Outlines of the pathology and treatment of syphilis and allied venereal diseases

Front matter

Shelf ..Z.4l

UNITED STATES OF AMERICA.

f

Preface To The American Edition

A treatise on Syphilis by one who has devoted his entire life to the study of this disease, and whose experience is the result of observation and treatment of upward of thirty thousand patients in private practice and in the wards of the Allgenieine Krankenhaus of Vienna, needs little additional testimony to attest its value. As a clinical observer of venereal diseases, and as a teacher, Professor von Zeissl stood deservedly high in Europe. The concise and graphic description of the various forms of venereal affections, the accurate delineations of the different phenomena of the pathological lesions, the terse and detailed account of the symptomatology and characteristic manifestations of the various phases presented by the different specific diseases, the conscientious records of results obtained, bear evidence of the scientific thoroughness with which the investigations were pursued, and therefore must serve as a valuable guide to those desiring to study them. The prominence given to pathology in this work indicates the value placed upon it by the author as a means to the proper understanding of the diagnosis and treatment of the various venereal affections ; and if it can not be said that the work contains an abundance of remedies and formulae for the treatment of the different phases of the different diseases, iv PREFACE TO TEE AMERICAN EDITION.

neither on the other hand is it overladen with polypharmaceutical combinations.

The few notes and prescriptions added by the translator will not, he hopes, be deemed superfluous.

H. Eaphael.

New York, May, 1886.

Preface To The Second Edition

The first edition of this book was composed for the purpose of placing in the hands of the student a brief guide to aid him in the study of Syphilis. Having been requested by my father to revise the second edition, it occurred to me that the reader would be pleased with it still more if, by making it as brief as possible, it should be as graphic and perfect in the description of the morbid picture of venereal diseases as possible. I sought to diminish the size of the book by omitting certain special subjects, giving greater prominence to clinical descriptions. Some chapters, which are only theoretically important, or methods of treatment that are only of historical interest, have been briefly sketched. The syphilitic affections of the skin were taken entirely unaltered from the former edition, while the chapters on therapeutics of gonorrhoea, of epididymitis, of strictures, of chancres and syphilis, as also the chapter on visceral syphilis and hereditary syphilis, have been almost entirely rewritten. Here and there parts of the fourth edition of the " Lehrbuch fur Syphilis," issued by my father and myself, were used. Professor von Schrotter aud Professor Mauthner were so kind as to write the articles on syphilitic affections of the larynx, trachea, and eye. I am fully aware that the book offers little that is new, but it is not intended that it should spread any new doctrines ; it claims vi PREFACE TO THE SECOND EDITION.

only the modest task of presenting a comprehensible picture of venereal diseases and their treatment as briefly as possible to the practical physician, whom time will not permit to read extensive works upon every special branch of our science.

It only remains for me to express the hope that this book will receive the same friendly judgment as the first edition, and that I shall succeed in concisely reporting my father's ideas, and at least preserve what he created. For the words of our great poet find their application in science too :

Von Zeissl.

Vienna, March, I884.

Contents

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Introduction 1

Section I. Gonorrhoea (tripper) Venereal Catarrh

Site of Gonorrhoeal Affection and Mechanism of Gonorrheal Infection . .17

Factors that usually favor Gonorrhoeal Infection 18

Gonorrhoea of the Male Urethra 19

Pathological Alterations in the Male Urethral Canal produced by the Gonorrhoeal Disease 25

Morbid Phenomena which occur as Co-effects and Sequela? of Urethral Gonorrhoea in Men 29

Prognosis of Gonorrhoea in the Male 30

Prophylaxis against Gonorrhoea, and Treatment of Acute and Chronic Gonorrhoea in Men 31

The Indirect or Internal Treatment of Gonorrhoea of the Male Urethra . . 42 Catarrh of the Glans Penis and Prepuce, Balanitis, Balano-Blenorrhcea, Bala-

nopyorrhoea, Balanopostheitis 46

Phimosis and Paraphimosis 47

Differential Diagnosis and Treatment of Catarrh of the Glans Penis and of the

Resulting Inflammatory Phimosis and Paraphimosis . . . .48 Affections of the Lymphatic Vessels and Glands in consequence of Gonorrhoea . . . .51

Inflammation of the Vasa Deferentia and the Epididymis . . . .52 Treatment of Inflammation of the Spermatic Cord and Epididymis . . .56

Chrome Hydrocele. Hernia Aquosa 58

Inflammation of Cowper's Glands 60

Morbid Alterations that are produced in the Prostate by Gonorrhoea of the

Urethra 61

Inflammation of the Seminal Vesicles in consequence of Urethral Gonorrhoea 66

Functional Disease of the Seminal Vesicle and of the Testicle. — Spermatorrhoea, Seminal Emissions, Pollutio Diurna 67 viii CONTENTS.

