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 UNCLASSIFIED ITS TREATMENT WITH 
 
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 BY 
 
 pAoFBSSO^^T 
 
 feKORGE LEWIN, 
 
 /ERSI'Af AND SURGEON-IN-CHIEF OF THE SYPHILITIC WAR. 
 DISEASES, CHARITE HOSPITAL, EERLIN. 
 
 TRANSLATED BY 
 
 L PRCEGLER, M.D., and E. H. GALE, M.D., 
 
 SURGEONS U. S. ARMY. 
 
 • WITH ILLUSTRATIONS. 
 
 
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Unlv.of 111* Library 
 52 * 
 
 JO L> 3 
 
 HkM-V . » ■«»■■ — II 
 
ON SYPHILIS 
 
 AND ITS TREATMENT WITH 
 
 SUBCUTANEOUS SUBLIMATE INJECTIONS. 
 
 BY 
 
 DR. GEORGE LEWIN, 
 
 PROFESSOR AT THE FR.-WILH. UNIVERSITY, AND SURGEON-IN-CHIEF OF THE SYPHILITIC WARDS 
 AND SKIN DISEASES, CHARITE HOSPITAL, BERLIN. 
 
 TRANSLATED BY 
 
 CARL PRGEGLER, M.D., and E. H. GALE, M.D., 
 
 SURGEONS U. S. ARMY. 
 
 WITH ILLUSTRATIONS. . 
 
 ti 
 
 1012 WALNUT STREET. 
 
 1882. 
 
 COPYRIGHTED. ALL RIGHTS RESERVED. 
 
c 
 
 Dedicate 
 
 TO IIIS 
 
 HIGHLY ESTEEMED COLLEAGUE 
 
 Dr. NICOLAUS KOSLOFF, 
 
 PRESIDENT OF THE IMPERIAL RUSSIAN MEDICAL AND SURGICAL ACADEMY, 
 MEMBER OF THE MEDICAL COUNCIL OF THE SECRETARY OF TUB 
 t, MEMBER OF SEVERAL LEARNED SOCIETIES, 
 
 ETC., ETC., ETC. 
 
 A TOKEN OF HIS ESTEEM. 
 
 *• 
 
 $ 
 

 I' 
 
 
TRANSLATORS’ PREFACE. 
 
 One of the translators having witnessed the success- 
 ful workings of the subcutaneous use of sublimate in the 
 cure of syphilis, at European hospitals ; both translators 
 having had pleasing results in the number of cases treated 
 here in private practice, — together with the well-known 
 standing of Professor Lewin in all matters pertaining to 
 syphilitic diseases, they have been induced to translate the 
 result of his experiments in the Venereal Wards of the 
 Royal Charity Hospital, Berlin, and lay them before their 
 American readers. 
 
 We hope our fellow-practitioners will receive the views 
 advanced as to pathology and treatment, with the same 
 spirit as have some of the best surgeons in Europe. And 
 trust whatever of value inheres in his conclusions will be 
 tested and adopted. 
 
 While we do not think that the hypodermic method is the 
 only way to eradicate syphilis, still, in many cases, we think 
 it the best, inasmuch as it is speedy and sure. 
 
 All who are opposed to introducing large quantities of 
 
 1* 
 
vi translators’ preface. 
 
 mercury into the system cannot fail to endorse this method, 
 if the drug is to be used at all, — since from 1J gr. to 2J gr. 
 of sublimate are sufficient for a cure on an average. 
 
 The tables and statistics given are very instructive ; the 
 report of cases is full and accurate in details of treatment 
 and diagnosis ; the deductions seem logical and conclusive. 
 
 We have aimed at accuracy, rather than elegance, in our 
 rendering, and hope the defects of the translation will not 
 be viewed too critically. 
 
 - P. & Gr. 
 
 Aurora, Illinois, August 1, 1872. 
 
PREFACE. 
 
 Nearly seven years have elapsed since I introduced the 
 subcutaneous sublimate injection into the syphilitic wards 
 under my charge of the Royal Charity Hospital, Berlin. 
 During this time I have treated by this new method upwards 
 of 2000 patients, including my private practice. 
 
 The very favorable success of the method may justify me 
 in responding to the numerous wishes of my colleagues here 
 and elsewhere. And I present here to the reader my work 
 laid down in the 14th volume of the Charity Annals, con- 
 densed and improved. 
 
 I remarked there the advantages of my treatment, espe- 
 cially the qmckness and precision of the results, the small 
 amount of relapses, &c., and more than all those theoretical 
 arguments ; I give here the following statistical data, which 
 speak for themselves. 
 
 In Berlin the law exists that every woman given to pros- 
 titution may be under police surveillance , and those who 
 lead a suspicious life have to be examined weekly, and any 
 exploration giving a warrantable proof of syphilis, gives the 
 examining surgeon the right to send them to my syphilitic 
 
VJ11 
 
 PREFACE. 
 
 wards. I have treated all these women exclusively, since 
 March, 1865, by my new method, and their number already 
 is about 1400. 
 
 At the end of July, 1869, there had not been more than 
 20 female patients who had returned to my wards on account 
 of syphilitic relapses , which were of a very light character, 
 as the following cases will show. 
 
 But I am far from thinking, notwithstanding its remark- 
 able results, that the injection method is the only cure to be 
 adopted, and I earnestly protest against such a onesidedness 
 on my part. 
 
 I express my profound obligation to all my colleagues, 
 who, unbiased and with a scientific zeal, have tried my new 
 method ; especially would I name Regimental Surgeon Der- 
 blich; Dr. Gruenfeld, assistant to Professor Siegmund, at 
 Vienna; Professor Bamberger, Wuerzburg; Dr. Bergson, 
 Professor in our University, and Dr. C. W. Richter. 
 
 Lewin. 
 
CONTENTS 
 
 I. Definition 
 
 II. The Manner 
 
 1. Instruments 
 
 2. Place for injection ...... 
 
 3. Medicated fluid for injection 
 
 4. Doses 
 
 III. On the Appearances occurring after Injection 
 
 1. Local appearance . . . 
 
 a. Inflammation 
 
 b. Formation of abscesses .... 
 
 c. Injury to vessels 
 
 d. Jnterruption of sensibility 
 
 2. General symptoms 
 
 a. Disturbances of digestion . . • . 
 
 b. Disturbances of respiration and circulation . 
 
 c. Disturbances of the urinary organs . 
 
 d. Disturbances in the functions of the skin and 
 
 hair ....... 
 
 e. Disturbances in the osseous system 
 
 /. Disturbances in the formation of blood 
 g , Disturbances of the nervous system 
 Symptoms of intoxication . . 
 
 IV. Dietetic Rules 
 
 a. Concerning the body 
 
 b. Psychical considerations 
 
 Y. Indication for Injection 
 
 1. Initial syphilis . . . . . 
 
 2. Condylomata lata 
 
 a. In women 
 
 1. Seat of condylomata lata . 
 
 b. In men . 
 
 c. Therapeutics of syphilitic sclerosis and broad 
 
 condylomata lata .... 
 
 PAGE 
 
 13 
 
 13 
 
 13 
 
 15 
 
 IT 
 
 19 
 
 20 
 
 20 
 
 20 
 
 21 
 
 22 
 
 23 
 
 25 
 
 25 
 
 32 
 
 32 
 
 32 
 
 33 
 
 33 
 
 35 
 
 37 
 
 39 
 
 39 
 
 42 
 
 43 
 
 44 
 
 47 
 
 51 
 
 54 
 
 54 
 
 56 
 
X 
 
 CONTENTS. 
 
 PAGE 
 
 3. Swelling of the lymphatic glands ... 63 
 
 4. Affection of the mouth and pharynx ... 66 
 
 Cavum pharyngo-orale . . . . . 67 
 
 Region of the sebaceous glands . . . 68 
 
 Region of the acinous glands ... 69 
 
 Cases 1 and 2 70, 71 
 
 Plaques opalines 72 
 
 Condylomatous granulations ... 73 
 
 Foveae tonsillaris 73 
 
 ♦ Cavum pharyngo-nasale .... 75 
 
 Choanse, tuba eustachii, tonsilla pharyngea 75 
 
 Case 3 76 
 
 Condylomatous and papillary 
 on the palate 
 
 Cases 4-8 . . . . 
 
 Deep ulcerations and defects in 
 Cases 9-18 .... 
 
 Infectio per os 
 
 Cases 19-27 .... 
 
 • Infection of nurse and child 
 
 5. Syphilitic affections of the larynx 
 
 Syphilitic catarrh of the larynx 
 Differential diagnosis 
 Submucous infiltration 
 Prolific granulations 
 Ulcerations 
 Gummous processes 
 Differential diagnosis 
 Therapeutics . 
 
 Cases 28-40 
 
 6. Syphilitic affection of the skin 
 
 Maculous exanthem . 
 
 Exanthema coeruleum 
 Papulous exanthem . 
 
 Miliary and lenticular species 
 Cases 41-43 
 Squamous exanthem 
 Cases 44-45 
 
 Condylomatous exanthem 
 
 the 
 
 granulations 
 
 . 78 
 
 . 79-82 
 
 pharynx 86 
 . 88-95 
 
 . 9£> 
 
 . 98-101 
 . 103 
 
 104 
 . 104 
 
 105 
 . 106 
 
 107 
 . Ill 
 1 14 
 . 115 
 
 116 
 118-130 
 131 
 . 131 
 
 134 
 . 135 
 
 136 
 137-139 
 140 
 142, 143 
 144 
 
CONTENTS. 
 
 XI 
 
 PAGE 
 
 
 Cases 46 and 47 
 
 . 146 
 
 
 Ulcerous exanthema and rupia syphilitica 
 
 147 
 
 
 Cases 48-50 
 
 148-150 
 
 
 Knotty syphiloid ..... 
 
 151 
 
 
 Lupus syphiliticus ..... 
 
 . 152 
 
 
 Cases 51 and 52 
 
 155-157 
 
 
 Gummata of the subcutaneous cellular tissue . 159 
 
 
 Cases 53 and 54 .... 
 
 161-163 
 
 
 7. Syphilitic affection of the eye .... 
 
 . 164 
 
 
 Cases 55-60 
 
 167-171 
 
 
 8. Syphilitic tumors of the scrotum 
 
 . 171 
 
 
 Case 61 
 
 173 
 
 
 9. Syphilitic diseases of the bone 
 
 . 175 
 
 
 Therapeutics- 
 
 176 
 
 
 Cases 62-64 
 
 177-179 
 
 
 10. Visceral-syphilis 
 
 180 
 
 
 A. Syphilitic diseases of the liver 
 
 . 181 
 
 
 Perihepatitis .... 
 
 181 
 
 
 Cirrhosis ..... 
 
 . 182 
 
 
 Icterus .... 
 
 182 
 
 
 Cases 65 and 66 
 
 184, 185 
 
 
 B. Syphilitic diseases of the kidney 
 
 186 
 
 
 Cases 67 and 68 ... 
 
 188-190 
 
 
 C. Syphilitic affection of the brain 
 
 191 
 
 
 Apoplexy, epilepsy, hemiplegia 
 
 . 191 
 
 
 Psychosis 
 
 191 
 
 
 Cases 69-71 
 
 196-199 
 
 VI. 
 
 Considerations with Sublimate Injections . 
 
 202 
 
 
 Age. Sex. Menstruation. Acute diseases 
 
 202-203 
 
 
 Dyscrasia 
 
 203 
 
 
 Cases 72 and 73 
 
 204-205 
 
 VII. 
 
 Quantity of Sublimate to be Injected 
 
 206 
 
 
 Statistics of 800 patients ..... 
 
 . 207 
 
 
 Results . . . * 
 
 209 
 
 nil. 
 
 Relapse of Syphilis 
 
 . 210 
 
 
 Devergie ........ 
 
 211 
 
 
 Desruelles 
 
 
 
 Fergusson 
 
 212 
 
 
 Thom. Clarke . . . ... 
 
 . 212 
 
Xll 
 
 CONTENTS. 
 
 PAGE 
 
 Royal Swedish Sanitary Commission . . . 213 
 
 Calderini • . . . 213 
 
 Hermann . 213 
 
 Diday 214 
 
 Yvaren 214 
 
 Engelsted 215 
 
 Boeck 215 
 
 Auzias Turenne 216 
 
 A. Oewre 217 
 
 Depres 217 
 
 Statistics taken from the Charite Journals concerning 
 the prevalence of relapses after sweat and mercury 
 
 cure 217 
 
 Quality of the relapses . 222 
 
 u 11 11 with botanic treatment . 224 
 
 “ 11 11 li mercury treatment . . 225 
 
 11 <l 11 u subcutaneous treatment 225 
 Cases of progressive relapses with subcutaneous injec- 
 tions 227 
 
 Doses of sublimate in relapses .... 230 
 
 Intervals between the single relapses .... 232 
 
 A. Sarsaparilla sweat-cure .... 232 
 
 B. Mercury cure . 234 
 
 C. Subcutaneous sublimate injection cure . 236 
 
 Tabulated review of prevalence of relapses in one and 
 
 the same patient ....... 239 
 
 Review of intervals with relapses occurring more than 
 
 once 240 
 
 IX. Effect of the Subcutaneous Treatment on Pregnant 
 
 Females 241 
 
 Review of the pregnant women treated subcutaneously 242 
 Influence on the foetus 243 
 
THE 
 
 TREATMENT OF SYPHILIS 
 
 WITH 
 
 SUBCUTANEOUS SUBLIMATE INJECTION. 
 
 I. DEFINITION. 
 
 By the new method, introduced by me, Syphilis may be 
 destroyed, in its various forms, when the remedy is brought 
 in contact with the system in the form of hypodermic in- 
 jections of corrosive sublimate. This method has the ad- 
 vantage over other anti-syphilitic cures, inasmuch as it 
 requires no preparation of the system for, nor any after- 
 cure in consequence of, the medicine taken, because we can 
 proceed at once in medias res , without losing any time 
 whatever. 
 
 II. THE MANNER. 
 
 I. INSTRUMENT. 
 
 The instrument used is a syringe, modified by Dr. Lewin 
 and manufactured by Geo. Tiemann & Co.,* New York. It 
 
 * They have constructed, by our request, a hypodermic syringe, ac- 
 cording to Lewin’s modification, and we recommend the instrument to 
 the profession, as an improvement upon the one in common use. — 
 Translator’s Rem. 
 
 2 
 
14 
 
 THE MANNER. 
 
 is essential to have this modified instrument, a drawing of 
 which accompanies this book. In private practice each pa- 
 
 tient ought to have his own “needle,” which must fit the 
 syringe used by the practitioner, so that no possible chance 
 of infection may exist. It is always a duty before using the 
 syringe to be sure it is in working order, because it is a 
 needless torture for the patient, if you insert a clogged and 
 unclean instrument. Great precaution and circumspection 
 are necessary on the part of the physician. To preserve 
 the good condition of the syringe, it is best to use distilled 
 water for cleansing it ; care being taken that no fluid remain 
 in the glass tube, which may be effected by repeated work- 
 ings of the piston. 
 
 The needle should be dried, blowing every particle of 
 water out of it ; use watch-makers’ oil to keep it from rust- 
 ing, Inserting a bristle instead of gold or silver wire. 
 
 The operation itself is the same as with any other subcu- 
 taneous injection. The cuticle ought to be raised, and the 
 point of the syringe pushed into the middle of the cellular 
 tissue, thus elevated. Be careful and not penetrate so deeply 
 as to injure the muscle, neither go too superficially, because 
 the medicated fluid remaining in the tense and unyielding 
 stratum of cuticle, will not be absorbed, but give rise to 
 inflammation and sloughing of the part ; therefore it is of 
 
PLACE FOR INJECTION. 
 
 15 
 
 vital importance that the medicated fluid be deposited in the 
 meshes of the cellular tissue. I saw quite a good many 
 sick, brought to the Charity Hospital, who were covered on 
 their backs and chests with deep-seated abscesses, complain- 
 ing of much pain, without my being able to detect any effect 
 brought about by the injection of the sublimate ; on the con- 
 trary, seeing plainly that the syphilitic taint was in full 
 bloom. Such cases, brought about through ignorance, may 
 give rise to misunderstandings and distrust against the effi- 
 cacy of the injection. 
 
 In persons with a good deal of fatty tissue ( panniculus 
 adiposus ), the skin sometimes cannot be raised in a fold, but, 
 without trying repeatedly, the “ needle” of the syringe may 
 be boldly inserted from half an inch to an inch, according 
 to the adipose tissue. I never noticed in such subjects, 
 abscesses. Generally speaking, there seems to be less sus- 
 ceptibility to inflammation. 
 
 In drawing the needle out, put your finger immediately 
 over the aperture and compress it, and by gentle rubbing, 
 the injected fluid will be equally distributed in the tissue. 
 This is indispensable for preventing any loss of the fluid, 
 
 the smallness of 
 be any bleeding, 
 it will be proper to close the opening with adhesive plaster, 
 but generally digital compression will suffice. 
 
 II. PLACE FOR INJECTION.* 
 
 Generally speaking, we find on all places of the body, the 
 same readiness of absorption, since salivation occurs readily 
 
 * By examining the cut accompanying this work, there may be seen 
 the regions best adapted for inserting the injections. 
 
 because such a loss is of importance, taking 
 the injection into account. If there should 
 
16 
 
 THE MANNER. 
 
 from almost any place. Since I fail to find any difference 
 as to locality, I seek parts that are the least sensitive, and 
 am guided solely by this consideration. The less sensitive 
 a place of the body is, when the tissues are punctured, the 
 less will the part inflame, and hence the better suited for 
 our purpose. This condition prevails in the infrascapular 
 and sacral regions. I have allowed my patients to desig- 
 nate, themselves, the special point in these regions. Most 
 of them selected the infrascapular, it being not so sensitive, 
 and the muscles coming but little into play while moving 
 the body. Here the nerve inosculations are more sparsely 
 disseminated. Should these spaces be insufficient on ac- 
 count of the repeated injections, the adjoining regions, or 
 even the chest has to be taken. There is no danger of ab- 
 scesses here, but patients complain of pains darting into 
 the upper extremities, and even numbness, which passes off 
 in a few hours. 
 
 The sacral region is not very sensitive, but the skin is 
 sometimes so adherent that a fold is hardly to be raised. 
 Better is the region of the gluteii muscles , and especially for 
 such persons as are used to horseback-riding, because of the 
 hardness of the parts. But the needle needs to be inserted 
 rather deeper here, and compression ought to be made 
 longer at the aperture, because the fluid escapes more easily 
 than at other points. 
 
 With most patients, the infrascapular region was best 
 adapted to our purpose. The pain was seldom much greater 
 than in other places mentioned above, and I have not seen 
 any abscesses arise here. They have occurred in other 
 regions, as on the anterior part of the forearm, which is 
 usually not very sensitive. With severe cases, which have 
 to lie in bed, the lower extremities may be used, and ought 
 
MEDICATED FLUID FOR INJECTION* 
 
 17 
 
 to be preferred instead of the back, on account of the decu- 
 bitus of the patient. 
 
 We should avoid those regions where there is a collection 
 of glands , because tedious and chronic abscesses may follow, 
 as the regio cervicalis , submaxillar is , inguinalis , cubitalis. 
 
 Whether an already injected place ought to be again used, 
 depends largely whether or not infiltrations or indurations 
 have been formed. With some patients infiltrations, after 
 use of the syringe, occur but slightly, and quickly disap- 
 pear ; with others, they stay for a longer time, and are, on 
 that account, a contra indication. 
 
 It is interesting that such infiltrations seem to compress 
 the sensitive nerves even to anaesthesia, a reinsertion of the 
 needle causing no pain. On this account patients have a 
 predilection for such parts where, if reapplied, sometimes 
 ulceration of the tissue may be induced. 
 
 MEDICATED FLUID FOR INJECTION. 
 
 I use for injections these three solutions of different 
 strength : 
 
 1. 3 grains to one ounce of water. 
 
 2 . 4 a a u a 
 
 More concentrated solutions than No. 3 cause often intense 
 local inflammation and sensitiveness, and abscesses form. 
 Weaker solutions than No. 1 have too little effect, and have 
 to be repeated too often. Which of the solutions to use in 
 any single case, must be determined by idiosyncrasy of the 
 patient, sensitiveness, susceptibility, &e. Generally, I pre- 
 fer in practice the middle strong solution, and w T ith patients 
 in Cliarite Hospital, I use it mostly. 
 
18 
 
 THE MANNER. 
 
 In private practice, considering many circumstances, I 
 prefer to begin with the weakest solution, getting gradually 
 to the stronger one, especially in patients who are very sus- 
 ceptible to pain and in a rather weakly condition. In pa- 
 tients where symptoms of weakness are predominant, it is 
 necessary to find out whether the debility is a product of the 
 syphilis, or is induced by weakening causes, such as insuffi- 
 ciency of food, exhaustive discharges, &c. Should it be 
 advisable to purge a healthy, robust individual, it is best to 
 begin with the weakest solution, continuing it till at least 
 the more concentrated ones can be applied. But I use the 
 concentrated solution in those patients mentioned above 
 (patients who have been reduced by syphilis), even if their 
 state of strength might be considered by a novice a counter- 
 indication for every mercurial cure. In such cases the 
 injection of sublimate shows triumphant results, even if the 
 pain induced by the concentrated solution is quite severe, 
 and wears on the patient. It will be of but short duration, 
 and the patient who has hitherto been pale and worried, 
 gets a better color and a better skin, noticeable even to a 
 non-professional eye. He himself assures you he feels 
 quite improved. 
 
 I use the stronger solutions in those cases wh^e the skin 
 tolerates it and other indications demand a heroic treatment-. 
 Those indications are given either by the dignity of the 
 organ which is syphilitically affected (and I mean here espe- 
 cially the brain, the larynx, the eye), or by a threatening, 
 intense course of syphilis, such as the phagedenic condition 
 of an ulcerating, broken-down venereal sclerosis. Those 
 affections which have existed in long and neglected syphilis, 
 especially gummy tumor of the scrotum, tophi of the bones, 
 &c., require tli e concentrated solution. The curative pro- 
 
DOSES. 
 
 19 
 
 cess commences very soon with them. We may use the 
 stronger solutions in cases of slight syphilis, if the patient is 
 willing and can endure the pain, or if urgent social reasons 
 are predominant. 
 
 To mitigate the pain attending any of the named solu- 
 tions, morphia, with or without glycerin, may be added. 
 The amount to be given varies from y 1 ^ grain to £ grain, 
 judging by the symptoms, if larger doses are demanded. 
 And I may mention here that in some cases a combination 
 of morphia and the sublimate had a narcotic influence, fol- 
 lowing more quickly than in ordinary cases. • In some cases 
 it was the reverse* Every one who has experimented knows 
 the difficulty in obtaining exact and uniform results. 
 
 DOSES. 
 
 Concerning the partial doses for every administration of 
 the injection fluid, the smallest dose is y 1 ^ gr. sublimate and 
 the highest g gr. These minimum and maximum doses I 
 but seldom overstep, and the same are sufficient for most 
 cases for one and the same day. In several exceptional 
 cases I have used, experimentally, § gr., and even a grain 
 per day ; but we must, in these instances, be on the alert for 
 appearances of intoxication, which I shall more fully de- 
 scribe by and by. 
 
 Which of the two doses ought to be used, depends on two 
 circumstances : first, on the individuality of the patient ; and 
 second, on the gravity of the case. 
 
 Concerning individuality, with weakly subjects, we begin 
 with the weaker, and with healthy ones, with the stronger 
 dose. In the course of the treatment, a good deal depends 
 on the sooner or later commencement of the mercurial 
 
20 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 stomatitis, or the susceptibility of the patient ; and by this 
 we may know whether to increase the dose or not. In all 
 cases where lues threatens important organs, higher doses 
 are imperatively indicated, as already said. In most cases 
 I do not inject more than the contents of a Pravaz syringe 
 in one place (the same as a half of my own, viz. : 15 grains). 
 But if I wish to use more, I inject in two places somewhat 
 distant from each other . Very often I take opposite parts 
 of the body. By this means greater doses may be injected 
 at once ; but if circumstances allow it, they ought to be 
 divided into two or three sections of the day, at intervals of 
 three or four hours." 
 
 III. ON THE APPEARANCES OCCURRING AFTER 
 INJECTIONS. 
 
 I. LOCAL APPEARANCE. 
 
 a. Inflammation. — The injection of the sublimate is soon 
 followed by more or less redness, diffused around the open- 
 ing, accompanied by a swelling, which seems to arise chiefly 
 from the depth of the subcutaneous tissue, where the subli- 
 mate has been deposited. A more or less tense infiltration 
 forms, which slightly elevates the non-affected surface above 
 the level of the surrounding. While the traumatic, su- 
 perficial erythema disappears quickly, the induration re- 
 mains a longer time. With some patients spontaneous 
 involution follows ; with others, knotty hardness remains 
 for quite a while. The cause of these differences lies in the 
 individual idiosyncrasies which generally characterize the 
 ability to withstand traumatic influences. But, in time, the 
 most obstinate knot will disappear, as I have seen with all 
 
LOCAL APPEARANCE. 
 
 21 
 
 patients discharged with some swelling, and who returned to 
 the Hospital afterwards without haying a trace left. 
 
 b. Formation of Abscesses . — Concerning the most dreaded 
 determination of the disordered inflammation in suppuration 
 and abscesses , I am able to quiet all apprehensions. From 
 one thousand patients of my private practice only one had a 
 small abscess on the forearm. More frequently they oc- 
 curred in the Charity Hospital, on account of newly-arrived 
 assistant surgeons, &c. Soon, however, they acquire dex- 
 terity, and abscesses are rare, hardly ever occurring with 
 ordinary precautions. 
 
 As I have said before, each local inflammation may be 
 produced by either the quality or quantity of the sublimate 
 solution. As small doses of very concentrated solutions, by 
 their more intense chemical action on the tissues, produce, 
 easily enough, local inflammation tending to abscesses, so 
 great quantities of a very weak solution will give rise to 
 mechanical tearing and loosening of the tissues, with the 
 same result. The regions which are especially predisposed 
 for abscess formations, seem to be the same which, with the 
 so-called syphilitic inclination, go over into profuse suppu- 
 ration. These regions show the same disposition with sub- 
 limate injections. 
 
 In the beginning of my experiments, viz.: the experi- 
 mental stadium of my practice, I generally took those 
 regions for injections which were situated in the neighbor- 
 hood of large lymphatic glands, and I then imagined the 
 deposits of the “ materia pecans/’ occasioned frequent 
 deep-seated abscesses. 
 
 The subcutaneous cellular abscesses take a different course, 
 according to not only either the greater or smaller quantity, 
 or stronger or weaker solution, but also according whether 
 
22 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 injected superficially, or more deeply into the cellular 
 tissue. Suppuration generally takes place when the fluids 
 are deposited in the stratum of cuticle, because, absorbing 
 vessels being wanting, the elastic fibres undergo a protracted 
 stretching, and finally tear. 
 
 With injections of a too concentrated character, or with 
 too great a quantity of weaker solutions in the subcutaneous 
 cellular tissue, especially in the regions of large glands, the 
 swelling (exsudat — Ger. Nosol.) commences immediately ; 
 but only after some time does it soften into an abscess. I 
 have not yet discovered a dangerous termination of an ab- 
 scess, nor erysipelatous, or lymphangoid inflammation. 
 
 c. Injury to Vessels . — Bleedings from pierced veins were 
 not very seldom with injections, but never was it of such 
 magnitude (depending on the locality of the injured vein) as 
 to have caused trouble. Bleeding cannot be avoided, even if 
 places of varicose veins, ncevi telangiectasia , &c., are not 
 touched. Digital compression is quite sufficient, and never 
 did I have to resort to ligation or Liquor Ferri, Sesqui 
 Chloridi, Argentum Nitricum, &c. But as cases occur 
 where, a little after the administration , venous hemorrhage 
 begins, and the patient may be surprised after the physician 
 is gone, it is best to avoid it by compression of the opening 
 for a few minutes, as it will prevent after bleeding. You 
 may instruct the patient himself to compress it after you 
 have left. If, however, a little bleeding occurs, it is rather 
 beneficial than injurious ; and so it is well to briefly delay 
 compression, since it may prevent stagnation of blood, 
 which is apt to be painful. 
 
 There are some published cases where, by the opening of 
 a vein with a hypodermic morphine injection, rapid intoxica- 
 tion commenced, as if the medicated fluid passed directly into 
 
LOCAL APPEARANCE. 
 
 23 
 
 the circulation of the blood. Nussbaum was first to report it, 
 and after him Spencer Wells and Feith (Cologne). In those 
 cases rapid intoxication, immediately after a small loss of 
 venous blood, ensued. I had two similar cases. Both were 
 young, healthy men, of whom the one, right after the injec- 
 tion, sank down with pallor and vertigo. The other com- 
 plained shortly after of dizziness, soon losing his conscious- 
 ness for a few moments. Without trying to explain these 
 phenomena, I doubt very much the view taken by several 
 professional gentlemen, that a thrombus was formed. 
 
