 
larva migrans to the then hypothetical parasite. The affection is said 
to be common in Russia. 
The symptoms, in more detail, are as follows: at the terminal of 
the line an inflammatory focus marks the location of the parasite. 
The more recent portion of the line forms a slight ridge, but the older 
portion is merely a thin red line, which may fade out of sight or be 
succeeded by a slight incrustation. 
While fhe parasite usually travels at the rate of half an inch to 
an inch in twenty-four hours, its rate of progress is exceptionally 
much more rapid. Authors do not mention the occurrence of more 
than one larva in a patient. There is no bifurcation or parallelism 
in the lines. It is not known definitely how the larva reaches the 
skin. The burrow usually begins at an exposed area-extremities or 
buttocks. The only subjective symptom is itching. 
Diagnosis 
No other affection could be confounded with this, unless it were 
some similar parasitic dermatosis. 
Treatment 
Since the larva is believed to be somewhat in advance of the 
269 proximal end of the line by reason of its rapid progress, it would be 
a mistake to treat the inflamed area. By computing the rate of travel 
it may be possible to inject some strong parasiticide into the parasite. 
This failing, a free excision of the area should be made and the larva 
removed. 
Fig. 205. Model in Finger's Clinic in Vienna {Henning}. 
270 Onychogryphosis 
Plate 127, Fig. 206 
This affection represents either a special type or an extreme de- 
gree of onychauxis, or hypertrophy of the nails. The onychauxis 
occurs in varying degrees, and may be due to more than one cause- 
that is, it may represent a congenital dystrophy, either alone or in 
association with other deformities, or it may be dependent on inflam- 
mation of the nail-bed, on some trophic affection or on a simple me- 
chanical causation. One or more nails may be involved, including those 
of both upper and lower extremities. 
In onychogryphosis (the word means curved nails), the nails at- 
tain such size and shape as to resemble claws or talons. The nail be- 
comes greatly thickened from above downward, and compressed later- 
ally, while its curvature becomes pronounced. There may also be 
more or less twisting, resembling that in the horn of an animal. The 
texture may be firm and homy, or brittle. The characteristic appear- 
ance of nail substance is completely lost. The hue becomes dusky and 
longitudinal and transverse furrows appear. 
The most typical cases of onychogryphosis appear to occur in 
elderly individuals, and to affect by preference the great toenails and 
perhaps, to a less extent, the contiguous toes. In some cases there 
appears to be no other causal element than poorly fitting shoes, while 
in others there is a history of onychia. These nails may attain a 
length of three inches. In some cases there is a fetid decomposition 
of accumulated epithelium beneath the nail, or secondary onychia. 
Diagnosis 
This affection can hardly be confounded with any other. 
Treatment 
This consists first in softening the nail substance by keratolytic 
substances like salicylic acid and strong alkalies dissolved in glycerin. 
271 After the softened nail has been detached the exposed surface should 
also be treated with salicylic acid plaster to prevent the return of the 
onychauxis. If these measures fail the nail-bed can be eradicated 
with the knife. 
Fig. 206. Model in Freiburg Clinic (Johnsen). 
272 SYPHILIS 
WILLIAM GAYNOR STATES, M.D., New York Introduction 
From the time of its appearance in Naples in the year 1494, no 
subject in medicine has been the object of greater interest and specu- 
lation than syphilis, justly regarded as one of the great human 
scourges, while its still debatable origin and its versatile and protean 
characters have furnished material for an enormous literature and 
themes for untold volumes. 
The history of syphilis, like that of other great subjects, has its 
dark periods, when reason and facts seem to have yielded to mere 
theories and fallacious doctrines. The early clinicians and writers 
had recognized the entity of syphilis and considered it a separate dis- 
ease, which they carefully differentiated from the other venereal affec- 
tions which had always been known, and from which its earliest no- 
menclature (the French evil, Neapolitan evil, Spanish evil, etc.), still 
further distinguished it; for it was not until some time later (1530) 
that the Italian physician Frascator wrote his famous Latin poem, in 
which a fictitious hero and the first victim of the new disease was named 
Syphilus. From this hero's name is derived the word syphilis, now 
universally applied to the disease. At a still later period Fernel termed 
it lues venerea, and popularly it was known as the pox or great pox. 
The ravages of the new disease, its loathsome and fearful effects, 
its malignancy, which, acting upon virgin soil, can be well imagined, 
were portrayed in detail in the descriptions given by the early writers. 
The dread and horror which syphilis inspired at the time was reflected 
in the restrictive edicts, laws and regulations passed by the authori- 
ties of the cities and towns, whereby the unfortunate afflicted were 
sequestrated or banished to designated places outside of the town 
limits, where many succumbed. 
Syphilis was impartial and respected no station in life-the rich, 
the poor, the exalted and the lowly were alike stricken. The gay 
275 Francis I of France, suffering from a fetid syphilitic caries of the 
nasal bones and miserably spent, became an object of loathing to his 
courtiers. Henry III of France and many high dignitaries of the 
state and church were also among the sufferers. 
Mercury, it is believed, was first used for the treatment of syph- 
ilis in 1514 by Jean de Vigo, physician to the pope Julius II. He em- 
ployed his celebrated plaster (still known by his name) and also fumi- 
gations. Carpi advised the use of mercurial frictions with neapolitan 
ointment, and Paracelsus in 1528 advocated the internal use of mer- 
cury. 
Syphilis was considered an external disease affecting the skin, 
mucous membranes and bones, and but little was known of its path- 
ology or effects upon the internal organs, although Tomitanus in 1563 
described a hepatic lesion from the autopsy of a syphilitic as a kind 
of distemper or pustule of the liver, and Astruc in the eighteenth cen- 
tury mentions that the liver engorged by syphilis is sometimes scir- 
rhous and indurated. Paracelsus had also noted the evil effects 
transmitted to the offspring by syphilitic parents. 
Thus the early clinicians had certain well-defined notions about 
syphilis which experience and time has demonstrated to be correct, 
but syphilis was destined to enter upon a dark era, when doctrinal 
beliefs and theories based upon wrong premises were to prevail against 
the knowledge acquired by more than two centuries of experience. 
John Hunter, the great English physiologist and surgeon (to whose 
classical description of the nodular primary sore the name of Hun- 
terian chancre was given), as a result of an unfortunate experiment 
whereby he inoculated himself with a supposedly gonorrheal dis- 
charge and developed syphilis, taught, in his Treatise on the Venereal 
Disease (1786), that there were three kinds of venereal infection: 
gonorrhea, chancre and lues venerea, and that all three were products 
of the same poison, the only difference being the nature of the surface 
upon which the virus acted, that gonorrhea always proceeded from a 
secreting surface, that the chancre was formed on a non-secreting sur- 
face and that lues venerea arose in consequence of the poisonous matter 
being absorbed. Nor did he admit the action of the disease on the 
internal organs. The great weight of Hunter's name brought him 
many followers, and his doctrines prevailed for many years. 
Many other theories found favor, and developed into various 
schools like the mercurialists and anti-mercurialists, who ascribed the 
ill-effects of syphilis to the action of the mercury administered. The 
theories of syphilization of Auzias Turenne, of Paris (1850), and his 
276 pupil Boeck, of Christiania, found supporters, and many denied the 
possibility of hereditary syphilis. 
The first glimmer of returning light came when Ricord, in 1838, 
disproved the identity of gonorrhea and syphilis, but he failed to es- 
tablish the difference between the two kinds of venereal sores. Leon 
Bassereau, one of his pupils, brought out the theory of the duality of 
sores, but Clerc, also a pupil of Ricord, attempted to prove that it 
was not necessary to have two kinds of poisons, but that the soft 
chancre, which he was the first to designate as chancroid, was pro- 
duced by the virus of an indurated sore acting upon an individual 
already syphilitic. Both theories found adherents, who were respec- 
tively known as unicists and dualists. 
Finally, in 1857, Ricord, in his work, "Legons sur le chancre," 
clearly established the difference between the simple venereal sore 
and the initial syphilitic lesion, which he termed the prelude of a dia- 
thesis. From that time the modern views and knowledge of syphilis 
may be said to date. 
The study of the pathology of syphilis received a great impetus 
in the middle of the nineteenth century and engaged the attention of 
many brilliant minds, among others, Rokitansky, Verneuil, Budd, 
Ricord, Cornil, Dittrich, etc. Virchow, in his treatise on constitutional 
syphilis (1865), described the lesions of the liver and kidneys and 
established the structure of the gummata, which he found to be anatom- 
ically similar to granulation tissue and accordingly included them in 
his classification of the granulomata. Since then pathologists have 
demonstrated the action of syphilis on practically all the organic 
structures and viscera, and particularly on the blood-vessels and ner- 
vous system. 
In 1876 Fournier expressed the opinion that syphilis was one of 
the most frequent causes of tabes. Erb was practically the only one 
to support Fournier's views, which at the time found many opponents, 
among whom were Westphal, Remak, Leyden, Charcot, Julliard and 
others. In 1882 Fournier again reasserted that the great majority of 
cases of tabes were of syphilitic origin. His conclusions were based 
upon the actual histories of 117 cases of tabes, of which 91.45 per cent, 
had syphilis. Erb, Oppenheimer, Bernhardt and others from inde- 
pendent investigations reached the same conclusions. Later Fournier 
expressed the same opinion with regard to general paresis. Further 
experience has demonstrated the correctness of these views, not only 
in tabes and paresis, but in other nervous affections. To this group of 
affections, the consequence of an anterior luetic infection but not 
277 deemed to be themselves of an active syphilitic nature, Fournier ap- 
plied the term parasyphilitic. 
Jonathan Hutchinson's contributions to the knowledge of congenital 
and hereditary syphilis and his observations of the characteristic mal- 
formation of the teeth and other stigmata are well known. 
In the treatment of syphilis many remedies had been tried, but 
until the introduction of salvarsan the only specific known was mer- 
cury, and this remained the therapeutic mainstay, despite the opposi- 
tion of the anti-mercurialists. In 1862 Wallace, of Dublin, introduced 
the use of iodide of potassium in the treatment of syphilis. 
Subcutaneous mercurial injections were used early in the nine- 
teenth century by Hebra, Scarenzo and Berkley Hill. 
Lang, of Vienna, in 1884, introduced the intramuscular injection 
of gray oil or ol. cinereum (a suspension of metallic mercury in lano- 
lin and oil). Since then numerous soluble and insoluble mercurial 
salts have been used for subcutaneous and intramuscular injections. 
This brief and necessarily imperfect review, covering a period of 
over four centuries, represents roughly the state of our knowledge 
at the beginning of the present century, and brings into greater relief 
the stupendous advances made since then, for beginning with the year 
1903 a new era has dawned upon syphilis, and it has been robbed of its 
mystery through the remarkable and epoch-making discoveries which 
have taken place in rapid succession, while many former long-held 
views and beliefs have been shattered. 
In 1903 Metchnikoff succeeded in inoculating the higher anthropoid 
apes with syphilis, thus opening the way to animal experimentation 
and at the same time disproving the former belief that syphilis was 
peculiar to man and incapable of transmission to animals. Since then 
the disease has been experimentally conveyed to monkeys, rabbits, 
dogs, etc. 
In 1905 Schaudinn, in collaboration with Hoffmann, announced the 
epoch-making discovery of the spirocheta pallida now known to be 
the cause of syphilis. Its presence in gummata and other late lesions 
has dispelled the old notion that tertiary syphilitic lesions were not 
contagious, while its recent discovery in the brains of paretics and in 
tabes dorsalis disproves the view that parasyphilitic affections are not 
active luetic processes. 
In 1906 Wassermann, Neisser and Bruck, applying the principles 
discovered by Bordet and Gengou to the diagnosis of syphilis, es- 
tablished the well-known serum test, which has since become most 
valuable not only for the diagnosis of syphilis but also for the control 
278 of its treatment. It has furthermore shown that Colle's and Prof eta's 
laws of immunity are no longer tenable. 
In 1911 Noguchi succeeded in obtaining pure cultures of the spiro- 
cheta pallida, and by their successful inoculation into experimental ani- 
mals proved the causal relation of the organism to syphilis. Shortly 
afterward he introduced his luetin cutaneous reaction test. 
Ehrlich's contributions of salvarsan and neo-salvarsan to the ther- 
apy of syphilis complete the series of brilliant achievements and re- 
markable discoveries which have taken place in less than a decade 
and which it may be hoped presage at no distant future the great at- 
tenuation if not the eradication of the terrible scourge which has af- 
flicted humanity for more than four hundred years. 
279 Syphilis 
Syphilis is a specific communicable disease caused by a definite 
organism, the spirocheta pallida, or, as now designated, the treponema 
pallidum. 
The disease is conveyed from an infected to a healthy individual 
by actual contact (immediate contagion), through the instrumentality 
of infected objects (mediate contagion), or it may be transmitted to the 
offspring through one or both parents (hereditary syphilis). 
The evolution of syphilis is chronic and its duration indefinite, its 
manifestations although following to some extent a chronological se- 
quence, are intermittent in character and are constituted by a very 
numerous series of symptoms or lesions, which may, under differing 
forms varying in gravity, affect any tissue or part of the organism. 
'Etiology 
It had long been surmised that syphilis, like other infectious dis- 
eases, was caused by some living organism, and a number were re- 
ported, notably the bacillus of Lustgarten in 1885, but it was reserved 
for Schaudinn, in collaboration with Hoffmann, to announce in 1905 
his memorable discovery of a spiral organism which he had constantly 
found in syphilitic lesions, and which from its pale appearance and low 
refraction he named the spirocheta pallida and later the treponema 
pallidum. 
This discovery was soon confirmed by many observers who in ex- 
tending their researches, noted the presence of the organism in the 
various external and organic syphilitic lesions in both the acquired and 
hereditary forms of the disease. 
The constant association of the spirocheta pallida with syphilitic 
manifestations and its very evident causal relation to the disease, led 
to its being generally accepted as the specific cause, although positive 
and rigorous proof was still lacking. 
The proof, however, was furnished by Noguchi who, in 1911-1912, 
succeeded in obtaining pure cultures of the treponema pallidum which, 
280 when inoculated into experimental rabbits, produced in due time lesions 
characteristic of syphilis and containing numerous treponemata. In- 
oculation of the cultures in monkeys was also followed by local mani- 
festations presenting the appearance of the initial lesions in man and 
those produced in monkeys by using material of human origin. Fur- 
thermore the blood of monkeys inoculated with pure cultures obtained 
from human lesions gave a positive Wassermann reaction, thus show- 
ing the relation of the treponema pallidum to the serum test and also 
the similar characters presented by the cultivated strains with the spe- 
cies existing in human syphilitic lesions. 
The treponemata pallida belong to a rather numerous and widely 
distributed species of spiral organisms or spirochetae which occur in 
shell fish, fowl, and to some extent in nature (fresh water). Their 
exact classification is still undetermined, for whether they belong to the 
lowest order of animal parasites or protozoa or to true bacteria is 
not decided ("Spirochetae," by Bosanquet). Blanchard places them 
among the trypanosomidce, and Luhe under the generic treponema in- 
cludes the treponema pallidum and also the treponema pertenue, the 
cause of yaws or frambesia tropica, a disease resembling syphilis in 
some respects. The organism, however, seems to present greater an- 
alogies with the protozoa, and is so considered by the majority of 
authorities at the present time. The importance of the question lies 
in the possibility of elaborating immunizing sera or vaccines, for, as 
Adami says, "the development of toxins by the protozoa is so slight 
and the toxins are of so low an order that it has not yet been possible to 
develop antitoxins or passive immunity by experimental means. ' ' 
In man several varieties of spirochetae belonging to the genus 
treponema occur; some deemed saprophytic, others more or less patho- 
genic. The spirochetae buccalis, macro-dentium and micro-dentium are 
found almost constantly in the healthy mouth. Vincent's spirocheta is 
usually found associated with the bacillus fusiformis in Vincent's 
angina. The spirocheta refringens occurs in smegma, in balano-pos- 
thitis, and is frequently associated with the pallidum in the ulceration 
of the primary sore. 
The treponema pallidum is a fine tenuous spiral organism varying 
from 10 to 26 microns in length and of almost immeasurable thickness 
(14 to % micron). It presents a number of deep, well accentuated 
regular spirals, ranging from 4 to 26 according to different observers, 
and presents finely pointed extremities. It moves to and fro by rota- 
tion on its long axis and retains its spiral form while in motion. It 
requires differentiation from the spirocheta refringens with which it 
281 is frequently associated in the primary sore, and from the spiral or- 
ganisms the spirochete buccalis, macro- and micro-dentium found nor- 
mally in the mouth and in conjunction with oral syphilitic lesions. Its 
reaction to the Wassermann test is positive. 
The spirocheta refringens (treponema refringens) is longer and 
much coarser than the pallidum, averaging from 10 to 30 microns in 
length by % to % of a micron in thickness. The spirals, which may 
number from 3 to 15, are wider, flatter, more sinuous in character and 
irregular; the organism is more refractile and its movements are snake- 
like and more rapid than in the pallidum. Its reaction to the Wasser- 
mann test is negative. 
The spirocheta micro-dentium (or treponema micro-dentium) most 
closely resembles the pallidum in its morphology, staining properties 
and refraction, and according to Noguchi it is almost indistinguish- 
able, except culturally, from certain thin strains of the pallidum. 
The micro-dentium is a fine delicate organism shorter and thinner 
than the pallidum. The spirals which may number from 4 to 20 are 
regular, moderately deep and closely set, while the extremities appear 
blunt. It moves by rotation on its long axis and retains its spiral 
form in motion. Its reaction to the Wassermann test is negative. 
The spirocheta macro-dentium (treponema macro-dentium) is 
longer and coarser than the pallidum; the spirals which may number 
from 3 to 14 are not so regular, and its movements are flexuous as well 
as rotatory. Its reaction to the Wassermann test is negative. 
The spirocheta buccalis is a coarse organism with rather long ir- 
regular flat curves; its movements are sinuous and snake-like. Vin- 
cent's spirocheta presents the general objective features of the buccalis. 
The treponema pallidum has been found in practically all the lesions 
of acquired syphilis and in all its stages. It is most abundant in the 
primary sore and in the lesions of the florid period when, although 
difficult to find, it is also present in the blood and lymphatics. It occurs 
in the organic lesions of the tertiary stage, notably in aortitis and it has 
been found in gummata, tabes and paresis. It is present in the lesions 
of early and tardive hereditary syphilis, and is especially abundant in 
the organic lesions of children dying with congenital syphilis, particu- 
larly in the liver. 
The presence of the organism in the initial lesion establishes the 
diagnosis of syphilis, and permits the initiation of treatment without 
waiting as formerly for the advent of the secondary phenomena. 
The treponema pallidum can be demonstrated in the living state by 
using the dark-field illuminator, or in stained smears and cut sections. 
282 The material for examination may be obtained from the primary sore 
or an eroded papule. The surface of the lesion should be cleaned by 
means of a pledget of cotton or gauze, moistened with normal salt- 
solution, so as to remove the superficial secretions usually containing 
many kinds of micro-organisms and but few treponemata. The cleaned 
surface is then scrubbed with a pledget of gauze or lightly curetted; 
this is ordinarily followed by slight bleeding, the blood is wiped away 
until bleeding stops. In a short time a certain amount of clear irrita- 
tion serum exudes from the surface of the sore and this may be in- 
creased by gently squeezing the sides of the lesion. A loopful of this 
clear serum is then mixed with an equal quantity of normal solution and 
examined with the dark-field illuminator, or the serum may be used 
for smears. 
Several methods for the quick staining and determination of the 
treponema pallidum are used. Burri's india ink method is simple and 
rapid, a loopful or more of the irritation serum is mixed with an equal 
quantity of Biggin's or Gunther's india ink, spread on a slide and 
examined with an oil immersion. The treponema appear as fine color- 
less spirals on a dark background. 
Oppenheimer and Sachs use a quick staining method, consisting of 
a 10 per cent, mixture of saturated alcoholic gentian violet in a 5 per 
cent, phenol solution; the organism is stained in a few seconds. 
Klopstock and Kowarshy 1 describe a quick staining method using 
the Giemsa solution. The specimen is covered with the diluted Giemsa 
solution (10 drops of Giemsa to 10 cc of distilled water), and held over 
flame until it steams; after 15 seconds staining fluid is poured off; this 
process is repeated four times, but at fourth time the staining fluid re- 
mains on for one full minute. The slide is then washed, dried and 
examined. In a well-stained specimen the treponemata are stained a 
distinct red and the leucocytes a very dark red; if unsuccessful the 
coloring appears blue. 
The organisms are not always numerous and it is advisable to pre- 
pare several slides, for sometimes a diligent search is necessary. The 
organisms are frequently seen in the vicinity of blood-cells and some- 
times one is seemingly attached to another in the form of a Y. It 
should also be remembered that the preliminary application of mer- 
curials, antiseptics or cauterizations will cause the disappearance of 
the organisms from the sore. 
1 Klopstock and Kowarsky: A Manual of Clinical Chemistry, Micros- 
copy and Bacteriology. (Illustrated with black, white and colored figures.) 
$3.00 Cloth. Rehman Company, New York. 
283 The treponemata are also present in the papular lesions. The epi- 
dermal covering of a papule should be carefully shaved off, bleeding 
arrested and the irritation serum exuded examined as with the primary 
sore. 
The examination of the exudate from mouth lesions requires care- 
ful differentiation between the specific organisms and those ordinarily 
found in that region. 
Hoffmann's method of aspirating an enlarged gland in the groin or 
elsewhere may be employed when the treponema cannot be demon- 
strated in the ordinary lesions. It is also particularly useful in anal 
chancres owing to the difficulty of getting access to the lesion because 
of its situation. Under strict aseptic precautions a hypodermic needle 
attached to an all-glass syringe is plunged into the nearest gland (it 
is known that the needle is in the gland for it moves with it) and as- 
piration made; if no fluid appears, the needle may be pushed into an 
adjoining gland without its withdrawal. The aspirate may be clear 
or slightly sanguinolent, and may be limited in quantity to a few drops; 
but amply sufficient for the purpose of examination. This method is 
very frequently satisfactory and presents the great advantage of re- 
quiring no differentiation, as only the treponema pallidum is found. 
The life cycle of the treponema pallidum is not yet determined, but 
the recent independent investigations of McDonagh (Lancet, Oct. 12, 
1912) and Ross (British Med. Journal, Dec. 14, 1912) show that the 
spirochetal form of the parasite is but a single stage in the develop- 
ment of the organism, and that apparently the cycle begins with the 
entrance of granular or sporelike bodies into large mononuclear cells. 
From these granules (termed inclusion bodies by Ross), short wavy 
filamental processes develop which ultimately grow into spirochetse. 
Noguchi has also observed granules in cultures from which the same 
filamental bodies develop. McDonagh believes that infection is prob- 
ably conveyed by these sporozoites or infective granules and not in the 
spirochetal stage. This seems to be confirmed by the period of in- 
cubation required after infection during which time the parasite under- 
goes its development. It would further explain the failure of salvar- 
san or mercury to completely sterilize the infected individual although 
both are fatal to the spirochetal form, and also the recurrences and 
later manifestations of the disease resulting from the subsequent de- 
velopment of these resistant spores or granules. The presence of these 
resistant granules may also account for some examples of mediate con- 
tagion from infected objects, for the spirochetse themselves are delicate 
anaerobic organisms that do not survive desiccation. 
284 Pathology 
Syphilitic lesions consist essentially of interstitial cellular infiltra- 
tions-in other words of an inflammatory hyperplasia. In the cutane- 
ous manifestations the infiltrate varies in degree from the transient, 
scarcely appreciable infiltration of the macular lesions to that of the 
tubercular eruptions in which the entire thickness of the skin is in- 
volved. As Darier describes it (Traite de la syphilis. A. Fournier): 
' * The cellular infiltration may be diffuse, but it is most frequently dis- 
tributed around a blood-vessel, surrounding it like a perivascular cuff 
or else arranged as circumscribed elementary nodules. 
In all syphilitic lesions of whatsoever nature the walls of the blood- 
vessels are the seat of inflammatory changes; the vessel usually form- 
ing an axis around which are grouped the infiltrative processes. 
The evolution of the cellular syphilitic infiltrate may terminate in 
three different ways. 
First: The infiltration may undergo complete absorption, leaving no 
traces or else insignificant ones. 
Second: It may undergo a fibrous organization or sclerosis. 
Third: It may undergo a gummatous or caseous transformation end- 
ing in necrobiosis. 
The first termination occurs in the lesions of the primary and 
secondary periods. 
The two last terminations belong to the tertiary period and con- 
stitute the gummatous and sclerotic processes, both of which are fre- 
quently associated or combined together. As a rule syphilitic altera- 
tions are almost exclusively interstitial as only the vascular or 
conjunctive tissue framework of the organs is involved. In some ex- 
ceptional cases the parenchyma of certain organs appears to be primar- 
ily affected. 
In the secondary period, the manifestations generally consist of 
lesions of the skin and mucous surfaces, disseminated adenopathy, 
transient affections of the periosteum and bones, occasional ocular, 
auricular and testicular troubles; exceptionally some disorders of the 
liver and kidneys, etc., all susceptible of resolution. 
In the tertiary period the pathological processes may attack any 
organ or tissue without exception, and bring about permanent disor- 
ganization or destruction. 
As already stated, the blood-vessels are affected in all syphilitic 
lesions, whether in the first, second or third stage, but in the third stage, 
isolated vascular lesions involving all the vascular coats and resulting 
in periarteritis, endarteritis, etc., occur; the arteries at the base of 
285 the brain are particularly affected, the aorta next in frequency, the 
alterations taking place in it being the most frequent cause of 
aneurism. The veins are also involved, the syphilitic processes lead- 
ing to the development of both arterio-sclerosis and phlebo-sclerosis. 
The tertiary cutaneous lesions are by far the most common mani- 
festations and are represented by tubercular and gummatous forms. 
Tertiary affections of the nervous system are next in frequency to 
the cutaneous manifestations (not including the parasyphilitic affec- 
tions) and present themselves in the various forms of cerebral syphilis, 
cerebro-spinal, medullary ocular paralyses, and other nerve affec- 
tions. ' ' 
The most salient characteristic of the pathology of syphilis is the 
involvement of the blood-vessels, and in consequence lesions most dis- 
similar in character may arise from a common origin. Thus an 
ulcerative syphilide is of vascular origin and, as Fournier aptly says, 
"What more different than an ulcerative syphilide and a syphilitic 
hemiplegia? Yet it is shown that both are derived from the same mor- 
bid affections of the vascular system; in the one an arteritis of the cere- 
bral system, in the other an arteritis of the cutaneous vascular system. ' ' 
The division into primary, secondary and tertiary periods intro- 
duced by Ricord and based upon the order in which the successive 
phenomena of the disease develop, while to a certain extent artificial, 
has from long usage and convenience of description been generally 
retained by syphilographers. 
Primary Stage 
In acquired syphilis (by far the most common form), the morbid 
phenomena observe in the beginning a certain order in their appear- 
ance, viz., infection having taken place, is followed by a silent period 
or primary incubation during which no evidence of the disease is pre- 
sented until the initial lesion appears, and this may take place in from 
15 to 40 days, exceptionally longer, but usually from the 21st to 26th 
day following date of exposure. The initial lesion always develops at 
point of contagion wherever that may be, and is always accompanied by 
more or less pronounced enlargement of the neighboring glands. 
Secondary Stage 
The initial lesion with its accompanying adenopathy constitute the 
primary stage and these remain the sole objective expression of the 
disease until the advent of the secondary or constitutional symptoms. 
These manifest themselves usually from 40 to 45 days from date of 
appearance of chancre. They may appear as early as the 30th day and 
286 occasionally as late as the 60th or 70th day; this interval termed the 
secondary incubation by some writers is devoid of symptoms. 
The manifestations of the secondary period differ from the 
primary, in that they are no longer local but are represented by multi- 
ple and disseminated symptoms and lesions, varying in character and 
degree, and consisting in various cutaneous eruptions, erosions and ul- 
cerations of the mucous membranes, alopecia, adenopathies, affections 
of the nails, muscles, periosteum, bones, of the special organs, the 
eye, ear, testicle, disorders of the nervous system and the visceral 
organs, impairment of nutrition, anemia, fever, etc. Some of these 
various manifestations may appear or recur at more or less frequent 
intervals during the first two or three years of the disease, even much 
later. The general characteristics of the secondary lesions are that 
they are more superficial, more benign, less apt to destroy tissues or 
organs than the tertiary manifestations and that under treatment they 
usually resolve without leaving permanent defects or scars. 
The diversity of expression manifested by the morbid phenomena 
of the secondary stage can be readily understood when it is remembered 
that the specific contagium is blood borne, and is capable of developing 
and manifesting itself in any and all parts of the body, wherever dis- 
tributed by the circulation. But notwithstanding its protean char- 
acter, syphilis usually exhibits a certain chronological order in its 
manifestations, for certain types appear during the early period of the 
disease, other types at more advanced or even remote periods; yet, 
while this is the general rule, it is far from being absolute. 
Tertiary Stage 
While the primary and secondary periods follow a certain order in 
the time of their appearance, the same cannot be said of the tertiary, 
for, as Fournier justly remarks, "When does it begin and when does it 
end?" Hence it is not susceptible of a precise definition. The differen- 
tiation between the secondary and tertiary periods rests upon the dif- 
ferent character, mode of evolution and objective appearance of its 
lesions, some of which like the tubercular and gummatous manifesta- 
tions are peculiar to the tertiary period, and also upon the sclerotic 
processes which it induces in various departments of the organism, 
particularly in the vascular system. 
The duration of the tertiary stage is indefinite, its symptoms may 
appear during the first year or even months of the disease and coexist 
with secondary manifestations, or may not appear for five, ten, twenty, 
even as late as fifty years or more after disease is contracted. In very 
287 many cases they are never observed. Their greatest incidence is from 
the second to the fourth year, thereafter they decline sensibly and 
markedly after the tenth year. 
The chief character of the tertiary manifestations is their greater 
gravity and destructive tendency. They are represented by distinct 
lesions consisting principally of tubercular, gummatous and sclerotic 
processes. The ulcerations resulting from gummata may destroy any 
tissue affected, skin, bone, and parenchyma of organs, while the sclero- 
tic and connective tissue changes, by affecting the integrity and intimate 
structure of the various organs, tissues, blood-vessels and particularly 
the nervous system, lay the foundation for the irremediable para- 
syphilitic affections. 
The contagiousness of syphilis is greatest during the primary and 
secondary periods owing to the activity of the disease and the greater 
abundance of moist and secreting lesions; even the blood during the 
florid stage is capable of transmitting the disease as proven by human 
experimental inoculation. The contagiousness diminishes in degree 
with the age of the infection, but never entirely disappears as long as 
local manifestations are present. Authenticated instances of infection 
from tertiary gummatous lesions, long believed to be innocuous, have 
been recorded; and this has been further demonstrated by the finding 
of the treponema pallidum in such lesions. 
In immediate contagion, syphilis is contracted from the actual con- 
tact of a receptive mucous or cutaneous surface, with either the primary 
sore or the moist and secreting lesions of the secondary period. A 
sound and unbroken skin opposes a protective barrier, but the slightest 
abrasion, a scratch or hangnail, may afford a point of entrance for the 
development of the disease. This is exemplified in the digital chancres 
acquired by physicians, midwives, etc., in the exercise of their pro- 
fessional duties. 
In mediate contagion the disease is contracted through the use of 
contaminated objects, such as smoking the infected pipe of one suffer- 
ing from buccal or labial mucous patches, for the same reason drinking 
vessels, forks, spoons, or other articles of intimate use may act as 
sources of infection. Contaminated dental or surgical instruments, 
tongue depressors, laryngoscopic mirrors, etc., have been the means 
of conveying the disease. Infected underclothing worn by healthy 
individuals may develop the disease in them. (An instance of this kind 
occurred in the practice of the writer in which a young man wearing 
the underclothing of his roommate suffering from syphilis developed a 
chancre on the posterior raphe of the scrotum.) 