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Diseases of the Bladder caused by Urethral Gonorrhoea . . . .69 Diseases of the Kidney that are produced by Urethral Gonorrhoea . . 74 Gonorrhoea of the Female 78

1. Gonorrhoea of the Yulva. . . ■ . . . . . .78

2. Gonorrhoea of the Vagina 80

3. Complications of Vulvo-vaginal Gonorrhoea 83

(a) Diseases of the Glands of Bartolini and their Ducts . . .83 (6) Inflammation and Abscess of the Lymphatic Vessels in the Labia Majora and Minora, and of the Lymphatic Glands of the Inguinal Folds 85

4. Urethral Gonorrhoea in the Female 88

Gonorrhoea of the Rectum 89

Gonorrhoea of the Mouth and Nasal Cavities 90

Gonorrhoea of the Eye (Ophthalmia Gonorrhoica Blenorrhoica) . . .90

Treatment of Gonorrhoeal Ophthalmia 92

The Effects or Sequelae of Gonorrhoea in general and of Urethral Gonorrhoea

in particular 93

Gonorrhoeal Rheumatism 94

Condylomata ; Vegetations ; Spitze or Moist Warts 97

Stricture of Urethra 101

Section II. Soft Chancre Or Chancroid

Action of Chancrous Virus and Development of the Soft Chancre . . .109

Pathology of the Soft Chancre 110

Course, Duration, and Cicatrization of the Soft Chancre .... 112

Varieties of Soft Chancre 113

Site of the Soft Chancre 115

Differential Diagnosis of the Soft Chancre . . . . . . .118

Prognosis and Treatment of the Soft Chancre 121

Prophylactic Treatment 122

Abortive Treatment ..... . . . . . 122

Curative or Methodical Treatment 123

Diseases of the Lymphatic Vessels and Glands (Lymphangioitis and Adenitis)

in consequence of Soft Chancres 128

Buboes originating as a Result of Soft Chancres 132

Site, Shape, and Size of Chancroid Buboes 135

Differential Diagnosis and Prognosis of Buboes 137

Treatment of Diseases of Lymphatic Vessels produced by Chancroids . .139

The Treatment of Open Buboes . 141

Fistulae in consequence of Suppurating Buboes . 142

Section III. Syphilis

General Conception 145

Nature and Vehicle of the Syphilitic Virus 145

CONTENTS. ix

PAGE

The Transmissibility of Syphilis, or the Various Ways in which Syphilitic Infection may take place 146

Transmission of Syphilis by Vaccination. — The Relation of Vaccine Lymph

to Syphilitic Virus 147

Transmissibility of Syphilis to Warm-blooded Animals .... 149

First Manifestation of the Action of the Syphilitic Virus .... 149

Anatomy of the Syphilitic Initial Sclerosis 151

Site and Form of the Huntcrian Induration 153

Combined Effects of the Syphilitic Virus and of the Chancroid Virus . .155

Inoculability of the Sclerotic Ulcer 156

Significance, Duration, Course, and Differential Diagnosis of the Syphilitic

Initial Sclerosis [Hard Chancre] 156

Unicity of the Syphilitic Infection 158

Affections of the Lymphatic System occasioned by Beginning Syphilis . .159 Induration and Hypertrophy of the Peripheral Lymphatic Vessels in consequence of Syphilitic Infection . 165

