4572 A MANUAL OF AND THp: SYPHILIS VENEREAL DISEASE^ BY JAMES NEVINS HYDE, A.M., M. D. PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE; DERMA- TOLOGIST TO THE PRESBYTERIAN, MICHAEL REESE, AND AUGUSTANA HOSPITALS; AND CONSULTING PHYSICIAN TO THE HOSPITAL FOR WOMEN AND CHILDREN, CHICAGO; AND FRANK H. MONTGOMERY, M. D. LECTURER ON DERMATOLOGY AND GENITO-URINAKY DISEASES. AND CHIEF ASSISTANT TO THE CLINIC FOR SKIN AND VENEREAL DISEASES, RUSH MEDICAL college; ATTENDING PHYSICIAN FOR SKIN AND VENEREAL DISEASES, ST. ELIZABETH HOSPITAL, CHICAGO. WITH 44 ILLUSTRATIONS IN THE TEXT AND 8 FULL-PAGE PLATES IN COLORS AND TINTS. PHILADELPHIA W. B. SAUNDERS 925 Walnut Street 1896. ^^)fi^JjiJj)jj Copyright, 1895, by W. E . SAUNDERS, ELECTROTYPEO BY PRESS OF WESTCOTT & THOMSON. PHILADA. W. B. SAUNDERS. PHILADA. Uwedicul Una I4-0 PREFACE. This Manual has been prepared with the intent of meeting the special needs of the student and of the practitioner rather than of the expert. The aim has been to supply in a compendious form, and with detail, all practical facts connected with the study and the treatment of syphilis and the venereal diseases. Care has been taken to avoid all points in controversy and to exclude the data which are to be sought for in the more '^ voluminous treatises on these subjects. The authors are glad to express their special obliga- tions to the classical works of Fournier, Jullien, and Mauriac ; to Keyes' exceedingly practical treatise on Gcnito-iirhiary Diseases, including Syphilis ; to Morrow's vj' valuable System of Genito-urinary Diseases, Sy philology, and Dermatology, in three volumes, and in especial to the carefully written chapters of that work on stricture of the urethra and syphilis of the eye and ear. The Nj treatise of Bumstead and Taylor, which has so long and i^> so well represented the advance of knowledge in vene- \^ real diseases, has frequently been consulted, as has also \the standard monograph by Finger on Blennorrhoe, and ^the excellent handbook of Messrs. Culver and Hayden. 3 4 PREFACE. The authors of this manual are also gratified in acknowledging in this public manner their appreciation of the courtesy of Messrs. William Wood & Co. of New York, who kindly gave permission to reproduce the plates originally contributed by Dr. Hyde to their Reference Handbook of the Medical Scioices ; to Dr. Petrini of Galatz, for permission to reproduce his fine plate showing the micro-organism of Ducrey ; to Dr. John A. Fordyce of New York, for his kindness in supplying the micro-photograph of gonococci which has been employed as one of the illustrations ; and to Messrs. Lea Bros. & Co. of Philadelphia, for permis- sion to make use of one of their original cuts. The authors are also glad to express their acknowl- edgments to Dr. W. F. Robinson for his efficient aid while these pages were passing through the press. CONTENTS. PAGE Introduction 17 Syphilis 27 Acquired Syphilis 27 Syphilis of the Skin . , 73 Syphilitic Affections of the Hair 133 Syphilitic Affections of the Nail 136 Syphilis of the Mouth and the Tongue 142 Syphilis of the Respiratory Tract 152 Syphilis of the Bones 159 Syphilis of the Larger Joints 165 Syphilis of the Bursse 166 Syphilis of the Tendons and the Tendinous Shealhs 166 Syphilis of the Aponeuroses 167 Syphilis of the Muscles 167 Syphilis of the Heart 168 Syphilis of the Blood-vessels 170 Syphilis of the Lungs . 171 Syphilis of the Gastro-intestinal Tract 173 Syphilis of the Rectum and the Anus 175 Syphilis of the Genito-urinary Organs 181 Syphilis of the Nervous System 187 Syphilis of the Eye and Ocular Appendages 194 Syphilis of the Ear 203 ^ Hereditary Syphilis 205 Treatment of Syphilis 227 Acquired Infantile Syphilis 283 Syphilis in Relation with the Family and Society 284 Chancroid 293 Disorders not Invariably Venereal 331 Balanitis and Balano-posthitis 331 Phimosis 334 Paraphimosis 338 6 CONTENTS. PAGE " Venereal " Warts 342 Herpes Progenitalis 344 Hypochondriasis 347 Acute Urethritis 360 Complications of Urethritis 417 Acute Posterior Urethritis 417 Epididymitis 422 Prostatitis 437 Vesiculitis 44^ Cystitis 450 Pyelitis 454 Folliculitis 456 Periurethritis 457 Cowperitis 459 Lymphangitis 460 Adenitis 460 Gonorrhoeal Rheumatism 461 Gonorrhoeal Conjunctivitis 470 Ophthalmia Neonatorum 479 Gonorrhoeal Inflammation of the Rectum and the Mouth .... 481 Chronic Urethritis 483 Stricture of the Urethra 526 Spasmodic Stricture of the Urethra 527 Congenital Stricture of the Urethra 531 Organic Stricture of the Urethra 534 Instrumentation of the Urethra 553 GONORRHCEA IN WOMEN 6oO Index 607 •33:ii.tsixn:o>i>{ LIST OF ILLUSTRATIONS. FIGURES. ^'^- PAGE 1. Palmar syphiloderm (after Keyes) 97 2. Moist papules (after Miller) loi 3. Large pustular syphiloderm (after Stelwagon) 107 4. Rupia (after Tilbury Fox) . 109 5. Resolutive tubercular syphiloderm in groups 114 6. Serpiginous tubercular syphiloderm (after Stelwagon) Il6 7. Ulcerative tubercular syphiloderm (after Keyes) 117 8. Gummata (after Jullien) I2i 9. Cicatrices resulting from extensive gummatous infiltration of the face 124 10. Sabre-blade deformity of the tibise in hereditary syphilis . . . .216 11. Hutchinson's teeth with osteo-periostitis and ulceration in inherited syphilis 219 12. Phimosis from gonorrhoea (CuUerier) 335 13. Paraphimosis (Cullerier) 338 14. 15- Reduction of paraphimosis 340 16. Urethral syringe 41 1 17. Kiefer's urethral irrigation nozzle 497 18. Klotz's endoscope 500 19. 20. Urethral specula 501 21. Brown's method of illuminating the urethra . 502 22. W. K. Otis's "perfected " urethroscope 503 23. Winternitz's psychrophor 519 24. Keyes-Ultzmann syringe 519 25. Annular stricture (Dittel) 535 26. Tortuous stricture (Dittel) 536 27. The normal urethra (Thompson) .... 554 28. Proper and improper curves for unyielding male urethral instru- ments 555 29,30. Sounding of the urethra (Keyes) 557 7 8 LIST OF ILLUSTRATIONS. FIG. I'AGE 31. Sounding of the urethra (Keyes) 558 32. Sounding of the urethra (Keyes) 559 II. Relative positions of triangular ligament and bulb of urethra (Cul- ver and Hayden) 5^^ 34. lianderson's gauge 5^3 35. Bulbous bougie 5^4 36. Otis's urethrometer 564 37. Olivaiy gum bougie 565 38. Mercier elbowed catheter 565 39. Gouley's whalebone bougies 5^5 40. Gouley's catheter-staff 567 41. Gross's modification of Civiale's urethrotome 590 42. Otis's dilating urethrotome 59^ 43. Teevan's modification of Maisonneuve's urethrotome with guide , 592 44. Suprapubic and rectal routes for the relief of retention of urine (redrawn from Holden) 594 PLATES. PLATE 1. Initial sclerosis of the penis Frontispiece. 2. Chancre and papillary growths of the tongue (Hutchin- son) facing page 35 3. Small papular syphiloderm (Slelwagonj " 92 4. Pustulo-ulcerative syphiloderm " 108 5. Pustulo-ulcerative syphiloderm in a cachectic subject . " no 6. Syphilitic disease of the tongue (Hutchinson) ... " 149 7. Fig. I. Hutchinson's teeth. P^ig. 2. Bacillus of Ducrey (Petrini de Galatz) " 296 8. Fig. I. Gonococci in gonorrhoeal pus (Fordyce). Fig. 2. Gonococcus (Bumm) " 362 SYPHILIS AND THE VENEREAL DISEASES INTRODUCTION. The venereal diseases are for the most part trans- mitted from one individual to another in the contacts incident to the relations between the sexes. The day is long- past, however, when a moral stigma could be affixed to the victim of such a malady by reason of the fact of infection. In the populous and crowded centres of modern civilization the innocent subjects of these dis- orders are numbered by hundreds and even thousands. They are in a special sense entitled to the encouraging assistance and the sympathetic service of the trained physician. The great majority of the other victims are patients infected at a time of life when passion is most imperi- ous, self-restraint less strenuously imposed, and the dis- cipline which unfolds the deeper meanings of life is less understood and appreciated. The result is twofold : on the one hand are patients for the most part, fortunately, of an age and possessed of a vigor best capable of endur- ing without serious shock the perils of an intoxication 2 17 1 8 SYPHILIS AND THE VENEREAL DISEASES. of the system, and in a social state least likely to burden others, such as a wife or a child, with the consequences of disease ; on the other hand are the subjects of these infections, who, without fixed habits, are obliged to con- form to the rules of best living when actually suffering from their ailments, and who learn lessons which at their time of life are often indelible. The most radical of moral reforms with the best of ultimate results is con- stantly wrought by the several accidents described in the following pages. In the early part of this century the prejudices of the people of most English-speaking countries and the odium connected with the acquisition and inheritance of venereal disease extended even to the professional men interested in their treatment. As a consequence, this department of medicine w^as largely relegated to the charlatan, who, under the control of ignorance and avarice, contributed to the exaggeration and confusion which still cloud the minds of many when they consider the subject. To-day the change in these particulars is noteworthy. Science has solved some of the profoundest problems and achieved some of its most brilliant bacteriological and pathological victories in the territory once aban- doned as a plague-spot. Some of the most cultivated, learned, and distinguished of the physicians of the last quarter of the nineteenth century have been content to labor and to glean in the field that was thus once neglected and abhorred. It has been well for the race that these men could thus with untiring industry and interest investigate the diseases commonly described as " loathsome." But many of them have paid a price for their courage. It is INTRODUCTION. 1 9 impossible to give accurate statistics of the number of physicians innocently infected with the venereal diseases, and particularly with syphilis, when engaged in the practice of their profession as accoucheurs, surgeons, gynecologists, and those giving special attention to the affections of the genito-urinary organs of both sexes. Hundreds of them have been under our observation and care ; thousands have thus suffered in every country. Only with the incessant precautions suggested by the later knowledge on the subject of the pathogenic micro- organisms can a physician hope to be successful in the management of these disorders and himself escape their defilement. Nor in his attempts to compass this end can he with safety rely only upon the products of pharmacy and the skill of the chemist. He must be, in his person, his instruments, and his entourage, an embodiment of scrupulous cleanliness. , The disorders usually classed under the general title of " venereal " are syphilis, the several forms of infec- tious urethritis, and the soft (" simple " or " non-syphi- litic ") chancre. In a stricter sense of the term, and in the light of modern investigation, there are other dis- orders described in these pages capable of transmis- sion in the sexual act. The more important, however, of the group are without question those here named. It is probable, though exact statistics are wanting, that infectious urethritis is the most frequent, soft chancre (certainly in particular classes of society) next, and syphilis, in all classes, last. Further comparison teaches that while gonorrhoea is most often a strictly venereal disorder, syphilis is with greater frequency an affection of the innocent; while, as respects a fatal issue, gonorrhoea, in its ultimate results upon the deep urethra, 20 SYPHILIS AND THE VENEREAL DISEASES. the bladder, and the kidneys, probably destroys more lives annually than does syphilis. Gonorrhoea more often than syphilis spares the subjects of tender age, and is further capable of indefinite recurrence in one subject; while for the immense majority of cases syphilis is a disease making but a single attack in the lifetime of the individual. The proposition once held cannot longer be sustained, that gonorrhoea and soft chancre are purely local diseases as contrasted with syphilis, which is admitted to have systemic effects. The generalized results of gonorrhoea are in many instances too striking to admit even of question ; and in special cases the perpetuation of the soft chancre for years, with the damage resulting to rectum, vulva, abdominal wall, and thigh, with the production of marked cachexia, often renders that affection one even of greater severity than the milder cases of syphilis. The questions relating to the history and antiquity of the venereal diseases have created a voluminous litera- ture, with results not wholly satisfactory. The sacred literature of the Hebrews seems to bear record to the fact that blennorrhagic affections existed among the people of a remote antiquity, and that the gonorrhoeal discharge was with them confounded with a seminal flow. Among the writings of Greek, Roman, African, and Spanish authors, both medical and literary, evi- dences are not wanting as to the existence of such a disease and its occasional confusion with other disorders of a venereal origin. Even as early as the beginning of the present century, English physicians confounded gonorrhoea, syphilis, and non-syphilitic chancre, and it was reserved for a comparatively recent date to distin- guish definitely and finally between them. INTR OD UCTION. 2 1 For the remote antiquity of syphilis there are not wanting authors who find in the sacred writings of the Hebrews, in the sarcastic, poetical, and historical litera- tures of Greece and Rome, in the ancient documents of Egypt, China, and Africa, and in the volumes written during the Middle Ages, records among the people of those periods of the existence of chancres and of the systemic results of certain genital lesions. The evi- dence of bones exhumed and supposed to belong to a prehistoric era is also adduced in support of the assumed antiquity of syphilis. On the other hand, there are many who believe that syphilis existed among the American aborigines before the advent in 1492 of Columbus and his companions to the American coast, and that the Spaniards, becoming infected by contact with the natives, brought the disease to Europe, where it appeared for the first time after their return. In the subsequent campaign of Charles VIII. of France against the kingdom of Naples the disease appeared and spread among the nations of Europe to an extent and with a severity before then unknown. In reviewing the entire subject many of the argu- ments in favor of the historical antiquity of these diseases are, it must be admitted, weakened by the indefiniteness of the descriptions given. The bones alleged to be both prehistoric and syphilitic are either lacking in the display of unmistakable lesions of that disease or cannot conclusively be demonstrated to be both of prehistoric sepulture and since then wholly undisturbed by the hand of man. The arguments in favor of a prehistoric syphilis in America and of its subsequent deportation to Europe are weighty, but not without flaw. 22 SYPHILIS AXD THE VENEREAL DISEASES. The conclusions are simple : the evidence of a remote antiquity for the venereal diseases in general is very strong. In the absence of the definite distinctions between them now established, and of a recognition of the pathological connection between the local mani- festations of such diseases and their systemic effects, great confusion has existed in the past. Lastly, the venereal diseases have all, without question, been con- fused inextricably in the past, not merely with each other, but with a large number of dermatological affec- tions, such as lepra, psoriasis, scabies, eczema, simple and venereal warts, and leucorrhoeal and catarrhal discharges. In the examination of patients affected with one or several of the disorders here considered, a systematic method is of as much value as in other departments of medicine. Besides ascertaining the name, age, resi- dence, married state, occupation, and previous history of the patient, as well as the habits respecting the use of both alcohol and tobacco, it is desirable to know, for reasons that appear later, in the case of both man and woman, the record as respects living and dead children, miscarriages and abortions on the part of a wife, and the relative order of these, as well as the period in pregnancy when a series of abortions or miscarriages occurred. In securing the history of the family and of any antecedent disease it is necessary to record all facts respecting any prior disease of the skin, persistent head- ache, especially with nocturnal exacerbation, any attacks supposed to be rheumatic, and any persistent or ulcera- tive affection of the throat, eyes, scalp, or nails. In the case of venereal disease it is important to know whether the patient can sleep at night without INTR OD UCTION. 