THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES i^ GIFT Mrs, William D, McFlaul l' J ' j ;i /rr^y SYPHILIS. BY Y. COllNIL , PROFESSOR IN THE FACULTY OF MEDICINE OF PARIS, AND PHYSICIAN TO THE LOURCINE HOSPITAL, TRA^^SLATED, WITH NOTES AND ADDITIONS, BY J. HENRY C. SIMES, M.D., DEMONSTRATOR OF PATHOLOGICAL HISTOLOGY IN THE UNIVERSITY OF PENNSYLVANIA, AND ASSISTANT SURGEON TO THE EPISCOPAL HOSPITAL, PHILADELPHIA, J. WILLIAM WHITE, M,D,, LECTURER ON VENEREAL DISEASES, AND DEMONSTRATOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, AND SURGEON TO THE PHILADELPHIA HOSPITAL. WITH EIGHTY-FOUR ILLUSTRATIONS PHILADELPHIA: HENKY 0. LEA'S SON & CO. 1882. Entered according to Act of Congress, in the year 1882, by HENRY C. LEA'S SON & CO., in tlie Office of the Librarian of Congress. All rights reserved. COLLINS, PKINTEK. Biomedical Library TRANSLATORS' PREFACE. Few departments of medical science are so well or so thoroughly represented in medical literature as that of syphilis, the best treatises upon which are, in our opinion, to be found in the English language. None of them, however, have so thoroughly considered the disease from its anatomical standpoint, as has M. Cornil in his " Le9ons," a book which has been -a genuine addition to our knowledge of syphilis. Its general aim and scope are set forth in the author's preface. Agreeing with him that the accurate diagnosis and rational treatment of the disease depend largely upon a knowledge of its morbid anatomy, we, therefore, offer no apology for presenting this translation to the profession, jDremising that it is intended to sup- plement and not to supplant the excellent works already alluded to. It is published with the consent and approval of the author, who kindly made suggestions as to some of the additions which seemed to him required. The form of lectures, which was adopted by M. Cornil, we have changed, for the sake of uniformity, into that of chapters, and we have omitted the two somewhat irrelevant clinical lectures of M. Bouchard, which were interpolated in the original text. Our additions, which aggregate about one-third of the present volume, have been made chiefly with a view of supplying additional clinical information upon topics of importance. They will be found throughout the text inclosed in brackets [ — ]. 782338 IV TRANSLATORS PREFACE. Ibije \lil1bJogrlifillic drawings of the original have been copied and enjgr'p,ve|c3.,Ufonivsiciofl)iand have been intercalated in the text. We beg to thank Dr. James W. White, for the preparation of the note on syphilis of the teeth, and Dr. John S. Walker, for kind assistance in making the translation. Philadelpuia, June, 1882. AUTHOR'S PREFACE. These lectures were delivered during the spring and summer months of 1878, in the Lourcine Hospital. Having occupied for hree years a position on the medical staff of this institution for syphilitic females, I am desirous, before retiring from duty, to take advantage of the immense material which has here been at my disposal. Through the valuable works of Ricord, Cullerier, Langlebert, Clerc, Bassereau, Diday, Virchow, as well as the more recent monographs of Rollet, Alfred Fournier, Lancereaux, Martin and Bel- homme, Mauriac, Louis Jullien, and others, syphiligraphy has been elevated into a veritible science. The discussions as to duality or unicity of the syphilitic virus, syphilization, the contagiousness of secondary lesions, the effects of mercury, etc., have been almost exhaustive. We now possess many excellent books upon these sub- jects, and I may add, that in no country have they been more thoroughly studied than in France. The most recent publications show, however, that we are far from having a correct idea of the minute anatomy, or of the histological evolution of the various lesions of this disease, from the initial chancre to the gumma, includ- ing the mucous patch, the superficial and deep cutaneous syphilides, the osseous and visceral aftections. I have endeavored to supply this deficiency, not only by relating, arranging, and interpreting what has been written, but also and chiefly by adding some new observations. The title which I have chosen has permitted me great latitude, but I have spoken almost exclusively of what I have myself seen and inves- tigated. It is not my intention to publish a complete treatise, but only a series of lectures upon the essential points of syphilis, and particularly upon its general pathological anatomy. H. Leloir, in- terne at the hospital, has given me much assistance in recording the lectures and cases, for Avhich service I beg to express my thanks. VI AUTHOR S PREFACE. I have especially endeavored to describe the histology and evolu- tion of the several varieties of chancres, of cutaneous and mucous papules, pustules, and tubercles ; of cutaneous and visceral gummata, etc. The continual progress made in technical microscopy, renders this study always new or open to re-examination or revision. It is a field in which there is still much to glean. My observations have almost always been made ujjon tissues removed during life, permitting me to examine at once the separate elements, and to place portions in preserving or hardening fluids before they had undergone the slightest cadaveric change. This is, in fact, the only method by which good preparations can be obtained. I have drawn with the camera-lucida the principal types of the different lesions ; but the drawings, reproduced in a single color by lithography, give only an imperfect idea of what is seen under the microscope. Yet I can vouch for their general accuracy. In the first eight lithographic plates Messrs. Leuba and Nicolet have represented my drawings as faithfully as possible. The original portion of my investigations consists in the histological descriptions. Therefore I could have limited this work to the small compass of a memoir, and, without doubt, would have also limited the number of my readers ; since those who study the evolution of such lesions from pure scientific curiosity are few. Again, I would not have attained my principal object, which was to place before the students of this subject the symptoms and course of the several patho- logical manifestations, having regard especially to their precise anatomy and evolution, as seen under the microscope. Pathological histology alone is not attractive, and we shovild, therefore, whenever possible, demonstrate its utility, and its direct application to the study of symptoms. As a simple illustration of the method I have followed, I may men- tion the syphilitic papule or pustule. I have studied first its com- plete anatomy ; and then have described in detail all the changes that the epiderm, rete mucosum, papillae, derm, and vessels undergo, and have thus learned howr far they extend and in what they consist. Such a description, aided, if possible, by a microscopic demonstration, or at least by accurate drawings, would seem to be an excellent pre- paration for the study of symptoms, which will then be promptly recog- nized. We learn in this manner the changes going on beneath the epidermis in the different layers of the skin, and cease to regard the eruption simply as a pimple limited in a certain way by a colored AUTHOR S PREFACE. vil surface. Add to this description of the minute details a knowledge of the evolution of the histolodcal phenomena from the be£i;inninatelies Vulvitis with mucous patches Abscess of vulvo- vaginal glands Vaginitis with mucous patches Metritis with mucous patches (Edema with mucous patches Vegetations with mucous patches Diagnosis of mucous patches Treatment of mucous patches Excision of chancre, mucous patclies, etc. PAGE 147 149 150 151 151 152 153 153 154 154 154 156 157 CHAPTER VI. EARLY CUTANEOUS SYPHILIDES. Syphilitic fever Neuralgia of syphilis Osseous and rheumatoid syphilitic p; Ana3mia of syphilis . Roseola Papular syphilide (small) Histology of superficial papule Papular syjihilide (lenticular) Histology of lenticular papule Efl'usion of blood into papide Diagnosis of papule and psoriasis Onychia and alopecia Macular syphilide . 164 165 165 165 166 168 171 172 173 177 179 182 186 CHAPTER VII. VESICULAR, PUSTULAR, BULLOUS, GUMMOUS, AND TUBERCULAR SYPHILTDES. Vesicular syphilides . . . . . . .189 Pustular syphilides . . . . . . . .191 Acne ......... 192 Impetigo . . . . . . . . .192 Superficial ecthyma . . . . . . • .193 Deep ecthyma . . . . . . . .193 Histology of papule . . . . • . - .194 Impetigo rodens .....••• 200 Bullous syphilides ......•• 200 Xll CONTENTS, Rupia Pemphigus . Cutaneous guramata Obliteration of vessels Phlegmonous syphllides Tubercular sy])hili(les Grave early sy])hilides General considerations as to syphilitic erupt Importance of their anatomy and histology Clinical characteristics of syphilides Treatment of syphilides PAGE 200 201 204 208 211 212 214 216 217 219 221 CHAPTER VIII, TERTIARY LESIOXS OF MUCOUS MEMIiliANES SYPHILIS OF THE MUSCLES. Tertiary lesions of the genital mucous membranes Tertiary syphilis of the mouth Supei-ficial or cortical glossitis Deep glossitis Desquamative glossitis Gumma of tongue . Diagnosis of lingual psoriasis Smoker's patches Tubercular and epitheliomatous ulcei Epithelioma and gumma Gumma of soft palate Gumma of tonsils and pharynx Diagnosis from scrofulides . Muscular syphilis Guuinui of muscles and heart 224 226 226 227 229 230 231 231 232 233 233 237 238 239 240 CHAPTER IX. SYPHILIS OF THE BONES Syphilitic osseous lesions 3, TEEl U, AMJ AKllC L1.A1H JISO. . 245 Simple osteo-periostitis Osteophytes Exostoses Enostoses Development of bone . 247 . 248 . 248 . 248 . 248 Rarefying osteitis Gummous osteo-myelitis . 249 . 252 CONTENTS. Xlll Gammons osteo-peri ostitis . Vegetating and giimnious j)achymenlngitis Eburnation of bone Varieties of exostosis Symptoms of syphilitic osseous lesions Osseous lesions in syphilitic new-born chihlr Syphilis of the teeth Syphilitic teno-synovitis and arthritis Syphilitic dactylitis . PAGE 252 253 256 257 2C0 2G5 287 290 ' 293 CHAPTER X. SYPHILIS OF THE NERVES AND NERVE CENTRES Lesions of the pia mater Lesions of the brain Large gumma of brain Small gumma of brain Syphilitic inflammation of arteries of brain Sj'philitic phlebitis and lymphangit Symptoms of cerebral syphilis Syphilitic epilepsy . Syphylitic paralysis . Syphilis of spinal cord Locomotor ataxia Diagnosis of cex'ebral syphilis 297 298 298 304 305 313 314 319 321 327 329 342 CHAPTER XI. SYPHILIS OP THE LIVER. Hepatic syphilis Syphilitic jaundice of secondary period Syphilitic interstitial hepatitis Gumma of liver Congenital syphilis of liver . 352 353 354 356 369 CHAPTER XII. SYPHILITIC LESIONS OF THE DIGESTIVE CANAL AND OF THE RESPIRATORY APPARATUS. Gumma, ulcerations, and stricture of the oesophagus Gumma and ulcers of stomach Syphilitic ulcers and stricture of anus and rectum . 373 375 377 XIV CONTENTS. Syphilitic lesions of larynx, trachea, and bronchi Syphilis of the lungs Gumma of the lungs Lesions of the lungs in congenital syphilis . PAGE 379 390 391 403 CHAPTER XIII. SYPHILITIC LESIONS OF THE SPLEEN, OF THE SUPRA-RENAL CAPSULES, OF THE LYMPHATIC GLANDS, AND OF THE GENITO-UKINARY OUGANS. Lesions of the spleen Lesions of the supra-renal capsules Tertiary lesions of the lymphatic glands Gumma of the epididymis . Interstitial orchitis in the adult Interstitial orehitis in new-born children Gumma of the testicles Syphilitic ovarian lesions Syphilis of kidney . Interstitial and gummous nephritis Amyloid degeneration of kidneys Albuminuria in syphilis 410 412 413 415 416 420 422 422 423 424 425 425 CHAPTER XIV. TREATMENT OF SYPHILIS. ]MercurIal medication ..... Anti-mercurialists ...... Absorption and elimination of mercury Mode of administration and dilTerent preparations of mercury Iodide of potassium ..... Mode of adminislration and doses of iodide of potassium . Treatment of syphilis ..... Bibliography ...... Index ....... 431 432 433 434 440 440 441 449 455 LIST OF ILLUSTRATIONS. 50 50 FIG. 1. Schematic section of indurated chancre 2. Elements from surface of chancre. X 300 3. False membrane from chancre. X 200 4. Indurated chancre. X 15 5. Schematic drawing of epidermal changes . 6. Superficial layers of epidermis of chancre. X 7. Superficial portion of u mucous patch. X 300 8. Connective tissue of chancre. X '-00 9. Arteriole from chancre. X 100 10. Arteriole from chancre. X 200 11. Vein from chancre. X 120 12. Vessels from chancre. X 200 . 13. Nerve from chancre. X 200 . 14. Indurated part of chancre 15. Indurated part of chancre. X 250 16. Soft chancre. X 20 . 17. Schematic section of soft chancre 18. Chancre showing suppuration in epidermis. 19. Chancre from nympha. X 6 20. Cicatrix from chancre. X 8 21. Cicatrix from chancre. X 8 22. Chancre from prepuce. X 8 23. Chancre from prepuce. X 15 . 24. Mucous patch from tonsil. X 12 25. Mucous patch from tonsil. X 150 26. Mucous patch from tonsil. X 60 27. Mucous patch from tonsil, eroded. X 60 28. Superficial part of mucous patch. X 300 29. Epithelial cells from diphtheritic membrane. 30. Hypertrophied vulvar mucous patch. X 100 31. Syphilitic papule. X 80 . 32. Syjihilitic squamous papule. X 20 . 33. Rete mucosum from syphilitic papule. X 250 34. Syphilitic lenticular papule. X 100 . 35. Syphilitic lenticular papule. X 300 . 36. Syphilitic lenticular papule. X 250 . 37. Hemorrhagic squamous papule. X 40 38. Ecthyraatous pustule. X 20 39. Epidermis from ecthymatous pustule. X 250 40. Eete mucosum from ecthymatous pustule. X 120 250 PAGE 43 45 46 48 50 52 54 56 57 58 59 59 63 67 67 71 71 109 112 114 115 116 118 134 135 136 136 137 146 148 170 173 174 175 176 177 178 195 196 197 XVI LIST OF ILLUSTRATIONS, FIG. 41. Ulcerated part of pustule. X 120 42. Pemphigus bulla. X 8 . 43. Rete mucosum from pemphigus bulla. X '-00 44. Cutaneous gumma 45. Cutaneous gumma. X 8 . 46. Capillaries and connective tissue of gumma. X 200 47. Vein from gumma. X 200 48. Vein from gumma, obli(|ue section. X 200 49. Cutaneous gumma .... .50. Cutaneous gumma. X 8 . 51. Tertiary syphilide of tongue. X 10 . 52. Syphilitic osteitis .... 53. Rarefying osteitis. X 500 54. Gummous pachymeningitis. X 6 55. Gumma of dura mater. X 40 . 56. Absorption of bone by gumma . 57. Syphilitic sclerosis. X 20 58. Syphilitic necrosis of frontal bone 59. Exostosis of cranium. X 10 . 60. Exostosis of cranium. X 12 . 61. Osteophyte from syphilitic child. X 150 62. Osseous trabecula of sjphilitic osteophyte. X 250 63. Syphilitic exostosis of cranium. X 12 64. Syphilitic exostosis of cranium. X 6 65. Cranial bone of congenital syphilis. X 15 66. Cranial exostosis of chihl. X 6 67. Syphilitic exostosis of child. X 100 68. Syphilitic exostosis of child. X 70 . 69. Normal incisor teeth 70. Syphilitic incisor teeth 71. Histology of cerebral gumma 72. A. Syphilitic disease of cerebral arteries. X 200 72. B. Syi^hilitic disease of cerebral arteries. X 100 73. Syphilitic gumraata of the pons Varolii 74. Syphilitic gummata of the pons Varolii 75. Deformed syphilitic liver . 76. Cicatrization of syphilitic liver 77. Gumma from liver 78. Gumma from liver X 250 79. Gumma from liver. X 1 2 80. Gumma from liver. X 150 81. Biliary capillaries in new-formed connective tissue of 82. Syphilitic interstitial pneumonia. X 300 83. Syphilitic testis. X 180 . 84. Gumma of kidney, x 200 cirrhosis PAGE 198 202 203 206 207 208 208 209 210 210 227 250 251 253 254 255 256 257 258 259 271 271 275 276 277 279 280 281 289 289 300 306 306 347 348 354 355 358 359 361 363 365 405 418 424 SYPHILIS. CHAPTER I. GENERAL CONSIDERATIONS OF SYPHILIS— CONTAGION AND INOCULA- TION—PERIOD OF INCUBATION. Definition of syphilis — The nature of sypliilis — Its periods — Its virus — Its relations to infectious diseases — Contagion and inoculation of syphilis — Unicists and dualists — Long duration of the incubation — Is syphilis constitutional before the appearance of the chancre ? Definition of Syphilis. — SypJiilis is an infectious, contagious, and inoculable disease, of sloto evolution; it first manifests itself hy an indurated or infecting chancre, afterwards hy eruptions of the skin and mucous membranes, later by chronic injiam,mations of the cellulo-vascular tissue and bones, and finally by special produc- tions in the form of small tumors or nodules tvhich have received the name of gummata. [It may not be amiss to mention one or two modifications of this definition, which would be necessitated by the adoption of any one of the several plausible, but as yet unproven theories as to the essential nature of the disease. Mr. Jonathan Hutchinson, who classes syphilis with the fevers, smallpox, scarlatina, measles, etc., defines it as a "specific febrile disease of prolonged but definite stages, which is produced by contagion only, which has a period of incubation, a period of outbreak (known as primary symptoms), a period of efflo- rescence or exanthem (known as the secondary stage), and which, in exceptional cases, differs somewhat from its more short-lived congeners, by being followed by sequelae, to which we give the name of tertiary symptoms."^ His arguments, in support of this position, may be summed up as follows : — [1 The London Lancet, Feb. 5, 1876.] 18 SYPHILIS. Syphilis is communicated only from individual to individual, and never appears de novo ; it does not occur twice in the same per- son ; it has a period of incubation, during which no signs of the disease are apparent ; the stage of efflorescence is characterized by symmet- rical, widely distributed lesions which tend in the majority of cases to spontaneous disappearance, and, after having once disappeared, these do not return ; in this stage, the disease is contagious. In cer- tain instances, especially where treatment has been imperfect or altogether neglected, we have other local symptoms, irregular in time of appearance, but nearly always much later than those just men- tioned, non-symmetrical and not contagious ; these symptoms, called tertiary, are re-growths in cell-structures Avhich have remained over in a quiescent state from the secondary period ; the i-elapsing chancre, an induration occurring spontaneously in the site of the original chancre, and now a well-recognized lesion, is an example of this tendency of parts once diseased to relapse; the "residual abscesses" of Sir James Paget, furnish another illustration of the same tendency. It is highly probable, that during the secondary stage, all, or nearly all the tissues of the body are affected ; the fact, therefore, that ter- tiary lesions may appear in any organ or tissue does not militate against the view which regards such symptoms as sequelae, and not as evidences of continued involvement of the blood; the absence of svmmetry, and of contagious properties strongly confirms this view; sequelae occasionally follow the other exanthemata at a time when all manifestations of acute or contagious disease have disappeared ; these sequelae are also non-symmetrical, as necrosis or phlebitis after typhoid fever, migraine after intermittent, nephritis or otitis after scarlatina, etc.i It is evident that the analogies between syphilis, and the contagious exanthemata are very striking, and the theory which thus classifies it is unquestionably deserving of careful consideration. There are, however, certain objections to it, which are, as yet, unexplained. Some of these are: The invariable occurrence of the primary symp- toms at the point of inoculation. In this respect vaccinia is the only specific fever which is known to furnish a parallel, and even this is by no means exact. The very gradual invasion of the general system apparently — in [• See remarks of Sir James Paget, in the discussion which followed the reading of Mr. Hutchinson's paper, of which the above is an incomplete summary. London Lancet, Feb. 19, 1876. ] REINFECTION OF SYPHILIS. 19 fact, demonstrably — through the medium of the lymphatics, all the exanthemata seeming at once to infect the whole mass of the blood. The fact, that in a small number of well-established cases, constitu- tional infection has been prevented by the early excision of typical forms of the initial lesion. All clinical and experimental evidence goes to prove that in the fevers, and the constitutional diseases produced by inoculation, vaccinia, glanders, the "rot," etc., absorption of the specific virus or poison occurs with great rapidity, and that excision or cauterization is powerless to arrest it.^ Boeck and Bidenkap, quoted by Baumler,^ report cases which demon- strate the possibility of the successful auto-inoculation of secretions from infecting chancres. With a single exception in all these cases, the sec- ond inoculation was made before the disease had produced constitu- tional symptoms. Dr. Hardaway, in a paper on syphilitic infection (N. Y. Med. Journal, Dec. 1877), thus alludes to these cases. " For a long time it Avas held as one of the best arguments for immediate constitutional infection, that the true chancre was not auto-inoculable ; then, when it was discovered that a chancre, which had been rendered purulent, could be inoculated upon its bearer, it was claimed that sores thus produced were merely chancroids ; but now that true chancres when auto-inoculated are seen to originate other true chancres — that is, when the inoculations have been performed in the incubation-stage, — the last refuge is in the supposition, that the blood has not as yet become fully saturated with the syphilitic virus. This hypothesis is clearly untenable by those who regard the chancre, and the ganglionic involvement as the result of syphilis already in the blood ; for, if there were sufficient of the virus absorbed to produce these local manifestations, there should, most assuredly, also be sufficient to pre- vent fresh inoculation with syphilitic virus ; and those holding with Baumler, and other authorities, that it is possible to prevent consti- tutional infection by destruction of the initial lesion, surely cannot account for these cases in this way." The protection Avhich syphilis aifords against a second attack is not nearly so great as in the case of the exanthemata. Dr. Fessenden Otis, in a private letter, thus expresses himself as to this point: — " Mr. Hutchinson, of London, who is chiefly responsible for the [' See Relhomme et Martin. De la Syphilis, Paris, 187fi, p. 51. Exiieriments of the authors and of MM. Renault, Bousquet, Steinbrenner, Trulujer, Petiet, Ray- nal, Cast^ra, and others.] * Ziemssen's Cyclopsedia, vol. iii. p. 97. 20 SYPHILIS. theory, or rather for the assumption, of a similarity in nature between syphilis and variola, scarlet fever, etc., distinctly claims this pecu- liarity of certain contagious diseases (z. g., protection against re-in- fection), as proof of the correctness of his views. In a cursory ex- amination of the question this allegation seems quite plausible. But the degree of protection afforded by an attack of syphilis against subsequent re-infection is by no means well settled. The published instances of re-infection of syphilis are much more numerous than of re-infection after the acute exanthemata, and when we consider the frequent epidemic prevalence, and the greater liability to infection through the atmosphere, through fomites, and through actual contact in the latter diseases, the contrast becomes so great as to cast reason- able doubt upon the claim of a protective influence for syphilis. What physician in his own experience has been able to record a dozen cases of the re-infection of variola — and yet Did ay and Gascozen each re- port twenty cases of the re-infection of syphilis in their own expe- rience. Koebner reports nearly fifty cases. Follin, Bouley, Caspary, Hutchinson, Ricord, and others have also reported well-authenticated cases. We have easy access to more than a hundred published in- stances of the -re-infection of syphilis, and all quite accidental. We have not, as far as I am aware, a single record of systematic, care- fully-conducted experiments bearing on this point. Even the extensive experience of Prof. Boeck, in his so-called syphilitic inoculations, is valueless in this, as in almost every other respect. It is true that he demonstrated a tolerance of the intesrument to the influence of chanc- roidal virus through repeated inoculations, and falsely claimed it as a protection against the re-infection of syphilis; but the same sort of tolerance was subsequently established by inoculations with the tar- trate of antimony. Admitting, however, that the occurrence of syphilis in an individual does protect against re-infection — this does not necessarily connect syphilis with the acute exanthemata any more than with contagious parotitis'. It appears to me that the only valid deduction to be drawn from the apparent protection claimed after an attack of syphilis, is that this is similar in some respects to the pro- tection afforded by the acute exanthemata under like conditions. But it has been shown that this protective property is not confined to the acute exanthemata ; hence it cannot be claimed as establishing any necessary connection between syphilis and these diseases. When Ave are able to explain why the occurrence of smallpox or scarlet fever protects against re-infection, we may then, perhaps, be able to ascer- LYMPHATIC THEORY OF SYPHILIS. 21 tain why a similar protection is exercised in mumps, in yellow fever, and in sypldlis.'''' "A second infection may be followed by general eifects as well as local. A large number of cases of this ' reinfectio syphilitica,' first described by Zeissl, have been published."^ Another objection to the theory under consideration lies in the necessity which exists for the employment of the same treatment, or a modification of it, in the tertiary as in the secondary stage, it being now generally admitted that mercury in some form should be used, even in the most tardy symptoms. Mr. Hutchinson says that " mer- cury is the true vital and physiological antidote of the syphilitic virus. "2 If this be true it would without doubt explain its beneficial action in the early stages of the disease, but would furnish no reason for its administration at a time when, according to Mr. Hutchinson himself, the "virus" has been eliminated. A theory which attempts to reconcile these apparent contradictions, and has claims on the attention of syphilographers which have not been^duly recognized, is one which attributes to infection through the lymphatic system, and to changes produced in that system most, if not all, of the symptoms of syphilis. Several distinguished observers have from time to time pronounced AvhoUy or in part in its favor, but it has been coldly received by the profession at large, for the reason that it still lacks demonstrative proof. As, however, in our opinion it pre- sents fewer inconsistencies than any of the other theories — all of which are also open to the same objection as to absence of decisive proof — we Avill endeavor to present it as briefly as is consistent with clearness. The infecting body in syphilis, as far as we yet have been able to isolate it, is a degraded or diseased cell, resembling a white blood- corpuscle, but much smaller, and corresponding to the bioplastic dis- ease germ of Beale. It is a particle of normal protoplasm which has undergone degeneration, and has acquired the property of rapid pro- liferation, and of impressing its own peculiarities upon germinal matter Avherever it comes in contact with it. This property is only what is seen and admitted to be the case in pus cells, in the transformation of embryonal cells into epithelium, and vice versa — the "epithelial infec- tion" of Rindfleisch — and is an instance of the unexplained but well- recognized influence which all cells, and especially diseased cells, ■ Baumler, Ziemssen's Cyclopsedia, p. 70. [2 Discussion before the Hunterian Society of London, 1874.] 22 SYPHILIS. have upon those immediately adjoining them.^ The cells of syphilis, therefore, chiefly affect the white blood- and lymph-corpuscles, which they contaminate, and cause to take on rapid growth, arresting the former in their development into red blood- cells, and producing the so-called syphilitic anaemia or leucocythaemia. These cells are found in every instance, and without exception, at the point of syphilitic inoculation, wherever that may be, and by their proliferation and accumulation constitute the induration of the infecting chancre. The characteristic hardness of this sore is due to the crowding together of these cells ; its dryness to their involve- ment of the walls of the vessels, preventing transudation of serum; its abrupt limitation to the absence of any true inflammatory exuda- tion, shading oif into the neighboring tissues ; its superficial scali- ness, abrasion, or ulceration to the degree of its interference by pressure with the blood supply to the epidermic layer of the skin. ' " It is not yet possible to say, in any universal sense, with regard to the meta- bolic contagia, what is the essential constitution of ' contagious matter,' or what the intimate nature of the ' transforming power' which the particle of such mat- ter exercises on the particles which it infects. As regards the question of the force, chemists, when they refer in general terms to the various acts which they designate acts of fermentation, allege that certain processes of change in certain sorts of organic matter induce characteristic changes in certain other sorts of organic matter, not by the common chemical way of double decomposition with reciprocally new combinations, but (so to speak) as a mere by-play or collateral vibration-eifect of the chemical force which is in movement ; and, though lan- guage can hardly be more vague than this for any scientific purpose, it expresses clearly enough the conviction of experts tliat a certain great force in nature lies beyond their power even of definite nomt*nclature, much more of exact identifica- tion and measurement." " It must not be forgotten that, among immediate effects of contagion in the Ifving body, are cases wherein the process (so far as we can yet see) is primarily not catalytic or disintegrative, but is, on the contrary, anaplastic or constructive. Thus when tubercle gives rise to tubercle, whether by secondary and tertiary infection in a single diseased body, or by infection from the sick to the healthy, each new tubercle which the contagion brings into being is a growth-product of the texture which bears it. And, similarly, when the innumerable varieties of cancerous tumor propagate themselves by contagion, each after its special type, in the bodies of the respective sufferers, it is growth, not disintegration, which we first see. It would seem that in those cases of anaplastic ' contact-influence' some- thin"- far beyond the analogy of chemical fermentations must be involved ; and, in view of some of them, the physiologist has to bethink himself of the analogy of that ' contact-influence' which becomes the mainspring of all normal growth and development when the ovum receives spermatic impregnation." — Contagion: Its Mode of Action. By John Simon, C.B., F R.S. British Med. Journal, Dec. 20, 1879. LYMPHATIC THEORY OF SYPHILIS. 23 The period of primary incubation, or that intervening between the reception of the poison, and the development of the initial lesion, on an average three weeks, represents the time occupied in the proli- feration of these cells at the point of deposit, and during this time the system at large is uncontarainated. The period of secondary incubation, or that between the appearance of the sore, and the outbreak of constitutional symptoms, on an aver- age six weeks, represents the slow passage of these diseased cells through the lymphatic channels and glands in which by their multipli- cation they cause enlargement and induration, thus giving rise to the glandular swellings invariably found in syphilis, and most easily ob- servable in the inguinal, epitrochlear, and post-cervical regions, and in the tonsils, which are essentially lymphatics, their involvement ex- plaining the early syphilitic sore throat. These two periods taken together constitute the "initiatory period" of Otis. It seems impossible, in the light of certain well-known facts, to deny that the syphilitic poison, whatever its character, gains access to the general cii'culation cliiejiy if not entirely by the lymphatics. Fournier, quoted by Baumler,^ has reported observations which tend to sustain this view : " In the collection of the Hopital de Lourcine there are three preparations of women who died of intercurrent diseases while affected with syphilitic sores on the vulva. In these preparations not only the inguinal glands are swollen, but there is a hyperplastic en- largement of a number of glands above Poupart's ligament. In the second case there occur in the fossa iliaca, along the bloodvessels, nine enlarged glands, arranged in three groups, one above the other, the uppermost at the origin of the hypogastric artery. The enlargement of the iliac glands had attained nearly the same degree as that of the inguinal glands, among which one or two on each of the three prepa- rations were distinguished by their greater size as the ones first at- tacked." Among the reported cases of artificial inoculation of syphilitic poison there are two where, the inoculation having been made upon the chest, not only were the glands of the first group enlarged, but also those of the second and third order, an indurated lyQiphatic cord connecting them with each other.^ After their entrance into .the blood, the diseased cells which, in accordance with the general properties of all cells, proliferate most rapidly when arrested or slowed in motion, on reaching the capillaries, ' Ziemssen's Cyclopaedia, vol. iii. p, 122. 2 Bidenkap, Wiener Med. Wochensclirift, 1865, Nos. 31-44. 24 SYPHILIS. probably affect their walls, and the sensory and vaso-motor nerves as soon as they have accumulated sufficiently to make pressure on them, thus producing the insensitiveness of the skin and the mottling of the surface (roseola) caused by the irregular dilatation of the capil- laries. In the papillcie of the skin, around the circumference of which the capillary vessels wind in corkscrew fashion, we have an increase of pressure, and retardation of the blood-current, conditions favorable, as has been said, to exudation and proliferation of cells. Therefore when these "syphilitic" cells carried in the general circulation reach the papillae, they escape into their substance, and multiply there. If the lymphatics, running through the centre of the papilliie from apex to base, were capable of taking them up again, and returning them to the systemic circulation, no local symptoms would ensue, but as these vessels are themselves pressed upon, and more or less occluded, we have an accumulation of cells going on, until little hard tumors are produced, which even become apparent on the cutaneous surface (papular syphilide). The pressure of this exudation prevents the imbibition of nutriment by the epidermic layers which die and desic- cate, and we have the papulo-squamous syphilide — greater pressure produces ulceration or pustulation of various degrees, and we have the corresponding pustular and ulcerative syphilides. This period — that of " general infection and localized cell accumu- lation" — extends over six to eighteen months, when it often termi- nates spontaneously, or more certainly under treatment, the diseased cells having undergone fatty degeneration, and been absorbed and eliminated. During this period, however, the lymph channels throughout the body have been more or less subject to continuous irritation or even to inflammation of a low degree, the well-known tendency of which is to cause the deposit of fibrous material which, by its presence and subsequent contraction, tends to damage and obstruct them. We therefore find at a period, that of " lymphatic obstruction," varying in its date of appearance from months to years after the primary lesion, that certain local symptoms occur, Avhich are called tertiary, which consist chiefly of the formation, of small tumors (gummata, nodes, etc.), or of the death of various tissues, produced by pressure (syphilitic necrosis and ulceration), and which are due to the accu- mulation at these points of the normal nutritive elements, which are always somewhat in excess of thJ rt o u t. (D 3 HISTOLOGY OF CHANCRE. 49 the normal epiderra, e, over the healthy portion of the skin, is thick- ened at m, Avhere the elevated margin of the chancre begins ; at the same time the papillae, ^^p, become vei-y much elongated and thickened in the whole circumference of the chancre. In the central part of the chancre, at n, the epidermic layer is much thinned and reduced to the rete mucosum, but remains, however, as a distinct layer. At d the epidermic layers and swollen papillae appear newly formed. All the connective tissue traversing this region between the smooth muscular fibres is sclerosed, and it is easily seen, even with this low power, that the coats of the arteries, a a, and all the vessels are enor- mously hypertrophied. In this preparation are very distinctly seen the hairs, t, b, and their glands; also the sudorific glands, s. In every preparation of chancre there are observed, as constant le- sions, changes in the cells of the epidermic covering, a papillary hyper- trophy at the margins of the chancre, and in all the subjacent con- nective tissue an infiltration of the papillary network and of the derm by embryonic cells — an inflammation with exudation. The fixed con- nective-tissue cells, and the flat cells, between the fasciculi of fibres, are swollen and proliferating. The vascular coats, especially the tunica adventitia of the arterioles and venules, are inflamed and thick- ened. The fasciculi of fibres of the connective tissue are well pre- served, perhaps even thickened, from which result the special indura- tion and resistance of the derm. The general disposition of all the lesions in a chancre having been described, we are now ready to study more minutely the modifica- tions of each part. Close attention to all the histological details, notwithstanding their length, is necessary, to thoroughly comprehend the subject. If a knowledge of only its external characters be desired, it is suflicient to examine a chancre moulded in wax ; but, in order to see what is beneath the surface, in order to study the lesions in detail, we must have recourse to histology. Alterations of the Epidermic Layers. — The layers of the epi- dermis are three in number, — the corneous, the granular, or inter- mediate, and the Malpighian, or rete mucosum. The superficial lamellae of the corneous layer differ but little, or not at all, from the normal. They are simply elevated, and their layers are separated by the changes in the deeper corneous layers, where we frequently find cavities containing lymph cells, or an in- 4 50 SYPHILIS. filtration of lymph cells interposed between the rows of epidermic cells. The cells of the deeper corneous layer, or of the granular layer, present a small cavity, which is hollowed around the nucleus of the cell, between the nucleus and the solid part of the cell (Fig. 5). The nucleus may be atrophied and flattened ; the cavity formed in the middle of the cell contains, with the atrophied nucleus, a few granules ; at other times the nucleus is large and budding, or the cavity may contain tAvo or three round and granular nuclei. ■/-.\ 4 V )^^ r ScLematM drawing of the changes in the epidermis, af(er Leloir. Very thin sections of the epidermis changed in this manner, some- times show the cavities empty (a. Fig. 5) ; the nuclei having been washed out by the fluid used in preparing the specimen ; and the nuclei are found at times lying across the trabeculse, as occurs, for example, in preparations of cartilage. HISTOLOGY OF CHANCRE. 51 When several neighboring cells undergo this lesion they are seen as a number of cavities, limited by a more or less thin border, which is the remains of their solid substance. Leloir, who was the first to describe, and explain this formation of cavities to the Society of Biology,^ from some sections of syphilitic vegetations that we had examined together, has compared the appearance of the excavated epidermic cells to that of vegetable cells. The comparison is very just, and there exists a great resemblance between epidermic tissue changed in this way and vegetable tissue. The solid protoplasm of the cell forms the thin membrane of a cavity containing one or more round and granular elements (6, g, Fig. 5). Alongside of these cells are found larger cavities, containing a greater number of pus corpuscles (tZ, Fig. 5). This would lead to the belief that these larger cavities are the result of the opening of the excavated cells into one another. Indeed, quite often a reticulum is seen, formed by the cell walls, traversing a cavity filled with pus corpuscles; the reticu- lum and cavities are similar to those I had previously described in variolous pustules. From the walls of these cavities arise incomplete partitions, which are the remains of walls of smaller cellular cavities. Figure 6 is a section of the corneous layer and rete mucosum in the proximity of a hair from the surface of an indurated chancre, magni- fied 150 diameters. The cells upon the surface at «, are raised and des(|uamating, at h they form a compact layer, beneath which we see numerous excavated corneous cells, c, and large cavities, cf, filled with pus corpuscles. The net-work of trabeculee, which separates these cavities, is formed by corneous cells, and the walls of excavated cells opening into one another. The corneous layer stops at m. Be- neath this the granular layer presents a few cells, in which is seen a cavity around a nucleus at|?. The rete mucosum, which is extremely thick, also shows excavated cells, r, and cavities filled with pus, n. Upon the surface of the corneous layer are seen, at *, a few nuclei and atrophied cells surrounded by a delicate net-work of fibrils and granules. At other parts of the surface of the chancre, are seen pus corpuscles dissociating and separating the layers of the corneous epi- dermis. From this description, it is seen that the superficial and interme- diate layers of the cutaneous epidermis, are, at the chancre, the seat of a true infiltration of lymph cells. It may also occur in the rete ' Gazette Medicale, Nos. 18 and 24, 1878. 52 SYPHILIS. mucosum, but in this region the excavated cells and collections of pus corpuscles are seldom seen, although, on the contrary, they are very frequently met with in the superficial layers. This kind of inflammation of the epidermic cells is not peculiar to chancre ; mucous patches, vegetations, and cutaneous syphilides usually present the same lesions when they are moist upon their surfaces, or when they are erosive or squamous. Fig. 6. Section of the superficial epidermic layers near a hair follicle upon the surface of an indurated chancre, b. Corneous epidermic layer, a. Cells which have become detached from the surface. c. Cavity excavated in a cell. d. Larger cavities filled with pus corpuscles. ?•. Cell of the granular layer, m, with a cavity in which exists the nucleus. In the rete mucosum, there also are seen cells with cavities, and small cavities, n, filled with pus corpuscles. Upon the surface of the chancre are seen, at *, atrophied and granular epidermic cells similar to those which are repre- sented at 6, Fig. 2. X 150. Similar lesions are also found in all inflammations of the skin. They are also notably found in tumors which include the derm, and which cause an irritation of the cutaneous surface. Further on, these lesions will be considered in connection with mucous patches and syphilides, in order to explain the process of desquamation and super- ficial erosion or scabby suppuration, without there being any notable loss of substance of the epidermic layers. But for the present, we will endeavor to ascertain how it is that pus corpuscles are met with in the epidermis. There are two hypotheses: A. The corpuscles come from the vessels of the papillae by emigration, pass between the cells of the rete mucosum, and collect in small groups in the difi"erent layers of EPIDERMIC PUS FORMATION. 53 the epidermis. Many pathologists, indeed, think that superficial in- flammations of the mucous membranes occur in this manner, and Auspitz and Unna, who have described these small collections of pus in the epidermic layers, where a chancre exists, do not hesitate to believe that the cells come from the papillary vessels, separate the epithelial cells, and form collections between them. According to these writers, the walls of the pus-containing-cavities, are simply formed of epidermic cells pushed aside and flattened by pressure. This view of the process may also be sustained by Avhat sometimes occurs in the indurated chancre, as pointed out by Ordonez, viz., a slight escape of blood between the papillae and rete mucosum, at which time there would also be an escape of white corpuscles, which would afterwards pass toward*^ the exterior. On the other hand, in our preparations it was always found that the corneous layer was the seat of pus ; that there were here numerous excavated cells, and cavities containing pus, while in the rete mucosum pus corpuscles were feAver in number and more seldom seen. It may be said, that the lymph cells pass out of the vessels, then readily into the rete mucosum, the cells of which are soft, and are afterwards pushed towards the cutane- ous surface, accumulating in the corneous layer where the resistance is greater. The pus corpuscles are arrested under the epidermis penetrating it only with difficulty. But, in every case, there should be found numerous lymph cells, between the cells of the rete mucosum, and this is precisely what does not take place. Again, when there exist small cavities filled with pus, there are always found alongside of them excavated epidermic cells, so that these two lesions appear to us the two phases of the same process. Therefore, we are much inclined to admit the second hypothesis, 5, that the pus corpuscles are formed in the excavated epidermic cells by division of the pre-existing nuclei and by an endogenous genera- tion. The nutrient material comes from the blood plasma by imbibi- tion, determining an exaggerated nutrition of the nucleus, which then divides ; each division is surrounded by a small quantity of proto- plasmic substance, which is also furnished by the blood plasma. Fig. 7 is a representation of this process, and is a very exact drawing from a preparation of a mucous patch situated on the tonsil. The thin section of the superficial layer of the epithelium shows a few cells which are excavated, forming cavities ; those at a are empty; at 6, they have a round nucleus; at c, a larger cavity containing several 54 SYPHILIS. spherical cells which are pus corpuscles. The substance between the cavities consists of the solid protoplasm of the cells, between Avhich are even seen their indentations and the unitino; substance. Section from the superficial part of a mucous patch seated on the tonsil, a. Excavated epi- thelial cell. 6. An excavated cell having a free nucleus in its centre, c. Excavated cell contain- ing several pus corpuscles, e. Larger cavity with a projection, d. Similar projections formed by the destruction of the walls of the cells and transforming them into a single cavity. X 300. Without wishing to deny absolutely that the white corpuscles pass out of the vessels, and, not being able to penetrate the epidermic layers, are collected in groups in the corneous epidermis, we believe that the endogenous generation plays a no less important part in the phenomena that we have been describing. It has previously been mentioned that at the margins of the chancre, and even upon the surface, in many cases, the rete mucosum was pre- served and increased in thickness. Ordonez, a very conscientious observer, whose scientific labors have prematurely terminated, has satisfactorily demonstrated the fact, that the epidermis is preserved and the rete mucosum thickened over a chancre.^ He says the cells of the rete mucosum send out prolonga- tions which penetrate between the papillae. Auspitz and Unna also insist upon this new formation of cells of the rete mucosum, and upon their penetrating deeply into the papillary layer. We think it is more correct to say, that it is the papillae of the derm, which in the chancre are constituted of embryonal tissue, infiltrated with young cells, which bud and elongate, while at the same time they are swollen by the formative inflammation of their tissue. From this swelling and hy- pertrophy of the papillae, the cells of the rete mucosum, between the ' Martin and Belhomme, Traite de la syphilis. CONNECTIVE-TISSUE LESIONS OF CHANCRE. 55 primary elongated papillae, are also elongated and extend more deeply than in their normal condition. When the superficial layers of the corneous epidermis are detached and destroyed, in Avhat is termed chancrous erosion, the rete mucosum is alone retained at the central portion. The cells of the rete muco- sum may be partly or entirely disintegrated, and are now replaced by lymph cells or pus corpuscles, and by the false membrane which has been previously described. In a thin section made vertical to the surface, after hardening the chancre, this false membrane presents a honiogeneous finely granular structure, separating the lymph cells. There are almost always found a few lamellie of corneous cells, or cells of the rete mucosum in the false membrane upon the surface of the chancre. Lesions of the Connective Tissue. — The lesions of the dermo- papillary connective tissue are most important in the chancre, for this tissue appears to be affected very early; there is usually found, first, a papule — which is an elevation due to a thickening of the papillary layer. Some twenty years ago C. Robin, after having examined indurated chancres, announced the results of his investigations, according to which the induration was formed almost entirely of fibro-plastic ele- ments.^ Later he gave a more detailed description, quoted in the lectures of Ricord on chancre .^ According to Robin the indurated tissue consists of a framework of fibres of cellular tissue, and elas- tic fibres, between which are found an amorphous substance, fibro- plastic cells and nuclei, and lymph cells (^cytohlaBtions) . These terms Avill be explained further on, Virchow, some time after, pub- lished, in several papers,^ and in his book upon constitutional syphilis,* a description of chancre, which latter he considered as a hyperplasia of the cellular tissue, and which he anatomically compares to gummata of the tertiary period. In this work Virchow gives an anatomical de- scription of gummata, and visceral syphilis, which has been the origin and foundation of all works since published upon this subject. In order to study the indurated connective tissue at the base of a ' Memoire pr^seute &, 1' Academie des sciences, stance du 2 Novembre, 1846. 2 Lemons sur le chancre, recueillies et publiees par A. Fournier, p. 131. 3 Virchow. Tageblatt der Naturforscher-Versammlung. Tubingen, 853, No. 6, p. 63. Virchow's Archiv, t. xv. p. 326. ■• La syphilis constitutionnelle, traduction de P. Picard, Paris, 1860. 56 SYPHILIS. chancre, it should first be examined in the fresh state, immediately after removal. Fragments of the tissue taken from the indurated base, and teased in diluted alcohol, show the fasciculi of the connec- tive tissue, which are preserved intact, and the fibrils of which are united together ; free cells are also observed in the fluid. These cells are small lymph ceils possessing a single nucleus, and are very numerous (^cytohlastioits of Robin), or larger lymph cells, such as are met with in all inflammations. At the period of absorption of the chancre, many of these cells contain fine fatty granules. The other cellular elements are the flat or fixed cells of the connective tissue, the nuclei of which have become larger, while the protoplasm is granular and swollen Qjibro-plastic cells of Robin). In thin sections of the dermo-papillary tissue, the arrangement of the connective-tissue fibres and the cells interposed between them is very well seen. Thus in Figure 8 is seen a capillary, jo, the lumen of which contains lymph cells, a, and an endothelial cell, h. Around this capillary the fibres of the connective tissue,/, are separated by rows of lymph cells, d, and by a few fixed connective-tissue cells, h. In the tissue Connective tissue of an indurated chancre, a. Capillary vessel -with its waH.p, and an endothelial cell, b. f. .Fibres of connective tissue separated by flat connective-tissue cells, h, and round lymph cells, d. X 200. of the papillffi, and in the superficial dermal tissue, the fibres are a little thickened, but in the deep connective tissue of the derm many fasciculi of its fibres have retained their normal size, and are also separated by small round cells, while the fixed connective-tissue cells are swollen. The adipose tissue also presents, in the deep layer of the skin, a new formation of elements, so that each adipose cell is transformed into a nest of small cells or is surrounded by these ele- ments, as occurs in every inflammation of this tissue. Besides these lesions, common to all inflammations of the skin, a special alteration is always met with in the indurated chancre, Avhich ARTERIAL SCLEROSIS OF CHANCRE. 