 The rapid narcotism seems to be due to quickened ab- 
 sorption, and perhaps to the regions where injected. In the 
 cases mentioned by me, I neither increased the usual dose 
 nor administered in any other place than the regions desig- 
 nated above. The mentioned cases had no resemblance to 
 the common ones of mercury poisoning. One of my pa- 
 tients, in whom toxic appearances were manifest, told me 
 afterwards that he “ could not see blood,” and it maybe 
 possible to attribute it to that. Further, as the related 
 cases did not end badly, they cannot, therefore, be paraded 
 to the discredit of the method . 
 
 It has been said that by drawing back the piston, the 
 inj^ed fluid might be pumped out, but I fail to understand 
 it, and I cannot sustain Nussbaum’s view, “to inject very 
 slow, so as to avoid these occurrences/ ’ 
 
 d. Interruption of Sensibility . — Through the piercing of 
 the needle into the skin, together with the action of the 
 always somewhat acrid solution, pain will be brought about. 
 The mechanical momentum , produced by piercing, does not 
 differ from the pain induced by any other subcutaneous 
 medication ; and, as I said previously, the pain can be con- 
 
24 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 siderably lessened by the dexterity of the operator, and the 
 good condition of needle and syringe. 
 
 Some patients ar6 highly sensitive — as I have had occasion 
 to observe, on the person of a healthy, robust military offi- 
 cer, who swooned away with every piercing of the needle. 
 To counteract this, it might avail to use a liniment of chlo- 
 roform or ether, according to the suggestion of my esteemed 
 colleague, Dr. Bergson. 
 
 The sensitive symptoms, produced by the injected subli- 
 mate solution , are of greater importance, especially through 
 the corroding injluence on the nerves of the subcutaneous 
 tissue. They may follow immediately after administration, 
 and quickly disappear, or continue, and after an hour or so 
 reach their climax. The sensitiveness of patients varies. 
 Some hardly feel the pain ; some describe it as very violent, 
 and even cases have occurred where patients were refrac- 
 tory. The wound remains for quite a time sensitive to the 
 touch, and so highly disagreeable to the patient is it, that he 
 cannot lie down on his side, as usual ; thus being disturbed 
 in his rest. It is best not to make piercings on the side 
 upon which the patient is accustomed to lie, and not too 
 near bed-time. But if, with all these precautions, the pa- 
 tient passes a sleepless night, morphine is not contraindi- 
 cated. In the course of the treatment, patients get used to 
 the described pains. A circumstance not ordinarily desira- 
 ble, the formation of a hard infiltration, as a consequence of 
 the injection, seems to blunt the nervous sensibility. Per- 
 sons who feel no pain when the skin is pierced, nor any 
 discomfort from the injected fluid, require for a permanent 
 cure a greater amount of injection. There are exceptional 
 cases, where the sensitiveness increases the longer the treat- 
 ment continues. 
 
GENERAL SYMPTOMS. 
 
 25 
 
 To find an infallible remedy for this hyperaesthesia would 
 be an advantage for the method and overcome this objection. 
 In general, a combination of morphia with the sublimate has 
 acted well in my hands. In some cases a cold compress was 
 sufficiently soothing ; in others, chloroform liniment had the 
 desired effect. And, as previously mentioned, it is best, in 
 these sensitive cases, to begin with the weaker solutions, 
 gradually rising to the stronger. If the hyperaesthesia be- 
 comes excessive, it is advisable to suspend for a few days. 
 
 II. GENERAL SYMPTOMS. 
 
 In thus using mercury hypodermically, the question 
 arises, to what extent, and in what way, will the know T n 
 symptoms of hy dr argyrosis exist ? 
 
 Without going into the discussion of the preliminary 
 questions, whether the dreaded symptoms have their origin 
 in this metal, or are a combination of syphilis with mercu- 
 rialism, or whether they are nothing more than derivations 
 of syphilis, and wrongly imputed to mercury, I must openly 
 confess that I hold the latter view, and will only point to 
 the fact that, after the hypodermic use of the sublimate in 
 patients with lues , I have had occasion to observe but few of 
 the so-called symptoms. The injury from the mercury was 
 but slight, and can be prevented for the most part. If we 
 consider more minutely the effect of subcutaneously injected 
 sublimate on the different organs, we see : 
 
 a . Disturbances of Digestion . — Concerning the digestive 
 organs , upon which mercury by the mouth acts so delete- 
 riously, I have to say, I could not detect anything injurious 
 resulting from the subcutaneous method. The smallness of 
 the dose was the self-evident reason. Whenever disturb- 
 
 3 
 
26 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 ances of the digestive apparatus arose, which was quite 
 seldom, the effect of the medicine was generally not the 
 cause, but other affections, as catarrh of the mucous mem- 
 brane of the stomach and intestines — an affection standing 
 in close connection to indigestion. Neither did I perceive 
 deleterious effects on other organs, as the liver , pancreas , 
 spleen — a fact in decided contradiction with Graves, Dieter- 
 ich, Rokitansky and Lorinser, who especially record dis- 
 turbances of manifold character in these organs, after use 
 of mercury by the mouth. 
 
 In many cases where the undesirable complication of icte- 
 rus was present (which we shall dwell on more fully here- 
 after), we have seen it, together with the syphilitic affection, 
 disappear with the subcutaneous injections. I never have 
 seen a symptom in any case which could be traced to mer- 
 curial hepatitis , adenophyma or adiposis hepatica . Con- 
 cerning the effect of sublimate on the mucous membrane of 
 the mouth, it seems as if mercury in any aggregated state 
 induces ptyalism . Only recently, Kirchgaesser, in Virchow’s 
 “ Archive,” tried to point out that mercurial vapors also are 
 in close connection with producing ptyalism. That mercury, 
 given in powders and assimilated by the stomach in the solid 
 aggregate state, induces salivation, is well known. And 
 even the sublimate , subcutaneously injected, gives rise to the 
 same process, and often very quickly. I have often ob- 
 served that after a few hours only, symptoms of salivation 
 would show themselves. 
 
 Generally, we may classify the affections of the mouth, 
 resulting from sublimate injections, in three categories: 
 
 1. The first form consists of a slightly inflamed condition 
 of the mouth , generally resembling simple stomatitis, ushered 
 in by gentle swelling of the submaxillary glands, sensitive 
 
GENERAL SYMPTOMS. 
 
 27 
 
 to the touch and somewhat painful. The mercurial stoma- 
 titis is characterized by a hyperemia of the mucous mem- 
 brane of the mouth, the gums and the mucosa of the cheeks. 
 Later, swelling, hyperesthesia and tenderness of the organs 
 of mastication, supervene, together with an increased dis- 
 charge of the secretion of the parotis and submaxillary 
 glands, probably in consequence of the inflammatory ex- 
 citement of the chorda tympani and sympathicus. Another 
 cause of the above condition may be the chemical alteration 
 of the saliva in the mouth, which induces an excited irrita- 
 tion of the mucous membrane of the tongue, fauces and 
 oesophagus. 
 
 2. The stomatitis ulcerosa diptheriticais , named by me 
 as the second form, properly deriving its name from the 
 gangrenous tendency of the ulceration of the mucous mem- 
 brane of the mouth, which is covered with a dirty yellow, 
 resembling a diphtheritic membrane. This is markedly the 
 case around the last tooth, and the fold produced at the 
 angle of the jaw by mastication ; also on the borders of the 
 tongue and cheek pressed by the teeth. 
 
 3. The ptyalism proper may be characterized as an in- 
 crease in the flow of saliva in the absence of even any inflam- 
 matory appearance , without being changed any, or but little, 
 in quality. 
 
 In the experimental phase of my subcutaneous method, I 
 hailed these increased affections of the mouth as signs of 
 established absorption of the sublimate, and I did not inter- 
 fere on account of studying the hyper-secretory effect upon 
 the lues and its recidives . 
 
 It is only attributable to that cause that, with the four 
 hundred patients subcutaneously treated, and who have 
 been the material for my first publication, the high figures 
 
28 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 of 35 per cent, were possessed of mercurial mouth affec- 
 tions. But soon I was convinced that this stomatitis, in- 
 stead of having a healthy effect, was hurtful, emaciated the 
 patient, took his strength and made it difficult to replace 
 this waste; also, as Sigmund says correctly, that “even 
 the lungs may become injured by the cadaverous odor of the 
 mouth.” 
 
 As salivation, on the one hand, promotes absorption of the 
 syphilitic hyperplasia , so, on the other hand, the sequela 
 due to the disease showed clearly that often no radical cure 
 was effected. And very often the treatment had to be in- 
 terrupted for days and even weeks. Among the one hundred 
 and forty-four named cases of mercurial stomatitis, which 
 were noticed in two hundred and fifty-six women, in seventy- 
 nine cases the injections had to be suspended on account of 
 the mouth affection. This interruption consisted of five 
 hundred and eighty-eight days, or an average of seven days 
 per person. It is well known that, aside from the disturb- 
 ance of the nutritive functions, salivation, when once inau- 
 gurated, may advance to such a degree that permanent 
 injury may occur to the teeth, bones, soft parts, &c. ; 
 therefore, I need not point out the dangers occurring from 
 such a state of things ; and for this reason, the chief aim of 
 the physician should be, in every mercurial cure, as also with 
 the subcutaneous method, not only to quickly check saliva- 
 tion, but to anticipate and prevent it. 
 
 The first aim is to use curative means, and then prophy- 
 lactic. Prophylaxis concerns such persons as are predis- 
 posed to salivation ; also such patients as cannot withstand 
 remedies unsuited to their organisms ; e . <7., delicate, anae- 
 mic, leucaemic and lymphatic constitutions. 
 
 This is why women are more apt to have stomatitis than 
 
GENERAL SYMPTOMS. 
 
 29 
 
 men. The frail, delicate, and those laboring under existing 
 dyscrasia, and persons who have either lived in unhealthy 
 surroundings, or, on the other hand, have lived too high, 
 are the ones affected. 
 
 To order good diet and to have proper food adapted to 
 our cure, to ventilate well the different rooms, is as much a 
 factor in preventive therapeutics as the regularity of all the 
 functions of the body by the suitable use of saline laxatives 
 — such as magnesia, the various salts, sulphur baths, &c. 
 
 The care of the teeth demands increased diligence, and 
 Sigmund has given us exact rules thereon : 
 
 Repeated cleansing of the mouth, and especially of the 
 teeth and gums, should be observed ; gargling with a solu- 
 tion of alum 5i ad Sxvj of distilled water. If bleeding 
 should be lightly induced, apply tincture of rhatany as a 
 lotion; and if painful, use tincture of opium in the same 
 manner. Extract decayed teeth, if any; and restrain the 
 patient from wearing false teeth, if possessed of them. 
 
 John Hunter, long ago, pointed out how a necrosed root 
 in the alveola process produced salivation. 
 
 In hospital practice, it is not easy to fix these rules and 
 have them fully obeyed ; but in private practice I was sel- 
 dom called upon to adhere to them rigorously, salivation 
 being so very much less frequent. 
 
 The warm weather of summer, and being much in the 
 open air, seems a preventive of ptyalism, while the winter 
 weather predisposes the patient to it. Those patients par- 
 ticularly, according to my observations, who have a diathesis 
 predisposed to mercurial stomatitis , will need to be regulated 
 in accordance with these rules. 
 
 The best remedy to prevent or combat salivation has 
 been, in my experience, chlorate of potash, as recom- 
 
 3 * 
 
30 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 mended by Herpin, Blache and others. The other rem- 
 edies, recommended by different authors, such as camphor, 
 some of the preparations of sulphur, sulphuric acid (used 
 by Lagneau as a lemonade-like drink), and iodide of potas- 
 sium, often had either no effect at all, or but little. 
 
 As soon as approaching signs of salivation appear, I let 
 my patient gargle with solution of chlorate of potash, gr. 
 x. to the fluid ounce of water. Internally, according to 
 intensity of symptoms, I use a solution of double strength, a 
 tablespoonful to be taken every one or two hours. If there 
 should be much inflammation, I use a solution of gum-arabic 
 and opium. Avoid a too concentrated solution of alum or 
 tannin, because both astringents are, according to Magitot’s 
 experiment (Gaz. Med ., No. 32, 1866), injurious to the 
 teeth ; the first, by destroying the enamel ; the latter, by 
 affecting the dentine. Only i,n ptyalism proper is tannin to 
 be preferred as an astringent. 
 
 But if other inflammatory symptoms have set in, espe- 
 cially on the mucous membrane of the mouth, the use of 
 nitrate of silver is indicated, at the same time diminishing 
 the doses of the sublimate injection, or even suspending the 
 treatment for one or more days, until the symptoms abate. 
 
 I noticed mouth affections to occur more quickly in those 
 patients whom I treated with my “ Combination Cure” 
 which I shall hereafter bring to your notice. These patients 
 either had undergone a mercurial cure before coming to me , 
 or, with the subcutaneous injection , a so-called “ Sarsaparilla 
 Sweat Cure ” had been instituted . Especially soon did the 
 mouth affections appear in such as took internally the iodide 
 of potassium conjointly with my treatment . Whether sali- 
 vation was hereby produced by quicksilver being eliminated 
 in the form of iodide of mercury, soluble in the alkaline 
 
GENERAL SYMPTOMS. 
 
 SI 
 
 serum of the blood, or whether the known effect of iodide of 
 potassium on the secretory glands of the mucous membrane 
 of the nose and eyes was brought about, forming here coryza 
 and blennorrhagia of the conjunctive, working in the same 
 manner on the glandular apparatus of the mouth — I cannot 
 decide, but leave it to further chemical and physiological 
 experiments. 
 
 Persons exercising much in the open air are not so sus- 
 ceptible to the affections following slight colds, such as 
 slight inflammation of the lymphatic glands , and glands of the 
 pharynx and submaxillary region . 
 
 Patients complain of pain in their throat, especially when 
 swallowing, and inspection reveals redness and swelling of 
 the tonsils and enlargement of the submaxillary lymphatic 
 glands, which are pained by pressure, as is seen in common 
 diphtheria. The symptoms, however, never got so aggra- 
 vated that interruption of the cure was necessary. Gargles 
 of emollient decoctions with opium, or slight pencilings with 
 nitrate of silver were sufficient. 
 
 In hypertrophy of the tonsils , an occurrence often met 
 after a successful subcutaneous cure, I only use local means, 
 and mostly nitrate of silver. When there is a tendency to 
 inflammation and ulceration of the mucous membrane and 
 alveoli, I use the same. In case the interstitial tissue is 
 tense and hyperplastic, causing hypertrophy of the tonsil, I 
 use the crystals of chromic acid, and apply them on the 
 surface, letting them melt there. This will cause a yellow- 
 brown soft mass, which can be removed after a time, or 
 when we wish to make a future application. If in this man- 
 ner part of the tonsils are destroyed, the remaining tissue 
 shrinks and causes an immunity against future inflammatory 
 hyperaemia. 
 
32 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 This same treatment I have instituted with persons having 
 a slight cold with tonsillitis catarrhalis, with a success most 
 gratifying. 
 
 b. Disturbances of Respiration and Circulation . — Con- 
 cerning the influence of the sublimate on the organs of res- 
 piration and circulation — how much the same may give rise 
 to inflammation, or figure in producing anginose symptoms, 
 and to what extent it may increase, or induce tuberculosis — 
 are questions we may put aside, if our assurance is sufficient 
 that, in individuals with disease of the respiratory apparatus, 
 or even with tuberculosis, we prefer our cure to any other, 
 as we shall more fully point out. 
 
 c . Disturbances of the Urinary Organs . — The English 
 physician Pavy stated, as a fact well known, that mercury 
 had a strongly deleterious effect on the kidneys. But I can 
 say, from my own experience, that I never noticed that 
 effect from the sublimate injections. I have not hesitated to 
 go so far in some cases, complicated with albuminuria and 
 mellituria, as to inject this solution with good results. I 
 will remark here that, notwithstanding mercury was to be 
 found in the urine, I never could detect in mercurial urine, 
 albumen, as Kletzinsky asserts ; neither could I detect 
 sugar, even in cases where the sublimate had been used for 
 a long time, expecting it, as I did, according to the experi- 
 ments of Laikowsky. 
 
 I may further add, that I never saw arise an affection of 
 the bladder , or urethra , and we may positively say that the 
 whole uropoetic system remains undisturbed by the use of 
 sublimate injections. 
 
 d. Disturbances in the Functions of the Shin and Hair . — 
 Of the injurious effects of the sublimate on these just men- 
 tioned parts, which effects play quite a roU in hydrargyrosis , 
 
GENERAL SYMPTOMS. 
 
 33 
 
 we had not a single case to record. My patients remained 
 free from the mercurial eczema which always attends the 
 “ rubbing cure,” as a troublesome companion; and, also, 
 erythema furunculus was never witnessed, complications 
 which sometimes arise from the internal use of hydrargyrum . 
 On the contrary, our injection healed relatively quickly 
 deep-seated syphilitic ulcerations of the skin, without caus- 
 ing any erosions whatever. Neither had a single patient of 
 mine that idiosyncracy, according to some writers, which 
 gives rise to a peculiar dermatitis, and is a contra-indication 
 for every use of mercury. 
 
 Concerning the affection termed “ mercurial alopecia” 
 (the falling out of the hair), a number of patients complained 
 of it at the beginning of the treatment; but these symptoms, 
 wrongly attributed to the mercury, disappeared as the cure 
 advanced. 
 
 In very many of my patients I noticed an increased ac- 
 tivity of the perspiratory glands of the skin, especially at 
 night; but whether there were other reasons for it than the 
 subcutaneous injections of the corrosive sublimate, could not 
 be ascertained. 
 
 e. Disturbances in the Osseous System . — Diseases of the 
 bones have always received a large share of attention from 
 writers on the effects of mercury. Their preconceived ideas 
 were based on wrong quotations and uncertain observations. 
 I myself had an ample opportunity to observe and treat 
 diseases of the bones ; but in no single instance could I pro- 
 nounce them to be the result of mercury ; and I never saw 
 symptoms arise as observed by Dieterich, and called by him 
 “symphoresis periostei mercurialis” — congestion of the 
 periosteum from mercury. 
 
 /. Disturbances in the Formation of Blood . — Neither 
 
34 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 chemical nor microscopical examinations of the blood of 
 mercurialized patients, revealed, for certain, a deficiency in 
 the red corpuscles , nor in the albumen. It is, nevertheless, 
 true that mercury deeply affects nutrition, depresses it and 
 produces a kind of cachexia, a form of which is chlorosis 
 and anaemia . According to these observations but few of 
 my patients complained of loss of strength, nor did I have 
 but few affected with chlorosis. Those affected with com- 
 plaints of that kind were patients where large doses for a 
 longer or shorter time had been used. I generally paused 
 with the hypodermic injections until those symptoms disap- 
 peared, when I resumed treatment again. I never noticed 
 that, after a longer or shorter duration of the. treatment, 
 symptoms appeared which could be connected with diseased 
 blood. Mostly my treatment ended without any of those 
 disturbances. Neither had I any occasion to notice other 
 alterations of the blood, more closely or remotely connected 
 with mercurial dissolution of the blood, symptomized by 
 epistaxis , hemorrhage of the rectum or uterus , disturbances 
 of the latter organ , resulting in amenorrhoea , dysmenorrhoea , 
 <fc. The hot summer months and the overcrowded rooms in 
 the hospitals would surely have been predisposing causes to 
 such hemorrhages. I failed to observe any change in the 
 catamenia, the female patients being undisturbed in this 
 respect, although I used the injection during menstruation. 
 
 One observation I will not pass over in silence, beeause 
 it might be classed under the head of blood affections. 
 With some patients, I observed, from six to twelve hours 
 after injection, ecchymosed patches , surrounded by a pale 
 red circle , on different parts of the body, and of the size of a 
 pin's head up to an inch in diameter. As suddenly as they 
 
GENERAL SYMPTOMS. 
 
 35 
 
 appeared they disappeared again, sometimes getting paler, 
 and followed by a desquamation of the epidermis. 
 
 They but slightly inconvenienced the patient by itching, 
 and when they appeared after every symptom of syphilis 
 was gone, they frightened the patient, taking the eruption 
 for a relapse of the disease. These patches disappear with- 
 out any local treatment, and I am not disposed to take them 
 for purpura , produced by mercurial dissolution of the 
 blood. I have learned to regard them as partial symptoms 
 of advanced syphilis, an opinion proved correct by the 
 result of the injection cure. 
 
 This observation may be a corroboration of the assertion, 
 doubted by few authors, that syphilis proper , not modified by 
 medical interference, can bring about, through metabolic 
 changes of the blood’s albumen, a lessening of the blood 
 corpuscles, developing the appearances of chlorosis and 
 ancemia , and such symptoms as were above described as 
 belonging to mercurialized persons. With persons of that 
 kind, who, with disturbances of some organs, had a cachectic 
 appearance, the sublimate worked in a wonderful and sur- 
 prisingly radical way, changing them so that after the treat- 
 ment was ended they seemed hardly the same persons. 
 
 g . Disturbances of the Nervous System . — A glance into 
 the literature on this particular branch (and I will name 
 here only the valuable works of the learned scientist, Kuss- 
 maul), shows how diffused the picture is of what is commonly 
 called mercurial neurosis and psychosis , and how contra- 
 dictory the symptoms are. It is not yet demonstrated 
 whether mercury itself causes these disturbances, whether 
 they result from impaired nutrition and deteriorated blood, 
 or whether these diseases are sequences from heterogeneous 
 causes. 
 
36 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 My patients generally showed no symptoms that could be 
 attributed to mercury causing alteration of the functions of 
 either the sensitive or motor nerves. We had neither anaes- 
 thesia, nor hypercesthesia , nor spasm , nor convulsion to com- 
 bat. None of our patients showed signs of spinal or cerebral 
 paralysis. We cannot report * a dizziness in the form of 
 vertigo mercurialis, nor swooning. We cannot chronicle a 
 case of psellismus, nor of aphonia. We have not witnessed 
 either epileptiform or apoplectic attacks. Only in four cases 
 did I observe anything simulating a nervous disturbance. 
 In three we designated a mercurial tremor ; in the fourth, 
 what is termed mercurial erethism. The first three were 
 individuals of a healthy, robust constitution. We observed 
 a tremor of a slight character in the outstretched hands, 
 after fifteen to twenty-five injections of £ gr. each. 
 
 The case of erethism occurred in a patient who received 
 large quantities of the sublimate subcutaneously, and who 
 underwent, without our knowing it, a “ hunger cure,”* 
 which case I shall relate more fully hereafter. 
 
 We used our treatment even in drunkards without any 
 untoward changes or any augmentation of their tremors, 
 which we shall point out in the course of this work. 
 
 The psychical effect of mercury we noticed, in some of our 
 female patients, by a greater sensitiveness and nervousness. 
 Whether this was occasioned by the specific effect of the 
 drug, or whether it was induced by the pain occurring from 
 the daily repetitions of the injection, we cannot say. The 
 male patients showed these symptoms in a less degree, and 
 
 * The 11 hunger cure” has been used in some hospitals in Germany for 
 the last ten or twelve years, as an anti-syphilitic treatment, suggested 
 by French authorities, and very much practiced in France. — Transla- 
 tor’s Rem. 
 
SYMPTOMS OF INTOXICATION. 
 
 37 
 
 therefore we are inclined to think the individuality of our 
 female patients had much to do with this psychical erethism. 
 So have I noticed, among the educated part of my patients, 
 that very many showed quite a marked change in their 
 minds for the better; and this change was the more re- 
 markable since quite a good many patients are very de- 
 spondent, almost hypochondriac, with a venereal disease. 
 This despondency every syphilographer has occasion to no- 
 tice — a condition equally bad for the patient and discour- 
 aging for the physician. Whether it was due to the quicker 
 perception of better feeling, or whether mercury has a spe- 
 cific effect on the nerves, we are, according to the present 
 state of our science, unable to tell. 
 
 SYMPTOMS OF INTOXICATION. 
 
 When I come to the conclusion that toxic appearances are 
 not significant, and are infrequent, I must remind the reader 
 that, to avoid them, he must cautiously administer the medi- 
 cine, in accurate doses, as pointed out by me. if, on the 
 other hand , the maximum doses are overstepped , then acute 
 sublimate intoxication , as I call it, occurs, according to the 
 individuality and quantity of injected sublimate. I shall 
 try to characterize the intoxication. 
 
 These symptoms, arising in such cases through intoxica- 
 tion, may be classed as clear absorption of the sublimate , 
 and interesting, therefore, because their character does not 
 present any complication. This differs from the internal 
 administration of mercury on the mucous tissue of the 
 stomach, or either when the atmosphere of the room is im- 
 pregnated with mercury, and it enters into the system by 
 inhalation, or when it enters by means of the rubbing cure. 
 
 4 
 
38 APPEARANCES OCCURRING AFTER INJECTIONS. 
 
 The totality of the symptoms in our intoxication gives the 
 impression of malignant g astro-enteritis , while, in point of 
 fact, the entire intestinal tract is unaffected by the direct 
 effects of the drug. In lighter cases, the intoxication is 
 ushered in by gastric disturbances like anorexia, coated 
 tongue, bad taste, sometimes metallic ; yet but seldom does 
 the patient complain of nausea and vomiting. After a little 
 time, pain of a sharp, burning character is experienced — 
 symptoms which manifest themselves not only spontaneously, 
 but by pressure on the abdomen especially, and in the re- 
 gions of the stomach and right hypochondrium. A little 
 later, diarrhoea commences, tinged with blood only when 
 occurring profusely. If this symptom occurred during the 
 day, the sleep was disturbed — often interrupted by sudden 
 waking up. These patients presented a marked pale ap- 
 pearance. The conjunctiva was especially pale, the eye ap- 
 pearing dull and the face wearing a look of suffering. They 
 complained of great languor, and after walking but^a short 
 distance, they were obliged to sit down and rest. On this 
 account many remained in bed. 
 
 The secretions showed nothing abnormal. With some, 
 the quantity of urine was increased, lessened in specific 
 gravity, of pale straw color, without any abnormal ingre- 
 dients. 
 
 Pulse, narrow and flexed, having from 90 to 100 beats 
 per minute, which rose to 130 by slight exertion. After 
 injections of relatively greater doses, the symptoms were 
 aggravated, patients generally complaining of a vertiginous 
 feeling , and after walking a few steps they would feel 
 obliged to seize hold of something for support. Even in 
 bed these symptoms were noticed, with comatose complica- 
 tions. Pulse, immediately after injecting the sublimate, was 
 
DIETETIC RULES. 
 
 39 
 
 accelerated and wiry, but would fall down to 60, and in 
 one case to 40 beats per minute. 
 
 The skin was in every observed case without any turgor ; 
 cool to the touch, and often covered with a clammy, cold 
 sweat. Stronger symptoms, denoting acute gastritis, oc- 
 curred later. With the already painful affection of the ab- 
 domen, vomiting occurred, sometimes with bloody dysenteric 
 stools and tenesmus. Urine was voided in small quantity ; 
 but nothing abnormal could be detected. I never noticed a 
 fatal termination of such cases, nor any lasting injury. Res- 
 toration came about under appropriate diet and treatment — 
 the disturbances of the digestive apparatus improving also. 
 The therapeutical treatment consisted of suitable tonics and 
 nutritious diet. For the dysentery we used opium ; for the 
 vertigo, excitants, with good and marked results. 
 
 IY. DIETETIC RULES. 
 
 I. CONCERNING THE BODY. 
 
 As remarked previously, our cure has the advantage over 
 all others, that .it does not confine the patient to bed or room. 
 On the contrary, I allow all my patients to exercise in the 
 open air , when the weather is not too inclement, only cau- 
 tioning them against the morning and night air, and di- 
 recting them to wear woollen wrappers and drawers. 
 
 Only in a few cases did I notice catarrhal affections in 
 the pharynx and larynx, and in but two cases, a heavy 
 bronchitis, both being patients who, contrary to my orders, 
 took a long walk upon an icy, cold winter day. On the 
 whole, it seems that by staying in a uniform temperature 
 during the entire treatment, cases like these are benefited — 
 
40 
 
 DIETETIC RULES. 
 
 a fact I had occasion to notice in the Charity Hospital and 
 among my private patients. 
 
 The same freedom prevails in the dietetic regime. I never 
 insist that my patients shall fast, as is the case with many 
 anti-syphilitic treatments ; yet it is certainly best to have 
 some regulation about the diet; still I never employ with my 
 cases a routine practice, laying down certain rules. On the 
 contrary, individuality and diathesis are my guide, and I 
 pay a good deal of care to such persons as have a chlorotic 
 or other complication with this venereal affection. 
 