2 3 rising from the bed to empty the bladder; whether there is pain on micturition, and, in the latter event, whether the pain occurs before, during, or after the passage of the stream. In the physical examination of patients the several bodily organs should be investigated with care, the surface of the body, when found practicable, being searched for traces of any existing or past exanthem, and particularly for scars, each of which may throw light on the conditions existing. The superficial glands of the body accessible to the fingers should be searched with a view to determining any enlargement or indura- tion. The mouth, nostrils, eyes, and ears require minute observation of lesions present; and even in the absence of the latter the nails may exhibit markings indicative of the character, and at times of even the date, of prior nutritional changes. In the case of male patients the entire surface of the body may often be exposed for examination, and the genital region then requires detailed inspection. By the fingers and the eye the physician can usually determine the existence of pediculi or nits in the pubic region, an eczema or a psoriasis of the cutaneous surface of the penis or the scrotum, moUusca of the latter region, or the evidence of scabies. By manipulation it will be discovered whether there is an inguinal hernia, a non- descended testis, a left- or more rarely a right-sided vari- cocele, a gumma of the body of the testicle, or traces of an ancient epididymitis involving the globus minor or major as a sequel of a preceding blennorrhagia. By the fingers alone it will often be practicable to recognize a urethral stricture, a periurethral phlegmon, an en- larged prostate, a syphilitic or a chancroidal bubo, a 24 SYPHILIS AND THE VENEREAL DISEASES. severe phimosis, a subpreputial sclerosis or other lesion, or a urethral chancre. In point of fact, a urethral sclerosis that cannot be recognized by the digit of the trained physician is among the greatest of rarities. Indeed, one might here enumerate the entire list of diseases of the ano-genital region, evidences of which the examining surgeon should not permit to escape his observant eye and trained touch. In all classes of women the examination should be made with the special consideration to which the sex is entitled. A follicular or furuncular affection of the labia, a catarrhal discharge from the vulva, a sclerosis of the meatus or of the fourchette, or a stellate chancroid of the anal region, may often be determined by inspec- tion alone. The physician must know to distinguish between a languette accompanying a syphilitic stricture of the rectum and a hemorrhoidal tumor. He must be capable of recognizing the marked differences between a pruritus of the vulva, which is simply tormented by scratching, and an eczema of the same part. By carefully inspecting the dry and " sticky " mouth of a woman it can be determined with reasonable probability, before subject- ing the urine to chemical analysis, that an " eczema " of the vulva is due simply to a glycosuria. The fingers should differentiate an inflammation of the vulvo-vaginal gland due to gonorrhoea from a syphiloma of the labium. Scabies of the genital region in a woman will usually be an echo of characteristic burrows about the axillae or the breasts. By the touch one should be able to discover a hydrocele of the canal of Nuck, a varico- cele, a carcinoma, an elephantiasis, a contracture of the vagina, a laceration, an atresia of the hymen, or a vag-inismus. INTR OD L 'C TION. 2 5 Nor should it be concluded in either sex that a deter- mination of the virgin state precludes the possibility of venereal disease. The physician should ever be on the alert to recognize a chancre of the tonsil, an infecting sclerosis of the lip in the child who has kissed a syphilitic nursling, a gonorrhoea affecting the vulva or the eyes of an infant, a paralysis in the middle period of life due rather to a pachymeningitis than to an apo- plectic effusion. Lastly, the physician entrusted with an intimate knowledge of the sources of diseases that are viewed with shame, loathing, and remorse, often imperilling the life of the individual, the safety of the uninfected, and the happiness of a home, has a part to perform which demands a high order of intelligence and sympathy. His it is to protect the innocent, to guard sacredly the secrets confided to his keeping, to conserve the family relation, and at the same time to bring the sufferer to a successful termination of the disease. It is difficult to decide that any one of these functions has a higher importance than another. It is only as the physician discharges his full duty in all points that he ultimately wins that trust and confidence which are the foundation of the largest professional success. SYPHILIS. Synonyms. — Lues venerea ; Morbus gallicus ; Pox ; "Bad disorder;" Fr. Verole ; ItaL Sifilide ; Ger. Lust- seuche; Krankheiten der Franzosen ; Span, Sifilis ; Swcd. Radezyge. Syphilis is a general infectious disorder transmitted from one individual to another by both contact and inheritance, chronic in course, and displaying in a more or less determinate sequence symptoms involving one or several of the organs of the body. It is classed with the infectious granulomata, and it is due to the toxic effect of the invasion of the bodily tissues by a morbific germ. Though the identity and relations of the latter have not completely been established (as has been done in the case of the bacilli of tuberculosis and lepra), no doubt can be entertained as to its existence and potency. ACQUIRED SYPHILIS. Syphilis is said to be acquired when transmitted in another way than by inheritance. The term " contact- syphilis " has also been employed to distinguish the former from the latter. Etiology. — The micro-organisms which are effective in the production of this disease have not yet been incontestably demonstrated. Donne, Hallier, Lostorfer, Klebs, Doutrelepont, Lustgarten, Fordyce, and many others have repeatedly, by difficult and delicate methods of staining, recognized bacilli in syphilitic tissue. The 2S SYPHILIS AXD THE VENEREAL DISEASES. failure to distinguish the exact micro-organism whose toxine may be efficient as a cause of the disease is due partly to the fewness of the bacilli present in any one section, to the circumstance that the bacilli found in the smegma praeputii are either identical with or very sim- ilar to the supposed syphilitic germ, and to a fact pointed out by Fordyce, that the general absence of giant-cells in syphilitic tissue forbids their use as a guide to the location of the bacilli. But if the germ of the disorder has not yet been distinguished satisfactorily, no doubt exists as to the fact that a germ-carrying secretion or virus, which may be collected on the point of a lancet, is capable of trans- mitting the disease. This virus must be furnished by a person infected with syphilis. The purveyors of this virus are usually in an early or active stage of the disease. They may furnish a patho- logical secretion, such as that supplied by a mucous patch, a chancre, a syphilitic pustule, or an ulcer. Such a secretion may be commingled with a physiological fluid (tears, saliva, milk), and be thus effective, however innocent to the view, though the physiological secre- tions of a syphilitic subject not thus mingled with a virus are rarely, if ever, noxious. The blood of such subjects is, however, capable of transmitting the disease. Pathological secretions of other character (gonorrhoeal, leucorrhoeal, vaccinal) may readily be commingled with the virus of syphilis, and thus be effective in its trans- mission. The evidence as to the date when the syphilitic subject can no longer furnish an infectious virus is con- fusing. Up to a recent time it was believed that the late lesions of syphilis (so-called ** tertiary ") were incapable ACQUIRED SYPHILIS. 29 of furnishing such a virus. Instances are, hov/ever, on record disproving this ; and, though the power to furnish a virus is gradually lost in every surviving subject of syphilis, it is safest to hold that any awaken- ing of the morbid process at a late date may, however rarely, render such persons dangerous to the uninfected. TJie modes of infection are both immediate and mediate. The direct contacts of the sexual act (includ- ing the perverted and unnatural imitations of the latter) and the opportunities of transmission afforded in kiss- ing, biting, sucking, etc. are often the beginnings of syphilis. In the same category may be named all the accidental contacts which occur in the service of the physician, the nurse, and the midwife, and those where prisoners are manacled together. The articles which have been mediately effective as virus-carriers are so many and so various as to forbid enumeration. The list includes a great number of household utensils (forks, cups, spoons), articles of domestic use (tooth-brushes, syringes, combs), articles employed in the professions (dentists' forceps, surgical instruments and appliances, razors, vaccinating needles, lancets), and, in brief, almost every substance brought into contact with the human body, from nursing-bottle to water-closet seat, and from the finger moistened in the mouth of the nurse and given to the nursling to the tools of the chiropodist. Given an infective germ in its vehicle (the virus), furnished by an infected subject of syphilis (in a stage of that disease capable of transmissibility by contact), it remains to inquire whether the person inoculated with such a virus, mediately or immediately conveyed, will suffer from the disease. A categorical answer to this 30 SYPHILIS AND THE VENEREAL DISEASES. question cannot be given. There is reason to believe that all individuals are not equally susceptible to the action of the virus. These reasons are based on the accepted fact of repeated exposures of certain persons without evident results ; of repeated exposures with results that are slight, or, if threatening at first, abortive as to any ultimate consequences; and of well-known analogies existing between this disease and others in which the proofs of susceptibility and non-suscepti- bility of individuals are irrefragable. All such instances are, however, exceptions to a rule that is enforced by constant experience. The husband recently infected as a result of infidelity to his wife communicates his disease to the latter with almost unfailing regularity; the lover with a mucous patch upon his lip gives his disorder with an appalling cer- tainty to the woman whom he kisses upon the mouth. For practical purposes it is best to assume that all men, women, and children are susceptible who have not been protected either by a previous attack of the disease or (a point to which attention is called later) by the experience of the mother who brings into the world a syphilitic child diseased by inheritance from the father, while she seems to escape. Chanxre. Synonyms. — Syphilitic chancre; Initial lesion or sclerosis of syphilis ; Hard chancre ; Infecting chancre ; Ger. Hartes Geschwiir; Schanker; Fr. Chancre syph- ilitique. The first evidence of a successful transmission of syphilis from an infected to a sound person is termed a ** chancre," or, as this last term has often been errone- ACQUIRED SYPHILIS. 3 I ously applied to non-syphilitic local venereal disorders, better the " initial lesion of syphilis." The First Incubation. — After the successful intro- duction of the syphilitic virus into a sound body an interval occurs before the evolution of the initial lesion is appreciable to the eye. This interval is called the " period of the first incubation," a phrase suggestive of the ignorance of the earliest observers. It is almost certain that from the instant of a successful inoculation the subject is, however imperceptibly to human tests, syphilitic, and that there is, without pause or arrest, a multiplication of the effective germs of the disease to the point where the lesions produced by these germs become apparent to coarse methods of observation. This interval is by different observers made to extend over a period of time with singularly varying limits. The average is between twenty-one and twenty-six days, but the period has been claimed to be as brief as from one to two days and as extended as three months. The numerous chances of error in all these estimates need not be pointed out. Between ten and thirty days after infection the vast majority of all infecting chancres appear. The reverse is also true : on the first appearance of a chancre it may safely be estimated that infection occurred previously between ten and thirty days. The chancre or syphilitic initial lesion appears at the site of inoculation. Its recognition, when first exhibited as the earliest indication of a serious disease, is a matter of the profoundest importance, seeing that the welfare of the individual, and often of others with whom he sus- tains intimate relations, may be conditioned upon its cor- rect diagnosis. The chief error committed by the practitioner and 32 SYrillLIS AXD THE VENEREAL DISEASES. student anxious to master this problem lies in an effort to identify some particular chancre as a type of all others, and to base a diagnosis upon a comparison of others with this as a type. This is the familiar process by which men recognize in nature a flower or a bird, and in medicine a disease of so fixed a type as a corn or a carbuncle. The sole constant characteristics of every chancre are — [ci) an incubative period preceding its appearance ; (h) a sclerosis, induration, or dense thickening of the base of the lesion, widely varying in grade and duration with different chancres ; (c) a simultaneous enlargement and induration of the gland or glands in nearest anatomical relation with the chancre, constituting the " syphilitic bubo," or primary adenopathy. The first of these con- stant characteristics is an historical symptom, a knowl- edge of which may be v/ithheld from the practitioner at the date of his examination. The last, though wellnigh constant of occurrence, may not have been declared fully at the date of the examination, or the glandular enlarge- ment may be so slight or so deeply situated as to escape detection. It follows that in some cases it is possible that at a given moment the sclerosis may be the sole chancre-symptom present whereby the nature of the disorder may be declared. Yet there are several non- constant symptoms which can usually be recognized without difficulty, and which leave the observer in little doubt as to the diagnosis. These symptoms are for the most part explained later. A chancre is a modification of the sound or patho- logically altered skin or mucous membrane, occurring after syphilitic infection, and displayed after an incu- bative period, characterized by a circumscribed sclerosis ACQUIRED SYPHILIS. 33 of tissue, and accompanied by an enlargement and indu- ration of neighboring glands. Every chancre means a syphilis, mild or severe, that will follow. Every case of acquired syphilis points to a precedent chancre, recog- nized or unrecognized. Every chancre, further, is a symptom not merely of a syphilis that will follow, but of a syphilis actually present. The proof is found in the fact that infection of a sound individual from such a chancre is followed by the development not merely of a new chancre, but also of a new syphilis. It is important to note at the outset, considering the definition given above, that a chancre may be either an isolated first lesion of syphilis or a modification of some symptom of another disease. Briefly, the study of chancres is the study less of lesions than of a series of singular modifications of lesions recognized in many other diseases, which, under the influence of syphilis, take on new aspects and undergo singular metamor- phoses. Thus, the chancre may develop upon the sound skin of the arm as a consequence of intentional experimental inoculation, or upon the sound mucous membrane of the vulva as the result of infection in the sexual act. It may also originate as an untoward modi- fication of a "cold sore" (herpes labialis) of the mucous membrane of the lip infected in the act of kissing, or be a significant change in the evolution of a vaccine vesicle, a blister on the finger, or an excoriated nipple. Chancres may thus be represented at one time or another by every recognized lesion of the cutaneous surface, including the macule, papule, vesicle, pustule, bleb, tubercle, tumor, and ulcer. Only the most com- mon types can here be enumerated conveniently. Erosion (Superficial erosion). — This is the least con- 34 SYPHILIS AND THE VENEREAL DISEASES. spicuous, the oftenest ignored or misunderstood, and yet the commonest of chancre symptoms. It is rec- ognized as a roundish, oval, or quite irregular macule or spot resting, soon after its evolution, upon a delicate bed of induration, giving to the touch the sensation of a thin sheet of parchment or of mica let into the under- lying tissue. It is usually distinctly circumscribed, and exhibits a shallow or scarcely depressed erosion, cen- trally fixed or involving its entire face. In size it varies from a large pin-head to a bean, and may be many times larger. Its color is dull-reddish, grayish, or even whit- ish ; it often resembles in hue a section of raw ham. It may be dry and glazed, or slightly moist and secreting a thin serum which ^lues to its surface anv dressins^s that may have been applied to it. At times it has a grayish-white film over its face, and may even have a diphtheroid aspect. It may be uniformly level with the neighboring skin, or its edges may be raised and its cen- tre slightly depressed. It very rarely suppurates freely or degenerates into a well-marked ulcer. These com- plications usually result from external irritation (caustics, mixed infection, urine flowing over the site, as in urethral chancre). The accidents of phagedena and sloughing are still rarer. When these chancres survive until gen- eral syphilis is declared, they are gradually transformed into symptoms of general syphilis, readily enlarging to elevated, granulating, rarely hemorrhagic masses smeared with a highly contagious puriform mucus and merging thus into the mucous patch and condyloma. These erosions may be lifted away from their original sites by extensive underlying scleroses, and be thus greatly modified in appearance. They are then changed from flat macules to large-nut-sized and even larger SYPHILIS. Plate 2. Chancre and papillary growths of the tongue (Hutchinson). ACQUIRED SYPHILIS. ^c irregularly outlined masses, ridges, and deformations of the lip, the vulva, or the preputial rim — favorite sites for their development. These odd-looking swellings, unlike each other and conspicuous chiefly for their irregular bulging, often as firm as ivory to the touch, are capped at one point or another by the smooth, shal- low, dry and glazed or slightly secreting erosion described above. All are essentially giant-papules, undergoing a special evolution because of the pressure- and friction-effects of their particular environment. Papule (Dry scaling papule; Non-ulcerating, indurated papule). — This is the common result of inoculation of' the skin as distinguished from that of the mucous sur-.l face. The chancre is here evolved as a pea- to a bean- sized papule or papulo-tubercle, indurated at the base, dry, scaling, and colored in various shades, according to its situation. It is occasionally seen upon the skin of the penis as the result of accidental infection of that part, and upon other cutaneous surfaces, as the thigh and the arm, as the result of accidental or experimental inoculation. Ulcer. — Ulceration of the chancre is probably in every case the result of local irritation. This irritation maybe accidental, as in the case where improper dressings or applications are made to the lesions, or intentional, as where savin cerate has been applied or horse-hairs have been passed through the base for the purpose of exciting suppuration with a view to supplying a virus for purposes of experimentation. Two types of ulceration may be recognized in chancres, the shallow and the deep. Both occur in beds o£ induration. Their causes have been discussed above; maceration (by mucus, by leucor- rhoeal and blennorrhagic discharges), friction, improper 36 SYPHILIS AND THE VENEREAL DISEASES. treatment by local applications, filth, and neglect may all be cited as of consequence. Shallow and superficial ulcers^ scantily secreting serum, are usually imbedded like erosions in thin sheets of induration, but they may cap considerable elevations of tissue. Their edges are sloping, almost never clean-cut, punched out, or undermined ; their floors rarely slough ; their outline is irregular. At times they resemble shal- low fissures, especially on the side of the fraenum ; at others they form at the bottom of a crevice between two walls of induration, as when the sclerosis involves the mucous membrane of both the corona glandis and the adjacent prepuce. Deep ulceration of chancres invariably results from the action in excess of the causes suggested above, or from similar agencies. The " Hunterian chancre," so named because Mr. Hunter beHeved that it was the sole precursor of general syphilis, is a deep excavation in a large mass of induration. This crateriform ulcer is roundish, oval, or very irregularly shaped, often with a floor set in an angle, presenting thus the aspect of a deep fissure in a neoplasm. Its secretion is commonly scanty, though when profuse it may be hemorrhagic ; its edges are sloping; its rim is densely indurated, cap- ping a tumor-like mass varying in size from a h azeln ut _to that of a pullet's tgg. Mixed Chancre. — By this term is generally desig- nated a venereal lesion which at the outset, usually a brief time after infection, exhibits all the characteristic features of the soft chancre (" chancroid," " chancrelle," etc.), but which, after a due incubative period has elapsed, becomes specifically indurated at the base, is accom- panied by syphilitic bubo, and later is followed by gen- ACQUIRED SYPHILIS. 