The Syphilitic Diathesis 166

Pathological Alteration of the Blood of Syphilitic Persons . . . .167

Eruptive Fever of Syphilis 168

Time of Eruption of General Syphilis 169

Localization of the Syphilitic Foci 169

The Cachexia produced by Syphilis 170

Combination of Syphilis 170

Succession and Phases of Syphilitic Affections 171

Development, Course, and Duration of Constitutional Syphilis . . .172

Mortality of Constitutional Syphilis 172

Development of Lymphatic Glandular Swellings originating in the Course of

Syphilis (Multiple Adenitis) 174

Morbid Lesions of the Skin caused by Syphilis (Syphilitic Diseases of the

Skin— Syphilides) 175

Definition and Classification of Syphilitic Skin-Diseases . . . .180

1. The Erythema Syphilide, Erythema Syphiliticum Maculosum et Papu-

latum, Roseola Syphilitica, Syphilitic Spots 180

2. Papular Syphilides 186

(a) Lenticular, Papular Syphilide 188

(b) Small Papular Syphilide (Syphilis Papulosa Miliaris) . .189

(c) The Papular Syphilide, or Squamous Syphilide of the Palms of the

Bands and Soles of the Feet (Psoriasis Palmaris et Plantaris), and Syphilitic Diffused Affection of the Epidermal Strata of the Hands and Feet (Syphilis Cornea) 192

(d) The Humid or Moist Papules, or Flat Condylomata ; Papules Humides ; Pustula Fcetida Ani ; Pustules, Plates, etc., of Various Authors . . . 196

3. Pustular Syphilide 201

(a) The Acne-like Syphilide 202

(b) Varicella-like Syphilide, or Varicella Syphilitica . . . 204

(c) Impetigo Syphilitica . 206 x CONTENTS.

PAGE

(d) Ecthyma Syphiliticum ... ... . 209

(e) Rupia Syphilitica 211

4. Nodular Syphilide of the Skin ; Tubera Syphilitica ; Tubercula Syphilitica ; Syphilitic Nodes of the Cutis and of the Subcutaneous Cellular Tissue (Gummata) ; Syphiloma, according to Wagner . . .213

The So-called Pigment Syphilis 222

Syphilitic Affections of the Hair 222

Syphilitic Disease of the Nails 223

Syphilitic Affections of the Mucous Membrane 226

(1) Syphilitic Erythema of the Mucous Membrane ; Syphilitic Catarrhal

Inflammation ; Erythema Syphiliticum Membranse Mucosae . . 226

(2) Syphilitic Papules on the Mucous Membrane 22*7

(3) The Syphilitic Node or Gumma of the Mucous Membrane . . 231

Syphilis of the Mouth and Fauces 233

Syphilitic Disease of the Tongue 238

Syphilitic Disease of the (Esophagus . . 244

Syphilitic Disease of the Stomach and Intestines 245

Syphilitic Affections of the Liver 247

Syphilitic Affection of the Spleen 250

Syphilitic Affection of the -Pancreas and of the Salivary Glands . . .250

Syphilitic Affections of the Larynx and Trachea 251

Syphilitic Acute and Chronic Catarrh 252

" Papules 253

" Infiltrations, Gummata 254

" Ulcers 256

" Perichondritis . . 261

" Cicatrices 261

" New Growths 263

Syphilitic Affections of the Bronchi and Lungs 263

Syphilitic Affection of the Kidney, Suprarenal Capsule, and Bladder . .265 Syphilitic Affections of the Testicle and Spermatic Cord . . . . 265 Syphilitic Affections of the Ovaries, Fallopian Tubes, and Uterus . . .270 Syphilitic Affections of the Mucous Membrane of the Genital Organs of Both

Syphilitic Affections of the Corpora Cavernosa Penis 272

Syphilitic Affections of the Breasts . . 273

Syphilis of the Heart and Blood-Yessels 273

Affections of the Brain, Spinal Cord, and Peripheral Nerves, as a Result of

Syphilitic Affections of the Nose 280

Syphilitic Affections of the Auditory Passages . . . . . 284

Syphilitic Affections of the Eye 285

Iritis Syphilitica 285

Affections of the Ciliary Body, the Choroid, and Yitreous Humor . . 290

Inflammation of the Retina and Optic Nerve 292

Affections of the Cornea, Conjunctiva, and of the Eyelids . . . 293 Affections of the Orbits, Lachrymal Sac, and of the Muscles . . . 294