 I classify them in general into three distinct groups : 
 
 1. Robust. 
 
 2. Medium strong. 
 
 3. Weak. 
 
 As a general rule, I do not allow any food that is difficult 
 for digestion, nor do I allow a diet which will produce flatu- 
 lence, hard stools and constipation ; so it is best to prohibit 
 sour, salty and spiced victuals. I observed, in the course of 
 time, that it required, in robust, healthy and well-nourished 
 individuals, more of the sublimate to produce a favorable 
 result. I also noticed that a complete cure was not estab- 
 lished until these patients began to lose flesh. For this 
 reason I adopted, in later cases, a little more restriction in 
 diet; and when I saw that completion of cure was not 
 taking place, I employed oftentimes mild, and in some 
 instances even drastic purgatives, and always with good 
 success. With persons of the second class I institute a 
 general diet, corresponding to such as they are used to at 
 home, with perhaps only half the quantity of meat for din- 
 ner, and then I prefer the white meats to the other. For 
 that shortening of diet, on account of less meat, vegetables 
 and soups may be allowed. 
 
CONCERNING THE BODY. 
 
 41 
 
 The first and second class of patients I permit to use 
 coffee, tea, cocoa, &c., for breakfast; but the use of fer- 
 mented liquor is strictly prohibited, and only in very excep- 
 tional cases do I make use of it. I insist strongly that none 
 shall be used, even among the better class of society, when 
 the patient has been habituated to it for years, and I never 
 saw any untoward result arising from the abstinence, as the 
 future history of my cases will show. In very exceptional 
 cases I allowed light Rhine wine. 
 
 I come now to the third class of my patients, typified by 
 a decidedly bad nourishment. I class among them here old 
 persons, debilitated by sickness, &c. They have to be espe- 
 cially cared for as to diet, because it seems that the injec- 
 tion of the sublimate, in such subjects, destroys a part of 
 the albumen of the blood, and on account of that loss a fur- 
 ther debility is induced. I allow such subjects beef, veni- 
 son, eggs in sufficient quantity, besides a glass of good beer 
 and good old wine. I not only allow it, but strongly re- 
 commend it. 
 
 As with other anti-syphilitic treatments, the skin, urinary 
 organs and intestines have to be watched, but not as closely 
 as in other methods, since our treatment does not induce so 
 much secretion there. 
 
 I use, in the incipiency of the treatment, the bath for the 
 patient, in order to induce a free action of the skin , and 
 follow it up from time to time. Should there be any suspi- 
 cion of scrofulous affection, or any other disease of the skin, 
 suitable ingredients for the bath should be employed, as 
 ley, &c. 
 
 Concerning the urinary organs , it is very important and 
 beneficial to have their function in a proper condition, and 
 
 4* 
 
42 
 
 DIETETIC RULES. 
 
 slightly diuretic drinks, as the carbonated waters, &c., are 
 indicated. 
 
 The chylopoetic viscera, especially the stomach and intes- 
 tines, ought to be watched, and particularly in such persons 
 as labor under habitual obstruction, attention to regular mo- 
 tion of the bowels is indicated. Remedies like eonfectio 
 sennce , or a compound infusion of senna , are proper reme- 
 dies to be used, care being taken that no dysenteric or 
 diarrhoeal condition is brought about. This would weaken 
 the patient without accomplishing any benefit. In only 
 such persons as are fleshy and well nourished, as I said be- 
 fore, should drastic purgatives be employed. 
 
 Many syphilitic patients have a predilection for purging, 
 thinking it will assist the treatment. Such persons should 
 be instructed differently. 
 
 II. PSYCHICAL CONSIDERATIONS. 
 
 It is of the utmost importance to be quiet, comfortable 
 and unirritated, because mercurial erethism may result from 
 not following the rules laid down by the physician. 
 
 It is with many sensitive persons a thing of no small im- 
 portance that they experience pain with each injection — 
 giving rise to erethism. It is doubly necessary that such per- 
 sons avoid all excesses and mental excitement. But should 
 such an unfavorable condition be unavoidable, on account of 
 family, business affairs, &c., it is best not to commence the 
 treatment at all. 
 
 Here I must point out, once again, a favorable sign for 
 our treatment, which has much to do with the final result. 
 Patients in a very depressed state of mind generally, after 
 the first injection, would give way to a better feeling , be- 
 cause they comprehend, on the one side, a rapid result, and 
 
INDICATIONS FOR INJECTION. 
 
 43 
 
 on the other side, see that it is not necessary to be restricted 
 to bed and room, nor to adhere to a rigid diet. All these 
 things have a salutary influence on the patient, and are 
 clearly in favor of our method. 
 
 V. INDICATIONS FOR INJECTION. 
 
 Before I shall enumerate more thoroughly the indications 
 for our treatment, I think it necessary to state, in order to 
 avoid misunderstandings, that I see in every syphilitic case 
 a dualism. 
 
 Therefore, the so-called chancre , the ulcus molle , which, 
 as a primary affection, is only to be treated locally, and not 
 constitutionally, must be separated most entirely from the 
 genuine syphilitic sclerosis. 
 
 The virus of a primary chancre is, according to its local- 
 ized condition and nature, never able to spread any further 
 than the region of the nearest lymphatic glands ; while the 
 poison of secondary syphilis, on the contrary, has the pecu- 
 liarity to -enter the system more quickly, infecting the 
 whole organism and producing injurious indurations, long 
 before it could have succeeded by absorption in entering 
 those parts of the body where, after a relatively protracted 
 incubation, every trace of the infection is swept away in a 
 hidden manner. 
 
 I do not think it necessary, but irrelevant, to repeat all 
 that h?” been said for the dualistic conception of the nature 
 of lues. 
 
 Only, then, when all the symptoms have been taken into 
 consideration, local affections, as such, will be differently 
 judged, and practice and science will gain, diagnosis and 
 therapeutics having a better result. 
 
44 
 
 INDICATIONS FOR INJECTION. 
 
 I. INITIAL SYPHILIS. 
 
 The first question that arises is, Is primary syphilitic in- 
 duration , not accompanied with other syphilitic affection , 
 except swelled inguinal glands , a disease for sublimate 
 injections ? 
 
 The question is not very easy to answer with precision. 
 Our most experienced authors are not yet certain whether 
 the initial sclerosis ought to he treated on a general anti- 
 syphilitic plan. Professor Sigmund, of Vienna, writes as 
 follows : “ Lighter forms of syphilis, especially in not very 
 healthy subjects — as simple induration with small papulous, 
 superficial, broken-down tissue, and infiltration of the neigh- 
 boring lymphatic glands, with progressing indolent swelling 
 of more distant glands, and erythema of the mucous parts of 
 the mouth, without giving rise to other symptoms in other 
 organs — need only a local treatment, and are often cured 
 spontaneously . But to come to a definite conclusion re- 
 quires long time for observation . I take from three to four 
 months as an average time for observation, since, experience 
 has taught me that within this time, if the infection has not 
 been previously eradicated, it assumes a new phase.” 
 
 To my mind the whole thing, as above, is uncertain and 
 unsatisfactory, and seems to be derived from a very super- 
 ficial observation. Such assertions can only be proved by 
 authenticated statistical facts. And it seems to me it de- 
 mands a greater material for observation to make it valuable 
 for statisticians. And the material of casual statistics, by 
 which the spontaneous disappearance of syphilitic sclerosis 
 could be accurately ascertained, is entirely wanting in our 
 syphilographic literature. It is for this reason our patients 
 pay no attention to the incipient nodule. Not only non- 
 
INITIAL SYPHILIS. 
 
 45 
 
 professional men fall into that error, but even medical men 
 and students, none of whom have paid scarcely any attention 
 to the primitive appearances of the papules, either not seeing 
 them, or if they did, they regarded them as irrelevant, and 
 employed no prophylactic treatment. 
 
 Patients only seek for help when the neglected sclerosis 
 results in ulceration and other threatening symptoms. 
 
 It is here that the second stage of incubation is partly or 
 wholly commenced, and the blood is already venereally 
 affected, as shown by the fauces and exanthematous erup- 
 tion on the skin. Directly real statistical proof and facts I 
 cannot give for my views, which cannot be expected, on ac- 
 count of the course the initial affections take ; but I have 
 data which will strongly support my opinion. 
 
 For the last eighteen months, in which I devoted my 
 attention to the point in question, I made observations on 
 eight hundred patients in the Charite Hospital, who suffered 
 with genital ulcerations. Of that number five hundred and 
 seventy showed the soft chancre, with its consequences and 
 combinations — the rest having syphilitic general diseases, 
 with or without sclerosis on the genitals. 
 
 Initial syphilitic effects were only present in nine per- 
 sons, and with six the sclerotic process showed already a 
 tendency of commencing destruction. In two cases the 
 diagnosis of ulcus durum (hard chancre) could be made out 
 with a probable, but not with an absolute certainty. 
 
 This great rarity of initial sclerosis, in its isolated appear- 
 ance, its coincidence and its combination with the more pro- 
 gressed general syphilitic symptoms, such as glandular 
 swellings, exanthematous affections of the mouth, &c., seems 
 to be the positive proof that a spontaneous healing, without 
 
46 
 
 INDICATIONS FOR INJECTION. 
 
 a sufficient general therapeutical treatment, occurs but very 
 seldom. 
 
 Zeissl confirms these views of mine somewhat, in saying : 
 u If the commencement of syphilitic affections is not altered 
 by therapeutical means, the whole run of the changes of 
 syphilis, with more or less interruption, is gradually devel- 
 oped. By great care of the patients, the symptoms may 
 disappear spontaneously ; and if the symptoms of disappear- 
 ance may be taken for a cure, it is certainly right to assert 
 that syphilis may heal itself ; but I never yet saw a case 
 where , with spontaneous healing of the earliest constitutional 
 symptoms of the disease , the disease itself was eradicated , 
 and where it did not lead to disturbances of other vital 
 organs 
 
 As I am of the same opinion, I think it not only justifia- 
 ble, but even highly advisable, to use the sublimate injection 
 where the initial symptoms of sclerosis appear. And fur- 
 ther, the perfect cure of the disease, whose continuance is 
 dangerous, on account of a very probable and possible 
 relapse, is, and ought to be, the main therapeutical point. 
 The curability of the indurations is not in proportion to 
 their continuance. I will give one example in illustration. 
 
 In a workman thirty-six years of age I found an indura- 
 tion of three years’ standing. He had used the mercury 
 treatment of Dzondi and Zittmann, and still the induration 
 remained of considerable size.* 
 
 * The decoction of Zittmann (Decoctum Zittmanni) is a preparation 
 of sarsaparilla, much used in Germany for purposes similar to the use 
 of^our “Compound Decoction of Sarsaparilla/ 7 and as it has attracted 
 some attention in this country, as a remedy in obstinate ulcerative affec- 
 tions, we give the formula of the Prussian Pharmacopoeia, which is gen- 
 erally followed in its preparation. 
 
 Take of sarsaparilla 12 oz., spring water 90 lbs.; digest twenty-four 
 
CONDYLOMATA LATA. 
 
 47 
 
 The nature of this sclerosis showed itself after three 
 months in the further development of syphilis in the form of 
 broad papules around the scrotum and anus, together with 
 a syphilitic eruption on the body, swelling of the tubera 
 frontalia , w T hich tormented him nightly in attacks of dolores 
 osteocopei (“ bone ache’’). On that account I think a mild 
 and moderate treatment by injections, in cases of surely 
 syphilitic indurations, very proper. 
 
 To wait three or four months , looking for further devel- 
 opments of syphilis, as Sigmund advises, under the super- 
 vision of a physician for that length of time, — it seems but 
 few patients would submit to it. 
 
 II. CONDYLOMATA LATA. 
 
 Of a greater and a more valuable importance in practice 
 is the second question, viz. : Are broad condylomata — well 
 known as the first syphilitic symptom in woman — as much 
 an indication for injections of sublimate as are syphilitic in- 
 durations of tissue ? I consider this question of more im- 
 portance than the first one, because it is met in private, and 
 
 hours ; then introduce in a closed bag 1J oz. of sugar of alum (saccha- 
 rum alumnis — seu saccharum aluminatum), consisting of equal parts 
 of pulverized alum and the whitest sugar, J oz. of calomel and 1 dr. 
 cinnabar. Boil down to 30 lbs., and near the end of the boiling add of 
 anise seed and fennel seed each J oz., senna 3 oz., licorice root 1^ oz. 
 Put aside the liquid under the name of u strong decoction.” To the 
 residue add of sarsaparilla 6 oz. and 90 lbs spring water. Boil down 
 to 30 lbs., and near the end of boiling add lemonpeel, cinnamon, cardo- 
 mon seed and licorice root each 3 dr. Strain and set aside the liquid 
 under the name of u weak decoction.” Mercury was detected in this 
 decoction by Wiggins in very small proportions. It should not be pre- 
 pared in metallic vessels, lest the mercurial solution should be decom- 
 posed. The decoction may be freely taken. — Translator’s Rem. 
 
48 
 
 INDICATIONS FOR INJECTION. 
 
 in hospital practice very much more frequently. Very often 
 we find female patients suffering from broad condylomata, 
 but seldom do they themselves apply voluntarily for treat- 
 ment, since they think the affection devoid of danger. 
 
 Here in Berlin, where prostitutes are compelled by law 
 to undergo a weekly examination, all having condylomata 
 lata , without any other affection, are sent right off to the 
 syphilitic wards of the Charite Hospital. 
 
 Before entering upon the treatment of this affection, I 
 wish to state my views in regard to its nature. I believe 
 condylomata lata to be an undoubted partial appearance of 
 constitutional syphilis in woman, without classing them, 
 either histologically or chronologically, under the same 
 head with sclorosis in men. 
 
 In a former work of mine on the treatment of syphilis 
 with hypodermic injections of sublimate (Annals of the 
 Charite Hospital, 1868, vol. xiv.), I endeavored to bring 
 forth my views, mostly accepted now, on the constitutional 
 syphilitic nature of those symptoms in woman, and to defend 
 them against a few skeptics like Thiry and Soresina. I en- 
 deavored to show there especially the coincidence of broad 
 condylomes with other grave diseases of constitutional 
 syphilis, and have given statistical references, and ex- 
 plained that these seemingly local affections were only par- 
 tial symptoms of general syphilis, and must not be con- 
 founded with slender warts or vegetations. The latter are 
 always a consequence of local irritation ; while, on the other 
 hand, the broad variety develops itself differently. To sup- 
 port that supposition for the here so-called secretory begin- 
 ning of the acuminata, versus the condylomata lata, (i. e., the 
 moist, versus the dry variety), more observations here follow. 
 
 In women in the latter part of pregnancy, and in many 
 
CONDYLOMATA LATA. 
 
 49 
 
 who were recently confined, broad warts* are developed, 
 and disappear spontaneously without treatment. The other 
 kind (i. e ., slender wart) is developed under the same 
 circumstances, and if already present it spreads more 
 quickly. Metamorphosis in the female organism being at 
 this particular time more rapid, absorption of already exist- 
 ing exudation and broad condylomes were favored, and pro- 
 gressive transformation hastened. On the other hand, the 
 acrid secretion of pregnant females ( fluor vaginalis) and the 
 lochia in childbed seems to assist the pointed condylomes 
 and favor their rapid spreading. 
 
 In the section quoted in my previous work, I have 
 strongly urged the point, which gave rise to much misun- 
 derstanding to syphilographs, and for which explanation only 
 statistics can be used, viz. : I mean the proportion in which 
 broad condylomes tend to initial sclerosis . The misunder- 
 standing arose from this cause : authors like Waller, Linde- 
 mann, Rinecker, Baerensprung, Lindwurm, Hebra, &c., 
 who experimented with inoculations of secretions of second- 
 ary syphilis, had a rather loose nosology, and named indu- 
 ration produced by inoculation , with different names, — and 
 sometimes used the word papules , which term heretofore had 
 been regarded only as a synonyme of condylomata lata . I 
 find another point corroborating me in this cause — that the 
 affection named by me as sclerosis in woman may arise more 
 frequently than hitherto supposed, and quite a time before 
 the development of broad warts, but indeed so hidden and 
 in such places in the female sexual organs that they are 
 
 * Called by Burastead “ Vegetations — papillary growths springing 
 from the skin or mucous membrane, chiefly in the neighborhood of the 
 genital organs, and identical in their nature with the warts found so 
 commonly on the hand.” — Translator’s Rem. 
 
 5 
 
50 
 
 INDICATIONS FOR INJECTION. 
 
 hard to discover on account of their anatomical position and 
 configuration. On the other hand, condylomes, appearing 
 later, are more easily visible to the eye. On those places 
 which are in juxtaposition to the female sexual organs, 
 during the physiological act of coitus , and where direct in- 
 fection may be transmitted, as, for instance, the labia mi- 
 nora , introitus vaginae , commissura posteriora , very seldom 
 are detected the broad condylomes ; but, on the contrary, 
 hidden sclerosis appears. Other places, like labia majora , 
 plicce femoralis , regio perinealis , places never directly 
 touched during coitus, are the most favorite localities for 
 the eondylomata lata , and but rarely show ulcus molle (the 
 soft chancre), produced by direct contact, as is frequently 
 the case on the labia minora and introitus vaginae. 
 
 From these observations I gradually came to the conclu- 
 sion that the broad warts were formed quite a time subse- 
 quent to the original infection. 
 
 The time condylomes first appear is generally from five 
 to ten weeks after the formation of an induration. If we 
 take the time for the incubation of the initial sclerosis as 
 three weeks, it is clearly evident that the broad condylomes 
 will make their appearance in from eight to thirteen weeks 
 after an unhealthy coitus. 
 
 But as the exanthema, especially of the maculous kind, 
 appears in six or seven weeks after infection, we see the 
 lata , in many cases, shortly before the outbreak of the ex- 
 anthema, and with some at the same time. 
 
 With most patients affected with condylomes, our aim 
 ought to be not only the treatment of the local affection, 
 but, in addition, to combat general constitutional symptoms, 
 as a product of those excrescences. This is the reason why 
 
CONDYLOMATA LATA. 
 
 51 
 
 I instituted the injections for broad condylomes , and think 
 this treatment justifiable in all those cases. 
 
 I shall employ this occasion to give the necessary statis- 
 tical proofs of the seat and appearance of condylomata lata, 
 and use those five hundred cases which I have statistically 
 arranged in my previous work, because the other observed 
 twelve hundred cases, which are the basis of the present 
 work, could not be so arranged on account of lack of time. 
 
 A. IN WOMAN. 
 
 I. SEAT OF CONDYLOMATA LATA. 
 
 Of the 356 women, there were infected with condylomata 
 lata , at and around the genitals, 280 persons = 78.65 per 
 cent. If we reckon in here those who had condylomata lata 
 either on the lips, mouth or throat, we see that out of 356 
 women, 305 persons = 85.67 per cent., had condylomata 
 lata. 
 
 The special seat of the lata was : 
 
 A. In one single region in 96 cases = 31.47 per cent. : 
 
 Around the outer genitals in 56 cases = 18 36 per cent. 
 
 In the throat in 21 cases = 6.88 per cent. 
 
 At the anus in 13 cases = 4.26 per cent. 
 
 At the lips in 4 cases = 1.31 per cent. 
 
 At the thigh in 2 cases = 0.65 per cent. 
 
 B. At the same time in two regions in 97 cases = 31.8 per cent.: 
 
 At the genitals and throat in 41 cases = 13.44 per cent. 
 
 At the genitals and anus in 35 cases = 11.47 per cent. 
 
 At the genitals and inside of thigh in 7 cases = 2.95 per cent. 
 At anus and throat in 7 cases = 2.29 per cent. 
 
 At genitals and lips in 2 cases = 0.65 per cent. 
 
 At genitals and tongue in 1 case = 0.33 per cent. 
 
 KSm »' ' uw0 ' 8 
 
52 
 
 INDICATIONS FOR INJECTION. 
 
 At genitals and between toes in 1 case = 0.33 per cent. 
 
 At lips and throat in 1 case = 0.33 per cent. 
 
 At nose and lips ) 
 
 A , , , t no cases. 
 
 At nose and throat j 
 
 C. At the same time in three regions in 74 cases — 24.26 per cent. : 
 
 Genitals, anus and throat in 41 cases — 13.44 per cent. 
 
 Genitals, anus and bend of thigh in 13 cases = 4.26 per cent. 
 Genitals, lips and throat in 6 cases = 1.95 per cent. 
 
 Genitals, lips and bend of thigh in 4 cases = 1.34 per cent. 
 Genitals, throat and nose in 4 cases — 1.34 per cent. 
 
 Genitals, anus and lips in 1 case = 0.33 per cent. 
 
 Genitals, throat and umbilicus in 1 case = 0.33 per cent. 
 Genitals, throat and between toes in 1 case = 0.33 per cent. 
 Genitals, lips and nose in 1 case = 0.33 per cent. 
 
 Anus, throat and nose in 1 case = 0.33 per cent. 
 
 Anus, tongue and nose in 1 case = 0.33 per cent. 
 
 Lips, tongue and throat in 1 case = 0.33 per cent. 
 
 D. At the same time in four regions in 27 cases = 8.85 per cent.: 
 
 Genitals, anus, throat and bend of thigh in 20 cases = 6.55 per* 
 cent. 
 
 Genitals, anus, navel and bend of thigh in 4 cases = 1.30 per 
 cent. 
 
 Genitals, tongue, lips and throat in 2 cases = 0.65 per cent. 
 Genitals, anus, lips and throat in 1 case = 0.35 per cent. 
 Genitals, anus, lips and nose — no case. 
 
 E. At same time in five regions in 8 cases = 2.62 per cent.: 
 
 Genitals, anus, lips, throat and bend of thigh in 6 cases = 1.95 
 per cent. 
 
 Genitals, anus, navel, throat and bend of thigh in 1 case = 0.33 
 per cent. 
 
 Genitals, anus, navel, throat and nose in 1 case = 0.33 per cent. 
 Genitals, anus, axilla, throat and chest in 1 case = 0.33 per cent. 
 Genitals, bend of thigh, lips, throat and nose in 1 case = 0.33 
 per cent. 
 
 F. At same time in six regions in 3 cases = 0.85 per cent.: 
 
 Genitals, anus, bend of thigh, navel, lips and throat in 1 case = 
 0.33 per cent. 
 
CONDYLOMATA LATA. 
 
 53 
 
 Genitals, anus, bend of thigh, tongue, lips and throat in 1 case = 
 0.33 per cent. 
 
 Genitals, between toes, bend of thigh, chest, neck and throat in 
 1 case = 0.33 per cent. 
 
 Respecting the condition of the broad condylomes, they 
 appeared with : 
 
 Complete epidermis in 63 cases = 22 per cent. 
 
 Eroded epidermis in 167 cases = 59.64 per cent. 
 
 Very much ulcerated in 35 cases — 12.5 per cent. 
 
 In the remainder, 76 women, who showed no lata , the 
 following was the result as to the genitals : 
 
 Hard ulcers in 15 cases = 5.35 per cent. 
 
 Ulceration of an indefinite character in 4 cases = 1.42 
 per cent. 
 
 Superficial erosion with a certain hardness in 27 cases = 
 9.64 per cent. 
 
 II. COMBINATION OF CONDYLOMATA LATA WITH OTHER 
 SYPHILITIC AFFECTION. 
 
 Exanthemata . — Of 280 women infected with condylomes, 
 combinations with exanthemata were in 233 persons = 83.2 
 per cent. 
 
 CASES. PER CENTAGE. 
 
 Exanthema maculosum in .... 
 
 95 
 
 40.77 
 
 u 
 
 maculo-papulosum 
 
 38 
 
 16.31 
 
 u 
 
 papulosum 
 
 25 
 
 10.73 
 
 u 
 
 maculo-papulo squamosum 
 
 21 
 
 9 
 
 u 
 
 papulo squamosum 
 
 14 
 
 6 
 
 u 
 
 maculo squamosum 
 
 12 
 
 5.15 
 
 u 
 
 squamosum 
 
 6 • 
 
 2.57 
 
 u 
 
 maculo-papulo squamo-pustulosum 
 
 6 
 
 2.57 
 
 u 
 
 papulo-squamo condylomatosum . 
 
 3 
 
 1.29 
 
 u 
 
 papulo-pustulosum 
 
 2 
 
 0.86 
 
 a 
 
 crustosum 
 
 2 
 
 0.86 
 
54 
 
 INDICATIONS FOR INJECTION. 
 
 CASES. 
 
 Exanthema maculo-squamo crustosum ... 2 
 
 PER CENTAGE. 
 
 0.86 
 
 U 
 
 maculo-papulo condylomatosum . 
 
 1 
 
 0.43 
 
 Cl 
 
 papulo condylomatosum 
 
 1 
 
 0.43 
 
 Cl 
 
 maculo-vesiculosum .... 
 
 1 
 
 0.43 
 
 a 
 
 papulo-vesiculosum 
 
 1 
 
 0.43 
 
 n 
 
 squamo-pustulosum . . 
 
 I 
 
 0.43 
 
 Cl 
 
 maculo-papulo squamo condylomato-crusto- 
 sum . . . ... , • 
 
 1 
 
 0.43 
 
 B. IN MEN. 
 
 I. SEAT OF CONDYLOMATA LATA. 
 
 Of 144 men, there were infected with condylomata lata 
 on the genitals 58 persons = 40.18 per cent. Taking 
 those who were affected in and around the mouth, we have 
 79 persons = 54.86 per cent. 
 
 The special seats were : 
 
 A. In one region in 31 cases = 39.23 per cent. : 
 
 In the throat in 13 cases = 1G.45 per cent. 
 
 At the anus in 11 cases = 13.92 per cent. 
 
 On the penis in 2 cases = 2.53 per cent. 
 
 On the scrotum in 2 cases = 2.53 per cent. 
 
 On the mouth in 2 cases = 2.53 per cent. 
 
 In the bend of the thigh in 1 case = 1.26 per cent. 
 
 B. In two regions in 26 cases = 32.91 per cent.: 
 
 On the scrotum and anus in 6 cases = 7.59 per cent. 
 
 On the throat and anus in 6 cases = 7.59 per cent. 
 
 On the throat and scrotum in 3 cases == 3.79 per cent. 
 
 On the penis and scrotum in 2 cases = 2.53 per cent. 
 
 On the mouth and scrotum in 2 cases = 2.53 per cent. 
 
 On the mouth and throat in 2 cases = 2.53 per cent. 
 
 On the penis and anus in 1 case = 1.26 per cent. 
 
 On the penis and throat in 1 case = 1.26 per cent. 
 
 On the scrotum and axilla in 1 case = 1.26 per cent. 
 
CONDYLOMATA LATA. 
 
 55 
 
 In the mouth and tongue in 1 case = 1.26 per cent. 
 
 In the nose and throat in 1 case = 1.26 per cent. 
 
 C. In three regions in 13 cases = 16.45 per cent. : 
 
 Anus, mouth and throat in 3 cases = 3.79 per cent. 
 
 Anus, scrotum and throat in 2 cases = 2.53 per cent. 
 
 Anus, scrotum and penis in 1 case = 1.26 per cent. 
 
 Anus, scrotum and bend of the thigh in 1 case = 1.26 per cent. 
 Anus, scrotum and umbilicus in 1 case = 1.26 per cent. 
 
 Anus, penis and throat in 1 case == 1.26 per cent. 
 
 Anus, bend of thigh and throat in 1 case = 1.26 per cent. 
 
 Anus, bend of thigh and umbilicus in 1 case = 1.26 per cent. 
 Anus, between the toes and throat in 1 case = 1.26 per cent. 
 Nose, mouth and throat in 1 case = 1.26 per cent. 
 
 Tongue, mouth and throat in 1 case = 1 26 per cent. 
 
 D. In four regions in 6 cases = 7.59 per cent. ; 
 
 Scrotum, anus, bend of the thigh and throat in 2 cases = 2.53 
 per cent. 
 
 Scrotum, anus, mouth and throat in 1 case = 1.26 per cent. 
 Penis, anus, bend of thigh and throat in 1 case = 1.26 per cent. 
 Umbilicus, anus, bend of thigh and throat in 1 case = 1.26 per 
 cent. 
 
 Mouth, anus, tongue and throat in 1 case = 1.26 per cent. 
 
 E. In five regions in 3 cases = 3.79 per cent. : 
 
 Penis, scrotum, mouth, throat and anus in 2 cases = 2.53 per 
 cent. 
 
 Penis, scrotum, anus, nose and throat in 1 case = 1.26 per cent 
 
 II. COMBINATION OF CONDYLOMATA LATA AT THE GENITALS 
 AND SURROUNDINGS, WITH EXANTHEMATA. 
 
 Of 58 men affected with condylomata lata , in 56 cases 
 (= 96.55 per cent.) it was combined with exanthema as 
 follows : 
 
 CASES. PERCENTAGE. 
 
 Exanthema maculosum in 18 31.03 
 
 u papulo-squamosum , 8 13.79 
 
56 
 
 INDICATIONS FOR INJECTION. 
 
 CASES. PER CENTAGE. 
 
 Exanthema maculo-squamosum .... 
 
 5 
 
 8.62 
 
 a 
 
 maculo-papulo-squamosum . 
 
 5 
 
 8.62 
 
 it 
 
 maculo-papulosum .... 
 
 4 
 
 6.89 
 
 a 
 
 papulosum . . . 
 
 3 
 
 5.17 
 
 a 
 
 papulo-pustulosum .... 
 
 3 
 
 5.17 
 
 a 
 
 squamosum 
 
 1 
 
 1.72 
 
 n 
 
 crustosum ...... 
 
