CUTANEOUS MANIFESTATIONS OF HEREDITARY SYPHILIS

Hereditary syphilis, as the term implies, refers to the disease as
transmitted by the parent. It is sometimes also designated congenital
syphilis and infantile syphilis, but these are not so clearly expressive,
and the latter could just as well be applied, as in fact it is, to the ac­
quired as to the inherited malady. The symptoms of acquired syphilis

814                                       NEW GROWTHS

in the infant are essentially those of the acquired malady in the adult,
and need not be separately discussed. Nor are, in fact, the syphilo-
dermata of hereditary disease materially different, often mixed, and
usually of the macular, papular, or bullous type.

In a syphilitic pregnancy in which the fetus has escaped abortion or
still­birth, the infected offspring may be born with or without the exist­
ence of manifestations at the time of delivery, and in the large majority
of cases the child in reality, when born, presents every indication of good
health, and the signs of the malady may not present for a few weeks
or a few months.¹ A child born of syphilitic parentage, which fails
to present manifestations within the first six months, may usually be
considered to have escaped infection, although some exceptions do occur.
Most of the cases, however, which have been described as examples
of syphilis hereditaria tarda, in which osseous, dermal, and other lesions
have been observed as the first evidences in later years, are to be looked
upon with considerable question, as the history is often vague or obscure,
and there is a probability that the disease, instead of being hereditary,
was contracted during or after delivery or at a later period, with latent
or mild early symptoms which escaped observation. Late and relapsing
manifestations may, however, sometimes be observed in those who have
been subject to the usual early postnatal symptoms, although it must
be admitted, fortunately, that the hereditary disease, if it yields to
treatment, shows, if the latter has been properly carried out, but little
tendency to recurrences, although some traces of its ravages or influence
may remain. These latter are, however, more commonly the effect of
incomplete or neglected treatment, resulting from the halting or damaging
effect the disease has upon nutritive processes. Among such symptoms
as are of dermatologic interest, and which are also not uncommonly
present in the first months or year, may be mentioned interstitial kera-
titis, notched teeth (Hutchinson’s teeth), disturbances of hearing, irregu­
lar thickenings or flattened nodosities of the skull, dactylitis (dactylitis
syphilitica), onychia and paronychia, inflammation, swelling, and tender­
ness of the region of the neck of the long bones, and sometimes resulting
pseudoparalysis.²

¹ In 1000 cases observed in a foundling hospital Miller (“Die frühesten Symptome
der hereditären Syphilis,” Jahrbuch für Kinderheilkunde, 1888, vol. xxvii, p. 359) states
that the disease manifested itself in 64 per cent, in the first month (8.5 per cent, in first
week, 13.8 per cent, in second, 24 per cent, in third, and 17.7 per cent, in fourth) and
22 per cent, in the second month. As the infants are sent out to the country at the end
of this time to prevent overcrowding, no further careful record could be made beyond
this time. The first symptom noticed was the maculopapular eruption in 46 per cent.,
papules on skin and mucosæ in 28 per cent., rhagades oris et ani in 22 per cent., maculæ
in 17.9 per cent., bullous eruption in 8 per cent., abrasions and ulcers in 5.9 per cent.,
paronychia in 4 per cent., and pseudoparalysis of the extremities in 4 per cent.

² Miller (loc. cit.), in his analysis of 1000 cases, shows that the affections referable
to syphilis and seated upon or in immediate relationship with the skin and adjoining
mucous surfaces were as follows: Papules, including moist papules on the integument or
mucous membrane, were present in 74 per cent.; fissures of the lips, angles of the mouth,
and anus in 70 per cent.; rhinitis in 58 per cent.; ulcers of the hard palate in 52 per cent.;
macules in 45 per cent.; ulcers of the tongue in 27 per cent.; bullæ in 25 per cent.;
onychia (paronychia) in 23 per cent.; lymphadenitis chronica in 29 per cent.; laryngitis
in 17 per cent.; pseudoparalysis of the extremities in 7 per cent.; ulcers in 4 per cent.;
ulcerative gingivitis in 4 per cent. The eruption was maculopapular in 46 per cent,
of the cases.

SYPHILIS

815

Hutchinson was the first to call attention to the notched condition
of the teeth as commonly indicative of syphilis, but this condition can
scarcely, as originally observers were inclined to believe, be absolutely
diagnostic, for the same or closely similar condition may occasionally
be observed as the result of profound nutritive disturbance upon the child
from other causes during the period of second teething. Nevertheless,
it possesses considerable import. While the canines and other teeth
may also show notching, Hutchinson places the chief significance upon
the upper central incisors. At first they are noted to be somewhat short,
with thin edges, the two teeth commonly converging, but sometimes
widely separated; later the central border breaks or crumbles away, and
leaves a broad, shallow notch. It generally disappears between the
twentieth and thirtieth years from wearing down of the projecting parts.

Syphilitic dactylitis is usually observed in the early months of the
disease, and differs in no respect from that of acquired syphilis, except
that there is ordinarily considerable bulbous swelling. It is persistent
and chronic, but, as a rule, will gradually disappear under treatment.
It bears close resemblance to tuberculous dactylitis, from which, except
by history and other symptoms, it often cannot be distinguished, and
with which, in fact, it may be associated. As a rule, however, there
is a greater tendency to break down in syphilitic dactylitis. The hair
is likely to show some disturbed condition, thinning out, losing its luster,
and dry and lifeless-looking. Lymphadenitis is an occasional occurrence,
especially in those of scrofulous tendency, and the ordinary adenopathy
as observed in acquired syphilis is also noted, but not so markedly or
even so commonly, and is not infrequently practically wanting.

Coming back to the more usual conditions observed, the child born
with evidences of the disease is generally noted to present a thin, wrinkled,
old appearance, the skin of a brownish-yellow tinge; having a snuffling
coryza, commonly a hoarse, peculiar cry, and presenting lesions both
upon the skin and mucous surfaces. The lesions in such cases on the
skin are usually vesicobullous or bullous, with cloudy contents, and
often becoming purulent, constituting the bullous syphiloderm. They
are more or less general, but the palms and soles are favorite situations;
there may be interspersed maculopapules and papules. The bullæ are,
as a rule, flaccid, sometimes distended, and are often surrounded by a
brownish or coppery rim of infiltration; and are seated either upon an
excoriated, eroded, or ulcerated base. About the anus and genitalia,
especially the former, moist papules, sometimes coalescent and slightly
hypertrophic, constituting the flat or broad condylomata, are not in­
frequently found. The angles of the mouth and nose may, more fre­
quently than in the acquired disease, be the seat of papules or fissures;
mucous patches and superficial abrasions or ulcerations are quite com­
monly found on the inner side of the lips and on other parts of the oral
cavity. The general condition becomes worse, the marasmus increases
in degree, and the child after some days or a few weeks, as a rule, succumbs.

The bullous syphiloderm is always indicative of a malignant form
of hereditary disease, and usually presages a fatal end, but in the rarer
instances in which it does not appear until later,—several to five or six

816

NEW GROWTHS

weeks after birth,—while still of generally lethal import, exceptionally
recovery takes place. In still rarer instances of children presenting
other lesions than blebs at the time of birth the manifestation is commonly
macular and papular, similar to the same eruptions appearing later and
to be immediately described.

As already remarked, however, the syphilitic offspring at birth,
as a rule, presents but little, if any, active evidences of the infection,
occasionally being thin, shriveled, and with an old look and a sallow,
dingy-looking skin. Ordinarily, however, the child exhibits a fair con­
dition of health, and often, indeed, has a robust appearance. After
some days or a few weeks slight coryza is noted, which usually develops
into a well-marked and purulent rhinitis,—“snuffles,”—more or less
completely blocking respiration through the nose. The child begins,
in most instances, to fall away, often shows cracks at the angles of the
mouth, and possibly one or more mucous patches in the mouth. Occa­
sionally in spite of the disease the general health seems to be but little
affected, although, with few exceptions, it sooner or later suffers. At
about the same time there appears a more or less generalized maculopapu-
lar eruption, commonly more marked on the palms, soles, and face and
neck than in the acquired disease. About the anus, genitalia, and folds
they frequently become abraded and moist, forming moist papules,
and about the anus showing a tendency to hypertrophic enlargement,
and presenting the same characters as the moist papules in the acquired
disease. The moist papules or mucous patches in the mouth are also
commonly present. The macules and maculopapules in the genitocrural
region sometimes increase in number, spread, and form larger plaques
or a more or less confluent sheet, of a dusky red or ham tint, and, in
places at least, somewhat sharply marginate. There may or may not
be some other symptoms, such as nail affections, dactylitis, exostoses,
etc

Quite frequently, indeed, a diffused erythematous or macular erup­
tion appears in the genitocrural region, usually also involving the but­
tocks, and with but few, if any, associated or outlying maculopapules
or papules; and, except as to the dusky red color, resembling erythema
intertrigo. Not uncommonly it is the first evidence of the disease, or
that which leads to procuring medical advice. As a rule, however, in­
spection or inquiry will show several of the associated symptoms, such
as the fissures or papules at the corners of the mouth, one or more
mucous patches in the latter, papules at the anus, and possibly lesions
on other situations.

These two manifestations,—macular and mixed maculopapular,—
according to my experience, are those most frequently observed in the
hereditary disease. While developing, as stated, usually in the first
several weeks, two, three, or more months sometimes elapse before the
outbreak, although the later the appearance, the more, it seems to me,
is the tendency toward a predominance of the papular element. Not
infrequently the eruption is at first chiefly macular, the macules later
developing into maculopapules or papules. In some of these latter
cases the papules become slightly scaly, although rarely to such a degree

SYPHILIS

817

as observed in the papulosquamous eruption of acquired syphilis. The
papules are of the flat variety, and not, as a rule, much elevated, and
somewhat variable as to size, although usually pea- to finger-nail-sized;
the acuminated papules are rarely seen in the hereditary disease.

The manifestations, whether predominantly macular, maculo-papular,
or papular, are somewhat persistent, and new lesions may continue
to appear for some days or longer; in severe cases, and especially in those
whose nutrition is impaired, probably through visceral complication or
other causes, as neglect or poor feeding, the general health fails, a mar-
asmic condition develops, some of the lesions may show ulcerative tend­
ency, and the child gradually sinks and finally dies. In less severe
cases, especially if well nourished and carefully looked after, the mani­
festations after a time begin to fade, and with or without a few relapsing
exacerbations the disease apparently runs its course and the patient
recovers; in some instances to have later other signs of the malady.
Whether without proper treatment so favorable a result sometimes
ensues is difficult to state, inasmuch as such cases usually receive medical
care. Nevertheless I have seen several instances of the hereditary dis­
ease, in connection with dispensary practice, presenting one or the other
of these milder manifestations, in which apparent recovery followed
in spite of gross carelessness and neglect on the part of the parent in
carrying out the treatment ordered.

The pustular syphilodermata are seldom met with as a hereditary
manifestation, although some of the vesicular, vesicobullous, and bullous
lesions of the bullous syphiloderm may become purulent and develop
into more or less perfectly formed pustules. More commonly several
or more pustules, usually flattened, will be seen about the mouth, nose,
and genito-anal region in association with the maculopapular or papular
syphilodermata. When they occur in any profusion, a grave type is
usually indicated. The vesicular syphiloderm in hereditary syphilis
is extremely exceptional—but has been noted by a number of observers;
usually, however, in association with the pustular or bullous eruption.¹
The tubercular syphiloderm is rare in the hereditary disease, although
it may occur as early as the sixth month, and sometimes later,—several
or more years after birth,—but at this period usually as a recur­
rence. The gumma is, as a rule, not met with in the first months or
first few years, but generally after the third or fourth year. It is
similar in its characters to the same lesion in the acquired disease in
the adult.

The diagnosis² of the hereditary syphilodermata is rarely a matter
of difficulty, as the associated symptoms of snuffles, mucous patches
in the mouth, moist papules or flat condylomata around the anus, the

¹ Grindon, Jour. Cutan. Dis. 1910, p. 284, has recently reported 2 cases, and
briefly reviews the subject.

² The Spirochæta pallida is also to be found in hereditary syphilis; Levaditi, in an
interesting paper (“L’histologie pathologique de la syphilis héréditaire dans ses rapports
avec le ‘spirochæte pallida,’ “ Annales mal. vén., 1906, p. 22), goes over the ground,
with review references to the work of Hoffman, Buschke and Fischer, Bodin, and
others. See also remarks under Etiology and Diagnosis of the syphilodermata in
general.