CONTENTS. xi

PAGE

Syphilitic Affection of the Bones and their Envelopes 295

Syphilitic Inflammation of the Periosteum ; Periostitis Syphilitica . .297

Ostitis Syphilitica 300

Cicatrization of Syphilitic Ulcers of the Bones 302

Site and Effects of Periostitis and Ostitis 303

Differential Diagnosis of Affections of the Bones produced by Syphilis . . 304

Syphilitic Affections of the Joints 305

Syphilitic Affections of the Cartilages 307

Syphilitic Affections of the Muscles, Tendons, and Sheaths of Tendons 303

Syphilitic Affection of the Bursa? 310

Endemic Syphilis ; Leproid or Syphiloid Disease 311

Malignant or Galloping Syphilis 312

Hereditary Syphilis 315

Manifestations of Congenital Syphilis 319

Macular Syphilide in the Infant ; Erythema Maculo-papulatum Syphiliticum

Neonatorum 320

Papular Syphilide in the Infant 321

Pustular, Gumroous, and Hemorrhagic Syphilide in the Infant . . . 322

Syphilitic Affections of the Mucous Membrane in the Infant . . . . 325

Syphilitic Affections of the Bones and their Envelopes 326

Affections of the Eye in consequence of Hereditary Syphilis . . . 328 Morbid Alterations of the Internal Organs resulting from Hereditary

Diagnosis and Prognosis of Congenital Syphilis 333

Syphilis Hereditaria Tarda . . . 334

Treatment of Syphilis 334

Prophylaxis of Syphilis 337

Treatment of the Initial Lesions of Syphilis ; the Hunterian Indurated Chancre ; the Indolent, Multiple, and Strumous Buboes .... 340

Treatment of Secondary Phenomena of Syphilis 342

(A.) Expectant Method 342

Therapeutical Application of Iodine and Iodine-Salts against Syphilis . . 345

(B.) Medical Treatment 345

The Treatment of Syphilis by Vegetable Remedies ..... 350

Therapeutic Use of Mercury 352

Mercurial Preparations which are best adapted to be introduced into the Blood

through the Digestive Organs 353

External Application of Mercury and its Preparations 358

(a) Mercurial Inunction Treatment 358

(6) Hypodermic Mercurial Treatment of Syphilis 371

(c) Treatment of Syphilis by Mercurial Fumigations .... 374

(d) Treatment of Syphilis with Baths containing Mercury . . . 375

(e) Treatment of Syphilis by the Application of Mercurial Suppositories

to the Mucous Membrane of the Rectum 376

Pathogenetic Effects which Mercury and its Preparations may produce during

Treatment ... 376 xii CONTENTS.

Effects of Cold- Water Treatment, Sea-Baths, and Sulphur Thermal Baths on

Syphilis and on Hydrargyrosis 380

Syphilophobia and Mercuriophobia on Hypochondria Mercurialis . . ,381

Syphilization 382

Treatment of some of the Local Syphilitic Affections 383

The Nursing of the Syphilitic Child and the Treatment of Congenital

INTEODTJCTIOK

Infectious discliarges from the genital organs of both sexes, and ulcerations on those parts, must have been known in olden times, even in the remotest antiquity. There is an allusion to an " unclean seminal discharge " in the third book of Moses (Leviticus, chap, xv), and the sanitary regulations prescribed by Moses himself indicate conclusively the actual infectious nature of such seminal discharges. It is likewise seen, from the writings of the old Greek and Roman physicians, that they treated ulcers of the genital organs which were caused by contagion.

At the end of the fifteenth century many persons were attacked, as in an epidemic, with morbid phenomena, especially diseases of the skin, whose origin the physicians' of those times regarded as being due partially to telluric and partially to astral causes. These affections were supposed to originate in a general deterioration of the cardinal secretions of the body and the liver as being the fountain of the disease. JSTot until it became apparent that these diseases prevailed among the troops of Charles YIII, which occupied Naples in 1495, and occurred especially among those women with whom they had sexual intercourse, did many physicians become convincd that the diseases in question originated by transportation from one person to another — this transportation or infection occurring especially during sexual congress, and starting with an affection of the genital organs. These circumstances led Fernelius and Bethencourt to call this disease venereal, or the veneria, and also "lues venerea." For the same reason it was also called mentulagra (from mentula, penis), when it attacked men, and pudendagra when it attacked women. At the time when it prevailed as a pest it received various names, based 1 mainly upon geographical grounds. The French called it " mal de Naples " and " la grosse verole " ; the Spaniards, " las bubas" (pocks). The Germans and Italians called it "mal de France " ; the Poles, the " Dutch disease " ; the Dutch and English, the "Spanish"; the Orientals, the "French"; the Portuguese, the " Castilian " ; the Persians, the " Turkish " ; and the Chinese, the "disease of Kanton" (Kouang tong Tschouang). But all these designations were supplanted by the name of syphilis, which has been universally adopted. This term was first applied to the disease by Hieronymus Fracastorius, deriving it from a shepherd by the name of " Syphilus," whom he apostrophizes in an ode, as the first to suffer from -this disease because he had offended the gods. Others derive the name syphilis from the Greek word cncfrXos, broken ; others, again, from the words en;? and <j>i\ia.