37 eral syphilis. This accidental implantation of the virus of syphilis upon a soft chancre (or upon its site before the appearance of the latter) is analogous to the com- plication which ensues when a herpetic vesicle ('' cold sore ") of the lip or a cigarette-burn of the same region becomes infected with the virus of syphilis. In these cases it is the modification of the original process that announces the syphilitic complication. The chancroid or " soft chancre " is essentially a pustular lesion, and its purulent secretion, whether from pustule or from suppurating abrasion or fissure, is indef- initely auto-inoculable, as distinguished from the secre- tion of the syphilitic initial lesion, which is scanty and non-auto-inoculable ; hence all infecting chancres secret- ing an auto-inoculable pus are of the ** mixed " type. The bubo, also, accompanying the soft chancre is usually inflammatory and has a tendency to suppurate, as dis- tinguished from the dense multiple buboes of syphilis, which rarely suppurate and are often non-inflammatory in type. It follows, then, that the buboes of " mixed chancre " may exhibit the features of one or the other of the two disorders thus commingled. The important point to recognize is that syphilis may ensue after the occurrence of " mixed " chancre ; and this possibility should never be forgotten in making the prognosis of any suspicious venereal sore. The individuals most often exhibiting these "mixed " chancres are of the pau- per class frequenting public dispensaries and out-patient departments of hospitals — persons whose female asso- ciates are as uncleanly as they are vicious. Another " mixed " variety, in the light of modern sci- ence, is the chancre of syphilitic origin that is also later infected with micro-organisms. This complication is 38 SYPHILIS AND THE VENEREAL DISEASES. more common than is generally supposed. All the pus cocci, several of the mucors, and a large number of for- eign substances, usually inert, may often be recognized in chancres, especially in those of the filthy, but also of those who never previously suffered from venereal disease, and who, in ignorance or as the result of im- proper advice, suffer from neglect of cleanliness or from positive aggravation of the original disease. Chancres of the Syphilized. — Persons infected with syphilis have usually but one attack in a lifetime. The exceptions to this rule are so rare as simply to enhance its value and importance. But the recent as well as the veteran victims of that disease expose themselves to it and to other venereal diseases with results which de- mand exact recognition. Such persons, of course, may contract " soft chancres." But when exposed to fresh sources of syphilitic virus they occasionally exhibit, as a result, chancres of a for- midable type and an obscure character, requiring some expertness for their proper recognition. Some of these results are {a) lesions like soft chancres, but atypical, less clean-cut at the edge, with much less purulent secre- tion, and non-auto-inoculable ; {b) slightly indurated chancres, strongly resembling the initial erosion chancre, without accompanying syphilitic bubo, and disappearing without leaving results of consequence ; {c) large indura- tions with deep central excavation, at times strongly resembling the " Hunterian " chancre, yet without bubo, and yielding completely to proper internal treatment. Some of all these are, without question, gummatous (so- called *' tertiary ") lesions of general syphilis, occurring with reawakened activity where, at the site of invasion, new bacilli have been introduced. Yet rarer are [d) pea- ACQUIRED SYPHILIS. 39 sized and larger, exceedingly dense, circumscribed thick- enings of the genital region, without erosion, ulcer, or hyperaemia, and due to the causes named above. Location of Chancres. — As distinguished from chan- croids, which are very rarely extra-genital in site, syphilitic chancres may occur upon any exposed por- tion of the body-surface; very rarely indeed do they develop at long distances from the mucous orifices of the body (as, for example, in the bladder, oesophagus, stomach, etc.). The genital region of the two sexes is most often involved merely because of the frequency of transmission in the ample opportunities of the sexual act. In this way the balano-preputial sulcus, the rim and inner face of the prepuce, the fr^num, glans, and integument of the penis, the scrotum, the inner face of the thigh in contact with the latter, and the perineum become common sites. Urethral chancres are rarely deeply situated, but they may commonly be recognized at the tip of the glans in men, where the indurated mass encroaching upon the limits of distensibility of what may be termed the " urethral nozzle " produces so much local irritation and consequent sero-purulent discharge that the symptoms are often mistaken for those of a blennorrhagia. When the glans in these cases is grasped firmly between the thumb and the finger, the induration may be felt, resembling a short section of a clay pipe let into the submucous tissue, and at the moment of pressure a characteristic whitening of the rim of the labia of the meatus urinarius bears witness to the extreme thickening of the initial lesion. In women the labia majora and minora, the four- chette, the os uteri, the clitoris, the vestibule, the meatus urinarius, and, very rarely, the point of the superior 40 SYPHILIS AND THE VENEREAL DISEASES. commissure of the vulva are the usual sites of chancres. In these situations their transformation /;/ situ to condy- lomata, mucous patches, and other secreting lesions of systemic disease is readily effected in consequence of the heat, moisture, and friction to which they are here exposed. In women the deformities of the genital region, venereal in origin, are commonly of exaggerated type, and, as a rule, in fetor, in abundance of secretion, and in volume they far exceed the corresponding lesions of the other sex. Chancres of the vagina are rare ; when they occur they usually escape observation. They are probably more common than is set down in the statistics of the malady. Chancres of the mucous envelope of the cervix are usually visible on its anterior limb. They are reddish or empurpled excoriations with an engorged areola; their face is often covered with a pultaceous and adherent film. In the genital chancres of women the inguinal glands usually escape involvement. Extra-genital chancres are not of rare occurrence in the larger cities, and, as already pointed out, may be recognized in every region of the body. The most frequent sites are the lips, fingers, nipples, anus, tonsils, tongue, nares, thighs, arms, and toes. They result from the contacts incidental to kissing, sucking, biting, vaccinating, the smoking of pipes, the njjrsing of chil- dren at the breast, the practices of sodomy, digital explorations and operations of the accoucheur, physician, and surgeon, and from many accidents of daily life. They belong, without exception, to the types of chancre already described, invariably following periods of incu- bation, occurring with well-marked induration, and accompanied by adenopathy of the glands in the vicinity ACQUIRED SYPHILIS. 4I of the infected part Some are densely indurated fis- sures (nipple, anus, lip); some are indurated dry papules (as after vaccination, biting, tattooing) ; some are flattish plaques of a dull-red hue, or ulcers covered with an ashen paste (tonsils, tongue, uterus); some are irregu- larly shaped tumor-like masses (lips) ; some, finally, are simply symmetrical ovoid thickenings of normal tissue (finger, toe, hang-nail, etc.). Number of Chancres. — The initial lesions of syphilis are seldom multiple ; most often they are single. If dual in number or more numerous, they are, as a rule, multiple from the beginning. In these cases the infer- ence is just that there has been a simultaneous acci- dental inoculation of all such points at a given moment. The non-auto-inoculability of the secretion of the initial lesion forbids its multiplication upon the person of an individual once infected, even as the result of an acci- dent. The auto-inoculability of the pus of the " soft chancre," on the contrary, offers abundant opportu- nities for its spread from one point to another of the subject of the disease, and at the same time furnishes ample supplies for infection at any given moment in several points simultaneously. It follows that while in exceptional cases a patient may exhibit at one time two or three initial lesions of syphilis on his person, he never compares in multiplicity of chancres with, for example, a woman whose labial sores have supplied a pus streaming over the perineum where fifty, and even a hundred or more, soft chancres may at times be counted. Induration of Chancres. — The specific induration of the initial lesion is one of its constant features. This sclerosis is recognized by the sense of touch in varying 42 SYPHILIS AXD THE VENEREAL DISEASES. degrees as a distinctly defined thin plate or_sheet of inelastic tissue let in beneath the excoriation, ulcer, etc., or as a dense mass with the hardness of ivory or carti- lage, varying in size from a split pea to that of a pullet's ^gg. ^"d even to masses still larger. At times the sclerosis is so dense as to suggest the hardness of marble. All these grades of induration are in part correlated to the degree of irritation to which, after its complete evolution, the chancre is subjected. The situation of the chancre is a factor determining in part the extent of the induration, as chancres of the vagina are proverbially less indurated, and those of the muco- cutaneous borders (lips, preputial orifice, etc.) more conspicuously sclerotic, than others. The induration may precede or follow (much more often the latter) the evolution of the chancre, or it may first be observed at the moment of detection of the sore itself The very late occurrence of induration in a chancre is usually a portent of good, as a delay of from twenty to thirty da}'s after the appearance of a lesion supposed to be a precursor of syphilis usually negatives the expectation of that disease. The sclerosis may disappear before the healing of the chancre, or, what is quite common, may persist long after the involution of the latter, and even long after the occurrence of general symptoms. Occa- sionally one may recognize the pigmented, pigmentless, or sclerotic, keloid-like relics of induration six months after infection, and even after all symptoms of general syphilis have for the time disappeared. Sooner or later the induration ahvays wholly disappears, and for the most part leaves behind it no traces of its existence, these facts seeming to bear no relation to the future of the patient. The so-called " relapsing indurations " are ACQUIRED SYPHILIS. 43 usually syphilomata, evidences of general syphilis, so- called ''tertiary gummatous infarctions of the genital region." The Portent of Chancres. — While it is true that every initial lesion of syphilis signifies that a syphilis, mild or grave, will ensue, it does not follow that from the number or the appearance of chancres a prognosis may be made as to the severity or the reverse of the ensuing disease. An exceedingly insignificant looking ham-colored spot in one individual may be followed by the most malignant form of the disease, and may lead to a syphilis of the second generation that may destroy in succession the fruits of a wife's pregnancies; while a group of three gigantic masses of sclerosis, each with excavations of an ulcerative type, may be followed by even meagre results. The reason for this disproportion may be found, as some allege, in the activity of the germs present, but it is more probably due to the kind of soil in which those germs are implanted. Duration of Chancres. — Chancres may persist until the evolution of systemic syphilis. They may, however, be resolved and disappear almost wholly at an earlier date. When persisting still later, they are always changed to conform to the type of the general symp- toms of the disease, and are in reality no longer chancres, but condylomata, granulating mucous patches, gummata, etc. When persisting to such a late stage, they usually announce the fact by significant changes, such as elevation of the surface, tumefaction of the mass, softening of the sclerosis wholly or in part, and hypersecretion. Termination. — Chancres may terminate by complete resolution. However numerous and formidable in 44 SYPn/LIS A. YD THE VENEREAL DISEASES. appearance, they rarely result in any mutilation of the part in which they have been seated. The simplest lingering traces of their existence are either moderately pigmented patches, such as occur on the skin of the penis in young subjects with ver}' dark hair and eyes, or, as a sequence of such pigmentations in that class of indiv^iduals, even non-pigmented plaques as large as the original chancre, being, in fact, pigmented spots whence the pigment has slowly been removed. Chan- cres seldom leave scars, for the reason already given, namely, their indisposition to undergo ulceration. In this respect they are strongly distinguished from soft chancres, which, as a rule, suppurate and ulcerate, and often leave punched-out scars as relics of their ravages. When syphilitic chancres actually leave scars, these are always the result of ulceration, and this ulceration is the fruit of some accidental complication of the local disease. Thus, the chancre of the urethra lies just where the stream of urine several times in the day necessarily passes over its entire face, and, this fluid being in a high degree irritating in consequence of the urinary salts it contains, the chancre often secretes quite freely, and may leave an odd-looking scar at the tip of the glans penis, this organ, after all is healed, looking as though it had lost its apex, while the external urinary meatus has for a distance of perhaps half an inch or more a " reamed-out " aspect. Deeply-cauterized and filthy chancres, as well as those of " mixed " type, may leave small cicatrices. It follows that in making exami- nations for the army and navy and for life insurance, the non-discovery of scars upon the progenital region of men does not prove that they have not had a preceding syphilis, and the actual discovery of such scars in the ACQUIRED SYPHILIS. 45 progenital region is by no means conclusive that the subjects of the same have been syphilitic. Diagnosis. — The diagnosis of the initial lesion of syphilis is made chiefly by a careful study of the symp- toms already detailed. By the recognition of these special characters, rather than by the exclusion of the symptoms of other diseases, is the end best reached. The chancroid or " soft chancre " is usually a pustular lesion, and is represented either by an unbroken pustule surmounting its characteristic sharply-cut ulcer, or, after the rupture of the pustule, by the pus-bathed ulcer itself, circular, oval, stellate, or linear in outline. However engorged its base, the latter is never indurated save in the " mixed " variety. There is no period of incubation, and, though at times single, the lesions are usually multiple and often exceedingly numerous, scores form- ing in extreme cases. The adenopathy of chancroid is represented usually by a single though occasionally by a double bubo. Rarely many buboes occur of a dis- tinctly inflammatory type, with a tendency to suppura- tion and the production in the lips of the wound, when there is spontaneous bursting of the gland-abscess, of a chancroid by secondary infection. The purulent secre- tion of the chancroid is practically indefinitely auto- inoculable — a fact accounting for the multiplicity of the" lesions in many cases. Chancroids are usually genital in situation ; ^rarely are they extra-genital, with the exception, particularly in filthy women, of the anus. The floor of the chancroidal ulcer is usually covered with a more or less tenacious slough resembling wet chamois-skin, and presenting in this particular a marked contrast with the shallow, scantily secreting, indurated, and sloping edges and floor of the initial lesion of 46 SYPHILIS AND THE VENEREAL DISEASES. syphilis. Lastly, the accidents of sloughing, phagedena, and enormous involvement of the skin and the subcu- taneous tissues of the thigh in ulcerative and burrowing sinuses are almost unknown in syphilis of the cleanly, and are by no means of very rare occurrence in chan- croids of all classes of patients. The lesions of herpes progcnitalis are very readily differentiated from syphilitic chancres. The former are transitory, lasting at the longest for but a few days — a feature of prime importance in establishing a diagnosis, for any so-called " herpetic lesions " followed by ulcers lasting for ten days are probably not such, and should be viewed with great suspicion. Herpetic lesions in the progenital region are essentially vesicular, and are visi- ble either as vesicles or as the relics of vesicles in the form of very superficial reddish plaques, where delicate and lightly-tinted crusts appear, or as slightly raw and tender, finger-nail-sized spots, furnishing a serum suffi- cient in quantity to moisten an applied bit of cotton. Their cause, further, may often be determined without great difficulty (venery, pollutions, gastro-intestinal de- rangements such as constipation, chills, gouty attacks, etc.). Balanitis. — In this affection, as in herpes progenitalis, the disease, as distinguished from all varieties of chancre, is always short-lived and yields readily to treatment. In typical lesions the mucous membrane of the sac of the prepuce and of the glans penis becomes reddened, tumid, and in extreme cases of a deep purplish hue, with super- ficial excoriations of the external layer of the membrane in plate-like, finger-nail-sized plaques, which can be studied best in a well-marked case of blennorrhagia of the conjunctival membrane. There arc distinct sensa- ACQUIRED SYPHILIS, 47 tions of itching and burning in the part, and the odor of the secretions is usually nauseous in consequence of the altered character, in this part, of the secretion from the glands of Tyson. There is no induration, no gland- ular complication, and never ulceration. The disorder is usually