52

8l8                                       NEW GROWTHS

frequently accompanying shriveled or “old-man appearance,'’ the mar-
asmic tendency, and the usually polymorphous character of the eruption
will give a picture more or less characteristic. At least two, sometimes
more, of these associated symptoms will generally be present, together
occasionally with dactylitis, onychia, keratitis, exostoses, etc. The
course and outlook of these hereditary cases have already been incidentally
touched upon. The prognosis depends upon the variety, severity,
general condition of the child, the probability of proper nursing or feeding,
and the careful carrying out of the treatment. In breast-fed children
the disease is much less fatal than in those artificially nourished. The
result is, however, always somewhat uncertain, and by far most cases
die. As a general rule, the more distant from the time of birth the mani­
festations appear, the more favorable is the outcome.¹ Occasionally
destructive action takes place in the nose, and a flattening of this organ
in such an event will occur.

Etiology.—Syphilis is acquired through heredity, which has been
sufficiently touched upon, and in various ways by direct inoculation.
The usual and, of course, the most common method is through the sexual
act, by conveyance of the syphilitic poison from an existing chancre or
other lesion present on the genitalia; houses of prostitution and street
prostitutes are its principal sources. But, as already referred to in de­
scribing the initial lesion, extragenital chancres are not at all uncommon,
and are the result of accidental and, with probably but few exceptions,
perfectly innocent inoculation, as by the act of kissing, from drinking-
cups² or glasses, or the common communion-cup; by infected razors,
etc, in barbershop, tattooing;³ by medical men also from operations and
other professional manipulations, and in many other ways. Knowing
the contagiousness of the secretion from mucous patches, which are to
be found quite frequently in the mouth, the wonder is, in fact, that
the innocent and unsuspecting are not more frequently accidentally

¹ Hyde’s paper, entitled “What Conditions Influence the Course of Infantile
Syphilis,” Medical News, Dec 4, 1897, is a valuable presentation, on pertinent points,
based upon his own observations and the statistics of such other careful observers as
Kassowitz, Lancereaux, Neumann, Coutts, Jullien, Warner, and others. It shows that
in 1700 syphilitic pregnancies the number of abortions and still­births amounted to
579, leaving 1121 born alive, of whom 956 died within the first twelve months; of the
remaining 165 who chanced to survive a year nothing is further known. Of 41 preg­
nancies in 25 syphilitic mothers under his own observation, there were 31 abortions and
children dead at birth or within one year. Henoch (Vorlesungen über Kinderkrank-
heiten, 1889, p. 105), quoted by Hyde, claims that all infants affected with hereditary
syphilis die if they are not suckled at the breast, and Widerhofer (“Klinische Vorle-
sung,” Wien. med. Zeitung, 1886), quoted by the same writer, puts the percentage of
such deaths in children artificially reared as high as 99 per cent. It seems to me, how­
ever, that it is not at all improbable that in some of those cases the result was consid­
erably influenced by improper or insufficient feeding, neglect of prompt and early treat­
ment due to parental indifference or ignorance, and thus affected the mortality percent­
age.

² Schamberg, “An Epidemic of Chancres of the Lip from Kissing,” Jour. Amer.
Med. Assoc, Sept., 2, 1911, p. 783 (9 cases); McIntosh, “Syphilis, Especially in Re­
gard to its Communication by Drinking Cups, Kissing, etc”; The Military Surgeon,
Feb., 1913, p. 184 (reviews the subject briefly, and cites personal observations).

³ Maury and Dulles, “Tattooing as a Means of Communicating Syphilis” (15
cases), Amer. Jour. Med. Sci., January, 1878; Barker, “Outbreak of Syphilis Following
on Tattooing,” Brit. Med. Jour., 1889, i, p. 985 (12 cases with several cuts).

SYPHILIS

819

infected through the common drinking vessel and in other similar man­
ner. There is an all too common belief that extragenital chancres,¹
especially about the mouth, as well as other parts, are frequently due to
unnatural sexual relation, but considering the chances of innocent con­
traction of the disease, such a suspicion is, with rare exception, an ex­
tremely unjust one. The readiness of accidental inoculation is shown
by the examples of physicians who, in the course of professional pursuit,
through digital vaginal examination, operations, and in other ways, con­
tract a finger chancre. Fifteen to twenty such instances have come to
my own notice.² It is, too, not improbable, indeed, that medical men
themselves have been occasionally, before the days of full appreciation
of the value of complete asepsis, the unintentional agents of conveying
the disease to others through infected instruments which had not been
properly cared for; and the same may be said more positively of dentists,
who have to do with a cavity in which contagious material is often pres­
ent. Fortunately, the best dentists now give attention to the necessity
of sterilizing instruments after each use, but there are still many who
show a lack of even common cleanliness. The number of extragenital
chancres which come under the observation of those engaged in certain
lines of special practice, more particularly those of diseases of the skin,
venereal diseases, and throat diseases, in which suspicion often points to
these various sources, is sufficiently large to make one feel strongly on
the subject.

Infected persons should always be informed of the danger of convey­
ing it to others, and to take all precautions against such possible mishap,
and this, together with proper treatment, at present seems the only method
of controlling its spread, as effective legal supervision seems both impos­
sible and impracticable. The period of danger of contagion is not a
wholly definite one: it exists through the active stages of the malady,
and therefore during the first one or two years; persisting, but its viru­
lence or potency probably becoming gradually less, in some instances
up to the third, fourth, and even fifth year. The pathologic secretion
from any lesion during the time of this activity is capable of producing
the disease. The blood of such an individual is also infecting, and while
the physiologic secretions, such as the saliva, milk, sweat, etc, are
believed to be generally innocuous, yet the possible admixture of even
insignificant quantity of blood or discharge from mucous patches or
other lesion, however small or unrecognized, renders such secretions
dangerous, and this fact is to be kept in mind. Contagiousness is, how­
ever, generally considered by those of largest opportunities to be uncom­
mon after the second or third year, but there are sufficient exceptions
to this during the fourth and fifth years to consider still the possibility

¹ See Bulkley’s most admirable monograph, Syphilis in the Innocent (Syphilis
Insontium), New York, 1894; Knowles, “Syphilis Extragenitally Acquired in Early
Childhood,” New York Med. Jour., July 18, 1908 (with bibliography).

² A. Blaschko, “Syphilis als Berufskrankheit der Aerzte,” Berlin, klin. Wochenschr.,
No. 52, Dec, 1904; D. W. Montgomery, “The Acquisition of Syphilis Professionally
by Medical Men,” Jour. Cutan. Dis., April, 1905 (7 cases, with review of many other
reported cases, and references); Knowles, “The Relationship of Syphilis to Dentistry,”
The Dental Brief, Nov., 1909 (with bibliography).

820

NEW GROWTHS

of danger.¹ The belief that the tertiary lesions are innocuous in this
respect is not so absolutely held to­day as formerly, as instances have
been noted in which the virulence still existed.

While the various facts above mentioned are now common knowl­
edge, the specific infective germ had long been eagerly sought for.² The
comparatively recent epoch-making rinding is that of the Spirochæta
pallida by Schaudinn and E. Hoffmann,³ whose findings have been since
repeatedly confirmed by themselves and numerous other investigators.
That this organism exists in primary and secondary lesions and lymphatic
glands is, therefore, now admitted, and its pathogenic importance seems
well assured. It is true that some doubt was engendered by the state­
ments of a few observers that they had also found the organism in non-
syphilitic lesions, but inasmuch as there are other spirochetes resembling
the Spirochæta pallida, these statements are, as is now known, due to
errors of that kind. Now that Metchnikoff and Roux,⁴ followed by Las-
sar and Neisser and others have shown conclusively that syphilis can be
transmitted by inoculation to chimpanzees and other apes, a field of
investigation is opened that may lead to a definite solution of some of the
problems connected with this interesting disease. Indeed, experiments
already made along this line go to prove the Spirochæta pallida the

¹ See interesting paper by Feulard, “Durée de la periode contagieuse de la syphilis,"
Trans. Third Internat. Dermatolog. Congress, and Annales, 1896, p. 1025 (shows that
four or five years or more afterward contagious examples have been noted—many cited
both from his own experience and that of others).

² Krzysztalowicz and Siedlecki, Monatshefte, 1905, vol. xli, p. 231, gave a brief
review of these various findings to date.

³ Schaudinn and E. Hoffmann, Arbeiten aus dent k. Gesundheitsamte, 1905, vol. xxii,
p. 527; Deutsch. med. Wochenschr., May 4, 1905; Berlin, klin. Wochenschr., May 29,
1905; ibid., July 10, 1905; E. Hoffmann, ibid., 1905, No. 32; E, Hoffmann and Halle,
Münch, med. Wochenschr., 1906, No. 31; E. Hoffmann and Beer, Deutsch. med. Woch-
enschr., 1906, No. 22; E. Hoffmann, Dermatolog. Zeitschr., Nov., 1909 (with colored
plates). Among the many contributions on the subject may be mentioned the admir­
able review papers by Shennan, Scottish Med. and Surg. Jour., 1905, p. 457 (with bibli­
ography), and Jour. Cutan. Dis. (same paper), 1905, p. 457; Fanoni, Med. News, Oct. 7,
1905, and New York Med. Jour., Nov. 4, 1905; Flexner, Med. News, Dec 9, 1905;
Pfender, Amer. Med., Mar. 10, 1906 (with bibliography); Schultz, “The Present Status
of Our Knowledge of the Parasitology of Syphilis,” Jour. Cutan. Dis., 1907, p. 429;
and Harris, Jour. Amer. Med. Assoc, 1909, vol. liii, p. 757 (with review, and numerous
references).

The Spirochœta pallida, now classified as Treponema pallidum, is an extremely deli­
cate organism; long, very thin, and filamentous, of a spiral, or cork-screw shape, with
pointed ends showing a hair-like flagellum; and as stated by some writers, with a nucleus,
although this last is not yet absolutely proved. Its length varies from 4 to 10 µ; its
breadth is difficult to gauge, being at most about 0.25 µ; the turns in the spiral number
six to fourteen, averaging eight to ten. It is vigorously motile, and progresses by rotat­
ing on its long axis, and when at rest it shows undulatory movements in its whole length,
suggestive of the play of a vibratile membrane. It exists in numbers and more numer­
ously in the deeper parts of the lesions; is very weakly refractile, stains with difficulty,
and is not easily seen, requiring very high power of the microscope, ¹/₁₂ oil-immersion ob­
jective with medium to No. 8 ocular. They have been found in primary and secondary
syphilitic lesions and the lymphatic glands, and in almost all tissues and organs in hered­
itary syphilis. They remain alive for several hours in physiologic salt solution, and
they can be seen in smears from the tissue juice, fixed in absolute alcohol, and stained by
a modification of Giemsa’s method; Schaudinn and Hoffmann employed Giemsa’s
eosin-azure solution.

⁴ Metchnikoff and Roux, Ann. de l' lnstitut Pasteur, Nov. 25,1905; Neisser, Deutsch.
med. Wochenschr., 1906, Nos. 1-3; Bowen, Boston Med. and Surg. Jour., 1905, vol. clii,
p. 285, gives a review of these “experimental inoculations”; Williams, Jour. Cutan.
Dis., 1907, p. 350, also gives a good review.

SYPHILIS                                             821

essential factor in its etiology. We have yet doubtless much to learn
about the life history of this organism.¹

Difference of opinion exists as to the explanation of the various grades
of the disease as shown by the manifestations, which are sometimes slight
or even almost wanting, or, on the other extreme, malignant. Some
hold that it is chiefly dependent upon the difference in constitution,
health, or resisting power of the individual; others, that there is possible
a variation in the degree of virulence of the organism itself. The former
certainly has considerable bearing, and the latter also, judging from the
observations of other infectious maladies, must likewise be considered
as not unimportant.

External agents, such as heat and cold, etc., do not seem to be pro­
ductive of any direct special influence, but in many instances of tertiary
cutaneous manifestations a determining etiologic factor of import is
local irritation or injury, which starts the syphilitic pathologic process.