The infectious discharges from the genital organs are called in males, "gonorrhoea" — fluxus sive profluvium seminis, from r) yovrj, semen, and pelv, to flow ; in females, " fluor " ; in German, " Tripper." The terms blennorrhosa and blennorrhagia mucifluxus, from to fiXevvos, or rj fiXevvoa, mucus, and pelv, or prjyvovcu, were first used by Swediaur.

We are indebted for the designation of the word " chancre," as applied to a sore on the genital organs originating from sexual intercourse, to the French, who substituted the word chancre for cancer, which Celsus had selected to designate this disease. With the word cancer Celsus wished to describe the spreading, corroding, malignant character of the ulcer. The physicians of the thirteenth and fourteenth centuries selected the words "caries," "caroli," or "taroli pudendum," to designate such malignant contagious ulcers.

THE VENEKEAL CONTAGIONS.

Fernelius was one of the first to properly comprehend the connection between diseases of the genital parts and syphilis. He suggested the hypothesis of the existence of an animal poison which he called the venereal poison. This virus, Fernelius believed, developed not only in the purulent secretion of certain ulcers of the skin and mucous membrane that originate during sexual intercourse, but also in the muco-purulent discharge of the inflamed or catarrhal affected mucous membrane of both sexes. From these two affections of the genital organs, Fernelius contended that the venereal virus passes into the secretions of the body and then attacks sometimes one organ and then again another. He was therefore of the opinion that syphilis, until then such a mysterious disease, resulted from well-known affections of the mucous membranes and of the skin covering the sexual organs, which we to-day designate as chancre and gonorrhoea (clap).

The opinion that gonorrhoea and chancre were the commencement of syphilis prevailed till the second half of the eighteenth century. In the year 1767 Balfour, an English surgeon, positively asserted that gonorrhoea and syphilis were essentially distinct diseases. Balfour's assertions, however, were stoutly opposed by John Hunter, who, in 1767, first instituted comparisons between the two diseases by performing inoculations with the secretions of venereal catarrhal affections of the mucous membranes and of venereal ulcers of the skin. Hunter inoculated the penis and prepuce (whose is not stated) with pus which he derived from the urethra of a patient presumably affected with gonorrhoea. As ulcers developed from these inoculations, upon which induration of the lymphatic glands of the right groin soon supervened, and a few months later ulcers of the tonsils and a roseola eruption became superadded, which symptoms of constitutional syphilis were promptly cured by mercury, Hunter deemed the identity of gonorrhoea and chancre as complete, and consequently also of the contagion of gonorrhoea and syphilis as conclusive. The difference in the form of the manifestations of this contagion he believed to be due only to the differences in the anatomical structures upon which the lesion was produced. Upon the secreting mucous membrane the poison in question produces a catarrhal, upon the general cutaneous covering an ulcerative, process.

The first one to oppose Hunter in this matter was Benjamin Bell, of Edinburgh. He adduced the following facts : Two young persons scarified the skin of their glans penis and prepuce with a lancet, and allowed bits of charpie dipped in gonorrhoeal matter to remain in contact with the scarifications for forty-eight hours. In one of the young men a balano-blennorrhcea ensued ; in the other, some of the dripping pus gained an entrance into the urethra, in consequence of which a catarrhal disease developed in two days in this canal. On the other hand, one of the experimenters, by carrying the pus of a venereal ulcer of the skin of the genital organs upon a probe several millimetres deep into the urethral canal produced a painful ulcer at tins place, which was followed by a suppurating bubo. Notwithstanding this and many other similar experiments, the virus of gonorrhoeal with chancre contagion was supposed to be identical till the thirtieth year of the present century, when Ricord first took sides in the matter. By the aid of Recamier's vaginal speculum, which was used very little by his predecessors and contemporaries, Ricord disproved Hunter's views, by the fact that venereal ulcers may exist upon the mucous membrane of the vagina and of the neck of the uterus, and consequently the vaginal discharge may be tainted with that of the chancre. From 1831 to 1837 he performed 667 more inoculations with gonorrhoeal matter, and from none of these did any chancre-ulcers result. Finally, Ricord proved that not infrequently the matter that exudes from the urethra is due to a chancre-ulcer situated in that canal, which upon inoculation produces a pustule from which a chancre will develop.