288 Indirect methods have also been recorded: for example, a healthy 
woman suckles a syphilitic child suffering from mouth lesions, and 
thereafter suckles a healthy child who contracts the disease from the 
contaminated nipple, while the woman escapes infection. In the same 
manner a finger inadvertently contaminated in the examination of an 
acute syphilitic lesion may communicate the disease in a subsequent 
examination to a healthy person who would thus innocently develop a 
syphilis of unknown and untraceable origin. 
Vaccinal syphilitic infection from the use of vaccine scabs taken 
from syphilitic children, is fortunately of rare occurrence at present, 
owing to the disuse of such method of vaccination. 
Hereditary syphilis results from the transmission of the disease by 
syphilitic parents to their offspring. 
Both parents suffering from syphilis before conception, will in all 
probability beget a syphilitic child. 
A healthy father and a syphilitic mother or vice versa may en- 
gender a child syphilitic at birth. 
In the so-called conceptional syphilis: a healthy woman conceives 
by a syphilitic father, the syphilitic issue of the syphilitic father may 
infect the mother through the utero-placental circulation. 
In post-conceptional syphilis: a healthy couple engender a healthy 
child, the mother during her pregnancy contracts syphilis, she may 
then infect her child through the utero-placental circulation, and give 
birth to a syphilitic offspring. 
The course of syphilis is far from being identical in all cases, for it 
may vary in severity from the fortunately rare malignant form with 
its early destructive lesions and profound systemic involvement, to a 
form so mild, with limited symptoms so slight and commonplace, that 
it may pass unnoticed as in ignored syphilis. In some exceptional in- 
stances the disease may be abortive. Several such cases were reported 
by the late R. W. Taylor as occurring in his practice. 
The majority of cases observed at the present day are of a benign 
type, many being limited to a roseola or slight papular eruption, some 
mucous patches, slight sore throat, and adenopathy, perhaps a mild 
alopecia, with sometimes cephalalgia and periosteal pains. 
The benignity of the disease in such cases being perhaps due as 
generally believed to the greater degree of resistance or immunity con- 
ferred by many generations of syphilized individuals, and also to its 
earlier recognition and more adequate treatment. 
Another possible factor is the different degrees of virulence in dif- 
ferent strains of the treponema pallidum, for Noguchi has observed that 
289 inoculations with certain malignant strains produced the large nodular 
lesions, and others diffuse infiltration; these results differing from 
those obtained with the ordinary strains (Journal A. M. A., April 12, 
1912). 
Syphilis also varies in type. In some cases its manifestations 
are chiefly external and objective, these being constituted by the various 
cutaneous symptoms and affections of the mucous surfaces. Their 
recurrences exhibiting the predilection of the disease for the cutaneous 
and mucous departments of the organism. In another type which 
might be termed the internal, the outward or objective evidences are 
comparatively few or absent, while certain symptoms predominate, such 
as headaches, ocular troubles, affections of the nervous system, peri- 
osteal and myalgic pains, anemia, functional disorders, etc., all of which 
may vary greatly in severity. The nervous manifestations indicate an 
early involvement of the nervous system, although this may take place 
without clinical symptoms, as shown by the results of the cytologic and 
serologic examination of the spinal fluid. 
No deductions as to the future course of syphilis can be drawn from 
its early benign and mild character, for experience has shown that 
many such cases ultimately develop parasyphilitic affections. In that 
respect the external type apparently offers a better prognosis from its 
revealed predilection for the skin and mucous membranes and from 
the tendency of syphilis to reinvade the site of former lesions. 
290 The Syphilitic Chancre 
Synonyms: Hard chancre, Initial lesion, Initial sclerosis, Primary sore, 
Hunterian chancre, Indurated sore 
The chancre is the initial lesion of an acquired syphilis, and 
always develops at the point of entrance of the contagium; it makes 
its appearance in from fifteen to forty days after infection (most 
frequently from the 21st to the 25th day), and, as in the majority 
of cases (estimated at over 90%), the disease is contracted during 
sexual intercourse, the resulting chancre is said to be genital; the 
remaining percentage, which may appear on any part of the body, 
constitutes the extra genital lesions. 
The chancre is a neoplastic growth, seated on a cutaneous or 
mucous surface, and presents two general types: either a lesion with 
a flat surface and underlying induration or an indurated nodular 
mass, varying in size from a pea to a small olive. 
Anatomically it consists of an infiltrative network of fine inter- 
lacing Conjunctive fibres, in the meshes of which are found great 
numbers of cellular elements densely crowded together. These 
elements consist principally of round cells which are more or less de- 
formed and of embryonal connective tissue cells, more rarely of giant 
cells. The abundant cell proliferation and its density produces the 
characteristic induration. The blood-vessels are also involved, the 
arterioles particularly, their external coat or adventitia is infiltrated, 
thickened, and their walls compressed by the surrounding pressure; 
in consequence the lumen of the arterioles is diminished or may 
even become obliterated. This probably explains the gangrenous 
degeneration of some lesions-the nodular especially. The perivascu- 
lar infiltration surrounding the vessels extends for some distance 
beyond the indurated base into apparently healthy tissues, which may 
also explain why excision of the chancre so rarely aborts the disease. 
The chancre, as observed clinically, ordinarily presents a moist 
eroded surface, of a red beefy color and of variable size, depending 
upon the age of the lesion. When recent it consists of a small red 
291 eroded surface, which, as the condition progresses, extends until fully 
developed, while at the same time the induration becomes more marked 
and the color deepens; in this state it remains for some time, usually 
two, three or more weeks, without appreciable change. It then 
retrogresses, the infiltration is absorbed, the surface cleans and heal- 
ing takes place, ordinarily without scar, but a certain amount of 
induration may persist for weeks. 
The fully developed chancre is usually of limited extent, most 
frequently of round or oval shape and the surface eroded rather 
than ulcerated; the floor is even and the borders are continuous with 
the surrounding tissues. The color is generally of a beefy red, oc- 
casionally of a grayish tint, while the secretion is slight, serous, or 
of a light seropurulent character. 
The base is indurated, and when palpated by seizing the opposite 
edges of the sore with the examining fingers and making slight pres- 
sure, a sense of resistance, comparable to the folding of an under- 
lying piece of cardboard is felt; the impression may be so slight 
as to simulate the resistance offered by a piece of writing paper (the 
so-called parchment-like induration), or so great as to resemble the 
interposition of a layer of cartilage. In the nodular type the in- 
duration is massive and of cartilaginous density. 
The chancre pursues an indolent course, is rarely accompanied 
by inflammatory symptoms, and unless irritated by unwise cauteri- 
zations or applications, is seldom painful; exception must be made 
for certain lesions so situated as to be exposed to the irritating effect 
of urine, vaginal discharges, friction or complications, as in urethral, 
vulvar, anal and perianal chancres. 
Not infrequently the initial sore may be so slight, painless and 
insignificant, that it may be unnoticed or else not considered. This is 
particularly the case in women. 
The average duration of the primary lesion is from four to 
six weeks; it may be as short as two weeks or as long as seven or 
eight-exceptionally longer. 
Many factors, such as the situation, local irritation, exposure to 
friction, complications and methods or lack of treatment, affect the 
duration. 
Adenopathy 
"Within a period rarely exceeding ten days from the appearance of 
the chancre, some enlargement of the nearest glands takes place. 
The glands involved, depend upon the site of the lesion; thus in 
292 genital, anal, and perianal chancres, the inguinal glands are affected; 
in lesions of the hand and fingers the epitrochlear and axillary glands; 
lips and tongue, the submaxillary; breast, the axillary, etc. In 
chancre of the penis, the penodorsal chain of lymphatics is frequently 
enlarged, and feels like a knotted whipcord. 
The enlargement of the inguinal glands constitutes the so-called 
syphilitic or satellite bubo. It may be polyglandular, in which event 
a number of enlarged glands (on both sides usually) will be felt, and 
this is the most frequent form, or else it may assume a monoglandular 
form, in which case one gland becomes greatly enlarged; this is usu- 
ally painless and indolent, sometimes slightly sensitive to pressure 
and, unless irritated, very rarely ends in suppuration. When this 
happens, the overlying skin becomes slightly red and adherent, a 
central soft spot develops which, incised or opening spontaneously, 
gives issue to a thick viscid fluid, but slightly purulent. As a rule, 
the adenopathy is of an indolent non-inflammatory character; it out- 
lasts the chancre and persists for months. 
The appearance of a chancre varies with its situation. When it 
occurs on a mucous surface, it usually presents a moist, red, smooth 
or eroded surface with scanty secretion. When located on the skin, it 
frequently forms a dark adherent scab, which if detached leaves a 
bleeding surface; when situated on a muco-cutaneous border, such as 
the lip, the affected skin is covered by a crust, whereas the affected 
mucous surface presents a smooth red or grayish exudative surface. 
See Plate 133, Fig. 217. 
In man the genital chancre may occur on any portion of the 
penis, and occasionally on the scrotum; in consequence it offers 
certain peculiarities depending upon its location. 
When situated on the glans penis the lesion is usually flat, round 
or oval with an induration of the parchment-like type; when located 
on the inner surface of the prepuce, the lesion is likewise flat, more 
extensive and the induration much greater, sometimes like a sheet of 
cartilage. Upon retraction of the prepuce the lesion will appear 
blanched by the tension, and frequently the prepuce goes back with 
a jerk like the eversion of an eyelid. 
The coronal sulcus is the most frequent site of the initial lesion 
(see Plate 129, Fig. 209), and it is in this locality also that the 
nodular type, with massive induration, is most commonly seen. 
Such chancres project from the surrounding surface and form ele- 
vations varying in size from a pea to that of a small olive, and of 
dense cartilaginous hardness. 
293 The small fossa on either side of the frenum is another favorite 
site. The lesion frequently extends to the opposite fossa, and under- 
mines the frenum, which becomes swollen, eroded, and often ruptured. 
Chancres of the preputial margin are generally fissural. The 
induration in this situation is usually dense and pronounced; it may 
involve all of the margin and form a cartilaginous ring. Its un- 
yielding character and the narrowing of the preputial orifice is the 
reason for the phimosis and balanitis which usually complicate this 
variety. 
Chancre of the meatus may involve one or both lips; the indura- 
tion is pronounced. Such lesions are usually somewhat painful on 
account of the constriction of the urethral orifice, and the passage of 
urine over the eroded surfaces, while a slight sanguinolent secretion 
is frequently present. 
Chancres on the body of the penis are not uncommon; they are 
frequently elevated above the surrounding surface and present a 
smooth beefy red appearance (see Plate 129, Fig. 210), or they may 
be covered by a dark brown scab. Ordinarily the induration is not 
as dense as in the preceding varieties, and presents more the char- 
acter of a hard edema. 
Phimosis and balano-posthitis are the most common complica- 
tions of the primary lesion; paraphimosis is more rarely seen. 
The genital chancre in woman, while pursuing the same course 
and presenting the same appearance as in man, offers a greater 
variety of lesions, due to anatomical differences and the great extent 
of cutaneous and mucous surfaces open to infection. 
The greater lips are by far the most common site of infection. 
In 239 cases observed by Fournier, the primary lesion was found 
on the 
CASES 
Greater lips, in 114 
Small lips, in 55 
Fourchette, in 38 
Cervix, in 13 
Introitus vagina?, in 9 
Urinary meatus, in 7 
Superior vulvar commissure, in 2 
Vagina, in 1(?) 
Chancre of the greater lips offers the usual type of eroded and 
ulcerated surface, and is most commonly round or oval; from its 
exposure to irritation it is sometimes surrounded by a localized hy- 
294 peremia (this is well shown in Plate 131, Fig. 213). The induration 
is distinct. Quite often when the lesion has existed for some time 
it becomes elevated, disklike and assumes a hypertrophied papular 
type; when it is seated on the cutaneous aspect it is apt to form a 
dark brown crust and resemble an ecthymatous lesion. Occasionally 
chancre of the greater lip is accompanied by a massive induration of 
the entire labia (the sclerous edema of the French). (See Plate 131, 
Fig. 214.) 
Chancre of the smaller lips may be situated on either the external 
or internal aspect; it usually presents the erosive type with parch- 
ment induration, but when the lesion involves the free border, the 
induration may be pronounced and extensive; sometimes the whole 
lip becomes indurated. 
Chancre at the introitus vaginae may be situated in some mucous 
fold or behind the caruncles; for that reason it is often unperceived 
and escapes notice. The lesion is ordinarily a small erosion, some- 
times fissural and but slightly indurated. 
Chancre of the urethral meatus is a red, eroded, and often pout- 
ing lesion; the induration is marked and at times may be felt ex- 
tending along the urethra like a rigid cylinder. The lesion, irritated 
by the passage of urine, becomes sensitive and bleeds easily on pres- 
sure. 
Chancres of the fourchette are most frequently fissural and pre- 
sent the usual red, elongated, eroded appearance of such lesions; the 
induration is slight. 
The primary lesions of the external female genitals are accompa- 
nied by enlargement of the inguinal glands. 
Chancre of the cervix is often discovered accidentally, for the 
lesion itself is symptomless; it is nearly always solitary and may be 
situated on any portion of the cervix or else at its orifice, where it 
may involve a part of its circumference and exceptionally extend 
into the canal. The lesion may consist of a smooth round or oval 
erosion, but more often assumes a papulo-erosive type presenting a 
slightly elevated surface of an opalescent grayish white color. The 
induration is difficult to appreciate or demonstrate owing" to the 
situation and normal consistency of the organ; the adenopathy the- 
oretically involves the pelvic glands, but sometimes the inguinal 
glands are enlarged. The evolution of cervical chancre is usually 
more rapid than that of lesions situated elsewhere. The differential 
diagnosis between the common erosions of metritis, endo-cervicitis, 
etc., is difficult, the more so as the two conditions may coexist. 
295 The ordinary erosions generally radiate from the cervical orifice 
and extend into the canal. They more often affect the inferior lip and 
frequently present a red granular appearance, and are accompanied 
by some degree of cervical tumefaction and softening, while their 
duration is often chronic. Whereas the primary lesion rarely extends 
into the cervical canal, and may affect any part of the orificial border, 
it has a smooth surface, frequently opalescent, is not accompanied 
by softening, while its duration is comparatively short. 
The differentiation from the simple venereal sore or chancroid is 
based upon the deeper character of the ulcer, its abrupt, sometimes 
undermined borders, its yellowish and uneven floor, the purulent se- 
cretion, its multiple tendency and the frequent presence of similar 
lesions on the external genitals. 
Extra-Genital Chancres. 
From his statistics Fournier finds that extra-genital lesions con- 
stitute about 7% of all cases, and that they occur regionally in the 
following order of frequency: 
Lesions 
CASES 
Cephalic region, in 849 
Upper extremity, in 78 
Anal and perianal, in 77 
Breast, in 59 
Trunk, in 33 
Lower extremities, in 14 
Cervical region, in 14 
Total 1,124 
The very great disproportion between the lesions occurring in 
the cephalic and all other regions is easily understood, for the lips 
are by far the most common avenue of infection, as shown by the 
following table, also taken from Fournier's statistics: 
Chancre of the Mouth 
CASES 
Lips, in 567 
Tongue, in 75 
Tonsil, in 69 
Gums, in 11 
Soft palate and pillars, in 4 
Internal aspect of cheeks, in 1 
296 Chancre of the Face 
Chin, in 54 
Cheeks, in 24 
Eye, in 21 
Nose, in 18 
Forehead, in 2 
Scalp, in 3 
Syphilitic infection of the mouth or lips results from direct or 
mediate contagion, and may be conveyed in many different ways. 
Sexual perversion, as a means of contagion, need not be discussed 
beyond the recognition of a lamentable clinical fact. 
The vast majority of direct syphilitic infections of the lips and 
mouth result from ignorance. The kiss of a lover, probably un- 
instructed and suffering from a trifling specific lesion, contaminates a 
young girl who, unaware of the nature of her trouble, infects a 
brother, sister, or mother. Whole families have been thus infected. 
Social gatherings of young people, ending in the promiscuous kissing 
of leave-taking, have been the means of starting veritable local epi- 
demics of syphilis from the multiple infections derived from the in- 
significant labial lesion of one individual. Hence it is the duty of 
a physician to instruct and warn his syphilitic patients that the 
trifling mucous patch or erosion they may suffer from is contagious 
and a potential source of danger to others. 
In mediate contagion, infected objects like glasses, forks, pipes 
or other articles susceptible of being held in the mouth, also medical or 
dental instruments, tongue depressors, laryngoscopic mirrors, etc., 
may all convey the disease. (In one of the writer's cases a young 
girl of fifteen was infected through dental instruments.) Many such 
instances of direct and mediate syphilitic infection are recorded in 
Bulkley's instructive work, so aptly named "Syphilis in the Inno- 
cent." 
TAe labial chancre is usually solitary and more commonly affects' 
the lower lip; although occasionally the lesion may be double and 
affect the upper lip, as shown in Plate 133, Fig. 217. It may be 
situated on either the cutaneous or mucous aspect, but very frequently 
involves both surfaces; in consequence it presents different appear- 
ances. When situated on mucous aspect it may be limited to a 
simple erosion, slightly indurated and comparable to a herpetic out- 
break, canker sore or smoker's patch; or it may be extensive of a 
deep red, sometimes of a grayish white due to exudate; the induration 
is pronounced and the lip thickened and everted. When situated on 
297 the muco-cutaneous border (the saddle-shaped labial chancre), the 
cutaneous lesion assumes a solid rather thick brown scab, recalling 
the appearance of the thick crusts of the tertiary rupial lesions. 
Sometimes the cutaneous lesion forms a disklike elevation which 
occasionally, through excessive hyperplasia, becomes exuberant and 
forms a tumorlike mass resembling a malignant growth, from which 
its comparatively rapid evolution differentiates it. An ulcerative 
type, with rather deep excavation, is sometimes observed; it may be 
associated with either the rupial or exuberant form. 
The primary lesions of the mouth and lips are accompanied by 
enlargement of the submaxillary glands, which are apt to become 
matted together and not infrequently present local inflammatory 
symptoms. 
Chancre of the tongue is usually single, of round or oval shape 
and, as a rule, is situated on the superior surface of the anterior 
third. Occasionally the lesion is double, as shown in Plate 132, Fig. 
216. Its appearance, generally, is that of an erosion slightly in- 
durated, but it not infrequently forms a saucerlike depression with 
raised borders and marked induration, well shown in Plate 132, Fig. 
215. An uncommon type is the fissural, in which the lesion is situated 
in one of the lingual folds. Another form rarely observed is accom- 
panied by a very dense induration of the anterior portion of the 
tongue. The adenopathy is represented by enlargement of the sub- 
maxillary glands. 
Chancre of the tonsil, first pointed out by Diday in 1861, is not 
uncommon. It is usually single, round, or oval, but not infrequently 
irregular in shape. Tonsillar chancres are apt to be somewhat pain- 
ful, the degree of pain varying with the character of the lesion, 
which clinically assumes three different forms. 
In an erosive form (the most common) which objectively presents 
the appearance of a red, grayish or opalescent erosion situated on the 
tonsil, the floor is even or else presents the irregularities of the 
normal gland. On palpation the tonsil will be found more or less 
indurated, and there is always marked enlargement of the sub- 
maxillary glands. 
The ulcerative form (see Plate 134) presents the appearance 
of an ulceration, frequently extensive and excavated; of a deep 
reddish brown, else a yellowish gray or a dirty white, due to exudate. 
The induration is always well marked; the adenopathy is considerable 
and in rare instances may involve glands of the neck. (In a case 
observed by the writer, in a young girl, the whole neck was involved 
298 and tumefied, and presented the appearance of a bilateral tuberculous 
lymphadenitis; the swelling, which was enormous, subsided and dis- 
appeared under specific treatment.) The ulcerative form is per- 
sistently painful and deglutition difficult, from involvement of the 
pillars and soft palate. 
The anginal form is the least common. It begins as a tonsillitis, 
the objective characters of which it presents in the red and swollen 
gland. The chancre may be of the erosive or slightly ulcerative type, 
sometimes reddish or covered by a grayish white exudate. Consti- 
tutional symptoms, fever, local pain, etc., frequently accompany this 
form. 
Chancres of the tonsil are not infrequently accompanied by gen- 
eral symptoms, chills, fever, muscular pains, etc., due probably to an 
added element of infection. There is also a tendency to the forma- 
tion of membranous exudates, but the mode of onset, the persistence 
of the local phenomena, the induration of the tonsil, which should 
always be palpated, and the pronounced adenopathy, help to dis- 
tinguish it from other conditions; furthermore a positive solution is 
offered by the finding of the treponema pallidum in the lesion. 
The local treatment should consist of emollient and soothing gar- 
gles, sprays, etc. On subsidence of acute symptoms applications of 
iodine preparations or light nitrate of silver cauterizations are bene- 
ficial. 
Chancre of the eye is comparatively rare. Conjunctival chancres 
occur not infrequently in Russia from the practice the peasants have 
of licking the sore eyes of their children. 
Chancre of the face is uncommon in the adult, and among other 
causes may result from the use of an infected razor. In young 
children it is much more common as a result of the promiscuous 
kissing to which they are subjected. 
Chancre of the breast in women results usually from infection 
by syphilitic nurslings or from the mouth drawing by midwives to 
relieve the engorged breast. Veritable epidemics have resulted from 
this practice. 
Mammary chancres present the characters of cutaneous lesions; oc- 
casionally they are multiple. Fournier mentions a case presenting 
twenty-three distinct lesions, seven on the left and sixteen on the 
right breast. 
Chancre of the nipple may be fissural; it is frequently covered by 
a crust, and may simulate the cracked nipple so common in nursing 
women. This, however, is usually tender and painful, its base supple 
299 and but little, if any, axillary engorgement exists, whereas the chan- 
cre is indolent and only slightly painful, it is, moreover, indurated 
and accompanied by distinct and at times marked adenopathy of the 
axillary glands. 
Chancres of the hand and fingers occur frequently in physicians 
and surgeons in the exercise of their professional duties; for the same 
reasons, midwives, nurses and hospital attendants are likewise ex- 
posed. The right hand and fingers are most commonly affected, the 
dorsal aspect of the hand and the index and medius being the most 
usual sites. 
Digital chancres may appear on any portion of the lateral or 
dorsal aspect of the finger, very rarely on the volar (see Plate 133, 
Fig. 218), but the extremity is the most common locality. The lesion 
may consist of a simple erosion of a beefy red appearance, and it 
may also present different characters according to its situation. In 
the periungual variety, it affects a part or most of the nail border 
and assumes a crescentic or horseshoe shape, or the lesion may 
become exuberant and elevated. In the form described by the late 
R. W. Taylor, as the panaritiumlike chancre, the finger is red, 
tumefied, painful, and presents the objective features of a deep felon. 
Exceptionally in another rare type the lesion may degenerate into a 
vegetating fungous mass. 
Digital chancres differ in some respects from lesions situated 
elsewhere in that they are frequently painful, particularly when they 
involve the nail-bed. The induration may be very great and at times 
affect a whole portion of the finger; the evolution is apt to be slow 
and, in some cases depending upon the type, persists for months. The 
adenopathy of the epitrochlear and axillary glands is sometimes ac- 
companied by a lymphangitis of the forearm. The digital chancre 
occasionally simulates the appearance of a felon or other local infec- 
tion, but its evolution is much slower, less painful, and not accompa- 
nied by the local heat and general symptoms common to those 
conditions. Furthermore, the microscopical examination for the tre- 
ponema pallidum will establish the diagnosis. The local treatment is 
important; the hand should be supported, and mercurial or calomel 
ointment, one part to ten, spread on lint applied to finger. Strapping 
with bands of mercurial plaster is often useful. Should these 
measures prove irritating, or if conditions are painful, recourse may 
be had to bland ointments or moist anodyne dressings. In the 
fungous type occasional touching with the solid stick is indicated, 
and, if need be, the thermo-cautery may be used. 
300 Chancres of the anus or perianal regions are, for obvious reasons, 
more frequent in women; in man they are rare, and usually result 
from sodomy. 
The anal chancre is fissural and is situated in one of the intra- 
anal folds, occasionally it may extend externally beyond the muco- 
cutaneous border, and present a little swelling resembling a sentinel 
pile. In woman, the lesion is most commonly anterior, whereas in 
man it is usually situated posteriorly. By causing the patient to 
bear down, and spreading out the fold with the examining fingers, 
the lesion is brought into view (if need be a small narrow Sims' 
blade may be introduced to facilitate the examination). It is usually 
of limited size, well defined and of a deep red color, it involves the 
floor and lateral sides of the fold, and is fan-shaped when spread 
out; the induration is not always perceptible. It differs from the 
common anal fissure in that the ulceration is larger, broader, much 
less painful and is accompanied by an inguinal adenopathy, which 
is absent in the ordinary fissure. The treponema may be found by 
aspirating the enlarged inguinal glands (see Hoffman's method). 
Perianal chancres present the usual characters of the cutaneous 
lesions, but from their exposed situation are apt to become irritated, 
more or less ulcerated, and painful. They are frequently situated 
in a perianal fold and are then fissural, the cutaneous folds becoming 
swollen and indurated. The adenopathy is represented by enlarge- 
ment of the inguinal glands. 
General Characteristics 
The initial lesion sometimes presents certain peculiarities or may 
vary from the usual mode of evolution. The induration, which in 
some cases is scarcely perceptible or even absent, may in other cases 
be excessive and extensive; in the nodular type it may form hard 
tumorlike masses the size of a large olive. The ulceration, especially 
in the nodular lesions, may, as a result of pressure necrosis, present a 
dark brown, excavated, worm-eaten appearance, or that of superficial 
gangrene. The loss of tissue, however, is at the expense of the 
neoplasm and leaves but little scar. 
Subpreputial chancres, particularly of the nodular type, occurring 
with long redundant foreskins, are very frequently accompanied by 
phimosis and a balanitis, giving an abundant excoriating purulent 
discharge; retraction of the prepuce is painful or impossible, the 
chancre may, however, be felt beneath the prepuce as a hard mass, 
most frequently in the region of the frenum. 
301 Multiple chancres. Usually the primary lesion is single, but not 
infrequently there may be two, three or more lesions (see Plate 
130, Fig. 211). As many as twenty-three have been observed. These 
multiple lesions may appear on any one region or in different regions. 
Successive chancres. As a rule, multiple chancres make their 
appearance simultaneously or practically so, but exceptionally they 
may appear successively at more or less long intervals; Fournier 
mentions a case in which the first lesion appeared on December 26th, 
the second during the first days of January, and a third on January 
10th, or nearly fifteen days later than the first. Gottheil reports a 
still more remarkable case (Amer. Journ. of Swrg., June, 1912), in 
which seven distinct genital and extra-genital chancres existed; three 
situated on penis, one on the lip and three on the chin and face. 
Thirty-nine days elapsed between the date of appearance of the 
first lesion on the genitals and that of the last on the lip. 
Chancre redux (sclerosis recidiva, chancre de retour). Occasion- 
ally, for some unknown reason, the induration remaining after the 
chancre has healed relapses, its surface again ulcerates and pre- 
sents a facsimile of the original sore, for which it might be readily 
mistaken. 
Phagadenic chancre is fortunately of very rare occurrence. Ac- 
cording to Fournier it presents two distinct types, the gangrenous and 
the ulcerative. 
In the gangrenous type (see Plate 130, Fig. 212), the surface 
of the lesion undergoes a gangrenous transformation, recognized by 
its dark or almost black appearance; in time this surface becomes 
separated and is cast off, leaving a surface and border which undergo 
a similar transformation, to be again cast off, and in this fashion 
the destructive process continues until arrested. 
In the ulcerative type, the phagedenic process is of an inflamma- 
tory character. The lesion is of a fiery red or livid purplish color 
with deeply injected borders, and furnishes a sero-sanious or sanguino- 
lent secretion. Under the influence of the process the tissues seem to, 
melt away, the destructive action progressing both in surface and 
depth; hemorrhages from erosion of blood-vessels are not infrequent 
and occur in both forms. The destruction of tissue is more or less 
extensive and results in mutilations and deforming scars involving 
the glans, prepuce, urethral orifice, labia, etc. 
The differential diagnosis between the phagedenic syphilitic lesion 
and the phagedenic chancroid depends upon the different objective 
characters and microscopic examination. 
302 The syphilitic phagedenic chancre is limited to the region affected; 
its borders are raised, and not undermined or abrupt; the surface 
of the lesion presents a dark or fiery red color, according to the type; 
there is marked induration, the destructive process is not accom- 
panied by pain, the secretion is sero-sanious, often sanguinolent, and 
not abundant, while the adenopathy is of an indolent character. 
In phagedenic chancroid, the process may involve several regions; 
the borders are abrupt, often undermined, the inflammatory areola is 
marked and considerable swelling of adjacent tissues may exist; the 
floor is eroded, irregular and of a bright yellowish color; the 
discharge is abundant and purulent, the base is supple, while the 
ulcerative process is more or less painful. The swollen inguinal 
gland is tender and prone to suppuration, the pus is auto-inoculable 
and examination reveals the bacillus of Ducrey (see Plate 165, Fig. 
272). 
Pseudo-phagedenic chancre, described by Ricord, is a destructive 
ulcerative process taking place at the expense of the indurated 
mass itself, and leaving but slight scars. 
Pseudo-chancre (Fournier's syphiloma of the penis) is the name 
applied to a small tertiary ulcerative gummatous lesion situated 
on the glans or sulcus penis, which, from its objective resem- 
blance, may be taken for the initial lesion, but from which it differs 
in two important particulars: the absence of the inguinal adenopathy, 
and the fact that the induration precedes the ulceration instead of 
developing afterward (see Plate 155, Fig. 255). 
Mixed chancre results from a double infection or from the grafting 
of a syphilitic infection upon a simple venereal sore, or vice versa. 
The anomalous features presented by the lesions, the union of an 
induration with an ulceration presenting the characters of a chancroid 
and other dissimilarities, will awaken suspicion which only micro- 
scopic examination and further evolution will decide. 
The diagnosis of the primary lesion is made from the known 
period of incubation, from the objective characters, the induration, 
the adenopathy and the finding of the treponema pallidum. The 
serological reaction is rarely positive before the second or third 
week. The differential diagnosis rests chiefly between herpes, the 
simple venereal ulcer or chancroid and occasionally the ecthymatous 
ulcerative lesions of scabies. 
Herpetic erosions may resemble the simple syphilitic erosions, 
but the onset of herpes is abrupt. It is accompanied by local stinging 
303 and smarting, and successive crops may develop. The herpetic lesion 
in the beginning consists of a number of clear vesicles which coalesce 
at points, and upon rupture leave an irregular superficial bright red 
erosion, whose borders represent segments of circles, the remains of 
the original vesicles, no induration at base, and no adenopathy. A 
variety of confluent herpes, with membranous exudate, is sometimes 
accompanied by a slight lymphangitis and inguinal engorgement. 
The chancre is usually round or oval, with regular borders, an 
indurated base and glandular involvement, and the treponema palli- 
dum is found in the secretion. 
The differential diagnosis between the primary lesion and chan- 
croid : 
Syphilitic Chancre. 
Incubation long, lesion most fre- 
quently single. Erosion usually. 
Borders even and continuous 
with surrounding tissues. 
Color beefy red or grayish, se- 
cretions scanty, serous or seropuru- 
lent. 
Base indurated, indolent satel- 
lite bubo. 
Secretion non-inoculable. Tre- 
ponema pallidum present. 
Chancroid. 
Incubation short, two to three 
days; true ulcer, most frequently 
multiple, excavated. 
Borders abrupt, often under- 
mined. 
Coloi' bright yellow; secretion 
abundant and purulent. 
Base supple, bubo absent or else 
inflammatory. 