relieved, when not complicated, in the course of a few days by the application of a stimulating vinous lotion aided by astringents, a thin layer of absorbent cotton being interposed between the two folds of mem- brane in contact. Verruca Acuminata (" Venereal warts," Moist warts, Condylomata, etc.). — Filiform, papilliform, single or mul- tiple, often numerous, vegetations may develop, for the most part in the progenital region of the two sexes. These warty growths are usually pedunculated, but at times are flattened. They secrete a mucoid fluid of offensive odor; this fluid in syphilitic subjects is highly contagious. The growths vary in size from a pin-head to compound masses as large as the fist and even larger. As distinguished from chancres, they are never indu- rated, they rarely ulcerate, they are not accompanied by adenopathy, and they survive for periods of time far out- lasting the life-history of even persistent initial lesions of syphilis. They may occur in virgins, but they are more common in the subjects of venereal disorders, as also in those suffering from leucorrhoeal and other pathological fluids bathing the genital region. Rarely they have an extra-genital site, such as the face. In males they are apt to form in the sulcus behind the corona glandis, about the fraenum, in the external orifice of the urethra, and over the scroturn; in wom^en, chiefly about the four- chette and the labia. They are readily recognized by their resemblance to the comb of a cock, bv the absence 48 SYPHILIS AND THE VENEREAL DISEASES. of ulceration and of induration of the base, and, when wiped clean, by their florid aspect and theirj;eadiness to bleed when scraped or cut away. EpitJiclioma of the genital organs occurs most com- monly after the middle periods of life in both sexes — ages when chancres are decidedly of less frequent occur- rence than at others. In men the most frequent site of the disease is the glans penis, where a circumscribed, flattened papule, verrucous elevation, or shallow erosion may occur. The period of duration of these lesions is for most cases far greater than that of either chancre or gumma. The base of one or two of these primary growths may become indurated and the neighboring glands may enlarge ; but the inactive, often slightly hemorrhagic or crusted papule or warty growth seated upon an infiltrated tissue, with an ulcer forming only after a long evolution of the primary symptom of the disease, is not to be mistaken for a chancrous lesion. When actually ulcerating, the resulting ulcer is of the type of the epitheliomata of the skin in general, with serous, scanty, or bloody secretion, everted edges, and excavated, often eroded, floor. For women the region of preference in the progenital forms is the clitoris, where the lesions above described may occur occasion- ally with striking deformity of the parts. The non- inflammatory, often scarcely colored thickenings, ero- sions, warty growths, etc. of both labia and clitoris, in women past the menopause, are all to be separated from chancrous changes. Mollusenni epitheliale of the genital region in young persons, especially those of the male sex, is characterized by the occurrence, on the scrotum chiefly, of split-pea- sized, yellowish-white, waxy-looking, and imbedded or ACQUIRED SYPHILIS. 49 projecting bodies, usually exhibiting at one point or another of their globular surface a whitish or blackish punctum representing the occluded orifice of a sebaceous gland. They may be few in number, but often they are exceedingly numerous, studding the region affected with isolated but closely approximated lesions. They are never ulcerated, indurated, inflammatory, nor the seat of evidence of any acute process. It is impossible for the trained physician to mistake them for chancres, but the error is occasionally made by young and timid lay patients, who, having for good reasons become anxious about exposure to disease of the affected part, discover for the first time, on careful scrutiny, the molluscous bodies, and are filled with terror at the sight. There is never any _^landular complication of these simple lesions, and in any doubtful case the expression of the cheesy mass from the orifice of the gland would establish the diagnosis. Liclicn planus of the genital region, particularly in the male sex, is at times liable to be mistaken for chancre. But the lesions are always papular, dry, and flattened at the apex, with a singularly characteristic polygonal out- line, often very sharply defined. They are never seated on an indurated base, are not accompanied by glandular enlargement, are not eroded nor ulcerated, and are usually multiple, with at times marked invasion of the skin of the lower belly and the adjacent region of the thighs. An interesting feature of lichen planus of the genital region is the grouping of the lesions in lines, so that at times half a dozen or more of the small crimson, reddish, purplish, or dull leaden-hued papules stretch in a direct line from one point to another over the dorsum of the glans penis, in the skin of the organ. Angular as well as rectilinear figures, and even odd-looking 4 ~~^ 50 SYPHILIS AND THE VENEREAL DISEASES. cockades, may thus be formed. Lichen planus lesions of the genital region are often the seat of_ intense, itch- ing, and may be well scratched with the evidences of such traumatism upon and about them. They com- monly persist for a period of time much longer than that limiting the continuance of chancres. Psoriasis of the genital region is exposed in well- defined disks covered, as a rule, with large-sized lami- nated scales, the disks varying in size from a pin's head to that of a silver dollar and even larger. The\' occur upon the skin of the penis and the scrotum, with fre- quent involvement of the pubic region, lingering near the line of the hair and projecting beyond the latter upward and downward. The absence of secretion^ of induratio_n, of ulceration, and of glandular complication, and the frequent presence of the disease in other regions of the body, suffice to determine its character. TJie late gnnnnatous {^'tertiary'') lesions of general syphilis occurring in the genital region are exceedingly liable to be mistaken for chancres. Here the diagnosis rests upon the discovery, elsewhere upon the person, of the relics of a preceding syphilis, the frequenth' obtain- able history of such a disease, the well-marked tendency of the late deposits of syphilis to ulcerate and spread by serpiginous destruction of the tissue involved (a rare complication of infecting chancres), and often upon a history of persistence of the gummatous thickening or ulceration for a time longer than that required for the fullest evolution of both chancre and general consecu- tive syphilis. The chancres of the syphilized, previously described, are often illustrations of this singular process, suggesting the origin of the mucous patch in the mouth of the tobacco-chewer, and in doubtful cases only the ACQUIRED SYPHILIS. 5 I most careful study will suffice to distinguish between the two.' Pathological Anatomy of Chancres. — As the syphi- litic chancre is like and unlike all other cutaneous and mucous lesions, and as the eruptions of syphilis are like and unlike all cutaneous affections, so the minute anatomy of chancres resembles that of many other pathological formations. Under the microscope one finds granulation-cells within reticulated fibrous meshes, and cell-infiltration partially or wholly blocking up the lumen of the vessels. Where erosions have occurred, naturally the epidermis is in various degrees removed, and the papillae, with little or none of the rete left, are exposed or are even in great part removed. The characteristic induration of the chancre is due in part to new-formed connective tissue and in part to epidermal thickening. It is highly probable, however, that the lymph of the part is profoundly affected by a special ferment produced by the bacilli responsible for the disease, when the latter first multiply in exterior regions of the body. The absence of dense induration of chancres of the vagina and the cervix points conclu- sively to the fact that induration is a condition of site rather than of infarcted vessel or of multiplying connec- tive-tissue fibres ; and the extreme indurations seen at the muco-cutaneous margins of the body point equally to the action in those regions of a special influence upon the effective germs of the disease. Treatment of Chancre. — Persistent efforts have been made from time to time to set aside the possibility of ' P'or a tabulated summary of the diagnostic ditiferences between chan- cre and other genital lesions, consult the section devoted to the subject of Chanc7'oid. 52 SYPHILIS AND THE VENEREAL DISEASES. syphilis following chancre by the radical destruction of the latter. The reasonableness of success in these efforts is on rt- //wr/ grounds so great that in all proba- bility they will never be abandoned wholly, but the actual results have thus far been disappointing and, for reasons that need not here be set forth, are enveloped in considerable doubt. The destruction of chancres by chemical agents and by the actual cautery has repeat- edly failed not only to relieve the local symptoms, but also to prevent the occurrence of general s}'mptoms. The same may be said of total excision of the primary lesion, and even of total excision of both primary sore and all the glands in the neighborhood involved in the disease. When the chancre, as is usual after cauteriza- tion, exhibits increased induration of its base, even though it may not be affirmed that the ensuing disease is the graver for the complication, it is certainly true that the chancre is less manageable than before. In some cases exceedingly grave destructive ulceration following gummatous deposits has occurred in patients where these attempts have been made with all possible precautions to jugulate the disease in sound men. In this connection it must not be forgotten that even experts may be deceived in the recognition of both the chancres of syphilis and the lesions closely resembling the latter ; and this possibility of error should not be ignored by the practitioner who is reasonably judicious. There is still a division among authorities on the ques- tion whether the initial sore is merely a local point from which, after sufficient multiplication, the microbe of the disease or its toxine is swept through the general economy, or whether the chancre is the local expression of an intoxication generalized at the outset. ACQUIRED SYPHILIS. 53 All chancres should be treated by strict observance of the requirements of hygiene. The affected part should be cleansed with warm water and soap, after which washings in hot borated solutions should be employed. In the event of tenderness or pain, as in the case of chancres of the pendulous portion of the penis, the part, when practicable, may be immersed in hot solutions of boric acid often each day, or even in extreme cases for hours at a time. After drying, the chancre should be well dusted with powder, such as boric acid (or boric acid and talc, i part to 4, when the acid itself is at all irritating), europhen, aristol, hydro- naphthol(i part to lOO of fuller's earth), calomel (or i part of the latter to 3 or 4 parts of starch), or iodoform when the odor of the drug can be tolerated, and especially in the case of painful, intractable, or irritable chancres. When erosions form, having a raw, reddish, slightly secreting surface, and also when ulceration occurs, it is generally well to paint the surface of the sore, after the washing and before the application of the powder, with a sokition containing from i to 2 grains of the bichloride of mercury in the tincture of benzoin. The drying, over the eroded surface, of the gum thus medicated is usually not unpleasant to the subject of the disease, and is also cleanly, protective, and efficient as a parasiticide. After all applications have been made, the surface, when prac- ticable, should be guarded from contact with neighbor- ing parts, not with a view to' the prevention of auto- infection (which in these cases is not to be feared), but in order to set aside the possibility, always great, of irritation of the sore. In the instance of chancres which may be by this means sufficiently well dressed (sac of the prepuce, fraenum, etc.), when practicable, it is well to 54 SYPHILIS AXD THE VENEREAL DISEASES. draw the foreskin well over the interposed Hnt. As a rule, when the chancres are large and tender the male organ should be wrapped in a thick jacket of mercurial- ized wool and be brought up in the line of Poupart's liga- ment before the clothing is readjusted. Elastic or other ligatures should never be fastened about the penis. In women the labia, when similarly affected, should be separated by antiseptic cotton, and for chancres of the cervix pledgets of lint, after dressing the part, should be pushed against the os with tampon supports. For these chancres the mercurialized benzoin lotion is an excellent application. Lotions often useful when chancres prove irritable under other treatment are the ordinary black wash, pure or diluted, and applied by the aid of moistened pledgets of lint ; tannic acid and red wine, i part of the former to 30 of the latter; in some cases the lead-and-opium wash. As a rule, all salves and unguents are to be discarded in the manage- ment of chancres. The chief exception to the rule is furnished by lesions which secrete a fluid gluing the dressing so tightly to the part that when the lint which has been applied is removed no little pain is experienced and slight hemorrhage ensues. In this event, after the applications described above, the sore should be dusted, and then there should be applied lint on one face of which (that next the chancre) has been smeared car- bolized vaseline. In the management of chancres of the urethral orifice a bit of medicated lint may be introduced into the gaping orifice if required ; but the most important of the meas- ures to be followed is the immersion of the penis, when- ever practicable, in a basin of warm water at the time of each urination, as by this means the urine is in a measure ACQUIRED SYPHILIS. 55 diluted at the time of its traversing the sore. Weak solu- tions of the nitrate of silver, employed not as a caustic agent, but with a view of making a satisfactory dressing of an eroded surface, may also at times be used with advantage. The question whether the treatment of syphilis should be begun at the date of recognition of the chancre or at the time of the appearance of symptoms of general syphilis is considered elsewhere. Internal medication, however, of a patient affected with a chancre which has been recognized as indubitably an initial lesion of syphi- lis is by no means necessarily the treatment of that syphilis. Infecting chancres are peculiarly responsive to a properly-directed treatment by internal medicine, and the refusal to employ the latter is unwarranted when the diagnosis is practically assured and the lesions are either painful, portentous, or the source, as is often the case, of much mental distress to the patient. Mercury by the mouth is in these cases the one efficient remedy. It should not be ordered unless the diagnosis is satis- factorily established. In the majority of all cases com- ing under the management of experts the diagnosis is practically ensured from the first, either as the result of confrontation (discovery, in the person from whom infection was received, of lesions capable of conveying the disease) or of the recognition of classical features of an initial sclerosis in the person acquiring the sore. It should not be forgotten, then, that the mercurial treatment of this period is a treatment directed to the chancre, and not to the as yet undeveloped disease to which the chancre points. If this be borne in mind, the end is readily reached. The metal should be used 56 SYPHILIS AXD THE VENEREAL DISEASES. or disused, pushed to a higher dose or reduced in the quantity administered, according as resolution of the sclerosis is announced, the erosion begins to heal, and the affected part to assume its normal character as to size, color, and freedom from obvious lesions. The preparations employed are those useful in the general management of syphilis, to which reference may be made. The protoiodide of mercury in doses of from ^ to ^ grain, calomel in doses of from ^^ to \ grain, gray powder, the bichloride (less preferable for this special purpose, as, in the doses ordinarily well tolerated, its operation is slower), and the biniodide may each be employed. In all cases of anaemic patients the hygienic and tonic remedies useful in the management of general syphilis should regularly be employed. " Mixed " chancres do not call for destruction by cauterization. They are often tender and painful, and in these cases much trouble may be avoided by earh' and persistent use of the hot borated immersions and wash- ings described above. The buboes accompan^-ing syphilitic chancre often require no treatment beyond that advised for the initial sore, whether local or by internal medication, as the progress of the one toward a favorable issue, or the reverse, is usually proportioned to the improvement or aggravation of the other. Often the glands are neither large, painful, nor tender, the patient scarcely appre- ciating the fact of their undue size and hardness. In other cases they are voluminous and are the source either of local distress or of discomfort experienced in the movement of neighboring parts (leg, thigh, arm, jaw, etc.). In this condition frequent ablution of the glands with water as hot as can be tolerated is the best, simplest, ACQUIRED SYPI/IL/S. 57 and most grateful method of treatment, followed, when needed, by a weak mercurial salve well rubbed into the skin covering the glands — ammoniated mercury, 10 grains to the ounce of lanolin and vaseline ; mercurial ointment, i part to 10 of simple unguent. To either salve, when there is much pain and tenderness, a small quantity of the extract of belladonna or of the watery extract of opium may be added. These unguents should, however, be not too amply supplied with drugs of the narcotico-stimulant class, as, even in the strength of 10 grains to the ounce, systemic effects have been induced after application to the groin. In the event of " mixed " bubo there commonly results abscess of the glandular contents and either spontaneous or artificial opening of the same. The treatment of this complication is that of the bubo of soft chancre. With the healing of the chancre, when this is secured before the onset of general symptoms, ends a tolerably well-defined phase of syphilis, the period once called that of '* primary syphilis," the period of lesions for the most part localized. Yet here, even at the outset of the evolution of the disease, it is made clear that no sharply-defined limits or periods are observed. For, as has already been shown, the chancre may at times persist long after general symptoms have been declared, and traces of it may be discernible even when grave complications of general intoxication have occurred. The Evolution of Syphilis in Stages or Excur- sions. In the early part of the present century Kernel and Hunter were followed by the late eminent Philip Ricord in establishing for the evolution of syphilis an artificial 58 SYPHILIS AND THE VENEREAL DISEASES. system based upon chronological data. This system commended itself to the medical men of the scientific world, and as a result it secured at an early date almost universal acceptance. According to this scheme, there were three " stages " of the disease : a " primary " stage, inclusive of the period of the infecting chancre and its accompanying adenopathy; a "secondary" stage, last- ing from a few months to two or three years, in which appeared most of the syphilodermata and the disorders of the appendages of the skin and the mucous mem- branes ; and a "tertiary" stage, lasting indefinitely from the close of the secondary period until a final result was reached either in one direction or the other, with the absolute cessation of the malady. In this latter stage occurred most of the affections of the deeper tissues, of the viscera, the bones, the testes, the nervous centres, and the fibrous and subcutaneous structures. The "secondary" was supposed to follow the "primary," and the " tertiary " was supposed to follow the " sec- ondary " stage. The objections to this chronological scheme have been multiplying for the last few years, until it has become needful either to abandon wholly its ingenious suggestiveness or to admit it and its conclusions only with exception and reserve. First among these objec- tions may be named the implication that a classical syphilis should in its evolution persist throughout these three " stages ;" the fact being that, as statistics clearly indicate, the largest number by far of all cases of syphilis never exhibit any signs of a "tertiary" stage. Second, the implication was made that in any given stage, especially in the so-called " secondary," the evolution of symptoms observed a definite order like ACQUIRED SYPHILIS. 