57 was fii'st described some years ago in Germany ; it is a sclerosed in- jiammatory tJiicJcening of the coats of the arterial and venous vessels occurring, particularly in their external coat or tunic adventitia. The arterioles of the dermic tissue, for example, when transverse sections of them are examined, sLow a thickening of their coats two or three times greater than normal. Figure 9 shows a section of an arteriole magnified 100 diameters. The internal coat — the part included between the internal elastic layer, I, and the lumen of the vessel, i — is a little thicker than normal. The lumen of the vessel is somewhat contracted, and filled with lymph cells, endothelial cells, and fibrine. The muscular coat — the part included betAveen the letters I and m — is not hypertroj)hied. But all that part external to the middle coat, from m to e, is considerably in- creased in thickness and infiltrated with cells between the fibrils of the connective tissue. The neighboring connective tissue is also in- filtrated, so that the whole vessel is surrounded by a considerable zone of inflammation. Fig. 9. Section of a seclerosed arteriole from the base of an indurated chancre, i. Internal bonndary of the internal membrane of the vessel; the lumen of the artery is filled with endothelial and lymph cells. The internal membrane, extending from i to I, contains round cells. I. Internal ela.stic tunic of the middle coat. m. Muscular layer, p. Much thiclceued connective tissue of the middle coat. n. Elastic fibres, e, e. Thickened connective tissue of the adventitia. X 100. Figure 10 represents a section of an arteriole, much smaller than the preceding, included in the indurated chancre, of which Figure 23 is an entire cut. In this figure, which is drawn with high power, the much contracted lumen is filled with an endothelial cell, m, and 58 SYPHILIS. some lymph cells, a. The elastic membrane,/, forms a circle around the lumen of the vessel, and sends prolongations of elastic fibres to the periphery. Between these fibres, the spaces contain round cells of new formation. We, therefore, find cells of new formation in the middle coat, 5, in the external fibrous coat, e, and numerous round cells surroundinor the latter. Section of an arteriole from the same chancre as Fig. 23. t. A fasciculus of connective tissue alon<;si(le of the arteriole, e. Its external coat 6. Its muscular coat. /. Elastic fibres, a. Lumen filled with lymph cells, m. An endothelial cell over which passes an elastic fibre, c. Lymph cells situated around the external coat. X 200. The veins present a similar modification, only more apparent, and more unlike the normal state, since normally, as a rule, the wall of the vein is thinner, and its calibre has the shape of an oval opening, when seen in transverse section. In a chancre, on the contrary, a section of the lumen of a vein is circular, its wall is greatly thickened, especially the external coat, and it has become thick and rigid as an artery. The veins are readily distinguished from the arteries by the absence of the elastic coat, which is represented at Z, Figure 9. The tunica adventitia of the veins is infiltrated with small cells. Figure 11 represents a section of a vein situated in the sub-dermic connective tissue of a chancre ; it is seen that the calibre of the vein is round like that of an artery and its coats, particularly the tunica adventitia, are considerably thickened, and, together with the peri- vascvilar connective tissue, are infiltrated with round cells. Figure 12, obtained from the chancre represented in Figure 23, is a very good example of inflammation of small veins. The four small vessels, which are here drawn magnified 200 diameters, possess very small circular openings filled with lymph cells. All the coats contain VENOUS SCLEROSIS OF CHANCRE. 59 round or flat cells of new formation, and the peripheral tissue is infil- trated Avith numerous round cells. Fis:. 11. Ct "6 Section of an inflamed vein -within the indurated part of a chancre, a. Central lumen of the vein filled with lymph cells and fibrin. 6. Middle coat. t. Connective tissue of the adventitia. c. Capillary vessels, g, g. Adipose vesicles. X 120. FiK. 12. .r^^( ^Ci/ '^^^^^<§i<^ Section of several vessels in the Indurated tissue of the chancre represented in Fie. 23. n. Lumen of vessels filled with lymph celJs, endothelium, and considerably contracted, due to the thickness of their walls, c. Peripheral connective tissue of the vessels infiltrated with small round cells, e. External coat of the vessels, t. Muscular coat. i. Internal coat. X 200. In all the figures where are shown sections of an indurated chancre with low power, in Figures 4, 19, 20, 21, 22, and 23 — whether the chancre is fully developed, as in Figure 1 ; ulcerated, as in Figures 60 SYPHILIS. 19, 22, and 23 ; or cicatrized, as in Figures 20 and 21 — it is always possible to see, even with very low power, from 6 to 12 diameters, the thickness of the ■walls of the vessels, and their inflammatory condition in the indurated portion of the chancre. In every chancre, the small arterioles and venules undergo the same changes. Thus when preparations of indurated chancres are ex- amined with a power of 50 to 80 diameters, the capillary vessels in connection with the adjacent sclerosed tissue are seen, increased in size by evident ridges, and surrounded by an accumulation of elements, such as are observed in chronic cirrhoses of the liver. The capillaries of the papillae, however, are frequently dilated be- neath the false membrane, and at the central ulcerated part of the chancre, but their walls are not thickened. In these cases, when thin sections are examined, the capillaries are found filled with red and white blood-corpuscles. This dilatation occasionally coincides with extravasations of red and white blood-corpuscles around the vessels. It also accounts for the facility with which the surface of a chancre bleeds, when the false membrane which covers it is removed. At those parts where the chancre is abraded or ulcerated, the pa- pillae are infiltrated with lymph cells, which become free upon the surface of the papillae, where they are in some manner secreted with a small quantity of fluid containing fibrin, which comes from the blood, as do also the lymph cells. In some chancres, the induration of which is considerable both in extent and density, the vessels — veins, and arterioles having their walls inflamed and thickened, especially their internal coats — are often completely obstructed, or nearly so, by an accumulation of swollen endothelial cells and lymph cells. When sections of them are ex- amined, after the action of coagulating fluids employed to harden the specimen (chromic acid, Mliller's fluid, or alcohol), there is seen in the transverse and longitudinal sections of the vessels a coagulum of fibrin inclosing round and endothelial cells. Is the fibrin coagulated immediately after the death of the part or during life ? We do not know : what is certain, is that some vessels are in places completely filled by the coagulum. In the examinations of the chancre of Case v., we saw in almost all the vessels within the induration, cells filling their narrow lumen, and, in several, a fibrinous coagulum similar to that which is represented in Figures 46, 47, and 48, drawings made from a cutaneous gumma. These coagula are stained a very deep orange-red by picro-carmine. Whether the fibrin is coagulated before INDURATION OF CHANCRE. 61 or after death, it is certain, that the circulation has been arrested more or less completely in these inflamed vessels, and that the cellular elements of the region nourished by these vessels had to suffer in their nutrition. This is, indeed, what takes place in these cases ; and the round or lymph cells of those portions of the chancre, where the cir- culation is impeded or impossible, become granular, fatty, or caseous. We have onl}'' seen these lesions — complete obliteration of some of the vessels, caseous condition of the cells of the central part of the chancre — well marked in one instance, that of Case V. The seat of the chancre is important in explaining the inflammation of the internal coat of the vessels, and their obliteration. In Case V. the chancre had involved the fossa and pi^epuce ; the irritation from stretching, which the small ulcerated chancre was subjected to during very frequent erections, and the tearing of the indurated tissue, which has resulted, have contributed to increase the local inflammation. The sclerosed thickening of the arterioles and venules is important, not only anatomically, as an essential character of chancre, which is only very seldom found in mucous patches, and never in any other syphilide or nodule, with the exception of some guramata, but is also very important syraptomatically. It is this vascular sclerosis, in connection with the complete general preservation of the firm trabeculae of the derm, with the normal state of most of the fasciculi of the connective tissue, and of the elastic* tissue, that gives to the infecting chancre one of its essential clinical characters, the induration. The induration is sometimes superficial, sometimes deep and super- ficial. This depends upon the arrangement of the vessels, which form on the skin two horizontal netAvorks, one superficial beneath the papillas, the other deeper, made up of larger vessels, at the base of the derm. When the sclerosis affects only the superficial vessels, we have a superficial induration. If the sclerosis has involved at the same time both the superficial and deep vascular net-works, the intermediate branches being equally aff"ected, we have a more extensive hard nodule, varying in thickness according to the region of the skin involved. In the first case the induration is foliaceous or parchment-like ; in the second it is ligneous, and gives the sensation of cartilage. Almost always the sclerosis is continued along the coats of the vessels further 62 SYPHILIS. than the induration itself, heyond the limits of which the vessels, whose walls are inflamed, are surrounded with normal connective tissue, while in the indurated portion this tissue is likewise inflamed. [The especial involvement of the walls of the bloodvessels may be capable of explanation on the theory that the poison of syphilis par- ticularly affects the white blood-cells, and is conveyed into the system largely, if not exclusively, by them, — a theory which there are many reasons for believing in, some of which have already been enumerated. The anaemia or leucocythremia of the early stages, the apparent im- munity of a mother bearing a syphilitic child, the absence of con- tagious property in the physiological secretions, are a few of many facts which seem to show that the action of syphilis, as far as the blood is concerned, is chiefly expended upon the corpuscular element, and especially upon the white blood-cells. Now, in the vast majority of cases of syphilitic infection, the con- taminating agent is more or less purulent and irritating in its char- acter ; and, after its introduction beneath the superficial epidermic layers, acts as a foreign body, and sets up, at least in a mild degree, the initial processes of inflammation. The slowing of the blood-cur- rent, the increase in number of the white blood-corpuscles, their adherence to the walls of the vessels, and their partial or complete penetration of the latter, are all conditions in every way favorable to the influence exerted upon them by syphilis, and which probably par- tially account for the peculiarly marked sclerosis, which is present in ' the vascular walls, chiefly in the small vessels, but also, it seems pro- bable, to some extent in the lymphatics.] This induration, and sclerosis of the arterial coats, this infiltration of the connective tissue with cells, are lesions which do not develop very rapidly, either in their period of formation and increase, or in their period of resolution. This fact, taken in connection with the intimate changes of the tissues involved, renders the long duration of a chancre, and the persistence of the indurated nodule when the indu- ration is thick and considerable, not at all astonishing. The nerve fasciculi which pass into the indurated tissue of a chancre, and which are surrounded by a connective tissue infiltrated with small round cells, are inflamed in their laminated sheaths, the connective tissue which accompanies the vessels between the nerve fibres in the interior of the fasciculi being also inflamed. Thus, in the examination of a chancre removed by Mauriac from Case V., I have been able to study transverse and longitudinal sections of nerve fasciculi. The NERVE LESIONS OF CHANCRE. 63 laminated sheath was separated ; the flat cells between the lammaB were larger and more swollen than normal, or were replaced by numerous elongated, oval, and small cells. Figure 13 represents a part of a section of a fasciculus so altered ; the lamina, m, ?, of the sheath, g, are separated by elongated or round cells, and between the nerve fibres, are seen small cells. The nerve fibres themselves, 5, ?>, are normal, and their medullary substance and axis cylinders are not changed. In another examination of a chancre, which had been treated by osmic acid, immediately after its removal by Heurteloup, the nerve fibres were also normal. I should say, however, that in these examinations, I have not searched for the ultimate terminations of the nerves in the papillae. ^ k Part of a nerve fasciculus found in a chancre, g. Dissected laminated sheath, the laminse of ■which, m, I, are separated by round or elongated cells, a, b, b. Transverse cuts of nerve fibres. X 200. The inflammation, the separation of the sheath of the nerve fas- ciculi by cells of new formation, in the tissue of the chancre, is not accompanied with pain. The chancre from Mauriac's patient, with whom the lesion was very intense, was absolutely painless. This neuritis without pain is a curious circumstance, and should be remem- bered. [This absence of pain and of other-subjective symptoms, which is one of the marked clinical characteristics, not only of the chancre but also of the cutaneous syphilides, is presumably due to the non-inflam- matory character of the exudation which separates the nerve sheath from the fasciculi. As a result of a specific influence inciting certain cells to rapid growth and multiplication, it produces here, as else- where, the physical effects of an inflammatory transudation, but is almost always unaccompanied by the hypersemia, the active vascular excitement, and the heat, pain, burning, or itching which accompany acute or well-developed inflammation. It would be interesting to note whether some such nerve disturbance, due to pressure, does not underlie the irregular capillary dilatations found in the erythema and 64 SYPHILIS. roseola of early syphilis, and soon followed (in the papular eruption) by visible and tangible evidences of exudative processes similar to those just described.] In the preceding descriptions, generalities have been adhered to, which may be applied as well to the skin as to mucous membranes, and to the different regions which may be the seat of chancres ; but there are a number of details to add concerning the changes of organs which may be included in the chancre, for example: hair, sebaceous glands, sudorific glands, mucous glands, etc. Not wishing to com- plicate the description, it may be said in a general manner that in all organs we observe a multiplication and hypertrophy, from excess of nutrition of their epithelial cells, and at the same time an infiltration of their peripheral connective tissue with young cells or lymph cells. Thus the ducts of the sudorific glands are increased in diameter, and their epithelial cells are larger than normal, while the periphery of the glandular ducts is surrounded by a zone of small cells pressed one against the other. The sebaceous glands, either in connection with the hairs or sepa- rate, as occurs in the labia minora, are changed in the same manner. In some chancres, as for example, those of Case II., there are no sebaceous cells in the glands situated in the chancre (see Fig. 19). The lining and contents of these glands consist noAV of pavement epi- thelial cells and pus corpuscles. Again, the cells of the rete mucosum, which pass into the hair follicles, form thick layers, and contain exca- vated cells or nests of small round cells. In regard to the hypertrophy, and increased nutrition of the epi- thelial cells of these diff'erent parts, from what occurs in the rete mucosum, and in the corneous layers of the epidermis, it may be concluded that the modifications of the epithelium are secondary to the sclerosis of the dermo-papillary tissue ; the cells of the sudorific glands are swollen because the neighboring tissue is congested and inflamed ; the fat disappears from the sebaceous glands on account of the inflammation ; the cells of the rete mucosum are swollen with nutritive fluids, because the papillge are inflamed and congested; the prolongations of the rete mucosum between the papillae are longer than usual, because the papillae are elongated and hypertrophied. During its period of development and acme, the chancre always occasions lesions of the surrounding parts, which consist of an oede- matous swelling of the skin and a lymphangitis which connects it with LYMPHATIC LESIONS OF CHANCRE. 65 one or more lymphatic glands, the latter soon becoming tumefied; this lymphangitis and swelling of the glands ai'e always present.' A chancre of the prepuce and fossa glandis is always accompanied by a hard oedema of the prepuce, an inflammatory oedema similar to that of elephantiasis. A chancre of the labium majorum is also always followed by an oedema of that region. This inflammatory oedema, looking like that of erysipelas, with red lines upon the cuta- neous surface, extends as far as the region of the groin. It is uni- lateral because the chancre is always situated only upon one of the labia majora. When either the labium or the skin on the back of the penis is carefully felt, there are found hard sinuous cords, which may be fol- lowed as far as the inguinal glands. They are the inflamed lymph vessels. In men, upon the dorsal region of the penis, are frequently seen secondary ulcerations and enlargements of these perivascular indurations. [' It -would seem evident that in this assertion Cornil is in accord with tlie majority of syphilographers. Berkeley Hill says that the involvement of the lymphatics in syphilis is cer- tainly more often present than absent, and is due to " thickening of the walls of the vessels by proliferation of the cellular elements, and invasion or multiplica- tion of leucocytes." Van Buren and Keyes define syphilitic lymphatics as a " specific induration of the lymph vessels and surrounding cellular tissue" — "starting in the induration of the chancre." Henry Lee says: "We have seen that the secretion of a primary sore is inoculable, so as to produce the specific induration only during its earliest stages; and it is during this same period that the action takes, place which produces the specific affection of the lymphatic vessels." Bumstead and Taylor, after making the assertion already quoted, that " specific engorgement of the lymphatics is dependent upon changes in the walls of those vessels identical with those which occasion induration of the base of the chancre and the ganglia," add that the distal extremities of these changed vessels are found "in the induration surrounding the chancre." Elsewhere, however, they quote with apparent approval the researches of Auspitz and Unna above alluded to. Von Biesiadecki, quoted by Biiumler, found " the miiscular fibres in the lymph- atic vessels enlarged through the presence of numerous exudation cells ; the adventitia was contracted, containing only a few of these cells ; the vessels were in places plugged by coagula, or closed by a thickening and folding of the intima." Many more authorities might be adduced, but these would appear to be suffi- cient to demonstrate the general belief in an involvement of the lymphatics in the early stages and in the sore itself.] 5 66 SYPHILIS. In the indurated portion of the primary chancre, the lymphatic vessels and spaces of the derm are filled and distended with lymph cells; the cellular tissue surrounding them is indurated and infiltrated with cellular elements. The same inflammatory change of the contents of the lymphatic vessels and peripheral connective tissue is extended along these vessels, on the back of the penis, and in the labia raajora. When there is ulceration of a secondary indurated nodule upon the penis, the connective tissue is here thickened over a considerable extent, and the bloodvessels are sclerosed. This histological exami- nation has been made by Verson from a secondary induration.^ [A description of the lymphatic vessels given by Auspitz and Unna^ is in direct opposition to the above. They describe the walls of these vessels at the beginning of the process of induration as free from granulation cells, differing in this respect from the adventitia of the bloodvessels, and, therefore, readily distinguished from the veins. It is only Avhen the surrounding connective tissue becomes infiltrated with young cells, that the walls of the lymphatics are affected. The gaping, oblong, round or oval openings, bounded by sharp edges, which are mostly empty, and are seen throughout the entire sclerosed portion, they consider to be enlarged lymph spaces. A later article by Unna,^ accompanied by a drawing. Fig. 14, shows a lymphatic vessel at/, the lumen of which is seen entirely free from any cellular obstruction. In order to ascertain if possible which of these descriptions of the lymphatic vessels — that given by Auspitz and Unna, or that accord- ing to Cornil — is correcc, a number of histological examinations of indurated chancres were made, from the results of which it would seem proper to infer that there is a certain amount of truth in both views, but that neither in their extreme should be adopted. Either to describe all the lymphatics in the indurated portion as empty spaces, or to say that they are all obstructed by corpuscles, we are convinced from our examinations would not be correct. But in sections of the diseased part, we find many openings such as represented in Fig. 14, at/, and which are empty lymphatics. This is more especially true of the preparations made from chancres hardened in alcohol, and colored with carmine. There is also seen such an appearance as represented ' VersoD : In Vii'cliow's Arcliiv fiir Path. Anat., vol. xlv. 1869. 2 Vierteljahreschrift f. Derm. u. Sjph., Wien, 1877, s. 160. ^ Vierteljahreschrift f. Derm. u. Syph., Wien, 1878, s. 543. LYMPHATIC LESIONS OF CHANCRE. 67 in Fig. 15, I; more particularly in sections made by freezing the tissue, immediately after removal, by means of the freezing microtome Fig. 14. Section of the indurated portion of a chancre, a. Artery, d. Vein. /. Lymphatic, c. Connective tissue ; and e, e, Vasa vasorum (Unna). with the rhigoline spray, and then placing them in a solution of osmic acid and mounting them in glycerine. We have here at Z a lymphatic, Fig. 1.5. /'^ \\ fe/W^\v '// Section from the indurated portion of a chancre, v. Vein. I. Lymphatic vessel, with lumen obstructed by lymph corpuscles, c. Connective tissue. X -^^0. which is very readily distinguished from the veins of the tissue ; its lumen is seen almost filled with lymph corpuscles, but the surrounding connective tissue presents no abnormal appearance. 68 SYPHILIS. Our examinations seem to prove, therefore, that while some of the lymphatics may be empty, there are also found others obstructed by lymph corpuscles. The endothelial lining of the lymphatic vessels we found presented the normal appearance as described by Unna. The chancre from which the drawing, Fig. 15, was made, was ob- tained from — J. H., aged 28, who came under observation December, 1881. A few days previously, at a period of about two weeks after a suspicious connec- tion, he had noticed a small papule on inner surface of prepuce just be- hind the corona glandis. T.'iis had taken on superficial ulceration, had become elevated upon an indurated base, and had all the characteristics of an indurated chancre. At the time of its excision, in February, it was a saucer-shaped ulcer, a few lines in diameter, raised above the surrounding surface, having a distinctly and specifically indurated base, movable upon the subjacent tissue, was covered witli a thin grayish tenacious secretion, was painless, definitely circumscribed, and was already beginning to cicatrize. After its excision, the clean linear wound, left by the cut of the curved scissors, healed promptly, the cicatrix remaining unindurated. A moderate en- gorgement of tlie inguiual gbands, wliich existed at the time, has since subsided, and four months afterwards the patient was still without con- stitutional developments. There was strong reason for suspecting the woman from whom be believed himself to have contracted tlie disease, but no examination could be obtained. Another patient with undoubted syphilis attributed his infection to her.] With the chancre and with the secondary lymphangitis, there is always found an alteration, first of one gland, then of a number of glands in the groin, if the chancre be situated on the genital organs. The glands are as large as a hazel-nut, are oval, hard, and roll beneath the fingers ; this enlargement of several glands is charac- teristic of syphilis ; it should always be looked for to confirm the diagnosis of an infecting chancre, and will be described later. When the chancre heals, there is simply a cicatrization and re- covery. The loss of substance due to the erosion is slight. The papillae are not usually destroyed by the ulceration, the epidermic layers only having suffered. The lymph cells contained in the papillne disappear; the rete mucosum and epidermis rapidly form upon the papillary surface. The rapidity of the healing and of this new formation of layers of the epidermis is sometimes astonishing. A chancre or mucous patch, that has been seen to-day Avith a gray false membrane upon its surface, to-morrow will present a new epidermic layer. The cicatrix is far from being always visible, especially in the CICATRIZATION OF CHANCRE. 69 case of chancres of the labia majora. This is, however, very variable. Thus there will be seen frequently coming to the hospitals nurses Avho have had a chancre of the breast. They still have copper-colored spots, but without induration, even when the date of the chancre is four or five years previous. When a chancre of the prepuce or fossa glandis is accompanied with intense induration, the latter may persist some months or a year after cicatrization. Upon the prepuce the cicatrix, which results from the healing of a chancre, is at times sunken or depressed as the ulcerated chancre itself. Here the chancre may have its seat at the bottom of the folds of the skin of the prepuce, and the erections may increase the ulceration.^ ' The cases relative to the pathological anatomy and symptoms of indurated chancre are placed at the end of the third chapter. 70 SYPHILIS, CHAPTER III. SOFT CHANCRE— SYMPTOMS AND COMPARISONS OF THE TWO CHANCRES. Pathological anatomy of soft chancre— Similarity of the anatomical characters of infecting and simple chancre — Comparison of infecting chancre with gum- ma, lupus, etc. — Symptoms of Infecting chancre — Its surface — Induration — Varieties — Healing of chancre — Its seat — Symptoms of soft chancre — Relative frequency of soft and indurated chancre — Mixed chancre — Diagnosis and treatment of chancre. Pathological Anatomy of Soft Chancre (simple, non-infecting chancre, chancroid). — In the case of a soft chancre, either produced by auto-inoculation, or contracted during sexual connection, there are observed from the first certain pathological phenomena. The first day we see a small red point, which on the second day becomes an acuminated red papule, and is converted into a small pus- tule by the end of the second or third day, especially in a region where the skin is very delicate, as, for example, the internal surface of the thigh. The pustule very soon breaks, and beneath the lowest epidermic layers, we find a deep suppurating ulcer, which rapidly extends in circumference and depth. The chancrous ulceration reaches its acme during the first week, and is then seen with all its characteristics. It is a deep crater-like ulcer, its borders are per- pendicular or undermined, its surface is granulating and irregular, formed of soft fleshy granulations and infiltrated with pus, of whicli there is an abundant secretion, and which gives it a grayish color. The serum upon the surface of an indurated chancre is small in amount and transparent. A vertical section of this variety of chancre, made after hardening, and examined with low power, twenty diameters, gives a picture similar to Fig. 16. The corneous epidermis, a, and the rete mucosum, h, which cover the skin in the proximity and at the margin of the chancre, are abruptly arrested at the point where the ulceration begins. The irregular cavity of the chancre appears upon section as a notch, like a volcanic crater. The cavity of the chancre, m, is limited by fleshy granulations, w, the tissue of which is directly con- HISTOLOGY OF SOFT CHANCRE, 71 tinuous Avitli the tissue of the hypertrophied papillas found at the border of the chancre. Fiff. 16. y- 'i;&- Section of a soft chancre, a. The epidermis, the rete mucosum, 6, is abruptly arrested at the edge of an anfractuosity, ?re, which forms the loss of substance of the chancre, n. Granulations continuous with the papillary tissue, i;. Vessels. X 20. The general appearance of a section of a soft chancre is seen in the accompanying diagram, Fig. 17. Fig. 17. Schematic section of a solt chancre, a. Corneous epidermis, p. Rete mucosum and papilla, which are abruptly arrested at the ulcerated surface, t. Deep border of inflammation. Passing to the details of alteration, there are found in the superficial layers of the epidermis, and in the rete mucosum, cells containing a cavity between the nucleus and substance of the cell, such as always exist when there is an inflammatory congestion of the cutaneous 72 SYPHILIS. papilloe, and which occur in all cutaneous inflammations or tumors, when they reach the surface of the integument. Numerous lymph cells are found infiltrating the tissue of the papillae, in the neighborhood of the ulcer, and which are larger than normal. These cells probably come from the interior of the blood- vessels by emigration. The external surface of the papillae is separated from the epidermic layers ; in other words, the epidermic layers are loosened at the border of the ulcer from the inflamed and hypertrophied papillae. In all parts of the inflamed skin, in the remains of the dermo- papillary tissue, in the derm, and in the subcutaneous cellular tissue, there is an infiltration of round cells between the constituent elements of the connective tissue. As the ulcerated surface is approached, the lymph cells become more numerous. The tissue of the granulations is granular, without fibrils, since the fibres have been separated, softened, and destroyed. By this destruction of connective tissue the pus corpuscles are set free, forming a layer upon the surface of the granulations, which varies in thickness. It is this infiltration of the granulations, and the purulent secretion which give to the surface of the ulcer its grayish color, and some writers have compared it to diphtheria. It is not intended, d, j)ropos of soft chancre, to give the histology of inflammation and suppuration of the derm and subcutaneous con- nective tissue ; but two points must be alluded do : First, in the soft chancre, there is not a sclerosis of the vascular walls ; we meet with nothing but what occurs in every common inflammation, that is, the external coat of the arterioles and venules presents a certain number of mio-rating cells between the fibrils of the connective tissue of the tunica adventitia, but there is no induration and thickening of the wall, and also we do not observe any narrowing of the calibre of the vessels. The second point is, that the fibrous trabeculae of the derm of the region involved are not preserved intact ; the fasciculi of fibrous tissue are separated, their fibrils are distinct one from another at points near to where there has been a loss of substance. The fibrils separated by the lymph cells are themselves destroyed by the soften- ing and suppuration of the tissue. These changes, upon the surface of a simple chancre, result in the fibrous tissue losing its firmness and normal elasticity ; its fibrous trabeculae have a tendency to dis- appear. The lymph cells, which collect in great numbers in the CHANCRE, GUMMA, LUPUS, ETC. 73 granulations and neighboring connective tissue, are large, turgid, and become free by softening the fibrils between which they are placed. The absence of specific induration comparable to that of the indu- rated chancre, and also a tendency to a progressive destructive in- volvement of neighboring tissues, result froai this anatomical arrange- ment of elements. Anatomical Characters of Infecting and Simple Chancres — If the histological lesions of infecting chancre are compared with those of simple chancre, it will be seen that there are differences which dis- tinctly separate them. In the infecting chancre, there is the sclerotic thickening of the dermo-papillary tissue and of the walls of the vessels ; the superficial epithelium and rete mucosum are partly preserved, even over the eroded or ulcerated surface ; the scanty secretion con- tains a relatively small number of lymph cells. In the simple chancre, on the contrary, there is a gaping crater- like opening, a result of the complete and rapid destruction of the superficial and deep layers of the epidermis, and from the progressive suppuration, a breaking down of the papillary and dermic layers ; the papillae, the connective tissue of the derm, and the sub-dermic tissue are transformed into a granulating tissue, in which the vessels are not sclerosed ; the fibrous trabeculse are separated and destroyed. From this it will be seen, that between these two chancres, there is a distinct and complete diiference ; one being essentially a prominent papule, the other an ulcer ; and if to their histological characters be added, the difference in the change occurring in the lymphatic glands, if it be recalled, that one occasions syphilis, while the other is a lesion purely local, it must be concluded that they are two very distinct diseases, which should not both be knowm by the name of chancre. It is not, however, absolutely necessary to change it, since its sigaifi- cance is so w^ell understood. • Infecting Chancre compared with Gummata, Lupus, etc. — The structure of an infecting chancre should not be compared only with that of the soft chancre, but also wnth other cutaneous lesions that closely resemble it. It is rather with visceral gummata, as of the liver and testicles, or with the gummata and later syphilides of the skin and genital organs, that the comparison should be made. This Virchow has done. These lesions, indeed, present a like induration to that of chancre. It will be seen later, that certain mucous patches 74 SYPHILIS. of the labia majora and minora also have an eroded appearance, and are accompanied by an induration of the connective tissue, which is somewhat analogous to that previously described as occurring in the primary lesion of syphilis. In these cases the vessels may also be notably thickened and sclerosed. The histological structures of infecting chancre have been compared Avith lupus as well as with syphilis. I have not recently examined lupus, and can only describe what has been lately given by Fried- lander,^ Lang,^ Volkmann,^ etc. In lupus there are found, besides the infiltration of the connective tissue with small cells, spherical collec- tions of large cellular elements which do not correspond to the epi- thelial cells of the rete mucosum, but which are similar to the large cells that have been described as giant cells in tuberculosis. Whatever may be the origin and nature of these " giant cells" of lupus, this disease has been associated with tuberculosis on account of its structure, and in some recent works, there is even a tendency to consider it as a manifestation of cutaneous tuberculosis. It is to be remembered, however, that giant cells, notwithstanding the opinion of Schiippel, and several other pathologists, do not belong exclusively to tuberculosis, since we also find them in scrofulous lymph glands, in inflammatory granulations of the skin (Jacobson, Heidenhain, Baumgarten), and in elephantiasis (Klebs). They are also met with in syphilis ; as, for example, in cerebral syphilis (Heubner) ; in ulce- rating syphilides (Bizzozero, Kd^ter) ; in gummata of the testicles (Baumgarten) ; in syphilitic papules (Griffini). Auspitz and Unna have not found giant cells in the infecting chancre ; I have also examined several chancres, to ascertain if this variety of cells was present, but failed to find them ; yet as pre- viously mentioned, there is frequently an inflammation of the internal coat of the vessels, a swelling of the endothelial cells, and at the same time there is occasionally an almost complete obliteration of the vascu- lar lumen by the endothelial and lymph cells united together by coagulated fibrin. We believe, moreover, that those cells which have been termed " giant cells," result primarily from an arrest of the blood circulation, followed by an accumulation of endothelial and ' Virchow's Archiv fiir path. Anatomie, t. Ix. " Vierteljahreschrift fiir Dermatologie und Syphilis, 1875. 3 Berliner klin. Wocheiischrift, 1875, No. 30. SYMPTOMS OF CHANCRE. 75 lymph cells, which retain their vitality for a certain time in the midst of a fibrinous plasma.^ Giant cells Avill again be referred to a propos of other syphilitic lesions in which they are met with, and of the comparison of the indu- rated tissue of chancre with other syphilitic productions ; d i)ropos also of mucous patches and gummata. The tissue of hard chancre is very similar to that of cutaneous fibromata, fibro-sarcomata, and elephan- tiasis, but the arrangement and extent of the parts involved by these latter diseases establish a sufficient distinction between them. Symptoms of Infecting Chancre. — It has previously been stated that the incubation of an infecting chancre continues a long time before any symptom is manifest upon the skin. This period is not less than fifteen days to three weeks, iaveraging twenty-five days, and it may be prolonged to two months. [Hence in cases in which abrasion or tearing of the mucous or cutaneous surface has occurred durino- sus- picious intercourse, it is not safe absolutely to deny the possibility of the development of syphilis until after the lapse of this latter inter- val. Perhaps it would be better, in view of the few rare, but un- doubted cases of prolonged incubation which have been recorded, even to extend this period still further, see p. 41.] What has been said of the anatomy and pathological histology of chancre, will aid us very much in understanding the symptomatology, since in all alterations of the skin analogous to those of chancre, the pathological anatomy and the symptoms are interdependent. Chancre sometimes begins by a papule, that is, a thickening with a slight elevation of the papillary layer of the skin, such as occurs in chancres of the skin and nipple ; sometimes by a superficial redness ; sometimes by a scarcely visible excoriation or superficial erosion. As these initial modifications of the skin and mucous membrane are very slight, and painless (the indurated chancre is painless from its beginning to its termination), it follows that such chancres almost al- ways are overlooked. The physician very seldom sees the beginning of a chancre, either in private practice — for it is seldom persons give that careful examination necessary to discover the lesion — or at the hospitals, where the men rarely present themselves when the chancre is in its initial stage ; in a hospital for women it can readily be under- ' See a communication upon this subject, by Spiellmann, to the Society of Biology, 1878. 76 SYPHILIS. stood how it is that a chancre is never seen in its earliest period. "With women, the chancre may be concealed in a fold or in a de- pression, so that the patient can only see it with difficulty, and, as she suiFers no pain, it gives her no anxiety ; these facts, together with her repugnance to consult a physician for any affection of the genital organs, explain very satisfactorily why, in hospitals for women, patients so seldom present themselves suffering with a typical and unquestionable chancre ; they have had the lesion for some time ; frequently the chancre is healed, and the patient presents secondary symptoms — mucous patches, roseola, papules, etc. If the chancre has not begun by a papular elevation, there are most frequently found during the first days a certain degree of thickening of the choriura, and an erosion or ulceration upon its surface. From the appearance of the surface of. the chancre several varieties are recognized : the papular, erosive, desquamative, excoriated, and ulcerating. These several forms, which define themselves, and vary from the simple papular to the ulcerative, constitute a series, the differ- ences in which are due chiefly to the different degrees of ulceration of the primary lesion. But it is seldom that an indurated chancre occa- sions a true and deep ulcer ; more often, as has been demonstrated in studying the pathological histology of chancre, the epidermic layers and rete mucosum are preserved, and even increased in thickness at the margin of the erosion, at the same time that the papillary layer is also thickened, so that the chancre represents an elevated flat surface; the whole of the affected part of the derm being thicker than the sur- rounding normal skin. In erosions and excoriations it has been seen that the epidermic layers at the centre of the chancre were destroyed somewhat irregularly, but nevertheless there still remain a few epi- dermic islands or patches of the corneous epidermis, and laminae of dentated cells of the rete mucosum, forming a layer upon the surface of the excoriation varying in thickness. Upon the surface of ulcerated chancres (Cases II., IV., and V.) the epithelium has entirely disappeared, and the superficial parts of the papillae, infiltrated with lymph cells, furnish a small quantity of pus Avhich covers them. In two of the chancres situated upon the preputial fold, and especially in Case V., the ulcerated surface was funnel-shaped. This, hoAvever, is a very unusual occurrence ; on the contrary, the surface of the indurated chancre is generally but slightly excavated, and the excavation is more apparent than real, since the margins of I SYMPTOMS OF CHANCRE. 77 the ulcer are elevated, owing to the hypertrophy of the epidermic and papillary layers ; the destruction of the most superficial layers of the epidermis occasions the excavation which is noticed. If the surface of a chancre be carefully examined during its stage of perfect development, when the induration is beginning to increase — that is, at the end of the first or during the second week after its appearance — it is found that the slight depression is continuous without interruption, by an even and smooth surface, with the margin of the chancre which is covered by the epidermis. The thickened epidermis, at the margin of the chancre, is continuous on one side with the healthy epidermis of the skin surrounding it, and on the other side with the gradually thinning layers of the epidermis covering the chancre. The surface of an eroded or excoriated chancre is smooth, as if varnished; we see islands of epidermis, and the parts are covered by the gray or yellowish false membrane previously described. The epidermic patches and false membrane are on the same level. Upon the surface of the lesion there is found a small quantity of a serous transparent fluid. If it be wiped with a cloth the surface remains intact ; even if it be rubbed or scraped it continues ^smooth, glazed, and is soon again covered with a small quantity of transparent fluid. The induration of a chancre occurs at the end of the first week, dating from its appearance. It may show itself only after fifteen days or three Aveeks from the beginning of the erosion, especially when it is of that rare form which will be described later — the mixed chancre. The induration is progressively developed from the surface, that is from the papillary network, to the deep dermic and sub-dermic layers. The variations in thickness of the affected part give rise to several well-recognized degrees of induration. Parchment induration, is that which gives to the fingers applied to the circumference of the chancre, the sensation of a piece of parch- ment forming the base of the erosion. Laminated induration, is thinner and less distinct than the parch- ment variety, and gives to the fingers the sensation of a piece of paper. Nodidar induration, is that in which the base of the chancre is hard and thick, feeling between the fingers like a nodule of cartilage or wood; it is the most characteristic, but is seldom seen in women. Annular induration^ is that in which only the margins of the 78 SYPHILIS. chancre are indurated, and form a hard ring, the tissue in the centre retaining its normal elasticity. The most readily recognized and the most characteristic chancre has the shape of a cup-like depression seated upon the indurated and elevated skin. If the description of the histological alterations of the connective tissue and vessels beneath the chancre be recalled, it will explain the anatomical reasons for these several forms of induration. The lami- nated or parchment induration corresponds to a sclerosis limited to the papill;^ of the derm and to the vascular network of the papillae ; deeper or nodular induration corresponds to a sclerosis of the dermic and sub-dermic connective tissue, and of the vascular network of these parts, which latter is much larger than the superficial network. There- fore, when there exists a lesion of large arterial and venous vessels^ it is slower in forming and disappearing than a similar lesion of small vessels. Indeed it is not to be expected, that an induration and thickening of the fibrous tissue of the external, middle, and internal coats of vessels would rapidly diminish. What is known of sclerosis in general leads us to suppose, d p7'iori, that like lesions will be long in disappearing, and this is found to be the case, for traces of induration have been observed four or five years after the beginning of the chancre (Puche). Ricord has found remains of the induration ten and fifteen years subsequent to the primary lesion. [Biesiadecki attributes the persistence of the induration to a transformation of the newly deposited cells into connective tissue fibres.] The induration and its extent are best appreciated by seizing the chancre, at its margin, between the thumb and finger, drawing it upwards, so that it may move upon the subcutaneous tissue, and then using slight pressure in a direction parallel to the surface of the chancre. By these means the resistance offered by the base of the chancre and the degree of its induration can be readily appreciated. This method of palpation is very easy in certain regions, but in other parts it is difficult to perform, especially in women; of course in some localities, as, for example, the os uteri, it is almost impossible. The degree of induration varies very much according to the seat or region of the primary lesion, and also in accordance with the structure of the part. When occurring upon the glans penis, upon the internal surface, or mucous membrane of the prepuce, or in the fossa glandis, the chancre is generally very distinctly indurated ; upon the SYMPTOMS OF CHANCRE. 79 skin of the penis, and upon the general integuments, the induration is not so marked or so extensive. With women, bhe induration of the chancre is greater upon the labia majora than upon the labia minora and fourchette. The skin over the labia majora, which contains dense fibro-muscular tissue, is a better foundation for the induration than the very thin corium of the labia minora or fourchette. Upon the fourchette the chancre is almost always parchment-like, and the induration is quite difficult to recognize, owing to the formation of the part, and the difficulty experienced in seizing the chancre be- tween the finger and thumb to elevate it. [Ricord, in speaking of the induration of chancre, says, that its development and amount depend upon the lymphatic supply. Where the induration is greatest, there the lymphatics are more numerous ; and that the induration consists in an inflammation of the capillary absorbents with effusion into the intervening tissue.^ From our investigations of the indurated tissue of chancre, we cannot coincide with this view of Ricord's. In all the sections examined, which were taken from chancres having well-marked indurated bases, none presented any appreciable change in the surrounding connective tis- sue of the lymphatics, and their endothelial lining appeared unal- tered. This is in accord with the examinations of Auspitz and Unna, who describe the lymphatics, within the indurated portion of a chan- cre, as free from any pathological changes. The opinion expressed by Cornil,that "the vascular sclerosis gives the infecting chancre one of its essential clinical characters — the induration" — is to us well sus- tained, and our examinations, all of which showed in an undoubted manner this modification of the arterial and venous systems, as described by him, incline us to accept his conclusions. It is possible, however, that the number, and position of the lymphatics of the affected part may exercise an influence upon the shape and amount of the induration, not, however, from a histological modification, but from functional properties. It would certainly seem that clinical observation and normal histology are in accord as to this point. Otis has called attention^ to a clinical fact which he says he has often observed, namely, that "indurations of the initial lesion at the frsenum and glans, posterior to the meatus, are uniformly small in extent. In the prepuce, on the contrary, where, according to the researches of Dr. Isidor Neumann, the lymphatics are much more deeply located, [' Bumstead and Taylor, 1879. ] [2 Op. cit., p. 13.] 80 SYPHILIS. we find indurations more extensive. These vessels are represented as still more deeply -seated in the base and body of the glans. These are also the known localities of occasional extensive indurations, while in the integument of the penis, where the lymphatic distribu- tion is very superficial, forming loops near the apex of each papilla cutis, we have the most common occurrence of that thin induration which is termed the parchment induration.^'''] In other regions, as the neck of the uterus, the induration is very diflficult to appreciate, because first, as previously mentioned, a lesion limited to the neck of the uterus cannot be raised between the fingers ; and, second, the fibro-muscular tissue of the neck is so rigid, that the hardness of the chancre could not be distinguished from the normal condition of the adjacent tissues. The induration of an infecting chancre is not only very variable, but, in very rare cases, it may be absent, as admitted by all who have specially studied syphilis. Vidal has recently published two cases of this kind. Therefore it is not a positive and constant symp- tom, and, I believe, that induration is a symptom less important in infecting chancre, than the characters of the erosion, and the condition of the surface of the chancre, especially if, in addition to these, we take cognizance of the several indurated, painless, and hypertrophied lymphatic glands, the so-called pleiade. The induration generally does not last longer than three or four weeks, and the chancre heals in five or six weeks ; but the indurated nodule, if it were primarily large and cartilaginous, may persist and be still recognizable after four or five years, or according to Ricord, after fifteen years. The healing of a chancre is very soon accomplished ; the loss of substance is very little, almost nothing ; it is only necessary that the papillary layer and the derm, neither of which has been destroyed, should rid themselves, either by the eliminative processes of ulcera- tion or by absorption through the medium of the lymphatics, of the migrated cells which have infiltrated the part ; the superficial epi- dermic layers then reform and become firm. As there is seldom an actual loss of substance — an ulceration — there is not found a true cicatricial tissue at the seat of the chancre, but simply a slight thickening of the skin, and a faint red or copper coloration which usually soon disappear ; the coloration may persist for several weeks or longer, although it gradually becomes less distinct. An indurated chancre may be transformed w situ, into a mucous MULTIPLE CHANCRES, 81 patch,or may even form vegetations. This change, which has been well studied by Davasse and Deville, has played an important role in the discussions relating to the inoculation of secondary lesions. Ricord regarded the mucous patches, which were the origin of the contagion, as chancres transformed into mucous patches, and believed that the contagion was in reality due to the chancrous element. These dis- cussions have to-day only a historical interest ; their value has been already considered. According to Fournier, three times in four the indurated chancre is single. In the fourth, where it is multiple, the chancres most frequently begin at the same time, and have simultaneously the same symptoms in reference to the induration, etc. The number of indu- rated chancres, which may exist at the same time, varies from three to four, but as many as nineteen have been reported by Fournier to have been present upon the genital organs of a syphilitic patient, all indurated and contemporary. Multiple infecting chancres all begin at the same time, for the primary lesion of syphilis is not auto-inoculable, and therefore it has no tendency to be reproduced alongside of the primary sore, as is the case with soft chancre. This is a very important fact in refer- ence to the course of this lesion, and will be considered a propos of the diagnosis of the two chancres. It will be seen that in obscure cases, the inoculation of the pus from the chancre upon the patient affected is one of the best means of arriving at a conclusion. If the inoculation determines a positive result, and occasions a soft chancre, it is certain the case is one of a simple chancre ; if the inoculation fails, it may be concluded that the chancre under consideration is not a soft chancre. [In our judgment, this statement is entirely too sweeping. Many authorities might be quoted to prove that the distinction thus claimed to exist between these sores is not by any means so absolute ; but we must content ourselves with calling attention to the opinion of Mr. James R. Lane,^ who, after either practising or witnessing seven thousand inoculations, writes as follows : " It is certainly not a fact that the hard sore is never inoculable on a syphilitic patient. With certain precautions it may undoubtedly be inoculated, and it Avill then produce a sore precisely similar in appearance and progress to a [' Lectures on Syphilis, p. 32. London, 1881.] 