Syphilis, a treatise for practitioners

Foreword

A WEARIED medical public, already surfeited with text-books, monographs, and essays upon syphilis and kindred matters, may well ask in resentful indignation : Why this new work upon syphilis ?

Being the father of the writer and the godfather of many of the generalizations advanced, I think I may answer.

The facts upon which the volume rests are the classified cases from the private office books covering forty years of continuous work by myself along syphilological lines, ten years of work in the same field by my son, and some gleanings from the twenty extra years included in Dr. Van Buren's case books, which the office has inherited — making a retrospect of sixty years.

In this considerable mass of experience there is much matter of value that would have remained buried but for the resurrection afforded it by this volume.

The generalizations, based upon the statistics above referred to, corroborate quite uniformly similar generalizations of other authors often based upon statistics numerically superior ; these latter statistics being sometimes largely from the hospital and dispensary point of view.

In certain of the views advanced, where this treatise differs from the majority of text-books, I am willing to share the responsibility with my son.

E. L. Keyes.

109 East Thirty-fourth Street.

Open Knowledge Commons

Preface

In order to make this work essentially a practical one, it has been founded upon the 2,500 cases of syphilis observed and adequately recorded in our office case books during the past forty years. The number of these cases might have been many times multiplied by the compilation of dispensary records ; but this would only have confused the picture. For the records taken of charity cases are so hasty and inaccurate, their histories so vague and incomplete, their disease so complicated by alcoholism and privation, their adhesion to any one clinic and course of treatment so brief and intermittent, that it is not fair to compare them with cases that have been, in the main, intelligently treated and watched for a number of years.

Yet it is perhaps too much to say that even these cases have been intelligently treated. All have received treatment at our hands, but a large minority have received most of their treatment, and especially of their important early treatment, at the hands of others. That the result leaves something to be desired may be inferred from the forty per cent incidence of tertiaries we have to record. Yet this result, which makes our cases more interesting, if less creditable, represents fairly well the status of syphilis in the middle and upper classes in New York, and in some measure throughout the United States, during this term of years.

During the last decade an increased appreciation of the horrors of syphihs, and a new method — the intramuscular injection of mercury — for its control, have certainly lessened the severity of the disease, and we may feel assured that, even without the viii . PREFACE

serum diag-nosis, immunization, and therapy, which the future seems to promise, syphilis during the next forty years will be far less destructive, because far more intelligently treated, than ever before.

Be that as it may — and it is very difficult even to-day to define accurately in what good treatment consists and to distinguish which case has received it — the contemplation and tabulation of these cases has proved most valuable, not so much for the statistics derived from them as for the point of view they have enforced and elucidated.

This point of view, in large measure inherited from and constantly inculcated by my beloved father, is his contribution to this work; and if the development of syphilology has spread these chapters over many more pages than those of his earlier work upon the same topic, the spirit of the two is the same. I can but regret that the advance of science permits me to incorporate so little of the letter of that work, and hope that thereby the text has not lost all its interest.

Whether the new theories that have poured in upon us since the discovery by Schaudinn of the Spirocheta pallida will destroy this point of view ; whether it will prove, for instance, that, after all, there are " periods " in syphilis, or that " paternal heredity " is possible, matters not at all. With this discovery we see the dawn of a new era of syphilology ; we hope for complete mastery of the disease; we pray that we may live to see the day when syphilis shall be reduced, from a volume to a chapter, from a scourge to a mere annoyance. Yet we fear that many a year shall pass ere some such volume as this one shall cease to be of practical interest to the student and the practitioner.

Such is the excuse for the publication of this book — to express practically a view of syphilis that has been two generations in the making, and to elucidate this by American statistics. Concerning the matter herein set down, it is impossible to be egotistical. The world's great authorities, Fournier, Neumann,

PREFACE

IX

Lang, Hutchinson, Finger, and Taylor — to mention only a few to whom a special debt is due — have been drawn upon freely for information, and reference upon disputed points has been made for the convenience of the student to the latest, the most comprehensive, or the most accessible monographs. Thus we hope to spare the reader aimless divagations among the literature, and ourselves the laborious sciolism of copious bibliography.