 1 
 
 1.72 
 
 a 
 
 luposum 
 
 1 
 
 1.72 
 
 a 
 
 squamo-condylomatosum 
 
 1 
 
 1.72 
 
 it 
 
 condylomatosum-ulcerosum 
 
 1 
 
 1.72 
 
 it 
 
 maculo-papulo-crustosum 
 
 1 
 
 1.72 
 
 a 
 
 papulo-pustulo-crustosum . 
 
 1 
 
 1.72 
 
 a 
 
 papulo-condylomato-pustulo crustosum 
 
 1 
 
 1.72 
 
 a 
 
 maculo-condylomato-squamo-crustosum 
 
 1 
 
 1.72 
 
 it 
 
 papulo-squamo-luposum 
 
 1 
 
 1.72 
 
 Further, there was found to be 
 
 Iritis in 2 cases == 3.45 per cent. 
 
 Tophi in 1 case = 1.72 per cent. 
 
 III. THERAPEUTICS OE SYPHILITIC SCLEROSIS AND CONDY- 
 LOMATA LATA. 
 
 Respecting the quantity of sublimate for a perfect cure 
 of the already mentioned initial syphilitic affection, I must 
 remark here, that among the patients treated by my new 
 method but very few were affected with syphilitic sclerosis 
 simply. The greatest number had several other syphilitic 
 ailments, so that it was more a total cure of general syphilis 
 than a destroyer of the single initial symptoms. 
 
 The indurations showed, in many cases, a very different 
 degree of resistance to the hypodermic medication. 
 
 In most cases the strength of this resistance, and the 
 grade of progress in the treatment, seems to be in propor- 
 tion to the duration of the already present affection, for the 
 
CONDYLOMATA LATA. 
 
 57 
 
 sooner the injections were used against the sclerosis, the 
 smaller was the dose necessary for a perfect cure. On the 
 other hand, the longer cases had delayed in applying for 
 treatment, the larger was the quantity requisite. 
 
 In the majority of cases, from 1J gr. to 2 gr. of the 
 sublimate were sufficient for the entire cure of sclerosis. 
 But in some cases, which had existed for quite a time, and 
 where large indurations had been formed, greater amounts, 
 and in some instances 4 gr. were hardly sufficient. The in- 
 tensity and size of the induration simultaneously lessened with 
 the continuance of the medication. Only in exceptional 
 cases did there remain any infiltration behind, which became 
 softer, still differing from the normal surrounding tissue by 
 its hardened consistence. 
 
 It was extremely difficult to get rid of these u cartilaginous- 
 like knots” which are very obstinate in resisting every mode 
 of treatment and medication, a fact well known to all syphil- 
 ographers. A very concentrated solution of the sublimate 
 seemed to me the most effective against such indurations. 
 The formation begins to disappear with its use, sometimes 
 even in a rapid and surprising way, so that the extended 
 skin covering the elevated knots fails to collapse, and remains 
 for a while loose, like a small empty pouch, after the indu- 
 ration vanishes. 
 
 In all cases where, after using a middle-strong solution of 
 sublimate, an unconquerable “stand-still” in the retro- 
 gressive metamorphosis seems to be visible, suspension of 
 the treatment for a time may be advisable. We have had 
 occasion to observe that, after the formation was again re- 
 produced, when the treatment was resumed, a thorough and 
 complete cure was the result. 
 
 We further observed that ulcerative complications , often 
 
58 
 
 INDICATIONS FOR INJECTION. 
 
 occurring with syphilitic sclerosis, are more tractable than 
 other symptoms. After using J gr. of sublimate, the ulcers 
 heal, and by the time f gr. to 1 gr. has been used, cicatriza- 
 tion is complete. With the same rapidity ulcera mollia 
 (soft ulcers) are healed, it making no difference whether 
 they have their seat on the induration or in its immediate 
 neighborhood, or whether they are in other regions of the 
 body. 
 
 The healing of the broad condylomes by injection of sub- 
 limate is quicker and surer than the cure of the sclerosis, in 
 both men and women, either whether their seat be, as usual, 
 on the genital organs or surroundings, or near the anus, or 
 whether reaching, as a confluent spreading, into the rectum. 
 
 If we consider the changes of regressive metamorphosis, 
 which show themselves during the cure by the sublimate 
 injection on condylomatous excrescences, we find that the 
 yellow crust covering them dries up, falls off and the condy- 
 lomatous bases are soon destroyed by healing. Even the 
 pale red patches remaining, if the injection is continued, 
 change their color to brown yellow, beginning to get paler 
 in the centre. The brown and somewhat darker pigment on 
 the periphery remains longer, but is without any therapeu- 
 tical significance whatever. 
 
 The amounts sufficient in all cases were from \ gr. to 2 gr. 
 of bichloride mercury for the entire healing of condylomes. 
 The sooner they were treated, so much quicker the cure, 
 and vice versa — showing that the ease and quickness of cure 
 depended on the preceding duration of the disease. In the 
 same ratio is the resistance against the sublimate, — as to the 
 consistence and spreading of the condylomatous excres- 
 cences. The softer these are, and the smaller the circum- 
 ference they have, the quicker the therapeutical result ; but 
 
CONDYLOMATA LATA. 
 
 59 
 
 larger and harder excrescences, especially when ulcerated 
 on their surface, require a more protracted treatment. 
 
 The process of cicatrization has first to be induced and 
 completely ended before real involution can be expected. 
 Even here the process of healing commences as quickly 
 with the subcutaneous use of the sublimate as in the already 
 mentioned cases of ulcerative indurations of male patients. 
 We had occasion to observe also how the fatty, dirty-like 
 secretion began to dry up with from four to six sublimate 
 injections, in doses of J gr. each. The condylomatous ulcers 
 begin to form new cuticle ; the excrescences become flattened 
 and sink down, and perfect cicatrization results. There is 
 also a difference of time in healing. The most obstinate are 
 the broad excrescences around the anus and genital organs. 
 They are especially unyielding when their form is pointed 
 and they reach into the orijicium ani , or even as far as the 
 mucous parts of the anus and rectum. Here we find those 
 deep ulcerated rows, produced by defecation and constant 
 tearing. Healing here is naturally very slow. 
 
 (Edematous swelling of the labia majora is not a very 
 rare result from broad condylomes, especially when the 
 latter are ulcerated and grouped together, giving rise to 
 fluxions, hypersemia and transudations. 
 
 These consecutive swellings of the labia do not require a 
 special treatment. On the contrary, the slender, long, indu- 
 rated excrescences, having their seat generally on the inside 
 and on the border of the labia majora, require more than 
 ordinary doses of the bichloride solution. We have used 
 here 2J gr., and sometimes even more for a cure. 
 
 And I must remark here, that in some few cases of con- 
 dylomes — and I have already pointed out this with sclerosis 
 — those excrescences are very unyielding to treatment, and 
 
60 
 
 INDICATIONS FOR INJECTION. 
 
 require rather increased quantities of mercury. Especially 
 was this the case with those mucous papules which, instead 
 of being covered with a thin stratum of epidermis or epithe- 
 leum, had a thick wart-like epidermis, so that I used in my 
 lectures the special term “ condylomata verrucosa” * 
 
 A second species of equal obstinacy, I gave the name 
 “ condylomata mixta ,” using the same analogy existing be- 
 tween them and the so-called ulcus mixtum. With the first 
 expression I designate all those papillary excrescences 
 which originally have the formation of broad condylomes, 
 but instead of undergoing a superficial fatty metamorphosis, 
 or an ulceration, they form on the surface papillary excres- 
 cences. These are elevated, and easy of being confounded 
 with pointed condylomes, and which, microscopically exam- 
 ined, show the same spreading peculiarity of the papillae. 
 
 I shall pass on to the local treatment of the described 
 syphilitic alfections, namely, syphilitic indurations and con- 
 dylomes, because I could not entirely lay aside local treat- 
 ment with my patients in the Charite, for the purpose of 
 experimenting on the pharmaco-dynamic effects of hypoder- 
 mic injections on broad condylomes. 
 
 In constitutional syphilis, local therapeutics has to support 
 the internal treatment for effecting and hastening a cure. 
 In syphilitic induration and ulceration produced by it, the 
 local treatment was quickly finished — extending it to total 
 extirpation, cutting the whole indurated surface off with 
 scissors, especially when seated on the frenulum glandis , 
 prepuce, or on the skin of the penis, or labia majora or 
 minora. 
 
 Not with a view, as often expressed, to check syphilis in 
 that way, which is contrary to the whole course of the pro- 
 * Warty condylomes. — T ranslator’s Note. 
 
CONDYLOMATA LATA. 
 
 61 
 
 gress of the disease, but by extirpation, I aim to lessen the 
 syphilitic virus and check its flow into the blood, regarding 
 these infected places, figuratively speaking, as reservoirs 
 from which the whole system could be contaminated. 
 
 In cases where extirpation is impracticable, the indura- 
 tions have to be destroyed deeply and thoroughly, with the 
 usual strongest caustics. 
 
 And here let me mention a new treatment, not only of 
 simple, but of obstinate ulcerations , such as have resisted 
 almost every kind of medication. I mean the use of medi- 
 cated fluids by 64 spray atomization.’ ’ [Vide my book, 
 46 Clinic of Diseases of the Larynx,” vol. i. Inhalation, 
 Therapeutics in Diseases of the Respiratory Organs ; second 
 edition, Berlin, 1865, p. 157.] * 
 
 I have treated in this manner, in the syphilitic wards of 
 the Charite Hospital, extensive ulcerations. The 44 atomiza- 
 tion treatment” begins with cold water or medicated fluid. 
 In many cases the effect is a striking one. The ulcerated 
 surface clears ; the virulent secretion entirely ceases in a 
 painless manner, and it seems that atomized spray of w T ater 
 has a very stimulating effect on the ulcer. Thus the tem- 
 perature in sluggish erosions may be augmented, while a 
 cooling off of inflamed ulcers and surfaces may be produced. 
 
 It matters not what the modus operandi may be by which 
 the spray produces these results. I can testify to its effi- 
 ciency in a great number of hard, obstinate cases, and think 
 the treatment a valuable addition to local therapeutics. 
 
 Not only in cases already mentioned, did I see the good 
 result, but also in ulcerated bubos. Whether having an 
 
 * The author here describes an apparatus constructed according to 
 Bergson. We, in this country, may use much the same instruments, 
 commonly called u spray atomizers.” — Translator’s Rem. 
 
 6 
 
62 
 
 INDICATIONS FOR INJECTION. 
 
 idiopathic, sympathetic or virulent origin, I have always 
 witnessed highly satisfactory results from the treatment with 
 the atomizer in bubos consequent upon inguinal ulceration. 
 
 I have no cases of failure to record, in consequence of 
 ulcerated bubo, when locally treated in this manner. The 
 only fatal cases occurring were — one man, insane, who could 
 not he induced to submit to it, and another man, recently 
 dead, who had an ulceration of a bubo nine inches in 
 diameter. 
 
 This result is of greater importance yet for us, consider- 
 ing that in our wards from three hundred to four hundred 
 patients are annually treated. Some of these cases had 
 been sent to us, where the ulcerations of the bubo already 
 had reached such a grade of destruction that the underlying 
 muscles could be seen as easily as in an anatomical prepa- 
 ration. We even had cases where gangrenous destruction 
 of enormous extent, at the bend of the thigh, was existing. 
 
 Shortly after taking charge of the syphilitic wards of the 
 hospital, and before using the spray, a number of fatal 
 cases occurred in consequence of ulcerations of bubos. One 
 died on account of the erosion of a blood vessel rendered 
 gangrenous ; another from the enormous undermining of the 
 cuticle, extending over the whole right half of the abdomen 
 and around to the spinal column. These cases, together 
 with the entire absence of any like instances of fatality 
 since using the spray atomizer, are ample reasons for sus- 
 taining this new method. 
 
 The favorable results since that time are the more 
 remarkable, if we take into consideration the fact, that in 
 other and extensive — and on this account not well circum- 
 stanced-charity hospitals, patients die of hospital gangrene 
 frequently. This occurs even in the smaller hospitals. 
 
SWELLING OF THE LYMPHATIC GLANDS. 
 
 63 
 
 According to Dr. E. Zeis, during the comparatively short 
 interval of three years (1864-1867), of twenty patients 
 having bubo, three died, or fifteen per cent. This occurred 
 at the Dresden Hospital. 
 
 As to the local treatment of broad condylomes , the results 
 are more favorable than with the before-mentioned indura- 
 tions, because they are more simple ; and further, the con- 
 dylomatous papillary excrescences have a tendency to mole- 
 cular destruction only, and very seldom produce deep-seated 
 ulcerations. 
 
 I prefer for local treatment of broad condylomes , a paste 
 of zincum oxydatum , or chloride of sodium and calomel. 
 This is best of all used remedies. 
 
 Condylomata mixta and condylomata verrucosa , as named 
 by me, are somewhat more difficult and complicated, since 
 here the hyperplasia of the thick, hardened epidermis is to 
 be overcome. In such cases it is not to be recommended to 
 use the sublimate injection to accomplish the final cure, but 
 resort, at your earliest convenience , to extirpation with the 
 scissors . 
 
 In condylomata mixta , I clip at first only the point of the 
 sharpened excrescences, on account of their origin from the 
 effect of the fluor vaginalis , and even sometimes of blen- 
 norrhoea of Duverney’s gland. As I have already stated, 
 they are more of a local affection, and are not necessarily 
 connected with constitutional syphilis. 
 
 III. SWELLING OF THE LYMPHATIC GLANDS. 
 
 Besides the already mentioned affection, I think in all 
 those processes denoting a more advanced state of venereal 
 affections, which go by the name of secondary syphilis , ac- 
 
64 
 
 INDICATIONS FOR INJECTION. 
 
 cording to Ricord, there is an undoubted indication for em- 
 ployment of the subcutaneous injections of sublimate . But 
 it is necessary to make a suitable division between impor- 
 tant and less important complexity of symptoms, and to 
 modify accordingly the indications as to treatment. It is 
 only in those cases where a certain range of characteristic 
 symptoms presents itself that the injection ought to be 
 resorted to. 
 
 It is sometimes difficult to arrive at an accurate decision, 
 especially in cases where, after all syphilitic symptoms have 
 subsided, only indolent swellings of the lymphatic glands 
 still remain. 
 
 Here we perceive almost the same appearances w T e have 
 pointed out above in sclerosis — that a complete cure , with a 
 single course of treatment, will hardly be effected. 
 
 The second important fact to notice is, that after the first 
 few injections, the swelled inguinal glands and glands of the 
 lower jaw lose perceptibly in volume and hardness; even 
 sometimes are reduced to half their former size. But a sud- 
 den stand-still in the progress of the cure occurs ; the 
 glandular swellings, to a certain point, cease to be affected 
 by the sublimate ; and even after the venereal virus is 
 eliminated from the system, undesirable knots still remain. 
 
 The patients who have watched with considerable pleasure 
 the diminishing of the wreath-like knots, become now uneasy 
 in mind, since these enlargements are in bad repute not 
 only among non-professional, but also among professional 
 men. We physicians ourselves feel suspicious in these un- 
 yielding cases, that the still remaining glandular swellings 
 are, to a certain degree, the store-houses and hiding-places 
 for a portion of the syphilitic virus or the filter of the glan- 
 
SWELLING OF THE LYMPATHIC GLANDS. 
 
 65 
 
 dular tissue. We fear that from here it will again enter the 
 circulation and invade the organism. 
 
 On the other hand, we have well-authenticated cases 
 where no relapse occurred, even with a remaining glandular 
 tumescence ; and, therefore, we may hope that the adenitis 
 chronica (chronic glandular inflammation), which runs a 
 tedious course, may eventuate in a perfect cure. 
 
 In cases where there are no suspicious complications we 
 may abstain from injections, and use other medication — as 
 baths, consisting of iodides and bromides, conjointly with 
 the internal administration of iodide of potassium, without 
 thus anticipating a complete cure in all cases. 
 
 Such therapeutics seem the more justifiable, because we 
 cannot ascertain, with a certainty, the normal size of the 
 gland. I here mean the difference in bulk between the ex- 
 isting swelled gland and the gland originally, for we can 
 place no reliance on the declarations of the patients, as they 
 proverbially deny the existence of any glandular swelling 
 previously. Especially is this the case with the glandulce 
 inguinales and submaxillar es 9 which are, even in non- 
 syphilitic individuals, sometimes considerably enlarged, 
 without having occasioned any notice. 
 
 Of greater significance are the cervical and occipital 
 glands. These are sometimes so small, in healthy and non- 
 scrofulous subjects, that in examinations of the persons the 
 glands are detected with difficulty. If here a hyperplasic 
 swelling arises, it is always suspicious. It is the same with 
 the cubital glands. The swelling here is, according to my 
 view, always a pathognomonic sign of syphilis, notwith- 
 standing the assertion of some authors, that this swelling is 
 always the product of a mechanical cause, especially hard 
 working, &c. I have noticed in syphilitic women, who 
 
 6 * 
 
66 
 
 INDICATIONS FOR INJECTION. 
 
 never did any laborious work, a swelling of these glands, 
 which only subsided after an energetic anti-syphilitic treat- 
 ment. That mechanical causes may have something to do 
 with these swellings, I have shown in the statistical tables 
 of my former work on the Charitd Annals (vol. xiv.). 
 There I show that the swelling of the cubital glands occurs 
 oftener in men who are mechanics than in women. 
 
 Lastly, I may remark that, in a relatively great number 
 of cases laboring under tertiary syphilis , I have never found 
 any swelling in the lymphatic glands, more especially be- 
 cause the seat of this tardy affection is in the deeper, rather 
 than in the superficial layer of tissue connected with these 
 named glands. 
 
 In the treatment of adenitis , inunction of unguentum 
 iodinum, for softening the hyperplastic glands, had but 
 little effect. I prefer rather to paint over the part with 
 the tinctura iodini. I here wish to urge caution, lest too 
 much local treatment by inunction excite the gland, and 
 thereby interfere with the process of absorption. 
 
 IV. AFFECTION OF THE MOUTH AND PHARYNX. 
 
 Shortly after swelling of the mentioned lymphatic glands, 
 and sometimes simultaneously with it, lues brings about, by 
 absorption of virus, an acute swelling of organs analogous 
 to the lymphatics , viz. : hyperplasia of the glandular ele- 
 ments and fibrous stroma of the tonsils . But swelling of 
 the tonsils is, as is well known, a concomitant phenomenon 
 of other diseases. These glands enlarge not only with 
 scrofulous persons, but a cold may produce a hyperaemic 
 swelling in healthy persons. Irritations, like smoking, too 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 67 
 
 free an indulgence in strong drinks, &c., are likely to induce 
 this swelling. 
 
 A differential diagnosis can discover no characteristic 
 criterion between tonsillar and syphilitic affections. The 
 painless course of syphilis, as characterized by some au- 
 thors, and the seemingly sharp division of the surroundings, 
 especially at the hard palate, and extreme follicular affec- 
 tions of the anterior part of the mouth (M. Cohn) accompa- 
 nying it, are, according to my observation, no sufficient 
 diagnostic symptom. Neither can I take, for a convincing 
 criterion, a singular bluish color , changing to red ; nor of a 
 red, changing to a copper-like color, as has been much em- 
 phasized by some authors, because these divisions of color 
 are fraught with liability to deception, since the most decep- 
 tive of all our senses is this sense of color. 
 
 From the above facts, I find myself compelled never to 
 regard tonsillar swellings as an indication for treatment by 
 injections. 
 
 Quite an importance, however, do anginous swellings 
 have, when completing the complexity of other suspicious 
 symptoms, which, as single factors, may not be charac- 
 teristic, but whose combination may have a great importance 
 for the diagnosis of syphilis. I (Jo not mean here those 
 cases where syphilis has already been developed, nor where 
 residues remained, leaving no doubt in diagnosis ; but such 
 cases where sure and decisive symptoms are absent, and 
 others have to be taken for diagnosis. 
 
 If in such persons not only the submaxillary glands are 
 swollen, which may be the case in scrofulous amygdalitis, 
 but if the cervical glands also have been drawn into the 
 hyperplasic process, or even the submental glands , and if 
 there should be a suspicious and unexplainable dejluvium 
 
68 
 
 INDICATIONS FOR INJECTION. 
 
 capillorum (loss of hair), if the pharynx or tonsils have on 
 the mucous parts white, grayish patches or erosions (more 
 fully to be explained by and by), I do not hesitate to order 
 the injection, even if syphilitic appearances have vanished 
 from the genitals. 
 
 The effect of the remedy is, in such cases, a very rapid 
 cure — using only from J gr. to f gr. of the sublimate. 
 
 Not only is the cause of hyperplasia of the tonsils difficult 
 to diagnosticate, but so is acute inflammation, arising from 
 fresh ulceration . Real syphilitic ulcers are very seldom to 
 be found in the first stages of the disease of which we treat 
 here entirely, but they belong to a later period. I have 
 seen in some cases ulcerations whose character did not seem 
 syphilitic, even if the indirect cause may have originated 
 in lues . 
 
 The ulcerative process hereby given is rather mechanical, 
 but is according to my observation. In the interstitial tis- 
 sues a specific inflammation commences; with the rising 
 inflammation a hyperplasic process on the one side, and an 
 exudative process on the other, begins — the effect being 
 somewhat identical on the open and on the closed follicles. 
 
 These two categories of glands are excited by compres- 
 sion, as shown above, bringing about ulcerations thus : the 
 follicles, which lead in an open way to the mucous mem- 
 brane, are undergoing, by pressure and excitement, a round 
 follicular ulceration, while the closed sebaceous glands form 
 a confined submucous abscess, which opens slowly, and then 
 forms a circular ulcer, spreading rather deeply into the 
 tissues. The interstitial tissue in these parts changes by 
 inflammatory hyperemia, and very often ulcerates on ac- 
 count of the hyperplasia and exudation. This process does 
 not form a round, but a diffused, infiltrated, irregular ulcer. 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 69 
 
 Even on other parts of the pharynx, where the glandulce 
 acinosce predominate over the sebaceous glands , the same 
 analogous process may take place. 
 
 The mucous glands, drawn into affection by sympathy 
 with the surrounding swelled and inflamed interstitial tissue, 
 are animated to a greater secretion, and very soon not only 
 the quantity, but the quality of the secretion undergoes 
 important changes. The already formed ingredients prevail 
 over the intercellular fluid, which becomes more consistent, 
 and by its final inspissation closes its own outlet. In time, 
 a u retention cyst ” is formed by the gathering of thick mu- 
 cous, rising above its surroundings. After a longer or 
 shorter time, the resistant cellular contents, by a process of 
 softening, go into a retrogressive metamorphosis, in conse- 
 quence of which an abscess breaks, and presents itself as a 
 small follicular ulcer. 
 
 This ulceration may enlarge in two ways : first, on the 
 arches of the palate by mechanical effects, produced by mas- 
 tication and deglutition ; secondly, the irregular histological 
 condition of the affected tissue may take on the ulcerative 
 process, enlarging, as has often been noticed, with the velum 
 pendulum palati . Here is a singular circumstance existing. 
 Between the folds of the anterior and posterior mucous sur- 
 faces there is situated a loose tissue, seeming to have but 
 few vessels of absorption. If now an abundant exudation 
 around the follicles is formed, as it sometimes happens, they 
 will very easily become ulcerated on account of the lessened 
 absorption. In this manner I have seen, in a few instances, 
 ulcerations and even perforations of the described region — 
 in persons, too, who have never been syphilitic, or when 
 syphilis had been eradicated. Such ulcers heal, as is well 
 
70 
 
 INDICATIONS FOR INJECTION. 
 
 understood, after an ordinary local treatment, especially by 
 pencilling with argentum nitricum. 
 
 Repeated observations, that especially scrofulous ulcera- 
 tions, producing loss of the substance forming the pharynx, 
 have been taken by the majority of physicians as syphilitic, 
 and even as tuberculous, induce me, from a variety of cases, 
 to select the following two. In both, later arising scrofulosis 
 showed that a scrofulous diathesis was the intermediate cause 
 of the ulcers, complicated with a diphtheretic affection : 
 
 Case 1 . — Marie B., from G., fifteen years old, descends from a family 
 where the father died with heart disease ; mother and sisters are in 
 good health. Patient had in her childhood measles and scarletina. 
 When fourteen years old she was taken sick (I quote here the words of 
 the attending physician, Dr. Strahler, who had the kindness to send me 
 the patient), in winter, probably from a taking of cold. She suffered 
 with scrofulous periostitis of the left tibia, and used cod liver oil. In 
 the spring of 1866, she was taken with a catarrhal angina and laryn- 
 gitis. The generally used anti-catarrhal treatment had no perceptible 
 effect, and resorted again to the anti-scrofulous treatment. The patient 
 took salt-water baths, drank mineral waters with whey, and later, cod 
 liver oil, and was pencilled every other day with a middle-strong solu- 
 tion of argentum nitras ) changing from better to worse, and vice versa. 
 Her condition became more precarious after a voyage to Berlin, where 
 a diphtheretic affection set in. Examination revealed a defect on the 
 anterior border of the epiglottis, and ulceration on the mucosa of the 
 arytenoid cartilages. Bathing, the use of u Adelheidsquelle ” (a min- 
 eral spring in Germany), and inhalations were employed. The result, 
 in a single fortnight, was a surprising one. Deglutition was less pain- 
 ful ; appetite increasing ; nutrition and strength visibly progressing. 
 Unluckily, the cholera, which broke out in the house of the patient, 
 retarded further progress. Patient was taken with diarrhoea, and her 
 mother took her into the country. The treatment could not be con- 
 tinued, consequently the ailments of the throat increased and a 
 hoarseness followed. 
 
 I saw the patient in October, 1866; found her greatly emaciated; 
 muscular development slight; stooping gait; pale, greenish-yellow 
 complexion, and of a general anaemic appearance. While telling me 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 71 
 
 her history, she was frequently interrupted by coughing ; mostly com- 
 plained of pain in deglutition, dyspnoea, cough and hoarseness, with a 
 good deal of 11 hawking,” and an expectoration of a tenacious sputum 
 filled with air-bubbles. During eating, a portion of her food would 
 pass through her nose. 
 
 Examination revealed copious ulceration of the pharynx, and especially a 
 part of the arcus palati-pharyngeus and velum was so united with the poste- 
 rior roof of the palate that only a small orifice remained for communication 
 with the pars nasalis and oralis. The uvula was, through ulceration, nearly 
 destroyed. At the left tonsil there was situated a great ulcer, covered with 
 unhealthy pus, extending to the posterior part of the palate roof and reaching 
 deeper down into the larynx. Laryngoscopic examination revealed a dis- 
 charging ulcer on the free border of the epiglottis, which had already destroyed 
 a large portion of it. The ligamenta aryepiglottica, especially the left, was 
 swelled, ajid seemed to be eroded on its surface. The vesicles of Galen were 
 covered with pus. The arytenoid cartilages were swollen, and showed, par- 
 ticularly the left, an oval purulent ulcer , with sharp borders on the one side 
 and flat edges on the other. The vocal cords could not be thoroughly exam- 
 ined , on account of the swollen thyroid cartilages. Shortly before the patient 
 came under my care, she was examined by two other specialists , one of whom 
 pronounced, as reported, her case incurable tuberculosis ; the other seemed to 
 think her syphilitically affected. I at once pronounced it to be a case of sim- 
 ple scrofulosis , amenable to treatment, and proceeded. 
 
 Besides the already prescribed anti-scrofulous medication, I treated 
 the ulcer on the pharynx and larynx partly with argentum nitricum and 
 partly with iodized glycerin. The patient was completely restored to 
 health in a few months. That the cure was a lasting one, a letter 
 from my esteemed colleague, Dr. Strahler, confirms. 
 
 Case 2.* — Miss S. A., seventeen years old, of healthy parents, has 
 generally been healthy, with the exception of an eruption on the scalp, 
 lasting from earliest childhood up to her twelfth year, and which, as 
 reported, disappeared regularly in summer and returned again in win- 
 ter. According to description, this eruption seemed to have the char- 
 
 * The most important cases in my practice of former years have been 
 mostly published in my already mentioned work on Injections of Subli- 
 mate. The material of the present work I have taken from recent ex- 
 perience, and hence have not taken cases from my researches on 
 relapses. 
 
72 
 
 INDICATIONS EOR INJECTION. 
 
 acter of eczema impetiginosum. The treatment was only a local one. In 
 the fourteenth year the catamenia commenced, but scantily, and have 
 continued irregularly till the present. 
 
 In August, 1868 , she was attacked, as it seems, with angina tonsil- 
 laris, accompanied with much pain, especially in deglutition. After a 
 few days an abscess was formed, which having opened, a great deal of 
 pus, mixed with blood, was discharged. After a few weeks, a relapse 
 occurred — a new abscess was formed, also discharging blood and pus. 
 Notwithstanding the use of gargarisms, the condition did not improve; 
 on the contrary, deglutition was still more painful, and the food was 
 regurgitated through the nasal passages. 
 