82 SYPHILIS. soft chancre,' On the other hand, the inoculability of the soft sore has been much exaggerated. It is said that it is communicable to all persons and at all times, whether they have previously been the sub- jects of syphilis or not. This, again, is not the fact, for as I repeat- edly witnessed, whenever there is any great depression of the vital powers, in tertiary syphilis, for instance, the difficulty of obtaining a positive result with any kind of matter is very great, though if the health can be made to improve the inoculations will succeed."] The appearances of an infecting chancre are varied ; it may be more or less indurated, of moderate size or very extensive, single or multiple. Thus, between an erosion or slight abrasion situated upon a base scarcely parchment-like, that may readily be overlooked, to an ulceration with a nodular cartilaginous base of considerable size, as large as a quarter of a dollar, and accompanied by great oedema of the labia majora and minora, or of the prepuce, there are found several intermediate degrees. The infecting chancre may be very small (dwarf chancre of Fournier), or it may be very large, occurring in patches resembling herpes (herpetiform chancre of Dubuc). The most frequent seat of chancres is the genital region ; they are very seldom met with upon other parts of the body ; this is especially true with men, less so in the case of women. The most usual seat of chancres of the genital organs with men is the glans penis, the internal surface of the prepuce, and especially the fossa glandis and froBnum. Three-fourths of all chancres are found in these localities. At times they are found upon the skin of the penis, at the meatus urinarius, upon the scrotum, upon the mucous membrane of the urethra, upon the groin. The existence of urethral chancres has comjDlicated the discussions between unicists and dualists. The presence of an urethral chancre explains the transmission of syphilis by men who have apparently only suffered from a simple blennorrhagia, but have actually been the subjects of chancre, which was situated within the urethra and Avhich occasioned the discharge. With women, the labia majora are the most common seat of genital chancres ; then follow the fourchette, the labia minora, the clitoris, the skin of the pubes or groin, the neck of the uterus, etc. It is doubtful if an infecting chancre has in a single instance been found upon the vagina, and yet this canal is certainly the part most [' In these cases it is inoculated after being irritated to free suppurative action, and the result is simply the effect of pus contagion. It may, however, in exceptional cases, produce a second typical hard sore.] EXTRA-GENITAL CHANCRES. 83 exposed to contagion. The cause of this immunity may possibly be found in the special structure of the vaginal mucous membrane, which is covered with thick layers of pavement epithelial cells. More proba- bly, however, the entrance of the virus is rendered difficult by the absence of glandular orifices over its entire surface ; the vaginal mu- cous membrane possessing papillae and prominent villi, but no glands. Extra-genital chancres, particularly those of the anus, are very much more common with women than with men. Yet all chancres of the anus with women do not indicate unnatural sexual relations : the anal orifice is so situated that in dorsal decubitus the fluids from the vulva flow over and often contaminate it. [Anal chancres are usually seated at the margin of the anus, at the bottom of one of the radiating folds of skin produced by the contrac- tion of the external sphincter. The ulceration is apt to follow the lines of these folds, and thus to assume an elongated or linear char- acter. They are hard, and do not give rise to the painful symptoms of fissures of the anus. They have been observed as high as the upper margin of the internal sphincter, and it is probable that in those countries where the practice of sodomy prevails, they are not in- frequent upon the walls of the rectum. Sauri-Ricardo records the case of a young woman who was infected by her husband during un- natural intercourse, and who subsequently developed dysenteric symptoms with a purulent discharge from the anus, then constitutional syphilis, and finally a stricture of the rectum.^ In France, tliey occur in the proportion of one out of every one hundred and nineteen in men, and one in every twelve in women. They are certainly much rarer in this country. Attention has been called to the fact, that when confrontation is possible, the chancre of the anus will usually be found upon the same side of the body as that on the penis of the infecting person. Of course in chancres of the genitals, the reverse is true. This may be of importance from a medico-legal point of view.] The seats of extra-genital chancres are the anus, mouth, lips, tongue, uvula, palatine arches, tonsils, cheek, nipple, etc. A cephalic chancre is almost always infecting, but it must not be supposed that the skin of the head and face is not susceptible to in- vasion by a soft chancre. It has been inoculated upon these parts as readily as elsewhere. Soft chancre is rarely or scarcely ever seen [I Jullien, p. 585.] 84 SYPHILIS. upon the lips or face, but this is probably due to the circumstance that it is more easily observed than infecting chancre, and is charac- terized by an ulcer so manifest that its presence causes more caution. Infecting chancre, when occurring upon the skin, is covered by a scab; when partly upon the skin and moist raucous surface, as the lips, that portion upon the skin is covered by a scab, while that upon the mucous membrane presents the yellowish-gray false membrane pre- viously described. The infecting chancre is rare in the Lourcine Hospital. During the two and a half years that I have served in this hospital, I have seen only twenty indurated chancres ; on account of its rarity many of my colleagues who have preceded me, as Cusco and Lancereaux, think that the chancre is not a necessary lesion of syphilis. Fournier, however, maintains the contrary, and reason and logic compel us to the conclusion that the syphilis of women does not differ from that of men, and that, as with men, there is invariably observed a chancre at the onset of the disease, a similar occurrence takes place with women, even although in certain cases, the chancre escapes notice. Symptoms of Soft Chancre [Chaxcroid]. — The symptoms of soft chancre will be briefly described. The details which have been given a propos of its anatomy need not be repeated. After having begun by a redness and a pustule or vesicle, or even by a small bulla which soon ruptures, it presents a crater-like and suppurating ulceration. This ulcer is painful and itching ; the pus, which is secreted in large amount, is inoculable upon the patient himself, and auto-inoculation is always successful during the course of the chancroid. [This can hardly be accepted literally. Failures are by no means uncommon.] The patient frequently inoculates himself inadvertently or from uncleanliness, so that the simple chancre is often multiple. During the stage of acme, the chancroid has its margins loosened and undermined ; the neighboring tissue is inflamed and doughy, and attacked with an oedematous inflammation, with redness of the skin but without any induration comparable to that of the infecting chancre. When the lymphatic glands are affected, there may occur a true suppurating bubo, if the patient be broken down in health, or, if he has been negligent of treatment. In this case, an inguinal gland is swollen and becomes very large ; the skin reddens upon its surface, and we soon feel a superficial fluctuation, due to pus formed in the cellulo-adipose tissue surrounding the gland. When this abscess is FREQUENCY OF CHANCRE AND CHANCROID. 85 opened, the gland in some cases suppurates, and there is formed an anfractuous cavity which secretes the sanious pus characteristic of simple chancre ; the skin constituting its borders is red, inflamed, and separated from the tissue beneath. These glandular abscesses, like the chancroid, sometimes become phagedenic. This is a formidable complication which occurs almost exclusively in soft chancre. It lasts a long time, occasions a loss of substance, destroys the tissues, and may even terminate fatally, if gangrene is very extensive. Chancroid is variable in its duration, which is sometimes very short, especially if it has had careful treatment, lasting three, four, or five weeks ; at other times it continues several months, and sometimes, if it is phagedenic, one or more years. The chancroid, when healing, presents fleshy granulations, which grow from the bottom of the ulceration, reaching to the surface of the healthy skin, where they are soon covered by the epidermis. If the ulcer has been deep and extensive, a cicatricial tissue forms, Avhich remains hard for some time, and which replaces the derm that has been destroyed. The place where the chancroid was situated is marked by a hard cicatrix, white upon the surface, irregular, and a little elevated or depressed relatively to the surrounding skin. Relative Frequency op Infecting Chancre and Simple Chancre. — According to the statistics of the Hopital du Midi, the soft chancre is seen much more seldom at the present time than it was some .years ago. Thus, Puche, whose statistics were based upon the immense number of ten thousand chancres, found one indurated chancre to four simple chancres. Fournier and Cullerier (statistics of the Hopital du Midi) give nearly an equal number of the two chancres. Clerc (statistics of Saint-Lazare) and Labarthe (from the cases of Simonnet), have found one indurated chancre to two soft chancres. The most recent analysis of cases by my friend and colleague Mauriac, of the Hopital du Midi, has given him the opposite result, and it appears determined, according to him, that the soft chancre has decreased in frequency and tends to disappear. But the frequency of soft chancre varies very much in the diff'erent social conditions. For example, it is much more frequent than the infecting chancre among the old and depraved prostitutes, from the fact that these women have generally, some time previously, had a syphilitic chancre, and as they are syphilitic, they are not liable to a new infection of 86 SYPHILIS. the primary lesion, while they may be indefinitely affected with the soft chancre. This lesion is also very frequently met with in the army, for the reason that soldiers generally are infected by the above class of women. Thus, according to the last statistics of the army in 1875, among 1000 soldiers who entered the hospital, there Avere 11 cases of soft chancre and 22 of syphilis ; among 1000 who were admitted into the infirmary, there were 17 cases of soft chancre, 16 of syphilis, and 127 of urethritis. About two-thirds of those affected enter these institutions ; therefore, if all who were attacked were admitted, it would give us 21 soft chancres and 28 infecting chancres among 1000 men. A proportion certainly very much below that of the syphilitic patients met with among the young rich and laboring classes of large cities. Mixed Chancre. — There is a variety of chancre which is con- sidered as possessing at the same time both the nature of an infecting chancre and that of a simple chancre. It has been observed that a certain number of syphilitic infecting chancres, perhaps two or three in a hundred, may be inoculated upon the patient affected, and that the result of this inoculation is a soft chancre. Again, Rollet and Laroyenne, of Lyons, have observed that by placing the pus of a soft chancre upon an infecting chancre, there results a special chancrous ulcer, the mixed chancre which Rollet considers a distinct variety. It is certain that a person affected with a mixed chancre communicates to a healthy person a similar lesion, that is, a chancre both infecting and ulcerating. These chancres have at the same time the characters of an infecting and simple chancre ; the ulceration occurs very rapidly, and with the characters of a simple chancre; then from the fifteenth day to the third week, that is, after the long period of incubation of a syphilitic chancre, the base, until then soft, becomes indurated, the lymphatic glands become hard, and the secondary eruptions occur in the regular order of syphilis. I believe that the mixed chancre should be considered simply as two lesions developed at the same time upon the same patient, the result of the union of two viruses, A mixed chancre is not ahvays due to the contagion of a mixed chancre. Ricordi, Maziotti, and others, cite^ cases of mixed chancre 1 Traite Pratique des Maladies Veneriennes, de M. L. JuUien. SPECIFIC NATURE OF CHANCROID. 87 contracted by patients who had connection with women suffering at the same time with soft chancres and mucous patches. Fre- quently a person already affected with an indurated chancre, has con- nection with another person affected with a soft chancre, and grafts a soft upon a hard chancre. The contrary occurs very seldom, that is, the grafting of syphilitic chancre upon a soft chancre, owing to the abundant suppuration and pain of the soft chancre. Finally, mucous patches, upon which the pus of a soft chancre has been deposited during connection, may ulcerate and present all the characters of a simple ulcerating chancre or mixed chancre. Vaecino-sypJiilitic mixed chancre is caused by the inoculation of vaccine virus contaminated with syphilitic virus ; it runs the same course as the preceding, the vaccine pustule appearing first and de- veloping normally, then fifteen or twenty days after the inoculation, the indurated papule of sj^philitic chancre showing itself. [There are many syphilographers who believe that the chancroid is a form of the initial lesion of syphilis, and that it is not followed by constitutional symptoms in the majority of cases, because the sup- purative action which accompanies it favors the elimination of the poison. Others deny its specificity in toto, and attribute it to the contagion of pus, which may or may not contain, as an accident, the germs of syphilis, the ulcerative process in such cases overshadowing or altogether preventing the new cell-growth which gives to the true chancre its clinical peculiarities. Still others, and probably the majority, believe with the author, that the chancroid is a distinct disease depending for its transmission and development upon the existence of a virus Avhich, under proper circumstances, produces the chancroid and nothing else, just as the poisons of smallpox and glan- ders produce only, and invariably, those affections. In other words, they believe it to be a ^'- specific'^ disease. Some of the arguments which are employed by those who deny specific character to the chancroid are as follows : — 1. The chancroid has no period of incubation, the pustule or ulcer appearing within a few hours of inoculation, or after about the interval Avhich would be required for the manifestation of the irritant proper- ties of any foreign body inserted beneath the skin. In no other specific disease is incubation entirely absent, though it may vary from three days in scarlatina, or twenty-five days in syphilis, to two years in hydrophobia. 2. The occurrence of chancroidal disease in any individual affords OS SYPHILIS. no protection against a second attack, as is almost invariably the case in the specific diseases. If it be urged in answer to these objections, that the chancroid as a local, contagious, specific disease is not strictly comparable with the exanthemata and those ailments which affect the system at large, it should be remembered that in that event it would be neces- sary to regard it as an isolated disease constituting a distinct class, and without congeners, a possible but improbable condition. 3. Sores in all respects resembling chancroids, have been produced •on different parts of the body by inoculation with the contents of acne pustules. 4. All rapidly forming ulcers tend to assume the appearance said to be characteristic of the chancroid. This is especially the case in the tissue of the glans penis, which by reason of the thinness of its fibrous envelope, the delicacy of its trabeculne, and the spaces necessi- tated for purposes of erection, breaks down easily under the ulcera- tive process. The direction of the connective tissue fibres composing the trabecule, and along which tissue all inflammation extends most readily, explains the undermined appearance of the edges of the sore, its other characteristics being simply those of active suppuration. 5. Extra-genital chancroids are very rare, and chancroids upon the skin of the penis are much less common than those upon the glans ; nineteen-twentieths occurring in the latter situation ; they are also very rarely found in the vagina;^ yet all these parts are exposed with great frequency to contagion from chancroidal sores. This seems a sufficient answer to the assertion that if chancroids were due to pus contagion they would be much more commonly found upon the fingers of surgeons, etc. 6. Ulcers found upon the glans penis after the relief of a phimosis complicated with balanitis are often instances of the truth of the above statement, being usually indistinguishable from chancroid. 7. Many competent observers are of the opinion that they have seen syphilis follow a sore having all the characteristics of the chan- croid from its appearance to its cicatrization. This is said to be especially the case in chancroids at the base of the penis. The testimony in this respect is too clear and direct, and the ability • Cornil calls attention (p. 82) to this point in speaking of the absence of in- fecting chancre from the same region, and adds yet " this canal is certainly the part most exposed to contagion." SPECIFIC NATURE OF CHANCROID. 89 of the witnesses too far above question to permit of reasonable doubt that this is a clinical fact. To say that in such cases, especially when they occur in men, a chancre has existed, but has been overlooked, is to impugn the accu- racy or the diagnostic powers of some of the most careful and most distinguished syphilographers of the day. When it is admitted that these cases are occasionally seen, they are variously explained. Those who believe that the chancroid is a sore produced by the virus of syphilis, assert that its appearance and general harmlessness are due, as has been said, to the accompanying suppuration, the elimina- tive action of which protects the constitution. They appeal to analogy in support of this position, citing the well-known differences in reaction to irritants in different constitutions ; the bullet which becomes en- cysted in one individual, remaining harmless in another, etc. etc. Their opponents, the dualists, claim that these cases are instances of what they call the " mixed sore," by which they mean that the two poisons, the chancroidal and the syphilitic, have been implanted simultaneously, and run independently of each other their respective courses. The objections to this latter view are, that it is entirely hypothetical, that it involves a belief in the frequency of an accident which from its very nature would be an exceedingly rare one, and that such a pro- cess, pathologically considered, is without parallel. When vaccino-syphilis is adduced as an example of the implantation of two poisons at the same time, it is replied, that in all the recorded cases the vaccine pustule has run its usual course, developed, matured, and desiccated, and that then the chancre has appeared, after its usual period of incubation, and with all its ordinary characteristics. 8. Confrontation, Avhicli undoubtedly shows that in the majority of cases the hard sore is derived from the hard sore, and the chancroid from the chancroid, is no more an argument for dualism than for the form of unicisra which recognizing only one specific poison, the syphil- itic, attributes the production of the soft sore to pus contagion. If the chancroid depends on the irritating eft'ect of pus, you would of course expect to find a suppurating sore in the individual from whom the disease was derived. On the other hand, every surgeon of experience must have met with some exceptions to the general rule : must have seen for exam- ple cases in which chancroidal sores resulted from intercourse with persons having the primary or secondary lesions of syphilis, particu- 90 SYPHILIS. larly wlien they were suppurating freely, or were acquired, in rare cases, from women in whom no lesion of either sort was discoverable, but simply a purulent vaginitis or endometritis. These cases are diffi- cult to explain on the dualistic theory, except by supposing that they are instances of mistaken diagnosis. On the theory of pus contagion of course their significance is evident. 9. Repeated inoculations from the chancroitl show progressive en- feeblement of the power of inoculation. This is not observed in the specific diseases : vaccine lymph may be handed almost indefinitely from individual to individual, losing little or nothing of its protective power. It is observed, however, in inoculation from ordinary pustules, and was remarked many times during the experiments on "syphilization" made in various countries. 10. Inoculation with the secretion of a hard sore, wliicli has been irritated so as to secrete 2}us, will produce a sore in no wise distin- guishable from the chancroid (Clerc's chancroid), and reinoculable through a lengthened series in the same way. It can hardly be claimed that the chancroidal "virus" has been generated by this irritation, and yet if some chancroids originate in this way, by pus contagion, why not all chancroids ? 11. Phagedsena supervening upon a syphilitic sore, has been experi- mentally shown^ to be transmissible by inoculation, and seems in such cases to have superseded the syphilis which did not manifest itself. We have recently recorded two cases of this character.^ This would appear to be an example of intensely irritant and destructive pro- perties accidentally acquired by pus, and of which the chancroid is only a milder manifestation. On the other hand, it is said that: — 1st. The chancroid is always the result of abrasion or inoculation of the secretion of a chancroid, and has a distinct individuality dif- ering from other forms of ulceration. 2d. That the bubo accompanying one out of every three cases of chancroid, is peculiar and characteristic. 3d. That if inflammatory products can produce chancroids, the latter would be much more frequent on the hands of surgeons, nurses, and others who are exposed to daily contact with pus. 4th. That, admitting the existence of specific characteristics in the ' Lectures on Syphilis. — Lane. 2 Apparent protection from syphilis afforded by phagedcena, Medical News, Feb. 25, 1882. DIAGNOSIS OF CHANCRE. 91 sore, some cori'esponding quality must be conceded to the pus, and that — 5th. To suppose that this is every now and then generated de novo, is to claim that the operation of the laws of nature and disease may now and then be arrested or upset. 6th. That chancroids are never followed by syphilis, and that in those instances in which it has been thought that this was the case, the sore was of the mixed variety, or an infecting chancre has existed and had been overlooked, or the diagnosis was wrong, the peculiar characteristics of the infecting sore not having been recognized. 7th. That the successful treatment of the chancroid requires the employment of some painful cauterant to arrest the spread of the ulceration, which it does by destroying the virus. We are of course aware that this is by no means an exhaustive statement of the opposing views held on this subject, but have thought it proper to call attention to these differences of opinion. We do not presume, however, to decide a question upon which so many emi- nent authorities differ. It is chiefly important in its relation to prog- nosis, as regards which it is proper to say that the effect of an implicit reliance on the dualistic theory will often be found productive of error. " It is unsafe to predict confidently that any venereal ulcer, even a soft sore attended with suppurating bubo, will entail no further con- sequences. There is a strong probability that an indurated sore will prove infecting: and there is a probability, though not nearly so strong, that a soft suppurating sore will not, but exceptions to both these general rules will be met with, and there is really no absolute proof of the infecting nature of any given sore, but the fact of infec- tion itself."'] Diagnosis of Chancre, — Infecting chancre should be distin- guished from simple chancre. This diagnosis, usually not difficult, is determined by the characters that have been described. The onset, the period of incubation, and the general appearance, are different. The infecting chancre is painless and almost constantly indurated, it is generally single, and is accompanied by induration of several inguinal glands. Soft chancre is often multiple, is pain- ful, and is complicated with suppurating bubo. ' Lectures on Syphilis. — Jas. S. Lane, London, 1881, p. 23. 92 SYPHILIS. Among the other lesions which may be confounded with infecting chancre is herpes, which it is difficult at times to diagnose both with men and women, as it is frequently confluent, forming numerous groups invading the entire vulva, and often occasions an oedematous swelling of the labia majora and minora. Herpes, however, is more liable to be mistaken for mucous patches than for chancre, although some multiple chancres very closely resemble this aff'ection (Dubuc) ; but these chancres are generally indurated. Again, herpes is at first vesicular, occurs in groups, which are regularly arranged, and when ulcerated, still keep the same arrangement. Finally, herpes, is attended with itching, heals in less than a week with simple lotions, and does not occasion adenitis. The difficulty sometimes experienced in distinguishing a mucous patch, with raised and hard base and ulcerated surface, from a chancre, will be considered more fully after the former lesion has been studied. At times there are seen tertiary syphilides of the glans or vulva, with a hard tuberculous or gummous base, and an ulcerated surface, and it is often very difficult, almost impossible, to diff'erentiate them from the initial chancre. If it should be determined that the patient is already syphilitic, we must distinguish between a return of an in- durated chancre, and a late syphilide. Here, it is to be apprehended, that doctrinal prejudices are liable to influence opinion. Pathologists who believe that syphilis once contracted remains during life, can scarcely admit the extinction of the virus, Avhich is proved by a return of an infecting chancre. Again, on the other side, the anatomical and clinical characters of indurated chancres compared with a papulo- tubercular tertiary ulcer are the same, so that, at the present time, from our knowledge of the disease, most writers on this subject con- sider these supposed returns of chancres as tertiary syphilides. The possibility of the development of a simple furuncle upon the mons veneris, penis, or glans, is not to be forgotten. These small furuncles probably arise from some local irritation and pursue the same course as elsewhere. They are situated upon a hard base, and consist of slight elevations, the summit of which soon becomes whitish as suppuration takes place. There are also oedemas of the prepuce or vulva, following coitus or labor. These are readily recognized, but sometimes they are accompanied by an abscess of the prepuce, or quite frequently in women by an abscess of the vulvo-vaginal gland. An abscess of this DIAGNOSIS OF CHANCRE. 93 gland may also be complicated by an indurated or a soft chancre upon its suppurating surface. This, however, is very rare, but its possibility should be remembered when such abscesses refuse for a long time to cicatrize. Ulcers due to arsenic and copper, also epitheliomatous and ele- phantiatic ulcers, should not be forgotten when making a diagnosis. [ The diagnosis of chancre is a matter of such great practical im- portance, that it may be well, even at the risk of repetition, to enter into it somewhat fully. In doing so we shall follow closely the paper of Ch. Mauriac, which is the best resume of this subject with which we are acquainted : — 1. In dealing with lesions apparently non-venereal in their origin and character^ we should consider carefully the following points : — a. The anatomical situation and the course of the lesion. Among those particularly to be viewed with suspicion may be mentioned herpetiform erosions of the lips, papules on the tip of the tongue, squamous or " scabby" ulcerations of the skin, scratches which obsti- nately refuse to heal, chronic inflammations at the tip of the fingers resembling felons, etc. h. Indolence, absence of suppurative tendencies and persistence in spite of treatment, are negative signs which should lead us to believe that any cutaneous or mucous lesion is not of a simple nature. c. If the morbid products are slight, rather serous than purulent, tend to form into crusts, or to assume a pseudo-membranous form upon an eroded surface, syphilis should be suspected. d. The consistence of the base upon which the lesion is situated is one of the most important diagnostic points, and should always be carefully investigated. If, upon palpation, instead of the usual in- flammatory swelling and thickening, shading off into the surrounding tissue, we meet with a cartilaginous, elastic, sharply circumscribed resistance, we may immediately suspect very strongly that we are dealing with a syphilitic growth, although even this symptom cannot be considered as infallible. e. If the lymphatics of the groin become slightly swollen and pain- ful and progress no further, or if these symptoms occurring in a single gland subside spontaneously, it is probable that they are due to a sympathetic adenitis, such as follows many irritations of the skin or mucous membrane. If, on the contrary, they steadily augment in size and hardness, are almost painless, and constitute a chain of little tumors including several or all the inguinal glands, it may be con- 94 SYPHILIS. sidered strong presumptive evidence of specific disease, though even yet not conclusive. In addition to these points, the history of the case must carefully be inquired into — the probabilities of infection, in regard to which we should not be misled by the beliefs of the patient, and the period of incubation — which, when it can clearly be established, is of great value. Confrontation will often, not invariably, decide the matter, but, in this country at least, is rarely obtainable. Difficulties of diagnosis are greatest during the first week or ten days, and steadily diminish with the age of the lesion, which, if syphilitic, is almost certain to assume in time definite character. The chief points among those mentioned are the period of incubation, the presence or absence of induration, and the condition of the nearest lymphatic glands. If, however, all of these seem to point to syphilis, the experienced observer will still refrain from giving a positive opinion, no symptom or group of symptoms being absolutely conclu- sive as to the specific character of any given primary lesion, cer- tainty only being attained by the development of some of those general or constitutional phenomena which in from six to eight weeks follow the infecting chancre. 2. The region occupied by a cliancre may cause errors or diffi- culties in diagnosis. a. In the cephalic region, chancres of the hairy scalp, of the supra- orbital prominences, and of the chin and cheeks are the most decep- tive. They always assume an ecthymatous form, and are so con- cealed by the hair on the head that it is impossible to judge of the character of their surface. In all such cases the hair must be carefully shaved, and if we then find that we are dealing with an ulceration, lacking the ordinary characteristics of ecthyma, and glazed, flat, or even elevated, our suspicions should be aroused, and after eight or ten days Avill usually be confirmed, if the sore is chancrous, by the development of induration and of neighboring lymphatic enlargement. Razor-cuts on the chin, cheeks, or lips, which, after having healed, re-open and become covered with a crust, should on d priori grounds be suspected. This is equally true of pseudo-furuncles, acneiform pustules, cracks around the circumference of the nostrils, etc., which persist without giving rise to pain, and become bloody, incrusted, and surrounded by an area of subinflammatory, oederaatous swelling. We should then carefully examine each day the preauricular, paro- tidean and submaxillary lymphatic glands. DIAGNOSIS OF CHANCRE. 95 A stye which behaves in an unaccustomed manner or is accom- panied by hyperplasia of the lid, or a conjunctivitis which becomes localized and causes an isolated swelling, should be attentively watched. In the neighborhood of the mouth, errors of diamosis should be less frequent than in other portions of the cephalic region, because it has been shown so extremely often that the lips, tongue, and fauces are frequently brought in contact with syphilitic discharges and con- stitute one of the principal channels of infection. Here, however, as elsewhere, the chancre assumes at the very outset the appearance of ordinary lesions. Thus, upon the lips, the chap, crack, or fissure often found in the median line, the little aphthous erosions, herpetic ulcerations, and cigar or cigarette burns, simulate very closely the characters of the initial lesion, and, as the latter will almost invari- ably be attributed by patients to some such ordinary cause, may give rise to serious error. At the end of the first week, however, the specific characters of labial chancre are usually so distinct as to render diagnosis easy. In several instances, two of which have come under our own obser- vation, these chancres have been mistaken for epithelioma and have been excised. The diagnostic differences may be indicated as fol- lows : — Labial Chancre. Epithelioma. No marked difFerences between the Twenty times more common in males sexes. than in females. The nicer may involve either lip. Almost invariably situated npon the lower lip. Occnrs at any age. Rarely occurs before middle life. Patient often strong and robust. Patient usually in impaired health. Is insensitive. Sharp, burning, lancinating pains. ReguLar in outline, smooth surface. Irregular in outline, ragged, filled with elevated. fungous granulations, bleeding easily. Indurated and sharplij circumftcrlheJ base. Induration less cartilaginous, unequal, not clearly circumscribed, and more extensive. Evolution of sore usually occupies a few Sore may be many months in develop- weeks at the most. ing after its first appearance. Glandular involvement follows closely Glands are not implicated for three or on appearance of sore. four months, often not until later. No marked odor from secretion of sore. Odor often extremely offensive. History of exposure to syphilitic inocu- Frequently no such history. lation often obtainable. Heals rapidly, or disappears under Not affected or rendered worse by such mercurial treatment. treatment. 96 SYPHILIS. While there is a possibility of error in diagnosis between a chancre and an epitheliomatous ulcer when a macroscopical examination alone is made, there is, on the contrary, no such apprehension when a micro- scopical examination of the lesions is instituted. The histological structure and arrangement are so very distinct and unlike in these lesions that a mistake cannot well occur. In the epithelioma we have the ingrowing of the interpapillary layers of epithelial cells, the branching or budding outgrowths from the sebaceous glands, Avhich constitute the very characteristic epitheliomatous pegs, and the forma- tion of the cell-nests or pearls upon ihese pegs, which are all so strikingly different, when contrasted with the histological composition of a chancre, that no doubt as to diagnosis remains. Upon the sides of the tongue ulcerations, produced by the continual contact of that organ with rough and carious teeth, have been mis- taken for chancres. This error should be guarded against, but is not so serious in its results as the failure to recognize the peculiar lesion when it is situated at the point of the tongue, the possibility of its communication to innocent people being, in such cases, an element of unusual importance. In the first five or six days it is impossible to diagnose it, but if the original little inflamed papule enlarges and extends, becoming elevated above the surrounding parts, if its epi- thelial covering drops off, and its surface becomes diphtheritic ; if superficial cauterization with crayons of nitrate of silver, which so rapidly cure the common small painful papule of the tongue, have no effect upon it, there is a strong presumption that it is a chancre. This will be confirmed later by the appearance of submaxillary glandular enlargement and induration of the sore. In the sloughing, phagedenic form (of which Mauriac has seen one case), it could hardly be confounded with cancer, certainly with nothing else except the later syphilides, and these will be considered later. Of all the chancres of the cephalic region, however, that of the tonsils, or the isthmus of the fauces, presents the greatest diagnostic diflBculties, on account of the effacement of its characteristics by the surrounding inflammation. If in a case of prolonged sore throat there be an appearance resembling a single mucous patch, and if there be no history of ante- cedent syphilitic poisoning, it becomes probable that the trouble is chancrous, and this probability is greatly increased if any induration can be felt by palpation with one finger in the pharynx and another DIAGNOSIS OF CHANCRE. 97 external to its walls ; if enlargement of the glands above the angle of the jaw occurs ; or, of course, if the patient confesses to having been peculiarly exposed to contamination. The sore is much more common in this region in females than in males, Mackenzie noting the fact that out of seven cases of primary syphilide of the tonsils which he had met with, six were women. h. Superior and inferior extremities. Chancres of the hands are often seated at the margin of the nail, and closely resemble simple whitlows. They may be diagnosed by their long duration, their abrupt limitation, the hardness of the tissues around and beneath them, and the consecutive engorgement of the epitrochlear ganglion. Upon the doi'sal face of the phalanges the initial lesion at first simulates an inflamed papule or a boil, but is less painful, discharges no " core," and is elevated, not excavated. The anterior face of the forearm in both sexes, the anterior surface of the thigh in men, and the posterior surface in women, are the parts most exposed to contagion. The chancre of vaccino-syphilis occurs after the evolution of the vaccine sore. It can only be confounded with the ulcerations described by Blot under the name of " vaccinal phagedenism" which are rounded Avith abrupt borders and indurated bases, and are often accompanied with engorgement of the axillary lymphatic glands. The diagnosis from appearances is difficult, but may be made by noticing the fact that these sores run an acute course, and are readily cured by poultices or emollient applications, which, of course, have no effect on chancre. c. Upon the trunk the mammary and hypogastric regions are those most frequently involved. In the former locality the initial lesion is most likely to be mistaken for eczematous excoriations, fissures, and small furuncular or papillary tumors. The diagnosis rests upon the presence of the characteristic induration, elevation, etc., and upon the poly-ganglionic axillary enlargement. In cases where syphilis has been transmitted during suckling, confrontation is almost invariably possible, and furnishes the most satisfactory guide. Chancres of the hypogastrium are generally large and ulcerating, and are most liable to be mistaken for chancroids. d. Genital organs. The diagnosis of sores situated in this locality, is chiefly between chancre, chancroid, and herpetic ulceration. The diagnostic table given below expresses the main points of difference. 7 98 SYPHILIS. I>'iTiAL Lesion of Syphilis. Local Venekeal Ulcek. Origin — Due to contagion from a chancre, a syphilitic lesion, or Wood, or pus from a person having syphilis. Incubation — Not less than ten days ; often three weeks ; very rarely six to eight weeks. Sittialion — Most frequent upon the genitals. Often seen on the hands, nipples, lips, etc. Commencement — Begins as an erosion, papule, tubercle, or ul- cer. May remain with- out ulceration through its entire course. Numhei- — Single or simultaneous- ly multiple ; occasional- ly but rarely succes- sively multiple. Shape — Round, oval, or symme- trically irregular. Depth — Usually superficial — cup-shaped or saucer- shaped — or may be ele- vated. Surface — Smooth, shining, red, glazed ; diphtheritic membrane or scab. Usually due to contact with pus from a similar sore, or to accidental inoculation of the secre- tion of a chancre upon a person already affected with syphilis ; more rarely to the irritation of pus from other sources. None. Almost always upon the glans penis or prepuce ; rare upon other portions of the genitals ; scarcely ever seen elsewhere. Begins as a pustule or ulcer. Often multiple, frequently by auto-inoculatioD. Herpetic Ulceeatiox. Mechanical irritation; fric- tion, as in sexual inter- course ; chemical irrita- tion, as of acrid dis- charges ; uncleanliness. Occasionally follows cold or fever ; may be a neurosis. None. Glans penis and inner layer of prepuce. Begins as a group of vesi- cles, which may coalesce or may ulcerate singly. Multiple, apt to be con- fluent. Round, oval, or unsym- metrically irregular with border described by seg- ments of large circles. Hollow, excavated, or " punched out." Rough, uneven, "worm- eaten," warty, whitish- grayish, pultaceous. Irregular, edges serrated or described by seg- ments of small circles. Superficial. Same as local ulcer, but more superficial. DIAGNOSIS OF CHANCRE, 99 Abundant, purulent. Readily auto-inoculated. Initial Lesiox of Syphilis. Local Venereal Ulcer. Secretion — Scanty, serous, auto-in- oculable with great diffi- culty, producing either a chancroidal sore or in rare cases a second sore like the first. Induration — Almost always present ; firm, cartilaginous, or parchment-like ; cir- cumscribed, terminat- ing abruptly ; movable iipon subjacent parts ; skin not adherent ; usu- ally persistent : disap- pears under specific treatment. Sensihiliti] — Very little or no pain. Course — Usually regularly pro- gressive towards healtVi, the sore often healing spontaneously. Phage- dena uncommon. Sec- ond attack also very rare. Only exceptionally pre- sent, may be caused by caustics or other irri- tants, or by simple in- flammation ; boggy, in- elastic, shades off into surrounding parts to which it is adherent ; disappears soon after cicatrization. Painful. Irregular, may cicatrize rapidly or may extend, taking on phagedenic action. No protection against a second attack. Herpetic Ulceration. Moderate secretion, auto- inoculated with diffi- culty. Same as local ulcer. Histology — A new cell-growth. Very little destruction of tissue. Bubo— Constant, painless, mul- tiple. Prognosis — Good locally ; constitu- tional syphilis will fol- low in the great majo- rity of cases, but in a few may not appear, or may be prevented by treatment. Treatment — Excision when seen early, other local treat- ment ineffective. An ulceration with more or less loss of sub- stance. In one-third of the cases ; painful, inflammatory, single. More serious locally on ac- count of loss of tissue ; occasional refusal to heal and possibility of phagedena. Very rarely is followed by syphilis. Painful. May spread in exceptional cases, by the appear- ance of successive crops of vesicles. Usually heals promptly under mild local treatment. Likely to recur, espe- cially in uncleanly pa- tients with long fore- skins. Originally an elevation of the epidermis in sj^ots by an eff'usion of serum. Rare. When it does occur painful, single, inflam- matory. » Always good if the diagno- sis be absolute. Should be guarded when there is the least doubt as to the herpetic cliaracter of the aifection. Local treatment curative. Local. 100 SYPHILIS. Chancres of the meatus are more often syphilitic than simple in their character. In the former case, they are attended with little or no ulceration, are confined to one lip of the meatus, are accompanied by the usual induration and glandular involvement, and are often, indeed usually, not discovered by the patient, who imagines he has a gonorrhoea. Chancroid of the meatus is irregular in shape, ulce- rated, involves both lips, is painful, and does not have the character- istic induration. The diagnosis between infecting urethral chancre and gonorrhoea may be tabulated as follows : — Infecting Urethral Chancre. Gonorrhcea. Incubation almost invariably more than Incubation almost invariably under ten ten days. days, or more properly absent alto- gether. Always occupies the meatus, certainly Beginning at or near the meatus soon never posterior to the fossa navicu- extends backward, involving the laris. deeper region of the urethra. One lip of meatus, red, swollen, everted. Both lips of meatus affected. Induration characteristic. (Edema or ordinary inflammatory hard- ness. Discharge slight, serous, or sero-san- Discharge abundant, purulent, or muco- guinolent. purulent. Ardor urinse if present, only felt at ex- Felt for some distance back. treme orifice of urethra. Chordee and vesical symptoms absent. Usually present in a greater or less de- gree. Uninfluenced by anti-blennorrhagics and injections ; rapidly disappeai's under mercurial treatment. The reverse is true. The small hard tumors which occasionally appear or may be felt along the under surface of the penis during an attack of gonorrhoea, and which are due to inflammation and enlargement of the follicles, should not be confused with chancre. They usually feel like grains of sand or small peas directly beneath the skin, are situated behind the fossa navicularis, have no characteristic induration, and subside spontaneously or go on to suppuration. When phimosis exists, the diagnosis between sub-preputial chancres and chancroidal, herpetic, or balanitic ulcerations is often one of gi'eat difficulty. It should be founded on the following considerations : — PROGNOSIS OF CHANCRE. 101 Sl'b-preputial Chancre. The incubation is that of chancres, ten to twenty-one days — or more. If the site of the original trouble can be felt or can be described by the patient, it will be found to be single. Inflammatory phenomena comparatively slight. Swelling, hard, dry, indurated charac- teristically. The discharge from the preputial orifice is moderate, thin, serous or bloody, not readily inoculable. The margins of the preputial orifice are not markedly inflamed or ulcerated. At some point the induration can proba- bly be isolated from the surrounding tissues, and raised and felt between the thumb and finger. Syphilitic buboes are invariably pre- sent. SCJB-PREPUTIAL ULCERATION (nOT Sypuilitic). The interval between the exposure and the subsequent ulceration, swelling, etc., is much shorter. Several points of ulceration, abrasion, or pustulation, will usually be found or described. Inflammatory phenomena, heat, pain, redness, swelling, very marked. Swelling oedematous, sero-purulent, like that of phlegmonous erysipelas. Discharge profuse, jjurulent, usually very irritating, and apt to be inocu- lable both accidentally and experi- mentally. Almost invariably ulcerated. Tliis is usually not possible, no distinct dividins: line existins. Buboes, if present at all, are of an in- flammatory character. The diagnosis between a new indurated chancre and an ulceration occupying the site of an old chancre, the induration of which has never entirely disappeared — " relapsing chancre" — is extremely diffi- cult, and unless a clear history of the case can be obtained, is impos- sible. The latter cases are often reported as instances of a second syphi- litic infection. The opinion must be based upon the presence or absence of a syphilitic history and the circumstances of the exposure, incubation, etc. The possible effect of local irritation on an old indurated mass, should always be taken into account. The jorognosis of syphilitic chancre considered as a local affection depends chiefly upon the seat of the lesion. A chancre of the con- junctiva may give rise to a grave ophthalmia ; a chancre of the tongue or of the fauces may, through interference with mastication, deglutition, and digestion, cause great general debility. As regards the genital organs, however, the prognosis is almost uniformly favorable. Phagedenic or gangrenous processes are rare, ulceration even is usually very slight, or, if seemingly extensive, is apt to be at the expense of the neoplasm and not of the normal tissues. 102 SYPHILIS. The relation between the constitutional disease of which the chan- cre is the precursor, and the sore itself is a question of great interest. It may be at once acknowledged, however, that our information upon this point is deficient. We are able neither to predict the form of local lesion from the character of the source of infection, nor, on the other hand, can we, with any accuracy, forecast the constitutional condition which will result from any given sore. The varieties of the chancre in form, extent, etc., depend more upon local causes or upon the idiosyncrasies of the patient, than upon any special source or peculiarity of the virus. Every syphilographer of experience, has seen the most widely differing forms of initial lesion derived from the same individual. Mauriac mentions a case in point : — Two men contracted syphilis from the same woman. In one, after an incubation of a month, a large, markedly indurated chancre ap- peared, and persisted for six weeks ; the other, at the end of five weeks, had a very small, scarcely indurated chancrous erosion which disappeared in two weeks. The same diversity exists in the forms of constitutional disease arising from a given focus of infection. It is probably safe to say, that a rapidly ulcerating and unusually extensive or obstinate chancre, indicates a grave form of early syphi- lis, but as the first secondary symptoms and the chancre are nearly contemporaneous, their apparent relation may be simply the effect upon them both of a general constitutional condition. The amount of glandular implication is also an entirely unreliable guide, and presents all sorts of variable phenomena. It may be said in conclusion of this question of prognosis, that while "primary syphilis permits us to anticipate to a certain lim- ited extent the character of the early secondary developments, it fur- nishes no reliable basis for opinion as to the visceral and other affections of the later periods."] Treatment of Chancre. — The treatment of indurated chancre is very simple; it tends naturally to recovery, as a local lesion. There is but little to be done except to apply suitable lotions or ointments, or to isolate the sore by means of charpie. Should extirpation of the chancre be performed? The statistics given by Auspitz and Unna are very favorable, as has been shown in Chapter I. ; they give the hope that the entire removal of a chancre, at its beginning, will pre- TREATMENT OF CHANCRE. 103 vent syphilitic infection. Therefore, the operation may be undertaken, if the chancre is situated in an accessible region, and one which will admit of interference ; for example, the labia, or the free portion of the prepuce. The question whether anti-syphilitic treatment should be immedi- ately begun when the presence of an indurated chancre is recognized, has been answered diflferently by different writers. Several authors, and particularly Diday, do not give mercury during the course of the chancre, waiting until the secondary symptoms make their appearance before instituting mercurial medication. It appears certain that mercurial treatment during the period of acme of chancre does not stop the evolution of syphilis nor prevent secondary symptoms ; yet the regular administration of mercury dur- ing the period of the chancre, or after its cicatrization, may retard the appearance of these symptoms. Since these eruptions occur, as they do, at the end of the second month from the first appearance of the chancre, or in three or five months even when mercury has been ad- ministered, it seems to many physicians unimportant. Some prefer not to give mercury, permitting the disease to take a natural course. In the hospital of Loui'cine, when the women are admitted with a chan- cre, it has generally begun to cicatrize ; they almost always present secondary symptoms, mucous patches, or beginning roseola, so that mercurial treatment is immediately begun. The administration of mercury will be more fully described when the general antisyphilitic treatment is considered. Although the treatment of indurated chancre is not very important, it is different with soft chancre, which has a great tendency to extend and inoculate the patient. It also frequently occasions suppurating buboes, and even goes on to phagedenic ulceration, therefore it is necessary to destroy it as soon as recognized. It may be cauterized with the actual cautery, with nitric or sulphuric acid, with Vienna paste, etc. The caustic preferred by Ricord and many others, is carbo-sulphuric paste, consisting of powdered charcoal made into a paste with sulphuric acid. It has the advantage of forming a black scab when placed upon the chancrous ulcer, and remaining until the granulations beneath become healthy, so that when the scab falls ofl the chancre is seen in a healinor condition. If cauterization be refused by the patient, we advise rest to prevent suppuration of the bubo, and apply astringent washes, or dust the ulcer with powdered iodoform. 