The many chapters on special subjects have been a source of grave concern, lest the writing of all of them by the same hand should sacrifice accuracy of matter to uniformity of manner. But my friends have kindly come to my aid. With a courtesy for which I cannot be too grateful, Dr. L. M. Hurd has reviewed the chapters upon Syphilis of the Nose, the Throat, and the Upper Air Passages ; Dr. E. G. Zabriskie, those upon Syphilis of the Nervous System ; Dr. J. I. Middleton, that upon Syphilis of the Eye ; and Dr. John Howland those upon Hereditary Syphilis.

Finally, while including in my general debt of gratitude all those whose writings or whose illustrations upon syphilis I have been able to lay my hands on, I must acknowledge a more precise indebtedness to the many others who have lent kindly personal aid to the matter in this volume : to my father, facili principi ; to my associate. Dr. Chetwood, for privilege to tabulate cases observed by him, as well as for the keen interest with which he has shared the labor of testing various methods of treatment; to Drs. G. H. Fox and J. A. Fordyce, for many original photographs ; to Drs. H. G. Piffard, J. Lincoln Davis, Prince A. Morrow, E. L. Shurley, and W. A. Pusey for illustrations ; to Dr. W. R. Bross for his contribution on Syphilis and Insurance ; to Dr. E. W. Caldwell and Dr. L. G. Cole for skiagraphs ; and to Dr. C. H. Jaeger and Dr. L. E. La Fetra for the loan of cases from whom these skiagraphs were taken.

109 East Thirty-fourth Street, New York City.

Chapter I

The prevalence of syphilis — Syphilis in marriage — The prophylaxis of syphilis

Chapter II The General Characteristics Of Syphilis

History of syphilis — Acquired syphilis: The primary lesion ; The secondary lesions ; The tertiary lesions ; The parasyphilids ; Are there periods of syphilis? — Hereditary syphilis — Clinical types of the disease: Mild early syphilis ; Malignant early syphilis ; Mild but persistent syphilis ; Relapsing syphilis ; Malignant late syphiUs ;

Mild late syphilis

Chapter III

The Spirocheta pallida: Methods of staining; Diagnosis; Where may 5. pallida be found ; Distribution and fate — Experimental syphilis: Inoculation; Prophylaxis; Inoculation immunity; Serum diagnosis and treatment 22-34

Chapter IV

The contagiousness of gumma: Persistence of spirocheta — Cause of relapses: Trauma and syphilis; The cause of parasyphilids^ Immunity: Racial immunity; Is our race immunized? — The second attack of syphilis — Syphilis in woman — Pathology: Lesions of the capillaries ; Disposition of the spirochetae ; Lesions of the larger vessels 35-54

XU TABLE OF CONTENTS

Chapter V Transmission Of Syphilis

Extragenital and non-sexual infection: Extragenital chancre — Age of ificidence — The probability and possibility of infection: Does exposure necessarily imply infection? What is the probability of infection from contact by kissing or sexual intercourse with a person known to be syphilitic ? When does syphilis cease to be infectious? — Syphilis and marriage ....... 55-64

Chapter VI

Syphilis and maternity — The theory of syphilitic heredity: Paternalheredity; Maternal conceptional heredity; Maternal post-conceptional heredity; Acquired syphilis in infancy — Hereditary syphilis of the third generation 65-77

Chapter VII

The onset: In man; In woman; Duration of primary and secondary incubation — The secondary symptoms: Definition ; Differentiation between secondary and tertiary lesions ; Secondary toxemia ; Local sj'mptoms ; Duration of the secondary symptoms ; Nature of late secondaries; Infectiousness of late secondaries; Prevention of late secondaries — The tertiary symptoms: Definition ; Occurrence ; Relapses ; The effect of treatment ; The effect of alcohol ; Regions involved; Incidence of all late lesions — The parasyphilids or syphilitic dystrophics: Definition; Varieties; Tabes dorsaUs and paresis ; Syphilitic spinal paralysis 78-112

Chapter VIII

Syphilo phobia — Means of diagnosis: Laboratory diagnosis; Clinical diagnosis — Diagnosis at different periods of the disease: The initial stage ; The secondary outbreak ; In a period of calm ; Later relapses — Differential diagnosis 1 13-123

Chapter IX

The patient's constitution: Interaction with other diseases and diatheses — The patient's environmeni: Climate; Age; Debility and trauma — The patient's habits: Alcohol; Tobacco — The effect of treatment — TJie lapse of time — Life-insurance estimates 1 24-137