Pathology.—The pathologic anatomy of syphilitic cutaneous
lesions has been studied by various investigators, among whom are
Biesiadecki, Auspitz, Neumann,² Kaposi, Cornil, Unna, Crocker, and
Fordyce, those of most recent date being by Crocker,³ Unna,⁴ and
Fordyce,⁵ and whose conclusions in the main coincide. In general
it may be said that the syphilitic deposit is essentially a new growth,
and consists of round-cell infiltration, especially about the vessels,
generally endothelial proliferation, and in the papular, tubercular, and
gummatous lesions, the presence usually of a variable, but, as a rule,
scanty, number of giant-cells⁶ The rete, corium, and in the deep lesions
the subcutaneous connective tissue also, are involved in the process,
although the initial changes are noted in the upper part of the corium.
It differs from some other neoplastic formations by the absence of all
tendency to organization, the retrogressive steps being by invo-

¹ Recent valuable papers by McDonagh, “The Life Cycle of the Organism of Syph­
ilis,” Brit. Jour. Derm., 1912, p. 381, and the “Complete Life History of the Organism
of Syphilis,” ibid., 1913, p. 1 (both papers well illustrated), and Ross, Brit. Med. Jour.,
Dec 14, 1912 (covering the same ground as McDonagh), may throw considerable light
upon the incubation and vagaries of the disease. These investigators conclude that
the well-known spirochæta is but a phase in the rather complicated life history of
a sporozoal parasite; that it is, in fact, the adult male gamete in search of the
quiescent female gamete, with which to unite and form a zygote. According to
McDonagh it would seem that an infective granule enters a large mononuclear leukocyte
and increases in size therein. In the male sexual cycle a mass of spirochætæ are
eventually formed from this, which are finally liberated, whilst in the female cycle a
spheric mass is eventually evolved which becomes also free. A spirochæte fertilizes
this mass to form a zygote. Four sporoblasts then form in the zygote, and from these
numerous sporozoites develop. The cell finally bursts, and the sporozoites are set
free to start again the sexual cycle. McDpnagh believes that these several stages
in the development of the organism account for the long period of incubation of syphilis,
and that the infection is. probably conveyed by the sporozoite. He thinks the organism
can be assigned to the order sporozoa, and the subclass Telosporidia; the order doubtless
being the coccidiidea, and the species leukocytozoön, and hence suggests the name for
the parasite—“Leukocytozoön Syphilis.”

² Neumann, Archiv, 1885, p. 209 (with many excellent plates and résumé of the
investigations of others).

³ Crocker, Diseases of the Skin, third ed., p. 845 et seq.

⁴ Unna, Histopathology.

⁵ Fordyce, “The Vessel Changes and Other Pathological Features of Cutaneous
Syphilis” (with illustrations), Jour. Amer. Med. Assoc, 1907, vol. xlix, p. 462.

⁶Fordyce, “Giant Cells in Syphilis,” Interstate Med. Jour., xviii, No. 1.

822

NEW GROWTHS

lution through fatty degeneration and absorption or by necrosis and
consequent ulceration. The ordinary changes are not so well shown
in the macular syphiloderm, where, in fact, the changes scarcely go be­
yond hyperemia with insignificant cell infiltration, and are practically
limited to the papillary layer of the corium; often tolerably sharply de­
fined, and sometimes extending a little more deeply, and also, when more
than the usual effusion takes place, upward to the lowest strata of the
rete. Sometimes also, according to Neumann, the changes extend still
more deeply, and cell effusion is noted around the glandular structures
as well. The capillaries and other minute vessels are dilated, and both
in and surrounding them is found cell accumulation, with also both round
and spindle-shaped cells in the adventitia of the larger vessels. A
variable number, usually large, of the Spirochæta pallida will, on careful
examination, and more especially after staining, be seen in this and
other types of lesions, being more numerous in the deeper parts.

Renaut¹ says that all the different forms of syphilitic lesions are,
anatomopathologically considered, structurally the same: a reactionary
defensive work against a pathogenic agent, which, at a certain stage,
gives rise to an endarteritis of a special kind, slowly obliterating, and
tending from the first to excite the production of hypertrophy of the
tissues about it.

In the miliary papular or follicular syphilid the process is seated
especially around and about the hair-papilla, and also in the tissues
immediately surrounding and slightly below the follicle, the cell infiltra­
tion being of a dense character. The vessels of the papilla are dilated,
and both surrounded and filled with cells, the vessel-walls exhibiting
numerous nuclei. The hair-sac, especially at its lower part, is dilated
and ruptured by the pressure of the dense cell collection. The adjacent
horny layers show slight changes, the rete is thickened, and the corium
more or less replaced or obscured by the cell infiltration.. The sebaceous
glands and neighboring sweat-glands are also involved. This papule
is not always, however, formed about the hair-follicle, as, according to
Crocker’s investigations, “it is also formed by the lifting-up of the epi­
dermis by dense cell effusion, in the center of which a sweat-duct can
sometimes be traced.”

The flat papule may be said to represent the more typical condi­
tions of the syphilodermata, and these show some resemblance to lupus
vulgaris. There is marked deposit here, and found seated in the rete,
all layers of the corium, and downward in the subcutaneous tissue,
where it is sharply defined beneath. There is also sharp definition
laterally. The cell infiltration is in places more or less dense, and in
others somewhat disseminated, but it is greater in the papillary and sub­
jacent layers, being primarily observed about the vessels and their
ramifications of the superficial and deep plexuses. It may be so great
in amount as to more or less obliterate the normal structures. A variable
number of incompletely formed, and a few typical, giant-cells, and oc­
casional epithelioid cells, are commonly also to be noted. The new

¹ Renaut, Rev. prat. d. mal. Cutan., Syph. et vénér., Jan., 1903—abs. in Brit. Jour.
Derm., 1903, p. 271.

SYPHILIS

823

growth in the papular syphilodermata, according to Unna, is composed
mainly of variously sized plasma-cells. The sweat-ducts and coils are
frequently involved to considerable degree, both by surrounding cell
infiltration and proliferation of the lining cells. The hair-follicle in this
papular form usually holds its shape fairly well. In the process of in­
volution the first steps are generally noted centrally, absorption taking
place, and the part sinking in slightly, and exceptionally absorption may
be so complete in this part, and then with halting or relatively slower
retrogression peripherally, that the papules present a ring-like aspect.
In the squamous papular lesion the epidermis shows considerable involve­
ment, the horny layers exfoliating, and usually with a moderately or con­
siderably thickened proliferating rete. The moist papule may extend
more deeply than the ordinary papule, but ordinarily the conditions are
essentially or closely similar, but the rete is usually considerably thick­
ened and the papillæ show variable degrees of hypertrophy and elonga­
tion from slight to extreme development.

The tubercle and gumma are not only clinically to be looked upon
as enlarged papules, but also anatomically, the process, of course, being
much more extensive, and going more widely and more deeply into the
tissues. The evolution of the tubercle is much less rapid, and its per­
sistence more prolonged, and atrophic or necrotic changes going into
ulceration usually follow. In gumma the infiltration is generally wide­
spread and much deeper, although it remains fairly well circumscribed.
While the deposit in this growth may ultimately disappear by absorption,
its usual course is that of necrosis and ulceration.

The pustular syphilodermata may, in great measure, be viewed as
papular processes, plus the consequences and changes produced by
local pyogenic cocci invasion. In the basal or more or less persistent
papular portion the alterations are similar to those found in papules.
Like the latter, therefore, they are well defined, and may be seated in
the corium or the subcutaneous tissue. According to Kaposi, as quoted
by Duhring, “the essential features of the pustule consist in the presence
of dimly contoured, highly granular, cloudy, nucleated cells, and free
nuclei within the uppermost layers of the corium, papillary layer, and
rete, seated in a succulent, large-meshed, serum-saturated tissue or even
in open spaces.” As with the papules, the pustular lesions may be
connected with the hair-follicles or be seated in the corium independently
of this structure and of the sebaceous gland. The anatomic conditions
of the several varieties of the pustules themselves are not greatly differ­
ent from those of similar non-specific lesions, as variola, impetigo, and
ecthyma. The pus-chamber is to be found between the epidermic strata,
often with the eroded rete as the basal portion, or the corium forming the
basal boundary, and not infrequently the suppurative or destructive
action extending superficially or more or less deeply through this latter
structure, and in such instances followed by more or less marked and per­
manent scarring.

The dark or dusky red or ham color commonly noted in the syph-
ilodermata is due to the blood-coloring matter derived from the wander­
ing or extravasated red corpuscles, and to the sluggish character of

824                                   NEW GROWTHS

the inflammatory element. The whole process is, in fact, usually slow
in evolution and more or less persistent, and this sluggishness is still
further emphasized by Neumann’s observations that the morbid prod­
ucts, chiefly exudation cells, are to be found four to eight months
after clinical evidences have disappeared; and this, as Crocker states,
“lends some support to Hutchinson’s doctrine ‘of residues of the early
period of syphilis being the starting-point of later lesions.’ "

Diagnosis.—The features of the various syphilodermata have
already been considered in connection with the description of each form,
and in the general observations concerning the special characters of these
eruptions; a study and clear understanding of the latter will go far
toward the prevention of errors in diagnosis. The general characters,
distribution, color, and associated concomitant symptoms in the early
syphilodermata, usually with the history of the initial lesion, are the
chief valuable differential points. The finding of the Spirochæta pallida
would be a determining factor in a doubtful case. Fortunately, cases of
syphilis are rare that cannot be recognized by the gross clinical symp­
toms alone. In the late eruptions the limited or regional character, seg-
mental, circinate, or serpiginous configuration, together with the color,
and commonly an ulcerative tendency, are to be given consideration.

Seven or eight years ago the serum reaction diagnostic test for syphilis
—now known as the Wassermann test—was brought forward by Wasser-
mann,¹ Neisser and Bruck, and the method and its value later further
explained and confirmed by themselves in association with Schucht.
A positive reaction, it was alleged, is presumptive evidence of syphilis,
and this belief has now been accepted by many others (among whom
Fleishmann, Butler, Hoffmann, Haldin Davis, Blumenthal, Lesser,
Levaditi, Blaschko, Noguchi, Boas, Howard Fox, Heidingsfeld, Swift,
and others). It is agreed that it furnishes an additional means of aiding
in reaching a conclusive diagnosis in doubtful cases. It is not as yet, in
my opinion, to be considered as in itself absolute—it fails of positive
reaction in a fair proportion of cases (25 to 30 per cent.) of primary syphi­
lis, in about 5 to 10 per cent, of secondary cases, and about 12 to 15 per
cent, in tertiary;² and a positive reaction has been frequently noted in
several other diseases, more especially in leprosy (not all cases), sleeping-
sickness, malaria, hookworm disease, frambesia, scarlet fever, etc.
While one is justified in looking upon a single positive reaction with doubt,
unless corroborated by symptoms suspiciously syphilitic, the significance
of a series of tests made at intervals and giving a constantly positive
reaction would scarcely be questioned. A single negative test is prac-

¹ Wassermann, Neisser and Bruck, “Eine serodiagnostiche Reaktion bei Syphilis,”
Deutsche med. Wochenschr., May 10, 1906, xxxii, and Wassermann, Neisser, Brucht, and
Schucht, “Weitere Mitteilungen ueber den Nachweis Specinsch-luetischer Substanzen
durch Komplementverankerung,” Zeitschr. f. Hyg. u. Infectionskrankheiten, 1906, lv,

P. 453.

² Boas, “Die Wassermannsche Reaktion mit besonderer Berücksichtigung ihrer
klinischen Verwertbarkeit” (Harold Boas, Berlin, 1911 (German translation)), claims
with the quantitative method of carrying out the Wassermann reactions its value is
much increased; he uses in every case five amounts of serum, ranging from the usual
.2 to .01 c.c.; Fildes, Brit. Jour. Derm., 1911, p. 13, gives a survey of Boas’ experiences
as gleaned from his book.