104 SYPHILIS. [It has been for many years the almost universal custom to cauter- ize freely all soft or suppurating venereal ulcers, i. e., all sores diag- nosed as chancroids, whether situated on the genital regions or elsewhere. This plan of treatment was adopted avowedly because the sore being attributed to the action of a specific virus, it was thought necessary absolutely to destroy that virus before any healthy reparative action could take place. Manifestly if the chancroid be regarded as an inflammatory ulcer, resulting from pus contagion, it is no more requisite to use painful cauterants in its treatment, than it wovdd be in a case of ulceration following a burn or scald. On the other hand, it may be said that if the theory of specificity be assumed to be true, there are yet reasons' for believing that during the past twenty years the chancroid has been so modified in character and tendencies as no longer to require the active measures instituted by our predecessors. Experiments have shown that after repeated inoculations, chan- croids lose all their virulence, and that it even becomes impossible to transmit them in this manner, the same fact being true as regards the inoculation of other purulent secretions. During the last half century it is possible that chancroids have undergone this progressive enfee- blement while being handed from person to person — a process similar to experimental inoculation — and that they have consequently become much milder in type. Leaving aside, however, these theoretical considerations, the prac- tical question, that which most concerns both the physician and the patient, is, as in every other case of disease, Avhat is at once the speediest and the safest method of cure ? The objections to cauterization, which have been well set forth by Dr. Greenough, in the paper already mentioned, are as follows: — First. The pain to which it gives rise, and which to many patients is almost unbearable. Second. The inflammatory action Avhich follows, and which often in the case of the male, produces enough oedema and swelling to cause phimosis, and thus to conceal the sore and prevent the proper appli- cation of remedies. Third. The subsequent effusion of lymph which is apt to cause an induration closely resembling that of the true chancre, and thus to greatly obscure the diagnosis. ' On the Treatment of Chancroid, by F. B. Greenough, M.D., Boston Med. and Surg. Jour., Jan. 11, 1877. TREATMENT OF CHANCRE. 105 Fourth. The occurrence of sympathetic buboes, which are much more likely to complicate the case if the additional powerful irrita- tion of cauterization be added to that of the original disease. Admitting then that these are valid objections to the use of the cautery, it remains simply to inquire whether there are advantages numerous or important enough to outweigh them, the question thus becoming one to be settled largely by clinical observation. During five years — since the spring of 1877 — we have seen and treated in the venereal dispensary of the University Hospital, in the venereal wards of the Philadelphia Hospital, and in private practice, a large number of chancroidal ulcers, and during that time have only used cauterization under certain exceptional circumstances presently to be mentioned. The favorite application, but not on account of any supposed specific action, has been iodoform in powder, ointment or ethereal solution; the general rule has been followed of meeting indi- cations — that is, of using sedative lotions, lead-water, or lead-water and laudanum, or sulphate of zinc and opium, in the acutely inflamed painful sores, and of using stimulating washes — sulphate of copper, strong zinc solutions, nitrate of silver, etc. — upon indolent, pale and flabby ulcers. Special indications having been met, iodoform gener- ally completed the cure. As compared with the former methods of treatment, we are confident that, while avoiding, to a great extent, the complications above mentioned, we, at the same time, noticeably shortened the period required for healing. The unreliability of hos- pital cases, which of course make the bulk of the statistics, and which disappear long before entire recovery, prevents us from giving exact figures, but it would be safe to say that the average time of cure did not exceed ten days or two weeks. In a few cases in which after four or five days' treatment no tendency to reparative action is observable it becomes necessary to employ a cauterant, and fuming nitric acid or bromine should be thoroughly applied to the surface of the ulcer with the idea of destroying the unhealthy granulations and surrounding them with a layer of plastic lymph which at once resists further ulcer- ative action, and furnishes a basis for new growth. Special formulae for lotions, powders, and ointments may be found in all manuals and text-books on these subjects. The local treatment of infecting chancre is of very little importance except as regards the question of excision. Healing will take place in the great majority of cases under any emollient application, or without any if only cleanliness be observed. 106 SYPHILIS. Cauterization, except in a few instances to be mentioned, is worse than useless in cases without gangrenous or phagedenic tendencies, because, on the one hand, it retards rather than hastens cicatrization, and, on the other, is manifestly inferior to excision as an abortive method. We feel no hesitation in saying that the evidence in favor of this latter procedure is sufficiently conclusive to warrant its adoption in most instances. No other plan of treatment results in so speedy a return to local health. If the chancre be picked up with a pair of vulsellum forceps, and removed by a sweep of the knife or by means of curved scissors, the wound will usually heal within two or three days, and Avithout complication. The statistics in reference to its influence upon the subsequent development of the disease have already been given, but we may add that the opinion deduced from them has been greatly strengthened by our personal experience. For a few months we have excised most of the typical infecting chancres which have come under our notice, and which have been favorably situated for the operation. In the majority of cases, some fifteen or twenty in number, .syphilis has followed, but in a few it seems probable that constitutional disease has been prevented. As most of them are unavoidably open to the doubt as to accuracy of diagnosis, so often urged against this form of proof, we do not give them in detail, although ourselves convinced of the great probability that they would have been followed by syphilis if uninterfered with. In two cases, however, we have had an opportunity of confirming the diagnosis by confrontation, and found that the sores had been derived from women with active syphilis, in both cases with mucous patches. In one of the male patients there was slight glandular involvement, which has since subsided ; in the other no glandular trouble was discoverable. In both the ordinary time of development of constitutional syphilis has long since passed, and no sign of general syphilis has manifested itself. Unless some hitherto unnoticed and untoward results should follow this little operation, it seems proper to us to employ it in all cases except those where an unusually deep induration occupies the tissues of the glans itself. In these, which are not very common fortunately, it may fairly be doubted whether the probabilities of protection are sufficient to compensate for the pain and the deformity resulting from excision. In such cases, or in those where the patient for any reason TREATMENT OF CHANCRE. 107 refuses the more radical operation, cauterization may be employed, but with greatly diminished chances of benefit. Nitric or sulphuric acid should always be used for this purpose, and should be freely applied and pressed into all the interstices of the sore. The reasons for and against the mercurial treatment of chancre will be given in the chapter on the treatment of syphilis.] 108 SYPHILIS. CASE I. Indurated chancre of the right luhium majorum — Excision — Histological examination. J., a cook, aet. 25, admitted to Lourcine May 16, 1878. Bed No. 21. No special personal or hereditary history. She has had three children. Three weeks previous she {)erceived upon the right labium majorum the lesion for which she entered the hospital. This lesion consists of a considerable swelling of the right labium involving the nympha upon the same side. At the inferior third of the labium majorum is found an erosion about the size of a ten cent piece. It is limited by a scab-like, yellowish swelling formed of epithelial cells. This swelling causes a slight elevation measuring about one to one and a half millimetres. The remainder of the surface of the chancre is eroded. There is also seen a dotting of small red spots, and yellowisli-gray spaces, consisting of false membrane, resembling diphtheritic membrane, adherent and about half a millimetre thick. If this membrane be removed with the forceps, the tissue beneath slightly bleeds. This chancrous erosion, more convex than excavated, presents a mani- fest induration of its base and margins. The induration is insensibly blended with the diffused and resistant ccdema of the labium. Alongside of the lesion, and internally, that is, upon the right nympha, at its free border, is found a festooned erosion, with irregular surface, cov- ered by thick layers of epithelium. The base of this erosion presents an evident induration. Upon the internal surface of the right labium are found three superficial, circular erosions, as large as lentils, coffee colored, and not indurated. The ulcerations of the nympha have api»eared consecutive to the chancre of the labium. Two or three hard, lymphatic glands, as large as hazel- nuts, exist upon both sides in tlie groin. The skin, the scalp, and the mucous membrane do not present any change. Cervical lymphatic glands are not abnormal. No fever. Slight chlorosis. 17th. The indurated chancre of the right labium was excised. The portion removed measured nearly two centimetres in diameter, and one in thickness. Ordered liquor of Van Swieten.* 20th. The wound caused by removing the chancre is almost cicatrized ; it is elongated, a little depressed, its surface is grayish, pultaceous. The tissue forming the base of the cicatrix is still slightly hard, but not more so than the tissue of the labium wliich is as (edematous as it was on the first day we saw it. ' Corrosive sublimate ...... 1 part. Alcohol 100 parts. Distilled water 900 parts. CASE I. 109 The ulceration of the left nympha has not changed its appearance, and is still a little indurated. The erosions upon the internal surface are not changed, and the nympha continues oedematous. The inguinal glands have slightly increased in size. 26th. The wound continues to heal. The ulceration of the left labium minorum is completely covered with a whitish, adherent coating, composed of epithelial cells and leucocytes ; the surface beneath this false membrane is bleeding. 29th. Mucous patches are observed upon both thighs. June 6th. The wound of the right labium is entirely healed, and has a brownish color. The labium is still swollen. Tiie ulcerations of the nympha and the mucous patches upon the thighs have disappeared. The patient left the hospital on the 18th of June in the same condition. Histological Examination of the Chancre. — The piece was hard- ened in Miiller's fluid, gum, and alcohol. Fig. 4 is a drawing of an entire section of this chancre, enlarged 15 diameters. The papillae are hypertrophied, and the epidermic layers increased in thickness at the margins of the chancre, j> and d. This thickening of the epider- mic layers and the inflammation of their cells were very distinct, even upon the surface of the chancre and near its borders, especially where the hairs emerge. In Fig. (3 we have drawn a section of the super- ficial layers of the epidermis upon the chancre near its border, where Fig. 18. Section from the surface of an indurated chancre, showing the suppuration in the epidermis. a. Layer of pus-corpuscles interposed between the superficial corneous lamina, c, and a lamina of deep corneous cells, d. At c' are seen the corneous cells having their nuclei atrophied, b. Isolated pus-corpuscles, m. Cells of the rete mucosum. X 150. a hair follicle exists. This drawing, magnified 150 diameters, shows the suppurating foci in the corneous cells of the epidermis ; the forma- tion of small excavated cavities in these cells, as at c ; the small islands of pus-corpuscles, c?, limited on all sides by epidermic cells. The larger cavities have changed the corneous epidermis into a 110 SYPHILIS. reticulum with large meshes, formed of corneous cells, filled with pus. Upon other parts of the surface of the chancre we see pus-corpus- cles arranged in groups, which are interposed between the corneous epidermic layers. Thus Fig. 18 shows a layer of round corpuscles placed between the laminae, c and (Z, of the superficial epidermis. The rete mucosum presents similar lesions, particularly in the epithelial sheath of a hair represented in Fig. 6. Here ai'e seen excavated cells, c, and small cavities filled with pus, n. The epithelial layer at the centre of the ulcerated chancre was thinned and mixed with pus. At this point the papillse form a layer in which they are each a little increased in size. The lesions of the connective tissue, the infiltration of lymph-cells, the inflammatory thickening of the cells are readily seen. In the region in which the sudorific glands are found, in the tissue of new formation of the chancre, they are scai'cely changed. The peripheral connective tissue especially is inflamed, and forms around the segments of their convolutions a border of small round cells. Here, also, the epithelial cells are a little enlarged, and the ducts larger than normal. Upon transverse section, the lumen of the ducts, lined with epithelial cells, frequently presents in its interior round cells, which are only the desquamated, free peripheral cells. CASE II. Indurated Chancre of labium minorum — Excision — Histological examination of chancre. E. B., seamstress, set. 19, until now has always enjoyed good health No special personal or hereditary history. Five days previous she first observed a small painful pimple upon the right nympha. The pimple gradually increased in size and finally changed into a superficial ulcer. IShe bathed it frequently, but it did not dis- appear, and she entered the hospital — St. Clement ward, June 26th, 1878. At the free border of the inferior half of the right nympha, upon its internal surface, is found a small superficial round ulcer, about eight millimetres in diameter. This slightly excavated erosion is covered with a brownish closely-adherent scab. The margins and base of the chancre are distinctly indurated, and have a cartilaginous feel, seeming to be a centimetre thick. The right nympha is very oedematous, but the induration is very easily distinguished from the surrounding tissue. In the right inguinal fold, are found two glands as large as small hazel- nuts, which are very hard, and roll beneath the finger. CASE ir. Ill Two or three small glands are felt in the left groin. The other glands, the skin and mucous membranes are normal. No fever. 29th. The inferior half of the labium minorum, upon which is located the indurated chancre, was removed with a bistoury. July 1st. The portion remaining is greatly oedematous, but we are not able to trace the slightest evidence of specific induration. The wound is suppurating profusely. 2d. Condition the same. Suppuration increased, the wound tends to granulate and cicatrize. Right inguinal glands diminished in size. Ordered liquor of Van Swieten. 3d. The wound whitish, the new-formed granulation tissue is infiltrated with pus; beneath the wound, the connective tissue is oedematous, but not more so than upon the day of operation. r)th. The wound is clean, discharging very little pus, smooth, and the adjacent connective tissue very much less oedematous, softer. 7th. The wound is covered by an epidermic layer. The adjacent con- nective tissue still presents some hardness, which in a few days gradually disappeared, as did the surrounding oedema. 23d. Two vegetations upon the left nympha, which appeared a few days after admission into the hospital, have since grown, and were to-day excised. As yet there are no secondary symptoms. Histological Examiyiation of the Chancre. — The piece removed was placed in alcohol, then, the same day, in picric acid, and after- wards in gum and alcohol. Figure 19 is a drawing of a section through the large axis of the chancre made vertical to its surface, magnified six diameters. The prominent part between m and n represents the ulcerated portion of the chancre. This part, as mentioned, was situated upon the border of the nympha, so that the section includes both the primary ulcer, and a portion of the internal and external surface of the labium. The epithelial covering, w, of the internal surface of the nympha, in the neighborhood of the chancre, is very thick and the papillse are very long. The normal epithelial covering tapers and stops at m. The surface of the chancre from m to n has lost its normal epithelial covering, in its place there exists a thin layer, a, formed of pus corpuscles and epithelial cells. These elements cannot be seen with low power. The papillge do not form an elevation upon the surface of the chancre ; their extremities give origin to a small quantity of pus, which dries and forms a thin layer. At the margin of the chancre, ?z, the normal epidermis remains, and the papillse are hypertrophied. From the drawing, it is seen that there is very little loss of substance. A layer of pus corpuscles and epithelial cells replaces the normal epidermic layers, and beneath this layer, the papillae infiltrated with lymph cells separate the elements. The 112 SYPHILIS, tissue of the chancre forms an indurated mass, and is composed of an infiltration of round cellular elements between the fasciculi of connec- tive tissue ; the walls of the vessels, arteries and veins, are thickened bj the formation of new cells. The tunica adventitia is especially changed. Section of au indurated chancre of the labium minorum. n. Normal epidermis at the margin of the chancre, e. Rete raucosum. a. Ulcerated part ; the epidermis is lost from m to n. g. Nor- mal sebaceous gland, g'. Sebaceous gland in which there still exist some sebaceous cells. h, h. Sebaceous glands situated in the ulcerated part of the chancre, and which do not contain sebaceous cells. I. Cul-de sac of an inflamed sebaceous gland, t. Indurated connective tissue. 1). Vessels. X 6 In this chancre there are all the elements for a complete study of lesions of sebaceous glands. In the labia minora these glands are very numerous, and in each preparation we find several in the various stages of alteration. We are able even with low power, as in Figure 19, to see the changes that occur in the sebaceous glands. Here the glands distant from the chancre, and outside of the inflamed and indurated tissue are normal ; they are seen to possess a single lining of pavement cells ; the excretory canal and acini present a distinct centre filled with normal sebaceous cells. In the gland, g, at the margin of the chancre, the sebaceous cells are not distinct as in the deep acini, and the lumen of the duct is filled with pavement cells. The seba- ceous glands, 7<, /;, and Z, which are in the inflamed tissue, do not contain any distinct, fatty sebaceous cells, but are filled with newly formed pavement epithelial cells. When an inflamed and a normal gland are compared under higher power, in the former it is found that the sebaceous cells are gradually crowded to the centre of the ducts, and the acini are filled by a development of pavement cells; in those parts most altered, at the centre of the chancre, there are no sebaceous cells: the pavement cells of the ducts and acini fre- quently show a cavity between the nucleus and protoplasm of the CASE III. 113 cell, and there are often round cells, pus corpuscles, or lymph cells in the interior of the glands, alongside of the epithelial cells or in the cavities which they have formed. It is particularly in that part of the glandular duct nearest to the suppurating surface, that these round cells are met with. The lesions of the sebaceous glands are secondary to the inflammation of the connective tissue. CASE III. Indurated chancre of the right labium minorum — Mucous patches. M. B., chambermaid, ret. 21, admitted into tlie Lourcine Saint-Clement Ward, May 9, 1878. No special personal or hereditary history. She first noticed her disease four days previous to entering the hospital. Present Condition Considerable oedema of tlie right hibium, also of the nympha of the same side; upon the internal surface of the latter we find a festooned gray ulcer, bulging at the centre; at the periphery, the depression from the loss of the epithelial covering is very slight. Upon the inferior part of the right nympha, and upon its free border is found an irregular ulcer, extending towards its internal surface. The margin of the ulcer consists of a whitish covering of epitlielial cells, thin- ning towards the eroded surface. This surface is yellowish-gray, and when wiped is immediately again covered with a clear serous fluid. The base of the ulcer is indurated, almost fibrous in nature. Upon the external surface of the labium on each side of the fourchette, are seen ulcerated mucous patches. The radiating folds of the anus are hypertrophied, and there are found here a few mucous patches. A single, very hard, and very large gland is situated in the right groin ; in the left groin are seen two small indurated glands. The skin and buccal mucous membrane are healthy. Cervical lymphatic glands normal. Ordered Van Swieten's solution. Histological Examination of the Surface of the Chancre and of the False Mernbrane. — The grayish false membrane covering the surface of the ulcer was removed by scraping. Microscopical exami- nation showed it to consist of: — 1st. Epithelial cells isolated or in various sized patches. Fig. 2 (see page 44). Several of these cells have arborescent prolongations resembling deer horns, as in the false membranes of diplitheria. Fig. 3 (see page 44). We also find spherical epithelial cells varying in age and size. 2d. Pus corpuscles provided with one or several nuclei ; various sized granules ; numerous vibriones ; collections of small spores. May 20th. The chancrous erosion has entirely disappeared, but the induration has increased. The oedema of the right labium majo- rum has very much diminished. 114 SYPHILIS, 26th. Extension of the mucous papules upon the labia majora. June 8th. The patient left the hospital with the mucous papules of the labia majora gradually disappearing. CASE IV. Histological examination of an indurated chancre of the prepiice. During the month of June, 1878, my colleague. Dr. Mauriac, sent me, for examination, an indurated chancre of the prepuce, which he had removed with a part of the prepuce from a patient in the Hopital du Midi. The chancre had existed some three weeks, extending transversely around the prepuce like the segment of a ring. The part first attacked was cicatrized, while that which remained, about one-half, still suppurated. The chancre measured in its greatest diameter about two and a half cen- timetres. The cicatrized portion was covered with normal epithelium and depressed; the ulcerated part was covered willi a thin grayish layer nearly even with the neigliboring normal skin. Beneath the ulcerated and cica- trized part was felt a characteristic woody induration. The piece was hardened in Miiller's fluid gum and alcohol. The prepuce, and especially its cutaneous portion, is certainly as to structure the most simple region, which may be the seat of a chancre, since here there are only connective tissue, vessels, nerves, and an epidermic covering. Therefore this case and the following may be Fis. 20 Cicatrix from a portion of the chancre, Fig. 22. a. Corneous epidermis, h. Rete mucosuni. p. Papill*. t. Very hard cicatricial connective tissue, v, v. Vessels witli extremely thick waUs. X 8. regarded as types of the pathological anatomy of chancre divested of %all foreign elements. Preparations made vertical to the cutaneous surface show us the followinsr conditions : — CASE IV, 115 1st. In the oldest part of the chancre, completely cicatrized, there is a point where the cicatrix is a little sunken, so that, upon section, Fig. 20, the cicatrix has the shape of an obtuse angle. The surface of the cicatrized chancre presents its two layers of epidermis, the corneous and mucous layers. The superficial epidermis, «, is partly separated at the summit of the angle. The rete mucosum, 6, is quite thick, but irregular. We see in this drawing, magnified eight diame- ters, the rete mucosum, b, very thick at the angle of the cicatrix which it fills up, and also at the points where the papillae are large as seen to the left of the drawing. The papillie are also very irregular, but larger than normal ; they are, however, mostly deprived of the em- bryonal cells which infiltrate them during the acme of the chancre. The connective tissue of the derm is fasciculated and dense, contains many round or flat cells, and its vessels, v, are extremely thick. 2d. Fig. 21 shows cicatrization of the chancre in a part where it is more extensive than in the preceding. The corneous layer of the Fig. 21. Cicatrized portion of the chancre, Fig. 22. a. Corneous epidermis, b. Rete muco-sura. a'. Epidermis, and b', rete mucosum of the cicatrized part. p. Papillse. t. Indurated couuective tissue. X 8. epidermis, a, a', is very thick; the rete mucosum, h, around the chancre and upon its surface, is also thickened. The margin of the chancre presents the rete mucosum extremely thick at b ; where the ulceration of the chancre exists, the papilloe are visible and large, also irregular. This irregularity and hypertrophy of the papillae are manifestly due to the circumstance, that they have been affected during the suppu- rating period of the chancre, and that they have developed during the healing period. 3d. Fig. 22 represents the ulcerated part of the healing chancre. In the central part of the figure, for about eight or nine millimetres, the epidermis and rete mucosum are lost. These two layers, a and b, 116 SYPHILIS. which are seen at the side of the ulcerated part, terminate by taper- ing at the edge of the ulceration. They are replaced by a layer of pus corpuscles, mixed with epithelium, c. The papillae, which are exposed, budding, and larger than normal, fill up the space left by Fi?. 22. CO P, Section of an indurated and ulcerated chancre of the prepuce, a. Corneous epidermis. 6. Rete mucosum arrested at the ulcerated portion of the chancre ; at this part are seen, at c, either pus corpuscles or a false membrane. The papilla;, d, possess vessels, n. t. Indurated connective tissue 7n. Subpapillary indurated tissue of the chancre, v. Deep indurated vessels and tissue of the derm. X 8. the loss of the epidermis ; they are very vascular. From an exami- nation of these papilhie alone, the vessels of which are permeable to the blood, and which are formed of embryonal tissue, we are able to say that we have a Avound in the process of healing, and not under- going destruction or elimination. In the latter case, the circulation would not be so perfect, and the cells infiltrating the papillary con- nective tissue would be modified in their nutrition or have under- gone granulo-fatty degeneration. In this case the examination of the papilloe shows their connective tissue with vessels of new formation which are very numerous, seen even with low power, eight diame- ters, as represented in Fig. 22. The deep connective tissue is fasciculated, infiltrated with numerous cells and thickened. We may now ask the cause of the deep, angular, V-shaped cica- trization, seen in a section of the old part of the chancre. If we refer to Fig. 20, it appears to us that there certainly is a loss of sub- stance of the dermo-papillary tissue at this point. The proof is, that a large arteriole comes nearly to the surface of the corium ; the shape of the loss of substance is singular, also its depression. We believe the cause of this angular depression is due to the exaggeration of the normal folds of the prepuce, and the localization of the chancrous ulcer at the bottom of one of these folds. CASE V. 117 CASE V. Infecting chancre of the border of the prepuce, removal on the 30th day of its existence — Histological examination of the chancre. M. L. H., fet. 25, commercial business, ward 8, No. 14 (service of Mau- riac). After two months' continence, the patient had connection twice, with an interval of eight days, with a girl in the Latin quarter. Forty days later, the 1st of August, he observed a small pimple situated upon the edge of the prepuce. Gradually this pimple enlarged, particularly on the mucous side, tlie preputial orifice contracted, and in about ten days complete phimosis occurred. This chancre began about the first week in June, 1878 ; it teas painless from its beginning until removed by circumcision. Very simple applica- tions had been employed. Adenitis was multiple and bi-lateral. There was no inflammation of the preputial mucous membrane, nor any other complication. The chancre was excised on the 13th of July, twenty or twenty-five days after its appearance. Tiiere was considerable hemorrhage from several arterioles, which was difficult to arrest on account of the vessels being in the midst of the sclerosed tissue. Union was not immediate, owing to frequent erections. But the wound has been healthy, and pur- sued the same course as in a non-syphilitic patient. July 31st. The first spots of erythematous roseola make their appearance (about forty-live days after the primary lesion). No disturbance of the general health. Extensive adenitis of the inguinal region. Beginning cervical adenitis. ITistoIogical Examination of the Chancre. — Dr. Mauriac, physician at the Hopital du Midi, sent us for examination, July 13th, a chancre of the prepuce, which Avas removed by circumcising the patient. This chancre is seated upon the free border of the prepuce, presents a very deep depression, a cone with a sharp angle, at the centre of the lesion. The chancrous connective tissue is extremely hard and dense, woody, and has the shape of a slightly flattened spheroid. The indurated part measures not less than 12 millimetres in its greatest diameter. The piece was examined after hardening in Mliller's fluid, alcohol, and gum. Sections passing through the middle of the chancre show it sepa- rated into two halves by a distinct space, of an infundibular form, or very sharp angle, which penetrates deeply into the tissue of the chan- cre. The surface of the margin of the chancre is covered with a thick epidermis, which tapers towards the infundibular part. Where the part is most contracted the epidermis ceases, and the connective tissue, which forms the margin of the loss of substance, 118 SYPHILIS. contains a few round or lymph-cells, which are mostly granular, fatty, large, and possess one or more nuclei. Fig. 23 is a drawing of this chancre, magnified 15 diameters, the tissue of w^hich is divided into two parts by an infundibular depression, section of a liigrhly indurated chancre of the prepuce during the state of acme and fuU develop- ment, ulcerated and seated at the bottom of a cutaneous fold. (Removed by Mauriac.) a. Super- ficial epithelium, which is very thick, and separated at «' from the rete niucosum, h. The epithe- lial layers cease at 17, the opening of the infundibulum, o. The depression o Is analogous to/, •which latter is lined with its normal epithelial layers, while from g to p the loss of substance from the surface of the chaucre is limited by a tissue infiltrated with cells. Throughout the indu- rated tissue represented in this figure, the walls of the vessels are extremely thick and inflamed : as ati), v', m, d; .?, cleft of the caseous central part. X 15. 0'. The superficial epidermic layers cease at g. The walls of the vessels, v, v\ m, d, are seen, with this low power, to be very thick. At s is seen an opening or slit in the central part of the indurated tissue, the cells of which have undergone caseous degeneration. At the bottom of the fissure, the chancrous tissue presents an open- ing Avhich increases its length, and is in the direction of the connective- tissue fibres ; it seems artificial, probably because the indurated tissue had been stretched during the erections, perhaps also because it has been forcibly pressed betAveen the fingers after the excision of the chancre to ascertain the presence of induration. CASE V. 119 Beneath the epidermis, the papiUre included in the chancre are hypertrophied, very vascular, and infiltrated with small round cells. The tissue of the derm is much inflamed, and filled with round cel- lular elements, still the fasciculi of fibres of the connective tissue can be distinguished ; these fasciculi, however, appear compressed by the cellular infiltration at the centre, beneath, and at the sides of the loss of substance of the chancre. The cells are here mostly granulo-fatty. Throughout the indurated part, the vessels are altered in various degrees. The vessels of the papillie are simply filled with blood, and surrounded by a few round cells, but the deep arterioles and venules, in all the indurated region, have their walls thickened by the forma- tion of cells between their external and middle coats. The internal coat is always very much less aifected than the external or middle coats. The vessels — arteries, veins, and capillaries — of the central part of the chancre, almost all have the lumen obliterated ; for example, the transverse sections of capillaries present collections of lymph-cells, which fill them ; longitudinal and transverse sections of arteries show large endothelial cells joined together with lymph-cells and coagu- lated fibrin. This coagulum, which is not always adherent to the internal coat, is also seen in longitudinal cuts of arterioles. The veins show a similar lesion. The calibre of these vessels is contracted at the same time that their Avails are thickened. Figure 12 (see page 59) is a drawing of a section of four small veins, magnified 200 diam- eters. Their lumen, a, is very narrow and filled w^ith lymph and endothelial cells, which form a mass in the centre. The walls have considerable thickness relative to their lumen ; some round or oval cells are disseminated in the internal coat, i, in the muscular coat, t, and in the external coat, e, which latter is limited by connective tissue, c, filled Avith round cells. Figure 10 (see page 58) represents a section of an arteriole, mag- nified 200 diameters, Avhich shows similar alterations of its coats. The elastic membrane,/, is seen in immediate contact with the endothelial and lymph-cells, filling the lumen of the vessels. Cells of ne^v formation exist between the fasciculi of the elastic membrane and outside of them, between the elastic membrane and muscular coat. The external coat, e, is little changed at this point, but it and the fasciculi of the neigh- boring connective tissue are separated by an accumulation of lymph- cells, c. At those points where the obliteration of the .vessels is more or less complete, the lymph-cells are granular and fatty. In a word, 120 SYPHILIS. there is here primarily an interference with the circulation of the blood, and secondarily a fatty degeneration of the cells. In this preparation are found several fasciculi of nerve-fibres ; these fasciculi are cut transversely and longitudinally. In the transverse cuts, the neurilemma, or, better, the sheath of the primitive fasciculi of the nerve-fibres, is dissociated by fusiform cells, that is, the flat cells of the connective tissue swollen by the peripheral inflammation, Fig. 13 (see page 63). The sheath is separated into several thin laminte, m, by fusiform and small round cells, a. The nerve-fibres, b, of the fasciculi are normal ; but, even within the fasciculi are seen hypertrophied cells of the connective tissue, and sheath of Schwann, or round cells. This inflammatory lesion of the nerves is certainly secondary to the specific inflammation of the connective tissue of the derm. It is singular, that this change of nerve fasciculi did not occa- sion pain. We see, from the above, that this chancre of the prepuce was in the period of caseous or fatty transformation of its elements, at the centre of the small tumor. This period coincides with the partial oblitei-ation of the vessels. The condition of the nerves shows that the inflammation involves all the tissues and all parts included in the induration. In regard to the shape of the loss of substance, characterized by a very deep infundibulum, it is occasioned by the normal arrangement of the part. The prepuce, at its free border, presents depiessions and ridges, which are unfolded during erection. In these depressions and ridges the papilli^ and rete mucosum have the same arrangement as upon the normal skin. The chancre was evidently developed at the bottom of one of these depressions ; it had caused an hypertrophy of the epithelial and dermo-papillary layers, so that the depression seemed still deeper. If the chancre had not been interfered with, and had healed, it would have presented a cicatrix having the form of that represented in Fig. 20 (see page 114). SYPHILITIC LYMPHATIC GLANDS. 121 CHAPTER IV. LYMPHATIC GLANDS DURING THE PRIMARY AND SECONDARY PERIODS OF SYPHILIS-CLASSIFICATION OF SYPHILIDES— MUCOUS PATCHES. Symptomatic and histological descripti(m of syphilitic lymphatic glands at the beginning of syphilis — Glands at the same time scrofulons and syjihilitic — Syphilides — Their general characters — Classification — Their many forms — Their copper color — Mucous patches — Pathological anatomy and symptoms of mucous patches of the vulva — Mucous patches of the tonsils — Lesions of the closed follicles of the tonsils — Extirpation of syphilitic tonsils. Almost at the same time that the chancre becomes indurated, the lymphatic glands, connected with it by means of the lymphatic vessels, become hypertrophied. Syphilitic Glcmcls. — The gland or glands nearest to an infecting chancre become enlarged and hard; they roll readily beneath the skin and the subcutaneous connective tissue which surrounds them ; they are remarkably painless, and do not suppurate. These clinical char- acters, which have been previously mentioned, are constant. They are found in the groin when the chancre is upon the genital organs or anus ; at the angle of the jaw when the chancre is upon the lips; in the axilla when the chancre is upon the nipple. The glands of the groin, in connection with a chancre upon the genital organs, are successively involved, the gland first affected being the most inferior of the group upon the diseased side ; for example, if the chancre be single and seated upon one of the labia majora, the nearest gland of the same side is first implicated, later the glands of the opposite side. [When the chancre is situated at one side of the frgenum it is not uncommon to find the buboes in the opposite groin, a certain amount of decussation occurring between the lymphatics of the former region.] The inguinal glands now form a mass, like a string of beads, in which they are all hypertrophied, but are distinct one from another, the skin remaining healthy. About a month and a half after the be";inning of this affec- tion of the glands nearest to the chancre, all the glands of the economy are successively invaded. At least all those which are 122 SYPHILIS. visible ; they appear a little inflamed before or at the same time with the eruption of the cutaneous syphilides. I do not doubt but that the glands concealed in front of the sacral, lumbar, and dorsal verte- brae undergo a similar change. [It was so found in a case reported and figured by Jullien, as far as the lumbar and iliac glands were concerned.] The subcutaneous glands affected by syphilis are the cervical, maxillary, occipital, etc. In what does the glandular lesion anatomically consist? It is characterized by Virchow as a simple hyperplasia, but this word is very vague, and it is necessary to examine the lesion in all its details before pronouncing upon it. I have several times had an opportunity to examine syphilitic lym- phatic glands in the fresh condition, immediately after they had been removed by operation. The normal structure of lymphatic glands consists of a fibrous capsule which gives off trabeculae which accom- pany the vessels as far as the hilus ; of a delicate reticulated tissue forming islands or follicles in the cortical portion; and of a reticulated tissue with larger meshes enveloping the former and leaving sinuses around the follicles. The afferent lymphatic vessels enter at the surface of the gland, form the sinuses and reticulated tissue with large meshes, and again form vessels which pass out at the hilus as efferent vessels. In syphilitic lymphatic glands, the follicles of the delicate reticu- lated tissue are hypertrophied, and occasion small lobulated projec- tions upon their surface when the capsule is removed. Again, if a section of a gland is made in its greatest diameter, there is seen a lobulated appearance due to the same cause ; the fibrous capsule is not very notably thickened, and does not adhere to the neighboring connective tissue. If the cut surface of one of these affected glands be scraped, and the scraping examined microscopically, there are found lymph-cells of ordinary size, and swollen cells possessing a large nucleus or several nuclei. Among the swollen cells, there are always some which pre- sent in their interior several red blood-corpuscles. There may be as many as eight to ten blood-corpuscles in a single cell. When there exist several nuclei in a large hypertrophied cell, there is always one which is much larger than the others and oval, while the other nuclei are round and small. These swollen cells are seated in the peri-foUicular lymph sinuses, but they are also sometimes found in the delicate reticulated tissue. SYPHILITIC LYMPHATIC GLANDS. 123 The fibrils of the reticulated tissue are not changed. The con- nective tissue of the fibrous trabecule, extending from the capsule to the hilus, is generally a little thicker than normal. It is this thicken- ing of the trabecule, joined with the swelling of the delicate reticu- lated tissue of the follicles, and the increase of the number of elements in the lymph sinuses which occasions the lobulated condition above mentioned. These are the changes which essentially constitute the special inflammation of glands during the period of acme of the primary lesion, and also during the period of the secondary lesions. Lesions identical to these are found occurring in the closed follicles of syphilitic tonsils. Such are the most frequent changes of these glands, which remain more or less hypertrophied, not only during the active period of the secondary lesions, but frequently after the syphilides have disap- peared. In certain cases, which are not very rare in hospitals especially devoted to syphilis, children, or young girls and women are met with who are ansemic and lymphatic, their glands presenting what Ricord calls a scrofulosis of syphilis, that is, the lymphatic glands of the neck or groin become very much enlarged, as large as a pigeon's egg, or even larger. When in a syphilitic patient the lymphatic glands present this great enlargement, they are identical with strumous glands, a histo- logical description of which has been published by me in the Journal de V Anatomie of Robin, 1878. This description need not be re- peated here ; it is sufficient, in order to characterize these syphilitic and strumous glands, to mention that the fibrous capsule is extremely tliick, and gives off" thick fibrous trabecule which divide the gland into small islands. The trabecule forming the reticulated tissue have their fibres soft and swollen, and enclose large cells with oval nuclei, and granular or granulo-fatty protoplasm. The sclerosis of the capsule is such that in removing the gland, part of the surrounding tissue is removed with it, since this tissue is also connected with the gland, and likewise sclerosed. These strumous glands are also characterized by their union one to another by means of the sclerosed tissue which surrounds them, and they thus form a single mass frequently adhering to the skin. [The following table will serve to contrast the buboes and lymph- angitis characteristic of the two chief forms of venereal sores. ^ ' It is based on one contained in the excellent work of Van Buren and Keyes. 124 SYPHILIS. Syphilitic Bubo. Always accompanies or follows infecting chancre. Several glands involved, making a group or chain of small, movable glands in one, or often in both groins. Appears soon after chancre. Slight enlargement. Cartilaginous induration. No inflammatory symptoms. Glands freely movable. Skin normal — not adherent. Painless. Indolent, slow. Terminates by resolution, rarely by suppuration. No marked tendency to phagedena. No local treatment elfective. Mercurial treatment hastens resolution. Inflammatory Bubo. Occurs once in three cases of chancroid ; occasionally, but more rarely in her- petic or balanitic ulceration. One gland implicated, rarely bi-lateral. No definite time of appearance. Great enlargement. Inflammatory hardness. Always present. Gland fixed (peri-adenitis). Skin red, adherent. Painful. Runs an acute course. Usually suppurates, rarely undergoes resolution. Phagedena not very uncommon. Local treatment required. Mercury has no influence upon the con- dition. Inflammatory Lymphitis. Syphilitic Lymphitis. Lymphatic vessels feel hard, like the Same, but less hardness vas deferens; size of a knitting kneedle. Painless to touch. No pain on erection. Skin normal. Terminates by resolution. Treatment unnecessary and inefi'ective Painful. Erection gives rise to pain. Skin red over inflamed vessel. Resolution or suppuration. Local treatment of great use. It is interesting to observe in relation to the bubo following the indurated chancre, that in these rare cases in which extensive suppu- ration or phagedenic action occurs, the system at large often escapes contamination. Two cases^ of this character have recently come under our notice ; in both of them, the primary sores having all the characteristics of the initial lesion, the inguinal glands breaking down, however, before the appearance of the earliest syphilide. In both immunity from constitutional trouble was complete. The same im- portant fact has been noticed by Fournier and Ricord to be true as regards the relation of bubo to the phagedenic initial sore, the latter form of chancre not being followed by the inguinal enlargement which, as has been said, is so nearly constant. The bearing of these facts upon the doctrines of syphilis and » Medical News, Feb. 25, 1882. GENERAL CHARACTERS OF SYPHILTDES. 125 cliancre is evident. They are altogether inexplicable on the theory, that the chancre is a symptom of constitutional syphilis, but if the theory of lymphatic absorption and the local character of the initial lesion be accepted, it becomes highly probable that such complete de- structive action as occurs in the case of phagedena, would result in the death or elimination of all the virus and the consequent protection of the system. This same view would also seem to give strength to those syphilographers who are still believers in the essentially syphi- litic character of the chancroid, and who attribute its general innocu- ousness to the elirainative action of the pus which it secretes. Occasionally extreme adenopathy occurs during the later stages of syphilis as a result usually of guramous infiltration, and if it affects the inguinal glands, and happens to be coincident Avith an ulceration of the genitals, it may be mistaken for chancroidal or sympathetic bubo. The treatment proper for the latter affections would of course be more than useless in this case, Avhich requires for its cure the vigorous use of mixed treatment. The history of the case should be carefully inquired into, and if there be ground for reasonable doubt as to the character of the enlargement, specific treatment should be tentatively employed. In the absence of such treatment the condition may remain un- changed, or the skin may soften and ulcerate, and the disease assume the appearance of a pustulo-crustaceous syphilide, which would of course be recognized very promptly.^] Sypiiilides ; their General Characters ; their Classifica- tion. — Constitutional syphilis exists when an indurated genital chancre is followed by a painless, hard swelling of the inguinal glands. The change in syphilis, of the lymphatic glands, is so characteristic that from it alone the diagnosis of syphilis is possible, especially when [' A case of this character, in which no syphilitic history was obtainable, but which subsequently developed well-marked syphiloderniata was rejiorted by Dr. F. R. iSturgis, in the Boston Medical and Surgical Journal, February 3, 1881. Dr. L. Duncan Buckley, in The American Specialist, January 1, 1881, reports a case of enormous double cervical adenopathy occurring eleven months after infection, and coincident with a papulo-syphiloderm. The condition here was probably similar, but the syphilitic history, the presence of the eruption, and the situation of the enlargement made the diagnosis easy. It can readily be understood that, in such cases, when the glands of the groin are attacked, and the patient either ignorantly or wilfully denies previous syphilis, the recognition of the true condition may be extremely difficult,] 126 SYPHILIS. the cervical, maxillary, and other lymphatic glands are invaded as well as those in the inguinal region. The eruptions of the skin and mucous membranes soon make their appearance, and constitute the first manifestations of the secondary stage of syphilis. Syphilides usually appear about the forty-fifth day after the be- ginning of the infecting chancre, sometimes sooner, at other times later, even two or two and a half months from the date of the chancre. They are seldom as late as three or four months, yet they have oc- curred even after five months have elapsed. The mercurial treatment, given during the existence of the chancre, has been accused of caus- ing this retardation of syphilides, but it must not be forgotten that the evolution of the disease is very variable. Very often the eruptive lesions of the skin and mucous membranes besrin at the moment the chancre is healed and cicatrized. The different classifications of writers on syphilides are all partly correct, but contain many defects ; it is difficult, however, to make a perfect classification, because there are many conditions to be consid- ered, such as the date of attack, the gravity of the disease with dif- ferent patients, the different anatomical lesions, etc. A complete classification, which would include all these conditions, would be too complicated. Most writers have based their classification, as Willan, upon the anatomical alterations of the skin ; in which are included, at the same time, the order of their appearance and evolution, for cutaneous and mucous syphilides are more superficial when they are more recent, and grow deeper as they grow older. Thus the syphilides of the first period of secondary lesions affect only the papillary surface and epi- dermic layers. These are, according to the anatomical classification, erythemata or superficial spots, as roseola ; limited, slight, and tem- porai'y inflammations of the papillary and epidermic layers, as papules. The older syphilides, on the contrary, belonging to the later second- ary period, appear as pustules or tubercles, which affect the deep dermic and sub-dermic layers in connection with the papillary net- work and epidermis ; they are destructive, and are followed by cica- trices. Therefore the anatomical classification will be retained, as it indicates with sufficient exactness the successive evolutions of syphilides from the surface to the deep parts of the skin ; the sequence of the deep lesions, followed by ulcerations and cicatrices upon the superficial and benign lesions. CLASSIFICATION OF SYPHILIDES. 127 The following is the classification we have adopted : — f Diffused ; 1st. Erythematous syphilides (ro- J ^^r , . seola). 2d. Papular Syphilides. Papular. Small papules. — (Papular or papulo-granular syphilide) ; Miliary syphilide ; Conical, lichen-like syphilide ; Large papules. — Patches of pa- pulo-lenticular syphilide ; Papulo-tuberculous ; Papulo-squamous. Varicelliform ; Eczemiform ; Herpetiform. Acneiform ; Impetiginous ; Ecthymatous (sometimes super- ficial and precocious, sometimes late and ulcerated) — ulcerous ecthyma. Pemphigus ; Rupia. 6th. Gummous and tubercular syphilides. 3d. Vesicular syphilides. 4th. Pustular syphilides. 5th. Bullous syphilides. In this classification there is indicated the gradual passage of the superficial lesions of the early period of secondary symptoms, the roseola and the papules, into the deeper and later lesions of the second period, such as ecthyma, and finally into the rupia, tubercles, and gummata of the third period. This transition is so insensible that some writers place the deep ecthymata, rupia and the ulcero-crustaceous syphilides, with the ter- tiary lesions of syphilis, while others, as Fournier, admit as tertiary syphilis only gummata ; this distinction has no positive value. Syphilides of the first period are almost always polymorphous, that is, the eruptions present at the same time the different varieties of roseola, papules, small pustules or scabby papules, and mucous papules. In ordinary eczema or impetigo of a strumous nature, we 128 SYPHILIS. have the same elementary lesion of the skin, and the same appearance of all the regions affected; but, on the contrary, there are found in syphilis varied elementary lesions, spots of erythema alongside of papules and vesico-pustules, and other lesions modified according to their location. If a number of syphilitic patients are^examined, there will generally be found several who, together with an erythematous roseola, either beginning, or terminating, or replaced by pigmented spots, will show some papules of roseola upon the chest, or larger and more prominent disseminated papules upon the arms, palms of the hands, and back of the neck ; vesico-pustules or small, scabby papules upon the scalp ; partly scaly and partly mucous papules at the angles of the lips or eyelids, or a variety of mucous patches upon the vulva and in the mouth. In other cases, there Avill be seen a papular syphilide in a somewhat chronic state; the papules when upon the skin of the limbs appear dry, their epidermis desquamating, or when upon the scalp appearing as scabby pustules with a yellowish exudation, consisting of epidermic laminae, and of sebaceous and pus cells ; the same papules, if seated upon the nipple, are large and scabby; beneath the scab, which is only an exudation containing pus corpuscles mixed wuth dry epidermic cells, there is a serous or puriform oozing. In those regions where the skin is in folds, as upon a dependant mammary gland, the papule instead of being dry, is moist : upon the palm of the hand, where the epidermis is corneous and thick, the epidermic layers over the papule form hard scales, which have incorrectly been compared with psoriasis (psoriasis palmaris). The epidermic layer faUing off from these palmar papules leaves a smooth deep copper-red surface, covered by the rete mucosum and a few of the cells of the corneous layer. The most superficial epidermic cells, lost over the surface of the papule, form an elevated border around its circumference. This polymorphous condition, in relation to the seat of the lesions, is more apparent than real, as will be shown when the pathological histology of the several syphilides is studied ; but it should be re- membered that the variation in appearance, and the blending together of the elementary lesions are among the best diagnostic characters of the general semeiology of syphilides. It is the same with syphil- ides of a later period, the elementary lesions being so seldom isolated, that it is difficult to decide whether to place a given eruption among the pustules or bullae, among the tubercles or gummata. There are frequently seen syphilides which involve all the layers of the MUCOUS PATCHES. 