Secretion auto-inoculable. Ba- 
cillus of Ducrey present. 
The scabby ecthymatous lesions of genital scabies, sometimes very 
closely resemble the cutaneous syphilitic chancre, from which they are 
easily differentiated by the presence of other lesions in various stages, 
the irritation, itching and the finding of the itch-mite. 
Local Treatment of the 
Primary Sore 
In the local treatment of the chancre it should be remembered that 
the lesion is self-limited, and usually pursues a definite course, during 
which it progresses to a certain point, where it remains stationary 
and then retrogresses. The aim of treatment therefore is to protect 
the lesion from external irritation, and assist its normal evolution. 
Local cleanliness is essential and is best carried out by bathing or 
immersing the organ in hot borated water, two or three times daily. 
Calomel ointment, one part in ten of cold cream or mercurial oint- 
ment, half strength, spread on lint, is usually a comfortable and 
304 beneficial dressing; in some cases strapping with strips of mercurial 
plaster is more efficacious. Should these measures prove irritating 
bland ointments like simple cerate or ungt. zinci may be used. The 
greasy applications have the advantage of not adhering to the sore. 
Moist applications are sometimes more agreeable, especially when 
some local irritation exists. A piece of lint or a thin layer of ab- 
sorbent cotton is applied to the part, and kept moistened with the 
time-honored black wash, a borated solution, or the aromatic wine 
of the French codex, diluted one part to two of water. 
Powders have the disadvantage of caking, and are irritating during 
the progressive period of the lesion, but are sometimes useful in the 
declining stage. The bismuth subnitrate, zinc stearate, aristol, etc., 
may be used. 
Strong cauterizations are harmful, but the occasional use of mild 
solutions of silver nitrate 2 to 3% or, exceptionally, the solid stick, 
are sometimes indicated in lesions covered by exudate or requiring 
stimulation. 
That the primary lesion is at some time prior to the advent of the 
symptomatic adenopathy a purely local manifestation is generally 
recognized, but its excision, although performed countless times, is 
rarely successful in aborting the disease, for the reason that the patho- 
logical infiltration extends for some distance beyond the limits of the 
lesion into apparently healthy tissues, which cannot be included in 
the excision; a possible exception being chancre of preputial margin, 
where a wide circumcision may be done. 
Phimosis, particularly when complicated by balanitis, requires re- 
peated subpreputial irrigations with warm permanganate or borated 
solutions. A solution of silver nitrate, 1 to 10,000 or somewhat 
stronger, is usually preferable. 
305 Syphiloderma 
The most common symptoms of syphilis are those affecting the 
skin and mucous membranes. To these manifestations the name of 
syphilides, first proposed by Alibert, is generally given. 
The syphilides inaugurate the secondary stage, and may, under 
different forms, be present during the first weeks, months, or years 
of the disease; those appearing during the first periods are spoken of 
as the early or precocious syphilides; some may appear at long in- 
tervals of even several years after infection and retain the charac- 
teristic secondary type. These are known as the late or tardive 
secondaries. 
The tertiary syphilides may appear during the first year or they 
may not appear for five, ten, twenty, or even as late as fifty years 
after infection. They are characterized by forms peculiar to the 
third stage. 
The early eruptive manifestations usually affect certain types 
corresponding to the age of the disease. They are more superficial, 
less destructive, but especially more generalized and disseminated 
than the late or tertiary forms, which are not only more profound 
and destructive, but also more circumscribed and apt to limit them- 
selves to certain regions. 
The syphilides have certain characters in common which serve 
to distinguish or differentiate them from other cutaneous affections. 
First.-They are apyretic, and develop slowly. This alone serves 
to differentiate them from the acute exanthemata, which are always 
accompanied by some degree of fever and develop rapidly. (Very 
occasionally during the early constitutional period a slight febrile re- 
action may accompany the eruption.) The syphilides are not accom- 
panied by any local inflammatory phenomena, and they may persist 
for weeks or months when fully developed, if untreated. 
Second.-Syphilitic eruptions are essentially indolent and apru- 
riginous, and unless complicated occasion no pain or itching. These 
two characters differentiate them from the skin affections accom- 
panied by pain or itching. (The syphilides of the scalp or other hairy 
306 parts may occasion slight itching, and also, at times, the small papular 
forms of a lichenoid type.) They are further distinguished from 
other dermatoses by their marked tendency to polymorphism, for dif- 
ferent eruptive elements may be present at the same time. Side by 
side with a roseola may be found some papules, or papules may co- 
exist with, moist lesions, pustular and crustaceous forms, etc., thus 
forming a mixture of differing lesions; whereas in the ordinary skin 
eruptions (with the possible exception of scabies) the tendency is to 
retain the basic eruptive element. 
The syphilides very frequently assume a characteristic color, re- 
sembling that of cut lean ham, first described by Fallopius, or else 
the coppery tint described by Swediaur. Finally, they offer another 
characteristic in their tendency to assume certain shapes either in the 
eruptive elements themselves or in their mode of grouping. Thus the 
papules are generally round and disklike in shape, while the various 
elements may group themselves into circles or segments of circles, 
affect horseshoe shapes or describe arcs, etc. 
The secondary syphilides follow no definite law in their distribu- 
tion, which may take place on any part of the body; but certain forms 
show regional preferences, as, for instance, the forehead, the scalp, 
palmar and plantar surfaces, etc.; per contra, the extensor surfaces 
are more rarely affected. The eruptions may be limited and discrete, 
or they may be profuse, generalized, more or less confluent, and vary 
in intensity according to the type of lesion and character of infection. 
The tertiary eruptions differ from the secondary not only in the 
type of lesion but also in their general characteristics. They are usu- 
ally more profound, involve a greater thickness of skin, if not its 
totality, are more destructive, and leave permanent scars. 
They are also relatively more discrete, more circumscribed, often 
limited to one region, and instead of the secondary polymorphism, gen- 
erally consist of one type, while their eruptive grouping is more 
orderly than in the secondary forms. 
The secondary syphilides may be classified, according to the 
type of the eruptive element they present, into: 
First.-A group in which the initial eruptive elements consist of 
macules, as in the erythematous or macular syphilides. 
Second.-A group in which the eruptive elements consist of pap- 
ules, as in the papular syphilides. 
Third.-A group in which the initial eruptive elements consist 
of pustules leading to the formation of more or less superficial 
ulcerations, as in the pustular or ulcerative syphilides. 
307 Fourth.-A pigmentary form. 
Each of these groups presents a number of varieties or sub- 
divisions due to modifications in the original eruptive element, either 
in the size, shape, mode of distribution, evolution, regional prefer- 
ences, depth of lesion, aspect, etc. Thus papular manifestations may 
be diy, or eroded and moist; if covered with scales, they are papulo- 
squamous. They may be of large size, as in the giant papules, or 
diminutive, as in the miliary and punctate forms. They may as- 
sume different shapes in their arrangement, as in the circinate forms. 
They may become hypertrophied, and through the coalescence or 
fusion of the original elements form elevated plaques, as in condy- 
lomata lata, or they may form diffused eruptive patches. The pap- 
ules may be crowned with diminutive vesicles or pustules, as in the 
herpetiform and papulo-pustular varieties, the resulting incrustations 
forming the papulo-crustaceous lesions, etc. 
In the pustular syphilides the initial element is a pustule which 
desiccates with the formation of a scab and a more or less extensive 
underlying ulceration, as in syphilitic ecthyma. 
Finally, a comparatively rare pigmented form is occasionally seen 
during the secondary period, which is usually described as pigmen- 
tary syphilide or leuco derma syphilitica. 
First Group 
The erythematous type is characterized by rose-colored spots or 
macules. These present no elevation above the skin, scales, or ap- 
preciable involvement of the underlying derma. Two principal va- 
rieties may be distinguished: roseola syphilitica and roseola circinata 
syphilitica. 
Roseola syphilitica (synonyms: syphilis maculosa, syphilitic ery- 
thema), is the most common of all the syphilides, and it is also the 
most precocious, for, as a rule, it marks the advent of the secondary 
period. It is usually noted from the sixth to the seventh week after 
appearance of the initial lesion. Sometimes the interval may be 
shorter, or it may be prolonged to fifty or sixty days, even longer. 
Lang has observed it as late as the seventh month. 
It consists normally in an eruption of disseminated and more 
or less confluent erythematous spots, at first rose-colored, but which 
gradually deepen to a reddish tint (see Plate 135), and ultimately 
become yellowish or tawny as they retrogress. The color at first 
disappears under pressure, but persists when the rash is fully devel- 
oped. The eruption is progressive, and ordinarily appears first on 
the flanks and abdomen, extending to chest, back, and extremities; 
308 it does not, as a rule, affect the face, except at margin of scalp and 
forehead, where it forms one of the varieties of the corona veneris. 
The eruption itself is rarely accompanied by any appreciable symp- 
toms, and may be so pale and slight as to pass unnoticed by the pa- 
tient until his attention is called to it by the examining physician. 
At times it is profuse and confluent, giving a generally mottled ap- 
pearance to the skin resembling measles (see Plate 136), from which 
it is readily differentiated by the absence of fever, catarrhal symp- 
toms, and slower evolution. 
The evolution of roseola is comparatively slow, and is rarely 
completed under seven or eight days; when fully developed, it may, 
if untreated, persist for weeks, whereas it disappears rapidly under 
treatment. Occasionally its onset is accompanied by a slight febrile 
reaction of short duration, and it often coincides with the early 
systemic phenomena of headache, general malaise, angina, dissemi- 
nated polyadenitis, etc. It is also subject to relapse, sometimes re- 
curring at intervals during the first years of the disease. The recur- 
rences generally described under the name of roseola recidiva differ 
from the original eruption in being more discrete and attenuated, 
sometimes assuming a circinate form (see Plate 137). 
Roseola Circinata.-The circinate form differs from the preced- 
ing in two respects: first, it appears at a later period of the disease 
at or near the end of the first year, or in the course of the second or 
third years, sometimes later. Secondly, it consists of rose-colored or 
reddish spots, slightly raised, arranged in crescentic, annular, semi- 
annular, or elliptical shapes, as shown in Plate 137. This form is 
also very apt to recur, and may reappear several times in spite of 
treatment. 
Occasionally roseolar eruptions depart from the usual type and 
may present slight elevations resembling a mild urticaria; exception- 
ally the macules may be diminutive and discrete or sometimes of 
large size, as in the follicular variety shown in Plate 138, Fig. 223. 
Differential, Diagnosis 
The confluent form offers some resemblance to measles, from 
which it is easily differentiated by absence of fever and general 
symptoms and its slower evolution. 
The medicinal rashes of copaiba and antipyrine present some 
similarities, but are distinguished by their ephemeral nature and dis- 
appearance with the cause. The eruption of copaiba is more con- 
fluent, more abundant on the extremities, near the joints, and is 
usually pruriginous. 
309 Papular Syphilides 
This group is in some respects the most important of the second- 
ary syphilides, for it is represented by a greater number of varieties 
and because these are extremely common. While the various forms 
differ from each other in appearance, size, abundance of eruption 
and mode of grouping, they all derive their origin from a common 
basic elemental papule, the different modifications of which furnish 
the many varieties classed as papular syphilides. 
The elemental papule may retain its original form and undergo 
no change for some time, but usually its surface desquamates with 
the formation of scales and is thus converted into a scaly or papulo- 
squamous syphilide. 
The papulosquamous syphilides offer several varieties based upon 
the difference in size of the papule and its eruptive form. These are 
subdivided into: 
The lenticular type. 
The miliary type. 
The giant or nummular type. 
The diffuse type. 
The lenticular type is the most common and characteristic. It is 
usually precocious, and sometimes marks the beginning of the second- 
ary period (see Plate 139). Objectively, it consists of small papules 
about the size of a lentil. They are generally round, and frequently 
describe perfect circles, as in the orbicular variety (see Plate 140). 
The surface is flat, and the general appearance suggests that of a 
round disk slightly elevated above surrounding surface. The color 
of the papule in its initial period is of a rose tint, but it deepens 
when fully developed into a dark red, resembling that of cut lean 
ham; more rarely it assumes a coppery tint, which turns to a lighter 
shade on pressure. The base presents a slight induration, recalling 
the minimal parchment induration of the primary sore. When fully 
developed, the surface of the papule desquamates (this is well shown 
310 in Plate 140, Fig. 227). The scales split, fall off, leaving a bright, 
smooth, shining surface, surrounded by a scaly ring, corresponding 
to the circumferential border of the papule, and constituting the so- 
called collar of Biett, who first described it (this is also well shown 
in Plate 140, Fig. 228). At times some thin fine scales may persist 
on the surface. 
The eruption is successive, appearing in different crops, so that it 
generally presents papules in different periods of development. It 
varies in abundance from a limited number of discrete elements to a 
profuse confluent type, but as a rule the papules are fairly numerous. 
Distribution 
The papulo-squamous syphilides may appear on any part of the 
body, but the extensor aspects of the extremities are much less 
affected; per contra, they exhibit a preference for certain regions, 
such as the back, the nape of the neck, the face, angles of the mouth, 
the forehead, specially at the hair-margin, where they constitute one 
of the varieties of the so-called corona veneris. 
Duration 
When fully developed, the eruption may remain stationary for 
weeks or months and then subside, leaving brown pigmented spots, 
which persist for some time, and then gradually fade, leaving a nor- 
mal integument; under treatment the eruption disappears quickly. 
This form of papular syphilide is very apt to recur; the recurrences, 
however, are generally more discrete, less abundant, and have a 
greater tendency to limit themselves to certain regions and assume 
annular, semi-annular, horseshoe, or bouquet forms. 
Miliary papular syphilides (synonyms: papulo-granular syphi- 
lides, syphilitic lichen, lichenoid syphilide).-This form is uncom- 
mon, and differs from the lenticular in the smaller size of the pap- 
ules and in their shape, which, instead of presenting a flat surface, 
are acuminate or convex. Their size varies from that of a pinhead to 
that of a small lentil, depending upon their period of evolution. To 
the touch they give a rough granular feeling or the sensation of small 
shot inlaid in the skin. 
The miliary papular eruption is much more confluent than the 
lenticular type; it may be very abundant, or else assume annular 
or circinate forms (see Plate 142, Fig. 230). Its duration is longer, 
and it is more rebellious to treatment. In some respects it resem- 
bles lichen planus, from which it occasionally requires differentiation. 
311 Differential Diagnosis 
Like the papular miliary syphilides, lichen planus consists of a 
disseminated eruption of small papules of slow evolution, which may 
also appear in the mouth and tongue and present the appearance of 
mucous patches. It sometimes, as in the annular form, presents a 
mode of grouping observed in the syphilides, and, like them, leaves a 
terminal pigmentation. 
The papules of lichen planus are of a yellowish red, sharply 
raised, with a smooth, shining, flat, waxy surface. They often as- 
sume a bouquet form, or the eruption may form confluent patches, 
especially on flexor surfaces of forearm, where, from reciprocal pres- 
sure, the individual papules become polygonal in shape and represent 
a tiled or mosaic effect. The eruption is symmetrical, and frequently 
abundant on palmar surfaces, the penis, and glans. Its terminal pig- 
mentation occurs successively in different spots, and it is generally 
pruriginous in varying degrees. Sometimes it produces a burning 
sensation. 
The miliary syphilitic papules are generally round, more elevated, 
of firmer consistency, and convex instead of flat; they are more scaly 
and do not present the peculiar waxy polish, and have not the same 
tendency to confluence in patches. The terminal pigmentation, when 
it occurs, is generalized, instead of in spots, and, as a rule, the erup- 
tion is not pruriginous; furthermore, the history, the presence of the 
secondary polyadenitis or other concomitant symptoms, as well as 
the serological reaction, will establish the diagnosis. 
A diminutive form of miliary papules, described as the punctate 
form, is exceptionally observed. It consists of dotlike rudimentary 
papules, reaching the size of a small pinhead, generally covered by 
diminutive scales, and excessively abundant. The eruption appears 
mostly on the back, then the flanks, thighs, and extremities. 
Large papular syphilide (sometimes called giant papules, num- 
mular papules).-This variety is not infrequent, and consists of flat 
papules of exaggerated proportions. They are usually the size of a 
dime, but may be considerably larger; in shape they are round, and 
present a brownish-red or raw-ham color; the surface is usually 
smooth and shining, as if polished. The base has a slight parchment- 
like induration, and upon disappearance they leave a dark-brown pig- 
mentation, which persists for some time. The eruption is discrete, 
scattered, never abundant, and often coexists with the lenticular 
variety. 
Diffuse Papular Syphilide.-This is a rare type, due generally to 
312 the coalescence of individual papules forming irregular eruptive 
patches of varying extent, but which may sometimes cover a large 
surface, such as the popliteal space, the axilla, genitocrural folds, the 
palmar and plantar surfaces, etc. The appearance as to color, ele- 
vation, and the mode of evolution conform to that of the ordinary 
papular eruption. 
The papular syphilides present certain peculiarities dependent 
upon the degree of desquamation, the mode of grouping, and the 
regions affected. At times the desquamation, never abundant, at- 
tains an unusual degree; under such circumstances the papules are 
covered by whitish or grayish scales, cast off quickly, as a rule, but 
which to some extent resemble psoriasis, and for that reason are 
usually termed psoriasiform syphilides. 
The papule likewise varies greatly in its degree of development. 
Sometimes it is very marked, and, owing to the dense infiltration, its 
base presents a degree of hardness comparable to the parchment-like 
induration of the initial lesion; per contra, the papules may be so 
small, so rudimentary, as to be hardly appreciable except as a slight 
thickening of the superficial cutaneous layers, accompanied by red- 
ness and exfoliation. In some cases the surface of the papule, in- 
stead of being uniformly flat, presents a slight depression in the cen- 
tre, which, from the dark-brown color it assumes, contrasts with the 
normal color retained by the borders. In other instances the papule 
may, from its volume, elevation and firm consistency, resemble a 
tertiary tubercle; it may even become excoriated and covered by a 
crust. This form is usually a late manifestation, and appears to be 
intermediary to the tertiary tubercular lesions; its differentiation is 
often difficult. , 
The circinate syphilides also present many varieties. The annular 
forms are constituted by eruptive rings of variable size, but rarely 
exceeding the circumference of a twenty-five-cent piece, and enclos- 
ing a central zone of normal skin. 
The ar ciform syphilides describe curves representing segments 
of circles, varying from a third to half or more of the circumference. 
This variety is very common. Sometimes the free extremities of the 
segments unite or conjugate and form a series of arcs resembling a 
garland or festoon. This peculiar arrangement is observed chiefly 
on the face, neck, and shoulders, but it especially affects the integu- 
mentary region surrounding the mouth, either on the upper or lower 
lip, sometimes the chin. The lesion consists of a thin eruptive line 
composed of small, rather pale, or grayish papular elements, cov- 
313 ered by fine scurfy scales, and describing a series of arcs like a fes- 
toon. This peculiar manifestation situated around the mouth is char- 
acteristic of syphilis. 
The concentric varieties are rarer forms, and are constituted by 
a series of parallel circles or arcs (see Plate 142, Fig. 231). Not in- 
frequently, these different circinate varieties present a more or less 
pigmented brownish centre. 
Varieties in the Mode of Grouping.-The late secondary papular 
syphilides differ from the earlier or precocious forms in being less 
disseminated and profuse, and in being relatively more circumscribed, 
regional and disposed to affect certain modes of grouping. 
The grouped papular syphilide, also called the bouquet form, is 
constituted by a varying number of papules closely distributed within 
a given area, in much the same manner as flowers are assembled in 
a bouquet; several such groups may occur in different parts, the 
regions mostly affected being the back, particularly in the scapular 
regions, the nucha, forehead, scalp, etc. 
A rare mode of grouping, styled the corymbiform, consists in the 
arrangement on one or more regions of the skin of a large central 
papule, surrounded by a number of small satellite papules, more or 
less confluent (see Plate 141). 
When a papule occurs in a cutaneous fold it frequently cracks at 
the point of folding and degenerates into a fissure, which secretes 
slightly or may be covered by small incrustations. This commonly 
happens at the angles of the mouth, the nasojugal folds, post- 
auricular folds, etc. (see Plate 142, Fig. 231). 
A peculiar modification of this process takes place at the naso- 
jugal fold, where, in the slight fissure caused by the infolding of the 
papule at this point, there develop a number of very small, dry, warty 
or papillomatous excrescences. This curious lesion is observed in 
syphilis only, and was regarded by Ricord as pathognomonic of the 
disease. 
Palmar and plantar syphilides, also described as psoriasiform 
syphilides, are a common and important variety of the papular mani- 
festations. They have considerable diagnostic importance, which is 
further enhanced by the fact that not infrequently they are the only 
visible evidence of the disease, especially in insufficiently treated sub- 
jects. The eruption is usually of the lenticular type, but it may be 
diffuse or circinate. 
The lenticular type consists in the appearance on the palmar sur- 
face of rose-colored spots, visible under the thick epidermis. These 
314 develop into slightly raised papules of varying size, usually round, 
and covered at first with grayish scales. When these are cast off 
the denuded papules assume a brownish-red or raw-ham color, and 
are surrounded by a scaly border or collar. They feel dry and rough 
owing to the circumscribed thickening of the epidermis, and usually 
number from four to six elements, sometimes less (see Plate 143, 
Fig. 233). 
In the diffuse type the eruption is spread over a variable extent 
of the palm, which, owing to the infiltration, feels dry, rough, and 
presents here and there grayish exfoliating spots, with scaly borders. 
The color is generally a sombre red, while fine white or chalky lines, 
corresponding to the normal furrows, are also observed. 
In the circinate form the papules may be grouped in semi-annular 
or crescentic shapes, or else the papules meet so as to form continu- 
ous tapelike bands, which describe various curves. 
A horny type also occurs, in which the papules, from an exag- 
gerated dermic infiltration, form dense, hard callous spots, resem- 
bling corns, which patients not infrequently dig out with a knife- 
point. 
The palmar syphilides are indolent, and may persist for long 
periods and recur despite treatment, to which they are sometimes re- 
bellious. They are very apt to become painful, especially in individ- 
uals with manual occupations, in whom the normal palmar and digi- 
tal flexures become the seat of fissures and raghades, usually of a 
deep and very painful nature. 
Plantar Syphilide.-With slight exceptions, the course of the 
palmar and plantar eruptions is identical (see Plate 140, Fig. 228). 
In the plantar region the eruption is paler in color, excepting when it 
appears on inner lateral border of foot, where it may have a yellow- 
ish coppery aspect. The desquamation, owing to the thickness of the 
skin, occurs in larger and thicker scales than in the hand, while fis- 
sures are rare complications. When the papules are situated in the 
interdigital spaces, they become converted into moist, exuberant le- 
sions, owing to the natural moisture of the parts (see Plate 147). 
The eruption is, as a rule, always limited to the palmar and 
plantar surfaces, and very rarely extends to the dorsal regions of 
these parts. It is frequently symmetrical, and affects both hands, 
but not necessarily, and when present on the hands it not uncom- 
monly appears on the soles as well. 
While there is no particular period for the appearance of these 
eruptions, the lenticular is the most common and precocious form; 
315 it often coincides with and corresponds to the type of the general 
papular eruption. The diffuse and circinate varieties are generally 
tardive, appearing during the second or third year, but frequently 
much later, and in full tertiary period. Well-characterized palmar 
and plantar manifestations are pathognomonic of syphilis. 
The flexor surfaces of the fingers are sometimes involved by ex- 
tension from the palmar manifestation, but may be affected independ- 
ently. The fingers are also apt to be the seat of small horny papules 
similar to corns. These are usually situated in the finger-pulp. 
The clinical diagnosis of the papulo-squamous syphilides rests upon 
their general apruriginous and indolent characters, their tendency to 
circinate forms, mode of grouping and regional preferences, as well 
as the history of recent syphilitic antecedents, the possible remains of 
the initial induration, more probably the satellite bubo, the coincidence 
of other secondary manifestations, mucous patches, adenopathies, 
scabby lesions of the scalp, etc., and the further confirmation given 
by the serologic test. 
Differential Diagnosis 
The papulo-squamous syphilides, from their resemblance, may be 
mistaken for some forms of psoriasis. This is especially true of the 
palmar and plantar eruptions, and of some marked scaly types occur- 
ring on the back. The chief points of difference are that psoriasis, 
while symmetrical in its distribution, shows a strong predilection for 
the extensor surfaces (the knees and elbows particularly), whereas 
the syphilides affect the flexor surfaces principally, and never occur 
isolated on the knees and elbows. The scales in psoriasis are more 
abundant, imbricated and silvery white, while they usually cover all 
of the eruptive papular base. The finger nail drawn across the crust 
leaves a chalky or micaceous streak, while its forcible detachment 
leaves a bright-red base with small red or purplish points, bleeding 
slightly. 
In the squamous syphilides the scales are thinner, lamellar, and of 
a dull or grayish appearance; they do not cover the eruptive base, 
are less adherent, and upon removal leave a surface at first somewhat 
red, but which soon assumes a brown or tawny appearance, without 
the characteristic bleeding points of psoriasis; furthermore, the cor- 
roborative evidence of other lesions, mucous patches, adenopathy, 
isolated papules, etc., is usually found. 
The differential diagnosis between the diffused form of palmar 
syphilide and chronic dry eczema of the palm which in some cases 
316 presents an identical appearance is often difficult. The chief points 
of difference being that in palmar eczema the eruption is frequently 
diffused over entire palm, including fingers, and shows a tendency 
to spread from palm to lateral or dorsal regions of hands and fingers, 
while the eruptive borders are flat, irregular and broken, diminutive 
vesicles also develop at intervals, and it is apt to be intensely pru- 
riginous. 
The palmar syphilide is usually confined to the palm, and only 
exceptionally involves its entirety or extends to fingers. The eruptive 
base is thickened, infiltrated and indurated, while the borders are 
generally in relief, well defined, and frequently circinate. The further 
evidence of the serologic test may be necessary. 
P apulo-crustaceous Syphilides 
These are generally composed of small or diminutive papules, 
characterized by the formation of thin, easily detached crusts, which 
leave a moist, seemingly exudative surface without erosion or ulcer- 
ation, or else the crust may form through the intermediary of a small 
vesicle crowning the papule, as in the papulo-vesicular or herpetiform 
type, or of a diminutive pustule, as in the papulo-pustular, acneiform 
variety, and in syphilitic impetigo. 
Herpetiform syphilide (synonyms: miliary herpetiform syphilide, 
vesicular syphilide, syphilitic varicella') consists of very small papules 
capped by ephemeral vesicles, which on rupture leave a diminutive 
crust. The eruption is markedly abundant and confluent. Its favorite 
locations are the trunk and extremities. It nearly always appears 
during the first or second year of the infection. 
Acneiform syphilide (synonyms: syphilitic acne, miliary pustular 
syphilide, syphilide varioliformis) is a papulo-pustular eruption con- 
stituted by small hemispherical papular elevations with an indurated 
base, and varying in size from a pinhead to that of a small pea. The 
apex of the lesion is crowned by a diminutive pustule which, upon 
rupture, leaves a small brownish or yellowish crust covering a slight 
superficial erosion. This eruptive form is usually discrete, and affects 
the face, scalp, chest, back and neck. It often coexists with papular 
varieties, and is very frequently found in the scalp, where it princi- 
pally constitutes the little scabby lesions so common in that region. 
The differentiation between this form and acne vulgaris, which it may 
greatly resemble, is based upon the fact that common acne is essen- 
tially a chronic affection beginning in adolescence and continuing to 
puberty and beyond, and that it is composed of lesions in different 
317 periods of evolution, whereas syphilitic acne is comparatively tran- 
sient, has a wider range of dissemination, is less inflammatory, and 
is constituted by elements belonging to the same period of evolution, 
while it is often associated with other papular lesions, mucous patches, 
adenopathy, etc. 
Syphilitic impetigo, or impetiginous syphilide, so-called from the 
aspect and characters of the crusts which resemble those of ordinary 
impetigo (see Plate 148, Fig. 241). The eruption consists of small 
pustules closely distributed and developing on a common red, infil- 
trated, papular base. As a result of the close grouping, the individual 
pustular crusts unite or coalesce, to form more or less extensive in- 
crustations presenting an uneven or granular appearance. They are 
of variable thickness, dry, porous, friable, and of a yellowish or amber 
color. This tendency to assume yellowish tinges distinguishes syph- 
ilitic impetigo from the ecthymatous varieties in which the crusts are 
of a darker color, brown, or almost black. 
The skin beneath the crusts is generally superficially ulcerated or 
eroded; occasionally when the eruption has existed some time the 
underlying erosion, instead of being depressed, becomes raised or 
slightly convex, so that when deprived of its crust the lesion resem- 
bles a moist papule. The crusts are but slightly adherent. 
The eruption occurs most frequently in lymphatic subjects of a 
blond type, women and children particularly. It is nearly always cir- 
cumscribed, and exhibits marked preference for certain regions, the 
scalp margin of the hair, beard, eyebrows and the face, especially the 
forehead, nostrils, and labial commissures; it rarely affects other 
parts. Resolution takes place with the detachment of the crusts and 
cicatrization of the ulceration, with a remaining brownish pigmenta- 
tion persisting for some time. 
Syphilitic impetigo is usually a benign eruption responding readily 
to treatment. 
Papulo-erosive Syphilides 
These are simply papules which, instead of remaining dry and 
squamous, become eroded, moist and secreting, owing to their localiza- 
tion. They are identical in appearance and present the same char- 
acters as the lesions appearing on the mucous surfaces, and will be 
described with them. 
Pustular or Ulcerative Syphilides 
These are the latest of the secondary forms to develop, and do not 
ordinarily appear until after the first six months of the disease, and 
more frequently at a later date. 
318 The lesions consist of ulcerations covered by a scab. They present 
some analogies with the tertiary ulcerative forms, but differ from 
them in the lesser extent and more superficial character of the ulcer- 
ation. They may begin as a small inflamed spot about the size of a 
lentil, from which the epidermal layer soon separates and becomes 
converted into a thin crust, which gradually thickens and covers an 
underlying ulceration, or else the morbid process begins with a pus- 
tule which eventually dries up, to form a scab covering an ulceration. 
The further course is identical in both instances. 
Syphilitic Ecthyma or 
Ecthymatous Syphilide 
The secondary ulcerative syphilides have been variously described 
as pustulo-crustaceous or pustulo-ulcerative syphilides, ecthymatous 
syphilides, 'flat, lenticular, erosive and deep ecthyma, impetigo rodens, 
rupia, syphilide pemphigoides, etc. Many of these confusing desig- 
nations applied by the older writers to variants of the same morbid 
process have become obsolete. 
Syphilitic ecthyma is generally initiated by a somewhat flattened, 
yellow pustule seated on an infiltrated base and surrounded by a dark- 
red inflammatory areola. The pustule eventually desiccates, to form 
a crust covering an ulceration, and the lesion progresses through the 
formation of a raised pustular zone surrounding the peripheral mar- 
gins of the crust. The desiccation of this pustular zone or annular 
pustule adds to the size of the original crust, which becomes still fur- 
ther enlarged through the repetition of the same process. "When the 
evolution is completed the lesions appear as round scabs surrounded 
by a red areola. They vary in size from a lentil to that of a dime 
or larger. These dimensions distinguish them from the papulo-crus- 
taceous or papulo-pustular forms, which are always small, rarely ex- 
ceeding the size of a lentil and from the tertiary incrustations, which 
are generally of much greater extent. The crusts are adherent, com- 
pact, of variable thickness, and present varying shades of dark-brown 
or greenish tints. 
The underlying ulceration is usually round, shallow, and with well- 
defined, abrupt borders, while the floor is yellowish or reddish, and 
covered by a puriform, concrescible secretion which soon furnishes a 
fresh crust to the denuded lesion. "When fully constituted the erup- 
tion may remain stationary for months. When it retrogresses the 
red areola fades and disappears, the crusts become gradually detached, 
fall off, and leave a terminal dark-brown pigmentation which may 
319 persist for long periods, to be ultimately followed by more or less 
appreciable superficial scars. 