SYPHILIS

825

tically of no value, as to be inferred from the data already presented,
which emphasizes what is well known—that it fails of positive reaction in
a small percentage of frankly syphilitic cases; a series of negative reac­
tions made at intervals would, however, be of great value. To be at
all reliable, however, such tests should be made by a trained laboratory
expert, or at least by one who is well practised in the somewhat elaborate
and delicate technic. The Noguchi¹ simplification and modification
of the Wassermann test is also considered trustworthy, but the predomi­
nant opinion favors the Wassermann test. Antisyphilitic treatment
sometimes rapidly, more often gradually, changes a positive reaction
to a negative, and this latter may continue for some time after such treat­
ment has been discontinued; sufficient and sufficiently prolonged treat­
ment will bring about, it is generally believed, a permanency in the
negative reaction, and presumably a cure of the disease.²

Noguchi³ has introduced another diagnostic test—cutaneous reac­
tion test, the so-called luetin⁴ reaction—similar to that of Von Pirquet

¹ Noguchi, “Eine, fur die Praxis gecignete, leicht ausführbare Methode der Serum-
diagnose bei Syphilis,” München Med. Wochenschr., March 9,1909, and “A Rational and
Simple System of Serodiagnosis of Syphilis,” Jour. Amer. Med. Assoc, Nov. 6,1909, and
Jour. Exper. Med., 1909, xi, p. 392; and “Serum Diagnosis of Syphilis and the Butyric
Acid Test for Syphilis,” Phila., J. B. Lippincott Co., 1910 (with bibliography of 200
selected articles).

² It is not considered necessary to go over the details of the Wassermann test here.
It requires an extensive and well-equipped laboratory, painstaking and skilled technic,
and infinite attention and delicacy in its management—it is, in short, laboratory work.
It was built up upon the already known basic principle (Bordet-Gengou) of the power of
the serum of one animal to dissolve the red corpuscles of that of another species—known
ashemolysis. This action is dependent upon the three substances: The complement,
always present in any blood-serum; the antibody or hemolytic amboceptor, resulting
from the reaction of the injected animal against the injected red blood-cells; and the so-
called antigen, in this instance the injected blood-corpuscles. The union of the three
constitutes the hemolytic system, and effects the solution of the injected red corpuscles.
It has been found that syphilis, as well as certain other diseases also, produces anti­
bodies or amboceptors which have the power of uniting with the complement of the
blood-serum and its special bacterial antigen. For the Wassermann test are mixed to­
gether the inactivated serum (serum that has had its complement destroyed by heating)
of the suspected patient, fresh serum complement from a guinea-pig, and the antigen—
extract of a syphilitic fetal liver or other organ. If the patient is syphilitic, the ambo-
ceptors use up all the available complement, and therefore, when later washed sheep’s
red corpuscles and rabbit serum amboceptors are added there is no solution of the red
corpuscles, but these gradually settle to the bottom of the tube; on the contrary, if the
patient is not syphilitic, the complement still being available, hemolysis, or solution of
the. corpuscles, takes place. It has been found that other substances, such as extract
of normal organs, of new growths, lecithin, etc, may be used as the antigen with the
same results. Indeed, Wassermann himself has already modified the technic and others
have made further changes, some quite material, as in the Noguchi test. Out of it all
comes the hope of a future possibility—a fairly certain diagnostic method for obscure
cases of great value and of simple technic.

³ Noguchi, “A Cutaneous Reaction in Syphilis,” Jour. Exper. Medicine, 1911, xiv,
p. 557; “Method for Pure Cultivation of the Treponema Pallidum (Spirochæta Pallida),”
Jour. Exper. Med., Aug., 1911, p. 557; “Experimental Research in Syphilis with Especial
Reference to the Spirochæta Pallida (Treponema Pallidum),” Jour. Amer. Med. Assoc.,
April 20, 1912, p. 1163.

⁴ Luetin is the name given by Noguchi to a suspension of Spirochætæ pallidæ that
have been grown in pure culture and then destroyed by heat. About ¹/₁₀ c.c. is injected
superficially in the skin of one arm, and an equal amount of the control (uninoculated
culture-medium) in the skin of the other arm. The reaction usually shows itself about
the end of twenty-four hours, and reaches its height in two or three days; it consists of
an inflammatory papule or nodule, with, in most instances, a bright red areola of
¼ to ½ inch or more in diameter; and later there may follow a phlegmonous inflammation

826                                       NEW GROWTHS

for tuberculosis, which he believes will be of considerable value. The
experiences of Cohen,¹ D. 0. Robinson,² Howard Fox,³ Pusey,⁴ Engman,
Winfield, Pollitzer, and Gradwohl⁵ with this test vary to some extent,
but are more or less confirmatory. As its action depends upon an es­
tablished anaphylaxis, which usually takes considerable time, it is not,
therefore, at all dependable in the early stages of syphilis, being most
reliable in the tertiary stage.

Prognosis.—The prognosis as to the syphilodermata, the dura­
tion of contagiousness of the virus, and hereditary syphilis have received
more or less consideration in connection with type description and
etiology. The cutaneous manifestations of the secondary stage, except
sometimes the palmar and plantar papulosquamous lesions, all disappear
sooner or later spontaneously, but much more rapidly by treatment.
In short, if the patient lives,—and in only rare instances of malignancy
does death take place in the secondary period of syphilis,—the eruption
or eruptions and relapses of this period are self-limited, even though the
patient be neglected. On the palms and soles, in the form mentioned,
there may be chronicity, and while many such cases yield more or less
promptly to proper constitutional and local measures, some are extremely
rebellious. Moist papules are, if untreated, sometimes persistent, but
yield rapidly to local measures and also to constitutional medication.

The late syphilodermata show but little if any disposition to sponta­
neous cure, but, as a rule, respond readily; in exceptional instances, more
especially in the tubercular or tuberculogummatous form, and more
particularly about the nose, and in the flattened, gummatous, infiltrating
variety, the improvement is often slow, and the final cure brought about
only by energetic and persistent medication. The apparent obstinacy
in some of these cases is due to the patient's tolerance of the specific
drugs employed, especially to the iodids. My own observations as to
these rare cases have shown me that mercury is the remedy which needs
to be pushed, the potassium iodid even in large doses proving ineffective,
and, if this is done, a result is soon obtained. In the past several years
arsenical preparations, especially salvarsan, have proved themselves par­
ticularly valuable in just such cases, in addition to their usefulness in
other manifestations and in other stages of the disease. Ordinarily, as
with the other eruptions, gummata likewise respond rapidly under treat­
ment, and sometimes disappear without ulceration, even after consider­
able softening has taken place; ulcerations from this as well as the tuber-

somewhat furunculoid in aspect, with or without any signs of suppuration, and some­
times presenting a thin scaliness. After several days to a week the reaction has usually
largely subsided, gradually disappearing and leaving behind for some time slight pig­
mentation. In some instances following the injection systemic symptoms of a febrile
character, malaise and headache, are noted for a day or two.

¹ Cohen, “Noguchi’s Cutaneous Luetin Reaction and Its Application in Ophthal­
mology,” Arch. Ophthalmology, 1912, xli, p. 8.

² Daisy Orleman Robinson, “Diagnostic Value of the Noguchi Luetin Reaction
in Dermatology,'’ Jour. Cutan. Dis., 1912, p. 410 (tried it also in 22 other skin diseases
—108 cases—and found it uniformly negative).

³ Howard Fox, “Experiences with Noguchi’s Luetin Reaction,” ibid., p. 465.

⁴ Pusey, Engman, Winneld, Pollitzer (discussion on Fox’s Paper), ibid.

⁵ Gradwohl. New York Med. Record, May 25, 1912 (48 cases: negative in primary
syphilis, often negative in untreated secondary syphilis, positive in all tertiary cases).

SYPHILIS

827

cular or other types show, as a rule, prompt reparative process. In rare
instances gangrenous ulceration, due indirectly to syphilis in consequence
of resulting endarteritis obliterans, without preceding formation of a
gummatous neoplasm, is observed, and which shows but little effect
from antisyphilitic treatment.¹ Mucous patches in the oral cavity may
be stubborn if smoking is continued and if kept up by irritation from a
sharp or rough tooth or by irritating drinks or foods; but with attention
as to these points will generally disappear either as the result of internal
treatment or local applications. There is a tendency to relapse or new
spots, especially under the above conditions, and particularly from
smoking. With smokers, even though the active patches themselves
finally go, those sometimes present just within, but slightly beyond, the
corners of the mouth, while they practically disappear, leave behind some­
what milky-looking, occasionally slightly thickened, areas, the so-called
smokers’ patches; these are probably to be looked upon as a mild phase
of leukoplakia, and not necessarily possessed of contagious properties.

The mildness or severity of the disease cannot always be foretold
by the character of the chancre or the early secondary symptoms. The
pustular syphilodermata are usually significant of a severe type, showing
either virulence of the virus or impaired resisting power, or both. The
condition of the general health has often a material influence in deter­
mining the grade of the disease, and subjects with tuberculosis or such
family tendency often show severe manifestations. The belief that the
infection following extragenital chancres is always more severe is some­
what general, but has nothing substantial to support it, and extensive
experience will soon prove that the infection, as regards degree, has no
relation whatever to the site of the inoculation. As a general rule it can,
I believe, be said that mildness of the early secondary symptoms is indica­
tive of a mild type of the disease, and less probability to late manifesta­
tions. This probability is always materially lessened, both in the mild
and severe cases, by proper and persistent specific medication. Indeed,
late symptoms are to be considered rather exceptional if treatment has
been thorough; in fact, one can truthfully say that the most important
etiologic factor in the production of the tertiary syphilodermata and
other syphilitic manifestations is to be found in imperfect, deficient,
and insufficiently prolonged treatment in the early periods of the disease;
and almost of equal importance are the habits and mode of living of the
patient himself.²

Treatment.—The treatment of syphilis as regards the specific con­
stitutional remedies is at the present day clearly understood, but concern­
ing the manner or method there is still some diversity; it is true that
the new remedy salvarsan has to a material extent with some and to a
moderate extent with others changed the plans somewhat. For the mi­
nute details and various plans of treating the initial lesion the reader is

¹ See paper by Klotz, “On the Occurrence of Ulcers Resulting from Spontaneous
Gangrene of the Skin During the Later Stages of Syphilis, and their Relation to Syph­
ilis,” New York Med. Jour., Oct. 8, 1887 (with references).

² Keyes, Jr., “Some Elements in the Prognosis of Acquired Syphilis,” Jour. Cutan.
Dis., 1910, p. 449 (gives an interesting survey of this subject).

828

NEW GROWTHS

referred to works on venereal diseases.¹ It consists practically in the
maintenance of cleanliness. This can be accomplished by washing the
parts with tepid water, occasionally using soap, two or more times daily,
according to the conditions, and the use of a bland antiseptic dusting-
powder, such as boric acid, of boric acid with 2 to 5 per cent, admixture
of acetanilid, iodol, or like substance; or, sometimes, the application of
lint wet with black wash, or with saturated boric acid solution containing
2 or 3 minims (0.135-0.2) of carbolic acid to the ounce (32.). As soon
as there is no longer question as to its nature, the best application, if
it is desired to hasten its disappearance, as more especially obtains on
extragenital parts, is mercurial plaster, full strength, or, if irritating,
with one or more parts of vaselin or other ointment base, and kept con­
stantly applied, changing twice daily. Ointments, as commonly under­
stood, however, are not usually satisfactory, except as a supplementary
application, spread upon lint, in those discharging cases in which there
is more or less gumminess, which glues the dry dressing too firmly. In
women the same plans are followed, but the importance of cleanliness—
frequent washing—is still more important, conjoined with the liberal
general use to the parts of mild antiseptic lotions, such as boric acid,
with or without a minute quantity of corrosive sublimate, or with a
weak solution of potassium permanganate. The parts should be kept
separated with pieces of lint. When administration of mercury is begun,
it will, if the induration is still present, and it often is when constitutional
medication is instituted, have a prompt influence in promoting its ab­
sorption. Caustic agents are not desirable or necessary.

Constitutional Treatment.—Before taking up the considera­
tion of the specific treatment proper, the occasional necessity of general
tonic remedies and the value of hygienic living in the management of
the disease should be referred to. The effect of freedom from excessive
or even moderate “drinking,” good food, healthy living, and reasonable
exercise cannot be overestimated, and are essential to final success in the
severe and especially malignant cases, and of more or less material help
in the proper handling of the mild types. Smoking is also detrimental,
and often the exciting causative factor in the production of mucous
patches in the mouth. While in spite of disregard of these ordinary
common-sense measures the eventual outcome as to the active stages
of the disease is usually seemingly favorable, there can scarcely be a
doubt that the tissue-resisting power and recuperative force are fre­
quently sufficiently impaired or lessened as to give a greater probability
of recurrent manifestations. With, however, the observance of such
precautions and the administration of the specific remedies, most cases
go on successfully to satisfactory end; some with no other manifesta­
tions than the macular or maculopapular, or possibly papular, syphilo-

¹ Metchnikoff has recently claimed that rubbing a strong calomel ointment (made
up of ¹/₃ calomel, ²/₃ lanolin, with 10 per cent, vaselin added) over the parts exposed, within
the first few hours after exposure will destroy the causative organisms and prevent
inoculation. In the past few years several observers (Duhot, Neisser, Hallopeau, and
others) have reported prompt cure or abortion of the disease in the very earliest chancre
stage by excision of the chancre and “intensive” systemic treatment; or by “intensive”
remedial treatment both of the initial lesion locally and systemically.