 The family physician, Dr. Stubenrauch, physician to the royal court, 
 transferred the patient to me. He said that he had only seen such 
 large ulcerations in this region exclusively with syphilitics, and there- 
 fore made a thorough examination of the patient and family, but failed 
 to get any warrantable, proof for his suspicion. 
 
 The patient was of medium size, well built, pale, and face somewhat 
 oedematous. Exploration of the chest did not present anything abnor- 
 mal. The ceryical and submaxillary glands were but little swelled. 
 The inspection of the pharynx revealed a great ulcer , reaching deeply into the 
 submucous tissue , of the size of a Prussian thaler , which seemed to start from 
 the left anterior roof of the palate , having already destroyed both tonsils. The 
 borders of the ulceration were livid and swelled , and somewhat undermined . 
 The pus was of a dirty gray color , firmly adherent and of a thick consistency. 
 Laryngoscopic examination shoivcd a hypersemia and slight swelling of the 
 mucous membrane of the larynx , without loss of substance. 
 
 Thinking that the basis of this disease was only scrofulous, I recom- 
 mended internal anti-scrofulous medication and local pencilling with 
 argentum nitras. After the lapse of some months, the patient was com- 
 pletely restored to health. 
 
 Exploration now showed a star-like cicatrix , reaching doivn to the vertebrse 
 of the neck , which resulted in gluing the right roof of the palate with the an- 
 terior wall of the mouth. Of the left roof a small part remained. The ton- 
 sils were wanting entirely. A small erosion of the nose indicated an exist- 
 ence of ozsena scrofulosa , now already healed. 
 
 The same precaution is necessary for that affection of the 
 fauces , resembling sharp-bordered , grayish ivhite, milky 
 patches , that French authors have named “ plaques opalines / 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 73 
 
 and recent German syphilograplis , according to Sigmund , 
 psoriasis oris . 
 
 The latter definition seems to me characteristic, regarding 
 the pathological and histological processes, which are the 
 same as in psoriasis vulgaris . 
 
 If these plaques opalines , as is sometimes the case in the 
 early beginning, appear isolated, it is better always to await 
 their. further course, and treat them meanwhile on the ex- 
 pectant plan — even if the grayish white patches, encircled 
 by a red border, commence to elevate , and the epithelial 
 stratum, seemingly adipose, appears to thicken. 
 
 Only then do I commence therapeutical treatment, when 
 changes of texture occur by which the plaques opalines 
 change to plaques ulcereuses , as one may call them. They 
 are thus characterized : after the removal of the fatty 
 epithelium, the eroded hyperplastic papules' appear flesh- 
 colored, and around the milky epithelium molecular detritus 
 is formed. We have a yet surer ground for diagnosis, since, 
 besides the mentioned processes, a condylomatous wreath- 
 like excrescence of infiltrated papillary bodies exists , arising 
 on those places ivhich have a locality favoring their forma- 
 tion — as , for instance , the back part of the tongue , hard 
 palate , <fc. 
 
 Sometimes these affections of the mucous membrane 
 evince the most marked characteristics during advanced 
 ulceration, which characteristics are on places not easy of 
 access for examination. I mean those pits called by me 
 fovece tonsillares , in which the tonsils are embedded . The 
 roofs of these pits are formed by the posterior surface of 
 the arcus palato-glossus and arcus palato-pharyngeus. 
 
 By deglutition and phonation, attrition is sometimes pro- 
 duced on these mentioned roofs, and in this manner excoria - 
 7 
 
74 
 
 INDICATIONS FOR INJECTION. 
 
 tions and deeper ulcerations are caused. Especially is this 
 the case -when these parts are swollen by the syphilitic pro- 
 cess, as they irritate themselves. 
 
 These symptoms are very obstinate, and remain quite a 
 time, even after all syphilitic appearances have vanished and 
 the venereal disease itself has been eradicated. Such pa- 
 tients complain of pains in the throat, which increase with 
 speaking, mastication and respiration, and particularly with 
 gaping. The sense localizing these pains is rather vague in 
 the pharynx and larynx, and for this reason patients are 
 apt to designate wrong regions as the seat of their com- 
 plaints, and thus are very liable to mislead a physician not 
 well versed in laryngoscopy. Such a physician, according 
 to his examination of the pharynx, finds no affection ex- 
 plaining the complaints, and, from want of diagnosis, is 
 obliged to declare the patient suffering from syphilis. 
 
 According to my experience, those tonsillar pits and 
 their diseased formations may be seen in a double manner : 
 first , with a small laryngoscopic mirror , held sideiuise ; 
 secondly , by using either the handle of the mirror or the 
 finger to push the anterior roof of the p>alate aside and back- 
 wards. If this manipulation should induce an effort to 
 vomit, so much the better, because the looked-for places are 
 seen the more clearly. 
 
 The ulcerations on the visible parts of the tonsils and 
 pharynx may either be a residue of a syphilitic affection, or 
 may be only an ailment of a local nature. The therapeutics 
 in either case are not identical. In the first case, I use im- 
 mediately injections hypodermically, with pencillings of the 
 parts with argentum nitricum ; in the other case, the latter 
 is sufficient. But the application to the hidden regions is 
 more difficult. Therefore, I recommend the physician to 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 75 
 
 hold the anterior roof of the palate back, and with the right 
 hand apply the pencil of argentum nitricum, care being 
 taken that it does not break or crumble. It is the safer 
 and better way to use the porte caustic of Lallemand. 
 
 According to my experience, the cavum pharyngo-nasale 
 has a like diagnostic and nosologic importance to the cavum 
 pharyngo-orale. In this region we find the same histological 
 elements as there, and that they are more subject to change, 
 particularly on account of their histological and anatomical 
 condition. The peculiar configuration and difficulty of 
 access is a more favorable condition for unimpeded destruc- 
 tion of tissue than exists in the deeper part of the lower 
 pharynx. We notice here that a tissue is predominant, 
 which, according to Hiss and Luschka (two eminent German 
 anatomists), is named adenoid tissue , having innumera- 
 ble folds and chinks, like a ravine. Here the swelling of 
 the extensive glandulce mucosce , analogous to the solitary 
 glands of the intestines, very often and easily gives rise to 
 erosion, which is seldom detected, because so hidden from 
 observation. Here swelling of the fibro cartilaginous sub- 
 stance of the tuba eustachii , covered by mucous membrane , 
 easily produces functional derangement of the auditory 
 nerve , like hardness of hearing , tinnitus aurium , <?. 
 
 Moreover, there is in those hidden regions (thoroughly 
 explored by but few anatomists) a glandular , fold-like , ele- 
 vated mass , in some individuals in the neighborhood of the 
 septum narium. This mass I wish to name tonsilla pha - 
 ryngea , in opposition to Luschka, who designates the greater 
 portion of the mucous membrane of the roof and posterior 
 part of the pars nasalis with this name. In not very rare 
 instances, I have here detected ulcerations in patients hav- 
 ing syphilis, and mostly in a comparatively early stage of 
 
76 
 
 INDICATIONS FOR INJECTION. 
 
 the disease. I often took occasion to demonstrate such 
 affections in my laryngoscopic and syphilitic lectures to my 
 students, aided by the rhinoscope. 
 
 Such affections on that locality have a greater importance, 
 since their existence is not easily produced by a simple cold. 
 The cold atmospheric air enters not directly, as into the 
 cavum pharyngo-orale , but it first passes by the nostrils 
 through the choance , and gets to this point in a warmed 
 state. Care has to be taken not to confound these ulcera- 
 tions with those follicular affections occurring here very 
 often without any visible lesions, and which are produced, 
 according to Luschka, either by fatty degeneration of the 
 cells or colloid destruction. With the destruction of the 
 substance of glands, erosions will appear on the surface. 
 
 Case 3. — S., twenty-seven years old, from healthy parents, suffered, 
 when three years old, from a swelling of the neck, which gave rise to 
 spontaneous abscesses. When ten years old, he had the misfortune to 
 cut with glass the brachial artery, so that ligation of the arteria ax- 
 illaris was necessary. Slight atrophy of the left arm, still existing, oc- 
 curred as a consequence. In the summer of 1864, patient was venereally 
 affected for the first time. The ulceration on the penis was diagnosed 
 in the beginning as a soft chancre, and treated accordingly. Only 
 after six weeks’ time was the physician convinced that the ulceration 
 had the character of a hard chancre. The treatment then consisted in 
 a combination of decoctum Zittmanni with pilulae Dzondi. This treat- 
 ment, with a run of ague, weakened the patient considerably. 
 
 A relapse of syphilis, occurring a short time subsequently, was again 
 treated with a “ sarsaparilla sweat cure” and Berg’s pills; but still 
 there remained an unyielding induration on the penis, which did not 
 subside. 
 
 In the winter of the same year, a papulous exanthem was found upon 
 the chest, beside psoriasis palmar is, with affections of the throat. 
 
 Entering a Berlin clinic, the patient again used decoctum Zittmanni 
 and inunctions for five weeks, besides using for a time a solution of 
 iodide of potassium. 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 77 
 
 After being discharged “ cured” from the hospital, in four days (!) 
 psoriasis palmar is showed itself again, together with the throat affection. 
 Iodide of potassium was again used, but being insufficient, he was again 
 obliged to undergo the inunction treatment for about seven weeks. 
 For after-treatment he was sent to Kreuznach, and took forty-two 
 baths. 
 
 In consequence of this treatment, a stand-still of the syphilitic dis- 
 ease occurred, and the patient went through the Bohemian campaign 
 of 1866. 
 
 A short time afterwards, there appeared again a maculous syphiloid, 
 for which he used, with good result, iodide of potassium. 
 
 In the summer of 1867, he went to Aachen for baths. Nevertheless, 
 he suffered again in autumn with syphilitic throat affection, for which 
 inunction for three weeks was again used. 
 
 In February he came to me for treatment on account of his throat. 
 He was emaciated ; had an ash-colored complexion ; muscles well 
 developed. 
 
 Examination of the pharynx showed superficial ulceration at the soft palate 
 — at the uvula and surroundings. There was also a deep loss of substance 
 of the size of a bean on the side and posterior surface of the left tonsil , which 
 reached somewhat on to the posterior roof of the palate ; but especially was 
 there ulceration , of the size of a penny , on the convex surface of the soft 
 palate , which I could only detect , naturally enough , with the rhinoscope. All 
 the ulcers had a clearly syphilitic character. 
 
 On account of swelling of the cervical and submaxillary glands, swell- 
 ing of the glands of the tongue, and erosions and infiltrations of the 
 latter, I thought an anti-syphilitic treatment indicated, since the other 
 medications had proved useless. I commenced with the subcutaneous 
 method, which effected a complete cure with twenty injections (2J gr.). 
 For after-treatment we sent him to Kreuznach, and later to Ostende. 
 
 The patient has since been free from syphilitic trouble ; but after the 
 lapse of four months, those singular follicular affections, described 
 above by me, commenced in different regions of the pharynx. They, 
 however, yielded to local treatment entirely. They first appeared mostly 
 under the form of a kernel, having the size of a pin’s head, and being of 
 a pale yellow color. They were embedded in the mucous tissue, and 
 resembled small metamorphosed, fatty pouches, the contents of which 
 soon became purulent, and breaking through the mucous tissue, the 
 small ulcers were open, but were tractable to the cautery. On the 
 
 7 * 
 
78 
 
 INDICATIONS FOR INJECTION. 
 
 convex surface of the velum, by the confluence of follicular ulcerations, 
 larger erosions were formed, which also disappeared with cauteri- 
 zation. 
 
 In consequence of collateral fluxion and exudation, a swelling of the 
 mucous membrane and the subjacent tissue followed, causing a stenosis 
 of the already narrow cavum pharyngo-nasale , and some trouble to the 
 patient. 
 
 Now, not only my experience shows that these affections 
 of the pharynx are not of a syphilitic nature, because I 
 have very often seen such ulcerations in persons who never 
 have had syphilis, but in this special case all other venereal 
 symptoms were absent, as shown by the previously described 
 specific ulceration of the pharynx not returning ; and lastly, 
 another evidence of the non-syphilitic nature is that the 
 pencilled places always remained in a healed condition. 
 New ulcerations always proceeded from other follicles. 
 
 I take this occasion here to direct attention to two inter- 
 esting processes, which I think have never been mentioned. 
 First, I saw in some cases, on the free borders of the palate 
 roof and even on the soft palate , and further, on the tonsils 
 and uvula , condylomatous granulations , which distinguish 
 themselves in size and height from the commonly here-occur- 
 ring vegetations , fully resembling those broad verrucous 
 condylomes which were considered as an exclusive preroga- 
 tive of the labia majora . They resisted in the same manner 
 all attempts at cauterization, and I had to extirpate them 
 with the scissors. 
 
 Scarcely a yet more singular appearance was there in 
 some cases, in which I had already used injections with 
 good result. The above described obstinate papillary granula- 
 tions commenced to form in the region of the pharynx, and 
 so extensively, particularly on the mucous membrane, that 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 79 
 
 the greatest part of the anterior roof of the palate and uvula 
 was literally covered ivith those grayish-white excrescences . 
 
 Very easily we could have been misled, and taken those 
 appearances for a sort of an after disease, consequent upon 
 the use of the sublimate, if those prolific cellular granula- 
 tions had not showed most clearly the papillary and condy- 
 lomatous type. On account of having derived the first 
 time no result on the vegetations , by the continuation of the 
 injection , I resolved to try other medication, especially 
 the “ sarsaparilla sweat cure” and inunction. But this 
 mode of treatment also was without efficacy, and I returned 
 finally again , in these desperate cases , to injections , which 
 brought about a complete cure. 
 
 Recently I have observed several cases in which , during 
 and after an anti-syphilitic treatment , the mentioned excres- 
 cences of the pharynx were formed in a similarly original 
 way; also, these cases yielded to the subcutaneous injec- 
 tions with such complete result that we may prescribe it 
 here as the ultimum refugium. The importance of the 
 mentioned cases will permit and justify me in reporting a 
 few more of this peculiar class. 
 
 Case 4. — Caroline K., twenty-six years old ; well built ; for the first 
 time infected with syphilis, and received on the llth of February, 1861, 
 into Charite Hospital. Besides greatly ulcerated condylomes on the 
 labia majora and right buttock, both tonsils, the palate roofs and uvula 
 showed large white-grayish papules, resembling a comb, and having 
 the appearance of condylomata mixta, as described by me ; i. e., pointed 
 warts like the comb of a cock, with an infiltrated, broad papillary base. 
 These excrescences nearly filled the space in the mentioned regions of the pha- 
 rynx, hindering their movement so that the voice took a nasal sound , as in 
 paralysis of the velum. 
 
 Subcutaneous injections, in suitable doses, to the amount of 2 gr. of 
 sublimate, with internal administration of 3 dr. of iodide of potassium, 
 and pencilling parts with argentum nitras, produced a complete cure. 
 
80 
 
 INDICATIONS FOR INJECTION. 
 
 Case 5. — Caroline F., twenty years old ; for the first time syphiliti- 
 cally infected ; was received into my ward January 17, 1867. Examin- 
 ation revealed broad, button-shaped condylomes on the labia majora, 
 and a large, pus-producing, ulcerated, flat swelling, of the size of a 
 dollar, on one of the hypertrophied folds in the vicinity of the anus. 
 
 On the tonsils, the anterior roofs of the palate and uvula, large, per- 
 manent papules were seated, forming a comb-like elevation resembling 
 in appearance my description of condylomata mixta. They evinced 
 much resistance to treatment. After an injection of 2 gr. of sublimate, 
 the genital erosions disappeared, leaving behind the hyperplasia pro- 
 ducts in the pharynx, which required the addition of 1| gr. of the sub- 
 limate to effect their destruction. 
 
 Case 6. — Emily S., twenty-three years old ; already three times in 
 our hospital for syphilis, besides also for some blennorhagic troubles; 
 was again received March 1 7, 1868, into the Charite. The following 
 was her condition: soft chancre at the vaginal opening; tonsils 
 markedly hypertrophied and somewhat eroded ; inguinal glands 
 swollen. 
 
 The patient was subjected to local treatment, during which time gray - 
 whitish condylomatous granulations were formed on the tonsils . Notwith- 
 standing our subcutaneous injections, these tonsillar granulations 
 increased so much that they were, after fourteen injections (t. e., after 
 the equivalent to 2 gr. of sublimate had been used), the size of a pea, 
 and covered much of the right tonsil. At the same time, the lower por- 
 tion of the arcus palato-glossus was changed into a comb-like elevation, 
 last-shaped, four lines broad and one-third of an inch long, with a firm 
 texture and a whitish-gray color. Only after the further use again of 
 2 gr. sublimate and repeated cauterizations, was complete cure es- 
 tablished. 
 
 Case 7. — Marie S., nineteen years old; was already in our hospital, 
 February 29, 1868, with an indurated ulcer, accompanied with a macu- 
 lous syphiloid. Being treated by injections, she was discharged seem- 
 ingly cured. 
 
 Three and a half months afterwards, being sick, she returned, and we 
 found again the maculous syphiloid, besides an extensively ulcerated 
 broad condylome on the labia majora. The patient besought us to use 
 with her inunction, and we prescribed of unguentum hydrag. cinereum 
 3j daily. After having already used of this gxij, and the genital affec- 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 81 
 
 tion being but little ameliorated, we saw, to our surprise, the appear- 
 ance on the tonsils, palate roofs and uvula, of grayish-white papules of 
 the size of a pea. The papillae of the roots of the tongue were swelled, 
 and also the vocal cords reddened and eroded in the middle with the 
 epithelium colored grayish-white. 
 
 After a still further using of the ung. hyd. cin. gxiij additional, to- 
 gether with the use of iodide of potassium, the hyperplassia of the pha- 
 rynx did not disappear, but, on the contrary, enlarged. 
 
 With the consent of the patient, we began again the hypodermic 
 injections, in doses of gr .per diem. On the second day after, a dose 
 of f gr. Slight symptoms of mercurial intoxication, in the form of 
 gastro-enteritis, connected with great prostration, followed. They 
 soon subsided, and after a few days we could use J gr. doses. After 
 having again used 2 gr., instead of the described papules, the tonsils 
 were covered with small milky epithelium, which subsided after ten 
 more injections of gr. each of sublimate. The patient looked, after 
 the cure was completed, rather pale and anaemic, but felt entirely well, 
 and all the functions were regular. 
 
 Case 8. — C. N., a student, twenty-one years old, was taken, accord- 
 ing to his statement, a short time after incubation, with a chancre, soft 
 in the incipiency, but which was said to be indurated subsequently. 
 With this ulcus durum he commenced treatment with me. I immediately 
 began the injections, continuing them with but few interruptions, and 
 in doses of gr. of sublimate, without any noticeable effect on the 
 induration. 
 
 After using it for six weeks, in all about 2 gr. of sublimate having 
 been administered, the patient went home, during a vacation. Here he 
 was treated, according to the view of a resident physician, for eight 
 weeks, with inunction of mercury, £ dr. daily. This treatment had, 
 according to the patient’s views, a contrary effect, not producing the 
 expected diminution of the sclerosis. There was rather an increase of 
 the disease, extending over the whole prepuce, causing pliymosis. 
 
 Simultaneously, the enlarged tonsils showed highly-raised mucous 
 papules, which would neither give way by gargarisms of kali chloricum 
 nor by cauterization with argentum nitras ; so that the attending phy- 
 sician declared them to be a mercurial affection. 
 
 The patient returned in November to Berlin, and saw me again. On 
 examination, I found on both tonsils grayish-white excrescences, of the 
 size of a pea, showing clearly a syphilitic character. Inasmuch as the 
 
82 
 
 INDICATIONS FOR INJECTION. 
 
 internal medication from iodide of potassium proved without result for 
 a fortnight, I resorted again to the injections of the strength of gr. 
 per diem — resulting, in three weeks, in a perfect cure, with the entire 
 disappearance of plaques muqueuses. 
 
 Ulcerative processes of the different regions of the pha- 
 rynx are, in the later period of syphilis , of a more destruc- 
 tive and deeper going-in character, as illustrated in the de- 
 tails of the above cases. 
 
 As to the genesis of those ulcerations, there is hut one 
 voice, that the origin is to be found exclusively in the so- 
 called gummy tumors , of which there are two varieties , 
 namely, the diffuse gummy infiltration and the isolated cir- 
 cumscribed knots — gummy knots — nar' et-oxyv. 
 
 The authors give not only a very detailed description of 
 this formation, but even describe their course and formative 
 process very minutely. Especially is their seat on the pos- 
 terior surface of the velum palati and on both angles formed 
 by the velum and uvula, described. Like the gummata of 
 the outside skin, they develop themselves in a slow and 
 painless manner on the mucous membrane or sub-mucous 
 tissue, either in single or group-like knots, of the size of a 
 pea or bean. Although plainly divided from their sur- 
 roundings, they appear less prominent and less hard and 
 circumscribed. 
 
 By and by the infiltration pushes against the most super- 
 ficial layers of mucous membrane, which softens. The 
 membrane quickly reddens, the inflammation increases, and 
 sometimes, after a few hours, from an “ imperfect examina- 
 tion,” the knots “ perforate, and on the velum we find an 
 irregular, round, funnel-shaped ulcer,” &c. 
 
 Seeking after this detailed process of formation, the real 
 material upon which these observations were based, it 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 83 
 
 seems strange that, with the exception of but two contra- 
 dictory observations from the French literature, no other 
 author till the present time has confirmed a case of the so- 
 called gummy tumor in its integrity, before its destruction, 
 or noted the perforation of the velum. The authors above 
 alluded to are Bouisson and Parmentier. One refers to the 
 subject thus: “ Chez plusieurs malades atteints de syphilis 
 inveter^e des indurations tantot circonscrites, tantot diffuses, 
 du voile du palais sans ulcerations de sa membrane de 
 revetement.” The other describes “ces tumeurs gom- 
 meuses” as “petites et a peine sensibles au debut,” “ ad- 
 herentes a la muqueuse par une sorte pedicule et mobiles 
 sous les parties sous-jacentes et voisines.” The form of 
 pedicled gummy tumors described by Parmentier is not only 
 in contradiction with all present descriptions, but is the 
 reverse of the known histological nature of them altogether. 
 Laying in the parenchyma of the tissue, never has there 
 been found a trace of pedicled insertion. 
 
 But if we go over to the other authors, who seem to de- 
 scribe so accurately the course and progress of gummata of 
 the velum without giving a case, wu almost find an excuse 
 for deficiency of cases and description of details in the fact 
 that these tumors progress without being noticed, because 
 they are situated on the posterior surface of the velum, and 
 also because their course is painless, and therefore the pa- 
 tient but very seldom by his complaints arouses the suspi- 
 cions of the physician. One author goes so far as to 
 explain the tumor as “invisible ,” and after describing it, he 
 recommends, for an early -diagnosis of this latent disease, 
 that the physician feel of the posterior part of the velum, or 
 examine the locality with the rhinoscope. 
 
 But, granted that this manual examination (described by 
 
84 
 
 INDICATIONS FOR INJECTION. 
 
 another author as “ troublesome”) is of some account, I 
 wish to emphasize here that the prognosis seems nowhere to 
 be published, at least I have not found it. 
 
 Concerning the rhinoscopic examination, I would say, 
 this method, even in a normal state of the velum, is very 
 difficult, and more so must it be when the tissue by layers of 
 small knots has increased in volume, and thus filling up the 
 already narrow cavum pharvngo-nasale. 
 
 By my quotations, one can see that here, as in many other 
 important questions in medicine, a traditional view has crept 
 along without any sure foundation, and has been handed 
 from author to author. Such views, sanctioned by tradi- 
 tion and impressing us with the idea that darkness must 
 have hovered over the processes investigated, yet already 
 better understood, are the cause why later authors do not 
 take the care to re-investigate for themselves anew. 
 
 It seems to me as if all authors drew their conclusions 
 “per analogium .” Proceeding, for example, with a right 
 view as to the formation of gummy processes on the outside 
 skin, they conclude that the gummata are brought about in 
 the same manner on the velum and posterior wall of the 
 pharynx. But whether this is really so or not, or whether 
 there are other pathological circumstances connected with 
 it, requires further investigation to determine. 
 
 My own observations have not enabled me to study the 
 progress of a gummy formation, neither on the velum, nor 
 tonsils, nor the posterior part of the pharynx.* 
 
 * Maisonneuve (’Lemons Cliniques sur les Maladies cau cereuses, 
 Paris, 1854) narrates a case in which he had healed a tumor of the 
 pharynx by iodide of potassium, which, after removal by an operation 
 of Blundins, appeared again. 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 85 
 
 Knots of the described variety, but which resembled 
 more the lupus kind, I have seen several times in the paren- 
 chyma of the tongue, but they did not terminate in ulcera- 
 tion. On the other hand, I have, in all those cases where I 
 found ulcerations, as on the soft palate and posterior part of 
 the pharynx, never seen knots preceding them in a primary 
 form, nor as a casual coincidence of their formation. 
 
 Only on the palatum durum have I detected, as a follow- 
 ing case will show, a tumor which, on account of its shape 
 and consistence, could be named “gummous.” 
 
 The processes which I had occasion to observe on the 
 velum were either recent, or processes which had already 
 existed for a long time. 
 
 In the first category belong : 
 
 1. j Diffuse infiltration , of greater extension, of hard con- 
 sistence and of a bluish-red color, plainly divided from the 
 palatum durum. The connection of ulcerative destruction 
 of such an infiltrated velum, I had not occasion to observe, 
 because, by energetic medication, resolution of the infiltra- 
 tion readily occurred. 
 
 2. Diffuse infiltration, just passing into ulceration , which 
 involved more or less of the velum, uvula and arches — 
 having produced in its course loss of substance more or less 
 deeply. 
 
 Secretion of such ulcers is not very profuse. The color 
 is generally yellow-white, and often firmly embedded in the 
 tissue, as in diphtheritis. 
 
 In some cases the erosion w T as in its incipiency, in others 
 the tonsils were already wholly destroyed, and I could only 
 see, instead, the ulcerated surface of the infiltrated Avails of 
 the anterior and posterior roofs of the palate toAvards the 
 fovece tonsillares . 
 
 8 
 
86 
 
 INDICATIONS FOR INJECTION. 
 
 3. Single circumscribed ulcerations reaching deeper into 
 the tissue of the velum and already threatening perforation . 
 They consisted mostly of an encircled, infiltrated, livid-red 
 tissue, covered with a puriform secretion and putrid detritus. 
 
 The condition of these ulcers was in no case so fixed that 
 I could draw a conclusion as to its origin, especially whether 
 resulting from pustules or gummy knots. 
 
 4. Ulcerations which already had given rise to infiltra- 
 tion , and extensive defects , mostly of the velum and uvula . 
 
 As to the second * category of the long-existing processes , 
 I saw : 
 
 1. Perforation of the velum , of small extension , when the 
 surroundings only showed a relatively insignificant inflam- 
 mation. 
 
 2. Entire or partial deficiency of the uvula and velum and 
 posterior palate roof \ — having resulted in a gluing together 
 of the remaining portions to the posterior wall of the 
 pharynx . In such cases once in awhile, particularly at the 
 upper point of the glued, adherent end, small ulcers, of a 
 non-syphilitic nature, were visible. They chiefly originated 
 from the mechanical effect of stretching and friction during 
 deglutition and phonation, to which, being grown together 
 and non-elastic, the parts were subjected. 
 
 The subjective complaints of the patient in all these men- 
 tioned cases arose naturally enough, considering the physio- 
 logical functions of the affected parts, and also the lymphatic 
 vessels, with commencing inflammatory processes. The 
 patients complained of a very troublesome gathering of 
 phlegm mixed with pus, and sometimes even with blood, 
 thus causing a continual expectoration. Another part of 
 the complaints is produced by the gluing together of the 
 velum and the posterior wall of the pharynx, which greatly 
 
AFFECTION OF THE MOUTH AND PHARYNX. 87 
 
 interferes with deglutition and phonation. In consequence 
 of the destroyed part of the cavum pharyngo-nasale, a nasal 
 sound of the voice is produced and a regurgitation of the food 
 through the nose takes place. 
 
 Concerning the other affections of the pharynx which 
 have to he noticed here, I have already mentioned that only 
 in one case had I occasion to see a tumor on the hard palate 
 that might have been “gummous” (Case 12). 
 
 On the tonsils , that very singular glandular apparatus of 
 the pharynx, I have very often seen, and mostly in a rela- 
 tively early stage of syphilis, the well-known extensive 
 swellings which occlude the isthmus faucium to a great 
 extent. Syphilitic knots are generally said to occasion 
 this, but I never succeeded in seeing or feeling them. And 
 so far as I know, there has not been a single author of 
 pathological anatomy who has observed or described a case. 
 
 On the posterior wall of the pharynx I had several times 
 occasion to see and treat successfully syphilitic ulceration. 
 The formation of the ulcer is generally round with seldom a 
 ragged or irregular edge ; the color mostly grayish ; the 
 secretion doughy, bad smelling and of a pus-like consistence. 
 