The eruption is less disseminated than the papular forms, and 
exhibits a tendency to group itself in certain regions, notably on the 
anterior aspects of the lower extremities, the scalp, forehead, and hairy 
regions of the face. 
Ecthymatous eruptions may occur isolated, but are more fre- 
quently associated with papular types. 
A severe form is occasionally observed beginning with a large flat 
pustule, which from its greater extent forms large stratified rupial 
scabs. 
The term rupia, meaning filth, is non-descriptive, and is usually 
applied to the large characteristic oyster-shell incrustations of the 
tertiary ulcerative syphilides. 
Frambcesia Syphilitica 
This is a rare type, consisting of a vegetating papillomatous 
process springing from the floor of an ulceration and forming an 
exuberant raspberry-like mass resembling the lesions occurring in 
yaws or frambcesia tropica. 
This form is usually limited to a few lesions grouped together. 
(See Plate 149, Fig. 243.) 
Malignant Secondary Syphilides 
This designation is usually applied to ulcerative manifestations of 
a tertiary type appearing during the early period of the disease, but 
Fournier describes as malignant certain papular forms, which from 
the exaggeration and intensity of the morbid process depart from the 
type ordinarily observed. These forms denote a severe infection and 
are usually associated with more or less serious systemic symptoms 
(iritis, cephalalgia, periostitis, myalgia, often syphilitic fever, nervous 
and other functional troubles, etc.). They are, furthermore, particu- 
larly rebellious to treatment. Three types are described: 
1. A papulo tubercular syphilide. 
2. An exfoliating papular syphilide. 
3. A pigmented type, or syphilide papulo-nigricans. 
Papulo-tubercular syphilide.-In this form the individual papules 
acquire an exaggerated volume and resemble the tertiary tubercles, 
whence the name papulo-tubercular. They are of a bright red, dif- 
fering in this respect from the raw ham or coppery tints of the or di* 
nary lenticular type. In shape they are round, sometimes perfectly 
320 so, and are firm to the touch. The eruption may consist solely of 
these exaggerated lesions, but frequently some lenticular papules are 
present. It retains the typical secondary characteristics in its abun- 
dance and in its dissemination, which shows preference for the face, 
scalp and lower extremities. It also exhibits a marked tendency to 
confluence, and may literally cover parts affected. Sometimes it pre- 
sents an annular form, and through the fusion of the individual ele- 
ments describes partial or complete circles with some pigmentation of 
the central integumentary zone. (See Plate 138, Fig. 224.) The evo- 
lution is slow, chronic, and when developed the eruption may last for 
months without showing signs of resolution. 
Papulo-foliaceous syphilide.-The tendency to confluence exhib- 
ited by the secondary malignant forms results in diffused placards, 
due to the coalescence or fusion of the individual elements. These are 
generally situated on the back, and may form raised eruptive plaques 
the size of the palm or considerably larger. The borders are poly- 
cyclic, and show vestiges of the original papules. The desquamation 
is abundant, and occurs in rather large, thin foliaceous scales, like 
onion skins, differing from those of psoriasis. 
P apulo-nigricans syphilide.-In this form the terminal papular 
pigmentation is greatly intensified, and presents very dark brown or 
almost black shades, which persist for long periods exceeding a year, 
and are very slow to fade. 
Syphilitic affections of the nails are not infrequent during the sec- 
ondary period. The nail itself may be affected in different manners, 
or else the nailbed and periungual regions may be the seat of the 
lesion. 
Onychia.-The different varieties of onychia are due to local dis- 
turbances affecting the nutrition of the nail. In one form the nail 
becomes rarefied and brittle, while the free border splits constantly; in 
another form the nail becomes partially separated from its bed and 
loses its natural polish, or else the separation may end with complete 
detachment of the nail, which then falls off, leaving a denuded matrix 
and nail bed. The loss of the nail is not permanent, however, for a 
new one forms, its formation sometimes beginning before the old one 
is entirely detached. Ordinarily the new nail presents defects, being 
of unequal thickness, with transverse ridges, and frequently arched. 
Occasionally, in a rarer variety, pachyonichosis, the nail becomes hy- 
pertrophied and greatly thickened. All of these lesions are painless. 
Perionychia.-In the periungual affections certain varieties are 
also observed. In the squamous form a papule develops at the nail 
321 border or beneath the free edge of the nail. In another variety, the 
integumentary nail border becomes thickened and callous, sometimes 
on one side only. Removal of the callous and thickened epidermis by 
paring or other means leaves a slightly sensitive red surface, which 
is soon covered by new thickened epidermis. This little lesion may 
persist for a long period; it is indolent, but may become painful 
through the development of little fissures at the cutaneous angles. In 
another variety the nail border (usually on one side only), and more 
rarely the root, becomes inflamed, thickened, of a deep red or brown- 
ish-red color, and somewhat sensitive. Its appearance suggests an 
ordinary whitlow, from which it differs by its slow evolution and 
lesser degree of pain. When fully developed the lesion may persist 
for a long time in the same dry condition. When it affects the big toe 
it is more painful and may terminate in an ingrowing toe-nail. 
The ulcerative form of perionychia may be consecutive to the pre- 
ceding or develop primarily. It consists of an ulcerative process, in- 
volving a part or all of the nail border and frequently the nail bed. 
The ulceration is generally deep, irregular, and surrounded by a thick- 
ened, prominent border of a deep red color; its secretion is sero- 
purulent, sometimes sanguinolent, and flaky. The border may also be 
covered by unhealthy granulations, which degenerate into a fungous 
mass, partially covering the nail, and occasionally when complicated 
by inflammation the whole finger-tip becomes tumefied and flattened. 
When the lesion affects the big toe it is especially apt to be compli- 
cated by inflammatory conditions owing to the situation. In this va- 
riety of perionychia the nail, as a rule, falls off. (See Plate 144, Fig. 
234.) The evolution is slow and chronic. 
Pigmentary syphilide (synonyms: syphilitic leucoderma, syphilitic 
leucopathy, syphilitic vitiligo), first described by Hardy in 1854, con- 
sists of a localized hyperpigmentation of the skin, which, although 
occurring in different regions, is almost always distributed around the 
neck and chiefly in women. The appearance of the pigmentation va- 
ries somewhat. Sometimes it occurs in streaks or bands around the 
neck, especially on the lateral aspects, or it may present a mottled 
effect or that of a coarse meshwork. (See Plate 144, Fig. 235.) The 
manifestation is primarily a pigmentation, and does not result from 
any previous lesion of the skin, which in all other respects remains 
normal. Pigmentary syphilide, which is not very common, is a sec- 
ondary manifestation, ordinarily developing in the first year. Its 
duration is indefinite, and it is but slightly affected by treatment. 
Syphilitic alopecia is a comparatively precocious symptom, occur- 
322 ring usually within the first six months of the disease. It may affect 
any hair-covered region, the scalp, beard, eyebrows and genitals, but is 
most commonly observed on the scalp and under two forms. 
In one form, the loss of hair is diffused over the entire region, and 
results in more or less thinning of the hair, which may become per- 
ceptibly less abundant and sometimes very markedly reduced in quan- 
tity, particularly over temporal regions. This form offers nothing 
characteristic, and does not materially differ from the loss of hair ob- 
served in the convalescence from severe illness or other impoverished 
conditions. 
In another form, which is characteristic and often diagnostic of 
syphilis, the hair falls out in spots, sometimes circular but more often 
of irregular contour, and which have been likened to small clearings 
in a forest. The bare spots are always numerous, generally small, and 
chiefly distributed over occipital and parieto-temporal regions, to 
which they give a moth-eaten appearance. Sometimes the spots, 
through confluence, become merged and form incompletely denuded 
areas with irregular or polycyclic borders. The denuded areas vary 
in size, but may be quite extensive, especially over parieto-temporal 
regions. The condition is very apparent even in mild cases, for the 
surrounding hair does not completely cover or conceal the bare places. 
(See Plate 128, Fig. 208.) This form of syphilitic alopecia differs 
from alopecia areata in the greater number of affected areas which 
it presents and in the incomplete denudation of the bare spots, in 
which some hairs generally remain. The presence of other secondary 
manifestations furthermore confirms the diagnosis. In alopecia areata 
(see Plate 128, Fig. 207), the affected regions are few in number 
and frequently limited to one. The denudation is complete and leaves 
a characteristic ivory white, smooth bald spot. The eyebrows, beard 
and genital regions may be similarly affected by syphilitic alopecia. 
The degree of alopecia varies from a simple loosening of the hair 
with imperceptible loss to a very marked reduction or extensive de- 
nudation; complete baldness is extremely rare. The loss of hair is 
temporary and is eventually replaced by a new growth. 
323 Moist Syphilides 
The moist syphilides developing on the mucous surfaces and in 
certain regions of the skin are the most important of all the secondary 
manifestations, not only because of their great frequency and tendency 
to recurrence, but because they are all secreting lesions and contagious, 
and without question furnish the most prolific source of infection. The 
initial lesion occurs but once, and is limited in its capability of convey- 
ing the disease to its duration, which is measured in weeks, whereas 
the moist lesions may recur for years, always retaining their contagious 
character. 
They are essentially secondary, and appear during the first months 
of this period, and may occasionally be contemporaneous with the 
roseola, but as a rule appear later. 
Moist Cutaneous Lesions 
The moist cutaneous lesions are constituted by erosive papules, 
sometimes called cutaneous mucous patches, moist, humid and secret- 
ing papules, condylomata, etc. 
When a papule develops in regions in which the skin is normally 
thin and moist, such as the intergluteal, genitocrural, perianal, scrotal, 
submammary, axillar, interdigital spaces of the feet, etc., it loses its 
epidermal covering through maceration and friction and is converted 
into a denuded lesion with a raw, moist secreting surface. In other 
respects it retains its papular characteristics of a generally round, 
slightly elevated, flat lesion. The eruption may likewise be discrete 
and confined to a few elements, or else confluent, and through fusion 
form more or less extensive plaques or condylomata. Further modi- 
fications may take place, resulting in a great increase in size, or hyper- 
trophy of the individual elements, as in the papulo-hypertrophic va- 
riety, and at times a papulo-ulcerative variety is also observed. 
The moist papules occur with greatest frequency in the inter- 
gluteal, perianal and genital regions, especially in women. When they 
develop between the buttocks the eruption, which is ordinarily sym- 
metrical, may be limited to a few discrete papules, generally of large 
324 size, presenting a smooth, red, secreting surface. These are apt to he 
pruriginous and painful from irritation caused by the pressure and 
rubbing of opposing parts, particularly in the act of walking. 
The moist papules occurring in the perianal regions are generally 
closely distributed, and as they develop become merged and coalesce 
to form the eruptive plaques known as condylomata lata. (See Plate 
145, Fig. 236.) These are elevated above surrounding parts and pre- 
sent a more or less eroded flat surface of varying shades of red, some- 
times with grayish streaks, depending upon the degree of irritation. 
The borders are scalloped, and represent vestiges of the peripheral 
margins of the papules entering into the formation of the lesion, 
while the secretion, which may be fairly abundant, is puriform and 
foul-smelling. 
The perineal raphe is frequently invaded by moist lesions, and may 
become infiltrated, greatly thickened and prominent. 
The scrotum is also a very common site for the moist lesions. These 
may be limited to a few smooth, beefy-red elements, of large size, or 
they may be numerous, more or less confluent, and assume circinate 
forms. When situated at the penoscrotal fold they are usually saddle- 
shaped. The scrotal lesions are often accompanied by similar ones 
developing on corresponding inner aspects of thighs. 
The female genital regions, owing to their anatomical disposition, 
delicate texture of the skin, mucous surfaces, heat and moisture, offer 
the most fertile field for the development of moist lesions, which in 
consequence are found there in greatest abundance and in different 
varieties. 
The vulvas (especially the free borders), genito-crural folds and 
superior internal aspects of the thighs are the parts chiefly affected, 
but extension to the perineum is common. 
The eruption may, as elsewhere, consist of a few discrete moist 
papules, distributed on the vulvae or genito-crural folds and sometimes 
associated with dry lenticular papules, or the eruptive elements may be 
numerous, confluent, and through fusion form plaques with polycyclic 
borders, which may occasionally be extensive and diffused over a con- 
siderable area. Such lesions usually present a reddish, inflamed ap- 
pearance, and are also pruriginous, sensitive, and furnish an offensive, 
purulent secretion. 
Papulo-Hypertrophic Variety 
The papulo-hypertrophic variety is simply an exaggerated type 
resulting from neglect and lack of local treatment of the preceding 
325 lesions, whereby the individual papules become greatly increased in 
size and amplified. Under these conditions an isolated hypertrophied 
papule may form a tuberosity or small tumor-like mass, the size of a 
hazelnut, and generally round and somewhat convex. The eruption, 
which may be limited to a few isolated elements, is more often con- 
fluent and agminate, and consists of hypertrophied, sometimes lozenge- 
shaped papules, distributed over cutaneous aspects of vulvae, particu- 
larly the free borders, where they become more or less fused and may 
extend to genito-crural regions and form condylomata presenting an 
uneven or mulberry-like surface. (See Plate 148, Fig. 240.) 
These may grow luxuriantly, become exuberant, and form large, 
vegetating, cauliflower-like masses, which in extreme cases sometimes 
attain huge proportions and may extend from vulvas to genito-crural 
folds, internal aspect of thighs and perineum. 
These lesions, unless irritated or inflamed, are generally of a pale 
red or reddish-gray tone, but they are frequently aggravated by in- 
flammatory complications and then present a more or less eroded, often 
ulcerative, uneven surface of a deep red color, with fissural indenta- 
tions corresponding to the points of fusion of the original papules. 
(See Plate 148, Fig. 240.) The vulvae are tumefied, the borders par- 
ticularly, while the surrounding skin is red, inflamed and excoriated. 
The whole appearance is repulsive and loathsome, and the abundant 
secretion is indescribably offensive and nauseating. 
The other localities in which moist papules are sometimes observed 
are the axilla, the interdigital spaces of the toes (see Plate 147, Fig. 
239), and the submammary, abdominal and other cutaneous folds, es- 
pecially in fat persons. 
Ulcerative Varieties 
Sometimes the surface of a papule, instead of being merely eroded, 
becomes the seat of an ulcerative process, which may extend quite deep- 
ly, but is usually confined to the neoplasm itself and leaves no scar. 
More rarely, true ulcerations, corresponding to the ecthymatous 
lesions, but minus the crust, are observed. These occur chiefly on the 
vulvae, and are generally round, with a smooth, yellowish floor, abrupt 
margins and red areola. They occasionally undergo fusion and form 
polycyclic ulcers. In their general appearance they resemble chan- 
croids, from which they have to be differentiated. 
The moist cutaneous syphilides may pursue an indolent course, but 
from their character, exposure to irritation and complications, are 
most frequently sensitive and sometimes extremely painful. They also 
326 persist for long periods if not treated, and not infrequently the differ- 
ent lenticular, moist, hypertrophic and ulcerative forms are found va- 
riously associated, and occasionally all may coexist. The aspect varies 
in color from a pale or rosy red to the deepest shades, according to the 
degrees of irritation, and at times the lesions present a pale gray or 
dirty white exudative appearance. 
The moist lesions are generally the result of neglect and personal 
uncleanliness, and are seldom seen in persons of the better class, ex- 
cept in mild forms. The interdigital and the large vegetating condy- 
lomatous lesions are only observed in persons of inconceivably filthy 
habits, of which the low class of prostitutes furnish the most striking 
examples. 
They all yield readily to suitable local treatment, which may be 
summed up as rest, local cleanliness through frequent bathing, isola- 
tion of parts, and keeping them dry with any inert desiccating powder, 
zinc oxide, bismuth, talcum, etc. Under these measures the lesions 
desiccate, retrogress, and lose their painful character. Even the large 
cauliflower masses will disappear under this treatment, although more 
slowly. Their resolution may be hastened by applications of silver 
nitrate solutions, 2 to 3 per cent., or occasionally a small actual cautery 
point may be applied. Excision is seldom, if ever, necessary. 
The syphilides appearing on the mucous surfaces consist of ero- 
sions or superficial ulcerations, to which the common name of mucous 
patches is generally given. These, as the name indicates, may appear 
on any mucous surface, but they are principally confined to the mouth, 
throat and external genitals in both sexes. They have been observed 
in the larynx, nasal fossa and palpebral commissures, but whether they 
also occur on the mucosa of the intestine, stomach, esophagus, etc., is 
not susceptible of proof. 
The mucous patches of the mouth, throat and tongue are probably 
the most common of all syphilitic manifestations, and are relatively 
more frequent in man than in woman, who, as a rule, takes better care 
of her mouth, and who, with few exceptions, does not smoke. Mucous 
patches are found in all parts of the mouth and throat, but show a 
marked predilection for the tonsillar and faucial regions, tongue and 
lips. They also present different types, usually described as erosive, 
papulo-erosive, ulcerative and depopulating. 
Erosive Type 
This is by far the most common, and constitutes the true typical 
mucous patch. It consists of small, superficial erosions or denudations 
327 of the mucous surface through loss of its epithelial covering. Such 
lesions are flat, smooth, and usually present a base of deeper red than 
the surrounding surface. Occasionally they are of a lighter hue, com- 
parable to a pale rose color; but their appearance varies considerably, 
for they often present grayish or whitish tints, ranging from a pale, 
opalescent gray to milky white, occasionally blue-white. The erosions 
are generally of small extent, of round, oval or irregular shape, but 
are frequently fissural, and then constitute the little sensitive lesions 
so often seen in the small furrows on the dorsum and edges of the 
tongue and labial commissures. The erosive type is not only the most 
common but also the most important, for it furnishes the small, insig- 
nificant but contagious lesions, which may recur for years in the mouth 
and on the genitals, and sometimes practically constitute the only ob- 
jective symptoms of the disease. 
Papulo-Erosive Type 
This is constituted by the eruption of papules on the buccal and 
lingual mucosa. When a papule develops on a mucous surface, it is 
deprived of the dry epidermal covering of its prototype appearing on 
the skin, and becomes a moist and secreting lesion; otherwise it does 
not differ from it, and appears as a round, slightly raised disk-like 
Jesion, of opalescent or whitish aspect. (See Plate 146, Figs. 237, 
238; and Plate 139, Fig. 226.) It occurs mostly on the tongue, lips 
and soft palate, where it occasionally forms eruptive patches with 
circinate borders. 
When situated at the labial commissure it forms a fissure or 
raghade, while its cutaneous margin is frequently covered by incrus- 
tation. 
The papulo-erosive type is less common than the erosive, and gen- 
erally corresponds to the period of the cutaneous papular eruption. 
Ulcerative Type 
This is not infrequent, and is usually the result of neglect and lack 
of treatment. The ulcerations are generally shallow, with a reddish 
but sometimes grayish or yellowish base, which is more or less uneven 
or anfractuous. They are often seated on an irritated or inflamed area, 
and are usually of small extent, of round, oval or irregular shape, and 
with non-indurated margins. They occur mostly in the tonsillar regions, 
lips and tongue, where they may lodge in some of the normal furrows 
and become fissural. 
328 Depopulating Type 
This peculiar lesion is observed quite often, and consists of de- 
papillated patches occurring on the dorsal aspect of the tongue, in 
the shape of small oval areas, from which the papillae appear to be ab- 
sent, as if shaved off. These areas are surrounded by normal papillae, 
and present a bright-red color, contrasting strongly with the normal 
appearance of the surrounding parts. The lesion has been compared 
to alopecia areata, and is sometimes described as lingual alopecia. It 
is usually painless. 
The Genital Mucous Patches 
While common in both sexes, they are relatively more frequent in 
the female genitals, where they develop on the labia, at the entrance 
of the vagina, and also appear on the cervix. They frequently coexist 
with the moist cutaneous forms. 
In man they occur on the glans, coronal sulcus and mucous aspect 
of prepuce, and almost always in the form of simple erosions. 
The radiating anal folds are sometimes the seat of fissural erosions 
developing between two or more folds, which in consequence become 
infiltrated, thickened, and form little prominent ridges radiating from 
the anal aperture. Upon separating the folds, little fissural erosions 
are perceived, extending to the muco-cutaneous border and beyond. 
Mucous patches present many variations or modifications. They 
vary in size, from insignificant, barely discernible erosions of epheme- 
ral duration to persistent and extensive manifestations. They may be 
limited in number or even solitary, or else be abundant and widely 
disseminated. Oftentimes they are confluent, and through extension 
or coalescence form the large lesions seen on the inner aspect of the 
lips or soft palate, where occasionally all of the free border and uvula 
is involved. 
These manifestations may present a smooth, deep-red surface. 
Sometimes the centre is of a deep purplish or brown-red color, shading 
off toward the borders, which may be partially covered by light, gray- 
ish exudate; or else the central portions may be covered by a slate- 
colored exudate, while at other times it is grayish white or even white, 
adherent, and resembles a diphtheritic membrane. This diphtheritic 
appearance is particularly noticed in the tonsillar and faucial regions, 
where it may give rise to some misgivings as to its nature. It is also 
seen on the lips and on the labia of the female genitals. 
A papnlo-hypertrophic variety is occasionally observed. This, as 
in the moist cutaneous lesions, is the result of neglect, and consists of 
329 an enlarged papule, forming a hard, elevated, discoid mass, sometimes 
with a vegetating papillomatous surface or else a central depression. 
Exceptionally, several such elements combine to form a raised mam- 
millated plaque. These hypertrophied lesions are situated at the back 
of the tongue almost exclusively. 
The buccal syphilides show but little tendency to circinate forms. 
Annular syphilides of the erosive type are occasionally seen on the 
palate, lips and tongue, but crescentic shapes are more frequent. The 
element of pain is variable, and depends largely upon the regional 
situation. Some lesions, even of large size on the lips or hard palate, 
may be but slightly sensitive, while the small fissural lesions situated 
at the labial commissures and edges of the tongue are apt to be very 
sensitive. Those situated on the pillars and tonsils are usually more 
or less painful. The early forms, accompanied by engorgement and 
tumefaction of the pillars and tonsils and constituting the syphilitic 
sore throat or angina, may be excessively painful and accompanied by 
severe dysphagia. 
Diagnosis 
The buccal syphilides do not exhibit any sufficiently distinctive 
characteristics upon which to base an absolute diagnosis. Their ap- 
pearance is sometimes more than suggestive, but demands the corrobo- 
rative evidence derived from the history, presence of other manifes- 
tations, and, if necessary, the serological reaction, for many non-syphi- 
litic affections present similar objective features and may require 
differentiation. 
Differential Diagnosis 
The simple erosions resulting from traumatism, rough teeth, burns, 
vesication, acrid substances, etc., must be excluded. Herpes differs by 
its abrupt onset, smarting, and the micro-cyclic appearance of its base. 
Aphthce differ from the ulcerative lesions by their orbicularity, 
bright canary-yellow color, funnel-shaped base, and their painful char- 
acter. 
Mercurial stomatitis presents exulcerations on the tongue, lips and 
cheeks. The exudates are of a dirty white color, with a yellowish cast, 
and occur mostly on the cheeks, but the principal difference lies in the 
affected, swollen, turgid gums, the frequent ulceration at the base of 
the lower incisor teeth, the salivation and the abominable fetor of 
the breath. 
Other affections, such as the impetiginous commissural fissure of 
330 children, the geographical tongue, exudative tonsillitis, diphtheria, etc., 
may require consideration from their occasional resemblance to the 
specific manifestations. 
Treatment 
The local treatment and care of the mouth is a necessary adjunct 
to the systemic measures, to which the buccal syphilides are frequently 
more or less unyielding. 
Mucous patches occur spontaneously, but their tendency to recur- 
rence, aggravation and persistence, is largely influenced by neglect, 
lack of oral cleanliness, smoking, chewing, alcohol, rough and decayed 
teeth, irritating substances, strong condiments, acid and spicy foods, 
etc. All of these act as aggravating and predisposing causes. In 
the same manner, lack of local care and cleanliness are predisposing 
factors in the genital lesions. Hence, oral hygiene, the prohibition of 
smoking and the avoidance of other irritating factors are absolutely 
indicated. Cleanliness of the genitals is essential, and in man, the 
daily cleansing and examination of the preputial regions should never 
be omitted, for small, insignificant, ephemeral erosions developing in 
these parts (practically overnight) have been the source of contagion. 
Topical Application 
Nitrate of silver is the most generally useful agent, and may be 
used in solutions of 2% or 3% for the simpler lesions, but more often 
the solid stick is preferable. The applications should not be repeated 
too often-once in four to five days is usually sufficient-and if solu- 
tions are used in the faucial or tonsillar regions, great care must be ex- 
ercised that none of the solution drops in the larynx, for this might 
provoke a terrifying, suffocative, spasmodic seizure. When the lesions 
are numerous or extensive, only a part should be treated at one time. 
For obstinate lesions Fournier recommends the acid nitrate of mer- 
cury. This is a very powerful and diffusible substance, most useful 
in old, unyielding lesions, from its penetration into the deeper layers, 
but it must be used with great care. A very small quantity of cotton 
should be tightly wrapped around the end of a toothpick or small ap- 
plicator, then dipped in the acid and expressed almost dry before using. 
The application must be limited to the lesion itself and followed by 
gargling the throat or mouth with water. Sedative mouth washes or 
gargles are useful when much irritation exists, while the more astrin- 
gent type, borated, chlorate of potash, tincture of myrrh, peroxide, 
etc., may be used during the intervals of treatment. 
331 Tertiary Syphilides 
The tertiary cutaneous manifestations are constituted by the sub- 
cutaneous gummata and the localized infiltrations of the skin or tuber- 
cular syphilides. The oro-pharyngeal cavity is also the seat of gum- 
mata and ulcerative syphilides, while the tongue is frequently the site 
of localized scleroses, resulting from the connective-tissue hyperplasias 
so often found in the late forms of syphilis. A late or tertiary form 
of erythema first described by Fournier is occasionally observed. 
Gummata 
The various names of gumma, gummositates and gummata were 
used by early writers in the sixteenth century to designate certain late 
products of syphilis, appearing as firm, elastic, more or less circum- 
scribed tumors, which at some period of their evolution contained or 
gave issue to a gelatinous gummy material. 
Gummata are the most characteristic and typical pathological le- 
sions of syphilis. They sometimes appear during the first year of the 
disease, but occur mostly from the second to the eighth year; there- 
after they progressively diminish in frequency, but are occasionally 
observed as late as twenty, thirty and even more than fifty years after 
infection. 
A subcutaneous or submucous gumma is an inflammatory neoplasm 
presenting the dual characters of a tumor and abscess, and, as Darier 
describes it, "consists originally of a firm, elastic nodule which grows 
rapidly and upon section presents the appearance of a fleshy almost 
sarcomatous tissue of a grayish rose color (the so-called crude gum- 
ma). As the evolution proceeds, the central parts progressively soften 
until eventually the gumma gives signs of fluctuation. At first the dis- 
integrated part shows a whitish translucent centre, sometimes punct- 
uated or streaked with red. Its consistency, which is soft, still further 
diminishes until it becomes a sort of gelatinous or syrupy fluid en- 
closed in a fleshy envelope. When about to evacuate, the skin or 
mucous membrane invaded by the gummatous infiltration becomes thin, 
332 ulcerates through and gives issue to a thick puriform fluid. The cavity- 
left behind is coated by a characteristic yellowish-white material, or 
contains a core which represents the necrosed but not yet liquefied re- 
mains of the gumma. When completely eliminated, repair takes place, 
by the filling up of the.cavity and the formation of a scar. 
"In its initial period a gumma, like all other syphilitic lesions, is 
constituted by the dense accumulation of embryonal cells around a 
small altered blood-vessel. The difference noted between a gumma and 
other syphilitic products such as a syphilitic tubercle is that the altera- 
tion nearly always involves a veinule instead of an arteriole. The 
alteration acts upon a limited point, and it is at this point only that the 
cellular infiltration takes place, and develops eccentrically into round 
or oval nodulations. The infiltrative cells are extremely abundant and 
crowded together. They insinuate themselves between the preexist- 
ing elements (which they only destroy after a certain time), and to 
this is due the firm consistency of the gumma. Ultimately, and unless 
arrested by treatment, the central parts always degenerate into ne- 
crobiotic tissue. ' ' 
Virchow found that gummata and other syphilitic products were 
composed of granulation tissue which did not differ anatomically 
from ordinary inflammatory granulation tissue, and he included them 
in his classification of the granulomata. He furthermore looked upon 
the initial lesion as a gumma, a mucous papule, as but an ill-developed 
form, etc. The essential and distinguishing character of a gumma, 
however, and wherein it differs clinically from non-specific granula- 
tion tissues capable of spontaneous resolution or of permanent organi- 
zation, is, that it is not viable, and that unless arrested by treatment it 
is destined to undergo degeneration and terminate in dead or necro- 
biotic tissue. 
Gummata present two clinical forms, one characterized by distinct, 
isolated, circumscribed tumors of variable size, the other by diffused 
gummatous infiltrates. 
A gumma may undergo a slow caseous degeneration terminating in 
a solid yellowish dry mass retaining the characters of a firm tumor 
{tuherculiform gumma), or else it softens, liquefies and eliminates its 
contents, and this is the more frequent termination. 
A subcutaneous gumma is constituted primarily by a small nodu- 
lar mass situated in the subcutaneous cellular tissues. As such it is 
most often unperceived, but as it continues to grow, it projects more 
and more above the surface of the skin and ultimately develops into a 
well-limited, localized tumor, generally of an oblong or hemispherical 
333 shape, and varying in size from a small olive to that of a pigeon's egg 
or sometimes considerably larger. At first the surface is smooth and 
covered by normal-appearing skin without redness, surrounding in- 
flammation or exudate, while the mass which feels firm to the touch is 
freely movable and usually painless. This constitutes the crude period. 
After a variable time, the gumma begins to soften and feel doughy or 
fluctuating, while at the same time it also becomes immobilized or fixed, 
and somewhat sensitive. The surface assumes a more or less red color, 
and the skin at the central point becomes thin, adherent, and finally 
ulcerates through, leaving a small round opening, which gives issue 
to a thick, gummy reddish or yellowish material of purulent aspect, 
but differing from true pus in that it contains but few leucocytes and is 
made up chiefly of degenerated and broken down granular tissue. 
Unlike an abscess, a gumma does not collapse after opening, and 
only undergoes a slight diminution in volume. The small opening 
gradually enlarges through progressive ulceration of its borders, to an 
extent corresponding to the proportions of the tumor, and ultimately 
uncovers a cavity containing a core-like mass of dead tissue, of a dirty 
white or yellowish color, which through progressive molecular degen- 
eration is finally eliminated. The remaining ulceration constitutes a 
gummatous ulcer, which, after repair has taken place, always leaves a 
permanent and indelible scar. 
A gummatous ulcer is usually round or oval, sometimes kidney- 
shaped or other circinate type. The excavation is always well marked, 
with abrupt, vertical and adherent borders surrounded by a brown- 
red areola. The floor is irregular and may be constituted by the core 
or its remains, or else be covered by a creamy yellowish material. 
The duration of an untreated gumma is variable, it may last three or 
four months, or else require six or seven to complete its course. Some- 
times, as in malignant syphilis, the evolution may be very rapid and 
completed in a few weeks. The duration of the various periods is also 
very variable, in some instances a gumma may remain in the crude 
state for very long periods-years sometimes. The stage of softening 
may also be very prolonged or limited in extent, while the ulcer may 
heal in a short time or persist almost indefinitely. 