TABLE OF CONTENTS . xiii

Chapter X Principles Of The Treatment Of Syphilis

Prevention — General principles of treatment — The routine treatment: Hygiene ; lodids do not prevent relapse ; Mercury does prevent relapse; Mercury is a tonic; In the routine treatment tonic doses of mercury are more effective than poisonous doses; So long as a sufficient amount of mercury is exhibited it matters not whether it is given by the mouth, by the skin, or by injection; The symptomatic treatment: For early secondary lesions mercury; for early painful symptoms iodid ; Gummatous lesions may be cured by iodid but better by mixed treatment ; Sclerotic lesions and lesions difficult to classify require mixed treatment; Lesions of the nervous system require treatment for short' periods with intermissions of hygienic treatment; Symptomatic treatment should always be vigorous and continued after the lesion has apparently healed; Vigorous treatment is that which effects prompt improvement; Local treatment avails little . . 13S-150

Chapter XI

The routine tonic treatment: How to administer treatment; The Vigorous interrupted method ; The modern interrupted method ; The continuous tonic treatment ; Method of administering mercury; Tonic treatment; Tonic treatment after late relapses; When to begin routine treatment — Treatment of the lesions of syphilis 1 51-160

Chapter XII Physiological Effects And Toxicology Of Mercury

Beneficial effects of mercury — Toxicology: Salivation; Treatment of salivation; Entero-colitis ; Nephritis; Dermatitis; 111 effects of prolonged mercurialization ; Contraindications . . . 1 61-168

Chapter XIII

Internal administration: Protiodid ; Gray powder ; Bichlorid ; Blue pill ; Calomel ; Tannate ; Other preparations ; Rules for treatment ; Do not give opium ; Do not begin with full dose ; An occasional interinission ; Merits of internal treatment— Intramusciclar injection:

xiv TABLE OF CONTENTS

Bichlorid; Benzoate; Biniodid; Salicylate; Gray oil; Calomel; Method; Frequency; Merits of various injections; Disadvantages; Advantages — Inunction: Preparations employed; Technic; Duration; Merits — Fumigation: Salts employed; Technic; Merits — Intravenous injection: Solutions employed; Technic; Complications — Intratracheal injection — Rectal administration — Comparison of various methods: For efficiency ; For comfort . 1 69-1 9 1

Chapter XIV

Therapeutic indications — lodism: Coryza; Indigestion; Acne and other skin lesions; Toxemia; Salivation; Neuralgia; Edema; Other lesions— Method of administration and dosage: The one hundred per cent solution; The minim drop; The time of administration ; Dilution ; The diluent ; Prevention of iodism ; Substitutes for potassium iodid ; Dose ; Duration of treatment ; How to increase the dose — Mixed treatment — The test course . 192-205

Chapter XV

Definition — The streptohacilhis — Frequency — Methods of contagion — Situation and number — Symptoms and course: Incubation ; Onset ; The ulcer — Complications: The mixed sore; Inflammation; Destruction of freedom ; Gangrene and phagedena ; Lymphangitis ; Inguinal adenitis — Diagnosis — Treatment: Abortive ; Palliative ; Prevention of bubo; Treatment of complications . . 206-221

Chapter XVI

The chancre: Synonyms; Description; Pathology; Multiple chancre; Types ; The eroded chancre ; The Hunterian chancre ; The Indurated papule ; Exceptional varieties ; Complications ; Lymphangitis; The mixed sore; Inflammation; Gangrene and Phagedena; Transformation into a mucous papule; Vegetations; Duration; Reinduration ; Diagnosis ; Prognosis ; Treatment — Characteristics of chancre in various locations: Of the male genitals; Urethral; Of the female genitals; Cervical; Extragenital chancre; Buccal; Tegumentary^T/z^ adenitis of chancre: Symptoms; Unusual varieties; Diagnosis; Treatment 222-241

TABLE OF CONTENTS xv

Chapter XVII

Requirements for diagnosis: The test of time — Differential diagnosis: Of genital chancre; Herpes; Scabies; Chancroid; Gumma; Table of differential diagnosis — Differential diagnosis of chancre of the mouth: Of the lip; Within the mouth; Vincent's angina; Chancre of the tongue 242-252