59 that of the " stages," one crop, for example, of syphilo- dermata following another in a definite procession of symptoms ; the facts being quite opposed to such a course, seeing that a syphilis thus regularly evolved, however conformed to the artificial time schedule of the schools, is clinically never seen. Third, there was overlooked or ignored a series of facts in which the chronological order of the scheme was violently reversed, so-called " tertiary " symptoms following " primary " without the evolution of any lesions which properly belonged to a "secondary" stage; while even the symptoms of the " secondary " period were at times found to succeed instead of preceding those described as " tertiary." Lastly, a fact of serious importance in the study of syphilis was to be considered — the fact that many, if not actually the larger number, of all cases of grave disease are thus grave from an early moment in the career of the malady, so-called "tertiary" symptoms developing with a degree of rapidity as startling as it is portentous. It was in recognition of these obvious and numerous violations of their chronological system that the French have been obliged to coin such explanatory phrases as "precocious," "late," "tardy," "galloping," etc. — terms confessing the inadequacy of the time schedule, and yet employed not in the ordinary course, but in the grave crises of the malady — epochs when a fairly good working system should be ready and fitted for every emergency that may arise. In order to grasp intelligently the facts of syphilis as they actually occur, it is well to make no attempt to force them into accordance with an artificial scheme, hovvev^er cleverly arranged and readily understood, but rather to classify them in natural divisions. Thus 6o SYPHILIS AND THE VENEREAL DISEASES. studied, it will be seen that for the vast number of all cases of the disease there is no fixed Hne of demarcation between its consecutive phenomena, and no fixed period of time in which any given series of symptoms will be begun or concluded. From the moment of infection to. any conclusion which the disease may acknowledge there is a regular progression, not- along one line, but along many lines, and these lines never alike or parallel, but divergent in a thousand directions. By classifying in certain groups these excursions along various routes a systematic knowledge of the evolution of syphilis may be obtained. Instead of a chronological schedule, one may more profitably, to use a different figure, employ the radii of a circle to represent to the mincTthe divergences of the different symptoms of syphilis from the fixed pathological centre represented by the initial lesion. The most of syphilitic histories may be traced along the lines of advance represented by the four divisions hereinafter described. From the point of infection each of these lines of advance, or excursions, represents, it should be remembered, not a narrowly-bordered path- way of symptoms, but a general direction, with varia- tions deflected on either hand to div^ergences from other directions — no single history, perhaps, following exactly the same course, but each trending near one or another of the excursions defined. I. Benignant Syphilis with Mild and Transitory Symptoms. — Upon one extreme in this category are the cases in which typical initial scleroses with characteristic accompanying adenopathy are followed by symptoms which are either not at all appreciated by the subject 6f the disease or which barely suffice to awaken his or ACQUIRED SYPHILIS. 6 1 her attention. A slight efflorescence upon the abdominal surface, a few days of malaise, and the disease is at an end, irrespective of any treatment whatever. It is true that it has been claimed that grave syphilis eventually follows, but a sufficient number of these patients has been observed to substantiate the fact of a further complete immunity from all signs of the disease. Similar facts have been recognized in attempts at the production of the infectious granulomata in the lower animals, and even in the vaccination of heifers for the purpose of cultivating vaccine virus. There are simply some individuals who seem to be protected against the incursions of the disease by reason of an individual idiosyncrasy. II. Benignant Syphilis with Relapsing- or Per- sistent Superficial Symptoms. — This is the excursion observed, in all probability, in the larger number of all cases of syphilis occurring in the white races, and especially among those inhabiting the northern por- tions of the American and European Continents. In this category are to be recognized the patients in whom typical chancres are followed by characteristic so-called "early" manifestations of general syphilis. But all the lesions which result are superficial, and whether, as is often the case, they prove relapsing or persistent for long periods of time, involution is finally reached with- out the production of any permanent relics of the pro- cess. These histories are usually those of skin-symp- toms (papules, scales, etc.) disappearing and reappearing — disappearing on the intervention of proper treatment, reappearing after neglect or discontinuance of the latter, or when the health, for any intercurrent reason, has been impaired, but never throughout producing a pro- 62 SYPHILIS AND THE VENEREAL DISEASES. found depression of the system nor inducing cachexia. The disease from first to last has been a serious annoy- ance rather than a formidable enemy, and if the cause were not known and the results had not been dreaded, but little anxiety would have been awakened by its encroachment. It is these cases that furnish abundant proofs of the skill of the trained ph\'sician, and also of the tremen- dous energy exerted upon the health by its worst enemies, lack of proper hygiene, alcoholism, senility, debauchery, poverty, and prior wasting disease. The cases included in this category may without warning, and often inexplicably, exhibit the symptoms enumerated in any of the other excursions described ; but it is true that the majority of all cases under observa- tion develop along the line here suggested — that of symptoms relapsing or persistent and superficial, and, however persistent, never ultimately followed by destruc- tive results. In other words, patients of this large class, as a rule, entirely fail of exhibiting symptoms of the type described as " tertiary." III. Malig-nant Syphilis with Relapsing or Persist- ent Profound Symptoms. — In this category are included the cases eminenth^ of transitory type. They are speedily transferred by the best of management into the list of benign cases, or with and even without treatment are readily exchanged into the graver list of malignant cases catalogued in the fourth of the divisions here con- sidered. The malignancy of these cases is declared in the deterioration of the tone of the system, in the produc- tion of cachexia, and in some cases by the degeneration of lesions which in other patients are resolved without ACQUIRED SYPHILIS. 63 producing permanent relics of the process. Here at times develop in the viscera, nerves, bones, etc. gum- mata which resolve under appropriate therapy ; at other times, when degeneration occurs, the repair is either satisfactorily good, or the damage resulting is so slight as not to interfere with the bodily health. The element of gravity is lacking in each case, however portentous at any one time may be the extent or the depth of the invasion. Often it is the fewness and depth, rather than the number and degeneration, of the lesions that justify the designation " malignant." It is in this class of patients, as in that just discussed, where the brilliant results of medicinal and hygienic treatment of the disease are most effectively exhibited. IV. Malig-nant Syphilis with Relapsing or Pro- found Lesions that are Ultimately Destructive. — In this division, represented probably by from 5 to 20 per cent., at the most, of all cases of syphilis, are cata- logued the number of patients exhibiting signs of what may justly be described as grave syphilis. Here the disintegrating and ulcerating gumma destroys renal, nervous, hepatic, and osteoid cells, pierces through bone and cartilage with appalling rapidity, converts into one hideous chasm both the nasal and the oral cavities, produces the paralytic, the imbecile, the repulsively deformed, and at times pushes its destructive forces to a fatal result. For the most part, however, in acquired as distinguished from hereditary syphilis, even in grave cases a fatal result is not so much to be anticipated as is serious damage of the sort suggested. Syphilis in its worst manifestations and activities often mutilates, para- lyzes, and cripples, but it rarely kills. In this connection it is worthy of note that the fright- 64 SYPHILIS AND THE VENEREAL DISEASES. ful consequences which hedge about the track of the disease are not more conspicuous than the rapidity with which it traverses its path. Often before the last traces of the infecting sore have disappeared the hard palate is perforated, the body is covered with sloughing ulcers, or the liver is stuffed with ominous nodules. Here there has been no chronological order, no possible interval for the occurrence of a " secondary " stage, no pause in which even the best of treatment might have averted the conclusion. It is these cases that have necessitated on the part of the French — who still, for the most part, adhere to the chronological order of syphilitic manifesta- tions — the adoption of such phrases as " galloping," "precocious," and "lightning." Indeed, of all cases of syphilis really entitled to be termed ** malignant," it may be affirmed that the majority bear the impress of such malignancy in the rapidity of progress of the malady. It is in this division also that the great triumphs of science may be achieved. Even in the worst phases of syphilis — those chiefly displayed in the fourth of the classes here enumerated — repair may be made to ensue when the destruction has been gravest and the systemic results are most profound. Between these four radii most of the excursions of syphilis may be discerned. These lines are not all rectilinear; many lie along or near the main divisions, but pursue a tortuous course from chancre to complete relief of all symptoms, the line now curving toward malignancy, now recurving to the other side. As a rule, the graver the case the straighter the excursion ; the milder the s}'mptoms the more numerous the ACQUIRED SYPHILIS. 65 deflections toward one side or the other, with no wide divergence to either. Rarely the course of syphiHs is to be represented by a Hne wholly diverted from the first to the fourth of the main divisions of the circle here suggested. The determining influences which result in these divergences are of the highest importance. First among all may be named the character of the soil in which the germ is implanted. The very young, the very old, those weakened by other maladies, by lack of food and of proper hygienic environment, the victims of drink, of debauchery, of poverty, of inherited weakness, — all suffer early and often from the added burden of syphilis. Second is to be named the early and effective intervention of proper treatment. Cases which have been neglected, those in which the disease has long been either ignored or treated inefficiently, are apt, before others, to display formidable symptoms. A third cause is described by authors as the complication resulting from the implantation of the germ of syphilis upon the system contaminated with tuberculosis, struma, and such cognate disorders as rickets, but these coinci- dences are much rarer than is generally supposed. Fortunately for the future of the human race, the sub- jects of acquired syphilis are, as a rule, between the middle of the second and the conclusion of the third decade of life — ^a period when the system is best fitted to endure the severe ordeal to which, in this affection, it is reasonably sure to be subjected. With the ample opportunities for good treatment afforded in the English- speaking countries of the world, the majority of all vic- tims of disease eventually escape payment of its severest penalties, marry, and beget healthy children. Though 6 66 SYPHILIS AND THE VENEREAL DISEASES. afterward they may in some degree be reminded of their old enemy, even as the victim of an ancient pneumonia or a broken thigh has reason at times to recall his for- mer mishap, they go to their graves as do other men and women, with diseases of a different type, and with con- sequences unchanged by the infection wrought at an early period of life. The Evolution of Syphilis Subsequent to the Chancre. It has been shown that chancres may persist to a point of time long after the exhibition of signs of gen- eral infection. Often, however, the period which may be described as the chancre-stage has been completed fully before such general symptoms appear. The term " primary syphilis," as has been shown, was once em- ployed to designate this chancre-stage, and the next period of evolution of the disease was, as distinguished from that which preceded and that which followed, called the stage of " secondary syphilis." Between the two periods it was believed and taught that a distinct interv^al of pause or arrest occurred ; this interval was given the title of " the second incubation," as subse- quent in time to what was called " the first incubation " of the chancre. It is true that in many cases an appar- ent delay occurs after a distinct conclusion of the chancre- stage before general symptoms of syphilis are declared, but it is equally certain that in other cases there is no appreciable delay, and that in yet others, where such delay or pause seems to occur, it is due to an apparent rather than a real incubation. Its features, when studied with the utmost care and skill, are declared both in the skin and elsewhere as symptgrns of the gradual evolu- ACQUIRED SYPHILIS. 6/ tion of the infective disorder, without any well-marked arrest. The wide range ascribed to this period of sup- posed incubation — from a few days to as many months — is a sufficient indication of the lack of precision involved in the use of the term. In general, it may be said that from the date of the appearance of a chancre to that of appreciable general syphilitic symptoms from forty to fifty days may elapse. This supposed period of incubation is without question shortened in malignant and rapidly-evolved cases, and is lengthened in those where an excellent constitution of the patient, excep- tionally good treatment, or the mildness of the dis- order has interposed a barrier to the extension of the malady. It is wellnigh demonstrable, with the ample means at the disposal of the expert, that from the moment of the appearance of the chancre to the date of the onset of the earliest symptoms of generalized disease the signs of a gradual intoxication are with each day of its advance progressively apparent. These symptoms, often at first obscure, become usually much more obvious as the term of the supposed incubation draws to its further limit. Even, however, to the gross observation of the eye the victim of infection loses at the outset the usual appearance of health, and exhibits another which gradually acquires characteristic features — features by which, at times, the stadium of the disease may be recognized. The skin, especially of the face, which is most often exposed to the eye of the observer, assumes a pecuhar sallow or muddy hue varying from a yellowish shade to a deep reddish, somewhat empurpled tint. The facial expression may be one of dejection ; there is often 68 SYPHILIS A AW THE VENEREAL DISEASES. cephalalgia, anorexia, vague or very well marked rheu- matoid pains, headache and backache, lassitude, neur- algia of various nerve-trunks, and, in cases, typical jaundice. By due exploration it may be discovered that transitory effusions have occurred beneath the perios- teum of exposed bones : there may be retinal hyper^emia, hepatic and splenic enlargement, or albuminuria. The percentage of the oxyhaemoglobin decreases with the number of the red blood-corpuscles, while the leucocytes increase. It is during this period also that there occur thermal changes which have been summed up rather loosely under the term " syphilitic fever." The febrile symptoms recognized in an early or a late phase of syphilis occur neither with sufficient frequency nor with sufficienth* characteristic features to justify the employment of a distinctive term. These thermal varia- tions are most often of early occurrence, either before or soon after the exhibition of constitutional symptoms, and are in general due to the reaction of the system against the recently-introduced and multiplying toxine of the malady. Abnormal thermal variation may be wanting in more than 50 per cent, of all cases examined, or may be so slight as scarcely to attract attention ; or it may be in a high degree pronounced, the physician, unaware of the precise cause of the disturbance, not infrequently assum- ing that the patient is suffering from a tertian or quotidian miasmatic fever. In well-marked and classical cases the temperature prior to the earliest eruptive phenomena rises to 103° and even to 106° F.,and may then assume a continued or intermittent type with vespertine exacerba- tion. The fever is rather more often observed in the cachectic and weak than in the strong, and is often a precursor, when well marked, of a severe type of con- ACQUIRED SYPHILIS. 