Subcutaneous gummata may appear upon any region of the body, 
but occur with greatest frequency on the leg, next on the upper ex- 
tremities, the head, abdomen and chest, thigh, scrotum, penis, neck, 
etc. Their evolution usually proceeds without symptoms, but when 
situated near an articulation they may interfere with its functions and 
occasion pain, as in the wrist or jaw. They also occasion pain and 
334 numbness by their pressure, when they develop along the course of a 
nerve or nerve plexus, as in the axilla. In point of numbers they are 
usually single, not infrequently double, but rarely exceed four or five 
(exceptional instances in which thirty-five or more have been observed 
at the same time in one patient are recorded in the literature). 
Subcutaneous gummata sometimes appear as small nodules, but 
they usually vary in size from a small olive or hickory nut to that of 
an egg. Exceptionally they may become enormous. Thus Fournier 
describes a gumma of the thigh almost the size of a fetal head. Char- 
rier and Renou (Annales de Dermatologie, 1896) reported a gumma 
of the calf which increased its circumference more than eight inches. 
Many other examples, of even larger proportions, have been reported. 
Diffuse Gummatous Infiltration 
In this variety the infiltration of the subcutaneous cellular tissues, 
instead of being localized and presenting a tumor, is diffused and 
spread out like a more or less thick layer over an area varying greatly 
in dimensions. Although observed in other regions such as the back, 
abdomen and chest, this variety principally affects the leg, where it 
may be diffused over the calf and lateral aspects and form extensive 
lesions, which may measure 6 to 10 inches in length by 4 or 5 in 
breadth, and of variable thickness (the so-called syphiloma of the leg). 
The evolution of a diffuse gumma is similar to that of the circum- 
scribed form, but if at all extensive the development is not simul- 
taneous, for different parts represent different periods. Some parts 
may be in the crude stage, hard and firm, while others are in the stage 
of softening or of ulceration. As a rule, several openings take place, 
succeeded by ulcerative cavities, which enlarge and form gummatous 
ulcers. These, as they extend, frequently meet, coalesce and form the 
enormous ulcerations sometimes seen on the leg. 
Serpiginous Forms 
Gummatous ulcers are sometimes complicated by a phagedenic 
process, through which they extend. The skin at the periphery of the 
lesion becomes infiltrated and eventually ulcerates; a fresh peripheral 
zone is then invaded by the infiltration and the process repeated. In 
this successive manner, the ulceration advances, sometimes at one point 
only, through infiltrative irradiations. At the same time repair is 
taking place in the central region, or parts originally affected (see 
Plate 157, Fig. 258). 
Serpiginous forms affecting the scalp are far more serious, for the 
tissues are frequently undermined, while the gummatous infiltration 
335 extends to the periosteum and cranial bones, and results in destructive 
caries and necrosis. (See Plate 152, Fig. 249.) 
Diagnosis 
The diagnosis of gummata rests upon the specific antecedents, the 
presence of other tertiary lesions or their cicatricial stigmata, but par- 
ticularly on the slow, generally indolent evolution, its progressive pe- 
riods of crudity, softening and terminal ulceration with its character- 
istic core, as well as the results of the serological test, or that failing, 
the luetin cutaneous reaction of Noguchi. The treponemata pallida 
have been found in crude gummata, but do not appear to be present in 
the ulcerative lesions. 
Differential Diagnosis 
Subcutaneous gummata when young and firm often present the ap- 
pearance of small fatty tumors, or sebaceous cysts. These are to be 
excluded by their longer duration, situation, general characters, and 
absence of specific antecedents, but as they occur in syphilitic subjects 
as well, the final determination may depend upon the further evolution 
and results of treatment. 
Gummata have also been mistaken for cancerous growths, but these 
differ by their generally uneven or nodular surface, the more rapid and 
extensive adherences of the skin, but especially by the lancinating pains 
which frequently accompany them, while cancerous ulcerations present 
an entirely different picture in their red, vegetating surface, everted 
borders, bleeding and characteristic fetid discharge. Furthermore, 
when cancerous growths are sufficiently developed, they are accom- 
panied by a glandular involvement, which as a rule is absent in gum- 
mata. 
Chronic varicose ulcers and gummatous ulcerations of the leg may 
present a striking resemblance, but differ in several respects. The 
varicose ulcer is habitually situated below the middle third of the leg 
and as a rule on its lateral aspect above the internal malleolus. The 
borders of the ulcer are irregular, declivitous, greatly thickened, hard, 
and surrounded by a chronic edematous zone-the floor is uneven, 
often dry and glazed, with necrotic, dark-red, or yellowish areas, while 
it emits a peculiar penetrating cadaveric odor, whereas the gummatous 
ulcers may occupy any part of the leg. The borders are abrupt, less 
thick and surrounded by a narrow, reddish-brown areola, while the 
excavation presents either a core or a creamy yellowish floor, some- 
times more or less scabby. The contour is usually of a circinate type 
or may present polycyclic margins due to the fusion of several ulcers. 
336 Tubercular Syphilides 
The tertiary manifestations of the skin have long been known and 
described as syphilitic tubercles or tubercular syphilides. Although 
applied in their descriptive dermatological sense, these ancient denomi- 
nations are apt to be confounded with the cutaneous products of the 
tubercle bacillus, with which these terms are now so closely identified. 
Hence they have also been variously described as cutaneous gummata, 
tubero-squamous, tubero-ulcerative, tubero-serpiginous, tertiary ulcers, 
gummatous tubercles, tuberculo-crustaceous, etc. 
The tubercular syphilides are constituted by small nodular infil- 
trations, usually limited to the true skin, and differing in this respect 
from the subcutaneous gummata, in which the infiltrate is hypodermic. 
They occur during the first years of the disease and also at very 
late periods. In a series of 1,108 cases observed in private practice, 
Fournier was able to definitely establish the period at which they 
appeared, as follows: 
1st year 118 cases 
2d " 127 " 
3d " 133 " 
4th " 95 " 
5th " 71 " 
6th " 75 " 
7th " 42 " 
8th " 53 " 
9th " 48 11 
10th " 55 " 
11th " 30 " 
12th " 22 11 
13th 11 20 11 
14th 11 20 11 
15th 11 26 11 
16th 11 19 " 
17th 11 15 " 
18th " 18 11 
19th 11 20 " 
20th 11 15 11 
21st 11 7 " 
22d year 11 cases 
23d " 8 " 
24th " 12 " 
25th " 6 " 
26th " 5 " 
27th " 6 " 
28th " 6 11 
29th 11 2 11 
30th " 3 11 
31st 11 3 11 
33d 11 4 " 
34th " 2 " 
35th " 1 " 
36th 11 2 11 
37th 11 2 11 
39th 11 2 11 
40th 11 3 " 
46th " 1 " 
1,108 cases 
337 From this it appears that they reach the maximum of frequency in 
the third year, then decrease sensibly up to the tenth year, thereafter 
markedly, although still ^presenting isolated instances up to the 46th 
year. 
The tertiary syphilides are regional, the eruption usually limiting 
itself to some given part, such as the hack, the scalp, the face, etc. 
(whereas the secondary syphilides are usually symmetrical and dis- 
seminated over several regions). They are, furthermore, destructive, 
and terminate in localized scleroses or ulcers of a deep character, 
which leave permanent cicatrices and, unlike the secondary eruptions, 
which are polymorphous, the tertiary syphilides are confined to one 
type. The eruptive elements are usually round or of circinate shape, 
and show a marked tendency to assemble themselves in groups. In 
their mode of grouping they also affect different forms. Sometimes 
they are closely distributed over a small area, as in the bouquet form, 
and several such groups may be present, or else the eruption may con- 
sist of a single group, composed of a few elements. At times they are 
arranged like a circle of beads, separated by intervening spaces of 
normal skin; or they may be disposed in crescentic shapes, rings, con- 
jugated arms, etc. The eruption is occasionally disseminated, and in 
certain regions, such as the palmar and plantar surfaces, it may be 
diffused. 
The tubercular syphilides present a dry or squamous type and an 
ulcerative type. Both are primarily due to the same infiltrative 
process, but the terminal evolution differs. In the squamous type, the 
lesion becomes condensed, shrinks, and ends by absorption, leaving a 
more or less marked local atrophy or cutaneous sclerosis to mark its 
site (tuberczdiform gummata). In the ulcerative type, which is the 
more common, the lesion undergoes gummatous degeneration, ulcer- 
ates, and becomes incrusted through a process in all respects similar 
to that of the subcutaneous gummata. This constitutes the ulcerative 
or gummatous tubercle. 
A squamous syphilitic tubercle consists of a circumscribed nodular 
infiltration, forming a small tuberosity or eminence, with a base deeply 
imbedded in the skin, as though inlaid in it. The small mass is round, 
solid and firm to the touch, while its summit, which is somewhat con- 
vex, projects above the surrounding skin. It is usually the size of a 
split pea, sometimes larger, and of a deep red smoked ham color. The 
surface is at first smooth and polished, but eventually it may become 
wrinkled and covered by fine scales. The evolution is slow and when 
fully developed the lesion may persist without change for months or 
338 even years if untreated. Finally it shrinks, is absorbed and disappears 
leaving a dark pigmented spot which lasts for some time and is suc- 
ceeded by a slightly depressed atrophic white spot or scar. 
The course of this form is unaccompanied by pain or special symp- 
toms. The eruption is occasionally disseminated and may be limited 
to a few isolated elements usually situated on the palm, face or leg, but 
it is much more frequently grouped and arranged in varying crescen- 
tic, annular, arciform or beaded shapes. 
Serpiginous or Creeping Form 
This mode of eruptive extension is common to both the squamous 
and ulcerative types, and is due to the development of successive crops 
of tubercles, in lines parallel with the peripheral border of the original 
grouped lesion. In this manner the eruption advances through the in- 
vasion of fresh cutaneous zones, while at the same time repair is taking 
place in the older or central parts. In consequence, the lesion presents 
elements in varying stages of evolution, the original tubercles being 
represented by the terminal macules. Others more recent may be in the 
retrogressive period, while the outer border is constituted by elements 
in the period of development. (See Plate 150, Fig. 244, and Plate 151, 
Figs. 246 and 247.) 
The diffuse type consists of an infiltrative eruptive patch of con- 
tinuous surface, generally of a deep sombre red color. While it may 
appear in other regions, it most frequently affects the palmar and 
plantar surfaces and constitutes the tertiary psoriasiform lesions. As 
a result, the palmar region is converted into a rose or dusky red des- 
quamating surface, thickened, hard and rough to the touch and inter- 
sected by white lines or sometimes painful fissures. The exfoliation is 
irregular, white and lamellar, while the borders are red and circinate. 
The palmar eruption may also be constituted by tubercles differently 
grouped. (See Plate 150, Fig. 245.) 
Eruptive Variations 
Sometimes, in a small grouped lesion, the intervening skin becomes 
infiltrated and thickened, the appearance being that of a number of 
tubercles seated on a common red hypertrophied base. The degree 
of infiltration varies, it is usually slight, but exceptionally it may be 
massive and bring about deformity of the affected part. Under these 
conditions the lips (usually the inferior), the nose, nostrils, lobe of 
the ear, chin, vulva, etc., may be enormously increased in size. These 
rare disfiguring lesions occur in both the squamous and ulcerative 
types. When the nose is involved it may present the grotesque ap- 
339 pearance brought about by hypertrophic acne or hypertrophic lupus, 
while the lip or ear lobe may be doubled or trebled in thickness. These 
various conditions also resemble some of the leontiasic deformities 
observed in tubercular leprosy, hence the term syphilitic leontiasis 
applied to them. The infiltration is of firm consistency and differs 
from an edematous exudate in not retaining the impression of the 
finger. 
Occasionally the tubercular elements are small and attenuated, and 
from their lack of volume and flat surface resemble the secondary 
papular forms, from which they are distinguished by the characteris- 
tic, circumscribed mode of grouping, and lack of dissemination com- 
mon to the tertiary forms. 
Ulcerative Tubercular Syphilides 
Synonyms: Tubero-ulcerative sypliilides, tuberculo-crustaceous sypliilides, 
tuberculo-ulcerative sypliilides, ulcero-serpiginous sypliilides, gumma- 
tous tubercles, tertiary ulcerations, etc. 
The tuberculo-ulcerative syphilides are the most common of the 
tertiary cutaneous manifestations, and also occur on the mucous sur- 
faces of the oro-pharyngeal cavity, nose and genitals. In its early 
stage a gummatous tubercle is identical in appearance with a squa- 
mous tubercle and offers the same initial characteristics, but differs in 
its termination, for after a variable time the lesion undergoes gum- 
matous degeneration and softens, while the skin at its apex becomes 
thin, eventually breaks and gives issue to a slight discharge, which 
desiccates and forms a small dark crust, that grows larger and thicker 
as the underlying ulceration, which it conceals, extends. 
The ulcerations vary in size from that of a lentil or split-pea (Fig. 
253) to that of a dime, half dollar or even larger, and sometimes 
through the fusion of confluent elements they may form lesions as large 
as the palm. The lesions may be perfectly round, but frequently assume 
crescentic shapes or represent segments of circles or long curves due to 
the mode of grouping and the fusion of the elements. The ulceration 
itself is usually deep, with abrupt, indurated and adherent borders, sur- 
rounded by a sombre red areola, while the floor presents the usual ir- 
regular corelike or creamy yellowish appearance of gummatous ulcers. 
The scab or incrustation which covers the ulceration is propor- 
tionate in size, and is usually solid and of great thickness. The edges 
are included in the borders of the ulcer as if in a frame and it is firmly 
adherent, while the shape corresponds to that of the lesion. The color 
varies from light brown or ochrous tones to dark chocolate-brown 
340 shades; at times, the scab is almost black or even black, and frequently 
presents deep bottle-green tints. The color is not always uniform, for 
different portions of the scab may present different shades, but the 
generally dark brown, blackish or deep green tones are very char- 
acteristic. 
Syphilitic Rupia 
The scab may be simply thick, but it is often stratified owing to the 
superimposition of different layers of crust resulting from extension 
of the ulceration, the uppermost layer being the smallest, while each 
succeeding layer becomes progressively larger, so that the scab pre- 
sents a somewhat conical elevation. In shape, the lesion may be round, 
and it frequently suggests the appearance of an oyster-shell, both by 
its shape and stratification, hence the name ostreaceous given these 
forms. These thick stratified lesions constitute the typical syphilitic 
rupial eruptions. They are chiefly seen on the back and extensor as- 
pects of the arms, where they may form several large incrustations, 
sometimes the size of the palm; and they are usually observed in old 
neglected cases and in the severe or malignant forms of the disease. 
(See Plate 149, Fig. 242.) Resolution may take place under the scab, 
which desiccates and is eventually detached. 
The tertiary scar is at first red, then turns to a dark brown or 
almost black color, which may persist for long periods, sometimes 
years. (These dark pigmentations are frequently seen on the legs, 
particularly the shins, and in colored individuals they are inky black.) 
After a variable time the color fades, until finally a dead or milky 
white surface remains, which by its lighter tone contrasts with the sur- 
rounding skin. The scar itself is slightly depressed below the level 
of the contiguous parts and corresponds in size and shape to the orig- 
inal lesion, which is commonly round or represents segments of cir- 
cles or various crescentic shapes. The scar tissue is of fine texture, 
smooth, and in the larger lesions of a parchment-like thickness, which 
may be picked up between the fingers. Small multiple scars occurring 
on the forehead, chin, or other portions of the face, frequently repre- 
sent by their arrangement the circinate contour of the original lesions. 
On the nose, which is a favorite site of the ulcerative syphilides, little 
white crescentic or pitlike depressions the size of small shot or some- 
what larger are left, while the borders of the nostrils remain with 
small scalloped, gouged-out indentations. Occasionally the loss of tis- 
sue may involve a good portion or the whole of a nostril, while perfora- 
tion or partial destruction of the septum is also a common result when 
the pituitary membrane is attacked. 
341 The tertiary scars are indelible and typical relics of syphilis, 
and when well characterized are practically diagnostic of the dis- 
ease. 
The tuberculo-ulcerative syphilides present many variations. The 
eruption is sometimes limited to a single group of a few elements sit- 
uated on some part of the face, back or leg, or per contra the lesions 
may become numerous through successive additions, as well as more 
or less confluent, and through fusion involve a large surface. A small 
isolated lesion may progress eccentrically through peripheral infiltra- 
tion and attain the size of a silver dollar while at the same time the 
scab which covers the ulceration grows proportionately larger. 
Phagedenic complications are sometimes observed; these are usually 
of an extensive serpiginous character, more rarely of a perforating 
(type. 
The course of the tuberculo-ulcerative syphilides is insidious. They 
develop slowly and may form extensive and destructive ulcerations 
unaccompanied by pain or apparent constitutional disturbances. A 
small incrusted and painless lesion situated on the nostril or nasal sep- 
tum is the prelude to a disfiguring loss of tissue or perforation. The 
evolution also varies in rapidity. Usually the ulcerative tubercle 
softens within a comparatively short time, but sometimes it remains in 
its firm, crude state for months, and in the same manner an incrusted 
lesion may remain without change for prolonged periods. The erup- 
tion may also present elements in different stages of evolution, and not 
infrequently ulcerative forms are found associated with dry, squamous 
elements. This is well shown in Plate 149, Fig. 242. The tubercular 
syphilides may occur on any part of the skin, but show predilection 
for certain regions. They appear most frequently on the face, and 
particularly on the nose and nostrils. (When situated at the scalp 
margin they constitute the tertiary form of the corona veneris.) Next 
in frequency the palmar and plantar surfaces, the lower extremities, 
extensor aspect of the forearm, the back (especially in the scapular 
regions), nape of the neck, scalp, etc. 
The diagnosis of the tubercular syphilides rests upon their ob- 
jective characteristics and the antecedents. In the dry or squamous 
type, the orbicularity, firm consistency, deep cutaneous insertion of the 
base and the dusky red, raw ham color of the eruptive elements fur- 
nish valuable diagnostic guides. 
The tuberculo-ulcerative lesions are distinguished by the dark- 
brown, blackish or greenish tints of the scabs, while the ulcers are 
generally deep, with abrupt, vertical, adherent and indurated borders, 
342 surrounded by a deep red, sometimes pigmented areola, and particu- 
larly by the corelike or creamy yellowish aspect of the floor. 
Both types exhibit the same regional preferences, and the same 
tendency to orbicular or circinate shapes of the eruptive elements. 
These furthermore follow the same modes of grouping, and according 
to their arrangement present the various bouquet, beaded, crescentic, 
annular, semiannular and other forms. 
These different characters taken singly or as a whole, together with 
the antecedents, serve to differentiate the tubercular syphilides from 
other cutaneous manifestations presenting at times a similar appear- 
ance, acne varioliformis, lupus, tuberculous ulcers, epithelioma and 
varying pyodermic affections, for the detailed descriptions of which 
the reader is referred to other parts of this work. 
Local Treatment 
The tubercular syphilides, as a rule, yield readily to mixed treat- 
ment, but certain lesions, like the ulcerations of the leg or chronic 
palmar and plantar infiltrates, etc., are often obstinate and rebellious. 
Their resolution is greatly hastened by additional appropriate local 
measures, and of these the occlusive method, first introduced by 
Chassaignac many years ago, remains the most useful and valuable. 
It consists simply in the strapping of the affected parts with narrow 
strips of mercurial plaster or Vigo's plaster, or where the surface per- 
mits, a piece of sufficient size to cover part and extend beyond the 
borders may be used, and maintained in apposition by a light bandage. 
Should these prove irritating, diachylon strips may be employed, for 
it is the occlusive principle rather than the mercurial element which 
is beneficial. 
The part to be dressed should be suitably prepared by a prelimi- 
nary removal of the crusts by means of wet dressings and immersion 
in warm borated water, and overlapping or intercrossing narrow strips 
of plaster applied to the surface of the ulceration and extending be- 
yond its borders until the whole of the lesion is covered. A thin layer 
of absorbent cotton is then applied over the dressing and kept in place 
by a light gauze bandage. At first these dressings may have to be re- 
newed twice daily, for, as in the case of an ulceration of the leg, the 
secretion is apt to be abundant, but later, daily renewal will prove 
sufficient and ultimately the dressing may remain on for a longer 
period. 
The results are usually very satisfactory, for after a few days an 
obstinate ulcerative lesion of the leg will begin to clean up and assume 
343 a better appearance, while the infiltrated borders become softer. Still 
later the surface will present an even, healthy, red appearance, while 
a pale, hazy-white marginal epidermized zone will be noticed which 
gradually closes in until lesion is covered. Great care must be taken 
not to injure the delicate newly formed epidermal layer by rough 
methods or irritative topical applications. In lesions of the leg, rest 
of the part is an important auxiliary measure. 
The thick infiltrated palmar and plantar lesions require prolonged 
immersion in warm borated water, not only for the cleansing but for 
the soothing and softening effects. The dressing should be applied in 
rather narrow strips so as to better conform to the parts, and over it a 
layer of absorbent cotton kept in place by a light bandage. 
Lesions of the nose, chin, forehead may be similarly dressed. 
Cleansing of the parts with warm borated solution or immersion 
should always precede the removal of the dressings, while topical ap- 
plications of solutions of iodine and silver or the solid stick are occa- 
sionally indicated to repress unhealthy granulations or stimulate slug- 
gish conditions. 
Tertiary Affections of the 
Mouth and Tongue 
These are not uncommon, and are important because of the serious 
and irreparable damage they occasion. 
The tongue may be the seat of gummata, but it more frequently 
undergoes sclerotic changes, which are always confined to the dorsal 
aspect. The sclerotic process is due primarily to a hyperplastic cel- 
lular infiltration, which later becomes organized and develops into 
vascularized fibrous tissue. As this newly formed connective tissue 
contracts, it strangles the parenchymatous elements, which in conse- 
quence atrophy and are ultimately replaced by a dense connective- 
tissue formation. 
The morbid process varies in degree, and may be limited to the 
surface of the tongue, as in the cortical or superficial form, or else it 
may extend and involve the deeper structures. 
Sclerous Glossitis 
The cortical or superficial form of sclerous glossitis is characterized 
by a thin parchment-like induration of the surface affected, while the 
deeper portions retain their normal softness and consistency. 
The lesions consist of small infiltrated patches or islands, usually 
two or three, varying from the size of a lentil to that of a bean, and 
generally of round or oval shape, unless situated on the lingual mar- 
344 gin. In the early period, these are of a deep cherry-red color, with a 
smooth depapillated surface, but as the sclerotic process nears com- 
pletion, the color becomes lighter and turns to a whitish or grayish 
tone. To the touch the affected regions feel smooth and give a sense 
of resistance or slight induration different from that of the surround- 
ing parts. Complications due to local irritation and consisting of 
linear erosions, excoriations or slight exulcerations are common. The 
infiltration sometimes occurs in bands or may be diffused and affect 
the anterior dorsal portion of the tongue or its anterior lateral half, 
which then presents the characteristic parchment-like induration, the 
same smooth depapillated surface, color, etc. This superficial variety 
prepares the ground upon which the hyperkeratotic patches of syph- 
ilitic leukoplakia develop. 
Deep sclerous glossitis, also termed lingual cirrhosis, lobulated glos- 
sitis, interstitial glossitis, is the typical tertiary lesion of the tongue. 
It is seldom circumscribed, but nearly always affects a large part of 
the dorsal surface of the tongue, its anterior half or two-thirds, some- 
times a lateral half and exceptionally the whole. The organ becomes 
tumefied, increased in size, deeply indurated, lobulated and deeply fis- 
sured. The lobulation is produced by the contraction of newly formed 
connective-tissue bands in the deeper planes of the tongue, precisely 
as in the cirrhotic or interstitial processes of the liver and kidney. 
The affected and tumefied region at first presents a smooth, de- 
papillated surface, of a deep vinous red color. As the condition pro- 
gresses the characteristic lobulations develop; these vary in size and 
number, they are of irregular shape and form slight prominences on 
the lingual surface, to which they give an uneven and mammillated ap- 
pearance. They are also separated from each other and more or less 
completely surrounded by irregular depressions or interlobular fis- 
sures. The fissures vary in depth, depending on the degree of tume- 
faction, and through the infiltration and eversion of their borders they 
are frequently V-shaped. They also pursue different directions, and 
may be longitudinal, transverse, oblique, etc. Thus the normal median 
furrow is ordinarily converted into a deep longitudinal V-shaped fis- 
sure, while transverse or oblique fissures branch out laterally from it. 
When the margins are affected the normal contour of the tongue is 
lost, sometimes the tip is spread out laterally and presents a square 
appearance, while the margins themselves become the seat of depres- 
sions and fissures. Indurated marginal protuberances filling the space 
left by missing teeth are also common. In the advanced stage erosions, 
painful raghades, exulcerations or ulcerations are usual complications. 
345 These chiefly affect the borders of the fissures and lingual margins 
and also develop at the bottom of the fissures. Irregular cicatricial 
bands and patches of a dirty white or grayish color are formed, which 
contrast strongly with the deep red of other parts, and sometimes the 
lobulations undergo gummatous degeneration and form deep, charac- 
teristic ulcers or sclero-gummatous lesions. 
In its ultimate phase, the thickened and hypertrophied region 
shrinks, atrophies and becomes converted into a hard, dense, irregular 
fibrous mass, excepting the inferior surface, which is never involved. 
Sclerous glossitis is chiefly observed in men, and is relatively rare 
in women. Its development is insidious and its evolution slow and 
chronic. In the superficial variety the symptoms are usually slight 
and pain is not complained of unless erosions and fissures develop, 
and these are not infrequent complications. In the lobulated form the 
initial period is characterized by some degree of functional impair- 
ment. The tongue feels big, thick and as if covered by a foreign sub- 
stance; its normal flexibility and motility are interfered with and 
speech becomes indistinct and modified by the difficulty of articulating 
properly. 
When the usual complications of erosions, raghades and ulcera- 
tions appear, all these symptoms are accentuated, the tongue is sensi- 
tive, inflamed and pain becomes a prominent symptom. It varies in 
severity, but is easily aggravated by the movements of the tongue in 
eating and talking and particularly by smoking and the use of irritat- 
ing foods, sweets and spirituous drinks. 
The duration of sclerous glossitis is indefinite, and unless recog- 
nized and arrested in its early period by energetic treatment, but little 
permanent benefit may be expected from subsequent measures, for once 
constituted the structural changes cannot be remedied. 
The local treatment requires absolute oral hygiene, prohibition of 
smoking and the avoidance of irritating foods, sweets and spirituous 
liquors. The frequent use of alkaline and soothing mouth washes is 
indicated, especially after eating, for the removal of food particles 
lodged in the fissures. Repeated painting of the erosions and raghades 
with a 20% solution of chromic acid usually gives prompt relief, or 
the lesions may be touched with chromic acid crystals, or a finely 
pointed silver nitrate pencil. 
The diagnosis of lobulated glossitis is based upon the characteris- 
tic lobulation, deep induration and irregular fissuration as well as the 
general appearance of the tongue, which is more or less deformed, 
mammillated, eroded or ulcerated and covered here and there by 
346 whitish, gray or deep red patches and cicatricial bands, the picture 
varying with the extent and degree of the morbid process and the age 
of the lesion. The diagnosis is further confirmed by the syphilitic 
antecedents and serological results. 
Epithelioma may resemble some of the ulcerated lesions of sclerous 
glossitis, but lingual epithelioma is relatively circumscribed and con- 
stituted in its early period by a red vegetating mushroom-like growth, 
or else by an excavated crater-like ulceration, surrounded by thick, 
elevated and everted borders of an almost cartilaginous hardness. The 
growth usually bleeds easily on the slightest provocation, while the 
breath and saliva have the characteristic fetid cancerous odor. The 
tongue is moved with difficulty and sometimes almost immobilized, 
while the painful symptoms, often of a lancinating character, are far 
more accentuated than in tabulated glossitis. Glandular involvement 
is also present in developed epithelioma and absent as a rule in sclerous 
glossitis. 
Gummata of the tongue occur less frequently than the sclerous 
forms of glossitis. They may be superficial and limited to the mucous 
membrane or else affect the deeper muscular structures. 
The superficial gummata are situated on the dorsum of the tongue 
and consist of gummatous tubercles the size of a split-pea or small 
shot. Sometimes there is but one, but more often three or four are 
found, while occasionally they may be numerous and grouped in horse- 
shoe or crescentic shapes. At first they feel like little round bodies 
imbedded in the lingual surface, but after a certain time they soften 
and following the usual evolution of gummata, end finally in small 
deep ulcers corresponding to the size of the lesion. 
The deep or muscular gummata correspond to the subcutaneous 
gummata. They are submucous and affect the deeper tissues of the 
tongue, but invariably point and open on the dorsum. There may be 
only one lesion, but two or three may exist, varying in size from that 
of a bean to that of a small olive or almond, occasionally somewhat 
larger. They pursue the usual course of gummata, and are at first 
felt as hard masses lodged in the lingual tissues. As they develop and 
increase in size a certain amount of swelling or protuberance of the 
surface marks their site. The protuberance is smooth, may be elon- 
gated, ovoid or round, and is sometimes very pronounced and deforms 
the tongue. Such lesions may remain in the crude state for two or 
three months, then soften and terminate in ulcerations. The ulcers are 
usually elongated and correspond to the tang axis of the tongue (see 
Plate 156, Fig. 256), but they are also frequently round or oval, 
347 notably deep-surrounded by a hard indurated deep-red zone-and 
present the gummatous characteristics of vertical, adherent borders 
and a yellowish irregular floor. 
The diffuse form is rare and is due to an irregularly disposed gum- 
matous infiltration, which may persist for long periods and terminate in 
ulcerations of various irregular shapes (see Plate 154). 
The evolution of lingual gummata is slow and generally painless; 
but when the terminal ulcerations have developed, painful symptoms 
due to the local irritation appear. The food lodges in the ulcerative 
cavities, which become irritated, sensitive, and some degree of func- 
tional impairment is usual. The local care demands a soft unirritating 
diet and the same measures adopted in sclerous glossitis, excepting the 
cauterizations, which are never well borne. 
The terminal scar is frequently linear and represents usually a 
much smaller loss of tissue than might be expected from the sometimes 
large size of the ulcer. 
Tuberculous ulcers may simulate the appearance of gummatous le- 
sions, but tuberculous ulcers are generally not as deep, while the char- 
acteristic gummatous induration is wanting. The borders are more 
ragged and sometimes undermined or detached instead of vertical and 
adherent. The base presents a brighter yellow, touched here and there 
with orange red, or else may present a red granular surface. It is also 
more painful and bleeds easily. Tubercle bacilli are usually found in 
the necrosed tissue from the bottom of the ulcer, and concomitant evi- 
dences of laryngeal or pulmonary tuberculosis are generally present. 
Leucoplalcia Buccalis 
This name was introduced by Schwimmer to denote an affection 
due to a localized keratosis of the buccal mucous membrane. Since 
then it has been described by different authors under the names of 
leucoma, leucoplasia, tylosis, heratosis lingua, psoriasis buccalis, 
ichthyosis buccalis, etc. 
Syphilis is a strong predisposing factor, and probably the most 
frequent cause of leukoplakia, but it is also observed in individuals 
who have never had syphilis, in gouty persons, and as the result of 
long-continued irritation due to rough, projecting teeth, excessive 
smoking and other irritating causes (glassblowers are often affected). 
According to Sabouraud, syphilitic leukoplakia is characterized 
by its exclusive localization on the dorsal aspect of the tongue, 
the syphilitic origin being doubtful when situated on the cheeks 
or lips. 
348 The lesions consist of white or lactescent spots, hands or patches, 
presenting a mother-of-pearl luster and situated on the dorsal aspect 
of the tongue and its lateral borders. 
The leukoplasic patches are due to a localized keratosis developing 
upon a sublying sclerosis, and present a smooth, level surface, which 
to the touch gives a slight sense of resistance or leathery feel. The bor- 
ders, although susceptible to many irregularities, are usually well- 
defined and contrast with the surrounding red surface. The affection, 
like all other syphilitic lesions of the tongue, is far more common in 
men and is comparatively rare in women. It occurs during the tertiary 
period as a rule, and is a frequent sequence of sclerous glossitis, 
and from its character is usually ranked with the parasyphilitic 
affections. 