With these and other experimental researches all apparent contradictions were explained, and the independence of the gonorrheal contagium was incontestably proved in every way, both as regards its indirect as well as its direct effect.

With the progress of science and more carefully observed clinical facts it soon became manifest that not all chancres were followed by syphilitic lesions. Hunter, who, although he looked upon gonorrhoea and ulcers on the genitals arising from sexual contact as the effects of one and the same poison, nevertheless maintained that not all the ulcers on the genital organs are of syphilitic nature. He only designated such ulcers on the genital organs chancre that were followed by syphilis. According to Hunter, the chancre was distinguished from all other sores on the sexual organs by a dense, hard, sclerotic base and by elevated indurated borders (Hunterian induration). All otherwise constituted non-indurated ulcers on the genitals were, in his opinion, not chancres ; they were simple, ordinary, non-infectious ulcers or secondary syphilitic sores. These secondary syphilitic sores were said to be distinguished from the primary sores by the fact that they were not callous, did not spread rapidly, produced no adenitis, were not auto-inoculable, and healed rapidly. At first, Ricord made no distinction between the indurated and non -indurated ulcers, calling them both ulcerating chancres, and deeming both to be the effects of one and the same virus. He called the virus " chancre-poison or primary syphilitic poison," which in some cases — not, however, in all — is followed by syphilis, and which, according to the grade and phase of development, he embraced in the category of secondary and tertiary affections. Gradually, however, he approached the position held by Hunter, in so far as to admit that only that chancre which was situated upon a hard base, or left behind it a hard cicatrix, was capable of producing general syphilis, and such chancres he therefore called " infecting chancres." The induration thus established was looked upon as a criterion of commencing blood-poisoning. The reason why induration resulted in one case and not in another, he maintained, was not due to the difference in the character of the virus, but partly to its more or less weakened power to infect (virulescence) and partly to the difference of

6 PATHOLOGY AFD TREATMENT OF SYPHILIS.

tissue upon which it was implanted. He regarded the Hunterian or the infecting chancre merely as a variety of chancre-infection, and which is additionally distinguished from the other varieties by the fact that it occurs but once upon one and the same individual during his whole life. Finally, Ricord, like Hunter, held that the primary sore was the sole fountain of syphilis and denied the ability of secondary manifestations to transmit the disease from one person to another.

This theory of Ricord, which has been called the unity or identity theory, was soon shaken by experience, which conflicted with it. It was repeatedly observed that a person had simultaneously a soft and an indurated chancre near each other, that many persons had multiple contagious soft chancres, without being affected subsequently by syphilis, while in another person a single hard ulcer was followed by constitutional manifestations. Lastly, numerous confrontations of infected and infecting patients showed that the indurated ulcer was always produced by similar or secondary syphilitic ulcers of the person infecting, while a soft chancre, attended only by local symptoms, propagated through contact only a local sore which was soft in character. All these circumstances led one of Ricord's scholars, Leon Bassereau, in 1852, to establish the proposition that the soft chancre was not a source of syphilis. In conjunction with Clerc, another pupil of Ricord, he propounded a new theory, namely, the duality theory, by which he maintained the existence of two essentially different chancrepoisons — the soft and the indurated — both of which are indebted to two totally different contagions for their origin. The soft-chancre sore, he maintained, was always a local disease, and was only capable of acting perniciously upon the general system by causing suppuration in the adjacent lymphatic glands. But the hard chancre always led to blood-poisoning and constitutional symptoms. Though, to be sure, it likewise causes swelling of the adjacent lymphatic glands, they never or very seldom pass on to suppuration, and the pus they contain can not by propagation produce a chancre. This new theory of Bassereau and Clerc was soon adopted by Ricord and Fournier, and formulated in the law that each variety of chancre was only capable of propagating its own kind.

The soft chancre or chancroid may be produced by inoculation upon sound as well as upon syphilitically diseased tissues ; the hard chancre can only be reproduced by inoculation upon healthy tissues, and never upon any that is already syphilitic.