129 derm and epiderm, and they are given compound names, as papulo- vesicular, papulo-pustular, tuberculo-pustular, etc., names which define themselves. The cutaneous syphilides have, for the most part, as a common cha- racter, a special coloration, which is said to resemble that of copper or tlie pinkish-yellow color of ham ; this coloration is owing particu- larly to extravasations of red blood-corpuscles ; as the spots are dis- appearing they become yellow, greenish-yellow, gray, following the tints of blood pigment in a superficial ecchymosis. The spots or papules for a time remain of a whitish color, but even when they have entirely disappeared, the surrounding skin is still a little pigmented (pigmentary syphilide, vitiligo). This special hue of syphilides is marked in the eruptions of the first period ; the ulcerous and scabby syphilides, on the contrary, frequently present at their border a pale color, which is not at all characteristic. The copper color is not seen in lesions of the mucous membranes. Another distinctive character of syphilides, except diffused erythe- matous roseola, is that they all have a regularly round shape, whether isolated or in groups. They form small circles, figures of 8, etc. Finally, the lymphatic glands are always aifected in the region invaded by the eruptions, and the action of mercury upon these eruptions is to cause their rapid disappearance. Syphilides are divided into cutaneous syphilides and syphilides of the mucous membranes, the latter including mucous patches of the secondary period, and some of the ulcerous syphilides of the tertiary period. Such are the general characters of syphilides. They will now be studied in detail. The histological changes which constitute the transformation of a papule into a vesico-pustule, or of a tubercle into a gumma, will be especially explained, so that the appearance of lesions may be Avell understood, and an examination of the surface of these eruptions will indicate the changes which have taken place in all the deeper layers of the skin. Mucous Patches ; their Different Types. — A mucous patch is of itself positive evidence of the existence of constitutional syphilis. Moreover, it is, of all syphilitic lesions, the one which most frequently returns ; it constantly reappears Avith any new outbreak of a cutane- ous syphilide. It is easily cured, or rather made to disappear from 130 SYPHILIS. the mucous membranes, but it recurs quite as readily. Patients leave the hospital cured of raucous patches at the end of a month's treat- ment, but they soon return with a relapse, and this is often repeated during two or three years, sometimes longer. In very young girls who are hospital patients, mucous patches of the vulva are not so difficult to cure or so apt to return as in adult women. This is explained by the less active state of the organs, due to the ab- sence of any genital function, and of menstruation ; but the duration of mucous patches of the lips or throat in children is equally as long as in older persons. Thus, in cases of congenital or acquired syphilis in infants, mucous patches of the mouth are seen to return during a period of four or five years. The several types of mucous patches are : — 1st. Small papules. — This variety occurs most frequently with papular roseola, or with cutaneous eruptions of small size, as miliary cutaneous papules and syphilitic acne ; these papules, which are seated upon the vulva and labia majora, with the exception of their size, present exactly the same characters as the following. 2d. Large papular jxitchcs. — These are the most frequent of all : their shape is generally round and regular. Those situated upon the skin are to be distinguished from those upon the mucous membranes. The former are always characterized by a papule, a regular thick- ening of the superficial layers of the skin, which forms an elevation I'epresenting a segment of a sphere. Their surface is red, smooth, polished, and moist ; at times they present a very superficial erosion, an elimination of the most superficial layers of the corneous epidermis. Upon the mucous membrane of the labia minora and of the vulva, the surface of the more or less prominent papule is whitish, owing to an imbibition of fluids, and to changes in the epithelial layers. jNIucous patches of the lips, tonsils, etc., present the same whitish-gray color and opacity of their superficial layers, as do those of the labia minora. 3d. Eroded mucous patches are only an ulcerated state of the preceding. 4th. Mucous ptatches loith indurated base. — In hospitals, patients are often met Avith, who have mucous patches situated on labia which are inflamed and oedematous from the irritation of a recent chancre ; these mucous patches, which are sometimes ulcerated, and the bases of which are indurated, rest upon a tissue already altered, and would be very difficult to distinguish from a chancre, if other HISTOLOGY OF MUCOUS PATCHES. 131 mucous patches were not frequent upon the vulva or elsewhere, or if only one of the patches were indurated. 5th. Diphtheritic mucous patches. 6 th. Hyijertrophied pajJides. 7th. Vegetating pap)ule8. — Even as the chancre may be occasion- ally, though rarely, changed into a raucous patch, so may a mucous patch be transformed into vegetations. Before describing the pathological anatomy and symptoms of the several varieties of these lesions, their most common seats should be pointed out. These are first, in the order of their frequency, the genital organs and region of the anus. But their location varies according to the sex. While with women mucous patches of the labia and of the vulva are almost constant in syphilis, with men, on the contrary, they are not very frequently met with on the prepuce or glans, the most common seats being the scrotum and anus. With women the anus is also frequently the seat of mucous patches, which occur in the radiating folds of this region, and occasion a tumefaction of the surrounding skin. The frequency of mucous patches upon the lips, tonsils, tongue, arches of the palate, eyelids, etc., is about the same in both sexes. ]\Iucous patches of the breasts and umbilicus are observed almost ex- clusively in women ; they are, however, much more rare than the preceding. Upon the neck of the uterus, mucous patches are very frequently seen. The special form of mucous patches Avhen they ai*e seated at the commissures of the lips and eyelids has been previously mentioned ; upon the skin side they present a small elevation, often scabby, and upon the mucous side a white patch. [Despr^s records five cases in which vegetative mucous patches occupied the external auditory meatus ; they caused a moderate amount of offensive discharge, and were covered at their most external portion by a grayish crust. He believes they appear by preference in patients who have previously had otorrhoea. He has also observed mucous patches upon the concha, in the perforation of the lobule, upon the vocal chords, on the caruncle of the eye and the conjunc- tiva, and in the umbilicus.] PATnOLOGICAL An ATOMY AND SYMPTOMS OF MuCOUS PATCHES. We may begin with the flat papule (moist papule) of the skin or labia 132 SYPHILIS. raajora. Nothing is more simple than its structure. If a thin section made through its greatest diameter be examined, it will be found that it is formed of a regular, imbricated thickening of all the superficial layers of the skin, corneous' epidermis, granular layer, rete mucosum, papillae, and derm. The epidermic layers are seen gradually to increase in thickness from the normal skin to the summit of the papule, and then again to diminish ; the normal papillae, at the border of the papule, progres- sively enlarge until at the central part of the papule they are two or three times their natural size. The rete mucosum penetrates between the hypertrophied papillae, as far as their base by epithelial prolonga- tions, separating one papilla from another. These appearances of mucous patches may be seen with low power. In studying preparations with high power, we find that the cells of the corneous epidermis and rete mucosum undergo the same lesions that have been described apropos of chancre : i. e., an excavated state of the corneous cells, with atrophy of their nuclei — conditions com- parable to vegetable cells — and desquamation of the most superficial epidermis. In some of these cells, which have been transformed so as to include small cavities, or which have united to form large cavities, several pus corpuscles are often seen. The desquamation of the corneous cells, and the presence of fluid and pus corpuscles in the interior of such of the corneous cells as may remain, or in the rete mucosum covering the papillary layer, fully explain the smooth and moist state of the surface of mucous patches. The cells of the rete mucosum sometimes show an analogous lesion — the formation of a cavity between the nucleus and substance of the cell — but it is particularly in the superficial layers that this alteration is observed. When a cutaneous mucous patch of the labium majorum, for exam- ple, is slightly ulcerated, but still has a smooth, moist, red or pink surface, it means simply that the superficial corneous layer of the epidermis has entirely disappeared ; there is then seen at the periphery of the patch a thin border which is the limit of the normal epidermis ; the surface of the ulcerated patch is covered by the thick and transpa- rent granular layer and hypertrophied rete mucosum. Beneath the latter — the rete mucosum — the hypertrophied papillae present an embryonal state of their vessels, a swelling of their endo- thelial cells, and an infiltration of round cells between the fibres of their external coat. The connective tissue presents the same infiltra- MUCOUS PATCHES OF THE TONSILS. 133 tion of lymph cells between its fibres. There is always in the papillae, and surrounding connective tissue of the derm, a true inflammation, which is evident from the tumefaction of the fixed cells, and the pres- ence of round migratory cells or proliferated cells. Such are the histological lesions of simple mucous patches of the vulva, whether small, miliary, and conical, or large, flat, and lenticu- lar, when located upon the skin of the labia majora or upon the raucous membrane of the nymphae. In the very soft moist part of the labium majorum the mucous patches, instead of being red and polished, are partly eroded, and appear covered with small, whitish granules, which resemble starch-grains moistened with water, or look like moist filtering paper. The most opaque points are simply collec- tions of epidermic cells softened by the imbibed fluids, and many of ■which have been changed so as to enclose a small cavity ; a few of these cavities contain one or more pus corpuscles. Whatever may be their seat or their appearance, remember that the regular thickening of the papules is due always to the inflammatory hypertrophy of the dermic and epidermic layers. Therefore it is not astonishing to find, in a confluent and persistent eruption of mucous patches of the labia a considerable inflammatory thickening of the derm. In many cases the skin is hard, thick, and of a deep red color. Mucous patches of the arches of the palate, the palate, and the tonsils, also of the tongue and lips, are slightly elevated, with a regular surface, oval or circular in shape, gray or whitish in color, and have the opaline appearance of mucous membrane which has been touched with nitrate of silver. This surface is smooth, and the white color gives the impression that the opacity of the part is in the most superficial layers of the pavement epithelium. Such patches are preceded by a redness of the palate and arches, and they are, almost always, accompanied by a hypertrophy of the tonsils. Several writers, particularly Aime Martin, think that the hypertrophy of the tonsils is primary, and the mucous patch second- ary. We have examined a number of women and children in regard to this point, and have several times positively seen the mucous patch begin before there was any tonsillary hypertrophy. Yet this hyper- trophy is very common, and may be primary, which is easily explained, since the whole organ may be considered as a lymphatic gland, and it undergoes the same lesion that all lymphatic glands experience (see p. 23). When one of these hypertrophied tonsils covered with opaline mu- 134 SYPHILIS, cous patches is removed, and thin sections are made of it, after hardening, there are found exactly the same changes as described in the vulvar papule. Upon all parts of a tonsil, which is the seat of a papule, there are seen the same thickening and the same inflam- mation of the epithelial layers of the papillary network and of the derm. The entire section, made vertical to the surface, forms a regular curve ; the papillae are two or three times longer than normal ; the epithelial layers penetrate between and separate them ; the most superficial layers of the epithelium show excavated cells with atrophied nuclei, or containing several nuclei or pus coi'- puscles. There are, in this superficial layer of the epithelium, small nests filled with pus corpuscles, true minute abscesses, containing four, ten, or even a hundred or more pus corpuscles. These small abscesses frequently open upon the surface of the mucous membrane, and form cup-like cavities which contain pus cor- puscles. This lesion cannot be considered an erosion of the patch, since the surface, to the unaided eye, is perfectly smooth, regular, and elevated, instead of ulcerated. The surface, although smooth, is moist, oozing, and discharges broken-down cells ; the cavities in the Fig. 24. Mucous patch from the tonsil, a. Thick ci..tl;L.;,i. i,i, u; il the swollen mucous patch, a'. Nor- mal epithelial layer. 6. Cavity filled with pus cells, excavated in the superficial layer of epithe- lium, and opened upon its free surface, c. Cavity also contaiu'ng pus in the epidermic layer. p. Hypertrophied papillte.;f!^v;*' Mucous patch of the tonsil, a. Superficial epidermis. m,7n. Cavities formed iu the epidermis, aud filled with pus corpuscles, n. Large cavity of tlie same nature situated near tlie surface of the patch, c. Cells of tlie rete mucosum, many of which present cavities between their nucleus aud the substance of the cell. d. One of these cellular cavities, p. Papillae. X 150. the cells of the rete mucosum, c, are mostly excavated, forming cavi- ties, seen even with this power. Figures 26 and 27 also represent mucous patches of the tonsil, magnified 60 diameters. In Fig. 26 the epithelial layers are very thick, the papillae are also thickened and elongated. In Fig. 27 the superficial layer of the epidermis presents several small abscesses similar to those represented in Fig. 25. But in Fig. 27 the epi- thelial cells are partly disintegrated, and the patch is in places ulcerated. 136 SYPHILIS. Figure 28 is a drawing magnified 300 diameters, of a part of the epithelial surface of a mucous patch of the tonsil, showing the details Fis. 26. Section of a mucous patch of the tonsil, a. Superficial epidermis. 6. Elevated part of the superficial epidermis, c. Rete mucosum, of Avhich the cylindrical cells, d, cover the much hypertrophied papillse, e, e, e'. The mucous epidermis is very thick over the entire region of the mucous patch extending from m to n. e'. A transverse section of a papilla showing its vessels. t. Embryonal connective tissue, v. Its vessels. X 60. of structure of the cellular cavities. Between some the uniting cement is seen, d. A few possess an atrophied nucleus in their Fig. 27. ■Jl 6 ^^ n Section of an eroded mucous patch of the tonsil, m. Fal«e membrane, consisting of pus coi-- puscles and fibrin upon the surface of the patch, d. A small abscess limited by the superficial epidermic cells, c. /. A small abscess of which the pus corpuscles are granular. n',n'. Abscess of the same kind limited upon all sides by layers of epidermic cells, n, 6', n. Rete mucosum. ■p. Elevated superficial epidermic layer, t. Hyperplastic connective tissue, 'o. Vessels. X 60. cavity, 5; others are empty, a; others, , form a network with irregular meshes in which are found lymph cells of various shapes, some flattened against the fasciculi, some round and others oval, etc. The cells of the rete mucosum, a, present numerous round or oval openings, b, c, d, which contain either the nucleus of the cell or a round cell. There are also seen the pro- longations, 7«, m, that the cells of the rete mucosum send into the papillary tissue. Between these prolongations the papillary tissue shows cells of new formation: for example, the cell n is seen lodged between the prolongations from the cell m of the rete mucosum. In the large papules, there is not only an inflammation of the papillae and the superficial corium ; but the entire derm, and with it the svibcutaneous cellulo-adipose tissue is inflamed in a like manner. In the derm, the fibres of the connective tissue are separated by HISTOLOGY OF SYPHILITIC PAPULE, 177 round cells arranged in rows or by the fixed swollen cells of the con- nective tissue. More deeply it is found that the adipose cells of the Fis. 36. Section of a papulo-squamous lenticular papule of the skin. a. Spinous cells of the rete mu- cosum. h, d, c. Openings which perforate these cells, or which separate them, m, h. Prolonga- tions from the cells into the papillary tissue, d'. Lymph cells situated between the delicate fibrils and fasciculi. »t. Lymph cells placed between the prolongations of the cells of the rete mucosum. X 250. subcutaneous cellular tissue are inflamed ; each adipose vesicle is surrounded by a circular row of lymph cells, and the fat is absorbed ; the entire fat lobule is transformed into islands of embryonal connec- tive tissue, the fat having disappeared. The alterations of the epidermis and derm, in the large cutaneous papules, are seen very closely to resemble the modifications which occur in the epithelial covering of the corium of mucous membranes affected with syphilitic papules. The same changes may be traced in both, differing only on account of the difference in structure of the skin and mucous membranes. But there are also other dissimilarities. In most of the preparations of cutaneous papules, there are seen a few papillae which have a tendency to separate from the rete mucosum. In sections there exists a distinct cleft between the summit of the papilla and the rete mucosum. These spaces are not empty during life, but are filled with blood plasma, numerous red blood-corpuscles, and a few white blood-corpuscles. In Figure 3-1 (see page 175), the papillae, c, are seen separated from the rete mucosum : in a papule which I have seen, there was an effusion of blood interposed between the papillae and rete mucosum. This is represented in Figure 37. As each papilla is covered by the cap formed by the rete mucosum ?n, and its inter-papillary prolongations m', there result as many small, limited, and circumscribed effusions of blood, o, as there are papillae. 12 178 SYPHILIS. Yet the rete mucosum was in places completely raised by the blood, so that its prolongations and the superficial portion of the ducts of the sudorific glands were separated from the papillae. Hemorrhagic squamous papule, e. Corneous epidermis forming thick scales, m, m'. Rete mucosum sending epithelial prolongations between the papilla, o. Spaces filled with blood situated hetweeu the papilla; and rete mucosum. v. Dilated vessels at the summit of the papilltC. •»', v'. Bloodvessels much dilated and filled with blood at the base of the papilla. X 40. It is very important to recognize these effusions of blood in syphi- litic eruptions. They account for the special copper coloration of the eruptions, as well as for the various secondary tints which are seen during their recovery, and which are exactly the tints of ecchymoses and infiltrations of the skin by the blood pigment. These bloody effusions are a manifestation of the alteration of the blood in syphilis — of the diminution of the corpuscles. The blood more easily passes through the walls of the vessels ; the latter are, however, dilated, and their walls are changed in the inflamed papilltie. In preparations of hemorrhagic syphilitic papules, the vessels are always found dilated, and their walls thinned at the summit of the papillae. These syphilitic papules, covered with thick and superficial layers of corneous epidermis, that is, Avith scales, are termed papulo-squamous syphilides. They are generally very obstinate, since the thick layers of the epidermis repose upon the thickened and chronically inflamed derm. But in the majority of lenticular papular syphilides, the superficial layer of the epidermis, that which is raised up in Fig. 32 (see page 173) has fallen off, and the surface of the papule is copper-red in color, smooth, and surrounded by a very distinct border, which belongs to SQUAMOUS SYPHILIDES. 179 the superficial epidermis of the neighboring normal skin, and forms a circular margin to the papule. This variety of cutaneous papules, Fournier names eroded papules, but they scarcely merit the name, since we really have not a complete erosion. In the papules that I have examined, the whole of the corneous epidermis has not been absent ; there always remained a notable layer which adhered to the granular layer and to the rete mucosum. But the amount of corneous epidermis which remains is very small, since this layer and the rete mucosum, by their transparency, permit a view of the papillse traversed by vessels filled with blood, so that the red color due to the inflammatory and ecchymotic congestion of the papillary network is very distinct. The term eroded papule may be retained, provided the anatomical change it corresponds to be not forgotten. The term squamous papule or papulo-squamous syphilide, which corresponds to a very characteristic group, should also be retained. The squamous syphilides have frequently been named syphilitic psoriases. The use of this compound word is not to be recommended, since the radical psoriasis represents a very distinct idiopathic cuta- neous disease, which has little in common Avith syphilis. Although there is, between the papule of psoriasis and the syphili- tic papule, considerable analogy, if not absolute identity, as regards the chronic inflammation of the skin, and the inflammatory hypertro- phy of the papilUie, yet the scales of psoriasis are, on the contrary, quite difierent from those of syphilis. The former, those of psoriasis, are bright, and of a silver white appearance when removed by scratch- ing with the nail ; they are seen as small, thin scales, easily detached, and the difierent stratifications have the same brilliant and mica-like aspect. This is not the case with the squamous syphilide ; the scales in this lesion are more adherent, more granular, grayer, more of a dirty gray color, and their stratification is by no means regular ; they have not the silvery appearance of psoriasis. Finally, the syphilide has not the same topographical distribution as psoriasis. The latter has for its most frequent seats the elbow and knee, the extensor cutane- ous surfaces of the limbs, while the syphilide is found upon the face, neck, trunk, anterior surfaces of the limbs, and inferior part of the thorax and abdomen. The name psoriasis has also been given to the squamous papules, covered with or deprived of their epidermic layers, which are situated upon the palms of the hands and soles of the feet. This is called palmar 180 SYPHILIS. or plantar psoriasis. This name is not advisable, since the papules are modified simply on account of their seat, and the structure of the skin of the hands and feet. Here the corneous epidermis attains considerable thickness and resistance ; it forms a layer which at times measures a millimetre in thickness and is dense and hard like parch- ment. Thus it offers more or less resistance to the development of the papules, especially at their beginning. These papules for some time remain flat and depressed^ on account of the thick epidermic covering, and their elevation is but slightly or not at all appreciable. Later, however, the epidermis covering the papule is raised, ci'acked, and partly or completely eliminated, or it forms hard and irregular strati- fications. The thick and corneous scales which cover the papule, have given the lesion the name of psoriasis. And as true psoriasis seldom or never occurs upon the palm of the hands or sole of the feet, Avhile these regions are a favorite seat for syphilides, it can be said that palmar or plantar psoriasis is generally syphilitic. Hardy and Bazin, however, admit a variety of non-syphilitic palmar psoriasis. The different cases of syphilitic palmar psoriasis that one meets with could not usually be mistaken ; at first they are seldom covered by epidermic scales ; generally the corneous layer of the epidermis has fallen from their surface, and it is arrested at the circumference of the papule, constituting a narrow border, fre<|uently separated from the subjacent skin. This margin or border of Biett is formed by a thick epidermis, which is directly continuous with the normal skin at the periphery of the papule. The papule is red, smooth, dry, and upon palpation its surface is found firm, owing to the thick papillary layer being covered by the rete mucosum and an appreciable layer of the corneous epidermis. Such papules are positively characteristic of syphilis. For the treatment of the severe forms of papulo-squaraous syphil- ides of the hand, those in which very thick callous-like masses are found in consequence of the epidermic accumulations and the induration of the derm, Ave have several times employed gloves made of India- rubber, which have the property of softening the epidermis, causing the scales to desquamate, and rendering the derm more pliable. This local treatment is difficult to carry out, and in order to be active, should be combined Avith mercurial medication. Although the papular syphilide is thus modified beneath the hard epidermis of the palms of the hands and soles of the feet, it presents HISTOLOGY OF SYPHILITIC PAPULE. 181 changes quite the opposite when situated upon regions where the skin is delicate and moist. Thus, in the flexures of the limbs, the folds of the elbow, of the groin, etc., every degree from squamous or dry papule to moist papule or mucous patch is met with. In those regions Avhere two skin surfaces are in contact, this transformation of the dry into moist papule always occurs, for example, at the umbilicus, mammae, axillie, etc. These metamorphoses are readily accounted for. The lesions are the same in all cases : there are pus corpuscles in the desiccated lamellae, as upon the surface of the mucous patch; the epidermic layers are dissociated, and their cells separated, if they come in contact with a fluid ; they are solidified and remain in place, if they are ex- posed to the air. Thus far in the description of papules, the pheno- mena which occur in the hair follicles, sebaceous and sudorific glands have been omitted. The role played by these structures in the limited inflammations, which constitute the syphilides, is not so important as that of the papillae and epidermic layers, although it may be said that the follicles and glands undergo the same alterations as the connective tissue and epidermic cells. The epidermic cells of the sheaths of the hairs are modified in the same manner as the cells of the rete mucosum ; the connective tissue and the vessels which surround the sudorific glands experience changes similar to those which aflect the connective tissue and vessels of the derm. The epithelial cells of the sudorific glands are swollen as in all cutaneous inflammations : the cells of the seba- ceous glands are also in a state of hyperplasia, and their fat is dimin- ished. These are lesions which occur in these structures during the course of any inflammatory processes. Therefore it is well not to accept certain descriptions of syphilides in which it is stated that a papule, a vesicle, or a pustule has its origin around a hair, and that the hair is found in the centre of a fully developed papule. This description of the importance of the hair follicle in syphilitic eruptions is found in Bassereau's book, otherwise one of the best monographs upon syphilides ; it also occurs in Neumann's work, etc. In regai'd to the bloodvessels which are found in the papillse and in the derm at the base of papules, it has been mentioned that the capillaries were frequently dilated, and that their walls were changed, as in all inflammations, in such a manner as to permit the passage of the red and white blood-corpuscles through them. But the large, deep vessels of the derm and subcutaneous tissue never have their walls indurated and thickened, as occurs at the base of a chancre. 182 SYPHILIS. [The essential histological changes, which enter into the formation of a syphilitic papule, are a hypertrophy of the papillae of the skin, an increase in the number of epithelial layers which form the epi- dermis, and a proliferation of the cells of the rete mucosum. The bloodvessels are congested, and there occurs an extravasation of the blood elements into the tissue of the derm, which gives the charac- teristic coloration to the lesion. Cavities are formed, and the nuclei divided in the cells of the epidermis. Desquamation of the superficial layers of the skin is one of the features of the papule. The changes are not limited to the papillae and superficial corium, but in some varieties the inflammatory process extends to the subcutaneous adi- pose tissue, and an infiltration of the fibrillar connective tissue of the entire derm with embryonal cells is present. There is seen no vas- cular sclerosis comparable to that met with in the chancre. Tliese changes are modified by situation, duration, etc., and will be found fully described under their appropriate headings.] The diagnosis of a large papular syphilide is never very difficult. If the special color of syphilitic eruptions be remembered, if the arrangement and modifications of the papules according to their seats be recalled, if the palms of the hands and soles of the feet be ex- amined, also the palmar surface of the fingers and plantar surface of the toes, where the same syphilides so frequently are seen, if the lymphatic glands are palpated, and the mucous membrane examined, there need be no hesitation or error in diagnosis. The papular syphilide is the most characteristic of all, and the most common after roseola. Its duration is relative to its intensity, but it is seldom that a syphilide with large papules continues less than two months, and frequently it remains three, four, or five months, especially if mer- curial treatment has not been employed at all, or too timidly. There is no form of medical treatment in which the curative power of a remedy is so evident and so admirable, as in the use of mercury in cutaneous syphilides, and particularly in the severe forms of papulo- squamous eruption. Onychia and Alopecia. — With syphilitic papules and at the same time with secondary syphilides, there occur two lesions allied to the lesions of the epidermis ; they are the changes of the nails and hairs. OnycMa is a disease of the nails which results from the anatomical structure of the matrix of the nail, and of the peri- and sub-ungual SYPHILITIC ONYCHIA. 183 papillo-epidermic tissue. There are described two varieties — the dry and the moist. V The dry variety of onychia generally accompanies the papular and papulo-squamous eruptions situated upon the fingers and toes. At the same time that the palmar or plantar papules appear, the ends of the fingers or toes are attacked by papules, which pass around their ex- tremities ; they are also seated at the roots, edges, and under the nails. Onychia is very variable in intensity. Sometimes the nail is slit, cracked, and readily broken ; it is dry and separated from the skin, so that a probe may be introduced between the nail and skin. When the papules exist at the ungual matrix, there is a swelling and an elevation of the skin at this region, and the formation of the epidermic layers of the nail is very much interfered with. At times there is an irregular thickening of the nail, by hard scabs, which are stratified and occasion a dense irregular elevation of a gray or opaque ungual mass, somewhat difficult to separate ; sometimes these masses are divided by deep transverse furrows. When the lesion is disappearing, and the papules are effaced and lose their color, the nail reforms beneath the preceding layer, and when the .latter falls off, under it is observed a transparent regular nail which permits the pink color of the papillary vascular network to be seen. These forms of onychia, due to papules of the nail and its root, are very common, the same patient being affected with them upon most of the toes and fingers ; or they are limited to one or two fingers or toes. Upon the toes they may be accompanied with a certain amount of oozing, and here is often seen, especially upon the great toe with per- sons who have their shoes too small, the painful inflammatory lesion of in-growing toe nail. The moist variety of onychia occurs with vesiculo-pustular or pus- tular syphilides. Sometimes true whitlow is met with, that is, a little pus forms beneath the epidermis of the ungual matrix, a suppu- ration or oozing into the lateral furrow of the nail. The suppuration, the nutritive changes of the nail, the inflammatory granulations of the skin of the nail, all constitute a small group of symptoms which terminate in a destruction of the nail, and necessitate rest, poultices, and afterwards some simple dressing,^ [' JuUen describes several forms of syphilitic oiiycliia, but calls especial atten- tion to the entire absence of pain, which he says characterizes all of them, the patient in some cases only becoming aware of the affection npon discovering the loss of one or more nails.] 184 SYPHILIS. Partial or complete alopecia of the scalp is a result of squamous or scabby papules, which are sometimes found here in great numbers. The falling out of the hair is also observed without our having seen any eruption upon the scalp, perhaps without any eruption having occurred. This alopecia, which supervenes during the secondary period of syphilis, and generally in the first year, is not permanent. The hair grows again as after typhoid fever, but it is often dull, brittle, and dry, although quite abundant. The scalp alone is not affected, the beard may also be lost as well as the hair of the genital region ; this, however, seldom occurs. Besides this early alopecia, many authors describe an alopecia which occurs late in the disease, and comes on gradually without the occurrence of any antecedent eruptions of the scalp. Fournier does not admit this kind of syphilitic baldness. He says " syphilis has never caused bald heads," [Fournier makes the following division of those cases of alopecia, which are not connected with evident and unmistakable lesions of the scalp : — • 1. Senile alopecia : — This is usually a consequence of age, but may begin early in life. Its causes are various and are but little understood. It is not known why it aflFects men so much more frequently than women, nor why it sometimes occurs in individuals in the most vigorous health and under the best hygienic condition, nor why certain families are especially liable to it. It is often associated with gout, may follow all kinds of excesses, mental or physical, and has been produced by intense grief or anxiety. It has these distinguishing characters: a, it is slow and progressive, occupying months and years in its course ; 6, it is con- fined to a definite circumscribed region, the vertex and the antero- superior part of the cranium, respecting the lateral and posterior parts ; c, it is absolutely symmetrical, affecting both sides exactly alike. 2. Cachectic alopecia : — This may occur during any severe illness or chronic, deep-seated malady, such as cancer, diabetes, tuberculosis, etc. It is general, dis- seminated, attacks all the scalp at the same time, and leaves the re- maining hairs, dull, dry, pulverulent, " like the hairs of a corpse." 3. The alopecia of convalescence : — Many grave diseases are followed by alopecia immediately upon their subsidence. Typhoid fever, erysipelas, pneumonia, all the ex- ALOPECIA. 185 anthemata, when intense, are apt to cause a general falling out of the hair. This may happen in women after a normal labor, and with no concurrent disease whatever. This form of alopecia is produced by the disturbance of nutrition during the course of the disease, and is recognized by : a, the rapidity with which it supervenes upon the fever or other ailment Avhich caused it ; h, its general and irregu- lar distribution ; . Papillae placed between the normal aud changed papillae, r, r. Prolongation of the rete mucosum belong- ing to the hair follicles and sebaceous glands, in' . Ulcerated part forming a flatsurfaceand cov- ered with a thin layer of flat cells, 'w, 1). Dilated vessels. *. Fasciculi of smooth muscular fibres. X 2"- ties are of variable size, and have their long diameter parallel to the surface of the skin. Upon examining the smaller cavities of the sub- jacent layer, e, it is evident that they are cavities in epidermic cells. Below the layer of cells, e, is formed a zone of large cavities,/,/,/, Avhich were originally filled with free pus cells displaced by the manipulation necessary for the preparation of the specimen. The walls of these large cavities are likewise formed by easily demon- strable corneous cells, some of which are detached, and appear in profile as at /i, or in full view as at ^, and the latter often contain a small empty cavity, and have crenated or indented edges. These walls often show notches as at /', and irregular branching processes, as is the case in all suppurations occurring amidst epidermic cells. There also are found, besides lymph and pus cells of the usual dimensions, some large cells containing two nuclei, /, or many nuclei, and even some cells containing red blood-corpuscles, i' . Then comes another layer, ^, in which are seen ramifying cells excavated with small cavities containing pus ; larger cavities are also observed. 196 ; -vaifiW -!y,«ii.ia Section of epidermic layers at the margin of an ulcerated ectliymatous pustule Part of Fig. 38 seen with higher power, a. Surface of the corneous epithelium, the cells of which form a limit- ing reticulum of the cavities, c, filled with pus corpuscles, d. Larger cavities, e, e. Layers of corneous cells with smaller cavities. f,f-,f- Large cavities having lost their pus corpuscles. /'. One of these large cavities containing pus corpuscles, h. Free cells g, g. Free cells exca- vated by a cavity, g' . One of these cells excavated and crenated. i. A free cell containing two nuclei, i". A free cell containing hloodcorpuscles. rii. Excavated cell forming a part of the partition of a large cavity, n. Projections having their origin from a cell which forms tlie wall. f. Layers of corneous cells more or less excavated with cavities, h. Layer of cells with indentations (spines). The rete mucosum extends from 6 to r. o. Cells of the granular layer. ^. One of these cells excavated with an oval cavity, the nucleus of which has disappeared. Many cells of the rete mucosum, r, for example, are excavated by a cavity at the position of their nucleus. X 250. Finally comes the layers of large spinous cells, either separated or united to one another. The granular structure presents a certain HISTOLOGY OF SYPI1[LITTC PUSTULE. 197 regularity, and the nuclei of the cells are sometimes preserved, as at 0, and sometimes absent and the cells excavated with a cavity, as at p. The spinous cells of the rete mucosura, r, are large, and almost inva- riably have a cavity around the nucleus, which latter is often atro- phied, replaced by granules, or absent. A part of a papilla may be seen at s. The figure under consideration is an example of one of the various forms presented by the altered epidermis at the edge of a pustule ; but these successive cavities filled with pus, and layers of altered epidermic cells, are very variable in their configuration. At the centre of the pustule the epidermis is destroyed, and the papilUie are laid bare, having upon their surface nothing but the pus, which, in drying, forms the imbricated layers of the crust of ecthyma. ~ The papillae at the margin of the pustule are hypertrophied, con- gested, with dilated vessels, and separated from one another by inter- posed prolongations of the rete mucosum. Fiff. 40. Section of the rete mucosum and of the papiUse of the deep-seated ecthyniatous pustule repre- sented iu Fig. 38. The two papillaj /;, p' are those figured at a and 6 in Fig. 38. a. Cavities formed in the corneous epidermis, and filled with pus corpuscles, e. Flattened epidermic cells. d. Cells of the rete mucosura which form a thin layer upon the surface of the papilhe j) and j)', and which penetrate between them at d'. d, v. Dilated vessels of the papillje filled with blood ; the connective tissue of these papillse Is transformed into true small abscesses containing a semi- fluid granular substance, some red and white blood-corpuscles. X 120. Figure 40 shows under a power of 120 diameters the two papillae figured at a and h in Figure 38. Beneath the corneous layer in 198 SYPHILIS, which are seen cavities filled with pus ?>, the rete mucosum forms a moderately thick stratum which sends in at d, d', prolongations be- longing to the sebaceous glands. The papillnep,^', thus limited by the epidermic cells resemble small abscesses. Their normal fibrous tissue has been destroyed, and only lymph and red blood-cells are seen in their interior. The capillaries v, V, which here form terminal loops, are enormously dilated. Figure 41 shows the condition of the cutaneous papillae converted into a uniform layer at a point near the centre of a pustule, as at m, Figure 38. There still remain some flat cells upon the surface of the inflamed connective tissue. The elevation of each papilla is no longer recognizable. The delicate fibres of this tissue are separated by a large quantity of pus cells, and the capillary vessels are much in- creased in size. In the ceatre of this pustule the papillary layer is no longer covered by the flat cells of the epidermis, and the lymph cells which infiltrate it are poured out directly upon the suppurating surface. FiK. 41. Section of the pustule, Fig. 38, at an ulcerated point, m. Superfleial and thin layer formed by flattened epidermic cells, c. Pus corpuscles free upon the surface ; the connective tissue is filled with lymph cells, v, v. Vessels containing red blood-corpuscles and lymph cells. The capillary vessels are much dilated. X 120. The deep layers of the skin are altered in the same manner as the papilloe, that is, there is a large exudation of lymph cells around the vessels, between the fibrillse and fasciculi of the elastic and connective tissues, around the fasciculi of smooth muscular fibre, in the lobules of fat — in brief — extending very deeply. DIAGNOSIS OF SYPHILITIC ECTHYMA. 199 Thus it is found, that the suppuration in ecthyma is of long dura- tion, attended with free formation of pus, and followed by an in- delible cicatrix, due to the papillce and the derm proper having been destroyed. The fibrous cicatricial tissue which repairs the pustule forms a slight depression, in the neighborhood of which the skin is at first stained and ecchymotic, subsequently white. [The histology of syphilitic vesicles or pustules does not differ from similar lesions due to other causes. The process of their de- velopment is essentially an inflammatory one. The proliferation of the elements constituting the skin results in the formation of a papule. Upon the surface of this papule there is exuded above the rete muco- sum, in the corneous layer, a yellow fluid containing lymph corpuscles, thus giving rise to the vesicle. An increase in the cellular elements of the fluid of the vesicle renders it purulent and develops a pustule. The pustule ruptures and its desiccated contents with the thrown-off" epider- mic cells constitute the scab. These changes may be limited to the cor- neous and Malpighian layers of the skin, or may extend deeper into the derm, involving the papillae and connective tissue, a true ulcera- tive process which results in an actual loss of substance, and the for- mation of a permanent cicatrix. The cells of the corneous layer and rete mucosum present the modifications met with in inflammation of the integument — an excavated condition of their protoplasm around the nuclei, formation of cavities, division of nuclei and development of foci of suppuration. Other minute changes depending upon the intensity of the disease, its duration, and location, are described under the several varieties.] The diagnosis of deep ecthyma does not depend, as is the case in so many of the superficial syphilitic eruptions, upon the copper color. This sign, so distinct in erythematous and papular eruptions, fails here. The edge of the ulceration, which looks as though it had been punched out, is red, if there be much inflammation — or it may be pale — or of a pinkish hue. The same color is noticeable in other pustular syphi- lides and in ulcerating syphilitic bullae. These ecthymatous ulcera- tions consequently do not materially differ in respect to color from the scrofulous and cachectic forms of the same malady. If the local lesion only were considered, the diagnosis between deep syphilitic ecthyma and scrofulous ecthyma would frequently be very difficult. The latter ulceration is often deep and with perpendicular borders, as in the syph- ilides ; the crusts, however, in syphilis, are drier, darker, and more imbricated, the cachectic lesion suppurating earlier and more freely, 200 SYPHILIS. consequently permitting of less adhesion of the crusts. This is not an invariable distinction, as in certain cases syphilitic ulcerations are attended with the formation of large quantities of pus. When the eruption is distributed upon the face and body as well as upon the limbs, the diagnosis of syphilis should be made, as the ecthyma due to scrofula is observed only upon the inferior extremities. It should be remembered, also, that syphilitic ecthyma appears usually in sub- jects previously enfeebled or placed under bad hygienic conditions, and is itself, by reason of the amount of suppuration when the pus- tules are numerous, a serious source of exhaustion. The history and concomitant symptoms almost always leaxl to a recognition of the disease, as it is a persistent eruption, lasting for months, or even for a year, and often reappearing with all its original characteristics. It necessitates a guarded prognosis on account of its persistence, and of the continual suppuration caused by it, especially when it is wide-spread. It is formidable also, because it indicates a grave form of syphilis, particularjy when it appears soon after the initial lesion. Impetigo rodens. — All that has been said relative to deep ecthyma applies equally to the grave ulcerative and suppurative forms of impetigo. 6th. Bullous Syphilides. — These consist of two varieties, rupia and pemphigus. Rupia manifests itself at first by large elevations of the epidermis, filled with a clear or blood-stained serum, soon becoming turbid and purulent. The bulla bursts, allows some of the liquid to escape, and as it desiccates is covered with a crust, which dries, accumulates new layers, and becomes imbricated, as in the variety of ecthyma just described. Rupia is, of all the syphilides, the one attended with the largest, thickest, darkest, and most characteristic crusts, as it is also the one presenting the most extensive ulcerations. Under these crusts, the papillary layer and the entire derm are undergoing suppuration, as in the last two eruptions considered. Deep ecthyma, ulcerative impetigo, and syphilitic rupia have many points of resemblance, are of the same significance, and appear as the last manifestations of the secondary, or as symptoms of the tertiary period. This distinction is somewhat arbitrary, the pustulo-crusta- SYPHILITIC PEMPHIGUS. 201 ceous sypliilide being sometimes assigned to the second and sometimes to the third stage of syphilis. Although these different pustules or ulcerating bullae generally appear in the two or three years following the chancre, they may show themselves five years or twelve years after the beginning of syphilis, and then it would be natural to place them in the tertiary stage. The pempJiigus of adults is never syphilitic. Three or four cases have been recorded in which pemphigus in adults was believed to be syphilitic, but these did not differ in any respect from ordinary pem- phigus, so that as a syphilitic eruption it is at least so rare, that we need not here consider it. This is not true, however, of the pempJdgns of neiv-horn children, which has some importance in the pathology of infantile syphilis. The question of the specificity or non-specificity of this disease received great attention at the Academic de Medecine, in 1851, Cazeavix,at that time, maintaining that pemphigus had no relation to syphilis, while Dubois endeavored to demonstrate the existence of such a relation. One series of observers regard pemphigus as simply a sign of cachexia (Trousseau, Lass^gue, Gibert, Diday, Bazin) ; others look upon it as a manifestation of hereditary syphilis (Caze- nave, Danyau, Bouchut, Vidal, OUivier, Ranvier, and Parrot) ; still others, as Ricord and Gubler, believe it to be sometimes the result of cachexia, sometimes a symptom of syphilis, and with these observers, we coincide. One or many bulU^ of pemphigus are frequently seen at birth upon children whose parents were never aff'ected with syph- ilis, and in whom the symptom is of no gravity. On the other hand, we often see at the Lourcine Hospital, children born prematurely or at full term, with pemphigus either fully developed at the moment of birth or appearing a few days afterwards, and who commonly die with syphilitic cachexia, the sad heritage derived from their maternal parents. Syphilitic pemphigus is characterized by an elevation of the epi- dermis containing clear or blood-stained serum ; the bullae are more or less prominent, have a diameter of five to eight millimetres or of a centimetre, and are usually seated upon the palms of the hands, the soles of the feet, the anterior aspect of the forearm, and the palmar and plantar surfaces of the fingers and toes. I have recently made an autopsy upon a child, still-born a little before full term, whose mother had been under observation for nearly eight months. She 202 SYPHILIS. contracted syphilis at the time she became pregnant, and on her ad- mission was affected with mncous patches. The chikl, which had not moved for five or six days before the accouchement, was a little macerated, and presented on the soles and palms some very charac- teristic bullae of pemphigus. The epidermis was raised, and the papillge congested in the region of the bullae. I examined many of these after first hardening them, and found two elevations of the two layers of epidermis placed one above the other. The corneous layer was separated from the rete Malpighii by a very large amount of liquid, while between the latter and the papillae was found a smaller quantity. This is represented in Fig. 42, under a power of eight diameters. The bulla was about one centimetre in diameter, and covered the plantar surface of the great toe. The distended superficial epidermis e formed a large circle ; be- tween it and the rete mucosum there was a li(juid containing a few red blood-corpuscles and some lymph cells. The rete mucosum c is detached at places, and raised in such a manner that at m are seen its FiR. 42. V \' 'o Pemphigus bulla from a new-born syiiliilitic child. The superficial epidermic layer e is ele- vated by a fluid exuded between it and the rete mucosum. The rete mucosum e is also partly raised, so that there exists a space filled with fluid between it and the papilla;, p. The epithelial prolongations and the ducts of the sudorific glands m, placed between the papillae, and which run between them into the derm, are broken and suspended from the rete muco-sum. d. Derm. a. Fibrous and muscular layers, t. Tendons and fibrous tissue, o. Cartilage of ossifica- tion of the first phalanx, v. Vessels. X S- inter-papillary prolongations, and the ducts of the sudoriferous glands which have been drawn out with it, and have escaped from the derm. The same sanguinolent liquid exists between the rete mucosum and the papillae f. Beneath the papillae are seen the corium (?, the adi- pose tissue and the sheath of the tendons #, and the epiphyseal carti- lage of the first phalanx o. HISTOLOGY OF PEMPHIGUS. 