Chapter XVIII

Acute syphilitic toxemia: Hematology; Pathological anatomy; Fever of early syphilis; General debility; Prodromes; Nervous symptoms; Symptoms of local congestion; Of the skin and mucous membrane ; Of the lymph nodes ; Of the bones ; Of the joints and muscles ; Of the brain and meninges ; Of the abdominal viscera; Alopecia — Chronic syphilitic toxemia: The fever of late syphilis ; Arterial and visceral sclerosis ; Amyloid degeneration of , the viscera 253-270

Chapter XIX Syphilis Of The Skin: General Characteristics

General clinical characteristics: Slow and progressive development; Polymorphism; Absence of inflammation; Absence of pain and itching; Peculiar color; Rounded form; The scale; The crust; The ulceration; The scar; General clinical characteristic of secondary and tertiary syphilids— 6^^n^ra/ pathological characteristics: The papule ; The macule ; The tubercle ; The gumma

271-279

Chapter XX

The macular syphilid: Varieties; Duration; Diagnosis; Differential diagnosis — The papular syphilid: Varieties ; Diagnosis ; Differential diagnosis — The vesicular syphilid — The bullous syphilid — The pjustular and crusted syphilids: Herpetiform ; Varicelloid ; Acneiform; Impetiginous; Ecthymatous — The squamous syphilid: Diagnosis — The pigmentary syphilid 280-301 xvi TABLE OF CONTENTS

Chapter XXI Secondary Syphilids Of Special Regions Including Onychia

Moist papules: Erosions and condylomata — Squamous eruptions of the palms and soles— Onychia: Atrophic; Detachment of the nail; Hypertrophic ; Other varieties — Paronychia: Squamous ; Ulcerating; Treatment — Eruptions in the scalp: Pustular or crusted syphilids ; Vegetating syphilid — Eruptions about the face: Corona veneris; Diffuse infiltration; Vegetation .... 302-312

Chapter XXII

The tubercular syphilid: The tubercle; Disseminated eruptions; Grouped eruptions; Diagnosis; Treatment — The ulcerative tubercular syphilid: Phagedena ; Characteristics of the lesion ; Ecth}^- ma; Rupia; Treatment; Other crusted lesions; The tertiary ulcer: Prognosis, Diagnosis, Differential diagnosis, Treatment —Subctitaneous gumma: Single; Confluent; Prognosis; Diagnosis; Differential diagnosis; Treatment .... 313-335

Chapter XXIII

Distribution — Etiology — Classification — The macular syphilid— The erosive or papular syphilid: The erosion ; The eroded papule ; The vegetating papule or condyloma — The ulcerative syphilid: The simple ulcer; The ulcerated papule or condyloma — The squamous syphilid — Diagnosis: 'Erosion and nlcevation inside the mouth; In the female genitals ; On the skin of the genitals and elsewhere ; Condylomata — Treatment: Local treatment — Secondary syphilids of the ear 336-34S

Chapter XXIV

TERTIARY SYPHILIDS OF THE MOUTH, PHARYNX. NOSE.

AND EAR

Occurrence — Influence of tobacco — Relapses: Concurrence of lesions— Lesions of the lips — Lesions of the tongue: Leukoplakia ; Etiology; Characteristics; Diagnosis; Prognosis; Treatment; Diffuse sclerotic glossitis ; Gumma of the tongue ; Differential diagnosis — Lesions of the tonsil: Infiltration; Gumma — Lesions of the pharynx — Lesions of the velum: Prognosis; Treatment — Lesions . of the palate: Treatment — Lesions of the nose: Symptoms; Diagnosis; Treatment; Other rare and obscure conditions; Syphiloma ; Fibroid degeneration ; Atrophic rhinitis — Lesions of the ear: Of the internal ear 349-367

TABLE OF CONTENTS Xvii

Chapter XXV

Etiology: Race; Sex; Age; Treatment; Alcohol; Date of onset — Pathology of brain lesions: Arterial lesions; Meningeal lesions; Secondary changes — Pathology of lesions of the spinal cord: Lymphocytosis of the cerebro-spinal fluid; Early secondary meningitis; Prognosis; Treatment — Symptoms: Prodromes; Onset; Course — Prognosis — Treatment 368-385