Clerc, it is true, succeeded, by inoculations with matter from a hard chancre, in producing ulcers, which he designated by the name of " chancroide," and which he believed to be of a similar nature as the soft chancre. He therefore maintained that the soft chancre was a bastard product produced by inoculating a syphilitic person with an infecting chancre, which, if it were once developed, was capable of propagating itself in an endless series, without ever assuming the primitive character of an infecting chancre.

In Ricord's " Lecons sur le chancre " cases were, however, reported which were supposed to prove that Clerc's chancroids were capable of reproducing the infecting chancre and the infecting chancre a soft chancre, even upon an individual who is not syphilitic. In order to save the dualism theory that was now apparently tottering, Rollet, of Lyons, suggested the hypothesis that both poisons can be transmitted simultaneously, and the result of this transmission is a " mixed " chancre (chancre mulet), whose auto-inoculation upon the same or upon a syphilitic person would produce positive results. "While the French physicians continued to entangle themselves by one-sided views of the forms of the sores in a labyrinth of contradictions and names, other investigators deeming the contagions that formed the basis of the ulcers to be of prime importance, and supported by experiments as well as by exact clinical observations, were soon able to throw new light upon the action of the soft chancre and of syphilis. The results of the researches instituted by Wallace, Waller, Heinecker, Lindemann, Daniellsen, Yon Barensprung, Hubbener, Lindwurm, Hebra and Kosner, Pelizzari, H. Zeissl, and many others, together with our own clinical experience, enable us to lay down the following principles :

1. The poisons of the soft chancre and of syphilis are totally different from each other. They have only in common the external quality that both of them are most frequently contracted during sexual congress ; hence soft chancres, like primary syphilitic lesions, are more often found upon the genital organs of both sexes.

2. The pus and tissue detritus, disorganized by the chancreinfection, are the vehicles by which the poison of the chancre is conveyed. The virus of syphilis is united especially with the disorganized detritus of the syphilitic inflammatory product, and also with the blood, and probably with the semen of syphilitic persons. The experimental inoculations performed with the blood of syphilitic patients produced positive results in some though not in all cases. Why all syphilitic parents do not beget syphilitic children is still unexplained.

3. Pus from an abscess or the contents of a non-syphilitic eruption on a syphilitic person, when transmitted to a healthy individual, have not hitherto, in our experiments, produced syphilis.

4. The poison of a soft chancre reproduces itself, if transmitted upon a syphilitic person, in the same manner as in a healthy one. The discharges from a soft chancre situated upon a syphilitic individual will always produce a soft chancre only.

5. If the secretions of a suppurating specific primary lesion are inoculated upon its possessor or upon another syphilitic person, there results upon some of the luetic (syphilitic) patients so inoculated an ulcer ; but this ulcer need not necessarily be a primary specific ulcer, because a person who is already luetic can not while he is still syphilitic again acquire syphilis. We maintain the correctness of the proposition that a primary syphilitic lesion, as such, can not be reproduced upon its possessor.

6. The minimum quantity of blood-particles which is apt to be present in a chancre of a syphilitic person is not capable of producing syphilis. But if syphilitic inflammatory products, such as papules or nodules, are made to undergo suppuration and disorganization by implanting upon them chancroid virus, a pustule may be produced, and if this detritus be then inoculated upon a non-syphilitic person, an initial syphilitic primary sclerosis or hard chancre will develop.

7. Little as the purulent sputum of a syphilitic person when transmitted to a healthy person can produce in the latter syphilis, so little will the pus of an abscess or the contents of a non-specific eruption from a syphilitic patient produce syphilis upon a healthy individual. Only the pus or the structural debris of the products especially belonging to syphilis is capable under favorable circumstances of producing syphilis. The supposition of the existence of a mixed chancre, in the sense advocated by the Lyons school, we have discarded long ago. To be sure, we have to admit that the secretion of a soft chancre, if implanted upon a syphilitic eruption, will exercise its destructive action in the same way as upon perfectly healthy tissues; but if the disorganization of the syphilitic eruption through the chancrous virus has once been established, the resulting ulcer will then have nothing in common with the soft chancre. Now, if the pus of an inflammatory syphilitic product — for instance, a syphilitic papule brought to the stage of suppuration by irritating it with the secretion of a soft chancre — is implanted upon a healthy person, syphilis will be produced ; while the same soft chancre if inoculated upon a syphilitic individual at any place that is unaffected by syphilitic inflammatory product will occasion a soft chancre only ; and this, again, if inoculated upon a healthy person, will give rise to a soft chancre only, and produce no syphilis.