69 secutive symptoms. It is said to be more common in women than in men, but on this point there should be great reserve. Fevers occurring in other stages of the disease are usually symptomatic of destructive processes due to the disease ; though it is to be noted that the subject of syphilis is often in a depressed condition, and furnishes a large field for the invasion of intercurrent disorders, such ^s la grippe diwd tonsillar and bronchial affections, several of which may excite febrile reactions not directly connected with the specific affection. Involvement of the Lymphatic Glands. The syphilitic bubo, or specific induration and enlarge- ment of certain glands in anatomical proximity to the site of infection, has already been described. It is at a period later in the evolution of the disease, and usually at or near the close of the so-called period of " second incubation," that the lymphatic system (the glands, more particularly, of the several accessible regions of the body) exhibits characteristic changes. In well-marked cases one, if not quite all, of the glands which may be appre- ciated by the touch of the observer becomes enlarged, euG^orged, soft, and voluminous, as distincruished from 00'' ' & the densely-indurated buboes accompanying the chancre. This ganglionic engorgement is one of the most constant of the signs of systemic syphilis, and though at times it may escape observation or actually be absent, it is so conspicuous a feature of some cases that patients themselves often call attention to it. At a given mo- ment it may be the sole appreciable symptom. It betokens, when well marked, a general intoxication, and, though not always proportioned to the intensity of the disease in any given case, it occurs at times as 70 SYPHILIS AND THE VENEREAL DISEASES. the result of an individual predisposition to lymphatic disorders. The glands most often exhibiting these changes are the post-occipital, the chain extending along the pos- terior border of the sterno-cleido-mastoid muscles, the supraclavicular, the inguinal and axillary, the epitroch- lear, the submaxillary, the submental, and the femoral. At times the lymphatic trunks leading to these glands exhibit similar changes. The tumefied glands vary in size from that of a bean to that of a pullet's ^^^ ; they are usually rounded or oval in contour, smooth to the touch, and painless ; at times, however, they are very tender, and, when not overlying bony tissue, movable. They have no ten- dency to degenerate, in this respect exhibiting a very noticeable difference from the syphiloma, or gummatous involvement, usually of a single gland, occurring early or late in cachectic subjects. The syphiloma has a uniform tendency to become at one point or another reddened and porky to the touch, and it soon breaks down into a characteristic abscess. The voluminous and softish ganglia of early syphilis are found on examination to be constituted by a small- celled infiltration of the lymph-channels and a succulent fulness of the tissue about the latter. Resolution is by the ordinary absorptive processes. Syphilitic Cachexia. The anaemia and leucocythaemia of syphilis occur either as a direct and sole result of systemic intoxication or as the indirect result of the latter in individuals predisposed to cachexia in consequence of an enfeebled condition of the system or of constitutional inheritance. This condi- ACQUIRED SYPHILIS. yi tion is well seen in the infantile forms of the disease and in the victims of debauchery, drink, poverty, hospitalism, filth environment, and of other affections than syphilis. Tuberculosis, rickets, and scrofulosis are less frequently responsible for this condition than is generally believed. The symptoms of syphilitic cachexia may be declared early or late — in the former event usually toward the close of the pre-exanthematous stage of the disease ; in the latter case at any time when the system exhibits signs of exhaustion in consequence of gummatous changes in bone, periosteum, nerve, or other important tissue of the body. The signs of cachexia are a peculiar dull-tinted pallor of the skin, with vague pains, persistent weakness, flab- biness of the tissues, a distinct whiteness of the con- junctivae, emaciation, and manifest disturbances of digestion, assimilation, and excretion. This condition, which may be produced solely by the disease and which may be relieved greatly by a properly-directed ferruginous and mercurial medication, may without question be induced or aggravated by the injudicious emplo\-ment of mercury in the treatment of the disease. Syphilis in Relation with Coincident Injuries and Accidents. It was at one time believed, largely on a priori grounds and after insufficient observation of cases, that syphilitic infection, if relatively recent, predisposed its subject to the exhibition of special lesions or special disturb- ances when exposed to traumatisms or to diseases of a different origin. These views have been changed radi- cally since the date of a wider knowledge on the subject of the antagonism of toxines. 72 SYPHILIS AXD THE VENEREAL DISEASES. As a matter of fact, the subject of recent syphilis exhibits a tendency to the production of lesions at sites of irritation (condylomata about the uncleansed anus ; mucous patches of the mouth irritated by tobacco, smoked or chewed; palmar lesions of the hand-worker); but it is also tolerably clear that for the most part syphilitic subjects undergo surgical operations (cachexia and its coinplications aside) with very much the same results as in the non-infected. They also exhibit the classical sig-ns of local irritation, not different from those seen in others (urticaria from the attacks of vermin ; erythematous redness on the application of a sinapism ; zoster after exposure of a nerve-trunk to the predispos- ing causes of that affection, etc.). It is now accepted that all pus-production in syphilis is the result of mixed infection, and that the staphylococci multiply in its sub- jects as at other times and in other persons. On the supervention of other typical disorders in those under the influence of syphilis, the result is con- ditioned upon the proportionate activity of the one or the other malady. Recently-infected syphilitic subjects ex- posed to typhoid fever speedily lose all symptoms of the original and exhibit all classical features of the later dis- ease, even to the date of a slow and apparently typical convalescence. On the re-establishment of the health the syphilitic affection, after an apparently absolute quies- cence for weeks, resumes its former activity, and the progress of the infective process seems to be resumed at the point where it was temporarily interrupted. Considering the number of both tuberculous and syphilitic subjects in large cities, it is a matter of great surprise that experts are so seldom confronted with the coincidence of the two affections in one indi- SYPHILIS OF THE SKIN. 73 vidual ; the same may be said of syphilis and of carci- noma, though the different ages of the patients hable to display early symptoms of these two affections may here exert some influence upon the statistics. An attack of erysipelas has often cleared the skin of syphi- litic lesions, and, even when occurring in a patient whose luetic affection was grave, has emphasized the date of a recovery without further relapse. Indeed, of the larger number of all injuries and diseases occurring as acci- dents of the period when the subject of syphilis is dis- playing evidences of his disease, it may safely be asserted that they proceed to a conclusion which would have been anticipated if no systemic infection had existed. Syphilis of the Skin. In hereditary syphilis the bones or the viscera may first nianifest the signs of the affection, since the new being is vitiated ab ovo. In acquired syphilis, on the contrary, the most obvious of the early lesions of the disease are perceptible in the skin and its underlying connective tissue and upon the mucous surfaces as well as in the superficial lymphatic glands and vessels. " Syphiloderma " is a term used to include many of these superficial lesions, the early eruptive and late infil- trations and deposits being termed " syphilodermata," or, as the term has been anglicized since its first employment by the French, sypJiilidcs. The word "syphiloma" is generally restricted to (late) gummatous deposits in the several organs of the body, not merely in the skin, but also in the bones and the viscera. The study of the eruptive symptoms in syphilis is of the very greatest importance not only for the expert, 74 SYPHILIS AND THE VEXEREAL DISEASES. but also for him who aims to be an accurate diagnos- tician in any department of medicine. He who cannot properly interpret these significant symptoms is usually not merely an ignorant but an unsafe practitioner. The peace of families, the conservation of the marriage relation between husband and wife, the reputation of an innocent girl, and the health of uninfected men, women, and children may all be hazarded by the decision of a single case. General Features and Relations of the Syphiloder- mata. — Syphilis may invade every organ of the body ; it may also involve any portion of the skin. As the chancre may be situated on any part, so the syphilo- derm may develop upon any given point of the bodily surface. As it has been seen that the chancre may be represented by every one of the several elementary and consecutive lesions of the skin, so the syphilodermata may develop in each of several forms — as a macule, a papule, a tubercle, a pustule, a bleb, or a tumor — and may betray such consecutive lesions as scales, crusts, ulcers, rhagades, fissures, and scars. A study of the syphilodermata is, in fact, a study of the changes impressed by the infective process upon the simple manifestations of all skin diseases. A syphiloderm may resemble an acne, a psoriasis, a seborrhoea, and even the skin-picture in variola. To determine with certainty that an eruption is syphilitic it is essential that the several modifications of lesions produced by syphilis of the skin be recognized fully. The actual result in any case is a composite of the ordinary pathological processes of congestion, inflammation, infarction of vessel, cell- multiplication, and secretory changes awakened in the tissues, which in all diseases resent these processes. SYPHILIS OF THE SKIN. 75 Characteristics of the Syphilodermata. — Symmetry. — Many disorders of the skin attended with eruptions exhibit symmetrically-arranged lesions, such as variola, the medicamentous rashes, and purpura. In syphilis the earlier cutaneous symptoms are usually symmet- rical, but as the disease progresses the skin-lesions exhibit a greater tendency to asymmetry, until the latter becomes the rule rather than the exception. The macular syphiloderm of an early stage of syphilis usually displays this symmetrical arrangement in a marked degree. Color. — Too much significance has been attributed to the supposed characteristic color of the syphilodermata, though often the hue displayed by such lesions is like none other. It is important to bear in mind the obvious fact that the color of an eruption in a blonde and in a brunette subject, in an infant and in an aged person, in a region such as the face and in another such as the inner and superior aspect of the thigh, exhibits the widest contrasts. It is also true that in every person affected with a cutaneous efflorescence the color varies from hour to hour with the degree of congestion of the integument. In syphilis there is displayed no color which may not at times be recognized in non-syphilitic subjects ; but the color with the other picture presented is usually highly suggestive. Its shades vary from a mixture of red, yellow, and brown to an empurpled hue, and they are rarely, if ever, commingled with the vivid and frank rosy tints of an erythema simplex occurring, for example, in a clear-skinned child, or the pure silver- white of the scales seen in lichen planus. The terms '' copper-colored " and " raw-ham tint " have been 76 SYPHILIS AND THE VENEREAL DISEASES. employed to designate the special hues of the syphilitic exanthem. The deepest shades of greenish-yellow, chocolate, and even black are often noted as sequences of the profound alterations occurring as the result of gummatous ulcers, particularly in the lower extremities. Polymorphism (Multiformity). — The frequency of the coexistence of several lesions of different types in one person and at one time is a characteristic of syphilis shared by but few other maladies. It is not rare to find a subject of the affection first named exhibiting at a given moment condylomata about the anus, scaling patches in the palms, pustules upon the face, and papules of the thighs. Configuration. — The arrangement of the syphiloder- mata in groups or, after coalescence, in figures having the outline of a circle, either complete or in segments, is highly distinctive. Thus are formed odd-looking and characteristic groups of lesions in figures suggesting the shape of a horse-shoe, a kidney, the letter S, the figure 8, and the arrangement of a brooch in oval or circular pattern with crescentic or circular " satellites " at its outer rim. The " serpiginous " feature of certain of the syphilodermata is the result of an evolution of lesions in similar lines spreading from one point of the skin to another in crescentic curves. This special configuration is probably associated with the distribution of the cutaneous nerves in definite areas. Absence of Subjective Sensations. — The absence of itching and pain in the great majority of syphilitic subjects displaying eruptive symptoms is a striking feature of the disease. The exceptions are, however, often well marked, a peculiarly sensitive individual suffering from pruritus even with macular lesions. It is SYPHILIS OF THE SKIN. 71 also to be remembered that in a few special syphilitic lesions (particularly condylomata about the anus and the vulva, pustules upon the scalp, etc.) the itching may be extraordinarily severe, while the pain of a syphilitic ulcer may be excessive. It is none the less .remarkable with how much toleration the average patient displays an abundant exanthem covering almost the entire surface of the body. Indeed, a careful physician is often the first to detect a syphilitic rash, the patient being wholly un- conscious of its existence until informed of the fact. Mode of Evolution. — The syphilodermata are de- veloped with remarkable indolence, and in some cases, especially in those neglected, they have a tendency to recur in different types, to be succeeded by others of a different character, and to undergo extreme metamor- phoses in sitii, so that, for example, a papule may enlarge, flatten, ulcerate, or disappear and be succeeded by others pursuing the same or another course. It may well be doubted, however, whether this is so much a mode of evolution of syphilis as a variation of its evolu- tion due to the accidents of environment. Syphilis is a disease of relatively chronic type, and it is peculiarly subject to changes induced by improvement in the general health of the patient or the reverse, and in favor- able cases by treatment. Situation. — Every portion of the bodily surface may be the seat of a syphiloderm, but in different localities there is usually seen a different expression of these local manifestations. Those of pustular type are often seen upon the scalp and on the face ; papules often appear over the neck and the brow ; secreting lesions, about the mucous outlets of the body ; scaling patches, on the palms of the hands, etc. y^ SYPHILIS AND THE VENEREAL DISEASES. Peculiarities of Eleinejitary and Consecutive Lesions. — Papules -are ever predominant lesions of an average syphilitic history. They are usually characteristically ham-colored, and in exposed situations they have a tendency to scale at the apex, to provide themselves around the border with a collarette of dirty-tinted scales, and in others to flatten into broad plaques, to crust, and even to ulcerate. Tubercles are also common in syphilis, and they are usually grouped. Their color and their frequent tend- ency to ulcerate and crust distinguish them from the much more indolent tubercles of lupus and lepra. The crusts of syphilis are usually bulky; they vary in color from a dirty greenish-brown to a dead black. When of rupioid type they are made up of laminated concretions like the shell of the oyster, this feature being produced by the concretion of pus and other inflam- matory products upon a secreting ulcer, which, as it spreads beneath, furnishes continually a broader base for the conical crust with which it is capped. Scales in syphilitic subjects are usually thin, are rarely very profuse or adherent, and are of a dirty- whitish hue. They never exhibit the nacreous shade of the psoriasic skin, nor, as heretofore shown, the silvery sheen of the scales in lichen planus. As dis- tinguished from similar conditions in non-syphilitic dis- ease, they are rarely the sole lesions present, but are more often complications or appendages of other lesions, as, for example, when they crown the apex of syphilitic papules or surround their base, or, as in the palm or the sole, when they furnish a ragged fringe encircling a dull- red patch either ulcerating or threatening such destruc- tive action. SYPHILIS OF THE SKIN. 79 Ulcers in syphilis are usually characteristic. Their ■ base is, as a rule, soft ; their edges are steep or under- mined and have a punched-out appearance ; their floor is covered with a foul pultaceous slough ; their secre- tion is purulent or haemorrhagic ; and their crusts are of the character described above. Often they are sur- sounded by an angry halo. Their outline commonly observes the several circular shapes already suggested, such as the arc of a circle, a horseshoe, a semilunar figure, etc. Scars left as relics of ulcerative and degenerative lesions are in syphilis usually pigmented when recent, but when old the pigment gradually disappears from centre to cir- cumference. In circular or oval contour they conform, for the most part, to the configuration of the ulcer or group of lesions that preceded their formation. When completely freed from their chocolate-tinted or violace- ous pigmentation they are of a dead-white shade, not greatly differing in this respect from scars in general, but they are, as a rule, much smoother, more superficial, less attached, and more elegant in delicacy of surface wrinkling than most other cicatrices. Their site is often