203 Figure 43 shows in detail the lesion of the Malpighian and papil- lary layers, enlarged 200 diameters. The latter largely consists, as in a new-born child, of embryonic tissue ; the rete mucosum presents an excavated condition of certain of its cells c ; from o to s is seen a sudoriferous gland ; n is an inter-papillary prolongation of the rete mucosum. The separation of the epidermis into two layers is at the granular layer. My opinion as to the true character of this case is corroborated by the fact, that the liver showed a lesion peculiar to hereditary syphilis — an interstitial hepatitis. /')^^. —a -m 1 t- Section of the internal lamina of a cranial bone from an exostosis of a child two years old. a, a. Large medullary canals filled with foetal marrow. The internal lamina extends from b to I. The osseous trabecula, e, unites the internal lamina with the system of other laminae of the bone. The internal lamina is traversed by Sharpey's fibres, the direction of which is more or less irregular, forming parallel and intersecting bands. These fibres are quite large at c and s, in all that portion of the external lamina which is nearest to the dura mater from/ to I. v. Vessels which traverse the fibro-osseous lamina and send capillaries, t, t, to the dura mater. The bone corpuscles, o, are seen cut longitudinally and transversely ; they vary in size ; for example, tliQ.se in the island p are large. At m is seen a notch due to a rarefying osteitis. X "i^- rate from each other, and are arranged concentrically. Their direc- tion determines the arrangement of the osseous corpuscles, o. In that portion of the lamina which borders on the dura mater, from s to I, the fibres of Sharpey are very large and very distinct. This portion of the bpne is probably of new formation, for the fibres are all of the same age, and they differ as regards appearance from the rest of the fibres of the lamina. In this portion of the bone, as in the entire exostosis, the vessels, y, and the capillaries, t, come from the periosteum and from the dura mater, and penetrate the medullary canals after having passed through the osseous tissue. Furthermore, and it is an important fact, the bone marrow, contained in the large 282 SYPHILIS. medullary lacunae, is embryonic, composed of round cells. In addi- tion to this inflammatory state of the marrow, there are seen along the canals notches, m, filled with cells, and the osseous lamellae at their surface are eroded, which indicates a partial inflammation of the exostosis — a rarefying osteitis, even in the tissue of the exostosis itself. After the histological details which we have given regarding a few of the facts concerning the syphilitic exostoses of young children, which we have observed, we must not suppose that we are familiar with the entire history of the development of these exostoses, although we might perhaps be excused for so doing if, in addition to these facts, we remember and rely upon our knowledge of physiological ossifica- tion. We may safely believe that these exostoses are developed fi-om the periosteum of both long and flat bones, like the normal bone itself, but we have not yet followed this development in its entirety. As to the manner of termination and cure of exostoses of those children who live to become adults, science is still less advanced. It is probable that after a certain number of inflammatory attacks, characterized by the embryonic state of the marrow contained in the bony canals, and by a partial absorption of the lamella, the process terminates in definite ossification with a normal state of the marrow, but we are not aware of authentic observations on this point. The above description applies entirely to cases of congenital syphilis, that is, to those where syphilis has been evolved and has affected the bones at the same time that physiological ossification is going on. It is perhaps useless to remark that later, when ossification is completed, hereditary syphilis, which may, as we know, show itself tardily, aff"ects the bones as does acquired syphilis. A very exhaustive memoir upon the histology of the bones of syphi- litic children by 11. Wegner,^ made from a great number of autopsies at the Charity Hospital of Berlin, is here given in abstract. Three stages of alteration of the long bones are recognized : — Id stage. — While in the normal state the boundary of the hyaline cartilage is distinctly marked by a line which indicates the direct transformation of the cartilaginous tissue into a spongy tissue, the unaided eye being unable to distinguish a spongio-calcareous layer ; in new-born syphilitic children, on the contrary, the bones are seen to ' Ueber liereditare Knochen Syphilis bei jungen Kiiidern, Archiv f. patholog. Aiiatomie und Physiologie, t. L. p. 30ij, 1870. SYPHILITIC OSSEOUS LESIONS IN NEW-BORN CHILDREN. 283 have a spongio-calcareous layer interposed between the bone and car- tilage, measuring two millimetres in thickness. This layer is limited on each side by a straight or undulating line. A microscopic examina- tion shows that this lamina is only a zone of calcifying cartilaginous tissue more extensive than in the normal condition. The cartilage also presents collections of proliferating cartilage cells, which are larger than in the normal state. There is, at the same time, a very active proliferation of the carti- lage, a larije calcareous incrustation, and an arrest of ossification. This abnormal layer is somewhat brittle and friable, and has a honey- combed appearance. 2cZ stage. — The changes are more distinct and extensive ; the cal- careous infiltration is irregular, and may reach four millimetres in thickness. Upon the side of the cartilage this layer is prolonged by papilla-like calcareous trabeculae, which are fre(|uently united at their extremities. The layer of hyaline cartilage nearest the bone presents here, as in rachitis, a bluish appearance, and is almost diffluent. The trabeculse of cartilage are proliferating, the cells are close together, and the intercellular substance is very small in amount. The vessels are sur- rounded by a large amount of fibrous connective tissue. At several points there is developed from the fibrillar tissue which surrounds the vessels, and from the cartilaginous tissue which forms the wall of the vascular canals, an osteoid substance, which later becomes true osseous tissue. Thus there is found in the interior of the cartilaginous canals, where there should only be cartilaginous tissue, trabeculie of true osseous tissue, which, in a longitudinal section, may be followed into the thick spongioid layer, and into the osseous tissue of the dia- physis. At the same time that this osteoid tissue is formed there is also seen around the vascular canals of the cartilage a calcareous incrus- tation of the cartilaginous substance and of the cells. This incrusta- tion is much more advanced in the vascular parts, that is, nearer the bone, and is much less marked as the hyaline cartilage is approached. The calcareous walls of the vascular canals present a papilla-like appearance, the papilhie arising from the bone and terminating by free extremities in the hyaline cartilages, or they are united to neighboring papillae. The perichondrium is calcified, and develops beneath it true osseous substance, which is an abnormal condition. The second stage is then characterized by an exaggeration of the changes found in the 284 SYPHILIS. first stage ; proliferation of the cartilaginous trabeculge, abundant calcification of the cartilage, too early and irregular ossification of the intercellular substance of the cartilage, a stationary state of the normal formation of bone from the epiphyseal cartilage. 3c? stage. — To the preceding changes of the cartilage is added a thickening of the periosteum and perichondrium at the extremities of the long bones and at the junction of the ribs with the costal carti- lages.' Again, at the union of the epiphysis with the diaphysis, the line of calcareous cartilage, homogeneous and hard to the touch, but still friable, is limited by a reddish-gray or yellowish layer of puru- lent appearance. The medullary tissue of the diaphysis is grayer than normal. In consequence of the formation of this soft, almost liquid layer, between the epiphysis and diaphysis, the two segments of bone are separated ; they may slide one on the other ; the two fragments are only united by the thickened periosteum, and are completely separated Avhen this membrane is divided. Upon microscopic examination, the intermediary layer between the epiphysis and diaphysis shows, when it is of a gray-pink color, a very vascular granulation tissue, formed of round and fusiform cells. When this layer presents a purulent aspect, it consists of pus cells with a fluid intercellular substance and granulation tissue. Beneath this semifluid layer the cartilage is seen very decidedly in a condition of calcareous infiltration. There is no proliferation of cartilage cells, but, on the contrary, a calcification and caseation of these cells. After decalcifying this cartilaginous tissue, the nuclei are found shrivelled amidst fine fatty granules. To repeat, there are retardation of ossification, calcareous incrusta- tion of the cartilage, want of nutrition, atrophy and fatty-degenera- tion of the cells of the cartilage, which form between the epiphysis and diaphysis a necrosed mass that irritates the living bone. The inflammation of the bone, the osteo-myelitis, which here results, occa- sions a separation of the epiphyses. There is frequently found an inflammation of the periosteum of the entire diaphysis. This syphilitic affection of bones begins during foetal life, and generally involves several long bones at a time. In the order of frequency, they are the inferior extremity of the femur, the inferior extremity of the humerus, the epiphyses of the bones of the forearm, the superior epiphyses of the tibia, femur, and fibula, and, finally, the superior extremity of the humerus. The bones in which growth is most rapid are those most predisposed to the malady. SYPHILITIC OSSEOUS LESIONS IN NEAV-BORN CHILDREN. 285 The description of the disease and its seat resembles the evolution of rachitis. Nevertheless it diflfers in its macroscopic and micro- scopic examination. While in rachitis there is a soft and non-calcified osteoid tissue, in this disease, on the contrary, the exaggerated calcification is the cause of the necrosis of the new formed tissue and of the consecutive inflammation which terminates in the separation of the epiphyses. This affection should be classed in the group of degenerative inflam- mations. Waldeyer and Kobner^ have confirmed the histological investiga- tions of Wegner. Their conclusions are based upon twelve cases. According to these authors, the alterations are always seen by the microscope when they are scarcely visible to the unaided eye. Lesions of the bones of the cranium and cranial gumraous periostitis were more seldom found by them. Instead, however, of considering with Wegner that all the phenomena which occur between the diaphysis and epiphysis are due to an osteo-chondritis, Waldeyer and Kobner believe them to arise from a formation of syphilitic granulations, or, in other terms, of a gummous tissue. They compare the soft tissue between the cartilage and bone which separates the epiphyses to em- bryonal tissue. The necrobiotic changes which follow at a later period, the vascular lesions, and atrophy of the cells are compared by them to the' modifications occurring in syphilomata. From studying the method of ossification along the cartilaginous trabeculae, they con- clude that the irregular ossification and the few and irregular osseous cells may be developed from the granular fusiform cells which are met with in the canals of the cartilage. Osteoblasts are not here seen regularly arranged in contact with the wall of the canals, as in nor- mal ossification. Waldeyer and Kobner believe that rachitis supervenes later as a result of osseous syphilis. The symptoms of cranial syphilitic exostoses of new-born children have been recently described, for the first time, by Parrot, who re- gards them as an incontestable proof of syphilis. We cannot do better than quote his excellent description.^ " On passing the hand over the child's head, inequalities are felt, ' Beitrage zur Kenntniss der hereditiire Knochen Syphilis, Vircliow's Arcliiv, t. \v. p. 367. * Le,9ons sur les maladies du premier age. Progres Medicale, No. du (3 Jiiillet, 1878. 286 SYPHILIS. the exact situation and configuration of Avbich may be recognized by a more careful examination. They are flattened elevations, spread out, as it were, of variable prominence and extent, at first not very large, and of a perfectly circular contour, sometimes increasing in size without changing shape, but more frequently elongated in one or two directions. They are hard, and if it were not for their prominence, we should imagine we were touching healthy portions of the cranium. It is only in rare cases, when the pressure Avhich we exert on their surfaces is considerable, that they appear to be endowed with a cer- tain elasticity. They have four seats of predilection, the only ones which interest us clinically, viz., the two frontal and the two parietal, in the neighborhood of the bregma. Ordinarily they are symmetri- cally placed in regard to the frontal and sagittal sutures, but some times they are found either entirely in front of or behind the coronal suture, or very unequally developed upon the right and the left. " These dift'erences, however, do not diminish the importance of these prominences ; it is sufficient to verify in one the characters that have just been considered to prove its syphilitic origin. " This alteration may attack all the peri-bregmatic bones, or only a few. " In the first case, the four elevations are separated one from the other, by ridges which are deep in proportion to the height of the prominences. They correspond to the sagittal and medio-frontal sutures, and to the coronal suture. Generally, when the patient is old enough, the position of the bregmatic membrane, completely ossified, is marked by a fifth projection hard and lozenge-shaped, appearing as if set in between the four others, and circumscribed by furrows, which seem to result from the duplication, at this point, of the two inter-fronto-parietal grooves. " In some cases the posterior prominences are very extensive, very prominent, separated by a deep groove, and give to the regions they occupy a certain resemblance to the organs termed nates by the Latins ; it is on account of this that I call the ci-anii altered in this way natiforme. " No matter how slight some of these lesions may be, it suffices to pass the hand over the cranial surface to recognize them ; and they may frequently be seen even at a distance." [These cranial bosses are often found in children who are at the same time syphilitic and rickety, but this does not diminish their clinical significance, which, as Paul has shown, is almost pathognomonic*.] SYPHILIS OF THE TEETH. 287 [Syphilis of the Teeth.' — In considering the conditions of the teeth pathognomonic of syphilis in the infant, the distinction must necessa- rily be made between those which are the effect of heredity and those which are merely congenital, as when the disease is acquired by the mother during gestation, and the child affected in utero, or when the latter is poisoned in its passage through the maternal soft parts. The term " germ infection," or " sperm infection," has been sug- gested by Mr. Jonathan Hutchinson to signify infection of the child through the mother or father respectively, as a consequence of their blood-contamination by the elements of syphilis at the time of impreg- nation. In congenital syphilis the interference with all the developmental processes is likely to produce irregularity as to eruption and position of the teeth; incongruity of size, individually and relatively ; a soft and friable dentine ; an opaque and chalky enamel, deficient in quan- tity and irregularly deposited ; and a consequent proneness to decay. It is doubtful, however, if there are any signs absolutely diagnostic of syphilis in the teeth of the first dentition. The evidences of a check in development by interruption of nutrition during their formative stage may depend upon other causes, and are of diagnostic signifi- cance only when associated wuth other and more reliable expressions of the disease. Certainly the indications of hereditary syphilis, which in the permanent set are generally recognized as characteristic, are never met with in the first dentition. Malformed teeth, early erupted and early lost, are frequently associated with evidences of syphilis in the child, and result, doubtless, from stomatitis due to that disease. The effects, however, do not differ materially from those produced by stomatitis from any other cause. The exemption of the teeth of the first dentition from the evidences of hereditary syphilis has been attributed to the fact that their calci- fication commences in utero, at a time when specific inflammations are not so likely to take place. Mr. Cartwright argues that the teeth, like the hair, being dermal appendages, and these superficial struc- tures being most affected in secondary syphilis, the specific poison which lies latent in them during intra-uterine life may develop, at a later period, in organs formed from these structures. Cachexia, independent of specificity, may account for early, late, or defective first dentition, as well as for various abnormalities in the teeth of the second dentition. Stomatitis, whether from syphilis, [' Tlie note on syphilis of the teeth has been furnished by Dr. J. W. White.] 288 SYPHILIS. mercury, or from whatever cause, is likely to register itself in badly organized teeth. The appearances characteristic of syphilis may also and frequently do exist conjointly with defective dental struc- tures associated with and depending upon rickets, scrofula, mercurial poisoning, gout, rheumatism, etc. Horizontal furrows across the teeth are not pathognomonic of syphilis, but are due generally to some interruption of nutrition during their developmental period — such as is caused by the eruptive fevers, convulsions, etc. The so-called mercurial teeth are apt to be seamed horizontally, to be irregular in foi-m, craggy, and honeycombed, and of an unhealthy, dirty yellow color, with wide spaces between them, the teeth seeming too small or too few to properly fill the jaw. In these teeth there is also apt to be a deficiency of enamel, which is particularly noticeable in the sixth- 3'ear molars and especially on their cusps. All malformed, defective, or irregularly aligned teeth are, there- fore, not to be regarded as indicative of a syphilitic taint, and great injustice may readily be done by want of discrimination. The association of mercurial with syphilitic teeth is naturally of common occurrence, but enough cases with definite histories have been observed to make the association recognizable. Nor are the special signs on the teeth which are considered as demonstrative of syphilitic taint to be found in all cases where known facts might justify the expectation, nor even in all the children of the same parents. Observation indicates that the special signs are likely to be most marked in the eldest, and least so in the youngest child. The special abnormity is valuable as a diagnostic sign when it is present, but its absence does not prove anything. It depends, doubt- less, upon inflammation of the alveolar processes ; but as the disease may have run its course without this special inflammation having been developed, the teeth may present no indications of syphilis. There appears a tendency in each case of syphilitic he*redity to some special form of degeneration, implicating some one class of structures, the serous, the connective, the vascular, or osseous tissues, the mucous surfaces, or the glandular system. The predisposition is probably due to diathesis, existing cachexia, or special environment. It may be worth while to note, as a clinical fact, that the dental peculiarities generally acknowledged as of syphilitic origin are very uniformly associated with interstitial keratitis. The characteristic syphilitic deformity in the permanent denture, consists of a peculiar evidence of stunted development, especially of SYPHILIS OP THE TEETH. 289 the upper central incisors ; sometimes of the canines and of the sixth- year molars. In the latter, there is a dwarfing of the cusps, showing that the interference was during the deposit of the first formed por- tion of dentine. In the incisors, however, are to be found those special pathogno- monic indications which Mr. Hutchinson considers so reliable that he calls these the "test" teeth, and challenges the production of a single case of these "syphilitic teeth" without syphilitic antecedents. Hereditary syphilis, doubtless, affects to a greater or less extent all the teeth, but not so uniformly or so characteristically as to afford decisive evidence of the taint. When, however, the unmistakable evidence of syphilis is shown in the central incisors of the upper jaw, the other teeth are likely to be smaller than normal, stumpy in ap- pearance, irregularly set in the arch, with spaces between them, and to have a stained, dirty appearance. The special pathognomonic sign in the incisors is a want of nor- mal width of the cutting edges, so that, instead of being broader there than at any other portion, they are narrowed, rounded, and have a peculiar crescentic'edge, the surface of which is inclined upward and forward, instead of backward, as in normal teeth. Besides this cres- centic edge, they are likely to be dwarfed in size, to stand apart and to converge toward each other. The cuts illustrate (Fig. 69) a pair of Fig. 69. Fig. 70. incisors showing, somewhat exaggerated, the serrations of the cutting edge which are frequently found in recently erupted normal teeth, and (Fig. 70) a pair of characteristic syphilitic incisors. It is this narrow- ing and rounding of these teeth, and the crescentic form of the cutting edges, together with the modification of the adjoining teeth — also narrowed and rounded — which gives the appearance likened by Mr. Hutchinson to a row of pegs stuck in the gums. As these teeth fre- quently project but half the normal distance from the gum, the simile of a row of pegs is descriptive. This appearance must not be con- founded with the saw-like edg-es — serrations — of the incisors when newly erupted — a condition which is entirely normal. The points of the crescentic edges and the points of the adjoining 19 290 SYPHILIS. teeth are generally worn away between the ages of twenty and thirty, so that the teeth resemble those of an old person, as though worn by long service, the denture appearing at thirty years of age like that of one sixty years old. In acquired syphilis inflammation of the gums is occasionally met with, but not accompanied with such free salivary secretion as when the peculiar effects of mercury are exhibited in like inflammation ; the gums swell and ulcerate, exposing the necks of the teeth, and unless counteracted, the disease involves the walls of the alveoli, causing loosening of the teeth, and ultimately necrosis of the jaw. It is exceptional, however, for the disease to reach the alveolar processes of the upper jaw unless led thereto by some local irritant, and still more rare to find such effects on the lower jaw without some predis- posing local condition. Nodes upon the periodonteum, abscesses at the roots of teeth not de- cayed, and syphilitic periodontitis are among the occasional evidences of syphilitic infection.] Alterations of the Tendons and Synovial Membranes in Syphilis. — The tendons, especially the large tendons, the tendo Achil- lis, the tendo patellge, the tendinous attachment of the sterno-cleido- mastoid muscle, the flexor and extensor tendons of the fingers, etc., may be the seat of diffused or circumscribed gummata, of a fibrous thickening of a syphilitic nature. The synovial bursae, and in par- ticular the patellar, more rarely those of the semi-tendinosus, of the tuberosity of the tibia, of the olecranon, etc., are affected in the same manner (Verneuil, Keyes). The wall of the serous sac becomes the seat of a chronic inflammation, which affects the fibrous tissue, and which thickens it ; there may also be gummata situated in the peri- pheral connective tissue. At the same time there is observed more or less abundant effusion into the serous cavity. This lesion begins and progresses slowly, most frequently following contusions. It is generally mild, unless a gumma of the cellular tis- sue makes its appearance in the skin, and causes an ulcer, which communicates deeply with the synovial sac. [" Syphilitic bursitis attacks the tendinous bursas more frequently in women, in contradistinction to gonorrhoeal bursitis, which affects most the opposite sex. Usually there is a pre-existing gouty or rheumatic taint. ^ The subcutaneous bursas, however, seem to be [• Mauriac, Edin. Med. Journal, vol. xxi. pp. 27£— 4-iS.] SYPHILITIC BURSITIS. 291 eqiaally aflfected in both sexes, although as traumatisms sometimes act as exciting causes, this equality may be more apparent than real, since men are more exposed to such accidents than women. "^ " Diagnosis. — Syphilitic bursal diseases occur most frequently during the tertiary period, although occasionally during secondary syphilis, and their recognition must depend on a careful consideration of the following abstract of diagnostic points given by Fournier, since there is often no incontestable sign of syphilis detectable. " 1. The history of a primary lesion. 2. The comparative fre- quency with which such diseases occur in syphilitics, especially in women. 3. The association of bursal troubles with other secondary manifestations or gummata in the tertiary period. 4. The presence perhaps of undoubted specific lesions elsewhere. 5. Symmetry of the lesions, although this is not at all absolute. 6. The development of the disease contemporaneously with other lesions, and subject to the general evolution of the diathesis. 7. The absence of any other assignable cause. 8. The failure of ordinary measures and the prompt response to specific treatment." Nancrede describes a subacute form of syphilitic bursitis, which is excessively rare, and occurs during the beginning of the secondary period. The pain is a marked symptom, and is increased by pressure or movement. The amount of effusion is small, and crepitation is felt when the tendon moves over the bursa. It lasts about a week, and may terminate in the chronic form, which is peculiar to the secondary period, and occurs much more frequently than the former. Its de- velopment is slow, from seven to ten months. The local symptoms do not differ from those of any other chronic bursal enlargement. The melon-seed bodies found in ordinary bursitis are not met with in that due to syphilis. Griimmata of the burs^e are seen more often than the forms of specific bursitis above described. They present symptoms which do not differ from those of gummata occurring elsewhere, viz., stages of formation, of softening, and, if permitted to take a natural course, of ulceration. They develop very slowly ; the situation of the tumor corresponds to that of a normal bursa; its size is never very large, seldom exceeding that of a hen's egg, but from irritation it may be temporarily enlarged ; the pain is slight, or entirely absent; its consistence is firm, elastic, and non-fluctuating. The skin may be unchanged, but is generally [' Chouet, De la sypliilis dans lea Bourses Sereuses, Paris, 1874.] 292 SYPHILIS. (lark- red in color, and frequently ulcerated ; the ulcer has sharp-cut edges, a grayish base, and discharges a sanious fluid. The diagnosis depends essentially upon a specific history, the inherent characters of the lesion, and the beneficial effect of anti-syphilitic treatment.'] The articulations are sometimes affected with chronic arthritis of a syphilitic nature, to which Richet has called attention in his excellent memoir on white swellings. The arthritis is not generally primary, but follows syphilitic alterations of the tendons or ligaments of the bones, or of the cellular tissue, which is contained in the folds of the synovial membrane. We have seen several specimens of these arth- ropaties, but we never have had occasion to examine them anatomi- cally. Autopsies showing the affection are uncommon, for none are men- tioned in the memoir of Richet, nor in the thesis of Voisin on the same subject ; indeed, we know of but one, the very important autopsy reported by Lancereaux. There existed in the right knee a yellowish- gray mass, elastic, of a gummous nature, four centimetres in thickness, occupying a portion of the tendo patellse, the fatty cushion situated behind the synovial bursa and all the fibrous tissues inserted about the tibia. A lesion of the same nature, but less extensive, was seen in a similar situation in the left knee. Besides these characteristic gummous formations, there were also synovial effusion, inflammatory thickening of the synovial membrane and erosion of the cartilages. It is diflacult to say what the anatomical alterations of the joint have been in cases which end in recovery. But as palpation of the articu- lation of the knee, which is the most frequent seat of this arthritis, renders perceptible soft masses, elastic or indurated points, or even hard borders at the sides of the patellar ligaments, or in the synovial folds, we can imagine that the synovial membrane is affected in such cases by fibrous or gummous neoplasms. After the knee, which is the most frequent seat of syphilitic arth- ritis, come the elbow-joint, hip, instep, shoulder, wrist, and inferior maxilla. Arthritis is generally confined to a single joint, but it may show itself in both knees. The symptoms consist in a tumefaction of the articulation in conse- quence of an inflammatory effusion into the synovial membrane. Thus, for example, the knee is SAvollen, and there is detected a moderately [' Abstract from article on ** Syphilitic AfFectlons of the Bursse." International Encyclopaedia of Surgery, vol. ii.] SYPHILITIC DACTYLITIS. 293 large quantity of liquid. Palpation gives the sensation of an elastic puffiness, less liquid than in hydrarthrosis, and a sensation approach- ing that experienced in the palpation of a white swelling. Sometimes indurated points or nodes can be felt. The pain is ordinarily slight, often is greater at night than in the daytime ; movement of the limb is generally difficult or impossible. The diagnosis usually cannot be made without taking into consider- ation the syphilitic antecedents and contemporary manifestations. There would assuredly be ground for considerable doubt in a great number of cases between a white swelling and a syphilitic affection. The employment of the iodide of potassium will then serve as a crite- rion in a difficult case when we suspect syphilis, whether in an adult or in a child. Syphilitic arthritis of ordinary intensity is rapidly benefited and cured by the iodide of potassium. [Syphilitic Dactylitis occurs at various periods of the disease, and in two varieties. One of these appears usually in the late secon- dary stage, and involves chiefly the periosteum and the fibrous and integumentary tissues surrounding a joint, usually a metacarpo- or metatarso-phalangeal articulation, involving a phalanx, and is cha- racterized by slow, almost painless, swelling and discoloration of the affected member. This is due to a gummous infiltration, Avhich, upon subsiding, leaves the finger or toe temporarily stiff, but not perma- nently disabled. The second form is a specific osteo-myelitis with accompanying inflammation of the periosteum, and appears from five to fifteen years after the infection with syphilis. It is chiefly limited to these structures, the integument being but seldom involved ; erosion of the neighboring articular cartilages often takes place ; all the ligaments and the capsule of the articulation become thickened, and its func- tion is frequently entirely lost. The absence of acute inflammatory symptoms in the subcutaneous variety of dactylitis enables us to diagnose it from paronychia, whitloAV, and gout. Rheumatoid arthritis begins in the joints, is associated with other symptoms, deformity of the fingers comes in early in the disease, and the sheaths of the tendons are involved. The second variety might be taken for enchondroma or exosto- sis, but these swellings involve only a limited portion of the bone, 294 SYPHILIS. increase very slowly, and present dense, circumscribed tumors.^ Dr. Taylor^ thus indicates the rules for prognosis : — ■ " The prognosis of this affection of the fingers and toes depends entirely upon the accuracy of the diagnosis, and to a certain extent upon the period at which it is recognized, and in the event of its being correct, and as a consequence an appropriate treatment being instituted, it may be stated to be good, for the final impairment of the members is not so great as to cause utter uselessness. But if the origin of the lesion is not recognized, the chronic enlargement of the bone, the chronic hydrarthrosis with crepitation, or the latter symp- tom combined with chronic capsular thickening, might lead the unwary surgeon to pronounce an unfavorable prognosis, and perhaps to institute unnecessary operative procedure. The treatme7it is that of late syphilis, the use of iodide of potassium either alone or com- bined with a mercurial. The combination always answers best in [' Mr. Deakin, in the Indian Medical Gazette, May 1, 1878, tabulates the diag- nostic points somewhat as below : — Syphilitic dactylitis. Ell chondroma. Phalanges ; metacarpal Metacarpal bones and bones and neighbor-j phalanges, ing articulations. Affpcts the compact tis- Usually ■within sub- sue (shaft of bone); stance of bone which periosteum; connect-: encases growth, ive tissue. . . j Occurs as a rule during Adolescence, during adult life. ..; growth of bone. Skin thickened enchon- Not involved, droinatims like, or I red, tense, glistening, tendency to nlceiate. ! Roundish, diffused .Clearly circumscribed, swelling. .. I not involving joint. Exostosis. Strumous disease of bone. Junction of shaft and Carpus and tarsus. epijihysis, points of muscular attachment. Dorsal surface last phalan.K great toe. .. Often with os.sitication Cancellous tissue and Varying from hard to'Usually firm. soft. Pain not severe, often less on pressure, worst at night. If tertiary, rarely sym- mntrical. Tends to suppurate. Runs a rather acute course. . . I Acconipaniedby specific General health good; cachexia. .. no syphilis. Painless. Often symmetrical. To ossify. Usually chronic. Single or few in num-Mul iple. ber. . . I Rapidly improved, if Not affected. not di-persed, by spe-l cific treatment. of epiphyseal carti- lage. Adolescence. Not involved. Clearly defined, broad and flat, or peduncu- lated. Hard. Painless, unless nerve involved. Often symmetrical. To eburnate. Chronic. General health good. Single. Not affected, as a rule. synovial membrane. Childhood. Not affected in early stage. Uniform enlargement of articular ends. Soft, doughy. Slight; wanting at first. To suppurate. Chronic. Strumous diathesis (i. e., a tendency to sup- purative iuflamma- tions). Mercurials, as a rule, injurious.] 2 On Dactylitis Syphilitica, New York, 1871. SYPHILITIC DACTYLITIS. 295 cases where there is a coexistence of tegumentary lesions, but when these are strictly osseous and ligamentous, our chief reliance is upon the iodide, and we can, if that is inefficient, add the mercury. When the parts are very much distended, a minute incision may be necessary."] 296 SYPHILIS. CASE X. Syphilitic arthritis. F. A., ajt, 35, seamstress, admitted to the Lourcine Hospital July 11, 1878, bed No. 4. Syphilis seemed to have begun with this woman, in February, 1869, by a very intense sore throat, followed by an eruption of large mucous patches on the lips. The latter continued two months. About April, 1870, there appeared upon the genital organs an eruption of confluent, very painful mucous patches, with considerable oedema of the labia majora. At this time the patient entered tlie hospital, under the care of Pean. Besides these patches, she then had an eruption of large papules upon the trunk, legs, arms, and palmar surfaces of the hands. She remained six months in the hospital, and was given pills of protiodide of mercury, sulphur baths, quinine, and iron. "When she left, the papules had partly disappeared, and the mucous patches were entirely cured. For two months the patient remained well, after this, she felt in the bones of the legs and thighs extremely sharp pains, especially at night, occasioning much loss of sleep. No similar pain in the clavicles, head, or arms; no headache. She again entered the hospital. At this time she had the itch. Upon the legs, buttocks, and thighs were also seen large red, painful pustules ; these were cauterized with nitrate of silver. The eru})tion secreted a very profuse amount of serum ; she now remained nine months in the hospital, and left entirely recovered. During the three following years the patient remained well with the exception of an eruption of psoriasis upon the palms of the hands, the elbows, and knees. There was also an entire loss of hair from the whole body. That of the scalp had partly returned, but elsewhere it had not reappeared. During her several sojourns in tlie hospital, mercurial treat- ment had been employed. Present condition, 1878. The face is pale, the skin elsewhere not colored, the emaciation considerable. There is some gastric disturbance. Pulse frequent. Appetite almost lost. General feebleness. Intense headache. Some vertigo. The predominant phenomenon is a very acute pain in the knees which renders walking difficult ; this symptom has been present for the past two months. The left knee is larger than the riglit. There is no change in the color of the skin. Upon the external surface of the articulation on the left side, there is seen a very appreciable swelling, especially when the knee is bent. By pressure there is felt a soft resistance, somewhat fluctuating, which appears due not only to fluid in the joint, but also to fungosities (fungous growths). On the right side the fluctuation is more evident, the movement of the patella is better felt. Flexion of the knees is painful ; even when quiet the pain is acute. There are seen some exostoses on the tibia and ulna. No other syphilitic manifestations are present. The patient was ordered iodide of potassium. August 5th. The left knee is of the same size as the right; but the skin is wrinkled. The patella is here more movable than the right. There still remains a little fluid. The patient left the hospital recovered in September. SYPHILIS OF THE NERVOUS SYSTEM. 297 CHAPTEK X. SYPHILIS OF THE NERVES AND NERVE CENTRES. Lesions of the pia mater — Inflammation and gummata — Lesions of the brain — Large gummata — Their pathological anatomy — Symptoms and diagnosis — — Their seat — Small gummata — Their relation to the vessels — Syphilitic in- flammation of the arteries of the brain — Syphilitic lesions of arteries — Symp- toms of cerebral syphilis — Syphilis of the spinal cord — Locomotor ataxy — Diagnosis and prognosis of cerebral syphilis. In treating of the vegetations and gummata which are developed on the external or periosteal surface of the dura mater, it was m.en- tioned that they frequently coexist with pseudo-membranous patches upon its internal surface. There are a certain number of recog- nized symptoms which are probably due to the presence of gummata upon the internal surface of the dura mater. Of all the cerebral and spinal membranes the dura mater is the one which is most frequently the seat of tertiary syphilis, chiefly owing to its intimate connection with the cranial bones, which are so often affected with this disease, and towards which it bears the relation of a periosteal lining. The symptoms produced by inflammation and by gummata of the dura mater are often mistaken for those of chronic osteitis, or of gummata of the cranial bones, and as the internal surface of this membrane, in contact with the pia mater and with the surface of the brain, is fre- quently attacked at the same time, it follows that this complication manifests itself by various cerebral symptoms ; intense cephalalgia, trembling, dulness, intellectual torpor, loss of memory, and coma. Besides these peri-encephalic lesions, the pia mater and even the brain substance and spinal cord may be the seat of sclerosis or of gummata. The pia mater presents two varieties of lesions: — 1st. A chrome inflammation, followed by fibrous thickening and by adhesions to the surface of the brain. Cases have been recorded in which this fibrous thickening of the pia mater has been very wide- spread, producing a manifest compression of the nerves, and a sclerotic condition of the walls of the vessels within the membrane. 298 SYPHILIS. 2d. Grummafa, lesions much more characteristic than the foregoing. Lancereaux has seen in the pia mater, situated beneath the bone, a tumor the size of a cherry-stone, and which was hard, dry, slightly vascular, grayish in color at its periphery, and yellow in the centre. The gummata of the pia mater should not be mistaken for tubercles of this membrane, for the latter seldom or never attain so great a size. Lesions of the Brain. — Gummata of the brain and their ana- tomical results have been admirably described by Virchow in his work on constitutional syphilis, and in his lectures on tumors. The works of Lagneau, Zambaco, Gros, and Lancereaux contain a large number of observations upon nervous syphilis. Cerebral gummata may be found in two forms : — 1st. As large gummous masses developed upon the surface of the brain, within the convolutions, and in the gray substance or encroach- ing upon the white substance, and usually attacking the base, the cerebral peduncles, the pons Varolii, and the optic tract. These tumors, which are ultimately associated with the brain substance are generally multiple and of various dimensions. They are also found upon the cerebellum and upon the superior surface of the cerebrum. 2d. In the form of smaller nodules accompanying the cerebral arteries, and in particular the sylvian (middle cerebral) arteries. These two varieties of syphilitic lesions do not differ materially in a histological point of view, as regards their structure ; but their evo- lution is slightly different, and the last are generally accompanied by endarteritis, which results in a limited angemic softening of the brain. In these cases the symptoms of arteritis are predominant. An ac- count of the syphilitic alterations of the cerebral arteries will be given in its proper place. A. — Large gummata of the brain surface possess perfectly distinct characteristics when examined by the naked eye. The two figures, (Nos. 73 and 74) which refer to a case of Coyne and Lepine,^ from the clinic of Prof. S^e, represent two flattened tumors, one of two, the other of three centimetres in diameter, both upon the right inferior aspect of the pons, and two other tumors resting upon the optic tract of the left side. These tumors, which are situated on the surface of the ner- ■ Coyne, Contributions to the Studj^ of Cerebral Syphilis. Journal of " Con- naissances Medicales," 1878, Nos. 17, IS, and 20. GUMMA OF THE BRAIN. 299 vous substance, penetrate deeply into the nervous tissue, as is shown in Fig. 74, which represents a section of the pons at the seat of one of them. These tumors, which are precisely of the same natui-e as those observed by Charcot and Gombault,^ and by Lancereaux,^ in another series of analogous observations — present generally a den- tate border, the projections of which extend between the fasciculi of the nerve fibres. The surface of these tumors presents two zones, a peripheral one, semi-transparent, without color, or pinkish and vas- cular ; the other, which is large in size and central in situation, is opaque, yellowish-gray, dry, and hard. The surface of the tumor is at times slightly prominent, in other cases somewhat depressed. This last condition is due to atrophic degeneration of the cells at the central point. The lesion taken in its entirety constitutes a consider- able mass, denser than the surrounding tissue, and forming a tumor which, in its development, can be recognized by the naked eye asAvell as by microscopic examination. These formations are hard, solid, and of a density analogous to that of the cerebral sclerosis sometimes found associated with the brain atrophy of crdtins and idiots. In the sclerotic condition, however, the morbid tissue retains the shape of the convolutions, while here we have isolated tumors. The pia mater is usually adherent to these tumors by an inflamma- tory fibrous tissue, and it is generally thickened at their summits. The microscopic examination of the tumors reveals numerous round cells of new formation, such as have already been considered in treat- ing of the gummata of the skin and periosteum, and a structural for- mation analogous to that of these gummata, but modified by the nature of the tissue in which they are developed. The peripheral zone, which passes imperceptibly into the normal nervous tissue, presents, in fresh specimens, or after maceration during two or three days in Aveak chromic acid solution, the elements of the neuroglia, and round or embryonic cells. Thin sections made after complete hardening and staining with car- mine, mounted in Canada balsam, show, especially at the periphery of the gumma, numerous sections of normal nerve-fibres. In these prepared specimens, as well as in those examined in the fresh state, the cellular elements, just as in the cases of Charcot and Gombault, ' Charcot and Gombault, Notes on a Case of Disseminated Lesions of the Nerve Centres in a Syphilitic. Archives of Physiology, 1873. * Lancereaux, Theoretical and Practical Treatise on Syphilis, p. 350. 300 SYPHILIS. as well as in those of Coyne and Lepine, assumed the form of stellate bodies described by Jastrowitch (spider-shaped cells). These cells contain a large nucleus, and a certain quantity of protoplasm, which continues into the extremities of the cell through the branching, rigid, refracting, prolongations, which are scarcely stained by car- mine. Alongside of these cells others are found which have an oval nucleus, and a granular protoplasm without prolongations. There also exist a number of small round cells. These elements are situ- ated in the midst of the reticulated tissue of the neuroglia. The round and oval cells are often collected together in groups (Fig. 71). Syphilitic lesion of the nerve centres. A. Elements from B. a. Branched cells (spider-shaped cells) much enlarged, belonging to the neuroglia, b. The same elements granule- fatty. B. Portion of a thin section through a small syphilitic nodule in the cortex of the brain, a. Exter- nal zone nearly normal, in which enlarged stellate cells are scattered among the nerve fibres. 6. Middle zone, almost exclusively eon.stituted by large brauched cells, mingled with a few round cells, d. Bloodvessel, partly covered by a mass of granular cells, e. Central portion of nodule, consisting of round granular cells. (Charcot and Gombault.) ] From the preparations of Coyne it was found that the bloodvessels were often surrounded by these small cells, situated in the lymphatic sheath which envelops them — but there was neither contraction nor GUMMA OF THE BRAIN. 301 vascular obliteration by arteritis or by phlebitis. The spider-shaped cells, which should be considered as hypertrophied normal cells of the neuroglia, were numerous at 'the periphery of the transparent zone ; they were entirely absent in the central opaque part of the tumor. These cells, which Charcot and Gombault considered characteristic of syphilitic gummata of the brain, Coyne does not believe to be con- stant, for in a solitary gumma of considerable size, attacking the cere- bellum, and which he studied with Peltier, there were no ramifying cells. Coyne considers their presence as being due to their previous existence in the normal state in the region affected by the gumma, both in his own cases and in those of Charcot and Gombault. In the central opaque and yellow part of the tumor only round and oval cells are found, more or less granular and atrophied, which form comparatively regular groups. These cells are not now seen forming a sheath around the vessels. The primitive structure of the nervous tissue is completely modified, very little remaining either of the re- ticulated tissue, the lymphatic sheaths, or of the nerve fibres. Ij^ho vessels are generally slightly compressed owing to the large number of cells surrounding them. In the two cases of Coyne, and in that of Charcot and Gombault, there was neither endarteritis nor fibrinous coagulation within the vessels. In other cases, there may be ob- served around the tumor a change in the cerebral substance, charac- terized by softness, by vascularity, by the presence of an opaque fluid, and when examined microscopically by a number of granular corpuscles. In the centre of the gumma, when it is of long standing, there may be found a cheesy condition, which, when examined histo- logically, is seen to consist of small round bodies, composed of minute acicular crystals of fat. But even at this stage, the central part of the gumma retains a certain degree of hardness. The cerebral gumma is, therefore, characterized by two zones : one peripheral, in Avhich are found nerve fibres, reticulated tissue, swollen and sometimes branching cells of the neuroglia, and a great abundance of small cells among the preceding elements and in the peri-vascular lymphatic sheaths ; the other central, in which the numerous cells of new formation, crowded one against the other, and compressing the vessels, have destroyed all the elements. of the ner- vous tissue, and are themselves undergoing a granulo-fatty atrophy. The diagnosis of gummata of the central nervous tissue may be made by their known characteristics as revealed both to the naked eye and under the microscope. They are tumors or neoplasms 302 SYPHILIS. formed in the normal tissue with which they incorporate themselves, and which they partially destroy in their process of formation. It is from cerebral tumors, and particularly from tubercle, that the diagnosis should be made. It would be difficult to confound, for ex- ample, a superficial gumma with a sclerotic patch ; the pinkish, gray- ish, semi-transparent tissue of the sclerotic patch is of the same color in the centre as at the circumference, and its 'appearance is that of organized fibrous tissue, and not of a neoplasm undergoing cheesy degeneration. The distinction between gummata and sarcomata is generally very easy. We do not refer to angiolithic sarcoma, so easily recognized by its large tiat cells, and by its vessels incrusted with calcareous salts; nor to sarcomata which are confined to the surface of the nervous tissue by a stroma of cellular tissue. Certain gliomata connected with the cerebral substance, and merging into ij: in an imperceptible manner, may give rise to difficulties, especially if their centres are cheesy. But these tumors are single ; furthermore, their structure, the reticulated tissue, the elongated connective-tissue cells, or the oval cells, are of the same shape ; the ease with which these elements are torn apart ; the softness and uniformity of the tissue, which is through- out very vascular, furnish well-marked diflFerences. The thin em- bryonic walls of the vessels which traverse them ; the fatty-degene- ration of some of their cells, which are often filled with fatty granules, but are not atrophied ; the absence of cohesion, and the mucoid con- dition of their older tissue, make them easily recognizable. The serious, but never insuperable difficulty of diagnosis is the distinction of gummata and large tubercles of the brain. The large cerebral tubercle appears to the naked eye as a single spherical tumor, or as numerous tumors of which the centre is yellow, often firm, the per- iphery gray and semi-transparent. But the opaque and dry portion, now and then fissured, or softened, is always more extensive than the central portion of the gumma. The circumference of the tubercle is more regular than that of the gumma ; the tubercle does not send radiated and irregular prolongations into the neighboring cerebral tissue. Sometimes about the circumference of the cerebral tubercle are seen small miliary, semi-transparent tubercles, which are them- selves spherical, and which blend with the semi-transparent gray surface of the large tubercle. In a great number of cases the tuber- cle is cheesy in its entirety, yet preserves its form ; this is never gujMma of the brain. 