Leukoplakia gives rise to but few symptoms, a certain amount of 
stiffness of the tongue is complained of, while the affected parts lose 
their normal sensitiveness and feel as though covered by a foreign sub- 
stance. Painful complications due to linear erosions or excoriations 
are frequent and result from the same irritating causes found in other 
syphilitic affections of the mouth and tongue. 
The duration of leukoplakia is unlimited, it persists in spite of all 
forms of treatment, and is, furthermore, apt to lead to the ulterior 
development of epithelioma. 
In the diagnosis it is necessary to exclude essential leukoplakia, 
dental glossitis, smokers' patches and the buccal lesions of lichen 
planus. 
Gummata of the soft and hard palate are not infrequent, and some- 
times they occur on the lips or at the angle of the mouth. (Plate 155, 
Fig. 254, shows such a gumma in the period of softening.) 
The soft palate may be the seat of grouped tuberculo-ulcerative 
syphilides, or of an isolated gumma, but the diffused infiltrative form 
is much more common and may involve a part or the whole of the soft 
palate. As the infiltration becomes constituted the soft palate assumes 
a dark red color of a much deeper hue than that of the surrounding 
parts. It is visibly thickened and swollen, indurated to the touch, and 
more or less immobilized by the infiltration, while at the same time 
the normal contour of the free borders and arches is lost, thus pro- 
ducing more or less deformity. It may remain in this condition for 
some time; it then softens and finally opens through a small orifice, 
which rapidly enlarges and becomes converted into an ulceration. This 
may extend and invade all of the infiltrated tissue, which it may per- 
forate or totally destroy, the result being more or less extensive 
349 mutilations, or even complete loss of the soft palate (see Plate 153, 
Fig. 250). 
The development is insidious, unaccompanied by pain, and during 
the infiltrative period the lesion gives comparatively slight functional 
disturbances; but when perforation or division of the palate takes 
place (and this occurs without warning), the functional impairment is 
at once evident and marked, and consists in a sudden alteration of the 
voice, which becomes nasal, and an accompanying difficulty of articu- 
lation, which may render the speech unintelligible. In addition, as the 
ulceration extends, the act of swallowing causes the regurgitation of 
liquids through the nose. The resulting deformities constitute perma- 
nent impairments, varying in character and degree, and depending 
upon the nature of the post-ulcerative adhesions. 
Sometimes the perforation is constituted by a round orifice, which, 
as it repairs, contracts down to a small opening, which subsequently 
may be made to close by cauterization of the edges. At other times 
the palate may be divided at one or both sides of the uvula, which is 
left hanging free, while the flaps retract like a pair of curtains and 
form posterior adhesions with their inferior and free extremities. In 
severe and phagedenic types the uvula and soft palate may be totally 
destroyed. 
The hard palate is less frequently affected, but it is also the seat 
of tuberculo-ulcerative syphilides, which leave irregular ulcerations 
with a yellowish base; these are succeeded by pigmented post-ulcera- 
tive scars. (See Plate 152, Fig. 248.) Isolated gummata involving 
the periosteum and bony tissues also occur; these terminate in perfora- 
tion. (See Plate 153, Fig. 251.) 
Phagedena is a serious complication of the tertiary ulcerative le- 
sions. Although rather common in former years, it is comparatively 
rare at the present time, and only occasionally seen in private practice. 
The etiology of syphilitic phagedena is not well understood, but among 
its recognized causes the absence or insufficiency of early systemic 
treatment is the most potent. Neglect, want of local care, uncleanli- 
ness and irritation are contributing factors, while debilitated or im- 
poverished organic conditions due to poverty, alcoholism, senility, 
excesses and inherited tendencies play a large part. The character of 
the soil is also an important factor, for phagedena may develop in 
young and apparently robust individuals, who seemingly have a mor- 
bid tendency or lack of resistance to infections, and this is exemplified 
in the precocious appearance of tertiary lesions in the malignant form 
of syphilis. The malignancy has been attributed to the source of in- 
350 f ection or to the virulence of certain strains of treponema pallida; but 
an infection contracted from an ordinary and benign syphilis may 
develop into a severe and malignant form, and per contra, this may 
beget a mild type. As a rule, phagedena is a late complication and 
limited to the tertiary ulcerations, the initial lesion which is some- 
times attacked forming an exception. Phagedena may complicate any 
lesion wherever situated, but it exhibits a preference for the face (nose 
particularly, see Plate 156, Fig. 257), the fauces and genitals. 
Tertiary malignancy, or phagedena, is a destructive process, char- 
acterized by an exaggerated intensity in the development and progress 
of the ulcerative lesions. Under its influence these spread, become 
amplified and attain unusual proportions; thus an ulcerative syphilide, 
while retaining its usual objective features, may extend and involve 
a very large surface, a half or two-thirds of the thigh, or it may cause 
large excavated ulcers of the leg, or else the back may be the seat of 
rupial incrustations as large as the palm, etc. The morbid process is 
sometimes of an inflammatory type. The lesion then presents an angry 
or livid red color and is surrounded by a deeply injected hyperemic 
areola, the secretion is abundant and sanguinolent, while its extension 
is rapid. More often it assumes a gangrenous form. The affected 
part presents small areas of a dark brown or black color, or else a 
massive gangrene involving a large surface may take place. In this 
manner a large tegumentary area may become stricken by gangrene 
and become inky black. (See Plate 130, Fig. 212, and Plate 162.) 
A nostril may become gangrenous and be cast off as an eschar, the 
whole evolution being completed in a few days. 
The phagedenic process may extend in surface or in depth, as in 
the perforative variety, and although rare, it is possible for both to 
be associated in the same lesion. The degree of the morbid action 
varies greatly; it is sometimes comparatively benign and limited to a 
single part, a nostril, a vulva or the glans penis, or it may affect a 
whole region of the skin, the genitals, the nasal fossa, or throat, and 
it may also attack different regions in succession. 
The superficial variety enlarges eccentrically through peripheral 
extension. An ulcerative tubercle becomes surrounded by a series of 
tubercles which undergo the usual evolution, soften, ulcerate and be- 
come merged with the original ulcer; a fresh series develops and fol- 
lows the same course, and thus the lesion progresses through the in- 
vasion of successive peripheral zones. At the same time repair takes 
place in the original ulcerations in the order of their appearance, so 
that a lesion may present at one time all periods of evolution. 
351 The diffuse gummata progress in the same manner through the 
peripheral extension and ulceration of the infiltrate. These serpiginous 
forms, so described from their creeping and snake-like mode of pro- 
gression, differ from the ordinary forms by their greater extent and 
more rapid course. (Compare lesions in Plate 151, Fig. 247, and Plate 
157.) The lesions may be circular, kidney-shaped, or describe wide 
curves, depending upon their mode of extension. (See Plates 157 
and 162.) 
Another serpiginous form proceeds in long, curved, undulating 
eruptive bands of limited width. In this snake-like form the advancing 
ulceration corresponds to the head, while repair takes place at the 
tail. Fournier describes such a lesion, which, starting from the mid- 
dle of the back, proceeded horizontally to the antero-lateral portions of 
the thorax, covering a distance of more than twenty inches, while the 
width of the lesion did not exceed three to four fingers ' breadth; and 
another, which, in the form of a narrow band one to two inches wide, 
described a large circle around the left scapula and covered a distance 
exceeding twenty-five inches. 
The perforating or terebrating form is the most serious, for it 
extends in depth and destroys all the tissues in its path. It attacks the 
skin, mucous membranes, cellular tissues, aponeuroses, muscles and 
bones. It may bring about extensive destruction of the scalp, expose 
the bones of the skull (see Plate 152, Fig. 249), or even perforate 
them and lay bare the coverings of the brain. It may destroy all the 
nasal bones, the orbit, and expose the eye, or it may perforate the 
urethra, the recto-vaginal wall or bring about the partial or complete 
destruction of the glans, scrotum, labia, nose, ears, hard and soft 
palate, etc.; or else cause deep excavations, denude the muscles and 
expose arteries, veins and nerves. 
Fournier describes a case coming under his observation in which, 
through the total destruction of the nasal bones, the ethmoid, hard 
and soft palate, the mouth and the rami of the superior maxillary 
bones, the face was converted into a huge cavernous opening, the 
pharynx itself being a mass of cicatricial tissue. Even more extreme 
cases are recorded, while the older writers in their descriptions give 
almost incredible accounts of the terrible mutilations wrought by the 
disease. Very fortunately these extreme cases are exceedingly rare, 
and may be ranked with other pathological curiosities. 
The cicatrices left by the malignant forms of syphilis correspond 
to the lesions. They are frequently disfiguring, and may represent 
severe mutilations. They may also form dense bridles, atresias 
352 and adhesions, which still further cripple the functions of parts 
affected. 
The evolution may be rapid or slow, and may affect any grade be- 
tween these two extremes. Ordinarily the perforating forms progress 
rapidly, while the superficial forms may be almost chronic. This is 
exemnlified in the large cutaneous lesions of the trunk and extremities. 
353 Hereditary Syphilis 
Children who inherit syphilis may present evidences of the dis- 
ease at birth or they may within a few days develop pemphigus, an 
eruption composed of straw-colored and wine-colored bullae distributed 
on the hands and feet, also to some extent on the extremities, and which 
almost always ends fatally. (See Plate 158, Figs. 259 and 260.) 
Ordinarily, the symptoms do not develop until later, and frequently 
children are to all appearances normal at birth; but when four to eight 
weeks old, sometimes later, they develop cutaneous manifestations 
similar to the secondary eruptions of the acquired disease. In infants 
the eruptions are usually of an erythematous, papular or scaly type, 
and owing to the delicate texture of the skin these are more apt to 
become confluent, or eroded and moist, than in adults. 
The erythema or roseola consists at first of rose-colored spots, 
which later assume a dusky red hue, from which the color does not dis- 
appear on pressure. The eruption may be more or less confluent, and 
sometimes forms diffused patches. It is distributed over the abdomen, 
back, neck, genitals and extremities. 
The papular type is well characterized and may coexist with the 
roseola. It is ordinarily distributed on the face, trunk, buttocks, gen- 
itals and extremities (see Plates 159 and 160). The eruption may 
be scaly, and this is not infrequently seen on the face, where its ap- 
pearance may suggest an eczema, from which it differs by its papular 
base. It may also be diffused and form more or less extensive plaques 
slightly raised above the surrounding surface. Papules situated in 
the axilla, genital folds, intergluteal and perianal regions are apt to 
become eroded and moist, and through fusion form the flat condylo- 
mata so often found near the anus. Impetiginous or papulo-pustular 
forms occur on the face and forehead, sometimes on the trunk (see 
Plate 148, Fig. 241, and Plate 143, Fig. 232). Acneiform elements are 
also observed in the scalp. The papulo-vesicular or herpetiform va- 
riety is of rare occurrence, while ecthymatous forms do not appear 
until late and as a rule in severe cases only. 
354 Erosions and mucous patches accompany the cutaneous eruptions 
and occur on the lips, tongue and inside of cheeks, particularly at the 
labial commissures. Their tendency to ulcerate is greater than in 
adults. Papules developing at the angle of the mouth and on the bor- 
ders of the lips become moist, fissured, and form scabby lesions, which, 
upon healing, leave fine, radiating linear scars that are pathognomonic 
of syphilis. 
Snuffles of a well-marked and persistent character is usually pres- 
ent. The coryzal symptoms may appear with the roseola, and papules 
also develop at the nasal orifices and form scabby lesions, which inter- 
fere with the breathing and nursing of the child. (See Plate 160, 
Fig. 262.) 
While some children remain apparently well during the course of 
these manifestations, the great majority show the effects of the sys- 
temic invasion and become puny, emaciated and shrivelled as if pre- 
maturely aged. 
The secondary symptoms usually disappear under suitable treat- 
ment and the child recovers and may remain well for some years. 
The effects of inherited syphilis may be very marked. Affected 
children develop badly; they remain small, puny and delicate. At the 
period of the second dentition, the upper incisor teeth present the 
stigmata of the disease in a peculiar notched malformation, first 
pointed out by Hutchinson (see Plate 161, Fig. 265). Such children, 
when older, are also very prone to develop affections of the cornea and 
of the ear, leading to deafness. The malformation of the incisors, the 
keratitis and otitis, constitute the well-known Hutchinson's triad, and 
all three are sometimes present in the same individual. At puberty the 
generative organs do not develop normally, and the ovaries and tes- 
ticles may remain immature in a state of infantilism. 
Tertiary gummatous lesions may develop in early adolescence or 
not until the adult age (the late hereditary form). They follow the 
same evolution as in the acquired disease, and result in deep ulcerative 
processes, which most frequently attack the face, where they may de- 
stroy the nose or eye and leave deep disfiguring scars. The destruc- 
tion of the nasal bones results in a characteristic deformity (the sad- 
dle-back nose), caused by the sinking in of the nose through the loss of 
its supporting bony frame. (See Plate 161, Fig. 264.) 
Deep and destructive lesions also occur on the extremities as in the 
acquired disease. Plate 162 shows deep phagedenic and gangrenous 
ulcers of the thigh. (Note the extensive scars.) 
355 Diagnosis and Treatment 
Diagnosis 
The discovery of the treponema pallidum, the introduction of the 
serum test of Wassermann, Neisser and Bruck, the luetin reaction of 
Noguchi (Lumbar Puncture, see Appendix, p. 378), and Ehrlich's 
salvarsan, with its later modification neo-salvarsan, have practically 
revolutionized both the methods of diagnosis and treatment. 
Prior to these discoveries the diagnosis of syphilis rested altogether 
on the anamnesis and the clinical evidences presented, while in doubtful 
and obscure cases the only recourse was the empirical therapeutic test 
based upon the assumption that, if syphilitic, the condition would be 
relieved by specific treatment. The treatment was likewise delayed 
until the provisional diagnosis was confirmed by the appearance of the 
secondary phenomena. 
The diagnosis of syphilis at the present time depends upon the 
demonstration of its causative factor, the history and clinical evidences 
presented and the serologic and cutaneous reactions. 
The treponema is the earliest discoverable evidence of syphilis and 
when found in the primary lesion, furnishes absolute proof of its 
specific nature; hence it should always be sought for in all suspicious 
local lesions however innocent or benign they may appear. It is pres- 
ent in the early period of the primary sore and can be demonstrated in 
the great majority of cases unless the sore has been locally treated with 
antiseptics, mercurials or cauterized, for these measures cause its dis- 
appearance. In that event it may be sought for in the enlarged in- 
guinal glands according to Hoffmann's method. During the secondary 
period it is found in the mouth lesions, moist papules, condylo- 
mata, etc. 
The clinical evidence offered by the typical cutaneous syphilitic 
eruptions is so characteristic that no other confirmation is required. 
The antecedents and the frequent presence of concomitant symptoms, 
mucous patches, condylomata, adenopathy, angina, alopecia, etc., still 
further establish the diagnosis irrespective of the serologic findings 
which may be negative in the presence of active lesions. 
356 S ero-Diagnosis 
In the absence of definite data and characteristic symptoms the 
complement fixation reaction, generally known as the Wassermann 
test, gives most valuable aid in the diagnosis of syphilis. It is partic- 
ularly valuable for the recognition of latent and obscure forms and as 
a guide for the control of treatment. 
The reaction is also present in yaws or framboesia tropica and in 
leprosy. It has been reported in late tuberculosis, carcinoma, malarial 
fevers, pneumonia and scarlatina, but even when syphilis can be ex- 
cluded, such findings, according to Bruck, are doubtful and due to 
faulty technique. 
Aside from these easily excluded affections and according to our 
present knowledge, a well-marked positive reaction showing a com- 
plete absence of hemolysis signifies that the individual has at some 
time contracted syphilis, but it does not follow that a given symptom 
or lesion is for that reason specific, for syphilitics may, like other peo- 
ple, suffer from other ills. 
A negative reaction, per contra, does not always denote the absence 
of syphilis, for it may be negative in the florid period and in the pres- 
ence of active secondary or tertiary symptoms. Thus Craig (Journal 
A. M. A., Feb. 22, 1913), from the examination of 3,381 syphilitics, 
found the reaction in the 
Primary stage 10 per cent, negative. 
Secondary stage nearly 5 per cent, negative. 
Tertiary stage nearly 14 per cent, negative. 
Latent stage nearly 35 per cent, negative. 
Congenital syphilis over 10 per cent, negative. 
Parasyphilis over 32 per cent, negative. 
and that furthermore a strongly positive reaction is rendered tem- 
porarily negative by the ingestion of from 90 to 120 cc of whiskey on 
the day preceding the examination. 
A negative reaction may also become positive through the adminis- 
tration of antisyphilitic remedies, this so-called provocative reaction 
being in all probability due to the liberation of organisms hidden in 
the lymph-nodes or elsewhere; hence a number of factors, some of 
which are known, may influence the reaction. 
The W ass er mann test is most useful as a guide to treatment and 
for its control. The reaction fluctuates under the influence of treat- 
ment; however, if this is adequate, it generally becomes weaker and 
finally disappears, but may shortly relapse to positive upon its dis- 
357 continuance, so that the first negative reaction cannot be regarded as 
an indication for the cessation of treatment. When the reaction re- 
mains negative after repeated examinations, the treatment is stopped 
and further tests made at intervals of two to three months. A nega- 
tive phase persisting for a year or more is only presumptive evidence 
of cure, as it is not yet known for how long a time the reaction may 
remain negative and still relapse to positive. The added confirmation 
of a negative luetin reaction would greatly strengthen the presump- 
tion, but at present reinfection furnishes the only absolute proof of a 
cure having taken place. 
The conversion of a positive Wassermann to a permanent negative 
reaction is more difficult in the latent than in the earlier stages and is 
sometimes impossible, no matter what treatment may be used. 
A strongly positive reaction signifies syphilis and furnishes an 
indication for treatment. 
A single negative reaction has no diagnostic value; it may mark 
the beginning of a negative phase and thus furnish information as to 
the effect of treatment. An individual with a history of syphilis 
should never be declared free from it as the result of a single negative 
reaction. 
The diagnostic value of a negative reaction depends upon its per- 
manence in the absence of clinical symptoms and as the result of treat- 
ment. An arbitrary period of one to two years is generally mentioned 
as a probable indication of cure, but the reaction has returned after 
more than one year's absence. 
In the presence of typical clinical evidence the Wassermann test 
is of secondary importance. 
The luetin test of Noguchi is similar in principle to the von Pir- 
quet cutaneous test for tuberculosis, and consists of an emulsion pre- 
pared from killed pure cultures of the treponemata pallida, which, in- 
jected into the skin of syphilitic subjects, produces a specific cutaneous 
reaction, characterized by a localized inflammation at the inoculated 
point and the formation of a papule. A control fluid serves to differ- 
entiate and measure the reaction. The formation of the characteristic 
papule constitutes a positive reaction. In normal individuals the re- 
sult is a slight erythematous area at the inoculated point, which is 
unaccompanied by either pain or itching and which gradually subsides 
within 48 hours, leaving no induration. The reaction in luetics devel- 
ops usually within 48 hours, but may be delayed in some instances as 
late as three or four weeks after inoculation {Noguchi, Jour. A. M. A., 
Oct. 5, 1912). It varies in intensity from a small papule to a later 
358 indurated pustular formation, lasting several days. The results ob- 
tained thus far by different clinicians show the luetin reaction to be 
specific for syphilis, that it is present in the majority of cases in the 
tertiary and latent periods, and in hereditary syphilis, but that it is 
not so constant in secondary cases that have not been treated. 
Per contra, the Wassermann reaction is present in over 95 per 
cent, of secondary cases, but is negative in about 14 per cent, of ter- 
tiary cases, and in nearly 35 per cent, of latent cases, these being the 
periods in which the luetin reaction is most constantly present; hence 
its great value in determining the presence of syphilis in Wassermann- 
free cases. If, as a result of treatment, a prolonged negative Wasser- 
mann is obtained, the luetin test should be used to confirm the absence 
of syphilis; if both are negative, the presumption of cure is greatly 
augmented and justifies a better prognosis or vice versa. 
Treatment 
The demonstration of the treponema in the primary lesion at once 
establishes the diagnosis and permits the immediate initiation of 
treatment instead of waiting as formerly for the advent of the second- 
ary manifestations, thus much valuable time is gained and treatment 
instituted at an early period when it can be most effective in destroying 
the invading organisms, preventing or minimizing the later symptoms 
and greatly increasing the probability of an early cure. 
The treatment of the cutaneous eruptions is that of syphilis, of 
which they only constitute an external or visible manifestation. Lo- 
cally, they demand the same general care that is given other skin affec- 
tions; cleanliness of the skin is essential, baths of a soothing and 
emollient character (bran or starch), are beneficial and grateful. Parts 
subjected to friction and rubbing, or that are normally moist, should be 
dusted with talcum powder, etc., to prevent the development of moist 
lesions, particularly in children, who are very prone to them. The 
care of the mouth and teeth cannot be too strongly insisted upon; 
smoking should be prohibited, for it is the most potent factor in the 
development of the annoying and recurring mucous patches and the 
severer forms of mouth lesions. This is illustrated by the great dis- 
proportion in the frequency of these lesions in men who smoke, as 
compared to women and non-smokers. The necessity of oral hygiene 
is still further indicated to prevent the toxic effects of mercurial medi- 
cation (salivation, gingivitis, etc.). 
General hygiene is most important. Syphilis reacts differently on 
different organisms. In some the general health is apparently very 
little affected, but others show its systemic effects in many ways, and 
359 by lessening the individual resistance may open the path to other ills. 
Hence all means should be used to combat the depressing effects of the 
disease, by regulating the habits, giving proper food, tonics, etc., for 
the administration of mercurials, salvarsan or iodides does not con- 
stitute all of the treatment of syphilis. 
The individual must also be treated. To some the very name of 
syphilis inspires terror, and in such the consciousness of the disease 
is apt to produce a severe mental shock, begetting loss of ambition and 
morbidity. Others become timorous, self-centred, and develop into 
confirmed neurasthenics, with all kinds of phobias. Such people must 
be encouraged, buoyed up, and the probability of an early cure through 
the newer methods held out to them. The majority, however, are more 
apt to be careless, and indifferent, provided the present symptoms are 
relieved; they are irregular in following the treatment, and it is diffi- 
cult to make them understand or appreciate the possible consequences 
of their neglect. 
Mercury, the arsenical compounds (salvarsan and neo-salvarsan), 
and the iodides constitute the antisyphilitic remedies; both mercury 
and salvarsan act as specifics by destroying the treponemata pallida 
with which they come in contact and are curative. The iodides are not 
curative in the same sense, for they are not spirillicidal, but they act 
energetically against a certain order of lesions and are invaluable as 
part of the syphilitic therapy, especially when combined with mercury 
in the form of mixed treatment. 
Mercury is active in all stages of syphilis. Under its use, the 
cutaneous manifestations subside and disappear rapidly; but to this 
there are occasional exceptions, for certain obstinate secondary forms 
of a lichenoid papular type or palmar and plantar eruptions are some- 
times rebellious and may persist for a long time. The lesions of the 
mouth are sometimes rebellious and relapse repeatedly, while old 
chronic tertiary ulcers and tertiary palmar syphilides are notably re- 
fractory to treatment; but aside from these exceptions, the effects of 
mercury in causing a rapid disappearance of symptoms is very 
marked. 
Mercury may be administered per os, through the skin by friction, 
and by hypodermic and intramuscular injections; it is also given by in- 
travenous injections, but this method has not come into general use. 
The therapeutic action of the drug is secured, however introduced, 
but its effects vary in degree of efficiency with the method used. 
The internal administration was for many years the method of 
choice, and it probably remains the one most widely used to-day, but 
360 it presents certain disadvantages, for it is apt to disagree and pro- 
duce gastro-intestinal irritations, necessitating temporary suspension 
of treatment. The dosage cannot be increased sufficiently to produce 
a rapid and intense effect, and the treatment is more likely to be car- 
ried on irregularly than by more precise methods; but it renders good 
service when these cannot be adopted 
The protiodide, gr. % to %, three times daily, or the biniodide, 
gr. %o to gr. %2, three times daily, are the most commonly used 
preparations. 
Mercurial rubbings furnish a rapid method of introducing the rem- 
edy into the system and for securing quick results, but it is a dirty 
procedure and its effects are difficult to control, for of all methods it 
is the one most likely to cause salivation, hence it must be watched 
and the number of rubbings included in one series limited to twelve. 
This method is largely used in the treatment of children, and is pre- 
ferred by some continental clinicians following the use of salvarsan 
or neo-salvarsan. Mercurial ointment is employed in doses of 5i to 
5ii; the rubbings should be made in different regions at night and fol- 
lowed by a bath on the following day. In children the dose should not 
exceed 5ss. 
Injections may be made with soluble or insoluble salts. The soluble 
injections are made into the subcutaneous tissues with an ordinary 
hypodermic syringe, the interscapular regions being the usual site. 
The preparations most commonly used being the benzoate of mercury 
and the biniodide. 
Hydrarg. benzoate 1 gram. 
Sodium chloride pure 2 grams. 
Distilled water 100 cc. 
15 to 30 minims to be injected daily. 
or 
Hydrarg. biniodide, 
Sodium iodide (chemically pure) aa. 0.10 centigram. 
Aq. dest 10 cc. 
15 to 30 minims to be injected daily. 
The soluble preparations have the disadvantages of being more 
or less painful and of requiring daily administration, to which most 
patients object. Their effects are rapid but not durable; for that 
reason the intramuscular injections of the insoluble salts are to be 
preferred. 
361 The intramuscular injections are generally used when an intensive 
mercurial action is desired and for routine use. 
Calomel is the most active and intensive but also the most painful. 
The injection may be prepared with sterilized olive oil or liquid 
petrolatum. 
Calomel 0.50 gram. 
Olive oil 10 grams. 
15 to 20 minims to be injected weekly. 
The salicylate of mercury is most generally used for routine in- 
jections ; it is made up in 10 per cent, suspensions with sterilized liquid 
petrolatum, each 10 minims representing one grain of the drug, which 
is the usual dose; but this may be increased to 15 or 20 minims to 
obtain a maximum effect if indicated; the injection is repeated weekly. 
Gray oil or the ol. cinereum of Lang is preferred by some. The 
intramuscular injections should be made deeply into the gluteal mus- 
cles alternately, and the most careful aseptic precautions observed. 
The needle should be withdrawn rather quickly so as not to leave any 
of the preparation in the tract, as this causes a painful swelling. Pul- 
monary embolism is an accident sometimes observed after the injec- 
tion of insoluble salts; it comes on quickly and is characterized by 
some oppression of the chest or by tickling and coughing. The attack 
may last an hour or two and then pass off. The accident is infrequent 
and usually of no significance. 
Iodide of Potassium finds but few indications in the secondary 
stage, except in early ulcerative and phagedenic lesions. It is useful 
in the recurrent mouth lesions and for the relief of periosteal and 
meningeal pains, but it is when directed against the tertiary gumma- 
tous and ulcerative lesions that its action is most manifest and marked. 
It is not so efficient in the dry or squamous tubercular eruptions. Its 
action in gummata of the tongue and soft palate is remarkable, and 
it is wonderful to observe how rapidly a gumma of the soft palate at 
the point of rupture and threatening its destruction, will resolve under 
adequate doses of iodide. It is useful in most of the tertiary symp- 
toms ; but to secure its therapeutic effects it must be given in sufficient 
quantity. The ordinary dose of ten to twenty grains two or three 
times daily may suffice, but much larger doses may be required, and 
where a rapid action is necessary, as in gumma of the soft palate, 5i 
to 5ii daily should be given and much more if necessary. Thus in the 
case, coming under the writer's care, of a young man suffering from 
a cerebral syphilis, marked by active delusions and hallucinations, no 
perceptible improvement was noticed until the dose exceeded 5iv daily; 
362 the quantity was rapidly increased until the enormous total of nearly 
§iii per day was reached, when complete recovery took place and was 
maintained until last seen several years later. Kingsbury has admin- 
istered the iodide intravenously in doses of 5ii in cases of cere- 
bral syphilis with good results. In the administration of iodide of 
potassium care should be taken to test the susceptibility of the patient; 
ten grains may cause a distressing anginal swelling, and the ordinary 
toxic phenomena of coryza and acne may be excessive. 
Mixed Treatment 
The combination of iodide of potassium with mercury forms the 
most generally useful and effective treatment in the tertiary and latent 
periods. It is best administered separately, the mercury under the 
form of intramuscular injections or per os, and the iodide in the 
form of a 50 per cent, solution, of which two minims represent one 
grain of iodide. In this manner the dosage of the respective drugs 
may be increased or decreased according to indications; thus in the 
dry squamous tubercular syphilides the proportion of mercury should 
be larger, whereas in the ulcerative forms the iodide should be in 
excess. 
Salvarsan 
The early enthusiasm over this remedy, caused by the extravagant 
reports sent forth, have given way to a more just and conservative 
estimate of its value. It is now known that it cannot be said to cure 
syphilis any more than mercury does, that relapses are frequent fol- 
lowing its use, and that only exceptionally does it cause a permanent 
disappearance of the Wassermann reaction. On the other hand, it 
has shown itself to be a most powerful symptomatic remedy for syph- 
ilis. It causes a more rapid disappearance of the symptoms, and will 
bring about the resolution of old chronic lesions that have proven re- 
fractory to mercury or the mixed treatment; but sometimes its effects 
are not so satisfactory. Its power seems to be in direct ratio with the 
age of the disease. Given in the primary period, it usually brings 
about a rapid cicatrization of the chancre and may prevent altogether 
the secondary phenomena, and in some reported instances it seems to 
have brought about a complete sterilization, as shown by subsequent 
reinfection. In the secondary period it causes a more rapid disappear- 
ance of the infective and recurrent moist lesions, mucous patches, etc., 
but its effects on the papular forms are sometimes no better than pro- 
duced by mercury; while in the tertiary and latent periods its superi- 
ority is not always demonstrated. 
363 Salvarsan presents greater dangers in its administration than does 
mercury, for a number of fatalities have been reported, and neuro- 
recurrences are far more frequent. Certain contraindications to its 
use have been pointed out by Ehrlich. Among these, affections of the 
auditory and optic nerves, non-compensated heart lesions, arterio- 
sclerosis and nephritis. Salvarsan, like mercury, is a specific, for it 
destroys the treponemata and is indicated in all periods of the disease. 
Neo-salvarsan is a modification of salvarsan, which, from its lesser 
toxicity, greater solubility, neutral reaction, and equally good thera- 
peutic effects, is generally used in preference to the older remedy. 
The intravenous method is generally employed for its administra- 
tion. It dissolves freely and rapidly when poured on the surface of 
the water, which should be freshly distilled (from 150 to 200 cc is 
sufficient). The solution should be prepared at the time of administra- 
tion and used immediately, with all aseptic precautions. The average 
dose for males ranges from 0.6 to 0.75 and from 0.45 to 0.6 gram for 
females, but smaller doses are advisable in the beginning of treatment. 
Further experience has also demonstrated that the best results are 
obtained by combining mercury and neo-salvarsan. 