of striking importance : as in syphilis, they are apt to be situated on the anterior face of the lower extremities (the leg particularly), though they may form in any portion of the body (face, arms, scalp, wrists, etc.). General Considerations relative to the Evolution, Involution, Variation in Type, and Accidental Feat- ures of the Syphilodermata. — The conception long held of the classical evolution of a syphilitic affection has to a great degree been modified by later observation and study. With reference to the syphilodermata, it was believed, and with some reason, that their evolution 80 SYPHILIS AND THE VENEREAL DISEASES. was by a series of successiv^e eruptions, the one in due course following the other, those of a so-called " second- ary" stage at first symmetrical and superficial, fading spontaneously and succeeded later by eruptions involv- ing a deeper structure of the skin. Thus papules were thought to follow macules, pustules taking the place of papules, until a late or so-called " tertiary " stage was in proper course reached, when the syphilodermata, no longer multiple and superficial, became fewer, deeper, isolated, and in various degrees destructive to the under- lying tissues. Such was the classical ideal ; but, as has been in part already shown, it was rather an artificial manikin for use in the schools than a pattern fashioned after observation of cases. If any such attack of syphilis has actually been observed, it was certainly an illustration of the very rare exception rather than of the rule. There are many facts which lead to the conviction that an attack of syphilis in a sound young subject whose case is perfectly managed throughout, with no intercurrent accidents to change its features, is a syphilis exhibiting a single exanthem. This eruption would be of the type of the superficial and symmetrical macular syphiloderm, after the disappearance of which as a result of vigorous treatment no other skin-lesions would appear. Persistent, faithful, and skilful management of the case subsequently should permit no further manifestations of the malady. This is, it must be admitted, a rare event, yet it is one that can be studied as an objective fact, and, rare though it be, it certainly is not so rare as the ideal case exhibiting in turn and in due course each of the syphilodermata in an ordered succession. The practical deductions from an acceptance of this SYPHILIS OF THE SKIN. 8 1 new ideal are of importance. In the light of our present knowledge on the subject of micro-organisms and their role in the production of disease, it is clear that some of the syphilodermata are the result of mixed infection. Staphylococci are responsible for many, if not all, of the pustular lesions in syphilis. Again, it is capable of demonstration that many of the other syphilodermata are the fruit of local irritations, of errors in diet, in dress, in exposure, and in the habits of the patient. The impression that every eruption recognized in the subject of syphilis is due solely to that disease is so grossly misleading that it should carefully be excluded from all conceptions of the malady. The medicaments swal- lowed, the soaps employed, the articles of diet and drink consumed, play a significant part in many of the processes to be considered later. Again, it has been believed that the profuseness of a syphilitic eruption of early development bears some relation to the severity of the disease and to the ques- tions concerned in its prognosis. This is a conception based upon the old rather than upon the new ideal out- lined above. As a matter of fact, the first frank expres- sion of constitutional syphilis may be an abundant exanthem of macular type, extensively spread over the bodily surface, possibly sparing no area, and this may prove of better augury than one which feebly manifests itself and is too speedily followed by the symptoms of malignancy to be described later. Complete involution of an eruption of this character is often not followed by the evolution of a crop of small- or large-papular syphilodermata, nor, indeed, by any other eruption. Classification of the Syphilodermata. — The skin- lesions of syphilis are classified as follows: 6 82 SYPHILIS AND THE VENEREAL DISEASES. I. Macular. {a) Pigmentary. ifi) Erythematous, (r) Purpuric. II. Papular, dry. {a) Miliary. [6) Lenticular. Papular, moist {a) Mucous patches (/;) Condylomata. III. Pustular. (c?) Miliary. (b) Lenticular. IV. Tubercular. V. Gummatous. The compound adjectives " pustulo - crustaceous," ** papulo-pustular," " gummato-ulcerative," and others are employed to express the frequent combinations of elementary and consecutive lesions to be recognized clinically in many cases of syphilis. In these pages all such terms as " syphilitic psoriasis," " syphilitic lupus," etc. are discarded. Combinations of syphilis with other diseases, however rare, are certainly never expressed in dermatological lesions, for an eczema (which certainly may occur in a syphilitic subject) is not a "syphilitic eczema," but is an eczema of unmodified type ; and a scaling syphiloderm is never by any possi- bility a " syphilitic psoriasis," but is a squamous skin- lesion of the specific disorder present. I. Macular Syphiloderm ata. Pigmentary. — The pigmentary syphiloderm occurs without previous involvement of the skin, as a distinct network of pigmented, brownish, chocolate, or even blackish macular, the hyper-pigmentation being con- spicuous by reason of contrast with the white and unaltered skin about each discolored spot. Gradually, SYPHILIS OF THE SKIN. 83 and very slowly as a rule, the pigment is diminished in the centre of each deposit, and there is formed a whitish central punctum from which the pigment is at last wholly removed. These colorations occur as uniform ill-defined shadings, as pea- to coin-sized spots, or as a reticular arrangement, one form often slowly passing into another as the pigment atrophy and hypertrophy progress side by side. The eruption is seen rather more often in women, and in them chiefly on the neck and shoulders, but it occurs also in men, and over the face, neck, and forearms. This condition is decidedly more often seen in brunettes than in blondes, in this particular sharing the lot of most of the achromias of the skin. It especially affects in both sexes the Chinese, Indians, and negroes who have contracted the disease. It was once supposed to be rare, but without question is more conmion than was believed. The eruption, if such it may be called, develops at any time after general syphilis is declared, but it is much more common in the earlier months of the malady. It is exceedingly indolent, persisting for months, and even in exceptional cases for years, being in but a slight degree amenable to specific treat- ment. Though thus persisting, the complete involution of the affection occurs without ulterior changes in the skin, which, as a result, does not become the seat of infiltration, of degeneration, nor of scaling. Indeed, it is probably more an indirect than a direct result of infec- tion, and is peculiar in that it is decidedly more com- mon not merely in those predisposed by individual characteristics to pigment anomalies, but also in the uncleanly and the neglected. Anatomically, it is found 84 SYPHILIS AND THE VENEREAL DISEASES. that a chronic endothehal inflammation of the smaller cutaneous capillaries occurs, under the influence of which the red corpuscles gradually lose their coloring matters, while eventually an obliterating endarteritis chokes the vascular channels. In the portions where the pigment has apparently been removed the normal quantity of coloring matter has at times been recognized; in other cases a true vitiHginous atrophy of the pigment has fol- lowed. It is highly probable that all these changes are under the immediate influence of the trophic nerves. The pigmentary syphilide should not be confounded with tinea versicolor, which develops often on the neck and the breast, for in the disease last named not only is a fungus visible under the microscope, but the fawn- colored patches are usually the seat of a fine furfura- ceous desquamation, readily recognized when the finger- nail is employed as a curette over the surface. The several chloasmata of other sources are, however, to be differentiated with care. Many of them appear on the face, and not elsewhere (the reverse of what is usual in the pigmentary syphiloderm). Vitiligo or leucoderma occurs often on the scalp as w^ell as over the body and the face. Its disks are far more extensive than those of the syphiloderm, being often palm-sized and larger, and when occurring upon the scalp the hairs which spring from the achromatous patch are commonly white. In any doubtful case the symptoms of syphilis, usually declared by other signs in the event of a syphiloderm, should decide the diagnosis. Circumscribed pigmentations of the skin in syphilis, and even of syphilitic lesions themselves, differ in a marked degree from the pigmentary syphiloderm, since all the former are, without exception, sequences of some SypniLIS OF THE SKTN. 85 other disturbance (relics of a papular or tubercular syphiloderm, ulceration and cicatrization of gummata, especially in the lower extremities, etc.). The Erythematous Syphiloderm (" Syphilitic rose- ola," " Syphilitic erythema "). — It has already been shown that there are grounds for believing that syphilis in an ideal case, occurring in a strong and healthy young subject, well managed throughout the entire career of the disease, would probably have but one cutaneous expression. That expression would be the erythematous syphiloderm. If syphilis be in type a disease of but a single efflorescence, the eruption here designated represents that exanthem. It is the most common, the most frequent, the most benign, the earliest, and the most classical of the skin-symptoms of the disease, to be expected in the great majority of all patients, and rarely failing to appear when awaited and searched for by the eye of the trained physician. It is also in syphilis the exanthem most often overlooked, as it may be limited to regions covered by the clothing, and is for the most part unaccompanied by any subjective sensation such as itch- ing. Women, especially those who are fleshy, when viewing its blush often suppose themselves to have been simply "overheated," and men, especially those inured to work in heavy flannels, look upon its lesions with no anxiety. It it often first demonstrated by the physician engaged in examining a patient for the detection of the character of a chancre. The exanthem usually first appears between the sixth and the seventh week after the appearance of the chancre, and with exceedingly insidious onset, so that on the very first inspection only a few delicately- tinted spots occur on the surface of the belly; and in S6 SYPHILIS AXD THE VENEREAL DISEASES. some cases, especially after indulging in a Turkish bath, a dance, or a generous dinner with wine, its lesions may be evolved with surprising rapidit\'. The faintest expression of this syphiloderm can scarceh- be described. It resembles to a degree the delicate mar- bling produced when the skin of a healthy person is ex- posed to cool air after immersion in a hot bath. When well defined, the spots appear as multiple, oval-shaped or rounded, irregularly-defined macules, neither elevated above nor depressed below the general level of the integu- ment, having a diameter of from one-tenth to one- fourth of an inch. Their color varies in different skins and at different stages of evolution of the exanthem, being rarely of a pure rose or a vivid pink, but rather of a dull shade of yellowish-red, sometimes having an empurpled tint, at times so light as almost to . suggest a simple erythema. The color fades under pressure of the finger, but later persists, and when further development of the exanthem occurs the maculations furnish a slight eleva- tion of the surface at each point of hypersemia — a condi- tion approximating that in which papular lesions appear. On complete involution, which often occurs without the sequel of another exanthem of the disease, there may be left transitory discolorations or lighth'-pigmented macules persisting for several ^\•ceks. As a rule, under appropriate treatment the eruption fades, without the production of desquamation or other consecutive lesions, in the course of from a week to ten days, though occa- sionally it persists for several weeks. The abdominal surface and the chest, both anterior and posterior, generally display the exanthem in great- est profusion, but it is also encountered in vivid efflores- cence over the extremities, the face, the neck, and, SYPHILIS OF THE SKIN. 8/ indeed, over all the bodily surface. When distinctly evolved over the anterior surface of the belly and the back, it is often supposed by inexperienced observers to be strictly limited to these regions, but in almost all cases a careful search will reveal a faint mottling about the outer angles of the lips, in the palms of the hands, over the brows, and elsewhere. It is most brilliantly displayed on the abdominal surface when faintly seen elsewhere, chiefly because of the warmth and clothing of that portion of the body. In some cases it will be seen on close inspection that the arrangement of the macules is in generally circular outlines. The eruption which represents the transition between that just described and the papular syphiloderm is termed the " maculo-papular." Its peculiarities are briefly those, in varying proportions, of the two primary lesions from which it has its name. The variations between these eruptive forms, macules and papules, are numerous and interesting. In an exceedingly common variety the macular rash exhibits here and there, often with wide intervals of space, a few isolated papules, usually of the larger or lenticular type, scattered with seeming irregularity over the eruptive field, and springing usually from maculae. They have a dull-reddish tint, and they often scale slightly over the flattish summit or at the base. These may be sparsely distributed over one region of the body ; or when the trunk, for example, exhibits macules in wellnigh pure type, the lower extremities, where there has been some friction and usually also effects of gravitation, display these papules seated on an ery- thematous base. In yet other cases the papules are of miliary type and spring in large numbers directly from 88 SYPHILIS AND THE VENEREAL DLSEASES. the er\-theniatous spots, till each of the latter is thus surmounted apparently by a small elevation. Here again the circinate arrangement may be conspicuous. In other cases the mouths of the orifices of the pilosebaceous crypts are the seat of the disorder ; in others the scalp becomes the site of a seborrhoeal flux, the secretion drying into light crusts superimposed upon a macular exanthem, the color of the latter often being displa}'ed beyond the border of the incrustation. The macular syphiloderm may relapse under ineffi- cient treatment in one or several efflorescences, but, as a rule, it appears in typical development but once in a syphilitic history. The evolution of what is often thought to be a late macular syphiloderm, occurring two and more years after infection, is an eruption which has erroneously been supposed to be due to s\'philis. In these supposed " late " cases there is developed over the surface of the chest, and at times on the belly and else- where, multiple, usually coin-sized, oval, elliptical, super- ficial patches, scaling very slightly at the periphery, and with a clear centre. They are usually brownish-red or purplish-red in hue; they have been noted as rebel- lious to the treatment indicated by the disease present. Most of these are instances of pityriasis maculata et circinata, " pityriasis rosea" of authors. In the spring and the autumn many of the subjects of syphilis are peculiarly susceptible to this somewhat rare disorder, whose innocent lesions commonly disappear in a brief time under the influence of a tonic regimen, well com- bined with the use of the cinchona preparations and the salicylates. Purpuric. — Hemorrhage into the several portions of the integument occasionally complicates not merely SYPHILIS OF THE SKIN. 89 the erythematous but also other s)^philodermata, such as papules and bullae. In these cases the occurrence of pin-head and larger purplish and mulberry-shaded spots that refuse to disappear under pressure indicates that the coloring matters of the blood have been ef- fused through the tunics of the vessels. It is to be remembered, in all cases of syphilis where iodide of potassium has been administered for the relief of the disease, that this drug is capable of producing purpura of the skin, especially of the lower extremities. In some instances large disks and even wide areas of purpuric maculation are produced in both early and late periods of the disease. This symptom is, however, most commonly seen in the inherited forms of the dis- ease, though it is not rare in adults. When due directly to the disease, and not to a drug administered for its relief, it should be viewed as a somewhat grave symp- tom. It accompanies several of the paraplegic and hemiplegic complications of nervous syphilis. Anatomy. — Section of a macular lesion exhibits merely effusion between the component parts of the upper corium, with some displacement and elongation of the fibres of which it is composed. The capillaries are distended, and both within and without are encum- bered with cells. The accessory portions of the skin lying in the upper part of the corium (sebaceous and pilary crypts) participate somewhat in the process, but the sweat-glands in the deeper portion are unaffected (Crocker, Neumann, Biesiadecki, and others). Diagnosis. — The macular syphiloderm is distin- guished from the eruptions accompan\'ing exanthema- tous fevers by the features described above, as also by the temperature-changes perceptible in such fevers. In 90 SYPHILIS AXD THE VENEREAL DISEASES. case of s\'philitic fever other evidences of a systemic infection are commonly observed (adenopathy of the post-occipital and other glands; mucous patches of the mouth, anus, or \'ulva; alopecia; crusts upon the scalp, etc.). In the medicamentous rash due to copaiba there is commonly excessive itching; this and other rashes due to drug-ingestion promptly disappear on the withdrawal of the exciting cause. In tinea versicolor the presence of the vegetable parasite and the distinct limitation of the eruption to the regions covered by the clothing are important points of difference. The color of the eruption — a very distinct fawn shade or deeper tint — never has the reddish-brown hue of the syphilo- derm. Pityriasis maculata et circinata is usually much less abundantly distributed, and its patches are always in ovals, commonly on the front and back of the chest and the shoulders, with scaling at the periphery of the clear centre, and displaying, when on the chest, an ar- rangement of patches with the long axis at right angles to the vertical line of the body. The prognosis