303 seen in guramata. Lastly, there may exist, rarely, it is true, very fine miliary tubercles of the pia mater, at the base of the brain, in the fissure of Sylvius, at the same time with large cerebral tubercles, and then the diagnosis is very simple. If these characters, drawn from naked-eye examinations, prove insufficient, the microscope will always overcome the difficulty. All the vessels in the opaque part of the tubercle are obliterated at their entrance into the opaque zone. In all this region giant cells are observed. On the contrary, in nearly all the recorded cases of large cerebral gummata, the vessels in the opaque part were patulous. It can very well be conceived by anal- ogy with what has been seen in the skin, in gummata, and in the chancre, that there may at times be vascular obliterations. But this is a very rare condition, and altogether exceptional in gummata, while, on the contrary, it is constant and uniform in the cheesy portion of the cerebral tubercles. The seat of these gummous tumors which attain the size of a walnut is at the base of the brain, near the pituitary body, on the surface of the pons, upon the peduncles of the cerebrum, and those of the cerebellum, upon the optic tracts, upon the anterior lobes, and on the surface of the frontal convolutions — which explains the aphasia often met with in these cases. They are also met with in the ventricles; on the sur- face of the cerebellum ; at the points of origin or emergence of the cranial nerves, the optic nerve, the occulo-motor, the pathetic, the trifacial, the facial, the auditory, etc. These nerves whether di- rectly invaded by the neoplasm, affected as a result of lesions at their points of origin, or surrounded and compressed at their exit from the brain by the thickened and inflamed membranes, the dura mater or the pia mater, especially at the orifices of the bony outlets, are very often altered in syphilis. The paralysis and the pain which result will be considered further on. The possibility of gummata ultimately becoming softened and absorbed, leaving after them a cicatrix, or one of those small cysts so common in the brain, the walls of which are formed by a loose or fibroid connective tissue, and which contain a liquid analogous to that of Avhite softening — cysts which are generally surrounded by softened or yellow cerebral tissue and filled with granular corpuscles — is a question difficult to determine. In the great number of cases collected by Gros and Lancereaux there were found small areas of softening, small calcareous and soft caseous masses, cerebral lacunae corresponding to the cicati'ices of softening, or cysts varying in size 304 SYPHILIS, and occupying the superficial or deep regions of the brain. These lesions are often coincident with gummata or vegetations of the dura mater, with syphilitic alterations of the bones of the cranium, and with gummata of the liver. I have met with many of these small areas of softening which were consequent upon well-established syphilitic lesions of the dura mater and of the cranium. But these changes, which are often evidently of syphilitic origin, do not have the anatomical characters of syphilis; and although it can be imagined that a gumma, in an advanced stage of its retrograde evolution, may form a small soft mass undergoing fatty-degeneration, and surrounded by inflamed and softened cerebral tissue, it is, however, more difficult to admit the gummous origin of the lacunse or of cysts. These last, indeed, appear to me to depend altogether upon chronic inflammatory lesions of the cerebral arteries connected with syphilis. B. — Sometimes small syphilitic gummata, the size of which varies from that of a hemp-seed to that of a bean, are developed in the connective tissue of the pia mater about the cerebral arteries at the point where they pass between the convolutions. The arteries of the base and the middle cerebral arteries in particular are the chosen seats of these small tumors just as they are the seats by predilection of the miliary granulations of tuberculous meningitis. But the tubercular granulations of the meninges possess in their development, in the lesion of the sheaths of the microscopic arterioles, and in the obstruction of these small vessels, characters entirely dis- tinctive. The small gummata which are now in question are situated in the tissue of the pia mater ; they surround the arteries which pass along- side of them and which are more or less compressed by a sclerotic inflammatory tissue ; they partially penetrate the substance of the neighboring convolutions. The arteries are in such cases very much changed — attacked with chronic arteritis, with thrombosis, with a thickening of their coats, particularly their internal coats, in such a way that the circulation of the blood, hindered at first by the con- traction of the calibre of the artery, becomes afterwards impossible. More or less considerable softening of the cerebral lobes follows, especially of the frontal lobe, or there are small areas of softening which in their further evolution leave in their places lacunae, cica- trices, and small serous cysts. In cases of this kind, where there exist areas of softening of the brain of a variable extent, there also SYPHILITIC ARTERITIS. 305 exists a fibrous thickening of the meninges which accompanies the vessels. The vascular lesions are of great importance in these cases of small gummata and circumscribed syphilitic inflammations of the pia mater, for the areas of softening and the symptoms noted are the result of arterial thrombosis. The alterations which take place in the vessels should be examined with care. They have been studied by Heubner, who has made 164 autopsies of the brains of syphilitic sub- jects. There were 68 cases of gummata in which the condition of the vessels was not stated, and 44 cases of these tumors where the alteration of the vessels was mentioned. In 36 observations of meningitis and encephalitis, the vessels were mentioned but twice. lie noticed 16 cases of vascular lesions without alteration of nerve- substance. When a sypliilome (gummy tumor) comes in contact with an artery, the latter occasionally but rarely remains intact, or it is mechanically altered by compression or thrombosis, or its walls take part in the change and are themselves inflamed; the specific arteritis then passes beyond the limit of the syphilome and extends along the arterial walls. In a certain number of cases the arterial lesions peculiar to syphilis and the syphilomata exist together in the same brain, but are independent of each other. More frequently, according to Heubner, a syphilitic lesion of the arteries is followed by inflam- mation and softening of the brain without the development ol syphilomata. This was the result in 24 cases observed by him or by other authors. Heubner describes syphilitic arteritis as altogether special and characteristic. He has given its pathological histology in detail; the following is a resume : At the commencement there is observed, on the internal surface of the artery, a formation of new endothelial cells which are arranged in superimposed layers, some flattened, others fusiform or round. This proliferation fills the openings and depressions of the fenestrated membrane in such a manner that the surface of the ax'tery becomes smooth and regular instead of being uneven. As a result, the fenestrated membrane, which, in its normal condition, is, in the arterioles of the brain, in immediate contact with the endothelium, is separated from it by a layer of newly-formed cells. This process begins at the internal surface of the vessel, and is due to the direct and irritating action of the syphilitic blood. This zone of proliferation by increasing the thickness of the internal membrane 20 306 SYPHILIS, of the artery, reduces its calibre or at least diminishes its dilatability and elasticity under the influence of the blood. Inflammation going on, the endothelial layer is raised up at one point by the multiplica- tion of the cells, and forms a lateral projecting vegetation into the lumen of the vessel, which by reducing the calibre of the vessel, may be the starting point of a thrombosis, or at least of a cerebral ischoemia. Heubner lays stress upon these characteristics of syphilitic [Fig. 72. '^"^^^^^^ Syphilitic disease of cerebral arteries. A. Segment of middle cerebral artery, transverse section, i. Tliicljened inner coat. e. Endothelium. /. Mcmbrana fenestrata. m. Muscular coat. a. Adventitia X 200 reduced one-half. B. Small artery of pia mater, transverse section, showing thickened inner coat, diminis^hed lumen of vessel, and considerable infiltration of adventitia. The cavity of the vessel is occupied by a clot. X 100, reduced one-half. (Green.)] arteritis, and believes the formation of a single lateral projection of the internal membrane a pathological symptom appertaining especially to this form of arteritis. The further consideration of the pathological histology of these facts will not be taken up, as they appear to us inadmissible until they are confirmed by additional evidence. For instance, Heubner believes that in the layer of newly-formed cells which is interposed between the arterial endothelium and the old fenestrated membrane, there are formed a new fenestrated membrane and new muscular fibres; he compares this new formation to a neoplasm reproducing the structure of arteries (an arteriomci). It seems to us, on the contrary, SYPHILITIC ARTERITIS. 307 d, pj'iori, more rational to admit that the newly-formed cells have separated the fibres and the elastic laminge by passing between the laminas of the old elastic membrane, and that the same process takes place in the muscular layer. Later the arteritis, which has com- menced in the internal membrane extends to the external coat of the artery ; the vasa vasorum dilate, and there is formed about them a collection of round cells, which come from the blood by diapedesis. AVhilst, according to Heubner, the newly-formed cells of the internal membrane are due to a proliferation of endothelial cells, the round cells which infiltrate all the external coats of the artery come, by dia- pedesis, from the blood contained in the small nutrient vessels of the artery. The external coat becomes inflamed, it is filled with lymph cells, and the inflammation is caused by the action of the syphilitic virus contained in the blood of the vasa vasorum. [During the discussion at the London Pathological Society, in 1877, dift'erent opinions were expressed as to the character of the changes in the internal wall. In the opinion of some they resembled athe- roma, or were due to organization of a peripheral thrombus, while othei's thought that they arose by a peculiar growth from the endo- thelium, and the interlarainar cells of the intima, producing a vascular structure, corresponding with other syphilitic new growths ; in short, a form of syphilitic endarteritis. According to Dr. Gowers, Heubner disclaimed any idea of there being any specific character in the structure of the growth itself. The description given by Heubner of syphilitic arteritis, is precisely the same as that given by Wilks and Moxon of " semi-cartilaginous thickening of arteries;" but the latter believed that the condition which they described was in no way connected with syphilis. It would seem, therefore, that the influence of the syphilitic dyscrasia w^as shown more in the degree to which the change was carried, than in the kind of change ; and that more significance was to be attached to the nodular thickenings of the outer wall than to the endarterial changes.] These pathological modifications occur with rapidity, and attain their maximum in the space of a few months. They may, however, remain stationary without notable change during several years. Heubner, and Lancereaux, who has followed him in the study of this process, maintain that the fatty -degeneration, so common in atheroma, and in senile arteritis, is not observed in syphilis. Yet, when the disease has lasted for a long time, there is a considerable diminution 308 SYPHILIS. of the calibre of the vessels which are transformed into tubes, or even into fibrous tracts, and sometimes portions of them ai-e found which have undergone calcareous degeneration. Heubner compares this syphilitic arterial lesion with chronic endarteritis, and claims to have established marked differences between these two processes. The age of the subjects is not the same ; the first attacks the old only, the second syphilitic subjects of all ages, during the secondary and ter- tiary periods. The commencement by the endothelium, in syphilis, differs from the beginning of atheroma, which begins simultaneously in the external and internal tunics. Atheroma has its seat in the aorta and in the large arteries, while syphilis has a marked prefer- ence for the small arteries, especially for the arterioles of the brain. [Other writers give, with great confidence, the diagnostic points between syphilitic arteritis and atheroma. Lancereaux believes that this difference can be recognized, clinically, chiefly by the occurrence of symptoms of thrombosis in young subjects Avithout evidence of dis- ease in other arteries. He also bases his diagnosis upon the know- ledge that the subject is syphilitic ; the fact that atheroma is devel- oped especially in the large vessels — aortic, splenic, mesenteric, and renal arteries — whilst in syphilitic arteritis the changes are chiefly found in the arteries of the brain ; upon the frequency with which young subjects are attacked ; and upon a certain symmetry in the development of the lesions. It does not seem to us, however, that these differences are suffi- ciently uniform to warrant a diagnosis during life. When, however, the clinical and pathological distinctions are considered jointly, the separation of the two diseases becomes more evident ; they have been stated^ as follows: — The syphilitic change is speedily developed, a few months being sufficient to cause great thickening of the coat and consequent nar- rowing of the lumen. The exact rate of progress of atheroma is not known, but it is certainly slow, and probably requires years for its development in most cases. The syphilitic process from the first causes narrowing of the artery, while in atheroma the vessel is widened very early .^ [' Hill and Cooper, op. cit., p. 199.] [2 "Atheroma is at first attended with a narrowing of the calibre of the vessel, in proportion to the thickness in which it is deposited. ... A later conse- quence of the disease is dilatation of the vessel." Mr. Moore, in Holmes's System of Surgery, Am. ed., vol. ii. p. 307.] SYPHILITIC ARTERITIS. 309 The development of the syphilitic change is a more localized affec- tion, indeed it may be limited to a short length of only a single vessel, and usually only the smaller arteries of a single organ or locality are affected. In atheroma the larger arteries are fii-st diseased. The site of the commencement of the morbid change is different in atheroma ; this may be well seen in an artery, such as the basilar, where the fenestrated layer is well developed. Atheroma begins by the production of nuclei in the gaps of the fenestrated membi'ane, which collect between it and the endothelium. But from the first these nuclei, and afterwards the cells produced around them, are surrounded by a plentiful protoplasm of striated appearance. In short, the first effect of atheroma is. to multiply the layers of elastic membrane. Thus a marked distinction is evident at once between the earliest development of atheroma and that of the syphilitic change. In the latter the new formation is cellular during all its early devel- opment, and the intercellular substance is only small in amount. Another clear distinction is the rapid fatty-degeneration in athe- roma of these new layers of cells and intercellular substance, by Avhich the artery is soon beset with patches of rigid whitish material, consisting partly of fat and partly of calcified granules, of which the appearance is well known. The relation of syphilitic arteritis to aneurism is one of the most interesting surgical questions of the day, but is yet sub judice. On the one hand, we have the statistics of Welsh, who, in 53 cases of aortic pouching or sacculation, 34 of which developed into aneurism, found ^'o per cent, of syphilis ; and we have, also, the testimony of Fournier, Russell, Lancereaux, lieubner, Chvostek, and others, who have reported cases of aneurism associated with extensive syphilitic disease elsewhere. The great frequency of syphilis detracts much, however, from the value of these observations, as it would hardly be difficult in this manner to prove a relation between syphilis and any other ailment that might be selected. In opposition, too, we have the evidence of Agnew, who, in twelve years' experience in the venereal Avards of the Philadelphia Hospital, which are exceedingly rich in cases of advanced syphilis, did not meet with a single aneurism. To this we may add our own experience, extending now over nine years, nor have we seen or heard of such cases in the service of our col- leagues. The conclusions which we are warranted in drawing in resrard to the entire subject of the relations of syphilis to arterial disease 810 SYPHILIS. were well expressed^ at the time of the discussion in the London Pathological Society in 1877 : 1. That certain changes have been found in the vessels affecting both the external and internal coats, occurring in patients who have contracted syphilis, and who have, moreover, died at a comparatively early age from disease which in most of the cases was the direct result of the arterial lesion. 2. That in many of the specimens examined the arterial lesion appeared to be of a gummous nature, consisting of a small celled growth and a deli- cate fibrillar stroma, while in other instances the disease appeared to arise from a form of chronic interstitial arteritis that could not be regarded as of a specific nature. 8. That one great point for future consideration will be whether these changes which are now regarded as specific have been observed in the bodies of patients who had undoubtedly never contracted this disease. Two or three such in- stances would throw much doubt upon the syphilitic nature of these lesions, while many such instances Avould upset the syphilitic theory altogether. 4. That it is desirable to collect and record cases where patients who have suffered from syphilis have prematurely died from a cerebral or any other affection resulting from arterial disease, inas- much as a large number of such cases would establish syphilis as an important factor in the causation of such disease, even were the new growth frequently found to be identical with interstitial inflamma- tion set up by other causes. 5. That, moreover, we should make the strictest inquiry into the history of patients suftering from aortic and other forms of aneui'ism, in order to see whether there is any founda- tion for the belief that aneurism occurs with much greater frequency in the subjects of syphilis than in non-syphilitics. The majority of these questions may still be considered as not absolutely decided, but are certainly of undiminished interest and importance.] The very decided opinions of Heubner are cited because his memoir is the result of much careful study, and because his anatomi- cal examinations and his drawings are those of an histologist ; but, nevertheless, we do not insist upon the adoption of his views. That the cells of the endothelium of the arteries are modified by the syph- ilitic virus circulating with the blood is possible, but in that case the change would be more frequent during the secondary period, and the lesion would be generalized. The vessels attacked by endarteritis [' Medical Press and Circular, March 21, 1877.] SYPHILITIC ARTERITIS. 311 and peri-arteritis in syphilis have not the same tendency to fatty-de- generation as in atheroma, or in the senile condition of the arteries. This is perfectly true ; in fact in atheroma fatty-degeneration of the internal membrane is primary ; it must not be thought, however, that the yellow points which are found upon the internal membrane of the aorta are rare in young subjects ; they are, on the contrary, very common in the cases of soldiers who die in the service (Ranvier). Age is not then one of the most important conditions. Syphilis, or more correctly, syphilitic affections of the viscera, are accompanied with endarteritis and peri-arteritis Avhich do not have a marked tendency to fatty-degeneration. But is this a reason that arterial lesions of this kind should appertain especially to syphilis ? We do not think so. We find, in fact, in every chronic phlegmon, in every chronic sclerotic inflammation of connective tissue, secondary lesions of the arterioles absolutely like those which Heubner describes, and which belong to ordinary arteritis. It is essentially what one would obtain artificially by placing a ligature loosely around an arteriole. [The order of frequency in which the tissues of the vessels are in- volved by inflammatory changes is usually believed to be determined chiefly by the character of the exciting cause. When internal or idiopathic disease such as gout, rheumatism, or syphilis, gives rise to arteritis, the tunica intiraa is first affected, though the disease may travel outwards involving successively the middle and external coats, and even the peri- vascular connective tissue. If the arteritis has a traumatic origin, however, the disease will be more likely to advance in the opposite direction. Thus Agnew^ says: The earliest evidence of the external form of the disease, that most commonly encountered by the surgeon, is hypersemia of the nutrient vessels of the cellular tissue of the artery and its sheath, followed by a fibrinous and cell transudation. Should the inflammatory distension of the capillaries continue, a similar infil- tration will extend to the middle coat, the effect of which will be to involve the tunica intima, producing endo-arteritis. Partly from the swelling and partly from the spasm of the muscular walls of the ves- sel excited under irritation of the vascular nerves, and thereby di- minishing the canal of the artery, the inner coat is thrown into plica- tions, and its nutrition seriously disturbed. The walls of the vessel [' Surgery, vol. i. p. 531.] 812 SYPHILIS. thus filled with the products of inflammation may undergo several important structural alterations.] Amono; cases of arteritis there are some which have a sli<2;hter ten- dency to fatty-degeneration than others ; for example, the cases of arte- ritis due to rheumatism or to alcoholism possess to a less degree areas of cheesy degeneration than those due to senile atheroma ; the chronic inflammations of the arterioles of the kidneys in interstitial nephritis, those of the vessels of the liver in cirrhosis, have almost no tendency to granulo-fatty degeneration. This anatomical characteristic is not of itself peculiar to si/pliilis. Nearly all cases of arteritis commence at the internal membrane. It is well, therefore, from these consid- erations, that Ave should be cautious before accepting the infallibility of the histological lesions described by Heubner in the cerebral arte- ries of syphilitics ; we shall regard them, until more ample proofs are given us, as entering into ordinary chronic arteritis, and we wait new confii-mative testimony before we admit that the arterial lesions are primary in cerebral syphilis, and independent of all inflammation and of all syphilitic neoplasms. That which relates to the syphilitic diseases of arteries can be summed up by saying that, while this agency is very evident and very important as regards symptoms, for cerebral softening is a conse- quence of their obstructive effects, no entirely satisfactory explana- tion of their origin has yet been given. Most frequently the first change is due to the existence of small gummata seated around the artei'ies, but we have seen gummous nodules commencing in their ex- ternal coat. Many writers even admit that the neoplasm can begin from the cells of their internal coat. Of this number is Dr. Celso Pellizari, who has recorded a case which may serve as a type of the rarity of the gummata under consideration.^ The case was one of a patient who died with multiple cerebral symptoms, and who presented at the autopsy the following lesions : A S3q)hilitic hepatitis, lesions of the dura mater, attachments of the brain to the cribriform plate of the ethmoid bone, a softening of the right hemisphere, a contraction of the middle cerebral and basilar arteries with organized thrombi and gummous nodules from the size of a pin's head to that of a bean, ex- tending the entire length of the former vessels. In the examination of this artery Vicenzo Brigidi found together with a vegetating endar- ' Celso Pellizari, Delia sifilide cerebrale, ein partico lare delle lesioni arteriose da sifilide uel cervello. SYPHILITIC PHLEBITIS AND LYMPHANGITIS. 313 teritis an amyloid degeneration of the walls. Gummata and endar- teritis with thrombosis were the cause of softening. [It is generally believed that the veins are not at all or but slightly affected in late constitutional syphilis, and little is known as regards the diseases of the lymphatics during that period. Mr. Hutchinson has called attention^ to the very few cases of syphilitic phlebitis which have been recorded, and yet he says most surgeons are familiar with the fact that inflammations around varices and even about healthy veins, are not infrequent in the subjects of syphilis. He continues : " T think, also, that I have seen several cases in which the thrombosis and phlebitis were attended by other condi- tions sufficiently peculiar to justify a belief that they were of specific origin. In some, there has been great excess of inflammation, a large, hard mass forming in the cellular tissue and threatening to slough, much as subcutaneous gummata often do. These cases are much benefited by the iodide of potassium, so far as prevention of sloughing is concerned, but the thrombotic plugging remains. I am not aware that any specimens have been produced showing syphilitic disease of the cerebral veins. As regards the lymphatic trunks, I believe that they are liable to disease just as the arteries are, and that it results in similar conditions of plugging and its consequences. In a clinical lecture, published some months ago, I detailed several cases in which one lower extremity became greatly swollen, and remained for a long time in a state of solid oedema, there being, in some, reason to believe that the lymphatic trunks were inflamed, whilst in all there was a history of syphilis. In one remarkable case, I had treated the gentleman many years before for syphilitic paralysis of the fifth nerve. In him, a large network of cord-like lymphatic trunks could be felt over the lower part of his abdomen, one thigh being greatly swollen. There was no gland disease — and I am not speaking now of affections of the glands, but of the trunks. It would be very interesting, should opportunity for microscopic examination occur, to ascertain how far in this condition the changes in the walls of the lymphatics are similar to those seen in the arteries." The possible frequent involvement of the lymphatics in the tertiary stage is interesting also in connection with the theory of syphilis which attributes the phenomena of that stage to obstruction of the lymphatic vessels. (See pp. 24, 25.) [' British Medical Journal, February 10, 1S77.] 31-4 SYPHILIS. Dr. Otis quotes^ a single case as the only one he was able, after much research, to discover, in which symptoms referable to lymphatic occlusion were actually proved, upon post-mortem examination, to depend upon that condition. Even here, however, no examination had been made of the walls of the vessels, and the cause of their ob- struction remained undetermined.] The syphilitic alterations of the spinal meninges and of the spinal cord are analogous to those of the brain ; but the cases that can be attributed to syphilis are very rare. The lesions of the meninges are nearly always secondary to those of the vertebrae. As to those concerning the spinal marrow itself, there are in the cases of adults but a very small number of incontestable observations. In the case reported by Charcot and Gorabault, the patient presented, at the superior region of the dorsal marrow, on the left side, on a level with the 3d pair of dorsal nerves, a hard swelling, a protuberance occupy- ing nearly a centimetre, in which were found fasciculi of fibres with stellate and round cells arranged along the vessels. The nervous substance was here replaced by a gummous neoplasm. The roots of the corresponding spinal nerve were altered at this point, and tlie pia mater and arachnoid were thickened. Apropos of this fact, Charcot, in examining the published cases of syphilitic lesions of the spinal cord, finds but three which are beyond criticism ; two reported by Lancereaux, and one credited to Moxon. When a syphilitic tumor is situated in a portion of the spinal cord, a secondary degeneration is found ; thus in the case of Charcot and Gombault, the left anterior column was changed beneath the gummous swelling, and the right posterior column was degenerated above it. In hereditary syphilis of new-born children, Lancereaux and Potain have published cases of difi'use induration of the spinal cord in its entire length. Symptoms of Cerebral Syphilis. — The symptoms depending upon the different alterations of the meninges, of the brain, and of the vessels, which have just been considered, differ, it is needless to say, according to the region of the brain which is affected by them. It is desirable that we should be able to diagnose the seat of the malady by the analysis of the symptoms, and we shall doubtless, at some future time, definitely effect these localizations ; this is, how- ever, impossible at the present time with the known facts of cerebral syphilis. We should remember that the lesions of the dura mater, of [' Op. cit., p. 52.] SYMPTOMS OF CEREBRAL SYPHILIS. 315 the pia mater, and often those of the cranial bones, coincide with gummata or more or less extended softening, in such a manner that multiple manifestations have to be contended with. Despite these difficulties, the progress of these encephalopathies, a certain number of characteristics which appertain to them, and, in doubtful cases, the antecedents of the patients and trial of the iodide treatment will ordi- narily indicate their nature. The most common, but not constant, initial phenomenon is cepha- lalgia, Avhich is frontal, occipital, or parietal, very intense, piercing in many cases, often worse during the night, and accompanied fre- quently by vei'tigo and mental dulness. This pain is at times in- tolerable, so much so,, that the patients become as if insane, or, on the contrary, they may be plunged into a stupor resembling coma. The cephalalgia may last for a long time with more or less intensity before any other symptom shows itself. If syphilis has been sus- pected from the antecedents of the patient, and iodide of potassium has been given with the result of lessening the pain or causing it to cease, the diagnosis is assured. During the cephalalgia, the patients often experience a diminution of their intellectual faculties — an unaccustomed inactivity — impossibility of transacting business, or of making the most simple calculations, forgetfulness of certain words, or of their actions of the day before, an alarming loss of memory, etc. Different forms of paralysis supervene. They commence nearly always, by being very limited, and are perceived either in loss of movement or sensation. The nerves at the base of the cranium are those the most frequently attacked. The paralysis of muscles supplied by the common oculo-motor nerve produces, for example, external strabismus, diplopia, impossibility of raising the eyeball, relaxation of the levator palpebrie superioris, blepharoptosis, mydriasis by re- laxation of the ciliary muscle, with moderate dilatation and immo- bility of the pupil. Paralysis of the superior oblique of the eye, the only muscle which is dependent upon the pathetic nerve, will lead to a diplopia. The diminution of the sense of taste, and even its complete abolition, the loss of the sense of smell, the diminution or the loss of hearing have been noted in connection with lesions of the bones, of the meninges, of the brain, or of the nerves of special sense. The disturbances of vision are exceedingly variable, and depend upon the seat of the lesion — whether it is localized in the optic tracts before their intei'- crossing, at the optic chiasm, or upon the optic nerves in their intra- 316 SYPHILIS. osseous canals. Subjective symptoms are observed, such as mus- cge volitantes, circles of fire, etc., the sight of only a portion of objects, an incomplete or total loss of vision. These phenomena are benefited and very frequently cured at their commencement by the iodide of potassium. The partial paralysis sometimes first shows itself in a limb — in the lower extremity of one side for example, and after a certain interval is followed by transient or permanent ameliora- tion, if the iodide of potassium employed in time has produced its curative action; if the lesion, instead of being checked, continues its progress, complete hemiplegia may supervene. This is generally progressive, slow at the commencement, with incomplete aphasia, especially if the paralysis be on the right side.^ [In an elaborate memoir founded on a careful study of seven cases of early syphilitic aifections of the nerve centres, Mauriac arrived at the following conclusions, most of which have been accepted by both syphilographers and neurologists : — 1st. Syphilis may attack the nerve centres at a period not far re- moved from the date of infection. a. The early, " precocious," cerebro-spinal syphilitic diseases ap- pear during the period of greatest activity of syphilis, i. e., during the first two or three years. b. They are the most frequent visceral complications of this stage. e. They are also the most dangerous, and their gravity has no re- lation to their date of appearance, the earliest being as formidable as those which supervene later. 2d. They may take any of the forms of disease which are produced at any time by the effects of syphilis upon the nervous system.^ a. There are, however, some symptoms which seem to predominate, the most frequent of all being complete hemiplegia. b. Right hemiplegia complicated with aphasia is the most common. c. The paralytic outnumber the convulsive or epileptic forms. d. They are characterized by an absence of systemization. e. They afiect the spine much less frequently than the brain.^ [' R. W. Taylor lias recorded (The Journal of Nervous and Mental Diseases, Jan. 1876) several interesting cases of early cerebral syphilis. In one of them hemi- plegia appeared in the fiftli month after infection ; the others were characterized by subacute meningitis, which also developed within the first year.] [2 HomoUe gives (Le Progres Med., Jan. 1, 187(3) a case of subacute myelo- meningitis with paraplegia occurring at the end of the second year of syphilis. The autopsy revealed softening of the lower portion of the cord and a thickening of the arterial coats. The vessels, however, were pervious. Dr. Keyes, in commenting SYMPTOMS OF CEREBRAL SYPHILIS. 317 3d. Hyperplasias of the pia mater and the cortical layer of the brain, may be either circumscribed or diffused, but are usually of the former variety, and together with characteristic alterations of the sylvian arteries and consecutive softening of the brain substance constitute the special lesions of these diseases. 4th. In the majority of these cases the initial lesion and the subse- quent mucous and cutaneous symptoms have been mild. a. The general development of the constitutional disease is not prevented or retarded by the occurrence of these nervous affections. h. The treatment is the same as would be proper at the particular stage of the disease at which the nervous phenomena appear, modi- fied as to dose, combination with other agents, etc., only by the special symptoms of the case in question.] These cases of hemiplegia are not accompanied, like those of copious hemorrhages, or of apoplectiform softening, by a total loss of consciousness. Patients preserve, on the contrary, to a great extent their consciousness, as is the case in certain forms of cerebral soften- ing, and the paralysis affects only the power of motion.^ The paralytic phenomena which have just been considered, or one of them, preceded by cephalalgia, terminating in convulsions, or in a comatose condition and death, constitute a common form of syphilitic cerebral disease (paralytic form of Lancereaux). But in other obser- vations, only hebetude and the paralysis of the insane are observed during the entire duration of the malady. In other cases it is apha- sia which predominates, the impossibility of finding other expressions than one or more words, coexisting with a certain relative intelligence, sometimes even with the possibility of writing. Aphasia is at times intermittent, returning by exacerbations, with a gradual or sudden weakening of the motor power of the right side (Mauriac). This aphasia is connected with gummata occupying, as in the case of Bour- on this case, remarks that this form of syphilitic spinal disease differs pathologi- cally from tertiary disease of the same region ; in the latter there is always either gummy tumor, sclerosis or disease of the bony canal, with or without meningitis or arterial lesions.] [• Buzzard has recorded ( The Lancet, .June 7, 1879) several cases of " prolonged somnolence," associated with hemiplegia, and resulting in recovery. The condi- tion was simply one of stupor and drowsiness, from which the patient could be readily aroused. Heubner attributes this somnolency to the narrowing of a num- ber of arteries, in consequence of which there is congestion and defective oxidation, and accounts for the temporary recoveries by the possibility of the nervous sub- stance becoming gradually accommodated to the change of vascular tension.] 818 SYPHILIS. ceret and Cossy, the posterior part of the second and third frontal convolutions, or with the limited softenings following gummata and thromboses of the middle cerebral arteries. Finally, along with sev- eral other phenomena connected with the intelligence or the power of motion, convulsive symptoms often predominate — veritable attacks of epilepsy characterized by facial grimaces, twisting of the neck, clonic convulsions, and biting of the tongue. However, these epileptiform attacks, which follow syphilis, and from which the patient has never suffered during infancy, do not present the same characteristics as idiopathic epilepsy. The initial cry is rare, the convulsions are often limited. The loss of consciousness is not always absolute ; intelli- gence is lost gradually, and the attacks leave after them lethargy and incomplete paralysis, which end by becoming absolute. In place of convulsive attacks a simple trembling has been noted. [Charcot believes partial syphilitic epilepsies to be among the most common developments of cerebral syphilis. He describes as follows' the characteristic symptoms of the disease : — Partial epilepsy, whether of syphilitic origin or not, generally com- mences by convulsive movements of the face or arms on one side of the body. An attack commencing in the lower extremity must, there- fore, be regarded as exceptional. In some cases, moreover, the dis- ease assumes the appearance of ordinary epilepsy, for the patient suddenly falls down in an unconscious state, followed by convulsions, which are moi'e or less general in character. The imminence of the latter is constantly indicated by severe headache, confined to a limited spot on the side of the head. The pain quickly extends to the face and neck on the same side ; but there are exceptions to this general rule. Another point to be noted is that the attacks very frequently set in towards evening. The manner of attack, and the succession of convulsive symptoms, are conformable to the rules established by Dr. Hughlings Jackson. That distinguished physician has observed that when the convulsive movements of partial epilepsy, commencing in the arm, tend to become more general, they attack the face before they extend to the leg. If the irregular movements have commenced in the face, the disease extends to the upper extremity first, and then to the legs. Lastly, if it be the lower extremity which is first attacked, the disorder of motor power is seen in the arm first, and then in the face. [' Medical News and Library, April, 1877.] SYPHILITIC EPILEPSY. 319 Circumscribed gummous inflammation of the pia mater appears to be the pathological condition most frequently connected "with par- tial syphilitic epilepsy. This has been pointed out by Todd, Eche- verria, Lancereaux, and some other writers. It is, however, certain that several other forms of cerebral disease may be determined by this same gummous meningitis. The variations, as we have good reason to believe, depend on the points of cerebral surface attacked. If we accept the theory founded on recent investigations, the gummous patches in partial syphilitic epilepsy should be found on, or very near to, the ascending frontal or parietal convolutions. This has not yet been established by actual observation, but Prof. Charcot feels con- fident that the proof is only delayed. So long as the disease has not become inveterate — so long, in a word, as there are intervals of free- dom from attack, we are entitled to conclude that the cerebral sub- stance has not been disorganized by the gummous inflammation of the meninges. From a record of 274 cases of epileptiform seizures of an undoubted syphilitic origin. Dr. Thomas Stretch Dowse summarizes his observa- tions very briefly as follows :^ The age of the patient is an important guide. Should a man or a Avoman be attacked by epilepsy between thirty and forty years of age, without any hereditary predisposition, or a previous seizure, then a syphilitic cause may be apprehended. And, apart from this, if between the attacks there is some degree of mental derangement, our basis for a diagnosis is greatly sim- plified, and it is even more so if there be a paresis more or less pro- found, localized, or unilateral, but generally passing off after the epileptiform seizure. * The reflex processes are rarely if ever com- pletely absent. The iris may contract under the influence of a strong light ; the lids close when the conjunctiva is tickled, and a state of semi-consciousness, rather than profound coma, is a prominent feature from first to last. The stages of the attack are ill-defined, and merge one into the other. The universal tonic spasm, with thotonism, rarely presents itself. Pallor, rather than cyanosis, is the facial exponent, and the duration of the fit is protracted to many hours, with intervals of wan- dering, delirium, and excitement. Foaming at the mouth is less prominent than a profuse flow of saliva, and all sorts of cries are associated with the seizure ; but they are rarely so exalted as Rom- berg expresses it, " shrill and terrifying to man and beast." [• The Practitioner, March, 1877.] 320 SYPHILIS. And, lastly, in reference to albumen in the urine. Considerable attention has been given to this point, but it has not been found in any but a few of the cases ; but epileptoid seizures, associated with albuminoid syphilis, and a plentiful secretion of phosphatic albuminous urine are not uncommon. M. Fournier says:^ 1. Every case of epilepsy appearing for the first time in an adult subject of known syphilitic antecedents should be attacked with specific treatment. 2. Every case of epilepsy hap- pening under the same conditions in a person of uncertain or denied syphilitic antecedents, should still at least, if not plainly explicable by some other cause, be submitted empirically to specific treatment. In obeying these two precepts marvellous successes may be sometimes obtained. It is denied, and it seems to us with great justice, that syphilis ever causes epilepsy without first producing some structural altera- tion, the most frequent lesion being chronic meningitis. Gowers asserts,^ that although attacks of syphilitic epilepsy closely resemble those of idiopathic epilepsy, they may be distinguished: 1, by the age of the patient ; they usually commence after twenty-five years of age, and, therefore, at a period of life at which epilepsy less commonly begins ; 2, by the persistent headache which commonly precedes their occurrence, and exists during the whole of the inter- vals between, and not merely after the attacks ; 3, by the frequent association of optic neuritis ; 4, by the coincidence of paralytic symp toms; and, 5, by the association of early, and often progressive, mental disturbance. We have seen during the last year three cases of syphilitic epilepsy, occurring in one case twelve months, in another eighteen months, and in the third two years after the contraction of the disease. The most interesting point which was common to all these was the development very early in the secondary period, as the most prominent and annoying symptom, of severe headaches. These yielded after some time to vigorous specific treatment, but returned at short intervals and on slight provocation. In one of these cases, the patient was confined to bed with a headache, Avhich lasted for nearly ten days, was agonizing at night, yielded only to large doses of morphia, and only very slowly subsided under active mixed [' L'Union Medicale, 1876.] [2 Hill and Cooper, op. cit., p. 221.] SYPHILITIC PARALYSIS. 321 treatment. The temperature varied from 100° F. to 102° F. ; the tongue was dry, furred, and cracked, and the condition was decidedly typhoid in its character. No sensorial or other cerebral disturbance was noticed, and no convulsions recurred. The early appearance of obstinate headache may probably be considered an indication that the special dangers which the patient has to run in the future are those connected with some of the developments of cerebral syphilis.] There exist observations on cerebral syphilis in which the symptoms have approached very nearly to general paralysis. [It is very important in many cases of suspected cerebral syphilis, associated with symptoms of insanity, to distinguish between the non- specific general paralysis of the insane and the paralysis not infre- quently found in the later stages of syphilis. The importance of making the diagnosis, if possible, rests upon the influence which it will exert in both prognosis and treatment, the syphilitic affection being often relieved, or apparently cured, by the employment of mercury and the iodides, Avhile the other affection is incurable. Dr. W. G. Mickle in a paper upon cases of this character thus details the points by which he believes syphilitic paralysis may be recognized: — " 1. Distinct history or symptoms of syphilis. 2. Preceding cranial pains, nocturnal and intense. 3. Exaltation less marked, less per- sistent, and perhaps less associated with general maniacal restlessness and excitement than in most cases of general paralj^sis. 4. Some- times by such complications as palsies of one or several cranial nerves, or hemiplegia, paraplegia, etc., having the character and course of syphilitic palsies. 5. The greater frequency of optic neuritis, early amaurosis, deafness, local aneesthesia, vertigo, or local rigid contrac- tion. 6. The affection of articulation is paralytic rather than paretic, and usually speech is not accompanied by any facial or labial tremors. 7. By cerebral or spinal meningitis, or pachymeningitis. 8. By the variety of the motor and sensory symptoms, their capricious associa- tion or succession, and transitory character, and by the absence of the general progressive muscular paresis of the other disease. 9. By the effect of anti-syphilitic treatment.'" Dr. Mickle also states that in general paralysis the faradic contractility of the muscles of the [' British and Foreign Med-Chir. Review, July and Oct. 1876, April, ]877. Abstract by Dr. E. C. Seguin.] 21 322 SYPHILIS. extremities becomes considerably and progressively lessened, while in syphilitic cases it is normal, or not much impaired.^ Dr. C. R. Drysdale^ believes that general paralysis of the insane is never caused by syphilis, although he recognizes the existence of syphilitic insanity in the form of mania, melancholia, or dementia. He adds : " It is true, perhaps, that many patients with general paralysis have had syphilis. Mendel speaks of ninety cases out of one hundred and seventy-six ; but there are many reasons why it is difficult to admit that there is any relation of cause and effect in these two diseases. General paralysis has very marked characters ; it is almost confined to the male sex, scarcely ever seen before the age of thirty-five, and, in the male, it almost always aifects the middle classes, whilst, in Avomen, it almost always is seen amongst the poor. Syphilis has no preference for either age or sex, and when the cranium of a patient with cerebral syphilis is opened, we never find (as in the general paralytic invariably is the case) generalized meningitis. Cerebral syphilis presents special lesions. The affection of the cra- nium in general paralysis never goes beyond the meninges ; whilst in the case of gummy tumor commencing in the meninges, it will extend and attack either the dura mater, the bones, or the cerebral pulp itself. If it has lasted long, we cannot say where it began. [' A table compiled from a lecture on insanity, by Dr. E. C. Segnin (Hospital Gazette and Archives of Clinical Surgery, September 12, 187S), contrasts the two diseases as follows : — GENERAL PABALYSIS OF THE INSANE. SVPHILTTIC GENERAL PARALYSIS. Prodromic stage. Absent. Exalted notions, numerous and varied, Rare or absent. and relatively exalted according to position in life. Speech is tremulous and jerky. Speech is thick. Tremor of hands and lips. Absent as a rule. Preservation of strength. Paresis or actual paralysis. Pupils are apt to be contracted. Apt to be open or wide. No involvement of cranial nerves. Palsy of the third or of other cranial nerves. No headache. Headache nocturnal. Transient aphasic attacks. More serious aphasic attacks. Spontaneous remissions. Progressive, except under treatment. Abnormal cravings or appetites. None. Satyriasis. Diminished virility. Elevation of temperature. Usually none. Irritation and incoordination, usually Actual paralysis.] without true paral^'sis. P A paper read before the British Medical Association, 1880.] SYPHILITIC PARALYSIS. 323 " Treatment again is of great service in many cases of cerebral syphilis, sometimes restoring apparently hopeless cases. When gene- ral paralysis exists, all treatment is unavailing. Specifics have no power at all against a meningitis, which, if it were syphilitic, would surely be affected by them. " Many cases, too, are on record, where syphilis has coexisted with general paralysis of the insane. In such cases specific treatment can remove an exostosis, or a paralysis of the motores oculi, or a gummy tumor in the palate ; but it leaves the other affection untouched." Hence his conclusion is that syphilis has nothing to do with the general paralysis of the insane. M. BalP gives a resume of Fournier's views on insanity attendingr syphilis, which, according to that observer, presents itself either as a syphilitic dementia, as mania, or as general pseudo-paralysis. In syphilitic dementia, the patient's temperament undergoes a radi- cal change. His intelligence is clouded and his conduct strange. He becomes moody and taciturn. Labor is fatiguing and intolerable. His memory fails, though judgment often remains. Loss of memory may either be sudden or complete, or gradual and imperfect. The patient becomes careless as to his personal appearance, and very irritable. This condition may be designated as a precocious senilit}^ of the mind, differing from senile dementia, however, in being curable. Syphilitic mania may be suddenly developed or present prodromal symptoms. The latter, when present, consist in a peculiar excite- ment, feverish activity, and in unusual loquacity. These prodromata terminate in delirium, which may manifest itself in several forms. Sometimes it is active and attended by complete insomnia. The patient becomes destructive, and suicidal tendencies show themselves. The delirium assumes the form of hypochondriasis or syphiliphobia. The patient believes himself persecuted. The delirium is impulsive. General syphilitic paralysis. This variety of the disease begins with mental hebetude and with incoherencies of speech. The speech may become embarrassed, and stuttering, and local paralyses, par- ticularly those of the eye, soon follow. The diagnosis is based upon the concomitant symptoms, as headache, alopecia, and gumraata, but particularly upon partial paralyses. Strabismus is another valuable diagnostic symptom. [' Annal. et Bull, de la Soc. de Medeciue, July, 1881.] 324 SYPHILIS. The prognosis is favorable if the case receives prompt treatment, although the disease sometimes terminates fatally. The treatment must be energetic and thorough. At the beginning the mixed treat- ment is indicated : 5 grras. (75 gr.), at least, of the iodide of potas- sium should be exhibited daily, and inunctions also employed. If mer- cury is not well tolerated, recourse may be had to the chloride of gold.] After a rapid survey of these syphilitic encephalopathies, it is seen that this is a malady which has not a constant and regular form, and of which no one symptom is invariably present. In one case they nearly all will be found united, as in the observation of Coyne and Lepine, given on page 344 ; in another case, no other symptom but cephalalgia will present itself, as in the case of Peltier and Coyne (see page 350), where sudden death took place without any other phenomenon than pain. Nevertheless, in this last case there was a gumma the size of a small walnut in the cerebellum. [Althaus has observed^ syphilitic affections of the nervous system most frequently in persons between twenty and thirty years of age ; he regards as predisposing causes the neuropathic diathesis, hereditary tendencies, excessive mental strain, sexual excess, injuries, depressing emotions, and incomplete treatment.^ He divides these affections into three forms: — 1. A congestive or hyperaemic form — characterized, when allowed to go on, by the general symptoms of paralysis of the insane, followed by aphasia, hemiplegia, paraplegia, etc. In some cases the cervical sympathetic nerve has been found in a state of degeneration, and it is probable that disease of the superior ganglion of this nerve may have an important influence in the produc- tion of the repeated attacks of hyperaemia. 2. A cerebral tumor — a gumma, either hard or soft. There are then, nocturnal headache, sleeplessness, epileptiform attacks — which are the most prominent symptoms, the various phenomena produced by involvement of the cerebral nerves, etc. 3. Disease of the arteries — when this involves the basal sphere of [} Medical Times and Gazette, Nov. 10, 1877.] [2 Dr. Dowse believes that there are two prime factors which tend to induce syphilis to expend itself upon the brain and nervous system, the first being here- ditary predisposition ; the second, previous inflammatory changes due to excesses, exhausting diseases, or traumatism. The Medical Press and Circular, Feb. 27, 1878.] CEREBRAL SYPHILIS. 325 cerebral nutrition, comprising the vertebral, basilar, and carotid ar- teries, the circle of Willis, etc., in Avhich there is little anastomosis, the result of occlusion of the vessels is some form of necrobiosis, red, yellow, or white softening followed by hemiplegia. In the cortical sphere, plugging of the vessels is not so directly dangerous, as the peripheral parts may still be supplied with blood by anastomosis from the pia mater. Still the sudden establishment of collateral circulation by increasing the vascular pressure often gives .rise to the temporary apoplectic seizures Avhich are so common in this form of syphilis.