SYPHILIS

829

derm, and one or several light, concomitant, secondary symptoms, with,
in others, a tendency to slight recurrence or outcroppings. In some the
disease is, of course, more troublesome, and with, for a variable time, a
persistent tendency to manifestations. In other cases the anemia re­
sulting, the depraved condition of the health engendered, and other
occasional accidental, non-specific affections, but indirectly due to the
disease, may require the administration of iron, cod-liver oil, strychnin,
digestive tonics, and other indicated remedies. It is true that the mild
anemia not infrequently encountered will often disappear upon the ad­
ministration of the specifics,—mercury and arsenic,—which, as Keyes
and others (especially as to the former remedy) have pointed out, have
a direct influence in increasing the number of red corpuscles.

The proper time for the specific constitutional treatment had,
up to a few years ago, been generally taught to be when the earliest
secondary symptoms put in an appearance, when there no longer re­
mains the least question as to syphilitic infection. The main reason
for believing the earlier administration of the specific drug injudicious
is that there may possibly be an element of doubt as to the nature
of the inoculative lesion, which, though it may present the characters
of the initial sore of syphilis, yet the induration which distinguishes
it may be the result of accident or meddlesome applications, and simply
be a chancroid or patch of herpes or other simple irritation which has
been thus transformed; under such circumstances the patient would
forever be under the impression of having syphilis, believing the con­
stitutional treatment had kept the secondary symptoms in abeyance,
which it frequently does in true infection when its administration is begun
during the early chancre stage. Another reason is that if administered
early, the patient may establish more or less of a tolerance for it, and
thus, when prompt effect against the appearance of severe symptoms
which may arise is desired, action, owing to this fact, cannot be so quickly
obtained. Of the two reasons, the former is the only one to be con­
sidered, the other having no rational basis; and now that any doubt as
to the character of the lesions can be cleared up by examinations for
the spirochæta, even that reason no longer holds. The time to begin
specific treatment, therefore, is as soon as the fact of the disease is
established—in short, as early as possible.

There are three drugs which are now considered to have more or less
specific influence in the management of the disease—mercury, potassium
or sodium iodid, and arsenic in its new combinations. The first two,
now long in use, will be considered first, and the arsenical preparation
later. Both mercury and arsenic are antagonistic to the syphilis organ­
ism and its products, and both tend more or less rapidly to change a posi­
tive Wassermann reaction into a negative one. Of the first two named,
mercury is fully entitled to be looked upon as the specific one, and the
one that has long been depended upon during the active or secondary
stage of the malady; and also to constitute a necessary part of the treat­
ment of the later or tertiary symptoms; although in the latter, whether
appearing precociously or at the usual period, the value of potassium
iodid is not to be underrated. While there is but little, if any, difference

830

NEW GROWTHS

of opinion as to the value of mercury, especially in the early stages,
there is a divergence as to the special form of the drug to be employed,
and, to a less extent, as to the method of its administration. The former,
if the matter is judiciously investigated, is probably almost wholly the
result of training and prejudice, for in reality any of the mercurial drugs
capable of invoking physiologic action will prove of antidotal power
against the disease. The choice is necessarily somewhat influenced by
the plan of administration selected. The several methods of adminis­
tration are by the mouth, inunction, and subcutaneous or intramuscular
injection, each having its advocates, although by far the most usual
plan with the rank and file of the profession is by the one first named.
Whatever be the method of administration, the producton of ptyalism,
sponginess and bleeding of the gums, and other toxic effects of mercury
are to be avoided. As measures against such accidents, the dosage is to
be carefully supervised, and thorough cleanliness of the teeth is to be
maintained, and frequent rinsing of the mouth with a potassium chlorate
and tincture of myrrh wash practised. Indeed, if cleanliness of these
parts is neglected, tartar and food allowed to collect and decay in the
dental interspaces, tenderness and actual soreness and sponginess will
result from smaller doses,—a decided detriment in those urgent or severe
cases where the fullest dose of the drug that can be satisfactorily borne is
desirable.

Administration by the mouth is, for ordinary purposes, a satisfac­
tory method in average cases, and is the one most convenient to
both patient and physician, and this will be first referred to. It is a
method that the patient will usually be willing to follow up over suf­
ficiently long periods to be permanently effective. There is much more
diversity in this method as to the particular mercurial to be employed
than with the subcutaneous plan—as regards inunction there is naturally
not much choice. My own preference, as, indeed, that of Taylor,
White and Martin, Hyde and Montgomery, as well as many French
physicians, is for the protiodid of mercury, and this is possibly in more
general use than other preparations. It is to be given in dosage of ¹/₈ to ¾
of a grain (0.008-0.05), in pill, capsule, or triturate form after each meal,
and if it should, as it occasionally does, especially in the larger dosage,
give rise to abdominal pain, griping, or diarrhea, a small quantity of
opium, on an average about ¹/₁₂ of a grain (0.0055), can be added to each
pill. Opium is, however, to be avoided if possible, and a good plan in
these cases is to prescribe the protiodid alone and give, if necessary, an
occasional dose of paregoric; or two prescriptions for the tablets or pills
can be given, one without opium and one with, the latter only to be
taken when the pain or griping demands it. Probably the most usual
dose of the protiodid is ¼ of a grain (0.016), and it is only occasionally
that troublesome pain is produced. Women stand less, as a rule, than
men. Unless the case is urgent, the beginning dose should not exceed
this latter quantity; this can be continued for four or five days, and, if
an evident impression is made, can remain the same. Should, however,
no effect be observed, and particularly if new lesions are appearing, the
dose is to be increased every two days by ¹/₁₆ to ¹/₈ of a grain (0.004-0.008)

SYPHILIS                                         831

until some influence is perceived, when the same dosage can be main­
tained. Or, if no benefit is noted, it is increased until evidences of
physiologic action present; the dose is then to be lessened slightly,
and continued at the reduced quantity. Occasionally the physio­
logic action shows itself somewhat suddenly, and not infrequently
in quite a pronounced manner, and in such instances it is wise to
discontinue entirely for one or two days, and then resume at the smaller
dosage.

In severe and urgent cases of the disease it is well to begin with a
larger dose,—³/₈ to ¹/₂ of a grain (0.024-0.035),—and increase daily by
the addition of ¹/₁₆ to ¹/₈ of a grain (o.oo4-o.oo8) to each dose until slight
physiologic effect is produced, and then reducing somewhat. The
proof of such action is to be found, first of all, as well known, in the con­
dition of the gums, such as slight soreness with swelling or sponginess,
especially adjoining the teeth, and a disposition to­ bleed easily; and even
before any evidences are visible there is a tenderness noticeable upon the
patient shutting the teeth together rapidly and with some force, and also
fetor of the breath and a metallic taste; with these there is not infre­
quently slight, but scarcely noticeable, increase and possibly thickness
of salivary secretion. It should not be pushed beyond the production
of such evident physiologic, or, as might be termed, mildly toxic, action,
nor this far if it can be avoided unless a prompt effect is, for reasons,
especially desirable. Under the administration of the mercurial the
syphilitic eruption and other symptoms gradually abate, and, after a
variable time, pass away; the anemia frequently noted gradually, and
often rapidly, lessens, the patient usually increases in weight, and the
mental depression often present gives way, and in most instances the
patient’s general health, in most cases impaired by the disease, seems
re-established. The disappearance of the manifestations of the secon­
dary stage does not mean necessarily, however, that the malady is
at end, for, especially if treatment is discontinued, there may be
relapses and other symptoms later in the disease. The duration of
administration should therefore be much longer, as will be later
especially referred to.

In cases in which the protiodid gives rise to pain and griping, and in
which the addition of an opiate is undesirable, gray powder—mercury
with chalk (hydrargyrum cum creta)—can be substituted. This prepa­
ration is, in fact, preferred over all others by some observers, notably
Hutchinson, and is also favored by Duhring and Crocker. The dose is

1  to 3 grains (o.o65-o.2) or more after each meal, according to circum­
stances and the tolerance of the patient, the larger dosage often requiring
the occasional administration of paregoric or the addition of 1 or 2 grains
(0.065-o.133) of Dover’s powder to each dose of the gray powder in order
to control the resulting diarrhea. Other preparations which have support
and which may likewise be prescribed with satisfactory effects are calomel,
blue mass, corrosive sublimate, and red iodid—calomel in dose of 1 to

2  grains (o.o65-o.133); blue mass, 1 to 3 grains (o.o65-o.2); corrosive
sublimate or red iodid, ¹/₂₄ to ¹/₈ grain (o.oo27-o.oo8), after each meal. In
the use of calomel or blue mass an addition of opiate is usually necessary

832

NEW GROWTHS

to restrain the laxative action and to relieve the pain sometimes pro­
duced. Corrosive sublimate and the red iodid are rarely used in the
secondary stage of the disease, but are the favorite preparations in the
late stage, conjointly with potassium iodid; in the largest dosage indi­
cated they sometimes give rise to gastric and intestinal irritation and
diarrhea.

The inunction method of administering mercury, which found its
greatest support under Sigmund, of Vienna, and very largely employed by
Zeissl, Neumann, Mracek, Kaposi, and others of that school, as well as by
other German physicians, is now one of the recognized methods. It has
long been an accepted plan in some cases in English, French, and Ameri­
can practice. It permits more readily of the conjoint administration of
tonics and potassium iodid by the mouth, if such should be indicated.
It is an extremely valuable method, and one that can be satisfactorily
employed in urgent cases. It is the plan to be adopted in those instances
of obstinate syphilis occasionally encountered, and in which mercury
by the mouth is often without material influence, or cannot, owing to gas­
tric irritation or other reasons, be pushed to a dosage sufficient to bring
about a result; or in which it may seem preferable to the mercurial (and
arsenical) injection method. Such cases are not common, but they are now
and then met with, as well as, moreover, instances where the patient is
exceedingly tolerant of the drug, not susceptible to ordinary mouth doses,
and in which a result is obtained only by inunctions freely employed. Of
this latter kind, I have met with 3 extreme examples of tertiary eruptions
in which a cure was obtainable only by overwhelming doses—the drug
being administered both by the mouth and inunction, with a disappear­
ance of the lesions and absolutely no sign of toxic action. Doubtless
the injection method would have been equally prompt and satisfactory.
There is a common belief that this method requires care as to the avoid­
ance of taking cold, and the exercise of some judgment as to proper diet
and other hygienic observances, but no more than with other methods
of administration. The mercurial preparations which have been em­
ployed for this plan are the blue ointment (unguentum hydrargyri) and
the oleate of mercury; the latter, which was urged as a clean substitute
for the blue ointment, proved, however, inefficient and unreliable, and
is no longer in use, the blue ointment now being solely employed. It
should be freshly prepared, as it is quite probable that the local irritation
it not infrequently produces is in many instances due to rancidity of the
base and not necessarily always to the incorporated drug.

The amount of ointment required for one inunction is, on the average,
about 1 dram (4.), although it is safer to begin with not over 30 or 40
grains (2.-2.65), the effect watched as to evidences of physiologic or
toxic action, and the dose thus properly regulated. As a rule, except
in those extremely susceptible to the drug, it can be safely increased
up to 1 dram (4.), and in some cases more. An inunction is made once
daily, intermitting if circumstances indicate; in private patients treated
at home the inunction is most conveniently made at night. A general
warm bath should precede; during the bath the part which is to receive
the medication should be thoroughly washed, soap being used to remove

SYPHILIS                                             833

the skin oiliness, so as to render absorption more complete. If a general
bath is convenient or impossible, the part itself can be washed with soap
and water. After rubbing dry the ointment is to be rubbed in, and
this is done best by a nurse or professional rubber, although in most
cases the private patient does it himself. The rubbing should be gentle
but firm, and should last twenty to thirty minutes. Taylor states that
after the general bath or local washing a 2 to 3 per cent, carbolic acid
solution should be applied to the part, as, “by strict attention to the
aseptic condition of the skin, dermal inflammatory complications can
almost always be avoided.” In order to lessen the chances of such acci­
dent the rubbing should never be upon the same part consecutively.
The regions usually selected are where the skin is softer and thinner
and less likely to be hairy, as the sides of the chest, inner aspects of the
arms, and thighs; other parts in extremely sensitive skins can also be
added, as the anterolateral surfaces of the abdomen, the lower part
of the leg, the soles, etc. This gives six or more regions, and one should
follow after the other, thus giving an interval of at least five days before
the inunction is again made on the same part. The palm, fortunately,
by which the rubbing is done, is not very readily irritated. The inunc­
tion treatment should be continued as in the mouth method until
symptoms have disappeared, and repeated later on, or give place
to another plan, as will be subsequently referred to. Old under­
wear of suitable thickness for the season of the year should be worn.
The chief objections to this plan of treatment, in addition to the
possible skin irritation, are the soiling of the wearing apparel next to
the skin and the feeling of messiness engendered, and the trouble of
its application.