of the macular syphilodermata is in general favorable, and no gravity need be argued from either their profuseness or their deep shade of color. II. Papules. It has been shown that papules are among the most common of the syphilodermata. Their grouping, color, situation, and environment in many cases of syphilis are so characteristic as to be absolutely diagnostic of the disease. They may appear at any time from the third month to the conclusion of the first year, and even much later ; they may develop in crops ; they may immediatel)- spring from a preceding macular exanthem, or succeed SYPHILIS OF THE SA'IN. 9 1 the latter after an interval ; and they are usually sym- metrical in the earlier and asymmetrical in the later of the periods named. They vary in size from a pin's head to that of a bean, and may be multiple or few, dis- seminate or grouped, generalized or limited to distinct regions of the body, conical or flat, dry or moist, in color shading from a light crimson to a dull copper. They may scale at the apex or be surrounded by a col- larette of scales at the base. Papules represent the syphilitic process in the skin and the mucous membranes, beginning with an indolent inflammatory process in the corium, inducing a thicken- ing of the rete, some effusion of lymph-cells, and a break- ing away of the horny layers of the epidermis from the summit of the circumscribed inflammatory product where the thickening of the skin occurs. As this change may involve different regions of the body, gross results are obtained, whose differences depend largely upon the site of each lesion. Papules upon the scalp, for example, are usually dry and scaly ; when picked or scratched they often bleed and crust. Upon the exposed and dry surface of the skin, such as the extensor faces of the extremities, they are usually acuminate, dry, and squamous. On the brow, near the border of the hairs of the scalp, they often surround themselves with a deli- cate collarette of dirty scales, exposing a copper-tinted integument beneath and around the individual papules, the group being so characteristic as to have gained the title of the " corona veneris." When papules form upon apposed surfaces, such as the skin covering the voluminous breasts falling over the thorax in women, or the folds of the nates in contact, or the scrotum lying next the integument of the thigh, papules 92 SYPHILIS AND THE VENEREAL DISEASES. enlarge, flatten, secrete, and in many cases produce a sensation of itching. Papules forming upon mucous sur faces also, by reason of the heat, moisture, and friction to which they are subjected, become flattened and secrete, forming thus the mucous patch. Papules de- veloping upon or beneath the thick epidermis of the palms and the soles of adults are so bound down that they rarely rise above the general level, but the cracking of the scarf-skin at the level of the thickened subepi- dermic focus produces a characteristic scaling of the skin in the regions named. Dry Papules. — {a) Miliary Papules. — ^This abundant efflorescence is less frequently noted than other of the papular syphilodermata, for the reason that its very pro- fuseness argues a neglected or ignored condition of the subject of the disease in its prior manifestations. Since these neglected and ignored patients are often women, the eruption is somewhat more often observed in them. The lesions are pin-head-sized, closely-com- mingled papules, symmetrically arranged, often widely dispersed, and even generalized, at times distinctly and even elegantly grouped in circles or segments of circles, light reddish to deep crimson in shade, the apex of each papule at times surmounted by a still finer vesicle con- taining a droplet of serum — an accident which usually points to a coincident febrile access. Involution occurs by fine scaling at the apex of each lesion and flattening of the papules to a dull, purplish-red maculation of the surface. In rare cases, chiefly of public patients, this eruption may be merely the preliminary stage of a diffuse pustular syphiloderm. At times it can be seen that the lesions are limited to the hair-follicles. There are few cases in which, when the eruption is at all well SYPHILIS. Small papular syphiioderni (Stelvvagon) SYPHILIS OF THE SKIN. 93 marked over the face, the neck, and the trunk, groups of much larger lesions, to be described below, may not be seen in other regions of the body. Diagnosis. — The coincident symptoms (mucous patches, adenopathy, etc.) indicating the presence of a disease accompanied by other than skin-involvement usually suffice for the establishment of a diagnosis in these cases. Scabies and ringworm, the former due to an animal and the latter to a vegetable parasite, are distinguished by the picsence of the exciting cause in each affection, the for- mer being, as a rule, accompanied by an intense and characteristic pruritus, the latter by a circinate arrange- ment of the patches. The lesions of lichen planus are flattened at the summit and usually exhibit polygonal outlines, while the frequent linear and angular distribu- tion of the papules is never seen in the syphiloderm. Psoriasis in some cases strongly resembles a scaling and well-developed papular syphiloderm, but the former dis- ease is, as a rule, more extensive, and the scales are more abundant, more voluminous, and more lustrous. Kera- tosis pilaris in extreme expression over the limbs and the body is to be recognized by the obvious situation of each papular lesion at the orifice of the pilosebaceous crypt. Prognosis. — The course of the eruption in healthy sub- jects, whether acutely or slowly pursued, is toward a favorable termination. At times the eruption proves intractable to treatment. ib) Loiticidar Papules. — The papules are here usually discrete, rounded or oval in contour, and vary in size from a pinhead to that of a large bean and even larger. They are rarely elevated to any extent above the level of the integument, and at times they are so flat as to be mis- 94 SYPHILIS AND THE VENEREAL DISEASES. taken for mere unsightly blotches of the surface. They vary in color from an exceedingly dull to a bright copper shade, and are usually remarkable for the fringe or col- larette of dirty scales fraying away from their base, as described in connection with the " corona veneris," The eruption may appear in a few months after infection, and then disappear, or it may occur in crops lasting, with varying intervals, for one or two years after the onset of the disease. These papules are among the commonest of the syphilodermata, and, with variations of the sort described above as due to the accidents of site and environment, probably figure in a modified form in most of the lesions which are to be observed during the first two years after infection. The eruption spreads both by the outcropping of new lesions and by the enlargement of individual papules insitit,\\\Q latter being rather more common. As resolution occurs the papule flattens to the level of the skin, leaving merely a pigmented macule as a relic of its existence. These pigmented patches, especially over the face, are apt to be exceedingly re- bellious to treatment and slow to disappear, much to the chagrin of the patient, who speedily comes to a realiza- tion of their peculiar significance. The eruption may be quite general at the first, and later may limit itself to a favorite locality, such as the forehead, the back of the neck, the belly, the buttocks, the flexor aspects of the joints, the scrotum, and the outer face of the labia majora. It is the modification by grouping and coalescence of the papular syphiloderm that produces the sub-varieties recognized by authors as "nummular" and " corymbi- form." In the former the papules enlarge to flat disks of the size of large, and even of the largest, coins, cir- SYPHILIS OF THE SKIN. 95 cumscribed, and with depressed crateriform centres, the contrast between the central area and the circumvalla- tion of the smooth, copper-tinted ring being conspicu- ous. In the corymbiform arrangement satelhte-Hke groups develop about the central disk. Other odd- looking forms are the result of different groupings of the coalesced or isolated papules, as in the shape of the letter S, of a kidney, etc. Midway between papules and purely squamous le- sions in syphilis stand the papulo-squamous syphilo- dermata, lesions in which the characteristically developed and situated papules of syphilis undergo a squamous transformation at the summit, where a little heap of dirty-looking, adherent, sometimes friable, but often cor- neous scales accumulates. This combination of scales and papules has been thought to resemble psoriasis, but the correspondence is rarely suggested to the trained eye, for the elevation of the lesions, the character of their scales, and the color of the dull-tinted papules on which they rest are significant. The circular outline of many of the confluent patches of the larger papulo-squamous disks and of psoriatic patches in general is often confus- ing, and yet the bulkier and dirty-looking scales of the syphiloderm, the dull, ham-colored patch in the centre of the circinate group, often slightly infiltrated or thick- ened, offer a strong contrast to the more vivid hues of psoriasis. The clear-tinted and uniformly spread scales of the psoriatic patch, its centre either evenly thatched with such scales or, if quite clear, showing only a slightly shaded and non-infiltrated epidermis, are also to be con- sidered in establishing a differential diagnosis. Over the face the papulo-squamous syphiloderm is often cov- ered with a mealy or granular mass of scales of a dirty 96 SYPHILIS AXD THE VENEREAL DISEASES. grayish hue, this character of the exuvium being due to admixture with a desiccated sebaceous product. Diagnosis. — The differences between psoriasis and syphihtic papulo-squamous eruptions are of importance. It is only atypical manifestations of either disorder that are liable to be confounded. The reddish and bleeding surface left on removal of the scales from a psoriatic patch is never exactly reproduced in syphilis, and the localization of the former on the extensor surfaces of the extremities is never characteristic of the syphilitic exanthem. Seborrhoeic affections, particularly of the face, resemble the scaling papular syphiloderm in the matter of the greasy crust with which they are covered and the generally dirty aspect of the patch, but the cir- cinate contour of the syphiloderm, never seen in the sebor- rhoeic disorder (save in exceptional cases on the trunk), and the characteristic copper hue of the surface beneath the scales, sufficiently distinguish the syphilitic exanthem. In almost all the syphilitic patches resembling those of either psoriasis or seborrhoea the infiltration of the body of the patch, with its higher wall of infiltration at the periphery, is evident on examination. Palmar and Plantar Syphilodermata (Palmar and plantar "syphilitic psoriasis," etc.). — The papules of syphilis, when developing upon the palms and the soles, have, as already shown, not only a characteristic aspect and career, but are rarely to be confounded with other disorders. The peculiarity of the papule in this situation is that it is developed within and beneath the dense and voluminous corneous envelope of these regions, and hence fails to produce either a conical or flattened elevation above the surface ; it produces instead a circumscribed thickening of the skin, (Fig. i), which in SYPHILIS OF THE SKIN. 97 the epidermal portions scales, and in extreme cases in- duces an ulceration in the region of each papular thick- ening. These eruptive symptoms are often early to appear, and sometimes they linger after years have elapsed as almost the sole symptoms of the disease. They are much more common than is generally believed in the early periods of the malady — that is, within three months after infection — being usually recognized in some form by the expert when they escape the attention of all Fig. -Palmar syphiloderm (after Keyes). others, even of the patient. They occur usually sym- metrically, involving both hands and feet, in the earlier manifestations, and asymmetrically in later stages, when either the feet alone or the hands alone, or even but one palm or one sole, is attacked. Instances are not very rare in which, with few other evidences of the disease, six and eight years after infection, a single palm exhibits a squamous syphiloderm, having displayed this symptom with slight variations for a series of years. In all the regions named the influence of the employment of the hands in labor is usually striking, the right hand being worse or solely involved in right-handed patients, and 7 98 SYPHILIS AND THE VENEREAL DISEASES. the feet worse in those who stand or walk much in the day; but marked exceptions occur. In its simplest expression the epidermis of the region involved displays merely split-pea to lentil-sized dis- colorations productive of no sensation by which the patient is made conscious of their existence. The centre of the palm or the inner face of the instep is usually first affected, and the spots may be either discrete and with- out apparent order as to grouping, or develop in arcs of circles to be distinctly or dimly discerned. From these points they may spread to the dorsum of the hands and the feet, even over the dorsum of the digits, but in all such instances the extension from the palmar or plantar to the dorsal surface can be determined without effort. In this way the extension may be toward the interdigital spaces and the wrists and the ankles, the squamous process being in obvious relation with that first invad- ing the palmar or the plantar area. When the digits alone are involved, the flexor aspect is always chiefly implicated, and here, as also in the palms and the soles, the natural folds and furrows of the skin furnish often a special territory for the incursions of the malady. As the disease advances, both in time and in degree of involvement of the integument, the maculae, of a ham- red shade, furnish from the surface of each a slight exfoliation, which, as the disorder advances, becomes a true scaling, the epidermis being lifted away centrally, so as to produce about the morbid spot a dirty-looking, ragged fringe of epidermis. An advanced stage of the disease is that where, usually in consequence of manual labor, friction, and exposure of the hands to soil, water, or chemicals, fissures result ; these fissures make inef- fectual attempts at healing, forming a new and tender SYPHILIS OF THE SKIN. 99 epidermis wliich floors over the crack in the skin, only in turn to give way and be supplanted by succeeding fissures and new formations of epidermis until a palmar or plantar ulcer or an ulcerated fissure is excavated, bor- dered by successive plateaux of newer or older skin, the outer edge being represented by large, partly-detached, and racfcred flakes of epidermis whose angular indenta- tions or scallops roughly resemble the fracture of a pane of glass by a missile projected through its substance. Deeply ulcerated and exquisitely painful lesions of this class are more often palmar than plantar, by reason of the use of the hands in labor ; but the feet of those who toil in sewer-digging, road-making, etc. suffer to a similar extent. A variation of this eruption is termed the corneous syphilodcnn, and its peculiarities are due to the accumu- lation at the site of each papule of a mass of horny cells, more or less friable, which may occasionally be dug out from their bed with the point of a pen-knife, or, being spontaneously thrown off, leave little shallow pits behind. Diagnosis. — Eczema of the hands and the feet usually involves the dorsum, or, if the sole or the palm at all, only by extension to the latter from the former region. Eczema limited to the palms and the soles does, how- ever, occur, but chiefly in adults whose organs are more or less continually immersed in water, especially water charged with mineral constituents. Patients of this class are usually dyers, laundresses, bar-keepers, or men engaged at soda-water fountains. The infiltrated areas of eczema are never well defined save in eczema mar- ginatum of this region ; the involvement of the skin is much more uniform ; there is apt to be pustulation and lOO SYPHILIS AND THE VENEREAL DISEASES. vesiculation ; there is never, under any circumstances, ulceration, even when the eczematous fissures are most painful ; and the itching is apt to be well marked. Psoriasis is said to be in very rare cases limited to the palms and the soles, but these exceptions are so few as simply to prove the rule. In any doubtful case the dis- covery of psoriatic patches on the scalp, the sacrum, the elbows, or the knees would determine the question. It has been said that syphilis of the palms and the soles is ever accompanied by some unexpected lesion elsewhere, and it is often true that a mucous patch in the mouth or, in advanced cases, an undeveloped gumma of the leg will reward the careful explorer for his pains. Moist Papules. — {a) Mucous patches (Mucous plaques ; Plaques inuqueuses). — The patch which is seated upon the mucous membranes in syphilis is pathologically identi- cal with the mucous plaque or the moist papule of the skin. In both cases the papule — which in the palm or the sole fails to become elevated, but flattens to the point of exhibiting merely a scaling and plain macule — shows, in the regions of moisture, of friction or apposition of contiguous surfaces, and of heat, merely an oval or circu- lar, scarcely elevated lesion. Its summit either furnishes a mucoid secretion or displays a thin pellicle more or less firmly attached, representing a sodden epidermal plate not as yet loosened from its underlying attachments. Moist papules of the skin in syphilis occur in regions where the conditions are similar to those of mucous membranes with respect to heat, moisture, and the appo- sition of surfaces, as between the breasts of women, between the nates, in the axillae and the groins of fleshy persons, and in the interdigital spaces. Here the lesions form flattened disks, slightly elevated above the general SYPHILIS OF THE SKIN. lOI level, covered with a whitish or grayish pellicle, often slightly depressed in the centre, and looking not unlike one of the varieties of the soft corn. At times they have a reddish tint. They are generally moist, secreting a thin mucus which in warm weather and in the uncleanly has a fetid odor. These lesions are decidedly more common Moist papules (after Miller). in women than in men, and in the young adult rather than in the middle-aged. Occasionally they develop into large vegetating masses; at other times they ulcer- ate. Their secretion is highly contagious. There is no better illustration of the moist papule than the chancre of the mucous surface of the prepuce, which, having sur- vived until general symptoms of systemic disease occur, undergoes a characteristic transformation in situ into a moist papule. (/;) Condylomata (Condylomata lata ; Verruca acumi- nata ; Moist wart; Venereal wart; 6^