 That these ulcers here have their origin, not on account 
 of mercurialization, (a thing much emphasized by anti-mer- 
 curialists,) is evident, “ ex- juv antibus et nocentibusf because 
 all the ulcers healed with the treatment of subcutaneous 
 injections of mercury quickly and thoroughly. 
 
 Concerning the therapeutics of the pharynx the same 
 indications prevail here as with affections of the larynx, and 
 I shall speak more fully on this point in the next chapter. 
 
 In the selection of the following cases I have taken those 
 in which either interesting pathological processes occurred, 
 or in which the effect of the subcutaneous medication was 
 
88 
 
 INDICATIONS FOR INJECTION. 
 
 clearly visible. The following case shows that even a per- 
 forated ulcer on the soft palate may be fully healed and the 
 perforation closed, if only early, energetic, hypodermic 
 injections of sublimate are employed. 
 
 Case 9. — A merchant, W. M., twenty-eight years old, coming from 
 a healthy family, suffered in his childhood with “ tetanic convulsions 
 and loss of consciousness.” Later he had acute muscular rheumatism. 
 His first venereal infection dates from the year 1860 and consisted of 
 an ulcus durum , for which he used for four weeks continuously iodide 
 of mercury. Six months subsequently there was a reappearance 
 of the syphilis in the form of psoriasis palmaris , for which the same 
 treatment was used with success. 
 
 Three years after he had inflammation of the e} r e which was diagnos- 
 ticated as syphilitic iritis — with a later return of the psoriasis palmaris. 
 
 In the beginning of the year 1868 Dr. Wallmueller, his family phy- 
 sician, being consulted on account of his throat, detected a suspicious 
 ulcer on the soft palate, and immediately sent the patient to me. 
 
 I perceived the presence of a perforating ulcer on the soft palate somewhat 
 larger than a bean on the right side of the uvula. The borders were well 
 defined , and the secretion purulent , of a fatty appearance but not very 
 abundant. 
 
 Besides swelling of the inguinal and cervical glands, there was no 
 other sign of syphilis. I commenced with the sublimate injections, the 
 patient visiting me daily. But after the tenth liypordermic dose, acute 
 muscular rheumatism set in, and the patient was obliged to remain in bed 
 a fortnight. After pausing a few days, I recommenced the treatment at 
 the patient’s house, notwithstanding the very marked febrile symptoms. 
 After using the amount of 3J gr. of the sublimate the ulcer was com- 
 pletely cured and the perforation closed. It is noticeable that the course 
 of the acute muscular rheumatism , according to the patient and family physician 
 was, with the sublimate injections , a shorter and milder one than usually. 
 
 The next following case is interesting from the fact, aside 
 from the quick result of the subcutaneous injection, in oppo- 
 sition to the already used treatment with iodide of potassium 
 without restoration, that it is a sure proof that ulcerous 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 89 
 
 syphilitic affections (and in this case an ulcer of the soft 
 palate), do arise without having previously used mercury. 
 
 Case 10 . — Joseph S., twenty-two years old, of sound parents and of a 
 healthy habitus, has always been in good health with the exception of 
 pneumonia, from which he recovered ht the age of ten, and a slight 
 rheumatic affection of the left knee joint. 
 
 In the month of July, 1868, he became infected, and according to his 
 statement, a small pustule was formed on the inner lamella of the pre- 
 puce, and out of which he, himself, pressed the pus-like secretion. It 
 seemingly healed with only a dry bandage. Six months afterwards he 
 had pains in his throat and he called on a physician, who prescribed 
 3g of iodide of potassium, after which the affection left. After a time 
 _the pains in the throat returned, and notwithstanding this, and a dis- 
 covery by inspection of his own pharynx, of the presence there of 
 “whitish ulcers,” he neglected to seek relief from a physician. 
 
 February 6th, 1869, patient consulted me. I found on the prepuce, 
 at the place of the former ulcer, a cicatrized, white appearance of skin 
 devoid of pigment, having a rather indurated feeling. The neighboring 
 inguinal and more distant lymphatic glands were in a normal state. 
 On the left nostril was an ecthymous incrustation. Small knots of the 
 size of the smallest shot, and covered with the thinnest hard dry coat- 
 ing, were near the region of the left corner of the mouth, and on the 
 forehead close to the border of the hair. The inner walls of the nostrils 
 were slightly eroded, somewhat swollen, and covered with a rather 
 thick greyish hard coating. 
 
 The whole of the soft palate with the uvula and palate roofs were consider- 
 ably infiltrated and covered in its whole extension with a number of greater or 
 smaller ulcerations. The ulcers themselves reach in some parts , deeply into 
 the tissue , being sharp pointed and reaching island-like over each other. The 
 tonsils I found completely destroy ed, also the inner walls of both palate roofs 
 showing deep-seated destruction . Secretion of the ulcers is of white , caseous, 
 mushy-like appearance , and so adherent that in trying to remove it, bleeding 
 commenced. 
 
 On account of great swelling of the soft palate, a desirable rhino- 
 scopic examination could not be made. The laryngoscopic examination 
 did not reveal anything abnormal. 
 
 Deglutition is somewhat painful and the voice somewhat dulled. 
 
 8 * 
 
90 
 
 INDICATIONS FOR INJECTION. 
 
 I began immediately the hypodermic injections in \ gr. doses per diem , 
 and after using 3 gr. altogether, a complete cure was accomplished. 
 
 In the following patient we see, after a treatment by the 
 subcutaneous method, but probably on account of too small 
 a quantity, ulcerations springing up on the soft palate. 
 With a continuance of the injections she was cured. 
 
 Case 11. — Henrietta K., twenty years old, has been treated five dif- 
 ferent times in our hospital for syphilis — once locally, three times with 
 the sarsaparilla sweat cure, and the fifth time by subcutaneous medica- 
 tion with the sublimate, using altogether 1J grains. The affections 
 consisted mostly of broad condylomes, maculous and papulous exan- 
 themata, besides condylomatous ulcerations of the soft palate. 
 
 She came under my care the sixth time February 12th, 1869, and we 
 found besides condyl. acum. near the labia majora an ulceration, quite 
 extensive, on the palatum durum. On the right half of the soft palate , on 
 the anterior and even on the posterior part , examined with the rhinoscope ) we 
 saw ulcerations which had destroyed nearly one half of the uvula. The 
 remaining part was hanging doivn loosely. The base of the ulcer had a yellow 
 appearance , with edges sharply defined , not much reddened , with secretion very 
 scant. Deglutition was, strangely, not much interfered with. The 
 lymphatic glands in the submaxillary and cervical regions were much 
 swollen, and those in the inguinal region but slightly. On account of 
 the robust appearance of the patient, we used, at once, \ gr. sublimate 
 hypodermically : but this dose seemed too strong, as appearances of 
 mercurial intoxication, with diarrhoea and colic, also vertigo, were soon 
 manifested. After a pause of two days we resumed treatment, giving 
 J gr. and soon J gr. doses of sublimate, without any hurtful effects, so 
 that in seventeen days the patient was discharged completely restored 
 to health. 
 
 With the following patients there is, beside ulcerations on 
 the palatum durum , a tumor justifiably called “gummy.” 
 
 Case 12. — Albert S., twenty-seven years old, mason by trade, of 
 healthy parentage, was up to his twenty-fourth year of excellent health, 
 when he contracted a hard chancre which developed its presence four 
 weeks after coitus. He remained without any treatment, a stain-like 
 
6(yvL^C otcJ 
 
 / f^Z. 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 91 
 
 exanthem appearing. He began now to use a mercurial treatment, 
 which induced a latency in the disease for eighteen months, when a 
 relapse occurred in the form of syphilitic throat affection, which is 
 reported to have been an erosion of the pharynx. But in spite of 
 various treatments with iodide of potassium and mercury, extensive 
 destruction of the soft palate was produced, followed by necrosis of 
 the palatum durum and exfoliation of several pieces of bone. He was 
 recommended to use Dzondi’s pills, but without any result. Soon the 
 nasal bones became involved. On the 18th of June, 1868, he was 
 admitted to the Charite with the following status pr as ens : Patient of 
 gracile habitus, pale and anaemic in color, very much emaciated, weak 
 muscles and shrivelled skin, with inflammatory swelling of the gums, 
 probably consequent upon recent salivation. 
 
 j Exploration of the 'pharynx showed putrid ulcers on the hard palate , of 
 offensive odor, and with an already extensively existing ulceration of the bone. 
 It was possible to reach through the hard palate into the cavum narium with a 
 common catheter. In the middle of the right half of the hard palate, a tumor 
 was to be seen of the size of a bean , elastic to the touch, borders well defined 
 and of a reddish yellow color. It very easily could be taken for a gummy 
 knot. On the septum narium there were also large unclean ulcers having a 
 fetid smell. The other regions of the pharynx and larynx were intact. On 
 the prepuce there was a hard cicatrix, and on the left testicle a gummy 
 swelling of the size of a hazel-nut, and painful when touched. 
 
 On account of a mercurial stomatitis we used a gargarism of chlorate 
 of potash and the same internally. This trouble having subsided in 
 the course of five days, we began to use injections of sublimate, com- 
 mencing with J gr. per diem, but soon reaching J gr. daily. 
 
 The patient endured the course of medication very well, but on 
 account of constipation laxatives had to be used occasionally. 
 
 Whenever prodromes of stomatitis mercurialis occurred, an interruption 
 of treatment for eight days was ordered. 
 
 After having used the amount of 6 grains of sublimate, the patient 
 was discharged cured, in the middle of August, 1868. The local treat- 
 ment of the “gummy tumor” on the scrotum consisted in binding it 
 with straps of sticking plaster. The ulcers of the nose and cavity of 
 the mouth were pencilled with argentum nitricum, they cicatrizing 
 over completely. The perforation itself was closed, so that a small 
 opening only remained. 
 
 April 7th, 1869, he introduced himself again to me, and I was con- 
 vinced of the completeness of the cure. 
 
92 
 
 INDICATIONS FOR INJECTION. 
 
 The following patient from my private practice showed 
 destruction of the pharynx and nose — the first I have met 
 where it existed to such an extent. Medical literature 
 seems to have described such cases but very seldom. 
 
 Case 13. — Henrietta R., thirty years old, of cachectic appearance, 
 delicate constitution, pale, anaemic color of the countenance, flabby 
 muscles and parched-like skin, was healthy in her youth. She was 
 infected with syphilis for the first time when twenty-five years of age. 
 The patient is apathetic and rather stupid, and therefore nothing reli- 
 able could be ascertained from her. The first symptoms reported were 
 ulcerative affections of the genitals, for which only external remedies 
 had been used, like lotions, washes, &c. She repeatedly assured us 
 that she had never taken any internal remedies . 
 
 A year later she was admitted into the Charite. The history of her 
 case was lost or could not be found. According to the patient, she had 
 sores on the body and in the mouth, and the sarsaparilla sweat cure 
 and iodide of potassium constituted her medication. 
 
 December 22d, 1868, she was again admitted into my wards, and the 
 status praesens was that on the whole body there were white, shining, 
 star-like cicatrices of different sizes, as is often seen in consequence of 
 lupous ulcerations. The face and forehead had large scarred. surfaces. 
 In the middle of the forearm a lupous superficial ulcer could be seen, 
 of the size of a Prussian dollar, with sharp undermined borders and a 
 thick, pus-like secretion. The cavity of the mouth and nose showed marked 
 destruction. By the complete absence of the soft palate and almost total dis- 
 appearance of the hard palate , both cavities were united into one. Of the 
 hard palate there was remaining only an arch of two shreds , the larger of 
 which , the size of a common goose quill , ran from the right side of the upper 
 jaw towards the posterior wall of the pharynx and was attached thereto. The 
 smaller shred , the size of the quill portion of a hen's feather , commenced from 
 the right pterygoid process , reaching oppositely in the direction of the maxilla 
 superior . 
 
 In the nasal cavity , the conchae superiores , mediae , and inferior cs were also 
 destroyed. The openings of both tubae Eustachii were easily visible. The 
 remaining mucous membrane on the eroded locality was covered with a pus- 
 like secretion of an offensive odor. On the posterior wall of the pharynx , 
 there were deep-seated syphilitic ulcers of the size of a penny. She was per- 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 93 
 
 fectly aphonic. Deglutition was surprisingly easy , on account of the patient 
 bending back the head somewhat , when taking solids or fluids. 
 
 Laryngoscopic examination revealed only a thickening of the epiglottis. 
 All the remaining organs were intact. 
 
 It was noticeable that the patient had been pregnant six or seven months. 
 
 Our treatment was subcutaneous injections of the sublimate, and 
 common injections of chlorate and permanganate of potassium into the 
 cavity of the mouth and nose. 
 
 We had frequent interruptions of the sublimate treatment on account 
 of salivation occurring. For this reason we used iodide of potassium 
 internally, but had to return to the subcutaneous use of the sublimate 
 again in order to bring about a cure. 
 
 After using, in the course of three months, 2| gr. of sublimate, the 
 lupous ulcer on the arm was cicatrized and also the ulceration of the 
 pharynx. The mucous membrane of the cavity of the nose and mouth, 
 which as noticed were in open communication, was rid of all secretion. 
 
 The looks of the patient were so altered, and according to her own 
 statement she felt quite well, that we discharged her cured. 
 
 Case 14. — F., twenty-eight years old, a blacksmith by trade, of a 
 delicate constitution, flabby muscles, sallow complexion, and already 
 gray hair, was taken into the Charite December 29th, 1866. 
 
 Patient had a chancre in 1857, for which he used blue pills. Another 
 similar affection was only locally treated. In 1863 he had chancre for 
 the third time, and used only calomel till it produced salivation. His 
 present condition he noticed only since three weeks previously. 
 
 Examination revealed an ulcer of the size of a penny and deeply seated , 
 covering the anterior and posterior left roof of the palate and even the tonsils. 
 It had destroyed a portion of this region in such a manner that a cavity the 
 size of a gold dollar was produced. The chest was covered with papulous 
 and vesiculous exanthemata. The lymphatics in the different region * 
 were only slightly swollen. 
 
 I commenced using injections hypodermically of J gr., but soon 
 increased strength to ^ gr. Already after the use of 1 gr., the described 
 ulcer was clean and partially covered with epidermis. The exanthemata 
 were mostly healed also. After using 2| grains of sublimate and 2 
 drachms of iodide of potassium, the patient was discharged cured. 
 
 Case 15. — Anna K , twenty-six years old, been already three times in 
 
94 
 
 INDICATIONS FOR INJECTION. 
 
 the Charite during the last five years, but was only locally treated, and 
 was admitted again October 1st, 1868. 
 
 Present condition. — Patient is of good healthy appearance ; has on 
 the genitals only slight erosions, small ulcers on both labia majora and 
 ft cicatrix on the posterior commissure of the vagina. There are only a 
 few dirty, pigment-colored patches on the body. Examination of the 
 pharynx showed an infiltration of the greatest part of the soft palate , which 
 was sharply divided from the normal color and quality of the hard palate. 
 Left of the uvula there was an ulcer of the size of a penny , perforating the 
 velum , with ragged , undermined , infiltrated borders. 
 
 The lymphatic glands were swollen in the inguinal and submaxillary 
 regions, and more still in the cervical. In doses of -J- gr. each of subli- 
 mate, thirty-one injections were given which, together with local treat- 
 ment, cured the patient, so that she was discharged in thirty-two days. 
 
 In the following cases no sure criterion of a syphilitic 
 affection could be found. 
 
 Case 16. — Bernhardine K., twenty-one years old, was taken, October 
 20th, 1868, into our hospital, with the following symptoms: Pigment 
 patches over the whole body, more or less spread, genitals of normal 
 size, lymphatic glands nowhere swollen; deep ulcerations on the posterior 
 roofs of the palate , and both tonsils destroyed. A large ulcer on the soft 
 palate which has destroyed the greater part of the left side, extending to the 
 border of the hard palate. The border red and fatty -like, is partially covered 
 with highly elevated granulations. The epiglottis thrice as large as natural , 
 especially on the right side , with superficial erosion. An ulceration existed , 
 of the size of a pea on the left processus vocalis. The left vocal cord was 
 somewhat infiltrated. 
 
 After twenty-five injections amounting to 4 gr. in all, the patient left 
 cured, having stayed five weeks only. 
 
 Case IT. — Mrs. S., forty-eight years old, received into the hospital 
 October 16th, 1868. Nothing could be found on the body indicating 
 syphilitic affection. 
 
 In the pharynx , the greatest part of the soft palate was destroyed , and the 
 remainder glued on the posterior wall of the cavity of the mouth. * On the 
 border of this , was an ulcer of the size of a penny , covered with a putrid 
 dirty, pus-like secretion , the edges being undermined. On the mucous mem- 
 brane of the nasal cavity , superficial ulcers were found , partly incrusted. 
 
 Complete restoration in four weeks was brought about by the use of 
 twenty-five injections of £ gr. each. 
 
AFFECTION OF THE MOUTH AND PHARYNX. 95 
 
 Case 18. — G., a drover, thirty-five years old, taken into the hospital 
 August 12th, 1867. 
 
 Examination revealed extensive , deep-seated ulcerations , with hollow , 
 reddened borders , and covered with a yellow , pus-like secretion , situated on 
 the soft palate. There was a destruction of one half of the entire uvula 
 reaching more upon the left side to the middle of the velum. 
 
 Ulcerations of a slighter character and smaller extension were seated 
 on the posterior part of the pharynx and left palate roof. Patient had 
 two years previously an ulcer and different exanthematous eruptions. 
 
 He used mercury internally. The present condition only developed 
 itself a few weeks ago. No other syphilitic complication could be found 
 on the body. Subcutaneous injections of J gr. each, completed the 
 cure in twenty-one days. 
 
 Infectio per os. — As known, there is quite a controversy 
 concerning the important question whether syphilitic infec- 
 tions can only be produced with direct contact of the genitals, 
 or if also other places of the body may be original openings 
 for infection. 
 
 Although, the oldest authors on syphilis were obliged to 
 consent to a possibility of a direct infection by way of the 
 lips , and even Torella,* Fernelius,f &c., reported several 
 cases, yet since the dualistic view of the nature of the syphi- 
 litic virus has gained more ground, the development and 
 origin of primary syphilitic sclerosis vid the lips has been 
 entirely denied by Ricord and his disciples. 
 
 Only after Ricord’s theories on the changing of the soft 
 chancre into the hard were completely refuted by exact 
 experimental demonstration, and especially, after the fact 
 was established that syphilis could be inoculated from every 
 
 * Et hoc accidit propter mammas infectas, aut faciem , aut os nutricis 
 seu cujus alterius. 
 
 f Juvenem, mulierem gallico morbo depravatam, ore exosculare 
 assuetum nullo per jovem exercitatio coitu, in morbum gallicum inci- 
 disse. 
 
96 
 
 INDICATIONS FOR INJECTION. 
 
 syphilitic secretion, — secretion of the hard chancre, of the 
 broad condylomes, as well as of the tonsils, — were the views 
 of Ricord abandoned. At the present day but few syphilo- 
 graphs dare to doubt the possibility of an infection per os. 
 
 There have recently been reported so many cases, espe- 
 cially by Fournier, Rollet, Koebner, &c., with proof so 
 corroborative, that the above remarks are well substantiated. 
 
 Further, I had a relatively great number of such cases 
 under my observation, and I may be permitted to narrate 
 some of them with the following clinical remarks preceding. 
 
 Generally the original syphilitic ulcer on the lips has such 
 a singular character, that it can not be confounded with an 
 abscess produced by a condylomatous, destructive process. 
 The latter may have entered ever so largely into ulcerative 
 metamorphosis , it will not enter the tissues so deeply , nor 
 have such a characteristic , hard , sharp-edged basis surround- 
 ing it as the ulcus durum of the lips. Great caution must 
 be used in forming a diagnosis from the remaining criterion. 
 Here also, as with the ulcus durum, the principle holds good 
 that never a single symptom, but the combination of all 
 the symptoms, should be considered and have the prepon- 
 derance. 
 
 Of great value for the decision here in this place is the 
 seeming absence of initial syphilitic affection and the pre- 
 sence of an intact hymen in womeii. And as, even in proved 
 infection via the lips, a syphilitic affection may occur after- 
 wards on the genitals in consequence of a syphilitic diathesis, 
 other diagnostic signs must be considered. These are the 
 peculiar course and development of the lymphatic glandular 
 swellings, which show themselves much sooner in the region 
 of the throat than in the inguinal regions. Generally the 
 submental glands swell first, especially often in the vicinity 
 
AFFECTION OF THE MOUTH AND PHARYNX. 
 
 97 
 
 of the spina mentalis interna , between the insertion of the 
 musculi genio-hyoideus and genio-glossus. Secondly, those 
 glands inflame which are situated more nearly at the angle 
 of the lower jaw, and not always the superficial only, par- 
 tially covered by the platysma myoides , but also, even some- 
 times the deeper glands which are scattered in the trigonum 
 cervicale, and which receive the vasa efferentia of the gland- 
 ule faciales profunde. In one case where the ulcer was 
 situated on the upper lip, I found on the corresponding left 
 side of the face some small swollen glands in front of the 
 ear near the parotis, which glands may be termed the gland- 
 ule zygomatice. Only after these glands are more or less 
 inflamed does swelling of the inguinal glands occur — pre- 
 ceded in some cases by swelling of the cubital glands. But 
 here it must not be forgotten that also scrofulosis brings 
 about similar glandular inflammation. 
 
 Some authors, like Zeissl for instance, have endeavored 
 to draw a distinction between syphilitic and scrofulous 
 swellings of the lymphatic glands, as largeness and uneven- 
 ness of the scrofulous, in opposition to the syphilitic. 
 
 Koebner characterizes (page 62 of his Clinical Reports) 
 such ulcerations on the lips and mucous membrane of the 
 pharynx, as the rapidly developing symptoms of the usually 
 later period of syphilis, which may be named “ syphilis 
 gallopante (galloping syphilis), causing the physician to fear 
 for the life of his patient. ” 
 
 My experience does not at all verify this assertion, as 
 seen in the following cases. It may be different when, not 
 the lips, but the finer mucous membrane of the deeper lying 
 pharynx is infected with the original syphilis, as has hap- 
 pened in some cases where infection resulted from catheter- 
 izing the tuba Eustachii. In the greater number of my 
 
98 
 
 INEICATIONS FOR INJECTION. 
 
 cases the symptoms were not very severe, nor were they 
 accompanied by fever, nor complications fraught with danger. 
 But I must remark that such persons were generally very 
 anaemic in appearance, and the cure in most cases was 
 retarded. 
 
 Case 19. — L., a merchant, twenty-seven years old, is a son of sound 
 parents. He says he has only once ever been sick; about four years 
 ago, with inflammation of the bowels. A syphilitic infection he denies 
 most emphatically , but confesses to repeated intercourse with women. His 
 present disease dates back to December, 1868, and began under the form 
 *of acute angina tonsillaris , and he says the swelling of the right submaxillary 
 glands was rather obstinate. The course of the disease was a very tedious 
 one, and only after the lapse of three weeks, and several incisions of the 
 tonsils, did a change for the better take place. At the same time he 
 had a yet existing exanthema, which was first regarded as small-pox, 
 and, on account of its unyielding nature, the patient came to the 
 hospital. 
 
 Examination on the 13th February, 1869, revealed: 
 
 A good muscular development and healthy appearance. The genitals 
 showed no ulcer nor cicatrix. But on the under lip there was a somewhat 
 hard ) whitish-grey colored appearance seemingly a cicatrix. The whole 
 body, especially the chest and back , is covered with dirty , reddish papules 
 of the size of common shot. Some are covered on the point with a gray- 
 white epidermis, others have become metamorphosed into small pus- 
 tules. On the right malleolus externus a small swelling was detected , which 
 seemed to arise from the periosteum. 
 
 Inspection of the pharynx and cavity of the mouth revealed an erythema 
 and swelling of the mucous membrane, the tonsils and palate roofs. 
 On the right side of the posterior wall of the mouth opposite the isthmus fau- 
 cium ) a scar is visible about five-sevenths of an inch long : sharp-edged , some- 
 what elevated and very hard to the touch. 
 
 Laryngoscopic examination of the very hoarse patient revealed : 
 
 Epiglottis very much swollen . On the right free border , there was an ulcer 
 with a firm adherent color , extending towards the laryngeal surface. The 
 cords of the ligamentum ary epiglottica , the mesoarytenoid folds were 
 swollen and the vocal cords slightly reddened. The glands of the 
 tongue were swollen and partially infiltrated, and here and there 
 superficially ulcerated. 
 
AFFECTION OF THE MOUTII AND PHARYNX. 
 
 99 
 
 Rhinoscopic inspection showed swelling of the mucosa of the cavum 
 pharyngo-nasale, covered with thick tenacious mucus. 
 
 The inguinal glands were but slightly enlarged , but the cervical and sub- 
 maxillary , particularly the latter, were swollen on the right side. 
 
 Subcutaneous injection had a quick result on the pharynx, but less 
 so on the papulous, syphiloid, which only after the use of J gr. of the 
 sublimate, began to disappear. We used, altogether, only one grain 
 for complete restoration. 
 
 Case 20. — Mr. N., twenty-two years old, originating from a family 
 where the father is healthy, but where the mother has epilepsy, had 
 always been healthy up till October, 1868, when he discovered on the 
 left side of his under lip a “ small crack.” This u cracked lip,” as he 
 termed it, did not seem to heal and was treated by his family physician 
 with glycerin and lastly with nitrate of silver, but without result. 
 After an elapse of three weeks, the lymphatic glands on the side of the 
 neck began to swell. Two somewhat carious teeth, thought to have 
 caused this, were extracted. Notwithstanding, the “ cracked lip” grew 
 worse and took a form like glandular swelling. On the 22d November 
 a celebrated surgeon was consulted and diagnosed chancre of the lip. 
 The patient consulted me a little time afterwards, when, except from a 
 pale appearance, he seemed of a healthy constitution. 
 
 The submaxillary glands , from the spina mentalis interna to the angulus 
 maxillse inferioris were much indurated and swollen. On the under Up there 
 was an ulcer of the size of a penny covered with a brown crust partly , and 
 partly with a tenacious , fatty detritus , of thick consistence. It had a well- 
 defined border also. 
 
 On the body there was a seemingly developing maculous syphiloid. 
 On the genitals , I could detect nothing suspicious. The inguinal glands 
 were not swollen. 
 
 We began, immediately, the use of the sublimate injections, but it 
 could be borne only in small quantities by the sensitive patient. But 
 the ulcer soon healed without leaving a scar. The indolent submaxil- 
 lary glands were lessened also, but 4 gr. of sublimate, in about fifty 
 injections, were given, before a real change for the better could be seen. 
 
 After the treatment was completed, the patient felt perfectly well till 
 three weeks thereafter, when he had an epileptiform attack. Another 
 occurred about one week later. During the first attack much vomiting 
 was present, and attending the second there was considerable diarrhoea. 
 When I saw the patient I detected on the right cheek a papulous infil- 
 
100 
 
 INDICATIONS FOR INJECTION. 
 
 tration of the size of a penny, of a brown color and medium soft con- 
 sistence. There also was an infiltration of the right upper eyelid. On 
 the left swollen tonsil there were gray-white patches, the patient com- 
 plained of a heavy feeling in his head. I prescribed iodide of potas- 
 sium, because the patient did not consent, then, to a repetition of the 
 hypodermic injections. 
 
 To prevent repetition of the following material, I empha- 
 size that in all the six following cases there were symptoms 
 present which I have characterized, in words preceding this 
 theme, as sure proof of infection by means of the mucous 
 membrane of the mouth. 
 
 The positive proof on the lips , the negative on the genitals , 
 and the singular course of the swellings of the lymphatics , 
 described in extended detail , were supported by the most 
 accurately taken histories . That the word of the patients 
 themselves was only taken with the greatest precaution, is 
 self-evident. 
 
 Case 21. — S., fifty-four years old, received under No. 3293 on the 
 20th May, 1867. 
 
 The ulceration on the lip was here accompanied with loss of sleep, 
 headache, and buzzing in the ear ; at the same time a clearly-defined poly- 
 morphous exanthem was present , showing those characteristic pigment colors , 
 remaining after a maculous syphiloid. There were also papules and scales 
 besides a marked defiuvium capillorum 7 and angina condylomatosa . The use 
 of 3 gr. of sublimate was sufficient for a perfect cure. 
 
 Case 22. — Ch. H , day laborer, twenty-one years old, was received as 
 No. 2710 on August 2 2d, 1867. 
 
 Here also were exanthema maculo-papulosum defiuvium capillorum and 
 angina condylomatosa , and the symptoms of ulcer on the lips. Complete 
 restoration was effected by the use of 4 gr. sublimate hypodermically. 
 
 Case 23. — K. H., laborer, received as No. 3957 on 25th June, 1868. 
 
 Besides the mould-like , broken and characteristic ulcer on the upper lip 7 
 there was a maculous syphiloid and an extensive swelling of the tonsils. Of 
 
AFFECTION OF THE MOUTH AND PHARYNX. 101 
 
 the greatly swollen submaxillary glands one had formed itself into an 
 abscess . 
 