Chapter XXVI

Clinical types — Ocular paralyses: Motor oculi; Abducens; Fourth nerve ; Optic neuritis ; Site of lesion ; Prognosis — Hem-iplegia and apoplexy: Onset ; Clinical type ; Prognosis — Aphasia — Deafness: Symptoms : Prognosis ; Treatment — • Facial paralysis — Other form-s of paralysis — Epilepsy: Jacksonian epilepsy — Insanity: Mania; Delusional insanity; Progressive dementia with paralysis ; Dementia without paralysis — Syphilis of the spinal cord: Symptoms ; Meningitis and meningo-myelitis ; Paraplegia ; Syphilitic ataxia with exaggerated reflexes — Parasyphilids — Syphilis of the nerves — Diagnosis: Nerves; Brain and cord . . 386-410

Chapter XXVII

Iritis: Pathology; Symptoms; Complications; Diagnosis; Prognosis; Treatment — Chorio-retinitis and retinitis: Pathology; Symptoms; Varieties; Prognosis; Treatment — Optic neuritis: Pathology; Symptoms; Diagnosis; Treatment — Gumma of the iris; Of the ciliary body; Of the choroid — Conjunctival syphilis — Keratitis and scleritis — Tarsitis — -Dacroadenitis — Orbital lesions . 411-423

Chapter XXVIII Syphilis Of The Bones

Varieties: Occurrence ; Bilateral lesions-, Multiple lesions — Etiology— Pathology: Osteoperiostitis: Gummatous osteoperiostitis; Osteomyelitis — Symptoms of medullary lesions; Of periosteal lesions — Diagnosis: Differential diagnosis — Treatment — Prognosis— Lesions of special bones: Cranial bones; Fingers; Lower jaw; Sternum; Vertebral column . . . • 1 • • 4^4-443 2 xviii TABLE OF CONTENTS

Chapter XXIX

SYPHILIS OF JOINTS, MUSCLES, TENDONS AND APONEUROSES, BURS^ AND TENDON SHEATHS

Syphilis of the joints: Arthralgia ; Hydrarthrosis ; Pseudo-rheumatism ; Tertiary arthritis ; Deforming arthritis ; Syphilis of the muscles: Contracture ; Interstitial myositis ; Gumma ; Myositis ossificans ; — Syphilis of the tendons and aponeuroses — Syphilis of the bursce — Syphilis of the tendon sheaths 444-451

Chapter XXX

Syphilis of the larynx: Secondary lesions; Erythema; Erosion; Papules; Condylomata; Infiltration; Symptoms; Diagnosis; Treatment ; Tertiary lesions ; Ulcerations ; Gumma ; Fibroid degeneration ; Perichondritis ; Paralysis ; Symptoms ; Diagnosis ; Prognosis ; Treatment — Syphilis of the trachea, bronchi and lungs: Tracheal ulceration ; Lesions of hereditary pulmonary syphilis ; Lesions of acquired pulmonary syphilis; Bronchiectasis; Complications, mixed infection with tuberculosis; Symptoms of tracheal and bronchial syphilis ; Symptoms of hereditary pulmonary syphilis ; Symptoms of acquired pulmonary syphilis ; Diagnosis ; Differential diagnosis; Treatment 452-468

Chapter XXXI

Occurrence — Pathology: Hereditary lesions; Secondary lesions; Tertiary lesions; Associated lesions — Symptoms: Neoplastic type ; Cirrhotic type ; Cachectic type ; Febrile type ; Silent type — Diagnosis — Prognosis — Treatment 469-477

Chapter XXXII Syphilis Of The Genital Organs

Syphilis of the testicle: Occurrence; Pathology; Symptoms; Prognosis ; Diagnosis ; Treatment — Chancre redux: Occurrence ; Diagnosis; Treatment 478-483

Chapter XXXIII Syphilis Of The Circulatory And Lymphatic Systems

Syphilis of the heart: Functional derangement; Sclerogummatous myocarditis; Pericarditis and endocarditis; Bradycardia and

TABLE OF CONTENTS xix

Stokes-Adams syndrome — Lesions of the coronary arteries: Angina pectoris — Syphilis of the aorta: Aneurysm; Frequency and date of incidence ; Diagnosis ; Treatment — Syphilis of the *

arteries of the extremities: Aneurysm; Arterial obstruction ; Intermittent claudication; Reynaud's disease; Gangrene — Syphilis of the veins: Acute phlebitis ; Sclerogummatous phlebitis — Syphilis of the lyniphatics: Qvivarad^ oi\h&\yra.-^\).xiO(ie.?, . 484-491