Subcutaneous and intramuscular injections constitute another method
of the introduction of mercury, the general trial or introduction of which
was due to Lewin, and which is more or less practised at the present
day by some syphilographers as a practically exclusive plan, by others
as occasional, and by still others, and by much the larger number, only
for particularly rebellious cases. It cannot be gainsaid that it is usually
slightly more rapid in its action than mouth administration, but not
materially superior, in this respect, to inunctions. Its dosage, at least
as regards soluble mercurials, can be accurately gauged, and the patient
is kept more under direct control. Its painfulness is variable, from trifling
and of short duration to somewhat severe and prolonged; the fact that
it necessitates the frequent personal attention of the physician; and the
occasional painful induration and exceptional abscess formation result­
ing—are the disadvantages. It is a method that is much in vogue,
and increasingly so at the present day, and one to employ especially
when circumstances, either as to the patient or the gravity of the
disease, demand prompt and effective action, and when the same cannot
be secured by mouth administration or inunctions; more especially when
objection is made to the latter on the score of possible betrayal of the
existence of the disease or when the eruption is of extensive and especially
pustular character, making inunctions impracticable.¹ The method is
¹ It is now quite frequently preceded by one or two salvarsan injections.
53

834                                   NEW GROWTHS

not entirely without risk¹ when the insoluble preparations are employed,
although those who make use of these as routine practice consider
the risk so slight as scarcely to be considered; with the soluble prepara­
tions the possibility of serious accident is practically nil, probably no
greater, at least, than with the hypodermic injection of any other soluble
drug.

Of the several soluble mercurial preparations urged from time to
time for this method—corrosive sublimate, succinamid, albuminate,
carbolate, peptonate, bicyanid, iodo-tannate, benzoate, and a few
others. the one which has the most support and in general use is corro­
sive sublimate; the dosage of this is ¹/₁₂ to ³/₈ grain (0.005-0.024), ¹/₈ grain
(0.008) being an average dose. It is dissolved in sterilized water,
so that 20 minims (1.35) will represent ¹/₈ grain (0.008) of the drug.
In fact, as great a dilution as convenient to inject, within reason­
able limits, is best, as least likely to be disturbing. It is considered
an advantage by some to add a minute quantity of sodium chlorid,
tartaric acid, or sodium chlorid and ammonium chlorid conjointly, to
such a solution, and others add a small portion of glycerin; upon the
whole, however, the plain solution is in common use. A rubber syringe
and good steel needle should be employed, and the injection made deeply
and carefully into the subcutaneous tissue; if only into the derma, slough­
ing is apt to result. Injecting directly into a blood-vessel or vein should
be guarded against. The points most commonly selected for the injec­
tion are the gluteal region, just behind the great trochanter and the sub-
scapular regions. It is, however, often made on other parts, where
some depth is possible. Great care should be taken that the solution,
needle, syringe, and skin at the point of injection are thoroughly aseptic.
It is well to have a number of needles, and if small items of expense are
not to be considered, a good plan is to use a fresh one for each injection.
The frequency and dose of the injection depend upon the effect upon
the eruption or other symptoms, and upon the physiologic or toxic evi­
dence of the drug; once daily or every second day constitutes the average.

Of the insoluble mercurial salts, which are always injected deeply
in the tissues—intramuscular injections—gray oil and calomel are the
favorite preparations. Other insoluble salts of mercury which have also
been extolled are the yellow oxid, black oxid, cinnabar, tannate, thymol
acetate, salicylate, and several others. The insoluble preparation under­
goes gradual absorption, and the action is continuous for several days
or longer. Calomel is administered in suspension in a mucilaginous
vehicle, in glycerin and water, or in liquid vaselin, about 1 grain (0.065)
at an injection, every three or four days, or a somewhat larger quantity
at longer intervals. Gray oil (oleum cinereum) is most frequently pre-

¹ Lasserre (“Le Passif des injections mercurielles,” Annales, 1908, pp. 215, 289, 655,
and 707) goes over the entire subject of the subcutaneous and intramuscular mercurial
injections, both as to the soluble and insoluble salts; gives brief citations of the pub­
lished instances of grave and fatal accidents; publishes the communicated opinions
and experiences of well-known men of most countries. He shows that there have been
70 fatal accidents and no serious accidents. Gray oil and calomel were responsible
for 38 of the deaths. There were but comparatively few deaths or serious accidents
from the soluble preparations. A complete bibliography is added to this excellent
paper.

SYPHILIS                                        835

scribed, of which an injection of 10 to 40 grains (0.65-2.65), an equivalent
of 5 to 20 grains (0.33-1.33) of metallic mercury, is made weekly; gray
oil is made according to various formulas, probably most commonly with
lanolin and liquid vaselin.

Fumigation, or mercurial vapor-baths, is a method of introducing
mercury in the treatment of syphilis that was at one time quite fre­
quently employed, but it is not much resorted to at the present day.
A special vaporizing lamp, both for water and the mercury, obtainable
in the instrument shops, is necessary; and an impermeable enveloping
garment or one or two ordinary bed-coverings or blankets, to be closely
adjusted around the neck to prevent damaging inhalation of the fumes.
Calomel and cinnabar are the salts commonly employed—the former in
average quantity of 1 dram (4.), and of the latter the same or a slightly
larger amount. The vapor-bath, if the sole plan of treatment, is given
every two or three days at first, and then daily or every other day, ac­
cording to circumstances. It is best given in the evening, and not less
than two hours after eating; the duration should be about twenty to
thirty minutes, and the patient can then, after cooling off some, retire
enveloped in the garment employed during the bath, if it is not too
moist. In a prolonged bath of this kind too much steam vapor is not to
be used, as the patient is often thereby weakened. The continuance
and duration of this active plan of treatment, as with others, depend
upon the obstinacy of the eruption and other symptoms.

Potassium iodid, or its equivalent salt of sodium, is an extremely
valuable remedy in the later stages of syphilis, but it is rarely needed in
the secondary or active stages of the disease, in which mercury is with
rare exceptions fully adequate to bring about a favorable result. It is
often stated that the iodid should be given in secondary syphilis and take
the place of mercury, when this latter is contra-indicated or not well
borne, but such instances, judging from dermatologic observation,
are exceedingly rare and almost unknown, for while one plan of mercurial
treatment might be found damaging to digestion, for instance, in
mouth administration, another method can readily be substituted. It
has also been alleged that mercury is not well borne in some cases of
malignant syphilis, and therefore it is often advisable to suspend its use,
but even in such instances, if properly and judiciously administered,
along with the conjoint treatment by iron, strychnin, minute doses of
arsenic, cod-liver oil, and other remedies, as may be indicated, its omission
or discontinuance is usually unnecessary. Profound anemia, which is
often the troublesome symptom in these cases, needs more than mercury
to promote the rebound or even to stop the downward trend, and it is,
I believe, the failure to recognize this fact or an unsuitable method of
administration that has given rise to the view that the mercury may be
doing harm. It is true, however, that in extremely rare instances the
temporary discontinuance of this drug may be deemed wise, or at least
tried, and to the treatment, consisting of tonics and nutrients, small or
moderate doses of the iodids be for a time given in its place. A compara­
tively few physicians are, however, inclined to give the iodids a more
prominent place in the active stages, although, with rare exceptions, all

836

NEW GROWTHS

of large experience have recourse to them at this period only when preco­
cious tertiary symptoms present, such as persistent rheumatic pains,
periostitis, gummata, destructive ulceration, troublesome cephalalgia,
and other evidences of more or less serious involvement of the nervous
system.¹

Its conjoint administration in moderate dosage is sometimes adopted
toward the end of the first year by some as a routine method, but, as
a rule, mercury is to be the recourse throughout, if tertiary or other
serious manifestations do not suggest its earlier use. It is especially
in the later manifestations, such as the tubercular and gummatous and
other tertiary evidences, that the iodid is extremely valuable, and under
the administration of which symptoms often disappear in a comparatively
short time as if by magic. But while it has this power, it does not, in the
judgment of many, including myself, seem to have the same influence
in preventing recurrences, or, in short, of extinguishing the syphilitic
poison, as does mercury, and the latter, therefore, is almost invariably
associated, constituting the well-known “mixed treatment.” Corrosive
sublimate and the red iodid of mercury are the mercurials used most
frequently with potassium iodid, the latter, I believe, deserving the pref­
erence. The two drugs are commonly ordered conjointly in mixture,
with mint-water, cinnamon-water, compound tincture of cardamom,
gentian, wine of coca, or the compound syrup of sarsaparilla as the vehicle.
This last has long been a favorite, owing to the erroneous or scantily
founded belief that it has itself some influence, but its syrupy character
has often seemed to me to be responsible for the nausea and gastric
uneasiness attributed to the iodid, although the latter is in many instances
the exciting cause. I have found that the sodium iodid is much less
likely to disagree than the potassium salt, and for that reason frequently
prescribe it in preference, although in the same dosage it is not quite
so efficient as the potassium salt. With the other iodid salts—ammonium
iodid, rubidium iodid, strontium iodid, and lithium iodid—occasionally
suggested as substitutes for the potassium and sodium salts I have had
no experience, although it is generally admitted that they are not com­
parable to the two in common use. Not infrequently the iodid is pre­
scribed as a saturated aqueous solution, 1 minim being equivalent to 1
grain (0.065), and the dose can thus be conveniently increased drop by
drop if necessary; it is taken diluted with water or milk, and the mercurial,
if advised also, separately in pill, solution, or by inunction. When
separately administered as pill or tablet, the mercurial can, as in the ear­
lier stages of the disease, be prescribed as the protiodid, although for this
plan also the biniodid or corrosive sublimate is frequently preferred,
especially the former, as less liable to give rise to gastric or intestinal
irritation or to the other toxic symptoms.

The dose of the iodid of potassium or sodium required is variable
—in some cases not requiring urgency it is, as a rule, not necessary
to exceed 10 grains (0.65) three times daily, and frequently 5-grain doses
(0.33) will suffice; and, indeed, in some cases of the late tubercular syphilid

¹With some physicians salvarsan has largely supplanted the iodids in such
instances.

SYPHILIS                                         837

the eruption will rapidly disappear under smaller dosage, as 1 or 2 grains
three or four times daily, a fact to which Hartzell¹ has recently called
attention. As a rule, however, the drug must be given in moderate
doses, and very often the quantity is gradually increased up to 20 or 30
grains (1.33-2.) or more at the dose, and occasionally the total daily
amount reached before improvement sets in will be 6 to 8 drams (24.-
32.) or more, as sometimes observed, and as I myself have noted in occa­
sional instances.² These large doses are, however, only rarely necessary
in the management of cutaneous lesions, being sometimes required if the
destruction is rapid and threatening, or if indicated by grave concomitant
symptoms. In such instances the beginning dose should be moderately
large—20 to 30 grains—and rapidly increased. In exceptional instances,
however, it is found that the case does not yield so readily to the increase
of the iodids as it will to increase in the mercurial, and it is in such that
the iodid of potassium or sodium can be given by the mouth and the
mercury advantageously by inunction. In rare instances of the late
tubercular and gummatous manifestations the iodid, even when increased
to extremely large doses, fails utterly to remove the eruption, but, for­
tunately, such cases are so exceptional that the value of the so-called
“therapeutic test” in doubtful cases of suspected late syphilitic eruptions
is not materially lessened. In such instances the discontinuance of the
drug is advisable; the institution of vigorous mercurial treatment, espe­
cially by inunction or hypodermic injections, will usually have a prompt
effect; or recourse may be had to salvarsan injections.