 Sublimate injections, to the amount of 4 gr., completely restored the 
 patient. 
 
 Of cases which concern women , I have selected the fol- 
 lowing three : — 
 
 Case 24. — L. H., a servant girl, twenty-five years old, was received 
 into the hospital April 25th, 1867. 
 
 Diagnosis was based in this case on an infection per os. There was an 
 unruptured hymen and a swelling of submaxillary glands , more extensive than 
 of the inguinal. 
 
 The accompanying symptoms were a papulous and maculous exanthem 
 and superficial broken-down condyolmatous granulations on the labia majora. 
 That such may be developed in the advanced progress of syphilis, even 
 if infection took place in regions remote from the genitals, I have 
 already pointed out. 
 
 Case 25. — Ch. F., servant girl, received April 23d, 1867. 
 
 Examination revealed an intact hymen. 
 
 Besides the characteristic ulcer on the under lip and large swellings 
 of the submaxillary glands , there teas a swelling also in the axillary region. 
 Along with the already existing maculous and papulous exanthemata , there 
 was also a gummy swelling on the frontal bone ) which disappeared after com - 
 vletion of treatment. 
 
 Treatment in this case consisted in the use of iodide 
 of potassium. Exact dates concerning the time and amount 
 of treatment are wanting in our hospital journal. 
 
 Case 26. — E. Sch., twenty years old, admitted at her own request on 
 the 27th of April, 1866, said that she only once in her life had indulged 
 in coitus, on March 15th, 1865, and her whole deportment verified her 
 assertion. Her lover kissed her repeatedly and she remembered that 
 he had cracked lips ; and she noticed shortly after an ulcer on her 
 under lip, which disappeared of itself. Subsequently she detected some 
 patches on her body and a little later affection of the genitals. 
 
 Inspection revealed, condylomata lata, near the anus ; on the labia majora , 
 
 P* 
 
102 
 
 INDICATIONS FOR INJECTION. 
 
 plicas femorales , tonsils , arac/ at the angle of the mouth , muculous exanthema. 
 The submaxillary glands were very much ) the cervical glands somewhat , awe? 
 tfAe inguinal glands not at all swollen. The hymen , with the exception of a 
 small rent ) was intact. Two and a half grains of sublimate, hypodermi- 
 cally used, restored the patient to health. 
 
 As we think we have established the occurrence of an 
 infection by the mouth, and especially by the mucous mem- 
 brane, we can also affirm that a child may convey the syphi- 
 litic virus to a wet nurse and vice versa . 
 
 I shall quote here a very remarkable case, — in itself 
 almost a unicum, — in which a woman nursing her own child 
 was infected by a strange child, while nursing it, who had 
 hereditary syphilis ; afterwards she infected her own child. 
 Here the singular combination occurred that a strange 
 syphilitic child infected a hitherto healthy nurse, producing 
 ulcers from which the healthy child was infected. The case 
 in its further development has still more singular symptoms, 
 as, after the woman had been thoroughly impregnated with 
 syphilis she infected two men, of whom one died on account 
 of this disease, and the other living was taken with the 
 disease also. The woman furthermore had a premature 
 delivery of a child, which very soon died. 
 
 A child from her second marriage has completed its sixth 
 year, but it recently had a pustulous exanthem, showing 
 plainly the character of syphilis. Lastly, the daughter, 
 eighteen years old, who was originally infected from the 
 breast and who suffered from the same throat symptoms as 
 the mother, w T as taken two years ago, after she seemed com- 
 pletely cured of the syphilis, with syphilitic disease of the 
 bones and a lupus. 
 
 The course of this singular case is almost similar to one 
 published two hundred years ago by Sartorius. 
 
AFFECTION OF THE MOUTH AND PHARYNX. 103 
 
 Case 27. — Mrs. F., grocery keeper, forty-three years of age, of healthy, 
 robust constitution, good complexion, twice married and mother of two 
 yet living children, was up to her twenty-fifth year, according to her 
 statement, perfectly . sound. She was confined and nursed her own 
 child ; but having a large quantity of milk, she took a strange child 
 under her care, acting as a wet nurse. This child, as subsequently 
 shown, came from a syphilitic mother, and infected the nipples of the 
 nursing woman in such a manner, that venereal ulcers were developed, 
 of which she took no notice. But her own healthy child was infected 
 by nursing the breast and certainly per os. The strange child died a 
 little time afterwards, notwithstanding an antisyphilitic treatment. 
 
 The mother and her infected little daughter had soon afterwards 
 syphilitic affections of the throat, which were treated by the same phy- 
 sician properly with a solution of mercury, and cured in a short time. 
 But the husband becoming infected by his wife, had several syphiloids, 
 afterwards tophi on the frontal bones, and lastly an apopletic attack, 
 in which he died in our hospital. 
 
 Some time afterwards she married again a healthy man, although 
 she suffered from relapsing syphilitic affection, especially in the throat, 
 for which she used, from time to time, with more or less success, dif- 
 ferent antisyphilitic remedies — as iodized mercury, pills, inunction, 
 Decoctum Zittmanni , &c. 
 
 She gave birth to a child in the eighth month of pregnancy, but it 
 died in consequence of hereditary syphilis after five and a quarter 
 months. Shortly afterwards she was confined at proper time with a 
 second child yet living, aged seven years. The same was healthy and 
 of plump appearance till the present, but it now has a suspicious 
 exanthem. 
 
 The second man was said to have been infected by the woman, but I 
 could get no positive proof of it. 
 
 Eighteen months ago my esteemed colleague, Dr. Koblank, had the 
 kindness to introduce this interesting family, and I have had them for 
 demonstration in all my recent clinical lectures. Seeing the patient 
 for the first time I noticed : 
 
 1. In the woman , a thickening of both arcus glos so -palatini. The right 
 tonsil was atrophied and showed still existing superficial ulceration. 
 The left was entirely gone. The posterior roofs of the palate were glued 
 on to the posterior wall of the pharynx by a tense cicatricial tissue. The 
 same was the case with the soft palate , which showed several defects. The 
 uvula was mostly destroyed by ulceration. 
 
104 
 
 INDICATIONS FOR INJECTION. 
 
 The consequence of this destruction and gluing process was, that with 
 phonation a clearly nasal sound was heard , while a regurgitation of the food 
 through the nose occurred when eating. Aside from this the patient was 
 well. 
 
 2. The daughter, eighteen years old, infected soon after nursing the ulcerated 
 breasts, suffered as already said with syphilitic affections of the throat, which 
 were properly treated with mercury . In her sixteenth year, fifteen years after 
 a seemingly perfect cure, a relapse of the affection took place. Tophi on the 
 frontal bones and on the tibia, were formed. They were cured, however, by 
 the long -continued use of iodide of potassium; but six months afterwards a 
 lupus-like exanthem showed itself on the left thigh, which is yet present, on 
 account of its obstinate resistance to a mercury treatment. She married two 
 months ago. 
 
 The pharynx showed pretty much the same appearance as in the mother. 
 The tonsils were destroyed ; the soft palate and the posterior roof of the palate 
 were glued together, for the most part, on to the posterior wall of the pharynx ; 
 besides a semilunar shaped defect of the epiglottis. 
 
 3. The child, seven years old, by the second husband, had a quite 
 healthy appearance ; but four months ago it was taken with & pustulous 
 exanthema. I used for it sublimate injections, but obtained not a very 
 quick result. After having used sixteen injections, the equivalent of 
 1 gr. sublimate, they were not wholly healed, and I ordered iodide of 
 potassium in cod-liver oil, which the patient still uses, without the 
 entire disappearance of the exanthem. 
 
 V.— SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 The syphilitic affections of the pharynx are followed by 
 those of the larynx , the same being intimately connected, 
 both topographically and anatomically. The disease most 
 met with here is 66 syphilitic catarrh .” 
 
 The characteristic symptoms between this and idiopathic 
 catarrh of the larynx, are especially : (1.) The chronic 
 course ; (2.) The dark red mucous membrane changing into 
 a livid diffuse color of the mucous membrane ; (3.) A ten- 
 dency to early erosions and ulcerations. 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 105 
 
 1. The idiopathic catarrh of the larynx has an acute 
 beginning and a well-defined course, as in catching cold; 
 and therefore is very often combined with catarrh in the 
 nose, or pharyngitis. The syphilitic catarrh of the larynx 
 develops itself very slowly , as do all syphilitic hypermmiae 
 and exudations. It very often keeps pace with the develop- 
 ment of the maculous syphiloid of the skin. 
 
 2. The singular color of the mucous membrane of the 
 larynx, which is dark red changing to livid, is probably the 
 result of the slow course of the disease. As the maculous 
 syphiloid has a singular copper-red color, on account of the 
 modification of the hyperaemic clear-red, produced during 
 the slow progress of the disease by the transudation of the 
 coloring matter of the blood, so the chronic progress of the 
 syphilitic process on the mucous membrane of the larynx, 
 not only gives rise to dilatation of the capillaries, but simul- 
 taneously here also, a transudation of the hmmatine occurs 
 and a change in hue. The color of the congested vocal 
 cords in common catarrh is a lighter red, and the dilated 
 capillaries, with their small branches parallel to the free 
 borders of the ligamenta vocalia, can be clearly seen. 
 
 But it should never be forgotten here, as in affections of 
 the pharynx, that great caution should be exercised in 
 making diagnosis from colors. 
 
 3. As the commencement of syphilitic catarrh generally 
 takes a chronic course, it is the more significant, that so 
 soon as the inflammation has over-reached the climax, the 
 formation of erosions through mollecular detritus , the peeling 
 off of epithelium , and subsequent ulcerations very rapidly 
 occur , — all of which symptoms come prominently into the 
 foreground. This quick destruction has a strong analogy 
 to the genesis of the plaques muqueuses in the pharynx. 
 
106 
 
 INDICATIONS FOR INJECTION. 
 
 As there, so in the larynx, where the papules, variously 
 situated, are swollen by a weak infiltration, and which, in 
 the beginning producing in excess, an already unhealthy, 
 unripe epithelium, quickly break down and give rise to 
 those gray-white, dull, shining patches, resembling places 
 cauterized by argentum nitricum . The epithelium, de- 
 stroyed by detritus, and peeling off from its place, leaves 
 a superficial erosion which, by the manifold mechanical 
 movements, as breathing, talking, &c., induces still deeper 
 destruction of the underlying tissue very easily. 
 
 As the whitish-gray patches are mostly situated near the 
 middle of the vocal cords in the free borders , more or less 
 scattered, we see, on the other hand, that the deep ulcera- 
 tions have a predilection for the region of the processus 
 vocalis, the Santorin and arytenoid cartilages. 
 
 Another consequence of the syphilitic catarrhal affection 
 of the larynx is, submucous infiltrations . The transuded 
 fluid in catarrhal parenchymatous inflammations is never of 
 a serous nature, but seems in syphilis to have a more con- 
 sistent formation, and thereby produces quill-like elevations 
 of a greater resistance, with seldom well-defined granulations, 
 and also tumors resembling polypus. The natural conse- 
 quence of these firm swellings are hoarseness, and even 
 . aphonia on account of paralysis of the vocal cords induced 
 by pressure on the motor nerves. This I shall explain in a 
 following case (No. 33). 
 
 But that a permanent stenosis of the larynx may be hereby 
 produced, seems to me only possible in exceptional cases. 
 I, myself, have had no occasion to observe it. The con- 
 dition for such a stenosis of the larynx, which can only exist 
 with the firmer infiltrations, belongs to a very late period — 
 the gummous one — and I cannot agree with Tuerck, who 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 107 
 
 designates such stenosis as a consequence of an early paren- 
 chymatous inflammation. 
 
 It is a question of importance whether condylomatous 
 granulations can be produced in the larynx, as we had occa- 
 sion to see them on different parts of the skin and mucous 
 membrane, more or less extensively, and in a more or less 
 altered formation. 
 
 “We believe the same (broad condylomes) to be the 
 general cause of early hoarseness in syphiliticallv affected 
 patients, and also that the accompanying difficulty in 
 deglutition, pain in the throat, &c., arise from the same 
 source.” 
 
 This is the answer which Professor Gerhardt of Jena and 
 Dr. Roth have given as the result of nine months study and 
 observation, taken conjointly on the syphilitic diseases of the 
 larynx from abundant material.* 
 
 “ Of fifty-four patients with secondary syphilis, of whom 
 forty-three were in the earlier stages, eight had already 
 broad condylomes in the larynx (15 per cent.) and were, 
 most of them, quite hoarse. Yes, one of us, in another 
 hospital, among three syphilitics, found broad condylomes 
 in two (66 1 per cent.), of whom one was not even hoarse.” 
 
 “ The distribution of the condylomes in the different 
 places in the larynx, was in the following manner : right 
 vocal cord, five times ; left, three times ; the folds between 
 the arytenoid cartilages (base of the larynx), four times ; 
 anterior commissure, once; aryepiglottic folds, twice.” 
 
 Concerning the appearance of this so-called broad condy- 
 lome, it is described as follows: “as broad, flat, quill-shaped 
 elevations ;” “ red, like the mucous membrane, with the sur- 
 face studded with fine excrescences;” “of velvety appear- 
 * Virchow’s Archives, vol. xx., p. 482, and vol. xxi., p. 1. 
 
108 
 
 INDICATIONS FOR INJECTION. 
 
 ance; ,, “flat, whitish drops ;” “round, quill-like elevations 
 of the size of a shot “ protuberances with sharp edges, of 
 the size of a pin-head, and white color.” In the ninth case, 
 first chapter, page 12: “There were on both vocal cords, 
 behind the middle, (?) flat, reddish protuberances on the free 
 border, and somewhat over-reaching it. In spite of mercu- 
 rial treatment, these broad condylomes multiplied themselves 
 so that the greater part of the vocal cords on the inside had 
 a mulberry-like appearance.” 
 
 This examination, communicated in 1860, upon broad 
 condylomes in the larynx, by Professor Gerhardt and Dr. 
 Roth, has been believed since then by nearly all the later 
 authors on syphilis and laryngoscopy. And I wish to ex- 
 plain here that these views and examinations of the named 
 authors must consist of a real delusion , and 'particularly is 
 the described formation of the excrescences contrary to the 
 condylomatous nature. The formation of “ flat, whitish 
 drops,” “sharp-edged protuberances of the size of a pin- 
 head,” &c., will not be found in the papules of the mucous 
 membrane of the larynx. If, really, condylomata lata were 
 to be found in the larynx, they would, like the same on all the 
 other mucous parts exposed to pressure and friction, be only 
 rudimentary, and would very soon ulcerate superficially. 
 
 As, furthermore, the condylomes belong to the homo- 
 geneous tumors which are produced by hyperplasia of the 
 pre-existing matrix of the papillae, they can only be found 
 where the maternal soil is, i . e. where papillae are present. 
 This papilla formation is found on the pavement epithelium , 
 but not in the regions covered with columnar (flimmer) epi- 
 thelium, as the surface on the folds of both “ arytenoid 
 cartilages,” “anterior commissura of the larynx wall,” on 
 which places Gerhardt and Roth had found such condylomes. 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 109 
 
 The pavement epithelium, which extends from the cavity of 
 the mouth towards the larynx, reaches but a few lines above 
 its entrance, to 4 make room for columnar (flimmer) epithe- 
 lium, consisting of long stretched cells, which are constantly 
 found on the laryngeal surface of the thyroid cartilage, the 
 ventricles of Morgagni. Only a small strip of flattened 
 epithelium descends from the walls of the pharynx through 
 the incisura interarytenoidea and covers the free borders of 
 the vocal cords. Here under this epithelium we find only 
 a few elevated papillae, as on the points and the outer bor- 
 ders of the thyroid cartilages. 
 
 Although the named publications of these two authors 
 appeared eight years ago, and although since that time 
 laryngoscopy has gained ground, immensely and rapidly, 
 and the larynx has been the object of many examinations, 
 yet only two authors , according to my knowledge — a very 
 insignificant number — have published any observation har- 
 monizing with the above histological facts. The names of 
 these authors are Vogler and Tuerck. 
 
 Dr. Vogler,* in a case at Ems, speaks of whitish, red, 
 pointed drops, like excrescences on the border of both vocal 
 cords, which he explains as condylomatous granulations, 
 without any explanation of his view. 
 
 Tuerck in his work, “ Clinic of Diseases of the Larynx 
 and Trachea” (p. 414), quotes in several places “ mucous 
 papules and granulations which are resembling each other 
 more or less and therefore must be, evidently, of a syphilitic 
 nature, because they exist with symptoms of constitutional 
 syphilis and disappear with any anti-syphilitic treatment.” 
 
 Of 258 cases published by him we find only seven which 
 really belong here. As the seat of the granulations was in 
 
 * German Clinic, 1863, No. 16. 
 
110 
 
 INDICATIONS FOR INJECTION. 
 
 nearest proximity to ulcers, it seems to speak against their 
 syphilitic nature, as it is well known that the here existing 
 so-called papillary granulations can under no consideration 
 be reckoned among the syphilitic broad condylomes. Even 
 Gerhardt is obliged to disavow it, and says emphatically , 
 “that in his cases there were never ulcerations present, ” as 
 is the case with granulations of the cellular tissue which 
 Tuerck has already described. 
 
 An unbiased and exact analysis of Tuerck’s cases shows 
 that those papillary granulations and ulcers, described by 
 him as syphilitic, must have been in many cases of a tuber- 
 culous nature, since in several patients death is described as 
 produced by tuberculosis. 
 
 What the final result of the mercurial treatment was with 
 the other patients of Tuerck, cannot be at all accurately 
 stated, “ on account of the running away of the patient 
 another time, “ from the non-appearance of the patient and 
 a third time, “further report was wanting.” 
 
 Finally, I have to fall back on my own observation . It 
 may be presumed that I paid particular attention, in my 
 patients, to the point in question. I have to affirm that in 
 only three or four patients did I find the small protuberances, 
 which, by only a superficial examination, could easily have 
 been confounded with the mucous membrane papillae. I 
 never found granulations on the vocal cords which could, in 
 the least, have been regarded as condylomata lata . If really 
 16 per cent, of constitutionally syphilitic patients were hoarse 
 and the cause of this hoarseness was condylomatous granula- 
 tions of the larynx, as has been the case with Gerhardt’s 
 patients, the number of mine so affected would be very 
 many. 
 
 I intended to thus dwell at length on the laryngoscopic 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 Ill 
 
 discoveries, because they have been, as already said, taken 
 as characteristic, and easily might lead into therapeutical 
 errors. Even Gerhardt and Roth say in their first case 
 (page 7), that only after laryngoscopic examination, “ the 
 suspicion of constitutional syphilis’’ was well founded. 
 
 The other consequences of parenchymatous inflammation 
 of the larynx, which occur sometimes in the early period of 
 syphilis — the ulcers — have generally a greater difficulty in 
 diagnosis than is usually supposed. 
 
 But if, already, the syphilitic ulcers on the genitals show 
 a certain modification concerning their configuration, their 
 color, their secretion, their borders, &c., according to their 
 different seats and singularity of the affected tissue, it seems 
 hazardous to speak about “ syphilitic typical ulcers,” as has 
 recently been done by certain distinguished German authors. 
 According to my observations, the syphilitic ulcerations of 
 the larynx, having a great line of modification, may be classed 
 in two general groups — genetic and histologic. 
 
 Concerning the genesis it is important to bear in mind the 
 fact whether the ulcer originated from a syphilitic catarrhal 
 erosion, or whether from a deeper inflammatory infiltration. 
 
 In a histological point of view , the ulcers present variously 
 
 different appearances, according to their locality in the rather 
 
 narrow cavity of the larynx, which, besides being made up 
 
 of a very heterogeneous anatomical tissue, as cartilages, 
 
 muscles, elastic fibres, have two different kinds of mucous 
 
 membrane, with or without glands. The functional activity 
 
 of some parts of the larynx modifies the appearances by 
 
 their mechanical workings. 
 
 © 
 
 The catarrhal syphilitic ulcers appear on the vocal cords 
 mostly (showing here only flat ulcerations), and their seem- 
 ingly deep appearance is produced only by contrast with the 
 
112 
 
 INDICATIONS FOR INJECTION. 
 
 elevation from the swelling of the mucous membrane sur- 
 rounding. With deeper inflammatory infiltration of the 
 mucous membrane, and with ulcers which arise by destruc- 
 tion of such infiltration, the ulcerative process, in its further 
 extension, reaches the underlying elastic tissue of the vocal 
 cord, which is much less yielding to the erosive process. 
 The ragged appearance that the ulcers assume, especially 
 on the free border, somewhat later, is probably caused by 
 the growing out of several soft fibres which are embedded 
 between the elastic fibrillae, that are less susceptible to 
 ulceration. 
 
 When the ulcer has reached the border of the processus 
 vocalis, its advance is less easy on account of the elastic 
 fibrillae being so compactly arranged -with the fibrillated 
 original substance of the reticular cartilage. Hindered from 
 further progress, the ulceration enters so much the more 
 the nearest surroundings of the appendages of the vocal 
 cords, and hereby produces in time, above the organ, a 
 singular semilunar cavity frequently observed. 
 
 But after fully destroying these barriers, it may give rise 
 to an entire uncovering of the cartilages, and lastly, necrosis 
 of the same, which even may extend to the posterior part of 
 several rings of the trachea. In the last two years I have 
 had two such cases under my treatment, in which the greater 
 part of the arytenoid and the whole Santorin cartilage of the 
 left side of the larynx were destroyed by necrosis. Tuerck 
 has also published a similar case. 
 
 In most cases the stratum thyreo-arytaenoideum externum 
 of the suffering vocal cord is destroyed, the muscles of the 
 vocal cord are exposed, and destruction must necessarily 
 follow. 
 
 It is different with the ulcers on the false vocal cords, 
 
SYPHILITIC AFFECTIONS OF THE LAHYNX. 
 
 113 
 
 ■which are rich in sebaceous follicles and tissues, and allow a 
 gradual progress from the centre to the periphery, and also 
 permit deeper erosions in themselves. The soft and early 
 destroyed tissue, which is abundant here, has a greater apti- 
 tude for the ulcerative process. 
 
 Very similar histological facts, as connected with these 
 superior or false vocal cords , we find at that part of the 
 epiglottis which is called petiolus . Consisting of net-like 
 tissue, adipose in character, and a layer of acinose glands, 
 the syphilitic ulcer can extend in the same manner as on the 
 false vocal cords, giving rise to great loss of substance. 
 
 But we find the syphilitic ulcers more on the free borders 
 of the epiglottis , than on the petiolus. These erosions seem 
 to have more of a tendency to go deeply, than to remain 
 superficially, and cause defects here, which, according to my 
 observation, take the form of circular segments. 
 
 But on no part of the larynx have I seen more significant 
 ulcers, than on the epiglottis. Although I have not ob- 
 served perforation like Tuerck, yet the destruction in many 
 cases was so extensive that the whole epiglottis was destroyed , 
 only leaving a small residue appearing as if quilted. 
 
 It was singular that the syphilitic process never reached 
 over the insertion upon the tongue. The same I noticed in 
 other ulcerations, especially of a carcinomatous nature. 
 
 Notwithstanding the absence of the epiglottis, which is 
 seemingly necessary in deglutition, it is only for a time that 
 fluids and solids occasion any difficulty when swallowing. 
 The neighboring organs induce closure' of the glottis, readily 
 accommodating themselves, so that even fluids, without 
 entering the larynx or trachea, could be taken devoid of any 
 hazard. For the physiological explanation of this act, we 
 
 10* 
 
114 
 
 INDICATIONS FOR INJECTION. 
 
 are indebted to the interesting observations of Professor 
 Czermak, the inventor of the laryngoscope. 
 
 The syphilitic ulcers, as above described, seem to find in 
 their progress toward the root of the tongue, a barrier. On 
 the other hand, we see it extend very easily to the ligamentum 
 ary-epiglottica and plicce glosso-epiglottica , and witness de- 
 struction frequently on account of contractility produced by 
 cicatrization. It is singular that such ulcers are very seldom 
 situated on the posterior wall of the larynx, where all the 
 most favorable conditions for ulcerative destruction exist. 
 
 In phonation, there is the ever opening and closing of the 
 glottis, causing the processus vocalis to be nearer or farther 
 away ; the plica inter-ary tenoidea, fold-like, is flexed and 
 stretched; and these are the reasons why this region of 
 mucous membrane, covered with numerous glands, is found, 
 in common catarrh, thickened, and in tuberculosis ulcerated. 
 But why syphilis, especially here, causes so much destruc- 
 tion, I most openly confess I could find no explanation. 
 
 In the important questions as to the specific processes 
 occurring in the larynx in the later stages of lues , the views 
 and observations of Virchow are decisive. This author has 
 not only observed, on the inner surface of the epiglottis, but 
 also in the larynx, “new gummous formations, ” and asserts 
 that he could plainly trace them in their various stages of 
 development.* But, with these processes, the condyloma- 
 tous granulations on the mucous membrane cannot be classed, 
 as described by Gerhardt and Both. I need not further 
 emphasize here, for, .according to the testimony of these 
 authors themselves, the appearances were in the* primary 
 stadium of syphilis. And I think I have shown above, 
 pretty clearly, that such formations do not exist here. 
 
 * German Clinic, 1860, No. 48, Malignant Tumors, vol. II., p. 413. 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 115 
 
 But on the other hand, 44 the two laryngoscopically ob- 
 served knotty swellings in the larynx of two syphilitic 
 women,”* might be classed among 46 gummy knots,” and 
 for this reason, since they were complicated with ulcerations 
 of the pharynx and knotty affection of the skin upon the 
 nose, as well as in other regions of the body. 
 
 Why Tuerck f should especially designate these two ob- 
 servations of Grerhardt and Both 44 as unwarrantable,” I 
 really do not know, since he, himself, publishes cases where 
 a want of complications and appearance of the excrescences, 
 has certainly no bearing whatever on their gummy character. 
 He, himself, is forced, by an interrogation set after the 
 expression 44 gumma,” to doubt one of his cases; and, too, 
 it is significant that in the second of his cases, the so-called 
 syphilitic tumor 44 gave way” to an ordinary treatment. 
 
 I had a large number of syphilitic patients under my 
 treatment in whom circumscribed tumors on the different 
 parts of the larynx were present , but, that they were, in 
 reality, gummy knots, neither the appearance nor other 
 diagnostic signs would warrant the assertion; yet still, the 
 gummous character of the diffuse infiltration was very 
 striking . They were seated on the epiglottis, and on the 
 posterior wall of the larynx, the chordae vocales and false 
 vocal cords. Their color was a dirty yellow-red, and their 
 consistency, as ascertained by digital examination, on the 
 epiglottis and false vocal cords, somewhat elastic. The 
 ulcers either were deeply seated in the tissues or ran along 
 superficially. After healing, the infiltrations remained in 
 an obstinate manner, causing here stenosis of the larynx, as 
 I shall further describe. 
 
 Differential diagnosis of tertiary ulcers from scrofulosa , 
 * Ch. I., pp. 23, 24. f Ch. I., p. 388. 
 
116 
 
 INDICATIONS FOR INJECTION. 
 
 or lupus , is, as every experienced clinicist well knows, very 
 difficult ; especially so to distinguish the latter from specific 
 syphilis , either in the larynx or pharynx. I found par- 
 ticularly with those patients who have been sent to me from 
 Poland and Russia, lupous ulcerations in the above-named 
 organs, which could not be classed among the syphilitic 
 because they appeared in such young persons that there 
 was no possibility of infection, and even the accurate exami- 
 nation of the parents excluded a possibility of a hereditary 
 taint . 
 
 The distinction of tuberculous ulcers is more easy, not 
 only on account of their less characteristic condition, which 
 is apparent to the eye, but also the condition of the lung, 
 which is here decisive. If tuberculosis has already caused 
 deep-seated destruction in the cartilaginous tissue of the 
 larynx, we may be sure that in the softer and more easily 
 broken down parenchyma of the lung, greater destruction, 
 especially vomicce , must be present, and be certainly revealed 
 by auscultation and percussion. 
 
 The therapeutics of the diseases of the larynx , is divided, 
 as in the pharynx , into a general and local one . As to the 
 former, the lighter processes, consisting of hyperaemia, weak 
 exudations and erosions, heal on an average very quickly and 
 readily, after using by injection J gr. or more of the sublimate. 
 For ulcerations already existing, larger doses from 1 J gr. to 
 2 gr. are necessary. But more rebellious are the so-called 
 tertiary processes, where the already gummous granulations 
 and tumors are formed, or have advanced to ulceration, and 
 where the cartilaginous tissue of the larynx, and the osteoides 
 of the pharynx, are involved. Iodide of potassium , as is 
 well understood, has a curative effect and may sometimes be 
 used in these affections. 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 117 
 
 According to my observations, injections of sublimate are 
 indicated in the following cases : — 
 
 1. If iodide of potassium has been used for a certain space 
 of time without any material benefit. 
 
 2. If after an apparent cure from the use of iodide of 
 potassium, syphilis reappears, showing its latent disposition. 
 
 3. If periculum in mora , or danger of fatal stenosis, 
 appear. 
 
 4. If the ulcers are situated on those parts, whose full 
 integrity is absolutely necessary for the normal function of 
 the affected organ, the destruction of which may easily 
 occur, e. g. the vocal cords. 
 