Chapter XXXIV

Syphilis of the digestive organs: Salivary glands ; Pancreas ; Esophagus ; Syphilis of the stomach ; Intestinal syphilis ; Syphilis of the rectum; Gumma; Ulcer; Ano-rectal syphiloma; Stricture — Syphilis of the urinary organs: Syphilis of the kidney ; Nephritis ; Diagnosis ; Treatment ; Sclerogummatous nephritis ; Symptoms ; Diagnosis — Syphilis of the pelvic organs: Of the bladder; Of the prostate and seminal vesicles ; Pelvic cellulitis — Syphilis of the ovaries and uterus 492-503

Chapter XXXV

Occurrence and mortality — Fetal syphilis: Pathology; Symptoms — Infantile syphilis: Inflammation of the nose ; Inflammation of the skin; The lesion; Polymorphism; Regional distribution; Confluence; Pemphigus; Circumscribed maculo-papular syphilid; Diffuse maculo-papular syphilid — Lesions of special regions: Erosions of the lips; Ano-genital lesions; Onychia and paronychia; Lesions of the scalp; Tubercular and gummatous syphilid ; Lesions of mucous membrane ; Aphonia ; Osteochondritis; Periostitis; Dactylitis; Arthritis; Myositis; Lymphadenitis; Orchitis; Inflammation of the liver and spleen; Pneumonia; Lesions of the nervous system; Lesions of the eyes; Lesions of the ear; Mixed infection of the skin; Of the respiratory tract; Sepsis; Tuberculosis; Rachitis — Syphilitic dystrophies . . . . . 504—526

Chapter XXXVI

HEREDITARY SYPHILIS: RELAPSES: LATE LESIONS: DIAGNOSIS: PROGNOSIS: TREATMENT

Relapses in early childhood — Late hereditary syphilis: Diffuse periostitis ; Parenchymatous keratitis ; Treatment — Stigmata of

XX TABLE OP CONTENTS hereditary syphilis: Hutchinson's triad; Dental stigmata; Hutchinson's teeth; Foumier's teeth; Ocular stigmata; Auditorystigmata — Diagnosis of hereditary syphilis: In infancy ; Examination of the family record ; Diagnosis in later years — Prognosis — Treatment in infancy; Local treatment; Treatment of relapses after the second year 527-542

LIST OF PLATES

PLATE

Fig.

I. Fig

Fig.

Fig.

Fig.

Fig.

Fig.

PLATE

II.-

Fig.

I.

, FACING

PAGE

I.— SPIROCHETE 24

— Spirocheta pallida.

— Spirocheta pallida and Spirocheta refringens.

— Spirocheta buccalis.

— Spirocheta buccalis.

— Spirocheta pallida.

■Spirocheta halanitidis.

■Spirocheta halanitidis.

—SPIROCHETE IN TISSUES 28

Macular syphilid. Section of venous capillary, showing distribution of spirochetae and phagocytosis by fibroblasts and leukocytes.

Fig. 2. — Spirochetae in bone marrow in hereditary syphilitic osteochondritis.

PLATE III.— SPIROCHETE IN TISSUES ..... 30 Fig. I. — Hereditary syphilis of liver.

Fig. 2. — Skin affected by hereditary syphilitic pemphigus.

PLATE IV.— EXTRAGENITAL CHANCRE ..... 234 Fig. I. — Chancre of breast.

Fig. 2. — Chancre of tonsil.

PLATE v.— EXTRAGENITAL CHANCRE 238

Fig. I. — Chancre of the lip.

Fig. 2. — Chancres of the tongue.

Fig. 3. — Chancre of the lip.

PLATE VI.— THE ONSET OF SYPHILIS 276

PLATE VII.— PIGMENTARY SYPHILID OF NECK . . 300

PLATE VIII.— TUBERCULAR SYPHILID . . . . .312

PLATE IX.— TERTIARY LESIONS OF THE TONGUE . .352

Fig. I. — Sclerotic glossitis.

Fig. 2. — Superficial sclerotic glossitis.

Fig. 3. — Gumma.

Fig. 4. — Tertiary ulcer.