^ Heubner' also divides cerebral syphilis into three distinct clinical groups, which, however, have certain symptoms in common, the most frequent of which are headache and sleeplessness. Of the three fundamental types which he lays down, the first con- sists in physical disturbances, with epilepsy, incomplete paralysis, and a final comatose condition, usually of short duration. This epileptic form is in nearly all cases found to be due to a gum- mous growth in the pia mater of the convexity of one of the cerebral hemispheres, either limited and superficial, or involving more or less of the cortex, and forming a distinct tumor. Out of twenty-six cases observed by Heubner, where the morbid process was of this form, epi- [' Dr. C. C. Gray (Proceedings of Med. Soc. of County of Kings, April, '79) thus alludes to these points : " The morbid changes are of two kinds. There may be diffuse infiltration or tumors of the dura mater and subarachnoid spaces, impli- cating the surrounding structures in their growth ; or there may exist disease of the arteries at the base of the brain. The arterial degenerations are of the arteries composing the circle of Willis, and especially the internal carotids and their branches. The specific deposit begins between the inner coat of the vessel and the endothelium, narrowing the calibre of the blood-channel, or even abso- lutely obstructing it. The lesions are thus manifold in their consequences. The new formations and the infiltrations are irritative to the membranes and the nervous structures beneath, or they may be destructive to the gray matter of the convolutions, by causing the death of cells upon whose existence the function of the part depends ; whilst the constriction or occlusion of the vessels diminishes or cuts oflf the aliment of the tissues, and correspondingly devitalizes them. Inter- ference with the blood-current in the internal carotids and their offshoots, the chosen site of specific arterial alteration, is peculiarly disastrous ; since the middle cerebral or Sylvian arteries, springing directly from the internal carotids, supply the corpora striata and optic thalami with branches whicli are terminal, so that there is no anastomosing and collateral circulation at hand to relieve these basal ganglia of the evils attendant upon a blockade of the blood-supply through their sole nutrient vessels."] [2 Ziemssen, Cyclopaedia of Medicine, vol. xii.J 826 SYPHILIS. leptic or convulsive attacks occurred twenty times ; whilst in nineteen other cases, where the growth was limited to the white substance or the base of the brain, this symptom was found only twice. Similar observations were made by Jaksch, and these records entirely agree with the experience of Wilks, Hughlings Jackson, and others. The second form described by Heubner is the apoplectic, charac- terized by " genuine apoplectic attacks, with succeeding hemiplegia, in connection with peculiar somnolent conditions occurring in often- repeated episodes, frequently phenomena of unilateral irritation, and generally at the same time paralysis of the cerebral nerves." The symptoms vary greatly in character and degree. It is in this form that the peculiar affection of the cerebral arteries, leading to their more or less complete obstruction, is found, and upon this change appear to depend the apoplectic attacks and the hemi- plegia. The third form described by Heubner resembles very closely ordi- nary general paralysis of the insane. It differs, however, in the comparative infrequency with which delusions of exaltation are ob- served, and in the fact that exacerbations in the psychical symptoms often coincide with the outbreak of fresh syphilitic eruptions, or other local affections of bones, throat, nose, etc. Later on, transient and irregular paralyses are observed, which come and go in a very rapid manner. Still the distinction from some cases of paralytic dementia is not easy to define. Mr. Hutchinson says:^ The occlusion of an artery and subsequent softening of brain-substance are one thing ; a gumma of the dura mater is another. They are different in their symptoms, course, and progress under treatment. If a man be hemiplegic from softening of the corpus striatum consequent on arterial occlusion, there is but little hope that he may recover, however vigorously the iodide be pushed. It may prevent further arterial disease, but can not repair the brain. In cases of gumma, the hopefulness of treatment is, on the other hand, indefinite, and the triumphs of the remedy are matters of everyday experience. In many cases, too, the diffei'ential diagnosis can be made with fair accuracy. If we say that w^e recognize three forms of cerebral disease — one in which the symptoms result from arterial occlusion, one from the irritation of gummata, and one from periosteal thickening — we may assume that sudden attacks of paraly- [' Medical Times and Gazette, Feb. 17, 1877.] SYPHILITIC LESIONS OF THE SPINAL CORD. 327 sis denote the one, that the second has all the symptoms common to cases of tumor, and that the severe pain and headache go with the last. To each of the three conditions a group of special symptoms might easily be assigned. We are surely advanced past the stage when it was necessary to mention all the symptoms which occur sev- erally in each, as if all were to be expected in the condition known as " cerebral syphilis." No doubt in some cases all three lesions are present together, and in many two of them ; but this ought not to prevent us from trying to discriminate, when, as is the case in most instances, discrimination is practicable. He is not sure that we shall not be obliged, as knowledge ad- vances, to admit yet a fourth group of cases — those namely, in which the symptoms are those rather of progressive and slow atrophy than of new growth or inflammation. He suspects that there are such cases, and that they are far less amenable to treatment than any of the others. A further consideration of this most interesting subject would lead us beyond the scope of the present volume, but the constantly increas- ing importance which is being given to sypliilis as a factor in the production of cerebral disease has led us to supplement the description of the author with those of the foregoing distinguished authorities.] A word should be said regarding the symptoms which correspond to the syphilitic lesions of the spinal cord. If only authentic obser- vations, and those in which the autopsy has confirmed the nature of the disease are considered, there is but little to do ; but there are re- corded, however, a certain number of paraplegic cases which have been improved or even cured by the iodide of potassium, in which, of course, anatomical confirmation was wanting. The phenomena observed in lesions of the spinal cord are, in the first place, pain more or less intensified, a rachialgitis limited to the diseased part of the marrow or extended in a circle, and a paralysis of the inferior ex- tremities, of the bladder, or the superior extremities, according to the seat of the lesion. [The syphilitic affections of the spinal cord are much more rare than the corresponding diseases of the brain and cranial nerves, and but few post-mortem examinations have been recorded. Circum- scribed gummata of the cord are not so common as a ditfused gummous infiltration of the meninges and lymphatic spaces. Althaus writes:^ Where the membranes urrow tosrether Avith the [^ Medical Times and Gazette, Nov. 10, 1S77.] 328 SYPHILIS. periosteum of vertebrae and the surface of the cord, there are generally proliferation of the neuroglia and wasting of the white columns. Some cases, in which the symptoms of acute ascending spinal paralysis are observed during life, seem to be owing to hypernemia simply, as no real structural alterations of the cord have been discovered. In this latter case the symptoms generally commence at an early period — viz., in the first year, — and are accompanied by the usual early manifestations of constitutional syphilis. The first symptom is sudden paraplegia, with incontinence of urine and faeces. There is no pain in the spine, and no anaesthesia of the limbs. Decubitus soon becomes developed, and the patient dies within a few weeks from the beginning of these symptoms. More frequently, however, paralysis comes on in the later periods of the disease, after many other symptoms have existed for a long time. There is muddy pallor of the skin, and a disagreeable smell about the patient, who is generally feeble and in a state of constant malaise. He experiences pain at different points of the spine, which is increased by pressure ; and also pain, pins and needles, numbness and stiffness, in the lower extremities. These symptoms come and go, and then there is all of a sudden an attack of paraplegia or hemiplegia. Where the seat of the disease is in the lower por- tion of the dorsal cord, there is also paralysis of the sphincters. If the case is not well treated, the paralysis remains stationary, and ultimately decubitus is developed, followed shortly by a fatal result. By pi-oper treatment, however, the patient may get well in a very short time. Where the cervical spine is affected, matters are more serious. There are then not only paraplegia and paralysis of the sphincters, but also of the thoracic and abdominal muscles, the upper extremities, and the diaphragm. Asphyxia from paralysis of the phrenic nerve, or from pneumonia, generally carries the patient off in a short time, unless, as we have seen it, the remedy proves stronger than the disease. But in cases of this class we cannot look forward to perfect recovery, as the posterior columns of the cord generally become disorganized be- yond thorough repair, and a state resembling locomotor ataxia may remain for life. When growths do occur, they usually involve the membranes, al- though they may come from the substance of the cord. Acute and chronic myelitis, meningitis, either with or without ver- LOCOMOTOR ATAXIA. 329 tebral disease, and sclerosis may also result from syphilis. The symptoms of the former do not differ from those of the ordinary idiopathic diseases ; those of the latter will be presently considered. 3 Fournier has recently pointed out a number of syphilitics affected with locomotor ataxia, and he has described syphilitic locomotor ataxia. [Of the many disputed points which, a quarter of a century ago, engaged the attention of the profession, but which the progress of medical science, and especially the increased frequency and exacti- tude of pathological research, have effectually disposed of or recon- ciled, none are of greater interest than those relating to that most distressing and intractable of maladies, locomotor ataxia. The differ- ing or opposing views which then existed, have been gradually sub- jected to a process of critical analysis, by means of which much that was doubtful or entirely false as regards the site and character of the essential lesion and the interpretation of the various symptoms has been rejected, the disease has become capable of accurate definition and classification, and its recognition by the general practitioner in one of its several stages is now a matter of daily occurrence. With its symptoms and pathology we need not long delay. The constant presence, as the specific lesion of the malady, of a hyperplasia of the neuroglia of the posterior columns of the spinal cord, followed by atrophy and degeneration of the nerve elements or, in other words, of spinal sclerosis, most marked below, but often advancing gradually until the brain is reached, is now universally admitted. The symp- toms, first of irritation of the posterior or sensory spinal nerves, the fatigue after moderate exertion, rheumatic or neuralgic pains, abnor- mal sexual impulses, vesical irritability, cutaneous hyperaesthesia, etc., followed by those of temporary or permanent paralyses of sensation, absence of the patellar reflex, annesthesia of the skin, impotence, in- continence of urine, amaurosis and deafness, and finally by the characteristic loss of muscular co-ordination without paralysis, the staggering, uncertain gait, the inability to maintain equilibrium, the dependence upon the sense of sight for recognition of position, all these are, as has been said, well-recognized evidences of the disease. Their association with and relation to the sclerotic condition are also so unmistakable in the light of our present knowledge of the physi- ology of the cord that they require no comment. The possible causes which may produce the sclerosis, and to which it has been assigned, are very numerous, the principal being heredi- 330 SYPHILIS. tary tendency, previous spinal shock, injury, or inflammation, over- exertion, rheumatism, gout, exposure to cold or wet, sexual excess, alcoholism, scrofula, and syphilis. It may be said, however, that, with possibly one exception, no such definite association has yet been shown to exist between locomotor ataxia and any of these conditions as to furnish satisfactory reasons for considering them as usually related, or as to supply reliable indi- cations for treatment. The views taken by most authors as to the probable cause and ter- mination of any particular case are exceedingly grave and discour- aging, but they nearly all agree in making an important exception in favor of ataxia of syphilitic origin. This is, of course, what might be expected from the well-known amenability of syphilitic lesions to properly directed treatment, Avhen- ever such treatment is applied before actual destruction or disintegra- tion of tissue has taken place. It would thus seem that the point of chief importance in the future study of locomotor ataxia, that which overshadows all others in its practical value, is the relation of this disease to syphilis. In its non- specific varieties it is admitted by the majority of authors to be but little if at all benefited by treatment, while, on the other hand, those cases in which the association with syphilis has been so distinct as to lead to the employment of specific treatment have been found to do well. If, therefore, it can be shown that in the majority of cases ataxia is of syphilitic origin, and that the spinal changes upon Avhich it de- pends are due to previous syphilis, the influence of the application of these facts to prognosis and to treatment becomes evident. Here, however, excellent authorities differ, and we feel that the subject is of sufficient importance to justify an extended resume of the various opinions. In an article on Syphilis and Locomotor Ataxia, by W. R. Gowers,^ he refers to a paper read at the Bath meeting of the British Medical Association, in which he had expressed the opinion that syphilis must be regarded as a cause of locomotor ataxia in one-half of the cases of that disease, and brought forward evidence in support of this assertion. During his investigations he had observed thirty-three cases of this disease. Of these cases, eighteen had a distinct history of constitu- [' London Lancet, Jan. 15, 1881.] LOCOMOTOR ATAXIA. 331 tional syphilis, fifteen having had both primary sore and secondary symptoms, three secondary symptoms alone, the primary sore not hav- ing been recognized ; five other patients had had the primary lesion, but no secondary symptoms. The remaining ten cases presented no history of a sore or constitutional symptoms. One of the latter had had a non-syphilitic rash, and five had suffered from gonorrhoea. From further considerations, Dr. Gowers concludes that at least 50 per cent, of the cases of ataxia must be regarded as having syphilis for their essential cause. It may not, he thinks, have been the only cause of the disease ; for example, sex possibly has some influence, " but the teaching of these facts, as far as they go, is that one-half of the patients with ataxia would not have this disease if they had not, at some previous period, suffered from syphilis." In regard to the histological lesion. Dr. Gowers says : " The lesion in locomotor ataxia is, however, very different from those which are ordinarily caused by syphilis. It is a degeneration limited to a sys- tem of structure, and contrasts with the random distribution of ordi- nary syphilitic processes and I can corroborate the statement of Westphal, that in cases which succeed syphilis, the lesion is precisely similar to that found in other cases. But theoreti- cal considerations of this character must yield to facts. We know too little of any morbid agency thus to limit its possible operation to certain forms of effect, with which we happen to be familiar. Indeed, a study of the morbid changes which are universally admitted to be due to syphilis might make us hesitate in exclusions. In the falling of the hair after syphilis Ave have a change which no one hesitates to ascribe to syphilis, but which is very unlike its other consequences, and might almost be described as a true " degeneration of a system of structure." " Other forms of degenei'ative diseases of the spinal cord, which occasionally follow syphilis, may also have a causal relation to it. It seems that one effect of constitutional syphilis may be to induce a neuropathic state in which certain degenerative diseases of the ner- vous system readily occur." Erb, of Germany, has recently published' some important facts re- garding the relation of syphilis to locomotor ataxia. They corrobo- rate his previously published statements, and agree with the above views of Dr. Gowers. In one hundred consecutive cases of locomotor [' Centralblatt fiir Med. Wissenschafteii, London Lancet, 1S81.] 332 SYPHILIS. ataxia, only twelve presented no history of a chancre or secondary syphilis. In seventeen cases the interval between the first symptoms of ataxia and the primary lesion was between three and five years ; between six and ten years in thirty-seven cases ; between eleven and twenty years in twenty-four cases, and more than twenty years in ten cases. To ascertain the truth of the objection that the large per- centage of cases of ataxia Avith preceding venereal sores, or with con- stitutional syphilis, is due simply to the frequency of the latter, an investigation of the history of four hundred patients over twenty-five years of age, who were under treatment for diseases which were not suspected to have any relation to syphilis, was made by Erb. He found a history of chancre only, in 11 per cent.; a history of sec- ondary syphilis, in 12 per cent. ; while among the ataxic patients, taken from the same social class, the proportion was no less than 88 per cent. These figures, Erb thinks, justify the assumption that there must be an etiological connection between syphilis and loco- motor ataxia. According to Rosenthal, locomotor ataxia at times develops after syphilis and as a result of it. Grasset, from whose work we have abstracted the following, gives' the views of the most recent writers in regard to locomotor ataxia and syphilis. He says: Fournier^ has forcibly called attention to syphilitic locomotor ataxia, which has no characteristic symptoms, but presents those of common ataxia. Although the lesion is not characteristic, it is at least similar to the usual lesions (sclerosis) of syphilis. The disease occurs too fre- quently in old syphilitics to be a mere coincident. Thus, in 30 ataxic patients, Fournier found 24 times a previous syphilitic history; Fereol 5 times in 11 cases ; Siredey 6 times in 10 cases. The non- success of anti-syphilitic treatment is due to the circumstance that its administration is begun too late, but that it frequently succeeds the following cases attest. Duchenne had, in 1858, drawn attention to the frequency of syphilis in progressive locomotor ataxia ; then Greppo^ reported a case of ataxia of the inferior extremities cured by anti syphilitic treatment ; still later Moore* published a similar case which recov- [' Traite pratique des Maladies du systeme nerveux, Paris, 1881.] [2 Anal, in Rev. des Sci. med., ix. p. 228.] [» Gaz. Med. de Lyon, Aug. 1859.] [* Dublin Quart. Journ., 1866.] LOCOMOTOR ATAXIA. 333 ered after the use of iodide of potassium ; Dreschfeld^ speaks of an ataxic patient affected with syphilis and cured almost completely by the same remedy. Later appears the work of Fournier of which we have spoken, and, finally, Drysdale^ has in a recent work confirmed this etiology. Like Fournier, he has seen this malady, said to be incura- ble, arrested and cured by the administration of iodide of potassium in large doses. Wiltshire and Bloxam strongly support his opinion. The latter has witnessed, at the Charing-Cross Hospital, several defi- nite recoveries of locomotor ataxia. Albert Reder^ has recorded, under the name of tabes syphilitica, the radical recovery by specific treatment of a syphilitic patient who had contracted his syphilis four- teen years previously. He presented only symptoms of disordered sensation and slight want of co-ordination of the inferior extremities. Finally, Caizergues,^ from whom the above references are taken, has published three new cases of syphilitic locomotor ataxia. In one, the beginning of the disease was manifested by motor symptoms ; in another by symptoms of pain ; and in the third by head and ocular symptoms. Chauvet has denied the existence of tabes syphilitica. He be- lieves, that syphilis never causes the development of a primary scle- rosis of the posterior columns, but Grasset does not agree with him. That syphilis produces diffused lesions in the brain, does not prove that it may not develop systematic lesions of the spinal cord. Grasset has recently made an autopsy of one of the patients whose cases are reported by Caizergues in his thesis ; the syphilitic etiology was manifest; the symptoms of locomotor ataxia complete in the inferior extremities ; there were besides some symptoms of general paralysis (ambitious delirium). He found, at the autopsy, in the brain diffused lesions of meningo-encephalitis, and in the spinal cord very remarkable systematic lesions, which, below the brachial enlarge- ment, occupied the entire space betAveen the posterior cornua, and above the enlargement was limited to the columns of Goll.^ Here the clinical demonstrations should outweigh the evidences of pathological anatomy. [' Tlie Practitioner, 1875.] [2 Med. Soc. London, April, 1877.] [3 Vierteljahrs., 1874, p. 29.] [* Des myelites syphilitiques, Cases IV., V., and VI., p. 72.] [5 See the communication by Estorc upon tliis case to tlie Congres de Reims, Aug. 1880.] 334 SYPHILIS. The posterior columns may also be secondarily affected. Broad- bent has remarked the frequency of this lesion. Homolle and Char- cot have seen them distinctly changed in consequence of a diffused myelitis. The columns of Goll may also be affected under the same circum- stances. Homolle reports a curious and unique example from an anatomical point. There were clinically neither ataxia nor tendency to move backwards. Moore has seen a case of ataxia with a tendency to backward movement, in which a lesion of Goll's columns may be supposed, from analogy with Pierret's case, which we have elsewhere^ referred to. Finally, we meet with some ataxias, certain forms of general spinal paralysis ; Caizergues cites an example.^ Dr. Julius Akhaus, in a paper published in the London Lancet^ analyzed a thousand consecutive cases of nervous diseases which came under his care in private practice ; his object was to ascertain the part played by syphilis as a causative agent. Among these cases there were found thirty-two cases of locomotor ataxia. In twenty-nine of these thirty-two cases there was a history of syphilis ; twenty-eight had had secondary symptoms ; one had a soft chancre and bubo, but no secondary lesions. Thus giving the enormous per- centage of 90.6 in favor of the syphilitic origin of tabes dorsalis. Dr. Althaus then says: "An overwhelming numerical testimony is thus clearly exhibited in favor of the view that tabes is habitually preceded — 1 do not say produced — by syphilis. But the real ques- tion at issue is whether syphilis is the originator of ataxia or merely an accidental concomitant of it Other considerations, however, serve to show that ataxia is a disease, 'per se, which occurs without any syphilitic taint whatever, but which may, like so many other diseases, be imitated by syphilis under certain circumstances." " 1st. Tabes has unquestionably existed in Europe long before the first appearance of syphilis in this quarter of the globe." " 2d. Numerous cases of ataxia are on record, more especially as having occurred in women, where no syphilitic affection had pre- ceded it." " 3d. Ataxia is not a common or inevitable consequence of syphilis, as, for instance, roseola or sore throat, but only appears to become [' Des myelites syphilitiques, Case VII., p. 81.] [* Note on the relations between syphilis and locomotor ataxia. Sept. 17, 1881.] LOCOMOTOR ATAXIA. 335 developed in the syphilitic, if they have neurotic constitutions, and if other causes, such as accidents, excesses, and the influence of wet and cold, etc., have also been active." " 4th. Treatment by iodide of potassium, even if used perseveringly and in large doses, is only exceptionally useful, even in cases with a pronounced syphilitic history, while the exhibition of nitrate of silver, ergot, the continuous galvanic current, nerve-stretching, and general remedial measures, which have the tendency to improve the condition of the central nervous system, but which have no influence on the syphilitic diathesis, are frequently productive of beneficial results." " 5th. The same disease, sclerosis, occurs in the lateral columns of the spinal cord, more particularly in young women who have never been exposed to venereal infection." " 6th. Syphilis may, however, imitate ataxia (to use an expression of Mr. Jonathan Hutchinson), just as it imitates iritis, lupus, rodent ulcer, and other diseases. Clinically the symptoms of syphilitic and non-syphilitic tabes appear to be identical. That ataxia should be so frequently associated Avith syphilis is probably owing, first, to the fact that syphilis, like masturbation and other excesses and irregu- larities, deteriorates the nutrition and power of resistance of the cen- tral nervous system ; and second, more particularly to the specific tendency of the syphilitic virus, to lead to low forms of local inflam- mation, which, when once established, are apt to spread in certain definite paths. Where this kind of inflammation attacks the posterior root zones of the spinal cord, it will produce the clinical aspect of locomotor ataxia, being aided in its development and further progress by the natural tendency of spinal disease to invade minute symme- trical and homologous, anatomical, and histological portions of the organ." Dr. Voigt' gives a list of 43 typical cases of tabes in male adults ; 29, or 67 per cent., had had primary syphilis, and had undergone specific treatment ; 8 presented no secondary symptoms. Of the remaining 14 cases of the 43, only 9 gave positive negative histories in regard to syphilis. In none was the cause of the disease referred to sexual excesses. Dr. Voigt here remarks, that locomotor ataxia occurs least often at that age when sexual excess is most common, and when the nervous system is least resistant. A comparison between syphilitic and non-syphilitic cases of ataxia is made: 1st. Age of occurrence. In both the maximum is from thirty to fifty years. 2d. First symp- • Berliner KlinischeWochenschrift, 1881. 336 SYPHILIS. toras. In both most patients complain first of the lightning pains. 3d. Other symptoms. These are very similar, any diflFerence depend- ing upon the small number observed. Therefore, from a careful com- parison of these points we find no distinct differences between syphi- litic and non-syphilitic cases, and it is manifest that, so far as these cases prove, syphilis does not in tabes act as a specific disease-pro- ducing influence, but as a general influence, disturbing, perhaps, the nutrition of the organism generally, or*of the nervous system particu- larly. In regard to the anti-syphilitic treatment of the disease, Dr. Voigt's results were not favorable, and therefore against the theor^j of syphilis being the cause of the affection. While the statistics given point to a causal connection between syphilis and locomotor ataxia, Dr. Yoigt does not think the question is more than sub judice. Among those who do not consider syphilis as a cause of locomotor ataxia, we have several German writers, whose opinion, from their great prominence as investigators in nervous diseases, must not be overlooked. Westphal,^ for example, in his study of this disease, found, in seventy-five cases of locomotor ataxia, only 18| per cent. Avho gave a primary sore, and 14| per cent, who suffered from secon- dary symptoms. Reraak^ found, in fifty-two cases, a history of syphilis only in one-quarter, and the statistics of Bernhardt,^ Avhich contain thirty-seven cases, give the same proportion. JuUien^ says, that, from a pathologico-anatomical point of view, he does not believe syphilis to have any direct influence in the etiology of tabes dorsalis. But from a clinical examination of this disease, he arrives at different conclusions. In the first place, syphilis is met with in nearly two-thirds of the cases, as antecedent to locomotor ataxia, and although syphilis is itself usually the result of debauchery, and precedes, in a great number of cases, a disease which is a frequent consequence of venereal excess, this coincidence, it must be admitted, affords much material for consideration. In the second place, ataxia is seen to develop at the same time, and to follow the same fluctuations as other lesions evidently syphilitic. Finally, with these patients, we are sometimes able, rarely it is true, to arrest the fatal course of the disease by means of the iodide of potassium or mercury. [' Berlin Klin. Wochenschrift, 1880. 2 ibid. » Ibid.] [} Maladies Veneriennes, pp. 980, 981.] LOCOMOTOR ATAXIA. 337 In conclusion, Juliien says : There is complete disparity between the information furnished by pathological anatomy, and that obtained clinically, when both are impartially considered. We, therefore, withhold our judgment, until further investigations have more satis- factorily elucidated the subject. Bumstead and Taylor^ do not consider syphilis as a cause of loco- motor ataxia, the latter being a lesion limited to the posterior columns of the spinal cord ; while, according to these writers, the syphilitic lesions always originate in investing structures, and subse- quently invade the cord. In regard to the similarity of symptoms, they say, the staggering gait, lack of co-ordination, darting pain and muscular spasms, caused by syphilis, may suggest locomotor ataxia ; but the slow, definite progress of the latter affection, compared with the irregular grouping and uncertain course of syphilitic symptoms, renders the distinction clear. Authorities upon both sides might still further be multiplied, but we shall now only be able to allude to the views of M. Alfred Four- nier which he has recently expressed at great length with his cus- tomary accuracy and clearness of observation and induction.^ Having first stated that in his opinion, which he has arrived at after mature reflection, the existence of ataxia of syphilitic origin must be considered a demonstrated truth, he reviews as follows the objections which have been urged against this view. The existence of syphilitic ataxia is denied : — 1st. Because it has no peculiar symptoms. This he admits to be positively true. But he does not consider it a serious argument against the syphilitic nature of certain cases of tabes, for to require peculiar symptoms in order to admit the specificity of a morbid mani- festation, will be to take from syphilis many symptoms which are by unanimous consent and Avell-known evidence duly accepted as pertain- ing to it. Syphilitic paraplegia does not present any special, still less any pathognomonic symptoms ; in fact, it has not a single symp- tom peculiar to itself. This is also true of syphilitic epilepsy and of syphilitic hemiplegia. Indeed, cerebral syphilis, considered as a whole, after careful study, could not be said to furnish any symptoms which were not found in encephalopathies of another nature. There are no peculiar symptoms claimed for syphilitic cirrhosis of [' Venereal Diseases, Bumstead and Taylor, 1879.] [2 Annales de Dermatologie et de Syphiligraphie, 25 Janvier, 1882.] 22 338 SYPHILIS. the liver, for syphilitic nephritis, and for many other syphilitic vis- ceral affections, why then for syphilitic ataxia ? Furthermore, ataxia may be said to be the clinical expression of the lesion of a system — of a portion of the spinal cord. Noav, the lesion of this medullary portion can only disturb or destroy the phy- siological functions vested in this part of the spinal cord. It cannot give to this portion new functions which reveal the disturbance by some extraordinary and special symptom. As a medullary system, either injured by this or by that, by syphilis or by some other morbid influence, it always evinces its lesions in the same manner. There- fore, the posterior columns, injured by syphilis, occasion functional disturbances as they would if injured by any other cause, and it is for this reason that syphilitic ataxia has no known peculiar symptoms, which distinguish it from ataxies of other natures. 2d. Syphilitic tabes has no peculiar lesion. This he also admits as true. But is there, he asks, in pathological anatomy, an element or even a process which may be considered as belonging exclusively to syphilis ? The anatomical changes occurring in tertiary syphilis, primarily consist in cellular hyperplasias, which terminate, in their ultimate evolution, either in sclerosis or gummata. Now sclerosis is a very common lesion, and may originate from various causes. It is a pro- cess almost as common as inflammation. As clinicians and surgeons we consider gummata as lesions peculiar to syphilis. But the histo- logists, better judges than we upon this question of the specific nature of morbid tissues, refuse to recognize in the gumma anything special, peculiar, or exclusively belonging to syphilis, which may, therefore, be said to have no pathognomonic lesion, which permits the investi- gator, even armed with the microscope, to positively affirm, the anatomical presence of syphilis. Scleroses, as has been so frequently repeated, are at any rate among the chief anatomical modifications produced by syphilis ; why, then, should we expect syphilis to occasion in the spinal cord some- thing diff"erent from that which it produces elsewhere ? If syphilitic tabes has for its lesion a sclerosis, it is an evidence in favor of our doctrine, since there is here an analogy which connects tabes with other syphilitic manifestations. 3d. Syphilis does not determine tabes, because it is not its nature to produce systemic lesions. Fournier does not admit the conclusions that are drawn from the systemic character of tabes, nor the anti- LOCOMOTOR ATAXIA. 339 systemic tendencies of syphilis. He thinks that in reference to their requirements, it is more correct to submit the alleged " laws" of the disease to observations, and if the observation demonstrates the exist- ence of a syphilitic tabes, to accept the fact, even in spite of apparent contradiction of a principle. The existence or non-existence of a tabes, having its origin in syphilis, is to be determined exclusively from clinical investigations, and not from general conceptions of transcendental medicine. It is true, that in most cases syphilis does not present systemic lesions, but exceptions to this law may be cited. With some patients the diathesis attacks and follows Avith marked preference, this or that organic system, for example, the skin or osseous system. Again, in secondary syphilis, the lesions are peculiar to the mucous membrane and lymphatic system. In regard to the ataxia, is it, whatever may be its origin, an exclu- sively localized lesion of the posterior columns of the spinal cord, as certain of our profession think ? Almost invariably, it affects not only the posterior columns, but also the corresponding meninges. Again, it frequently invades other por- tions of the cord, the posterior cornua, the posterior fasciculi of the lateral columns. Further, if the posterior columns of the spinal cord are alone affected in tabes, what anatomical reason can be given for the paralyses of the cranial nerves? Finally, there are frequently associated with tabes some cerebral symptom, congestive icterus, epi- lepsy, aphasia, hemiplegia, intellectual disturbances, general pseudo- paralysis, general true paralysis, etc. For these reasons, Fournier concludes that locomotor ataxia is not a strictly local disease, it is generalized and, although a clinical en- tity, cannot be defined by reference merely to the lesion of the pos- terior column. 4th. Tabes observed in persons affected with syphilis is not a syphilitic tabes, because it is not benefited by the ordinary treat- ment of syphilis. In answer to this objection Fournier asserts, from his personal experience, that mercury and iodine sometimes exert a decided therapeutic influence in syphilitic tabes. Several other authors have obtained results similar to him, and indeed, some were more fortunate, since they speak of recoveries, which notwithstanding all his efforts, he has never obtained. He attributes this failure to the following facts : — a. In almost all cases, specific treatment is only begun at a period 340 SYPHILIS. when the disease is more or less advanced, generally a long time after its onset. h. Before the appearance of its characteristic symptom — want of muscular co-ordination — tabes may exist as a complete and irremedia- ble lesion in the posterior columns of the spinal cord. Pathological anatomy describes true ataxia as a destruction of the spinal cord, atrophy or beginning atrophy of the posterior columns, or, in other words, as due to lesions of an irremediable nature. Now, our specific agents have not the power to cure what is incurable, and cannot repair what does not exist. No one, even the most ardent partisan of mercury and iodine, has ever claimed for these remedies the power of creating anew anatomical parts already destroyed. 5th. Tabes of syphilitic patients has no connection with syphilis, except as a coincident occurrence. To this Fournier says, here is not a clinical question, but one of simple good sense. Recent statistics demonstrate the existence of syphilis in cases of locomotor ataxia in a proportion of from 70 to 91 per cent., an average of about 80 cases in every 100. Fournier himself, in 103 cases of undoubted tabes, found an undeniable previous history of syphilis in 91:. These statistics, which show the extraordinary frequency of a pre- vious syphilitic history in tabes, furnish, in his opinion, peremptory reason for connecting tabes and syphilis, as effect and cause. Having thus I'eplied to the objections, he proceeds to state the fol- loAving reasons for believing that the great majority of cases of loco- motor ataxia are of distinctly syphilitic origin : — 1. The significant frequency, already mentioned, with which the diseases are found to be associated. 2. The almost exclusive development of ataxia in the tertiary period of syphilis ; out of 85 cases of ataxia observed in syphilitic subjects, in 81 the disease developed in the fourth year of the syphilis, in 3 in the third year, and in only 1 in the last month of the second year. This extraordinary regularity in the date of its occurrence, is inex- plicable on the theory that it is derived from some cause independent of syphilis, the association with the latter disease being merely an accidental one. If that were the case, it is difficult to conceive Avhy it should not at least occasionally be met with in the secondary or primary stages. On the other hand, its appearance at that epoch is conformable with the general system of evolution of syphilis, which does not, as a LOCOMOTOR ATAXIA. 341 rule, produce its visceral coraplications for some years after the pri- mary contamination. 3. The frequent similarity or identity of ataxic symptoms with those long known to be characteristic of syphilis, as, for example, paralysis of the cranial nerves, and even of the same pairs, the optic and oculo-motor ; hemiplegias, epileptiform and aphasic attacks, etc. ; progressive general paralysis, a not uncommon sequel of ataxia, is also a frequent and incontestable symptom of syphilis. 4. The beneficial influence exercised by specific treatment, which he claims to have used in many of his cases with the result of dissi- 'pating isolated symptoms, arresting or " immobilizing" the disease, and in some cases causing its complete and permanent disappearance. 6. The coincident development during the course of the ataxia of undoubted syphilitic symptoms, among which he mentions various ulcerative syphilides, guramata, exostoses, necroses, caries, etc. 6. The impossibility, in many cases, of finding any other imaginable cause for the production of the disease. This review of the testimony as to the relation between syphilis and locomotor ataxia, cannot be said to supply positive and con- clusive evidence of their etiological connection, but would certainly lead to the belief that there is something more than mere coincidence in the frequency with which the two diseases are associated. That syphilis gives rise to locomotor ataxia, in the same sense that lead poisoning causes muscular paralysis, may not yet be demonstrated ; but that it acts as a predisposing or excitant element, so affecting or altering the nervous system that the cause or causes, whatever they may be, of locomotor ataxia, are free or more liable to produce the malady, seems to us beyond question. Therefore, although not quite pi-epared to accept the positive opinion of Dowes,^ that locomotor ataxia is, with very few exceptions, due to syphilis, we may unhesi- tatingly, in the light of our present knowledge, coincide with Erb, in believing that the results of investigation justify us in concluding that there must be some not very indefinite etiological connection between syphilis and locomotor ataxia. As to treatment, this opinion would naturally lead us to the fol- lowing conclusions: — In every case of ataxia, careful and minute search should be made for evidences of antecedent syphilis, either acquired or inherited. [' The Medical Press and Circular, November, ISSO.] 342 SYPHILIS. If this be found to have existed, the patient should be placed at once upon vigorous specific treatment, and should be directed to con- tinue it through long periods. If only a fair presumption of previous syphilis exist, the same treat- ment should be employed, as it would, at the most, be useless, not hurtful. If the disease be recognized in its earliest stages, and found to be associated with syphilis, and treated in this manner, a prognosis may safely be given of a more favorable character than at present seems justifiable in any other variety or under any other mode of treatment. Finally, the best prophylactic treatment of locomotor ataxia would consist in the thorough and long-continued use of specifics during the different stages of syphilis, even in the absence of characteristic symptoms.] The force of Fournier's assertion, that syphilis is met with in two- thirds of the cases of locomotor ataxia, is weakened by the fact that in these cases there are merely the symptoms of common locomotor ataxia, showing that syphilis had modified neither the symptoms nor the lesion of the disease in question. It would seem, therefore, to be only a very remote predisposing cause. Want of coordination is, in itself, not a syphilitic symptom. Diseases directly caused by syphilis are always impressed Avith its own anatomical peculiarities, but in ataxia we find neither special inflammatory product nor gumma. Ataxia with syphilitic antecedents is the same anatomically as that which attacks the non-syphilitic, consequently we cannot admit the direct action of the virus. The diagnosis of cerebral syphilis is based less upon the symp- toms taken singly or in groups than upon the progress of the affec- tion and upon the therapeutic action of iodide of potassium. An intense cephalalgia of long duration, which is cured, or benefited by the iodide, but relapses, which is accompanied by intellectual troubles, loss of memorj^, hebetude, slight paralyses limited to the muscles of the face or to the muscles of the eye, then a paralysis very slow in progress ending in hemiplegia, aphasia, and epi- leptiform convulsions, such are the varied symptoms upon which the diagnosis is established. These symptoms are slow in show- ing themselves, and they grow more intense very gradually. At their commencement they are benefited or cured by the iodide of potassium. Each one of them presents some characteristic peculiar to syphilis in such a way that recognition of the cause is possible DIAGNOSIS OF CEREBRAL SYPHILIS. 343 in the great majority of cases. The diagnosis from apoplexy and from softening is generally easy. The sudden onset of an attack with absolute loss of consciousness and complete hemiplegia ex- cludes the idea of syphilis, for with the latter the commencement of paralysis is slow and progressive, and complete loss of consciousness is rare. It is more easy to confuse it with chronic softening; but in syphilis there are the violence of the cephalalgia, the possibility of improvement under the treatment by iodide of potassium, the epi- leptiform convulsions, and especially the presence of old or concur- rent syphilitic lesions. Cerebral tumors are easily confounded with syphilis, but the age at which they are noticed will render the con- sideration of cerebral tubercles unnecessary, as they are an affection of infancy. Sarcomata might be mistaken for gummata ; however, they are exceedingly rare, and the symptoms which govern them are progressive, without its being possible to benefit them by the iodide treatment. The prognosis is very grave. According to the statistics of Ligneau, who collected 147 cases, a fatal termination ensued in two-fifths of the cases, that is to say, 57 times. It is true that 7 of these cases succumbed to an intercurrent disease, which reduced the number of deaths to about one-third. 344 SYPHILIS, CASE XL Cerebral sypliilis ; Apoplectiform phenomena. By Drs. Lepine and Coyne. S. C, age 42 years, admitted to tlie charity hospital December 2d, 1^73; bed No. 22, Saint Cliarles ward, under the care of Professor G. See. The patient was brought to the hospital on account of acute and very grave cerebral symptoms, which rendered his clinical examination dilR- cuit and incomplete upon several points. Previous history He is tall and well formed. When young was a soldier, and for some years past has been employed by the minister of the interior in the prison service. In the latter position his duties were very laborious, and he obtained but little sleep during the night. He has always been very temperate, never drinking alcoliol to excess. His wife and brother-in-law were not aware of his ever luiving had syphilis ; but they knew that he had for a long time taken iodide of potassium, and that, separated from his wife during the war, he had at that time a urethral discharge. In 1871, four days after very laborious extra duty, during which he had remained wet all night, he was seized with violent pains in the lower part of the back, accompanied witli a sensation of cold in the lower extremities. Eight to ten days after the occurrence of these pains, his legs began to give way and to tremble; walking was possible, but difficult; he staggered, and liis knees bent under him. A piiysician, who saw him at tiiis time, ap[)lied a blister to tiie lum- bar region, and endeavored to promote sweating. Tlie day after the application of the blister, there occurred retention of urine. For this complication he entered the Necker Hospital, under Dr. Guyon. When he arrived at the hospital, he was able to ascend tlie stairs, notwithstand- ing the feebleness of his legs. During tliis time the j)atient liad not felt any weakness in the arms, his ment;d faculties were not impaired, and vision was not perceptibly interfered with. His wife believed she had noticed a little deviation of his mouth, but the information upon this point was not very precise. The patient remained two months in the Necker Hospital, under Dr. Guyon's care, who determined the existence of a stricture, and ordered iodide of potassium and pills, the name of which could not be ascertained. During his stay in the liospital the feebleness of the legs continued; at the time he left he began to walk, and in two months his improvement was such tliat he again began work; but he never regained his former strength, and was soon fatigued. From this time until a month ago, his health was not bad, but he complained of weakness, extreme lassitude of the muscles, and espe- CASE xr. 345 cially of violent headache, which was more severe during the evening and night. A month previous he began to complain of his left knee; he had some ditticulty in bending it. Five days later he came to Paris, after a very difficult journey, and he experienced a sensation of continual cold in the lumbar region and in the left leg. These sensations continuing, a phy- sician ordered cold douches and stimulating frictions. Tiie first douche seemed to cause a certain reaction; but the following day, in leaving the hospital, where he had been to receive the second douche, he experienced some peculiar phenomena. Vision was disturbed, there was vertigo, he walked like a drunken man ; then his left leg became suddenly cold and stiff"; the arm of the same side was also similarly affected, and he finally fell. He was taken home, and it was found that the left arm and leg were paralyzed, and the tongue was affected. During the same day, the left arm, although feeble, ceased to be completely paralyzed ; the patient could move it. This also occurred in the left leg during the same evening. The next day the patient was so far recovered that he could walk with the aid of a cane. During the night from Sunday to Monday he was disturbed, and com- plained of violent suffering in the head. Talking was yet easy. At 6 o'clock in the morning he lost his speech, and the right side was com- pletely paralyzed. He remained in this condition during the whole day, and the following morning, December 2d, was brought to the hospital. Present State The right side is completely paralyzed ; the skin of the ai*m of this side is warm ; the patient cannot close the hand ; the paralysis of the arm is accompanied by contracture ; the fingers are closed on the palm of the hand. Sensibility, although much lessened, is still present. The thigh and left leg are warm to the touch ; they are in a most complete state of l^aralysis without contracture ; their insensibility is almost absolute. The arm and leit hand have some jiower. The patient can move this member and close the hand witli considerable force. Sensibility is preserved. The intelligence is relatively clear; he can understand what is said to him, and endeavors to reply, but his speech is not distinct. December 3d to January 9th. The patient remained in the same condi- tion. He complained of violent attacks of headache. The right paralyzed side showed a tendency to contract ; more marked in the superior than in the inferior extremity. The existence of a left hemiopia is determined ; the inferior part of the retina is paralyzed ; there was no examination of the eye-ground. The patient gradually lost strength, and died January 9th. Autopsy January 10, 1874. The lungs are empliysematous at the apex and at their anterior borders; a little congested posteriorly. Tiie spleen is larger and softer than normal. The kidneys are small, but normal. The liver presents nothing special. Tiie cranium is normal on the exte- rior ; its thickness is as usually found ; the internal surface of the skull- cap and of the base of the cranium present nothing abnormal ; there are no exostoses or carious points. The dura mater is normal. The convex surface of the encephalon shows nothing special ; the ves- sels are congested, but there is no subarachnoid oedema, nor any change of color or consistence or arrangement of the visible parts of the convolu- tions of this region. The base of the encephalon, on the contrary, pre- 346 SYPHILIS. sents important lesions seated npon the inferior surface of the pons and in the left lateral part of the great transverse or cerebral fissure of Bichat. Pons Varolii Upon the inferior and anterior surface of the pons, in its right half, two gray-pink patches or gummata with a moi-e opaque centre are seen. These two patches are situated, the one anterior. Fig. 73, m, p, and near tlie anterior border of the pons, the other posterior, n. They are both depressed at their centre, and have very much the external appearance of disseminated sclerosis, modified only at their cen- tral part by the addition of a new character. Tlie posterior patch is the smaller; it lies transversely and is situated 6 mm. anterior to the posterior border of the pons. It measures 2 cent, in its large transverse axis, and a mm. in its antero-posterior diameter. Its internal extremity passes a little over the median line, and is hidden by the trunk of the basilar artery. The anterior and inferior cerebral artery and the trunk of the sixtli pair of nerves cross it. Its periphery is jagged, and extends between the fasciculi of fibres as gray-pink lines. It is not distinctly defined in its limits. Its centre is depressed and covered by a thin layer of gray- pink transparent tissue, through which is seen a deeper layer formed by an opaque tissue which is also irregular in its external outline. Tlie anterior patch occupies almost the whole extent of the right half of the pons ; it begins where the fifth pair of nerves emerge, and termi- nates in the fissure which contains the basilar artery. This patch, much larger in every way than the preceding one, is more depressed at its centre, resembling a cicatricial contraction. Its color is similar to the other, gray-pink with a brown tint. At its periphery, p, it has a moist and almost gelatinous appearance. In its centi-e, the aspect is modified by a more opaque appearance, and the nucleus, m, which causes this appearance, is more distinct than in the posterior patch. The arteries forming the circle of Willis are healthy ; the basilar artery only at its mid