Sometimes even moderate doses of the iodid salt give rise to such
distressing symptoms of iodism that it cannot be increased, and occa­
sionally must be discontinued. One or two drops of belladonna tincture
with each dose will sometimes lessen the severity of such symptoms, and
administration of small doses of arsenic or potassium bitartrate occa­
sionally seems to exert some control. The belief that the iodid eruption
—iodid acne, for instance—and other symptoms of iodism do not arise
when the drug is administered for syphilis, and that if they do, it indicates
an erroneous diagnosis, is absolutely without basis, as such symptoms
arise just as often in a given number of syphilis cases as in the same
number of cases of other diseases for which it may be administered, as
shown by J. William White,³ myself,⁴ and others.

Other alleged specific remedies for syphilis lauded from time to time,
more commonly proprietary in character, such as the various vegetable
remedies, which need not be enumerated, gold chlorid, opium, decoctions,
etc., have made no permanent impression, and their supposed effects

¹ Hartzell, “Some Practical Points in the Treatment of Late Cutaneous Syphilis,”
Therapeutic Gazette, May 16, 1898.

² Stelwagon, “A Case of Late Cutaneous Syphilis, Illustrating the Occasional Neces­
sity of Large Doses of Potassium Iodid,” Philadelphia Med. News, June 27, 1885.

³ J. William White, “Contributions to the Discussion of the Diagnostic Value of the
Tolerance of the Iodids in Syphilis,” Therapeutic Gazette, March 15, 1889 (presenting
communicated opinions from a number of eminent syphilographers and neurologists);
and “Valeur diagnostique de la tolérance des iodures dans la syphilis,” Union Médicale,
1889, pp. 628 and 639.

⁴ Stelwagon, “On the Alleged Tolerance of the Iodids in Late Syphilis,” Therapeutic
Gazette, Oct. 15, 1889.

838

NEW GROWTHS

have mostly been based upon their use in the secondary stage of the dis­
ease, when nature alone is, in reality, when properly guided or supported
by suitable hygiene, often amply sufficient to bring the eruption and other
symptoms to a favorable termination.

Arsenical Preparations.—Arsenic has claimed much attention re­
cently in the treatment of syphilis, and if the experiences so far with
its use continue to be further verified and the effects prove lasting, it
will be given probably an equal—possibly a superior—position to that
so long and satisfactorily occupied by mercury. While several arsenical
preparations, such as sodium cacodylate, atoxyl, arsacetin, soamin, and
hectine,¹ have been introduced, the Ehrlich-Hata preparation, known
as “salvarsan”² or popularly as “606,” has met with the greatest ac­
claim, and seems to have established a reputation for curative power
as to make it the arsenical remedy of choice. The leading German and
Austrian dermatologists and syphilographers have given it the most
thorough and extensive trials, and it seems to be accepted by them as a
peculiarly specific remedy for the disease. The French have been rather
lukewarm in its praise, some, among whom particularly Hallopeau, giving
a preference for hectine. England and America have been more conser­
vative than the Germans, but have, nevertheless, leaned toward sustain­
ing the German enthusiasm. Among ourselves it has gained rather
general use, and has been accorded high value by those who have given
it extensive trial, most prominent among the careful and exact observers
may be mentioned Fordyce, who has employed it largely, and is warm in
its praise. Salvarsan seems to have its most pronounced influence in
the primary stage, and quite decided in the late stages; it has a remarkable
action in dissipating mucous and ulcerative lesions; and in chronic de­
structive lesions it acts with greater rapidity, as a rule, than mercury
and potassium iodid, and acts in some cases in which the latter remedies
have failed. The hope that a single large dose would prove destructive
to the spirochætæ and annihilate the disease has long been abandoned;
and recurrences have been sufficiently frequent after its use to make
us somewhat more conservative in estimating its true value. It has
been claimed by several observers that excision of the initial lesion
at the earliest possible moment, together with a full dose of salvarsan,
repeated two or three times at intervals of five to ten days has succeeded
in aborting the disease. There has been a trend in the past year or so
to give salvarsan in the earliest stages of the disease, to the extent of
several moderate doses, and then to follow this up with a mercurial
course as formerly. It is also considered by many the remedy of choice
either in early or late syphilis of malignant type. The most common
dose of salvarsan is 5 to 9 grains (0.33-0.6) given in properly prepared
solution made just before administration, intramuscularly or intraven­
ously; the former in the same regions (buttocks) as mercury is similarly
given, and in the arm vein intravenously. Neosalvarsan, another prod­
uct of the Ehrlich laboratory, has been brought forward as a substitute
for or an improvement on salvarsan, chiefly on the basis of its much

¹  The chemical name being sodium benzo-sulphonpara-amino-phenyl-arsenate.

² The chemical name being paradiamidodioxyarsenobenzol dihydrochlorid.

SYPHILIS

839

easier preparation in solution for administration; it is somewhat weaker
than salvarsan and should be given in slightly larger dosage—about one-
tenth to one-eighth more. Salvarsan has been tried experimentally
(Kolmer and Schamberg)¹ by the mouth, but with slight therapeutic
effect. The intramuscular method gives rise to considerable pain,
sometimes sufficient to call for hypodermic injections of morphia, and
may be followed with fever and a possibility of local sloughing. The
intravenous method is more comfortable for the patient, quicker in its
action, but requires some technical skill in order to avoid any possible
grave accidents; there is less reaction; general symptoms of chilliness
and fever, with rise of temperature often persisting for several hours,
but, as a rule, not lasting more than a day or so. Those who depend
upon salvarsan completely, usually repeat this dose once in one to two
weeks till 3 to 5 doses are administered, or till the Wassermann reaction
becomes permanently negative. It would seem for the average case,
when seen for the first time after the chancre has well developed and too
late to attempt to abort the disease, that for the present the mercurial
treatment would be the one of a choice, unless extremely urgent symptoms
should show themselves; in such event or, as many practice, in average
cases, first a dose of salvarsan, and subquently the continued or inter­
mittent mercurial treatment. If the case comes within a short time of
the first sign of the initial lesion, excision should be practised, and a full
dose of salvarsan administered; if no untoward, arsenical symptoms
present the dose of salvarsan is repeated in several days—it is alleged
that in some instances the disease has been aborted in this way.

Of the other arsenical preparations “ Hectine” has probably had the
most commendation. Hallopeau² and other French observers give it
high value, stating that in a large number of cases administered early in
the primary stage it has repeatedly aborted the disease; the injections
are given daily in 3-grain (0.2) doses dissolved in sterilized water; and
are given mostly in and about the chancre, and using, when necessary,
novocain to relieve the pain. This treatment is continued for thirty
days; the Wassermann reaction becomes negative, it is stated, and re­
mains so. Sodium cacodylaie, in 1½- to 5-grain (0.1-0.33) dose in solu­
tion hypodermically, every two to three days, has also been given credit
(Murphy, Spivak, and others)³ for favorable action in syphilis, but it is
much inferior to the other arsenical preparations named, but safer.

¹ Kolmer and Schamberg (“Experimental Studies on the Administration of Sal-
varsan by Mouth to Animals and Man,” Jour. Exper. Med. 1912, xv, No. 5) found that
doses of salvarsan in doses of high as 7½ to 9 grains (0.5-0.6) could be given to man by
the mouth, without disturbing symptoms, with, however, but comparatively slight
therapeutic influence on the syphilitic manifestations; in cats and rabbits doses ap­
proximating those given to human subjects failed to produce toxic effects, either
symptomatically or in visceral examinations following autopsy.

²Hallopeau, Annales des Maladies Vener., Nov. 1911, p. 848.

³ Murphy, Jour. Amer. Med. Assoc, Sept. 24, 1910, p. 1113; Spivak, New York
Med. Jour., March 2, 1912, tried sodium cacodylate in 43 cases with the conclusions:
—it has a decided effect upon the initial lesion; not so much upon the secondaries, but
some effect on the adenopathy, and a decided effect on mucous patches and condy-
lomata; very little effect in tertiary lesions. He gave 3 grains (0.2) daily in fresh
solution, and states that the “human system can take 100 grains (6.66) in three
weeks without arsenical poisoning.”

840

NEW GROWTHS

Atoxyl, one of the first arsenical compounds to be used, had unques­
tionably, as Neisser and others have shown, considerable specific power
over the disease, but the serious accidents, especially optic atrophy and
permanent blindness, which sometimes followed its use, has practically
led to its abandonment.

There have been fatal results from the use of salvarsan, and doubt­
less would be from other arsenical preparations if given in large dosage.
The number of fatalities and serious accidents has not been large when
one considers the thousands of times it has now been administered; it
should never be given to those with serious cardiac or other vascular
disease, to those with pronounced kidney disorders, to those with grave
cerebral or other nervous disease, or to those with middle-ear or eye
disease—if independent of syphilis; nor to the profoundly cachectic
and weak.

Doubtless remedies having diaphoretic and diuretic properties and
promotive of proper action of the bowels do have some influence in
hastening the elimination of the syphilitic virus, but such are often
attainable by the observance of ordinary rules of hygiene. In this way
balneotherapy—warm or hot baths—is doubtless of some service.¹ It
is not necessary that patients go to “hot springs” for bathing purposes,
for tub- and vapor-baths at home will answer the same end, provided
patients will give the same attention to diet, temperate living, etc.,
as they willingly follow at the “springs”; and, if they do so, then the state­
ment made by Taylor, “take away the mercurial ointment and iodid of
potassium from any thermal spring, and its business will soon close up
for want of patronage,” is a simple, but strong, expression of the truth.
There are, however, patients who are not docile at home, who eat too
much, “drink” too much, and smoke too much, and who do not follow up
carefully the advice given, and for such the thermal spring, with its strict
regimen, moral living, and the incidental change of scene, and the usually
rigorous treatment, is a resort sometimes to be professionally advised.

The serum treatment is still in the experimental stage.

Duration of Treatment.—The active treatment of syphilis, if
with mercurials, is continued for a few months after all the symptoms
have disappeared; and then usually at intervals of one or two months
repeated for a few months, and so on for at least eighteen months to two
years, the treatment in the second year being somewhat less in dosage.
Should at any time fresh evidences of syphilis show themselves, the treat­
ment is naturally to be actively energetic again. I have been accus­
tomed to advise my patients to resume treatment for six weeks to two
months in each of the following two to three years. So far as my own ex­
perience goes, now covering a number of years, the results have been,
with very few exceptions, permanently satisfactory. If the preliminary
treatment is with one or two doses of salvarsan, followed by mercurials—
the plan largely practised just at the present time—the duration should
be almost the same as detailed above. Those who follow the salvarsan

¹ Interesting papers on the subject are contributed by Bogart, Brooklyn Med. Jour.,
Dec, 1895, and Neisser, Berlin, klin. Wochenschr., 1897, No. 16; and Baum, Medicine,
1896, p. 253.

SYPHILIS

841

treatment exclusively, usually base its continuance or repetition purely
upon symptoms and the serum reaction test, as referred to again a few
paragraphs further on. In fact, there is a disposition to depend upon the
Wassermann test indications, whatever the plan of treatment, for con­
tinuance or discontinuance, but for the present the patient should still
have the benefit of a prolonged period of treatment—it means, in my
opinion, greater safety.

Probably sufficient has been said as to the treatment of tertiary
manifestations in discussing the iodid salts. The cases coming der-
matologically under observation are chiefly those of limited tubercular
eruptions or gummatous lesions, sometimes several to five, ten, or more
years after the disease was contracted. The treatment of these and other
tertiary or late manifestations consists in the conjoint administration
of the iodid and the bichlorid or biniodid of mercury, 5 or more grains
(0.33) of the former and ¹/₃₂ (0.002) to ¹/₁₂ (0.006) or more of the mercurial,
in any suitable vehicle three times daily; if rebellious, increasing the dose
of the potassium or sodium iodid salt, if well borne, up to 2 drams (8.),
and then if, as exceptionally occurs, there is no result, giving the patient
an active mercurial course, either by stomach, inunction, or hypodermic
injection. The inunction plan often acts very satisfactorily in such
cases. A dose of salvarsan usually acts quickly in these cases, and
should certainly be prescribed in serious and rapidly destructive cases
which are rebellious to the iodid and mercurials. The treatment in
these late manifestations is to be continued actively for one or two
months after the disappearance of the symptoms; the iodid is then
omitted, and the usual daily dose of the mercurial continued for six
weeks to two months, and again resumed once or twice at intervals
of three or four months. If the symptoms had been of an urgent char­
acter, the subsequent employing of one or two short courses by inunction
at the above intervals is to be advised.