LIST OF ILLUSTRATIONS IN TEXT

FIG. PAGE

I. — Microphotograph of chancre 48

2. — Microphotograph of symmetrical atrophy of skin with syphihs 49

3. — Microphotograph of tubercular sj^phiUd 50

4. — Strepto-bacillus of Ducrey 206

5. — Strepto-bacillus of Ducrey 207

6. — Chancroids of penis . . . .210

7. — Chancroids of penis 211

8. — Chancroids of vulva .212

9. — Pathology of eroded chancre 223

10. — Pathology of ulcerated chancre . . . . . . .224

II. — Hunterian chancre . 226

12. — Scabies of penis resembling chancre 227

13. — The "mixed sore" . . . 229

14. — Chancre of vulva: papulo-macular syphilid . . . . -236

15. — Herpes progenitalis 244

16. — Syphilitic alopecia . 266

17. — Pathology of syphilitic tubercle 279

18. — Macular syphilid . . . .281

19. — Labial chancre: macular syphiUd 282

20. — I\Iaculo-papular syphilid 283

21. — Back view of same 285

22. — Confluent papular syphilid . . , . . . . .287

23. — Papular syphiUd, marked on neck 288

24. — Papular syphilid on a negro . . . . . . . .289

25. — Acneiform syphilid 294

26. — General papulo-squamous syphilid 297

27. — Confluent papulo-squamous sj^philid 298

28. — Circinate papulo-squamous syphiUd 299

29. — Macular syphilid of palm 304

30. — Squamous syphilid of palm 305

31. — Eczema of palm, resembling syphihs -305

32. — Annular syphilid of soles 306

33. — Sj^philid of sole with thickening of epidermis . . . -307 34. — Confluent tubercular syphilid of nose . . . . . -315

35. — Serpiginous tubercular syphilid 316

36. — Pathology of serpiginous tuberculo-ulcerative syphilid . -317 37. — ^Serpiginous tuberculo-ulcerative syphilid . . . . -318 xxii

LIST OF ILLUSTRATIONS IN TEXT xxiii

FIG. PAGE

38. — Serpiginous tuberculo-ulcerative syphilid , , . . .319 39. — Serpiginous tuberculo-ulcerative syphilid .. , . . .320

40. — Phagedenic ulcers 321

42. — Crusted tertiary ulceration 325

43. — ^Tertiary ulcer 326

44. — Gummatous ulcer: tibial node 329

45. — Ancient gummatous leg ulcers 333

46. — Pathology of condyloma 339

47. — Macular syphilid and condylomata 340

48. — Condylomata 341

49. — Ulcers of soft palate . . . . 360

50. — The same, healed 360

51. — Loss of septum in acquired syphilis 365

52. — Skiagraph of syphilitic osteo-periostitis 427

53. — Skiagraph of syphilitic osteo-periostitis 428

54. — Skiagraph of saber tibia 429

55. — Tibial node 430

56. — Skiagraph of gummata of femur and tibia 432

57.^ — Extensive gummatous destruction of skull 440

58. — Syphilitic dactylitis 441

59. — Syphilitic bursitis 450

60. — Syphilitic pneumonia 463

61. — Gumma of liver . 472

62. — Congenital syphilis . ' . . . 508

63. — Sunken nose (en lorgnette) 511

64. — Sunken nose 511

65. — Maculo-papular (hereditary) syphilid 515

66. — Syphilitic osteo-chondritis (skiagraph) 519

67. — Saber tibia 530

68. — Hutchinson's teeth 535

69. — Irregular and decayed teeth, due to but not characteristic of

syphiHs • • • 535

CASES CITED

Extragenital infection: syphilis insontium (I) . . ... 4 Extragenital infection : syphilis insontium : hereditary syphilis : prolonged syphilis (II) 4

Severe toxemia in female : tuberculosis (III) . . . . . . ig

Alcoholism: malignant early syphilis (IV) 19

Malignant early syphilis : carcinoma (V) 19

Malignant early syphilis in a healthy woman : destruction of velum,

gumma of tongue, necrosis of mandible (VI) .... 20 Malignant early syphilis: hemiplegia, death (VII) .... 20 Illustrating the general nature of syphilitic relapses: twelve years

of health; then neuralgia, gummatous periostitis (VIII) . . 39 Companion case: four years' interval; then gumma of nasal septum, gumma of parietal bone, laryngeal syphilis, chancre redux, cerebral syphilis (IX) 40

Alleged second attack of syphilis (Lang) (X)

Alleged second attack of syphilis (Koebner) (XI)

Cases of extragenital infection (Foumier)

Cases of exposure to syphilis without infection .