Given a case in the primary period and presenting no contraindi- 
cations, an initial dose of neo-salvarsan of from 0.15 to 0.3 gram is 
given, followed in seven days by one of 0.3 to 0.45 gram, and this is 
repeated weekly until four to six injections have been adminis- 
tered. Between the injections of neo-salvarsan an intramuscular in- 
jection of mercury is given, and these mercurial injections are contin- 
ued afterward. When the injections of neo-salvarsan are begun during 
the florid secondary period, a short preliminary course of mercurial 
injections is advisable to prevent severe reactions and the development 
of neuro-recurrences. Ravaut (Presse medicate, ler mars, 1913) uses 
concentrated solutions of neo-salvarsan which he administers intra- 
venously by means of an ordinary glass hypodermic syringe, 10 cc 
of distilled water being sufficient to effect the solution of the larger 
doses, 0.75 gram or even 0.90 gram. The treatment is initiated with a 
dose of 0.45 or less; the injections are repeated every eight days and 
the dose progressively increased, provided the preceding one has been 
well tolerated, the doses being successively increased from 0.45 then 
0.60-0.75 and 0.90. A thermic reaction is noted in primary cases that 
have received no anterior treatment. In those having had some pre- 
liminary treatment or in whom the chancre was recent, no reaction was 
observed. In individuals presenting active lesions or in the latent 
period and who had not been recently treated, the first injection was 
364 followed by a febrile reaction, its absence being exceptional, whereas 
after the following injections absence of fever is the rule and its pres- 
ence the exception. 
As a result of his experience, Ra/vaut makes the following deduc- 
tions : 
1. To begin treatment with a small dose. 
2. To allow an interval of at least eight days between each injec- 
tion. 
3. If the injections are well tolerated, to progressively increase the 
dose, which, however, should never exceed 0.90 gram. 
4. Aside from the first injection, which may sometimes determine 
some fever, nausea, etc., the other injections should be apyretic. 
5. If, after an injection, signs of intolerance are manifested and 
these have disappeared at the end of eight days, the injection may be 
renewed, but without increasing the dose. If, however, the manifes- 
tations persist after eight days, the dose should be diminished or the 
injection postponed until they have subsided. If the following injec- 
tions are well borne, the dose may again be increased. 
6. If the signs of intolerance recur notwithstanding the reduced 
doses, it is advisable to have recourse to mercury and stop the use of 
neo-salvarsan. 
The advantages claimed for the concentrated method is its great 
simplicity, the uniformity of results and the elimination of possible 
dangerous factors due to the distilled water, since in this method 
the quantity used is so small as to render its ill effects negligible, for 
even the ordinary commercial distilled waters have been used. The 
technique is simple, but great care must be taken to see that the needle 
is within the lumen of the vein. 
The rectal administration of salvarsan was first suggested by 
Geley, of Annecy. Luis del Portillo1 from a series of experiments 
found that weekly intestinal injections of an alkaline solution of sal- 
varsan in rabbits during a period of six weeks produced no ill effects 
and that the intestinal mucosa of the killed animals presented micro- 
scopically no detectable alterations. 
Rajat, director of the bureau of hygiene of Vichy, who has em- 
ployed this method in 125 instances, claims results equal to those ob- 
tained by intravenous or intramuscular injections, and he reaches the 
conclusion that rectal administration should be the method of choice 
1 Dr. Luis Del Portillo, Tecnica de la applicacion del "606" por la via 
rectal. Revista espanola de dermatologia y sifilografia.-No. 163, Juillet, 
1912. 
365 from the advantages it presents; these being its innocuous, painless 
character and simplicity. Febrile reactions were not observed and 
only very slight after-effects, such as transient vertigo, were noted. He 
considers the method particularly applicable in reduced dosage for the 
treatment of children. It would be equally so in cases presenting con- 
traindications to the intravenous method by reason of arterial hyper- 
tension or non-compensated heart lesions. 
The technique is simple and consists in a preliminary cleansing, 
entero-clysis, on the day of injection and the administration of an opiate 
to control the bowel. An alkaline solution of salvarsan, in 120 cc of 
normal solution, or neo-salvarsan, may be used. The patient being in 
the lateral decubitus the injection is given by means of a small rectal 
tube or rubber catheter connected with an ordinary glass funnel, 
slightly elevated above the patient so as to allow the solution to flow 
very slowly into the bowel; or a syringe of sufficient capacity may be 
employed. The usual aseptic precautions should be observed, and the 
patient kept at rest after treatment. 
The method of treatment will often be governed by circumstances. 
In suitable cases and when there are no contraindications, the com- 
bined neo-salvarsan and mercurial treatment gives the best immediate 
results, particularly in the early stages of the disease. Either the intra- 
muscular mercurial injections or mercurial rubbings may be employed 
in combination; the rubbings are much used on the continent of Europe, 
and are preferred by some authorities. "When the neo-salvarsan treat- 
ment cannot be adopted, the choice of mercurial methods will lie be- 
tween injections, rubbings or internal administration. Injections are 
to be preferred as being more definite in dosage and more easily con- 
trolled. The insoluble injections require less frequent administration 
and are productive of more durable results. Mercurial rubbings are 
very effective, but present the objectionable features mentioned. In cer- 
tain cases the internal method is the only recourse, for sometimes 
sensitive patients will refuse any other form of treatment, and under 
certain conditions it is the only possible method, as with individuals 
constantly travelling, living on shipboard, in mining or lumber camps, 
or in localities where adequate medical care cannot be had. When 
under the same conditions the diagnostic confirmation of a Wasser- 
mann test cannot be had, it should also be remembered that the thera- 
peutic test is still as effective as of yore, and may prove life-saving 
in obscure cases of possible or suspected syphilitic origin, as in develop- 
ing gumma of the brain, cerebro-spinal or visceral syphilis, etc. 
366 The Simple Venereal Ulcer or 
Chancroid 
Synonyms: Soft chancre (Latin, ulcus molle; French, chancre mou, chan- 
croide, chancrelle; German, schanker; Italian, ulcero molle). 
A chancroid is a contagious ulcer affecting the skin or mucous mem- 
branes, and is usually contracted from sexual intercourse with a person 
similarly affected. In consequence, it is found in the vast majority 
of cases on the genitals in both sexes, but it may be extra-genital and 
result from either direct or mediate contagion and develop wherever 
inoculation takes place, and in experimental inoculation. It is not in- 
frequent in the female perianal and anal regions, and is occasionally 
observed in other parts, such as the lips, tongue, fingers, etc. (See 
Plate 162, Fig. 268.) 
Etiology 
The causative factor is the bacillus of Ducrey, so named after its 
discoverer. The organisms are short, thick bacilli with rounded ends, 
appearing in pairs, groups and singly, both within and without the 
cells and usually associated with other microorganisms. Smears made 
from the secretion of fresh ulcers are readily stained by Loeffler's 
methylene blue and decolorized by Gram. 
The initial result following contagion is the early appearance at 
the infected point of a slightly sensitive or stinging red irritated spot, 
which within 24 hours becomes somewhat elevated and surrounded 
by a red areola. At the end of 48 or at most 72 hours a pustule 
develops which soon ruptures and leaves a diminutive ulcer, which en- 
larges into a generally round excavated lesion with a yellowish floor, 
abrupt, vertical borders, and secreting an abundant purulent con- 
tagious discharge. As the ulcer extends, and depending upon its 
situation, it is apt to become irregular both in contour and depth 
owing to the variable resistance offered by different tissues to the de- 
structive process, which may thus burrow under the marginal skin 
367 and leave undermined borders and overhanging edges, or penetrate 
deeply into the follicles, while sometimes it follows cutaneous folds, 
forming ragged linear ulcerations. The ulcerative floor is irregular, 
pitted and more or less covered by an adherent slough, difficult to re- 
move and leaving bleeding points when detached. The discharge is 
usually abundant, thick, purulent and of a dirty white, yellowish or 
sometimes greenish color, while the base is soft or feels doughy ac- 
cording to the degree of inflammatory exudate present. 
Chancroids are frequently multiple at the start and appear simul- 
taneously, but the discharge from an ulcer, originally single, very 
often contaminates the surrounding surface and leads to the develop- 
ment of successive sores, which, owing to their proximity to each 
other, often meet as they enlarge, and coalesce to form ragged elongated 
lesions. 
Location 
As chancroids are in the very great majority of cases of venereal 
origin, they are usually found on the genitals, and in order of fre- 
quency they appear upon those parts most subject to abrasion or injury 
during coitus. 
In the male, the inner surface of the prepuce, the coronal sulcus, 
the glans, the frenum, the preputial margins and the urethral orifice 
are the parts chiefly affected. The little pockets at either side of the 
frenum are also favorite sites, from retention of contagious material 
deposited in them. 
In the female the parts most commonly involved are the introitus 
vaginae (particularly the fourchette), the inner surface of the labia 
(see Plate 165, Fig. 271), and occasionally the cervix. The vagina, 
from its greater resistance, is very rarely affected. 
Chancroids vary in type. Sometimes they are represented by 
irregular superficial exulcerations or erosions, with a raw red surface 
surrounded by well-defined red edges, while occasionally the surface 
is elevated above the adjoining skin or mucous parts. At other times 
there may be very little evidence of inflammation and the sore has a 
lardaceous or diphtheritic appearance; this particular type is apt to 
remain stationary and have a prolonged duration. A chancroid de- 
veloping upon the skin, as on the cutaneous surface of the penis or 
labia, is often covered by a thin brownish crust, beneath the edges of 
which a yellowish pus exudes upon pressure. The infection of a fol- 
licle leaves a rather deep and conical ulcer. 
Chancroids also offer certain peculiarities due to their regional 
368 location. They are generally multiple when situated on the inner sur- 
face of the prepuce and coronal sulcus, and are apt to extend in sur- 
face and present irregular undermined borders; lesions of the sulcus 
are usually elongated. Those occurring on the glans are most fre- 
quently round, cup-shaped, with abrupt adherent borders and tendency 
to extend in depth, while corresponding ulcers on the inner preputial 
surface are not uncommon. 
Ulcers of the preputial margin are ordinarily multiple (see Plate 
164, Fig. 269), and apt to extend along the cutaneous folds. Mar- 
ginal sores are generally painful from the irritation caused by urina- 
tion and erections; retraction of the prepuce is difficult or sometimes 
impossible owing to the phimosis, which is a frequent complication. 
The frenum is frequently the seat of linear ulceration, and is also 
apt to be undermined by ulceration of the subfrenal fold, which be- 
comes perforated and sometimes leaves the eroded frenum like a thin 
band bridging over the little chasm. This usually leads to its rup- 
ture. Lesions of the frenum are ordinarily painful, owing to its nor- 
mal sensitiveness and the irritative effects of erections. 
Ulcer of the urethral orifice may affect one or both lips and some- 
times extend into the urethra. (See Plate 162, Fig. 267.) (Cica- 
tricial narrowing of the orifice is a common result when repair has 
taken place.) 
Extra-genital chancroids occur most frequently in the female peri- 
anal and anal regions. They are generally multiple and sometimes 
quite numerous, and may result from direct contagion or auto-inocula- 
tion from preexisting lesions. 
Anal chancroid is, for obvious reasons, most frequently seen in 
women. In man it is rare and ordinarily results from sodomy. 
C omplications 
Chancroids may be complicated by buboes, lymphangitis, phimosis, 
paraphimosis, balanitis and phagedena. 
The bubo is the most common complication. It may be either 
simple or virulent. The simple or sympathetic inguinal bubo is a more 
or less sensitive glandular swelling which is generally limited to one 
side. It sometimes goes on to suppuration and upon opening reveals 
a healthy looking base while the purulent discharge is non-inoculable. 
Its further course is that of an ordinary abscess and is followed by 
prompt repair. 
The virulent bubo is due to the absorption of contagious elements. 
This is followed by a painful glandular swelling which progresses 
369 rapidly to softening and fluctuation while the skin assumes a livid or 
purplish red color. The opened abscess presents a deep irregular 
cavity covered by a foul pultaceous material and with deeply under- 
mined edges; while the abundant unhealthy-looking pus contains the 
bacillus of Ducrey and is auto-inoculable. Sometimes the peno-dorsal 
lymphatics are involved and one of the small glands may break down 
into a small virulent abscess or bubonocele (see Plate 164, Fig. 269). 
Phimosis is not an uncommon complication and most frequently 
accompanies lesions of the glans and preputial margins. 
Paraphimosis is less frequent and often results from the inability 
to restore a foreskin which has been forcibly retracted for the purpose 
of examination or treatment. 
Phagedena is by far the most serious complication, and as in 
phagedena occurring in other conditions, usually reflects a low, vitiated 
constitutional resistance due to acquired causes or individual tenden- 
cies rather than to any inherent property of the original morbid 
process. 
In lesions attacked by phagedena the formerly abundant and puru- 
lent discharge becomes thin and scanty while the appearance of the 
ulcer also changes. It becomes dry with dark brown or black slough- 
ing necrotic areas emitting a foul odor, the surrounding surface being 
generally of a livid red color. After a time the discharge becomes 
more abundant, the sloughs separate and are detached leaving a clean 
granulating surface which may proceed to repair, or else the destruc- 
tive process may begin anew. In other instances the process may as- 
sume an inflammatory type and extend rapidly through a molecular 
disintegration of the tissues involved (see Plate 165, Fig. 272). Vast 
serpiginous gangrenous ulcers sometimes result from extension to the 
surrounding surface of lesions situated on the vulvas or from phage- 
denic buboes (see Plate 164, Fig. 270). Serpiginous ulcers are gener- 
ally chronic and progress superficially along the lines of least re- 
sistance. They may remain stationary for long periods and then take 
on renewed activity, unless successfully arrested. 
Phagedena may cause great destruction of tissue and result in 
severe mutilation or deformities, thus the glans, which seems to be a 
favorite site may be very largely destroyed (see Plate 165, Fig. 272); 
at other times the process may burrow beneath the skin for long dis- 
tances. In a case coming under the writer's care the process besides 
destroying nearly half the glans, had burrowed under the dorsal skin 
of the penis which it undermined to nearly the root, and ultimately 
formed a long foul ulceration. 
370 Phagedenic chancroids may become chronic and persist for months 
or longer, sometimes progressing slowly or remaining practically sta- 
tionary with attempts at partial repair, and they are also apt to start 
afresh with renewed activity. 
Diagnosis 
The characters upon which the diagnosis is made are the short pe- 
riod of incubation, the lesion usually appearing within two or three 
days after exposure, sometimes six or seven; the multiple number of 
lesions, the soft and non-indurated base, the frequently undermined 
edges, the irregular yellowish ulcerative floor and the abundant puru- 
lent discharge which is auto-inoculable and contains the specific bacil- 
lus of Ducrey. The differential diagnosis between chancroid and the 
syphilitic-chancre with which it is most apt to be confounded, will be 
found under the heading of Syphilitic Chancre. 
Treatment 
A chancroid is a purely local condition and its effects are limited 
to the part affected. The aim of treatment is to destroy the virulent 
and specific character of the ulcer so as to convert it into a simple 
lesion capable of prompt repair and also to protect the surrounding 
surface from inoculation by the contagious discharge. For this pur- 
pose various cauterizing agents are used, chiefly solutions of silver 
nitrate, fuming nitric acid, carbolic acid and the actual cautery. Other 
substances sometimes recommended such as caustic potash, and acid 
nitrate of mercury are very diffusible and difficult to control, while 
caustic pastes of sulphuric acid and charcoal or zinc chloride present 
no advantages, and furthermore mask the parts. 
The dressings or applications generally used subsequent to cauteri- 
zation vary. Greasy substances, ointments, etc., are not, as a rule, well 
borne or useful, particularly when the ulcerative process is active and 
the discharge abundant. They are sometimes serviceable in cutaneous 
lesions in the period of resolution. Powders are preferable, but they 
also have the disadvantage of caking and disappearing from the sur- 
face they are intended to cover owing to the abundance of the discharge, 
hence they must be reapplied with sufficient frequency. Iodoform, al- 
though best, is not adapted for general use on account of its intolerable, 
permeating and tell-tale odor; for that reason, aristol, nosophen, euro- 
phen, dermatol, etc., are to be preferred. Moist dressings, consisting 
of a thin layer of absorbent cotton or lint moistened with a weak solu- 
tion of bichloride, 1 to 4,000, black wash or aromatic wine diluted one- 
371 third, are most useful in subpreputial lesions when the ulcerative pro- 
cess has abated and the secretion is slight. The dressings may be 
kept constantly moist, without their removal, by retracting the prepuce 
sufficiently to allow a few drops of the solution to fall on them from 
time to time. 
Scrupulous local cleanliness should be maintained and all applica- 
tions and dressings should be preceded by cleansing the affected parts 
with mild solutions of bichloride, permanganate of potash or peroxide 
of hydrogen diluted one-half or more, and then carefully dried. The 
choice of caustic will depend upon the type of the lesion. When this 
is of the mild superficial erosive or exulcerated variety, the daily appli- 
cation of a 2 to 3 per cent, solution of silver nitrate to the sore with 
subsequent dusting of aristol or the application of a moist dressing 
will generally prove sufficient to bring about resolution. In the severer 
types with undermined edges and sloughing irregular ulcerative floor, 
nitric acid or carbolic acid should be used. To lessen the pain the ulcer 
should first be cocainized with a few drops of a 5 per cent, solution 
of cocaine, or a tablet may be allowed to dissolve in the ulcer. The 
part should be carefully dried and a toothpick wrapped with a little 
cotton dipped in pure fuming nitric acid is then applied to every part 
of the ulcer, particularly the undermined edges and in-filtrated pe- 
ripheral zone. Carbolic acid is less efficient than nitric acid but suffices 
in many cases; its application should be followed by a few drops of 
alcohol to limit its diffusion. It has the advantage of being anesthe- 
tic and in consequence may also be used as a preliminary application 
to deaden the pain caused by nitric acid. One thorough cauterization 
is generally sufficient to abort the chancroidal process, but repetition 
may be necessary. The actual cautery is indicated in rapidly pro- 
gressing lesions and in phagedenic types. It must be thoroughly ap- 
plied and under general anesthesia. 
Treatment of Complications 
A threatening bubo requires complete rest and the application to 
the part of hot moist dressings; if suppuration ensues the abscess 
should be opened and if virulent in type, the cavity is to be flushed 
out with pure peroxide of hydrogen, dried, then mopped out with tinc- 
ture of iodine or carbolic acid, followed by a little alcohol and loosely 
packed with iodoform gauze. 
Phimosis is an annoying complication requiring rest, frequent 
immersions in hot water and subpreputial irrigations. "When the pre- 
puce cannot be retracted so as to expose a concealed chancroid a dorsal 
372 or bilateral incision may be necessary and the incised edges should 
be thoroughly cauterized to prevent their contamination. After heal- 
ing has taken place the flaps can be resected and circumcision com- 
pleted. Chancroids situated on the margins of long and redundant 
foreskins should be cauterized and removed by a circular circumcision. 
Phagedena is fortunately uncommon and should be treated by rest 
and constitutional measures. Local applications or immersions in 
very hot water are both grateful and beneficial from the local hyper- 
emia they produce. Hot air from a cautery point, held intermittently 
in close proximity to the sore until it desiccates, is also a valuable 
procedure to arrest the process. The actual cautery is the most ener- 
getic measure and should be used freely in rapidly progressing lesions 
unchecked by other means, or in the unyielding chronic sluggish types; 
general anesthesia is necessary. 
Peroxide of hydrogen is the best topical agent and may be used in 
half or full strength, particularly in burrowing lesions. 
Crystals of permanganate of potash applied to a sluggish ulcer will 
often convert it into a healthy one. The application is somewhat pain- 
ful and should be preceded by cocainization. 
Dusting the ulcer with salvarsan has also been recommended; it 
produces a dry brownish or black adherent eschar, but its necrotic 
action is apt to be excessive. Fig. 207. Half-tone, Dr. Kingsbury, New York. 
Fig. 208. Half-tone, Dr. Trimble, New York. 
Figs. 209 and 210. Models in Lesser's Clinic in Berlin (Kolbow). 
Figs. 211 and 212. Models in Freiburg Clinic (Vogelbacher). 
Fig. 213. Model in Women's Clinic (Geh. Rat Leopold) in Dresden 
(Kolbow). 
Fig. 214. Model in Municipal Hospital am Urban (Dr. Buschke) in Berlin 
(Kolbow). 
Fig. 215. Model in Neisser's Clinic in Breslau (Kroener). 
Fig. 216. Model in Lesser's Clinic in Berlin (Kolbow). 
Fig. 217. Model in v. Bergmann's Clinic in Berlin (Kolbow). 
Fig. 218. Model in St. Louis Hospital in Paris, No. 1574 (Baretta). 
Quinquaud's case. 
Fig. 219. Model in St. Louis Hospital in Paris, No. 306 (Jumelin). 
Fournier's collection. 
Figs. 220, 221 and 223. Models in Freiburg Clinic (Johnsen). 
Figs. 222 and 228. Models in Neisser's Clinic in Breslau (Kroener). 
Fig. 224. Model in St. Louis Hospital in Paris, No. 1786 (Baretta). 
Halopeau's case. 
374 Fig. 225. Model in Freiburg Clinic (Johnsen). 
Figs. 226 and 227. Models in Neisser's Clinic in Breslau (Kroener). 
Fig. 229. Model in Municipal Hospital Friedrichstadt (Dr. Werther) in 
Dresden (Kolbpw). 
Fig. 230. Model in Lesser's Clinic in Berlin (Kolbow). 
Fig. 231. Model in Neisser's Clinic in Breslau (Kroener). 
Fig. 232. Model in Municipal Hospital Friedrichstadt (Dr. Werther) in 
Dresden (Kolbow). 
Fig. 233. Model in Freiburg Clinic (Johnsen). 
Figs. 234 and 235. Models in Neisser's Clinic in Breslau (Kroener). 
Fig. 236. Model in Polyclinic of Dr. Max Joseph in Berlin (Kolbow). 
Fig. 237. Model in Freiburg Clinic (Vogelbacher). 
Fig. 238. Model in Freiburg Clinic (Johnsen). 
Fig. 239. Model in Freiburg Clinic (Vogelbacher). 
Figs. 240, 241, 242, 243, 244 and 245. Models in Neisser's Clinic in 
Breslau (Kroener). 
Figs. 246 and 247. Models in Freiburg Clinic (Johnsen). 
375 Fig. 248. Model in St. Louis Hospital in Paris, No. 371 (Jumelin). 
Fournier's collection. 
Fig. 249. Model in Pospelow's Clinic in Moscow (Fiweisky). 
Fig. 250. Model in Freiburg Clinic (Vogelbacher). 
Fig. 251. Model in St. Louis Hospital in Paris, No. 417 (Jumelin). 
Fournier's collection. 
Fig. 252. Model in St. Louis Hospital in Paris (Jumelin). Jullien's 
collection. 
Fig. 253. Model in St. Louis Hospital in Paris, No. 678 (Buretta). 
Lailler's case. 
Fig. 254. Model in Freiburg Clinic (Vogelbacher). 
Fig. 255. Model in St. Louis Hospital in Paris, No. 1917 (Baretta). 
Fournier's case. 
Fig. 256. Model in St. Louis Hospital in Paris, No. 1451 (Baretta). 
Fournier's case. 
Figs. 257 and 258. Model in Neisser's Clinic in Breslau (Kroener). 
Fig. 259. Model in Schlossmann's Infant Asylum in Dresden (Kolbow) 
Fig. 260. Model in Lesser's Clinic in Berlin (Kolbpw). 
Fig. 261. Model in Neisser's Clinic in Breslau (Kroener). 
376 Figs. 262 and 263. Models in Schlossmann's Infant Asylum in Dresden 
(Kolbow). 
Fig. 264. Model in Lesser's Clinic in Berlin (Kolbow). 
Fig. 265. Model in Greeff's Ophthalmological Clinic in Berlin (Kolbow). 
Fig. 266. Model in Freiburg Clinic (Vogelbacher). 
Fig. 267. Model in Cochin Hospital in Paris, No. 384 (Jumelin). 
Heurteloup's case. 
Fig. 268. Model in St. Lazare Hospital in Paris (Jumelin), Dr. Jullien's 
department.-A very typical soft chancre on the right index finger. 
Several similar chancres were present on the vulva of the same pa- 
tient. 
Fig. 269. Model in Freiburg Clinic (Johnsen). 
Fig. 270. Model in Lesser's Clinic in Berlin (Kolbow). 
Fig. 271. Model in Neisser's Clinic in Breslau (Kroener). 
Fig. 272. Model in Cochin Hospital in Paris (Aumelin). Mauriac's case. 
377 Appendix 
Lumbar Puncture 
Normally the cerebro-spinal fluid presents a clear limpid appearance, 
sometimes with a slight yellowish tinge. Its specific gravity varies according 
to different observers from 1006 to 1010, and it contains either no cells or 
at the most a few lymphocytes (4 to 5 per field. Widal). A few red cells 
are sometimes seen resulting from the slight hemorrhage caused by the intro- 
duction of the needle. The protein content (globulin, nucleo-proteid and 
protalbumose) varies according to Quincke from 0.2 to 0.5 per litre. As a 
result of syphilitic infection the cerebro-spinal fluid may undergo certain 
alterations first pointed out by Widal, Ravaut and others, and these furnish 
valuable diagnostic elements. In the late syphilitic affections of the central 
nervous system, paresis, tabes, hemiplegia and cerebro-spinal syphilis, the 
serologic reaction of the spinal fluid is frequently positive while that of the 
blood serum may be negative. The cytologic examination shows a variable de- 
gree of lymphocytosis, sometimes quite marked (exceeding 100 lymphocytes 
per field). The protein content is increased and a flocculent globulin pre- 
cipitate is obtained with Noguchi's butyric acid test. This, according to 
Noguchi, is positive in 90 per cent, of cases. Other changes sometimes noted 
being hypertension and a cloudy appearance of the fluid. Excluding the tre- 
ponemata which have recently been found in the spinal fluid but are exceed- 
ingly difficult to demonstrate, these various findings appear to be the earliest 
discoverable pathologic signs of the late syphilitic nerve lesions. 
Cytologic alterations are also observed in the secondary stage in subjects 
presenting clinical symptoms of early involvement of the central nervous 
system, and they may also be present at that period in the absence of clinical 
evidence as shown by the results of lumbar puncture. 
These facts have an important bearing on the treatment, for according to 
Ravaut it is in this class of cases that the severe nervous reactions some- 
times observed after the administration of salvarsan or neo-salvarsan during 
the florid secondary period occur. As a rule they are absent in the early 
primary period and also in subjects in the secondary period who present a 
normal cerebro-spinal fluid. 
In the secondary period it is therefore advisable for the purpose of at- 
tenuating or preventing severe nervous reactions, to begin the treatment with 
a short preliminary mercurial course (soluble injections given daily for six 
or seven days or inunctions), in order to secure the more gradual spirillicidal 
action of mercury and thus prepare the ground for the more intensive action 
of salvarsan or neo-salvarsan, the initial doses of which should also be small. 
THE COPYRIGHTS OF THIS BOOK, IN ALL ENGLISH-SPEAKING COUNTRIES, ARE 
OWNED BY REBMAN COMPANY, NEW YORK 
378 Tab. 128. 
No. 207. Alopecia syphilitica. Tab. 128a. 
No. 208. Alopecia syphilitica. Tab. 129 
No. 209. 210. Scleroses syphiliticae. Tab. 130. 
No. 212. Sclerosis phagedaenica. 
No. 211. Scleroses syphiliticae. Tab. 131. 
No. 213. Sclerosis labii majoris. 
No. 214. Sclerosis et oedema indurativum (in infante). Tab. 132 
No. 215. 216. Scleroses syphiliticae. Tab. 133. 
No. 217. 218. Scleroses syphiliticae. Tab. 134. 
No. 219. Sclerosis syphilitica tonsillae. Tab. 135. 
No. 220. Syphilis maculosa (Roseola). Tab. 136. 
No. 221. Syphilis maculosa confluens; Leucoderma. Tab. 137. 
No. 222. Syphilis maculosa recidiva (Roseola recidiva). Tab. 138. 
No. 224. Syphilis papulosa annularis. 
No. 223. Syphilis maculosa follicularis. Tab. 139. 
No. 226. Syphilis papulosa mucosae oris. 
No. 225. Syphilis papulosa lenticularis. Tab. 140. 
No. 227. Syphilis papulosa orbicularis. 
228. Syphilis papulo-squamosa. Tab. 141. 
No. 229. Syphilis corymbiformis. Tab. 142. 
No. 231. Syphilis circinaria. 
No. 230. Syphilis milio-papulosa (lichenoides). Tab. 143. 
No. 233. Syphilis papulo-squamosa 
No. 232. Syphilis papulo-pustulosa. Tab. 144. 
No. 235. Leukoderma syphiliticum. 
No. 234. Paronychia syphilitica. Tab. 145. 
No. 236. Syphilis papulosa (Condilomata lata). Tab. 146. 
No. 238. Syphilis papulosa linguae. 
No. 237. Syphilis papulosa mucosae et anguli oris. Tab. 147. 
No. 239. Syphilis papulosa. Tab. 148. 
No. 240. Syphilis papulosa (Condilomata lata). 
No. 241. Syphilis papulo-pustulosa. Tab. 149 
No. 243. Syphilis framboesiformis. 
No. 242. Syphilis maligna (Rupia syphilitica) Tab. 150. 
No. 244. Syphilis tubero-serpiginosa. 
No. 245. Syphilis tertiaria. Tab. 151. 
No. 247. Syphilis ulcero-serpiginosa. 
No. 246. Syphilis tubero-serpiginosa. Tab. 152. 
No. 249. Caries syphilitica ossium cranii. 
No. 248. Cicatrices palati mollis post ulcerationes syphilitica? Tab. 153. 
No. 251. Syphilis ulcerosa palati duri. 
No. 250. Syphilis ulcerosa palati mollis. Tab. 154. 
No. 253. Syphilis gummosa digit 
No. 252. Syphilis gummosa linguae diffusa, Tab. 155. 
No. 255. Syphilis gummosa glandis 
(Pseudo-chancre). 
No. 254. Syphilis gummosa. Tab. 156. 
No. 256. 257. Syphilis gummosa. Tab. 157. 
No. 258. Syphilis ulcero-serpiginosa. Tab. 158 
No. 259. 260. Syphilis hereditaria bullosa (Pemphigus syphiliticus Tab. 159. 
No. 261. Syphilis hereditaria papulosa. Tab. 160. 
No. 262. 263. Syphilis hereditaria papulosa. Tab. 161. 
No. 264. Syphilis hereditaria ossium nasi. 
No. 265. Hutchinson teeth. Tab. 162. 
No. 266. Syphilis hereditaria (tarda). Tab. 163 
No. 268. Ulcus molle digiti 
No. 267. Ulcus molle orificii urethrae. Tab. 164. 
No. 269. Ulcera mollia-Bubonulus. 
No. 270. Ulcus molle gangraenosum. Tab. 165. 
No. 271. Ulcera mollia vulvae. 
No. 272. Ulcus molle phagedaenicum. Index 
(The black figures denote the page in the text where the principal subject may be 
found, also the plate illustrating that particular subject, except in the section 
dealing with syphilis.) 