Duration of Treatment Based upon the Serum Test.—Whatever
may have been the plan of treatment pursued, or whatever may have
been the stage of the disease, the Wassermann test or its modification,
the Noguchi test, is at the present time largely depended upon for the
continuance or renewal of active treatment. Therefore, after patients
have been thought sufficiently treated and free of all manifestations for
several or more months, a series of such tests, more especially the Was-
sermann test, should be made at intervals of one or two weeks; and if
found constantly negative it is thought, by many observers, presumptive
evidence that the disease is at end. Such a series of tests should not,
however, be made till treatment has been discontinued for at least
several weeks, as it is well known that the antisyphilitic remedies have
the power, even in the active stages of the disease, of suppressing the
positive reaction for the time. Should the reactions show positive
active treatment is to be again resumed. While I do not question the
value and significance of the serum test, nevertheless I should not as yet
be willing to deprive my patients of the additional safety of a prolonged
period of mercurial treatment, as heretofore extending, with intervals of
interruption, over two or three years.

842

NEW GROWTHS

External Treatment.—In the majority of cases of the secondary
cutaneous manifestations no local applications are called for, but in
severe types of the papular eruption, and also in the pustular syph-
ilodermata, baths of corrosive sublimate, ¹/₂ to 3 or 4 drams (2.-12.
or 16.) to 30 gallons of warm water, can be employed, the patient re­
maining in the bath for five to fifteen minutes. When the surface
shows a good number of abraded lesions, absorption is likely to take
place, and the smaller quantities should be used. This bath method
was formerly occasionally employed as a plan of treatment for the in­
troduction of mercury, but it was found, except under the condition
just noted, that absorption practically did not take place, or at least
was uncertain. As the patient is at the same time taking the remedy
by the mouth or by one of the other methods, the possibility of such ab­
sorption is, however, to be kept in mind, so as to guard against toxic
action. A much better plan of medicating the general surface is by the
mercurial vapor-bath, but this is not always practicable. Very often
the surface in such cases can with advantage be sponged with a saturated
solution of boric acid, containing 1 to 2 drams (4.-8.) of carbolic acid to
the pint, with or without the addition of 2 to 4 grains (o.13 5-0.265) of
corrosive sublimate. Or this lotion can be applied to the covered surface,
and an ointment applied to the lesions on exposed regions, such as one of
ammoniated mercury, 20 to 60 grains (1.35-4.) to the ounce (32.); one
of oleate of mercury, 5 to 10 per cent, strength; mercurial plaster, full
strength or weakened with lard or petrolatum; blue ointment, full
strength or weakened; a 2 to 20 per cent, ointment of iodol; resorcin, 20
to 60 grains (1.35-4) to the ounce (32.). The selected ointment is gently
rubbed on the spots twice daily, or it may be, when possible, as when in
the house, applied spread upon lint as a plaster. The base used can be
made of equal parts of lard and petrolatum, with some stiffening, as
cerate or wax, if it is to be applied as a plaster. For exposed situations,
the most elegant, as well as most cleanly, is the ointment containing
ammoniated mercury, and this often acts satisfactorily, but in the event
of its making no positive impression, one of the others can be tried. In
the larger pustular lesions, especially when exhibiting an ulcerative
tendency of the base, the crust can be softened and removed, the surface
cleansed with mild antiseptic lotions, such as the above, and an ointment
spread upon lint and applied, changing once or twice daily, according to
circumstances.

In the late or limited syphilodermata, the same applications are,
when necessary, resorted to, the ammoniated mercury ointment, the
oleate of mercury, the blue ointment, and the mercurial plaster, full
strength or weakened, are the most satisfactory. The ulcerating lesions
can be cleansed first, an antiseptic lotion dabbed on, and an ointment
applied as a plaster. One of the above lotions can be employed, or,
and especially in offensive ulcerations, one slightly modified can be sub­
stituted, containing 2 to 6 grains (o.13 5-0.4) of corrosive sublimate, 10
to 20 grains (0.65-1.35) of carbolic acid, 4 drams (16.) of alcohol, ¹/₂ to 1
dram (2.-4.) of glycerin, and water to make 4 ounces (128.). Occasional
cleansing with a weak hydrogen peroxid solution is often of advantage.

SYPHILIS

843

Iodol may also be applied to ulcers as a dusting-powder, usually mixed
with one to several parts of boric acid or zinc oxid. In sluggish ulcera-
tions the healing process can often be advantageously started, as Zeisler¹
has especially emphasized, by a light cauterization with silver nitrate,
and in rebellious cases, if necessary, by a preliminary curetting. The
palmar and plantar syphiloderm, occasionally observed both in the late
secondary and later periods, is treated by the various ointments already
referred to, but when there is much thickening this is first to be removed
by the continuous application, for one or two days or longer, of a 10 to
25 per cent, salicylic acid plaster; frequently it is necessary to repeat
this from time to time; vigorous constitutional treatment conjoined with
active local measures is usually required in these cases.²

To the papules, often moist and fissured, sometimes found at the
angles of the mouth in the secondary period, one of the several oint­
ments can be gently rubbed or smeared on two or three times daily, or
they can be painted over, once or twice at one time, with tincture of
benzoin containing ¹/₄ to 1 grain (0.018-0.065) of corrosive sublimate to
2 drams (8.), and repeated night and morning. Moist papules on other
regions, as about the anus and genitalia, often disappear upon the institu­
tion of rigorous cleanliness, washing the parts twice or more daily with
tepid water and small quantity of soap, rinsing, and tapping dry with
absorbent cotton, and dusting on the iodol-boric acid powder noted
above, or a powder of one or two parts calomel to the ounce (32.) of
boric acid or zinc oxid powder; or in obstinate lesions pure calomel
powder alone can be applied. In the latter cases the preliminary use
of one of the mild lotions already named can be advantageously used
before the powder is applied. Ointments such as named are sometimes
advised, but, as a rule, they are not well borne, and the above dry methods
are much superior, and along with the constitutional treatment suffice.
Very obstinate lesions can be occasionally painted with a 5 to 10 per cent,
solution of silver nitrate. These same plans are alike applicable to the
hypertrophic warty and vegetating papules. For the mucous patches
in the mouth absolute cleanliness of this cavity and of the teeth is a
measure of usefulness. For this purpose frequent cleansing with the
ordinary potassium chlorate and tincture of myrrh or similar mouth-
washes or gargles can be employed. Any roughened teeth are to be
smoothed down, and smoking prohibited, as well as the ingestion of very
hot or acid or other foods which seem to irritate. Sometimes, under
such measures, and as the result of constitutional medication, the mucous
patch will disappear. In all cases, however, their disappearance can be
promoted by touching with the silver nitrate stick, and if no change is
observed in two or three days, the application is to be repeated. In
sensitive subjects or slight cases a 5 to 10 per cent, solution will answer
the purpose. In other cases touching carefully with a minute quantity
of lactic acid, nitric acid, or acid nitrate of mercury is sometimes neces­
sary, rinsing the mouth afterward.

¹ Zeisler, “The Importance of Local Treatment in Syphilis,” Jour. Amer. Med.
Assoc, Mar. 16, 1889 (with references).

² Stelwagon, “Observations Concerning Some Palmar Eruptions,” Jour. Cutan.
Dis., Jan., 1905 (illustrated).

844                                   NEW GROWTHS

The nail affections—onychia, paronychia—sometimes observed
require, in addition to the active constitutional treatment, rigorous
cleanliness, and the application of mild antiseptic lotions, such as already
named, and the enveloping of the part in a mild mercurial ointment,
redressing twice daily; when loose, the nail is to be removed. Falling
of the hair is managed in the same manner as described in other cases
independent of this malady (see Alopecia); the hair usually regrows as
the general constitutional disease abates.

Treatment of Hereditary Syphilis.—The constitutional treatment
of hereditary syphilis is essentially that of the acquired disease in adults,
with modifications as to dosage and method. It is understood that if
opportunity is afforded in a suspected syphilitic pregnancy that the
mother should be vigorously treated with mercurials during this period,
as in this way a healthy or seemingly healthy birth will result, or the
child will exhibit the disease in a milder phase. In a child born of syph­
ilitic parents and not showing specific symptoms treatment should not
be instituted until evidence of inherited disease appears, as it may have
wholly escaped infection; to this, however, the exception should be made
with children born during a recent syphilis in the mother, especially if
it has been untreated. The condition of the general nutrition should
be carefully looked after, however, so if the disease does exist, there will
be a better chance to subdue its symptoms when they present. In fact,
the nourishment of the child in all cases of inherited syphilis, whether
the evidences are present at birth or show themselves later, is of greatest
importance. The best method of introducing mercury in these cases is
by inunction, but the ordinary mercurial ointment should be weakened
with 2 or 3 parts of vaselin or cold cream, according to the age of the
child; about ¹/₂ to 1 dram (2.-4.) of this is spread upon a binder on the part
which goes over the abdomen. The surface should have a preliminary
washing with a mild soap and water, and, to lessen the chances of irrita­
tion, Taylor advises the application of a lotion of boric acid, after which
the ointment is bound on. From time to time, in order to avoid irritation,
the ointment can be applied to the back instead of anteriorly. The
dressing is to remain on twenty-four hours, the motions of the child
serving to rub it in; the binder is then removed, and the washing, etc.,
gone through with again, fresh ointment gently rubbed in, and the same
binder applied, and so the treatment is continued, a fresh binder being
substituted every few days. In spite of precautions and care, however,
the parts often become irritated, and this plan must give way, temporarily
at least, to inunctions gently rubbed on other parts, as with the adult.
Under the mild lotions and dusting-powders, such as are employed in
erythema intertrigo and acute eczema, the irritation soon subsides.

In some cases of extreme sensitiveness of the skin the inunction
method becomes impracticable, and in such instances, and in others
where seemingly preferable, treatment by the mouth can be tried. The
most satisfactory preparation for this purpose is the gray powder, which
can be administered as a powder with sugar of milk in dosage of ¹/₁₂ to
1 grain (0.006-0.065) three times daily after nursing, the dose depending
upon the age and effect, the larger doses not infrequently proving too

ORIENTAL SORE

845

laxative. Jacobi and others prescribe in preference minute doses of
calomel, about ¹/₂₀ of a grain (0.0032) three or four times daily. The
drug is also sometimes prescribed as corrosive sublimate in solution, ½
grain (0.033) to 6 ounces (192.) of water, of which the dose is one or two
teaspoonfuls. In some cases the laxative effect of the mercurial is to be
counteracted by the administration of compound chalk powder or other
mild astringent. Treatment by corrosive sublimate baths (10 to 30
grains (0.65-2.) to a bath of 8 or 10 gallons) is at times a serviceable
method much more frequently employed formerly than at the present
day. It is not, however, so certain a plan as those already mentioned.
The bath should be warm and the patient remain in for five to ten
minutes. Potassium iodid is sometimes prescribed in place of the mer­
curial, but if deemed advisable, their conjoint administration is preferable;
the dose of the iodid ordinarily varying from \ of a grain to 2 or 3 grains
(0.017-0.2) three times daily. Older children can tolerate larger doses.
In addition to the specific treatment, cod-liver oil and the iron prepara­
tions are sometimes demanded; of the latter, the syrup of the iodid being
the most feasible. The duration of active medication depends upon the
continued presence of symptoms or recurring evidences of the disease;
the patient should be under observation and more or less treatment for
a prolonged period, as advised in the acquired disease in adults. Hor-
wjtz advises that the child undergo four to six weeks’ treatment every
year until it reaches the age of puberty.

The external treatment of the lesions of hereditary syphilis is prac­
tically the same as in the adult already described. The erythematous
or erythematomacular condition sometimes observed about the genito-
crural region and the buttocks requires, as a rule, no special application,
but mild dusting-powder or lotions can be prescribed with advantage,
and especially in cases which may be complicated with a true erythema
or eczema intertrigo. The blebs of the bullous syphilid, if distended,
should be opened, the contents pressed gently out, and the parts cleansed
and dressed with a dusting-powder of boric acid and zinc oxid. Mouth
lesions and moist papules about the anus and genitalia usually require
attention, similar to that in adults.

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