The fate of eleven men exposed to syphilis, gonorrhea, and chancroid

(Connors) 60

Squamous syphilid during the sixth and the twenty-fifth year (XII) 88

Secondary syphilid of tongue in the twenty-third year (XIII) . . 89

Pustular syphilid in the thirtieth year (XIV) 89

Relapsing erosive lesions of tongue for twenty years (XV) . . 90

Squamous syphilid and suppurative onychia in the twenty-fifth year

Infection of wife after nine years of syphilis and four years of marriage

(Spillman) (XVII) 94

Interval of forty years ; then tertiary lesions of larynx, nose, tibia, and

frontal bone (XVIII) ■ . . 98

Interval of twenty years; then tertiary lesions of tibia, ulna, thigh,

skin, calf, and skull (XIX) 99

Relapses of secondary lesions for twenty years and of tertiary lesions (chancre redux, tongue gumma, tubercular syphilid, interstitial glossitis, syphiloma of intestine) from the fourth to the twenty-fourth years (XX) 100

Lost palate in the eighth year; interval of twenty-eight j'^ears; then

tuberculo-ulcerative syphilid (XXI) 10 1

XXVI CASES CITED

PAGE

Syphilis and epithelioma; illustrating the difficulty of diagnosis

Syphilophobia (XXIII) 114

Syphilophobia (XXIV) . . .115

Chancre not followed by secondary symptoms; gumma of pharynx

and nasal septum after six years (XXV) 116

Cases of excessive alcoholism with and without relapse of syphilis . 130 Case of excessive smoking without relapse of mouth lesions . . 131 Case illustrating the method of treating an obstinate lesion . .160

Note on the treatment of Cases IV and V 178

Case illustrating the virtue of insoluble injections . . . .183

Syphilis untreated three years; marriage, healthy child, ulcers, iodid three years, great debility and lesions only partly controlled, mercury, marked improvement, iodid resumed, cure (XXVI) . 202 Phagedenic chancre of lip (XXVII) ... .... 231

Probable Vincent's angina mistaken for chancre (XXVIII) . . 250 Probable Vincent's angina mistaken for chancre (XXIX) . .250

Vincent's angina in husband and wife mistaken for chancre (XXX) 250 Example of the blood changes in early syphilis, and the effect of

treatment upon them . . . . . . . . .256

Toxemia due to the lesions of late syphilis (XXXI) . . . .268

Early syphilis treated briefly; interval of twelve years, then headache, sciatica, and lesions of cranium, clavicles, tibiae, and rib, brief treatment. Five years later brief left hemiplegia ; two months later right monoplegia, relapsing a month later; treatment six months, six months later left hemiplegia (XXXII) . . . 391 Early syphilis treated briefly ; after three years left hemiplegia and aphasia followed by ulcers and periostitis of femur; irregular treatment and relapses of ulcers and aphasia. In seventh year coma followed by mania, almost cured, relapse two months later of coma and mania with right hemiplegia, then epileptiform

seizures and death in six weeks (XXXIII) 392

Extragenital chancre ; prolonged secondaries and treatment, headache at three months, left hemiplegia within a year, ocular paralyses; at three years coma, spontaneous recovery, healthy child ; at eleven years node on clavicle ; at thirty years left hemiplegia, spontaneous recovery . 400

Case of syphilitic arthralgia (XXXIV) 444

Death from inhalation of detached arytenoid cartilage (Labbe) . 457 Hepatic syphilis eluding diagnosis by exploration (Cumston) (XXXV) 475

Syphilitic testicle resembling tuberculosis 480

Instances of functional tachycardia occurring during syphilis . .485 Cases illustrating the differential diagnosis of gummatous adenitis . 490 Nephrectomy for sclero-gummatous kidney (Israel) (XXXVI) . 500

Nephrectomy for sclero-gummatous kidney (Israel) (XXXVII) . 500 Diffuse pelvic cellulitis due to hereditary syphilis (Foumier)

(XXXVIII) .- 502

STATISTICS AND STATISTICAL TABLES

PAGE

Age at onset of syphilis 58

Aneurysm, date of occurrence of (Etienne) 488

proportion of syphilitic (Etienne) 487

rarity of 487

Ano-rectal syphiloma, rarity of . 494

Aphasia, frequency of and lesions with which associated . . -395

Appendicitis, association of with syphilis (Gaucher) 494