Acacia, 123 
Acarus scabiei, 258 
Acetanilide, 12, 18, 45 
Acetic acid, 185, 264, 268 
Acid nitrate, 331 
Acne, 66 
bromic, 44 
keloid, 129 
pustular, 115 
rosacea, 69, 124 
syphilitic, 317 
varioliformis, 116, 173 
vulgaris, 118 
Aconite, 45 
Acrodermatitis, 170 
Acroneurosis, 131 
Acroparesthesia, 74 
Actinomycosis cutis, 253 
Adamson, 236 
Addison's disease, 43, 140 
Adenitis, 70 
Adenoma sebaceum, 147 
Adrenalin, 10 
Alcohol, 13, 45, 58, 71, 80, 102, 141, 185 
Aldersmith, 235 
Aleppo evil, 205 
Alibert, 216, 306 
Alkalies, 271 
Alkalines, 40, 48, 58, 60, 62, 67, 86, 149, 
151, 165, 250 
Alopecia, 47, 70 
adnata, 136 
areata, 131 
congenital, 136 
Alphos, 63 
Alum, 12 
Aluminum acetate, 90, 102 
Ammonia citrate, 8, 121 
carbonate, 184 
Anemia, 66, 72 
Angioma, 161 
Angioneurotic edema, 101 
Anodynes, 176 
Anthrax, 251 
Antimony, 45, 61 
Antipyrine, 43, 45, 54, 61, 98, 102 
rash, 43 
Antirheumatic medication, 7 
Antistreptococcus serum, 102 
Aphonia, 208 
Aphthae, 108 
Aphthous stomatitis, 108 
Area Celsi, 131 
Argyrol, 13, 85 
Aristol, 12, 305, 371 
Aromatic wine, 305, 371 
Arsenic, 13, 17, 18, 20, 28, 30, 32, 37, 42, 
43, 48, 54, 61, 67, 121, 135, 139, 155, 
158, 168, 184, 202, 211, 215, 218, 220 
rash, 43 
Arsenious acid, 61 
Arteritis syphilitica, 74 
Asiatic pill, 61 
Aspirin, 7, 99 
Astruc, 276 
Atheroma multiplex, 180 
Atrichia, universal congenital, 136 
Atrophia cutis idiopathica, 170 
Atrophy, idiopathic, 170 
Atropin, 85 
Aurantium, 61, 62 
Auto-intoxication, intestinal, 2 
Autotoxemia, 27 
Auto-vaccino-therapy, 213 
Bacillus Ducrey, 12, 367, 370, 371 
Friedlander, 213 
fusiformis, 281 
ozenae, 213 
Balanitis, 11, 305 
Balano-porthitis, 294 
Baldness, 131, 231 
Barber's itch, 22, 242 
Basham's mixture, 99 
Bassereau, 277 
Bazin, 248 
Bazin's disease, 199 
Bedbugs, 38 
Belladonna, 98 
Benzoic acid, 45 
Bernhardt, 277 
Betanaphthol, 68, 122, 135, 261 
Bichloride of mercury, 61, 211, 235, 241, 
264, 371 
Biett, 49, 311 
Billard, 108 
Biniodide, 361 
Biskra button, 205 
379 Bismuth, 54 
subnitrate, 12, 305 
Blackheads, 122 
Blackwash, 305 
Blanchard, 280 
Blastomyces, 191 
Blood serum, human, 10 
Blue ointment, 268 
Bockhart, 22 
Body lice, 265 
Boeck, 277 
Borated solution, 305 
Bordet, 278 
Boric acid, 12, 40, 45, 54, 62, 85, 86, 90, 
92, 111, 122, 185, 204, 264, 266 
Boroglycerine, 154 
Bosanquet, 281 
Bosellini, 217 
Bovine virus, 89 
Bran, 62 
Bromides, 40, 85 
Bromine, 44 
carbuncle, 44 
rash, 44 
Bromism, 44 
Bronchopneumonia, 86 
Bruck, 278, 356, 357 
Bubo, 369 
Bubonocele, 370 
Budd, 277 
Bulkley, 40, 61, 184, 201, 245, 297 
Burns, 28, 32 
Burri's India ink, 283 
Cacodylate of sodium, 58 
Cade, oil of, 46 
Calamine, 15, 25, 37, 54, 62, 185 
Calomel, 7, 12, 88, 95, 99, 304, 362 
Calx sulphurata, 45 
Camphor, 15, 54, 62, 123 
Cancer, 106 
cauliflower, 228 
Cannabis indica, 45 
Cantharides, 135 
Capsicum, 135 
Carbolic acid, 3, 32, 37, 62. 135, 154, 174, 
252, 371, 372 
Carbon dioxide, 185 
monoxide, 17 
Carbonic acid snow, 143 
Carbuncle, 251 
Carcinoma cutis, 229 
en cuirasse, 229 
linguae, 226 
penis, 228 
Carpi, 276 
Cascara sagrada, 121 
Casein, 71 
Castor oil, 7, 95, 123 
Cauliflower excrescences, 160 
Caustics, 144, 146, 151, 158, 178, 179, 223, 
240 
Cautery, 129, 174, 191, 218, 223, 225, 228, 
252, 371, 372 
Cavernoma, 161 
Cellulitis, 101 
Cerate, 305 
Cerebral sclerosis, 20 
Chancre, anginal, 299 
anus, 301 
breast, 299 
cervix, 295 
de retour, 302 
errosive, 298 
extragenital, 296 
eye, 299 
face, 299 
female genitals, 294 
fingers, 299 
fourchette, 295 
gangrenous, 302 
greater lips, 294 
hands, 299 
introitus vaginae, 295 
labial, 297 
meatus, 294 
mixed, 303 
mou, 367 
mouth, 296 
multiple, 302 
nipple, 299 
paranitiumlike, 299 
penis, 294 
perianal regions, 301 
phagedenic, 302 
preputial margin, 294 
pseudo-phagedenic, 303 
redux, 302 
smaller lips, 295 
soft, 367 
subpreputial, 301 
successive, 302 
tongue, 298 
tonsil, 298 
ulcerative, 298 
urethral meatus, 295 
Chancrelle, 367 
Chancroid, 277, 304, 367 
Chancroide, 367 
Charcoal, 371 
Charcot, 277 
Charrier, 335 
Chassaignac, 343 
Chaulmoogra oil, 211 
Cheiro-pompholyx, 19 
Chickenpox, 87 
Chilblain lupus, 140 
Chilblains, 72 
Chloasma, 140 
uterinum, 140 
Chloral, 44, 54 
Chlorate of potash, 61, 111 
Chlorine rash, 44 
Chloroform, 45, 235 
Chromic acid, 106 
Chromophytosis, 244 
Chrysarobin, 46, 68, 135, 232, 235 
Cinchonism, 45 
Circumcision, 13 
Clerc, 277 
Cocaine, 372 
Codein, 92 
Cod liver oil, 37, 93, 168, 198, 202, 204, 234 
Cold cream, 54, 122, 304 
380 Cold sore, 14 
sounds, 13 
Colle, 279 
Collodion, 62, 135, 141, 158, 178, 185, 235 
Colloidal silver, 102 
Condylomata acuminata, 159 
Conjunctivitis, 85, 92 
Copaiba rash, 44 
Copper, oleate of, 243 
Cornil, 277 
Corona veneris, 311 
Coronal sulcus, 293 
Corrosive sublimate, 54, 135, 141 
Coryza, 14, 92 
Crab louse, 267 
Craig, 357 
Creeping eruption, 269 
Creosote, 61, 195 
Creta, 60 
Crocker, 37, 211, 269 
Cubebs, 45 
Curved nails, 271 
Czerny, 103 
Dandruff, 69 
Darier, 285, 332 
Darier's disease, 164 
Dermatitis contusiformis, 63 
exfoliativa, 33 
gangrenosa infantum, 76 
herpetiformis, 26, 28, 35 
malignant papillary, 224 
medicamentosa, 2, 42 
papillaris capillitii, 129 
pruriginosa, 35 
seborrhoica, 66, 69 
venenata, 20, 42 
Dermatol, 371 
Dermatomyoma multiplex, 156 
Dermographism, 38 
Devergie, 49 
Diabetes gangrenosus, 75 
mellitus, 75 
Diachylon, 62, 115 
Diapedesis, 10 
Diday, 298 
Digitalis, 45, 199 
Diphtheria, 93 
antitoxin, 93 
bacillus, 93 
Dittrich, 277 
Dobell's solution, 85 
Dover's powders, 85 
Drug eruptions, 42 
Dry cupping, 18 
Ducrey, 303 
bacillus, 12, 367, 370, 371 
Duhring, 201 
Duhring's disease, 35 
Duquet, 267 
Dyschromia gingivae saturnina, 112 
Dysidrosis, 19 
Dysmenorrhea, ovarian, 141 
Ecehymoma, 9 
Ecthyma, 33 
deep, 319 
Ecthyma, gangrenous, 76 
Eczema, 15, 22, 28, 49, 65, 70, 90, 114, 
acute, 52 
vesicular, 20 
chronic 52 
dry, 53 
erythematous, 49, 52, 101 
genital, 51 
gouty, 51 
impetiginous, 49 
intertriginous, 51 
in the nursling, 51 
legs, 51 
madidans, 52 
marginate, 237 
moist, 28 
nipple, 51 
nummular, 52 
orificial, 51 
palms, 52 
papular, 49 
professional, 51 
pustular, 49, 53 
rub rum, 49 
scrotum, 51 
seborrhoic, 49, 52, 69 
soles, 52 
squamous, 49, 52 
upper lip, 51 
vesicular, 49 
vulval, 51 
weeping, 20, 52 
Efflorescence, papillar, 1 
Ehrlich, 279, 356, 364 
Electrolysis, 127, 143, 146, 147, 148, 176, 
178, 179 
Elephantiasis, 63 
Grecorum, 206 
penis, 166 
scroti, 166 
Eosinophilia, 36, 217 
Epithelioma, 43 
Erb, 277 
Ergot, 10, 45 
Ergotism, 45, 80 
Erysipelas, 17, 33, 52, 100 
Erysipeloid of Bosenbach, 101 
Erythema asyndrome, 1 
induratum, 7 
scrophulosorum, 199 
iris, 1, 4 
multiforme, 1, 4, 27, 36, 39 
nodosum, 4, 6 
pernio, 72 
scarlatiforme, 98 
syphilitic, 319 
ErythSme nouveux, 6 
Erythrasma, 246 
Erythromelalgia, 74 
Ether, sulphuric, 122 
Ethylchloride, 18 
Europhen, 371 
Exfoliatio areata linguae, 103 
Fallopius, 307 
Faradism, 74 
Farcy, 255 
381 Favus, 230 
Fermentative liquors, 13 
Fernel, 275 
Fever blisters, 14 
Fibrolysin, 86, 176 
Fibroma molluscum, 155 
Filaria sanguinis, 166 
Filariasis, 206 
Finsen light, 191, 204 
Folliclis, 203 
Folliculitis barbae, 114, 129 
varioliformis, 116 
Foot and mouth disease, 108 
Formaldehyde, 84 
Formalin, 84 
Fournier, 277, 285, 294, 299, 302, 331, 332, 
335, 352 
Fournier's syphiloma of the penis, 303 
Fowler's solution, 61 
Fox, 236 
Framboesia syphilitica, 320 
tropica, 281, 320 
Frascator, 275 
Freckles, 24 
French evil, 275 
Friction, 169 
Furunculosis, 129 
Gadfly, 269 
Galvanism, 18, 74, 86, 169 
Galvano-cautery, 160, 195 
Gangrene, 18, 43, 76 
diabetic, 75 
dry, 73 
symmetrical, 73 
Geley, 365 
Gelseminum, 54 
Gengou, 278 
Genital mucous patches, 329 
Gentian, 61, 121 
Geographical tongue, 103 
German measles, 94 
Giant cells, 203 
Gibert's disease, 248 
Giemsa, 283 
Ginger, 8, 121 
Glossitis, 226 
Glossitis, Moeller's, 104 
sclerous, 344 
Glottis, edema of, 86, 93 
Glycerine, 37, 62, 123, 135, 238, 271 
Glycerol of starch, 149 
Glycerophosphate of lime, 62 
of soda, 62 
Glycerotannin, 160 
Gonorrhea, 11, 44 
Gottheil, 302 
Gout, 67 
Gram, 367 
Granuloma fungoides, 53, 216 
infective, 60 
Granulosis rubra nasi^ 130 
Gray oil, 278 
powder, 99 
Green soap, 153, 185, 261 
Guenther's India ink, 283 
Gumma, 196, 332, 347 
Gurjun oil, 211 
Halipre, 136 
Hansen's bacillus, 209 
Hard chancre, 291 
Harlequin fetus, 152 
Hartzell, 62 
Hebra, 28, 49, 60, 169, 248, 278 
Hebra's diachylon, 20 
Hemophilia, 9 
Hemostatic remedies, 10 
Heroin, 92 
Herpes facialis, 4, 14 
genitalis, 11 
iris, 4 
labialis, 14 
preputialis, 11 
progenitalis, 4, 11 
simplex, 14, 21 
zoster, 16, 43 
Herxheimer, 170 
Higgin's India ink, 283 
Hill, 278 
Hives, 38 
Hoang-nan, 211 
Hodgkins' disease, 214 
Hollander, 185 
Hoffmann, 278, 280, 284, 301, 356 
Hunter, John, 276 
Hunterian chancre, 291 
Hutchinson, 76, 278 
teeth, 355 
Hydrargyrum, ammoniated, 23, 268 
oxide, 235 
Hydroa, 26 
aestivale, 24 
Hydroa herpetiforme, 35 
vacciniforme, 24 
Unna's, 25 
Hydrocystoma, 130 
Hydrogen, bichloride, 123 
peroxide, 12, 32, 98, 106, 111 
Hydrotherapy, 74, 85, 98, 127 
Hyperpigmentation, 140 
Hyperplasia, lymphoid, 217 
Hyperpyrexia, 98 
Hypophosphites, 20, 202, 234 
Hypotrichosis, 136 
Ice bag, 98 
cap, 92 
collar, 86, 98 
Ichthyol, 37, 40, 55, 102, 115, 126, 184, 185 
Ichthyosis buccalis, 348 
congenita, 152 
hystrix, 150 
simplex, 148 
Idiosyncrasy, 38, 42 
Impetigo, 15, 108 
contagiosa, 21, 33 
rodens, 319 
syphilitica, 318 
Indian meal, 80 
Indicanuria, 36 
Indurated sore, 29 
Influenza, 10, 14 
382 Initial lesion, 29 
sclerosis, 291 
Intertrigo, 70 
Iodide of potassium, 44, 67, 218, 254, 255, 
257, 278, 362 
rash, 44 
Iodides, 184, 360 
Iodine, 86, 184, 185, 235, 238, 241, 257, 
372 
lodism, 44 
Iodoform, 111, 184, 195, 372 
Iron, 8, 10, 13, 18, 20, 37, 93, 99, 102, 
121, 135, 168, 204 
wine of, 8 
Itch, 258 
Ivy poisoning, 20 
Jackson, 235 
Jadassohn, 130 
Jean de Vigo, 276 
Jellyfish, 38 
Johnston, 40 
Julliard, 277 
Kaposi, 31, 75, 163 
Keloid, 175 
Keratin, 184 
Keratosis follicularis, 164 
linguae, 348 
palms, 43 
pilaris, 153 
senilis, 162 
soles, 43 
Kerion, 234 
Kerosene, 264 
Klopstock, 283 
Koplick's spots, 83, 91, 92, 95, 98 
Kowarsky, 283 
Kummerfeldt lotion, 122 
Labarraque's solution, 32 
Lactic acid, 106, 135, 195 
Land scurvy, 9, 10 
Lang, 278, 308 
Lanoline, 154 
Larkspur, 264 
Lassar's paste, 20, 122 
Lavender oil, 20 
Laxatives, 61 
Lead, 8, 20, 102, 112 
line, 112 
Lee, 269 
Leishmaniosis ulcerosa cutis, 205 
Lemon, 99 
Leontiasis, 206 
Lepra, 63, 206 
anesthetica, 208 
larynx, 208 
nodular, 210 
tuberosa, 206 
Leprosy, 63, 206 
Leucoderma, 138 
syphilitica, 308 
Leucoma, 348 
Leucoplasia, 348 
Leukemia cutis, 214 
Leukemic tumor, 220 
Leukoplakia, 105, 226 
bucealis, 348 
Leyden, 277 
Lice, 38, 263 
Lichen pilaris, 153 
planus, 53, 59 
scrophulosorum, 197 
simplex chronieus Vidal, 46 
tropicus, 113 
jichenoid syphilide, 311 
Lime water, 37 
Linese albicantes, 172 
Linear hystrix, 150 
naevus, 144 
Lingua plicata, 107 
scrotalis, 107 
Linseed oil, 264 
Loeffler's methylene blue, 367 
Lotio alba, 122, 126, 185 
Lues venerea, 275 
Luetin, 279, 358 
Luithlen, 130 
Lupus erythematosus, 69, 182 
hypertrophicus, 190 
papillomatosus, 190 
pernio, 72, 187 
verrucosus, 190 
vulgaris, 93, 188 
Lustgarten, 280 
McDonagh, 284 
Macroglossia, 107 
Maculae atrophicae, 172 
cseruleae, 267 
Magnesia, 25, 185 
carbonate, 3 
sulphate, 158 
Magnesium sulphate, 102, 121 
Malaria, 17 
Marasmus, 217 
Mask of pregnancy, 140 
Massage, 74, 169 
Mastoiditis, 98 
Measles, 91 
Menthol, 54 
Mercuric chlorid, 204, 239 
Mercury, 32, 45, 61, 174, 232, 235, 276, 278, 
304, 331, 360 
acid nitrate, 371 
bichloride, 84 
ammoniated, 117 204, 235, 239, 243 
rash, 45 
Metchnikoff, 278 
Microsporon Audouini, 234 
minutissimum, 246 
Miculicz, 107 
Miliaria, 130 
rubra, 113 
Miliary syphilitic papules, 312 
Mineral waters, 67 
Moist cutaneous lesions, 324 
Mole, 219, 222 
Molluscum contagiosum, 116, 173 
fibrosum, 155 
pendulum, 155 
Morbilli, 91, 98 
Morbus maculosus Werlhofii, 9 
383 Morphia, 18, 85 
Morrison, 267 
Mosquito, 38 
Mother's mark, 142 
Mushrooms, 39 
Mustard bath, 92 
Mycosis fungoides, 216 
Myiasis linearis, 269 
Myrrh, 331 
Naevus linearis, 144 
papillaris pigmentosus, 145 
sanguineus, 142 
vascularis, 142 
verrucosus, 142 
Naphthol, 58, 117, 245 
Nastin, 211 
Neapolitan evil, 275 
Necrotic granuloma, 203 
Neisser, 278, 356 
Neo-salvarsan, 279, 360, 364 
Nephritis, 10 
Nettlerash, 38 
Neuralgia, 18 
Neuritis, 18 
Neurodermatitis, 46 
Nicolle, 136 
Nitric acid, 58, 158, 160, 179, 371, 372 
Noguchi, 279, 282, 284, 336, 356 
reaction, 7, 358 
Noire, 236 
Nosophen, 371 
Nux vomica, 8, 60, 121, 135, 139, 211 
Oil of cade, 46 
Oils, 169 
Ointments, 169 
carbolized, 85 
Oleum cinereum, 278, 362 
Olive oil, 20 
Onychauxis, 271 
Onychia, 271, 321 
Onychographosis, 271 
Onychomycosis, 240 
Ophyasis, 13 
Opium, 8, 45, 102 
Oppenheimer, 277, 283 
Orange, 99 
Oriental boil, 255 
Orthoform, 78 
Ostridse, 269 
Otitis, 86, 98 
Outdoor air, 66 
Pachymeningitis, 80 
Paget's disease, 224 
Papillomata, 159 
Papules, giant, 312 
nummular, 312 
Papulo-necrotic tuberculide, 203 
Paqualin, 195 
Paracelsus, 276 
Paraffin, 122 
Parakeratosis, 164 
Paralysis, 17 
Paraphimosis, 294, 370 
Parasiticides, 232, 235, 241 
Pearson's solution, 61 
Pediculosis, 21 
capitis, 263 
pubis, 267 
vestimentorum, 265 
Pellagra, 79 
Pellagrins, 79 
Pemphigoid affections, 31 
eruptions, 26 
Pemphigus, 2, 20 
foliaceus, 29 
gangrenous, 76 
neonatorum, 33 
periumbilical, 34 
pruriginous, 35 
vegetans, 31 
vulgaris, 26, 29 
Perionychia, 321 
Permanganate, 305, 373 
Pernio, 72 
Peroxide, 331, 372, 373 
Peruvian balsam, 261 
Petechia, 9 
Phagedena, 350, 370, 373 
Pharyngitis, 93 
Phenacetin, 18, 45, 54, 98 
Phenol, 54, 55, 84 
Phimosis, 294, 305, 370, 372 
Phosphorus, 37, 135, 184 
Phthisiasis capitis, 263 
Picis liquor alcalinus, 37 
Piffard, 66 
Pigmentation, 43 
Pilocarpin, 58, 135, 168 
Pirquet test, 191, 358 
Pityriasis linguae, 103 
maculata, 248 
rosea, 248 
rubra pilaris, 47 
versicolor, 244 
Plaques of the tongue, 103 
Plica polonica, 263 
Pneumonia, 14 
Poison ivy, 42 
Polymorphism, 307 
Polynucleosis, 217 
Pompholix, 19, 26 
Portillo, 365 
Port-wine mark, 142 
Post-mortem wart, 193 
Potash, 10 
caustic, 371 
Potassa, 8, 151, 185, 238 
Potassium acetate, 8, 54, 61, 121 
arsenate, 8 
bicarbonate, 61 
borated, 331 
carbonate, 40 
chlorate, 331 
citrate, 60 
iodide, 32, 168 
permanganate, 32, 37 
sulphuretted, 122, 185 
Precipitate ointment, 264 
Prickly heat, 70, 113 
Primary sore, 29 
Pringle, 61 
384 Prurigo, 57 
Prurigo, summer, 25 
Pseudo-chancre, 303 
erysipelas, 101 
farcy, 255 
granuloma fungoides, 219 
variolosa, 83 
leukemia, 214 
pneumonia, 93 
Psoriasis, 53, 63, 69, 70 
buccalis, 348 
Psorospermosis, 164 
Pumice stone, 241 
Purpura, 2 
hemorrhagica, 9 
Pustula maligna, 251 
Pustules, bromic, 120 
iodic, 1, 20 
Pyemia, 254 
Pyogenic coccus, 193, 254 
infection, 254 
Pyrogallic acid, 191 
Pyrogallol, 67, 204 
Quinia, 2, 10, 13, 18, 20, 28, 45, 93, 98, 
102, 121, 168, 184, 185 
Quinine rash, 45 
Radiography, 213 
Radiotherapy, 236 
Radium, 228 
Rajat, 365 
Ravout, 364 
Ray fungus, 253 
Rayer, 49 
Raynaud's disease, 72, 73 
Red light treatment, 85 
nose, 130 
Refrigeration, 179 
Remak, 277 
Renou, 335 
Resorcin, 53, 117, 123, 126, 149, 185 
Rhagade of the tongue, 195 
Rheumatism, 67 
articular, 7 
Rheus, 120 
Rhinophyma, 128 
Rhinosleroma, 212 
Rhubarb, 45, 120 
Ricinus oil, 88 
Rickets, 108 
Ricord, 277, 286, 303, 314 
Riggs's disease, 226 
Ringworm, 60, 70, 114, 233, 237, 240 
Ritter's disease, 33 
Roentgen ray ulcer, 78 
Rotheln, 94 
Rokitansky, 277 
Roller bandages, 10 
Roseola circinata, 309 
recidiva, 307 
syphilitica, 308 
Ross, 284 
Rubber plaster, 62 
Rubella, 92, 94, 98 
Rubeola, 91 
Rubia escharotica, 76 
Rumex, 121 
Rupia, 319, 341 
Sabouraud, 102, 236, 348 
Sachs, 283 
Saddleback nose, 355 
Salicin, 7, 37, 99 
Salicylate of sodium, 2, 8, 62 
Salicylates, 184 
Salicylic acid, 45, 48, 54, 62, 67, 71, 106, 
117, 141, 149, 151, 158, 165, 178, 191, 
240, 250, 271 
Salines, 7, 40, 99, 126 
Salol, 2, 40, 184 
Salt, 86, 98 
Salvarsap, 17, 32, 61, 106, 211, 278, 360, 
363, 373 
Sapo viridis, 235 
Sarcoma cutis, 219 
melanotic, 219 
pigmented, 219 
Saturnism, 112 
Satyriasis, 206 
Scabies, 20, 90, 258 
Scarlatina, 10, 92, 96 
Scarlatinoid exanthem, 44 
Scarlet fever, 96 
angina, 98 
Scars, 226 
Schaefer, 75 
Schamberg, 22 
Schanker, 367 
Schaudinn, 278, 280 
Schwartz, 34 
Scleroderma, 74, 167 
Sclerodactylia, 167 
Sclerosis recidiva, 302 
Scratch dermatitis, 57 
Scrofula, 108, 190 
Scrofuloderma, 190, 201 
Scrotal tongue, 107 
Sebaceous cysts, 180 
Seborrhea, inflamed, 69 
Seborrhoic eczema, 69 
wart, 221 
Sepsis, acute, 33 
buccal, 33 
Septic coryza, 33 
pneumonia, 33 
Sequeira, 236 
Sexual hygiene, 13 
Shedding of hair, 13 
Shellfish, 39 
Sherwell, 262 
Shingles, 15, 16 
Silver nitrate, 12, 85, 106, 158, 305, 331, 
371 
Skin hemorrhages, 9 
Smallpox, 82 
Smoking, 226 
Snuffles, 355 
Soap, 149 
Soapsuds, 240, 261 
Soda, 71, 120 
Sodium arseniate, 61 
bicarbonate, 88 
carbonate, 40 
385 Sodium hyposulphite, 239, 241 
sulphite, 245 
Soft soap, 122 
Spanish evil, 275 
Spasm, 17 
Spedalskhed, 206 
Spiritus vini recti, 122, 123 
Spirocheta buccalis, 281 
Spirocheta macrodentium, 281 
microdentium, 281 
pallida, 12, 278, 280 
refringens, 281 
Vincent's, 281 
Sporotrichosis, 255 
Sporothrix, 257 
St. Anthony's fire, 100 
Staphylococcus aureus, 108 
pyogenes, 114 
Starch, 55, 67 
Startin's mixture, 121 
Stomatitis mercurialis, 110 
ulcerosa, 110 
Storax, 261 4 
Strawberries, 39 
Strawberry tongue, 98 
Streptococcic serum, 99 
Streptothrix, 211 
Striae atrophicae, 172 
distensae, 172 
Strophanthus, 99 
Strophulus, 113 
Strychnia, 62, 168 
Strychnine, 10, 13, 20, 28, 36, 62, 85, 92, 
93, 99, 121 
Sudamina, 130 
Sulphonal, 45 
Sulphur, 53, 84, 115, 117, 122, 123, 135, 
149, 232, 235, 239, 243, 245, 261 
ointment, 37, 174 
Sulphuric acid, 121, 371 
Sulphurous acid, 239 
Sunlight, 66 
Supersensitiveness, 42 
Sycosis, 22, 114, 129 
Syphilides, 306 
acneiform, 317 
annular, 313 
arciform, 313 
bouquet form, 314 
circinate, 313, 315 
concentric, 313 
corymbiform, 314 
creeping, 339 
depapillating, 327, 329 
diffuse, 315 
papular, 312 
ecthymatous, 319 
erosive, 319, 327 
eruptive, 339 
flat, 319 
giant, 310 
grouped papular, 314 
gummatous, 340 
herpetiform, 317 
horny, 315 
impetiginous, 318 
large papular, 312 
Syphilides, lenticular, 310, 314, 319 
malignant secondary, 320 
miliary, 310 
papular, 311 
moist, 31, 324 
nummular, 310 
palmar, 53, 314, 317 
papular, 66, 120, 310 
papulo-erosive, 318, 327, 328 
granular, 311 
hypertrophic, 324, 325 
squamous, 53, 310 
ulcerative, 324 
pemphigoides, 319 
pigmentary, 308, 322 
foliaceous, 321 
nigricans, 321 
tubercular, 320 
plantar, 53, 314, 315 
psoriasiform, 313, 314 
pustular, 317, 318 
pustulo-crustaceous, 319 
ulcerative, 319 
secondary, 307 
serpiginous, 339 
tertiary, 332 
tubercular, 115, 332, 337, 340 
tuberculo-crustaceous, 340 
ulcerative, 340 
ulcerative, 318, 326, 327, 328, 340 
uleero-serpiginous, 340 
varioliformis, 317 
vesicular, 317 
Syphilis, 7, 10, 22, 31, 53, 60, 66, 70, 76, 
101, 106, 273 
adenopathy, 292 
diagnosis, 356 
hereditary, 354 
history, 275 
maculosa, 308 
mixed treatment, 363 
primary stage, 288 
secondary stage, 288 
sero-diagnosis, 357 
tertiary stage, 289 
treatment, 356 
Syphilitic alopecia, 322 
chancre, 291 
erythema, 308 
lesions, 226 
leucoderma, 322 
leucopathy, 322 
lichen, 311 
vitiligo, 322 
Syphiloderma, 306 
pustular, 115 
Syphiloma of the leg, 335 
Syphilus, 275 
Syringomyelia, 74 
Swediaur, 307 
Talcum, 18 
Tar, 58, 67 
soap, 55 
Taylor, 299 
Teeth, sharp, 106, 226 
386 Tertiary affections of the mouth, 344 
affections of the tongue, 344 
malignancy, 351 
Thermocautery, 194 
Thiosinamin, 86, 169 
Thompson's solution, 184 
Thrombophlebitis, 17 
Thymol, 54 
Thyroid extract, 168 
Tinea barbae, 242 
circinata, 233, 237 
favosa, 230 
trichophytina capitis, 233 
corporis, 237 
unguium, 240 
versicolor, 244 
Tobacco, 13, 61, 106 
Tomitanus, 276 
Touch-me-not, 223 
Treponema (see spirocheta) 
pallidum, 280, 336, 356 
pertenue, 281 
Trichophyton, 237, 240, 243 
Trichophytosis, 238 
Trimble, 123 
Trypanosomidae, 281 
Tuberculides, 203 
Tuberculin test, 210 
Tuberculosis, 10, 17, 76, 93 
linguae, 195 
nasi, 196 
skin, 188 
verrucosa cutis, 193 
Tuberculous tumor, 196 
ulcer, 195 
Turenne, 276 
Turpentine, 45, 135 
Tylosis, 348 
Ulcer, chronic varicose, 336 
from Roentgen ray, 78 
Ulcerations gummatous, 336 
tertiary, 340 
Ulcero molle, 367 
Ulcus endemicum tropicum, 205 
molle, 367 
rodens, 221 
Unicistic, 277 
Unna, 49, 62, 69 
Urticaria, 2, 38, 58, 90 
bullosa, 26, 28, 39 
chronica, 38 
factitia, 38 
giant, 40 
hemorrhagica, 39 
papulosa, 266 
pigmentosa, 39 
Vaccination, 21, 89 
Vaccines, autogenous, 115 
Vaccinia, 76, 89 
generalized, 89 
Vagabond's disease, 265 
Varicella, 76, 83, 87 
Varicella bullosa, 87 
hemorrhagica, 87 
syphilitic, 317 
Variola, 10, 82, 88, 116 
Varioloid, 83, 88 
Vaseline, 23 
carbolized, 55 
Veils, dark colored, 25 
orange, 25 
red, 25 
Verneuil, 277 
Verruca necrogenica, 193 
senilis, 161 
vulgaris, 157 
Vesiculitis, 13 
Vidal, 46 
Vigo, 343 
Virchow, 277, 333 
Vitiligo, 138 
Walker, Norman, 25, 243 
Wart, 222 
Warts, common, 157 
gonorrheal, 159 
senile, 161 
venereal, 159 
Wassermann, 278, 356 
reaction, 7, 66, 74, 84, 116, 168, 191, 
210, 226, 281, 282, 357 
Welander, 76 
Wens, 180, 219 
Werlhof's disease, 9 
Westphal, 277 
Whiskey, 85, 92, 99 
White precipitate, 23, 67, 115, 245 
Whitehouse, 184 
Willan, 49 
Wine of iron, 8 
Xanthoma palpebrarum, 179 
planum, 177 
tuberosum multiplex, 177 
Xeroderma pigmentosum, 163 
X-rays, 62, 78, 129, 162, 165, 169, 176, 178, 
191, 194, 204, 211, 215, 218, 220, 223, 
225, 228, 232, 235, 243 
Yaws, 281, 320 
Zingiber, 8 
Zinc chloride, 371 
oxide, 3, 12, 15, 23, 25, 37, 54, 62, 185, 
305 
phosphate, 137 
stearate, 305 
sulphate, 122 
Zona, 16 
Zoster, 16 
ophthalmicus, 18 
Zosteroid eruptions, 17 
387