 The quantity to be used in these cases is quite different- — 
 sometimes 2 gr. will be sufficient, and again greater quanti- 
 ties, even' up to 5 gr., maybe necessary. 
 
 But if defects should still remain on the cartilaginous 
 parts of the larynx, or on the bone of the palatum durum, 
 after all other symptoms caused by syphilis have disappeared, 
 it is best not to force a cure by further injections. 
 
 To help granulation, a more strengthening treatment is 
 necessary than the sublimate , which is hurtful to the protein, 
 since these places are so poorly supplied with vessels, and 
 nutrition is in consequence here materially impaired. 
 
 Local therapeutics here is very necessary. With a forced 
 internal or external use of mercury a cure can never be 
 established, but the destructive process will rather be favored. 
 We must concede that local treatment plays, very often in 
 these affections, quite an important part. Though super- 
 ficial erosions sometimes may disappear of themselves, still 
 their cure may be hastened by pencilling with argentum 
 nitricum. This is quite indispensable in ulcerations. Only 
 in cases where either the attending physician, from lack of 
 
118 
 
 INDICATIONS FOR INJECTION. 
 
 dexterity, is unable to use argentum nitricum, or where the 
 seat of the ulcer is difficult to reach, or where finally, the 
 patient shows a great hypermsthesia against the argentum 
 nitricum, which is very seldom the fact, would I recommend 
 the atomizer , either charged with this named caustic in solu- 
 tion, or with the sublimate ; of the strength of the former, 
 5 gr. to 10 gr. to 100 parts of water, or the latter even 
 stronger. The patient must not inspire too deeply, because 
 medication ought to reach the larynx and not the trachea 
 and bronchi. Concerning the prevalence of the diseases of 
 the larynx in constitutional syphilis, there were out of 1000 
 patients, forty-four persons, or 4J per cent., who were more 
 or less affected with hoarseness, a result quite in contrast 
 with the already mentioned high percentage of Gerhardt 
 and Roth. 
 
 The following cases have a double purpose — to serve as 
 paradigma for the different formations in laryngeal disease, 
 and to illustrate the extent and effects of subcutaneous 
 medication. 
 
 The first case shows how needful an examination of the 
 larynx is in all persons suffering with syphilis, even when 
 not complaining of pain in that locality. 
 
 Case 28. — Clara T., twenty-five years old, of weak constitution and. 
 flabby muscles, suffered from her earliest childhood from bone affec- 
 tions, which had their painful seat in both elbow joints, and which are, 
 in consequence of caries, yet very much anchylosed. In her nineteenth 
 year she was infected for the first time, and received in 1863 into our 
 hospital. Being discharged after some time, she returned again in 
 the year 1865, Both times she suffered from vaginal catarrh and 
 pointed condylomes. Treatment both times was a local one. 
 
 In the following year and till the end of 1868 she was treated four 
 times for syphilis — the third time for broad condylomes situated on the 
 labia majora. They subsided after treatment for five weeks with the 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 119 
 
 11 sarsaparilla sweat cure.” She soon returned to our wards, and there 
 was not only a relapse of the condylomes, but on both tonsils deep 
 ulcerations were found. At the same time there was a knotty syphiloid 
 on several places on the back and left forearm, being only partly ulcer- 
 ated. After using 1 gr. of sublimate and f gr. iodide of mercury hypo- 
 dermically, restoration was effected. 
 
 After repeatedly returning to our hospital with nothing but primary 
 and local symptoms, she was again admitted, March 1st, 1869, for the 
 seventh time. Besides a superficial erosion nothing marked was found 
 on the genitals. But the cicatrices which remained from the already 
 mentioned “ knotty syphiloids,” showed on their periphery a dirty 
 reddish color, and occasionally small papules of the size of a pea, 
 covered with scales, which gave rise to the suspicion that syphilis was 
 not wholly eradicated from the system, and therefore we searched for 
 something more tangible and local on other organs. 
 
 The glands on the different parts of the body were only slightly 
 swollen. Examination of the pharynx revealed a certainly already 
 longer existing defect of the tonsils, and thickening of the roofs of the 
 palate. 
 
 Laryngoscopic inspection of the patient, who complained neither of pain 
 in the throat nor of hoarseness, showed, besides a large swelling of the seba- 
 ceous follicles of the root of the tongue, a broad ulcer, four to six lines long, 
 on the free border of the epiglottis , reaching towards the left ligamentum 
 glosso-epiglotticum, and having sharply defined edges, which were surrounded 
 by broad cherry -red borders . On the surface of the ulcers, was a dirty, 
 yellow, firm coating. 
 
 Cod-liver oil with an addition of iodide of potassium and iodine were 
 used ; but, as this medication caused but slow progress, subcutaneous 
 injections of sublimate were ordered. 
 
 This caused not only a quick cicatrization of the ulcer of the larynx, 
 but also a complete healing of the papulous and squamous exanthemata, 
 so that 3 gr. of sublimate in all were sufficient for a complete cure. 
 
 Of a large number of cases of affections of the larynx, I 
 shall only give the following ones, embodying important 
 symptoms : 
 
 Case 29. — Otto L., received into the hospital May 16, 1868, and was 
 as follows : 
 
120 
 
 INDICATIONS FOR INJECTION. 
 
 Hard ulcer on the inner fold of the prepuce, erosions on the upper 
 lip and left arcum glosso-palatinum. The cause of an existing hoarse- 
 ness was from a swelling of both vocal cords , on which were long gray-white 
 colored patches, parallel to the free border . There was a small loss of sub- 
 stance of the upper third of the left vocal cord , which was quite visible , with 
 the closure of the glottis during phonation. There was a redness and slight 
 swelling of the mucosa , epiglottis , false vocal cords ; greater swelling of the 
 left ligamehtum glosso-epiglotticum ; besides superficial erosions of some of 
 the swelled sebaceous follicles of the tongue. At the same time , gray -white 
 pea-like ulcers could be seen on the soft and hard palate. 
 
 Only after the fourteenth injection, amounting in all to If gr. of sub- 
 limate, was a change for the better visible. The restoration advanced 
 with steady progress ; so that he was discharged cured at the end of 
 two weeks, after having used 2J grs. of sublimate. 
 
 Case 30— Anna P., maid-servant, twenty-five years old ; from a good 
 family, and healthy constitution ; had already been treated, and quite 
 often, with the sarsaparilla sweat cure, for broad condylomes on the 
 labia minora and majora, maculous exanthema, and for superficial ulcer- 
 ation at the corner of the mouth. 
 
 She was received again April 2, 1868, into the Charite. She had 
 large condylomata lata at the pudenda and around the anus, maculous 
 exanthema, loss of hair, urethritis, purulent vaginal discharge, condy- 
 lomatous angina tonsillaris, glandular swellings and hoarseness. La- 
 ryngoscopic inspection revealed the cause of the hoarseness to be gray- 
 ish-white patches on the epithelial covering of the reddened and somewhat 
 swollen vocal cords ; also on the false vocal cords and on the arytenoid cartil- 
 age similar patches could be seen. On the tongue , around the papillse cir - 
 cumvallatse , excrescences of a round , pea - like size were visible. The sebaceous 
 follicles of the root of the tongue were greatly swollen and of a gray-white 
 color . 
 
 I prescribed injections of sublimate. At first the hoarseness in- 
 creased, and a second examination with the laryngoscope revealed 
 small erosions on the vocal cords, especially at the places where the 
 grayish-white patches were seen. But very soon the treatment was 
 successful ; so that, after the hypodermic use of 2J grs. of sublimate, 
 the laryngeal affections and the other syphilitic appearances disap- 
 peared. The glands, however, did not return to their original size. 
 
 Case 31. — B., forty-five years old, from healthy parentage and of 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 121 
 
 robust constitution ; large panniculus adiposus ; lias suffered several 
 years, more or less, with renal calculus, for which he has used, with 
 more or less benefit, the Carlsbad water. During the last treatment he 
 experienced hoarseness and painful deglutition. Professor Botkin, of 
 St. Petersburg, was consulted, and he diagnosed at once syphilis, and 
 sent the patient to me. 
 
 I saw the patient the first time in August, 1867, and found, besides 
 the lymphatic glands of the submaxillary region swollen, only a few 
 remaining scales, covered with thickened epidermis on the palms of 
 both hands. Inquiry elicited that infection took place six months pre- 
 viously. Laryngoscopic inspection confirmed the existence of syphilis 
 in the larynx, which was suspected by Professor Botkin. In the middle 
 of the free border of the epiglottis there was a crescent- shaped loss of sub- 
 stance !, besides an ulcer of the size of a bean , deep-seated and situated on the 
 left thyroid cartilage. It seemed to be still developing. Thick pus covered 
 its base. 
 
 We used energetically subcutaneous injections, in doses varying from 
 J gr. to gr. of sublimate. After using three grains altogether, there 
 was not only no change for the better, but, on the contrary, the ulcera- 
 tions had spread further and a violent cough had set in. Professor 
 Virchow was consulted, and he discountenanced the arising suspicion 
 of the tuberculous character of the ulcer ; so that the same treatment 
 was continued, and after using 2J grs. more of the sublimate, entire 
 recovery was effected. 
 
 Now, after an elapse of eighteen months, the patient is perfectly well. 
 
 Case 32. — Agnes F., twenty-three years old, of delicate and sickly 
 appearance, and emaciated ; suffered in her childhood with scrofulosis, 
 especially in the glands of the cervical region, which formed into ab- 
 scesses, where clear traces of cicatrization are plainly visible. 
 
 When twenty-one years old, she was first received into the Charite 
 Hospital, suffering with broad eroded condylomes on the labia majora 
 and minora. The right tonsils were also ulcerated, and on the body 
 there was a maculous and papulous exanthema. After thirteen injec- 
 tions, consisting of 2\ grs. of sublimate, she was discharged cured. In 
 October of the same year a relapse occurred, taking the form of broad 
 condylomes on the labia majora and small impetiginous incrustations 
 in the neighborhood of the glutaei. 
 
 She was again discharged, after the further use of 2J grs., only as 
 seemingly cured. After the expiration of eight months, she was again 
 
 a 
 
122 
 
 INDICATIONS FOB INJECTION, 
 
 compelled to seek relief at the hospital. She suffered not only with 
 broad condylomes this time, but also with throat affections. On the 
 anterior part of the left palate-roof there was a long, flat and large ulcer , 
 which was covered with a grayish-yellow , firm , adherent coating. Both ton- 
 sils were swollen and red. On the right tonsil there were small yellow ulcers 
 and very similar ones were to be found on the false vocal cords , on the left lig - 
 amentum ary epiglotticum , and on the left arytenoid cartilage. Everywhere 
 the ulceratious showed a superficial course , resembling more diphtheritic than 
 syphilitic ulcers. Notwithstanding the lack of a sure diagnosis, and the 
 emaciated condition of the patient, I used the subcutaneous medication. 
 Hardly were lj gr. of the sublimate used before cicatrization of the 
 borders of the ulcers began, and complete healing with 2J grs. was 
 brought about. 
 
 Case 33. — The following case may serve as an example of paralysis 
 of the vocal cords, in consequence of syphilitic infiltration, and a quick 
 restoration to health by the use of sublimate, subcutaneously adminis- 
 tered : 
 
 F. C., a merchant, of a healthy family and healthy appearance, aged 
 twenty-three ; says he never suffered from throat affections, nor syphil- 
 itic disease. During the last several years, at intervals, he has been 
 attacked with furunculosis. Further investigation revealed that two 
 months previously the patient contracted gonorrhoea, which was neither 
 lasting nor painful. Other symptoms, which might follow a chancre in 
 the urethra, were not present. His hoarseness dated back for only a 
 fortnight, gradually becoming more intense, dyspnoea existing for the 
 last two days only. When I saw the patient the first time, I was some- 
 what astonished at the extreme hoarseness and that the respiratory 
 murmur had mixed with it a certain degree of stridor. Examination 
 revealed a maculous syphiloid that was very marked on the trunk, be- 
 sides swelling of the inguinal, cervical and submaxillary glands. The 
 pharynx, tonsils and palate-roofs were swollen, and the first especially 
 was covered with the already described grayish-white and somewhat 
 elevated plaques. 
 
 The laryngoscopic examination was very interesting . Aside from the sus- 
 picious redness of the larynx , there was an important swelling of the vocal 
 cords , with a diminished ability for movement , as in paralysis. The glottis 
 was of a sharp , triangular shape. In quiet respiration the swollen vocal 
 cords touched themselves on the anterior corner , wholly occluding the pars 
 ligamentosa and the pars cartilaginea , so that a fissure showed itself , about 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 123 
 
 four or five millimeters in length. In forced inspiration and expiration the 
 opening as well as the approaching of the vocal cords was hardly perceptible. 
 The same immobility was present during intonation , while the false vocal cords 
 very nearly approached each other in the first act of phonation. 
 
 These symptoms, together with a marked defluvium capillorum, in- 
 duced me to base my diagnosis as syphilis, taking the paralysis of the 
 ligamenta vocalia as a consequence of pressure, produced by syphilitic 
 infiltration, upon the motor nerves of the vocal cords. The result of 
 the treatment justified this diagnosis ; for after the use of 2J grs. of 
 sublimate, given subcutaneously, the patient was discharged as cured. 
 
 After ten injections, the movements of the vocal cords were more 
 perceptible ; but as the redness did not wholly disappear, local reme- 
 dies were used for it. 
 
 The following cases show that with affections of the larynx 
 an energetic treatment is necessary in the beginning, because 
 a loss of substance of the vocal cords may easily occur, in- 
 ducing an alteration in the voice which cannot be remedied 
 by later administration of strong subcutaneous injections. 
 
 Case 34. — K., brewer by trade, twenty years old, of healthy consti- 
 tution, received into the Charite, June 14, 1868, patient No. 3196, had 
 on the prepuce sharp, circumscribed, hard, superficial erosions, swelling 
 of the inguinal, and especially of the submaxillary glands, and consider- 
 able hoarseness. Laryngoscopic- inspection revealed an ulcer four to 
 five lines long, very deeply situated, sparingly covered with pus, together 
 with superficial erosions of the right swelled vocal cord. Also the 
 posterior wall of the larynx was swollen, and had a milky hue of 
 epithelial covering. The epiglottis seemed to be thickened, and had on 
 its free borders a few yellow spots which could be distinguished either 
 as fatty follicles, or as a small submucous layer of pus. The swollen 
 false vocal cords showed also similar appearances. Besides thislarjmgeal 
 condition, the whole body was covered with but a slight maculous 
 syphiloid. Inquiry revealed that infection took place about twelve 
 weeks before, and the syphilitic sclerosis quickly caused phyinosis, 
 which had been operated on eight weeks ago. 
 
 After the use of 2 gr. of sublimate hypodermically, the epithelial 
 erosions disappeared, and the ulcer on the vocal cords healed, but the 
 
124 
 
 INDICATIONS FOR INJECTION. 
 
 loss of substance, and cicatrization caused thereby, left the hoarseness 
 remaining. 
 
 Case 35. — Mrs. V., thirty-six years old, of robust build, but of un- 
 healthy, pale color ; was, up to her twenty-fourth year, quite well. Three 
 weeks after marriage she became sore at the genitals, and a little while 
 later wart-like excrescences with well defined edges appeared. It seems 
 also that the patient suffered from broad condylomes. She used iodide 
 of potassium and Russian vapor baths, with seemingly a curative result, 
 but some weakness remained. After eight years a throat affection made 
 its appearance characterized by a hoarseness and pain in deglutition. 
 The same therapeutics were repeated with similar results. After the 
 lapse of three years more, the throat difficulties reappeared, but in a 
 different way, causing complete aphonia. Decoctum Zittmanni, with 
 inunction treatment, was employed. But in a year these symptoms ap- 
 peared again. Sixty-four bottles of Decoctum Zittmanni were used, 
 but without any very favorable result, as the aphonic voice yet remained. 
 It is mentionable that during these twelve years of married life, she had 
 never given birth to a living child, but on the contrary she had aborted 
 every year, and always in the third month, the last time being one 
 year ago. 
 
 November, 1868, the patient commenced treatment with me. I found 
 on the left tonsil a small ulceration , swelling of the right vocal cord and a 
 very great loss of substance of the left one ) reaching from the middle to the 
 processus vocalis. 
 
 I used with the patient the injection treatment. Already, after using 
 but If gr. of sublimate, the swelling of the right vocal cord was less- 
 ened and the ulcerations were cicatrized, but the aphonia caused by 
 the contractility of the cicatrice was not very materially altered. 
 
 Case 36. — Lieut. S., thirty years old, of healthy constitution and ap- 
 pearance ; had always enjoyed good health. January, 1867, he was 
 infected. On the prepuce an ulcer appeared, which was designated by 
 his attending physician as u ulcus molle,” and he was treated only 
 locally this first time. But seven weeks later, a throat affection ap- 
 peared, for which gargarisms were used. The physician in attendance 
 denied the existence of any syphilitic affection. 
 
 Shortly afterwards, about nine weeks from the time of the suspicious 
 coitus, a maculous exanthem appeared. Another physician was 
 brought into consultation, who called the exanthem a syphilitic erup- 
 
 i 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 125 
 
 tion, and detected a yet existing induration on the prepuce. Dzondi’s 
 treatment was ordered, and one hundred and eighty pills taken, besides 
 sarsaparilla tea. But the results were not lasting. Painful deglutition 
 and hoarseness appeared again, and the patient used for six weeks de- 
 coctum Zittmanni. Even the effects of this were but temporary, and 
 relapse occurred again after three months. Iodide of potassium was 
 prescribed in larger doses, and twenty-five drachms were used. The 
 disease of the pharynx disappeared, but hoarseness remained. 
 
 April, 1868, the patient began treatment with me. Both tonsils swol- 
 len ; the right grown together with the anterior roof of the palate. The 
 velum and posterior wall of the pharynx were very much reddened, and 
 the latter, especially, interspersed with white capillaries. On the free 
 border of the palatum molle , left from the appendage of the uvula , there was 
 an ulceration of the size of a bean , which was dispersed through all the tissue , 
 encircled by a cherry-red colored border , and covered with a grayish-white 
 pus-like secretion. Similar extensive ulcerations were seated on the anterior 
 border of the left arytenoid cartilage , and on the right vocal cord. On the 
 latter , one ulcer occupied three-fourths of the processus vocalis ^ of which 
 already a small part was destroyed. In phonation this defect of the glottis 
 was more visible. On the left swelled vocal cord only superficial erosions could 
 be detected. 
 
 Besides swelling of the cervical and submaxillary glands, I could not 
 detect any further complication of syphilis ; I instituted a local and 
 subcutaneous treatment, and after the use of only lj gr. of sublimate, 
 already all the ulcers of the larynx and pharynx disappeared, and also 
 the raucedo syphilitica was mostly gone. Patient thought he was com- 
 pletely cured ; caught cold, and the hoarseness increased, as a conse- 
 quence. Laryngoscopic inspection revealed, this time, great swelling of 
 both vocal cords , and a new ulceration of the size of a pinhead , above the cir- 
 cumscribed loss of substance on the right appendages of the vocal cords. We 
 began again to inject the sublimate solution, and it required the further 
 amount of 2 gr. to effect perfect restoration. 
 
 But after a complete cure, a raw and somewhat hoarse sound of the 
 voice remained, resulting from the retraction of the cicatrized tissue 
 above the processus vocalis of the right vocal cord, and thus bringing 
 about an insufficient closure of the glottis. 
 
 In the following case, the sublimate injection w~as used 
 with good result, for ulceration in the larynx, but probably 
 
 li* 
 
126 
 
 INDICATIONS FOR INJECTION. 
 
 interruption caused the later arising stenosis of the larynx, 
 which produced so much dyspnoea even impending suffocation, 
 that tracheotomy had to be performed. 
 
 Case 37. — Mrs. B., thirty-eight years old, mother of a seven years old, 
 healthy child ; married about twelve years ago ; was taken in December, 
 1865, with painful deglutition and cough. Two physicians examined 
 her, and declared her to be suffering from tuberculosis. The treatment 
 being of no avail, a third physician was consulted. He declared her 
 disease to be syphilis, and prescribed a mercurial treatment, followed 
 by iodide of potassium. But, as the patient got no better, she was sent 
 to our hospital. 
 
 Status prsesens March 21, 1868. — Patient is pale and cachectic; exami- 
 nation of the genitals reveals only oedematous swelling of the labia 
 majora and superficial erosions of the swollen mouth of the womb. In- 
 spection of the phrynx shows the right arcus palato-pharyngeus to be 
 changed into broad and almost transparent fibres ; the left partly grown 
 together with the posterior wall of the pharynx. The place of this growth 
 exhibits a longitudinal ulcer, with papulous granulations in the sur- 
 roundings. No trace is left of either tonsil. In both pits, where 
 formerly the tonsils were, which are enlarged by the mentioned flexion 
 of the arches, the mucous membrane is covered with superficial erosion. 
 But very little of the uvula is remaining, it now having a conical shape. 
 Above the same there is a scarred centre from which fibrous stripes 
 radiate. 
 
 Rhinoscopic examination is only partly admissible, and reveals super- 
 ficial ulcerations of the posterior part of the soft palate, and a swelling 
 of the mucous membrane, reaching high up into the cavum pharyngo- 
 nasale. 
 
 The papillae circumvallatae of the tongue are small and very difficult 
 to distinguish. In examining with the finger around the root of the 
 tongue, we find an atrophy of the sebaceous glands, producing here a 
 singular smoothness. In passing the finger further along, we feel in 
 place of the epiglottis a very hard, narrow and last-shaped excrescence. 
 
 Laryngoscopic inspection revealed a very great defect of the epiglottis , of 
 which there remained only the mentioned last-shaped excrescence. The liga- 
 mentum glosso-epiglotticum medium is very much thickened. The fovese glosso- 
 epiglotticae are , on account of the deficiency of the sebaceous glands and 
 flexions of the named ligaments very large. The ligamenta aryepiglottica are , 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 127 
 
 like the false vocal cords very large and swollen , and show on their yellow-red 
 surface long and shallow ulcers. The vocal cords are of the same color , and 
 also are infiltrated , besides being grown together at their lower point of attach- 
 ment, so that in phonation and deep inspiration no movement is visible. The 
 yet open space of the glottis is oval-shaped , hardly five to six millimetres long , 
 and about one and a half or two millimetres broad. Through the opening of 
 the glottis quill-shaped formations are visible , but are not easily seen. 
 
 The patient complains of great pain during deglutition and respira- 
 tion. The latter is performed with a certain stridor. The sound of the 
 voice is hoarse. 
 
 Subcutaneous injections were ordered in doses of £ gr. of sublimate 
 pro die. The treatment was somewhat interrupted on account of 
 threatened salivation. After using 2 gr. of this, the described ulcera- 
 tions of the pharynx and larynx were completely gone, but the mentioned 
 thickening and infiltration were but slightly reduced. With the further 
 use of \ gr. more of sublimate, the swelling of the larynx subsided but 
 little, yet the stridor in breathing was gone. By urgent request of the 
 husband, she left the hospital in April, 1868. Two months afterwards, 
 she gave birth to a healthy and yet living child, and was taken four 
 months later with considerable menorrhagia. In October, of the same 
 year, difficulty of respiration increased so much that tracheotomy had 
 to be performed. 
 
 The patient is now under my treatment, and my experiments to en- 
 large the stenosed opening by catheterization has not yet been crowned 
 with success. 
 
 In the following case, deep seated ulcerations in the larynx 
 and pharynx, and ulcerative skin affections began to develop 
 themselves. The patient was very weak, but nevertheless 
 we used quite large doses of sublimate subcutaneously, which 
 quickly effected a complete restoration. 
 
 Case 38. — Charlotte L., forty years old, was received on February 
 28th, into the Charite Hospital. The patient was very much emaciated, 
 weak and of a very cachectic appearance. She was married fifteen years 
 ago ; has had several miscarriages, only one child being born alive, 
 which died in its twenty-first month, with convulsions. She farther 
 says she has always been well up to four months ago and always been 
 
128 
 
 INDICATIONS FOR INJECTION. 
 
 well nourished. Then she first complained of pain in her throat, which 
 made deglutition almost impossible. Very shortly afterwards, and 
 “ almost suddenly” spots appeared on the skin, with scaly formations. 
 She used for her complaints “gargarism” and internal medication, 
 which latter seems to have been iodide of potassium. 
 
 In examination we found small superficial ulcerations on the posterior 
 commisura of the vagina. On the head, in the region of the right axilla 
 and upper and lower extremities, there were ulcers which reached deeply 
 into the cuticle, and were covered by ecthymatous and rupia-like crusts. 
 
 In the pharynx we found quite deep ulcerations on the tonsils, the 
 arches and root of the tongue in the vicinity of the ligamentum glosso- 
 epiglotticum dextrum. The latter showed an infiltrated base, and was 
 partly covered with a dirty looking pus. Laryngoscopic inspection re- 
 vealed an important thickening of the epiglottis, whose left free border 
 showed a semilunar deficit in consequence of an ulcer seated there. The 
 lig. aryepiglottica were thickened. On the left thyroid cartilage a deep 
 ulcer was present, the size of a bean, and covered with a grayish-white 
 pus. 
 
 On the left patella we found a diffused reddened place, painful to the 
 touch. 
 
 The treatment of this intricate case consisted of baths, to which bran 
 was added ; the subcutaneous injections of sublimate in doses from Jgr. 
 to J gr., besides a good meat diet, and the liberal use of wine. 
 
 With the treatment gradual recovery followed. After the use of ljgr. 
 the affections of the pharynx and larynx disappeared, and also a portion 
 of the skin syphiloids. Complete cure of them was only effected after 
 injecting a total of 3 gr. sublimate within four weeks. 
 
 In the next case, which had used for the manifold and 
 severe syphilitic affection almost every treatment, a seem- 
 ingly gummous infiltration of the vocal cords, which were 
 partly ulcerated, was found. At the same time the subjective 
 as well as the objective signs exhibited a tendency to 
 perichondritis. 
 
 Case 39. — Agnes P., eighteen years old, of pale, anaemic appearance, 
 and flabby muscles, had been, notwithstanding her age, seven times in 
 the Charite for syphilis. The first time she suffered with a blennorrhaeic 
 
SYPHILITIC AFFECTIONS OF THE LARYNX. 
 
 129 
 
 and primary affection ; the sixth time with broad condylomes and large 
 ulcers on the tonsils, together with a papulous exanthem, for which she 
 used a sarsaparilla sweat cure, followed with iodide of potassium. Four 
 months after her discharge and seeming restoration, she again returned 
 to the hospital, having deep ulcers on the palate-roofs and uvula. 
 Again sarsaparilla and iodide of potassium were used, and seemed to 
 effect a cure. But on the 6th May, 1866, she came back once more with 
 the following status prsesens : 
 
 On the right palate-roof there was an ulcer of the size of a penny , with sharp 
 edges , deep base, a dirty -diphtheritic coating , and infiltrated surroundings. A 
 second ulcer of a lesser size and same consistency , was situated on the posterior 
 wall of the pharynx. 
 
 On the mucous membrane of the septum narium , there was a deep seated per- 
 forating ulcer , with swelling in the vicinity . 
 
 On the lower border of the nasal opening , were also ulcers of the same 
 character and quill-like elevations of the size of a bean , red color , and a third 
 of an inch long , whose inside borders were also ulcerated. 
 
 The lymphatic glands of the submaxillary and cervical regions were 
 largely, while those of the inguinal region were but slightly swelled. 
 
 Subcutaneous injections were ordered, and twenty-nine doses ad- 
 ministered, — seventeen with nearly t 3 q- gr., and twelve with £ gr. per 
 dose, — so that altogether 4J gr. were used. 
 
 We noticed that after the seventeenth injection, the ulcerations on the 
 posterior wall of the pharynx were completely gone. After the twenty- 
 second injection, the ulcers on the nose and palate-roofs were all per- 
 fectly cicatrized. But the quilt-like formations were not gone till after 
 the twenty-fifth was administered, or the use of about 3£ gr. Slight 
 ptyalismus occurring, an interruption in the hypodermic medication of 
 four days was necessary at the twenty-fifth injection. 
 
 On the 8th of June, 1866, the patient was discharged, cured. 
 
 After an elapse of six months, Agnes P. came again, for the ninth time, 
 into our ward with a light pigment-colored exanthem, and small isolated 
 knots of the size of a pea, on the nose and upper lips. They were particularly 
 on the point of the nose and borders of the nostrils. They were already deeply 
 seated in the cuticle , ulcerated and covered with a yellow coating. 
 
 Scars on the septum narium and contraction produced by cicatrized 
 ulcers, flattened the nose somewhat, especially at the point, and lessened 
 the openings. Patient said she had pus-producing pimples on her nose 
 three months ago, which she opened herself, and applied to them 11 red 
 
130 
 
 INDICATIONS FOR INJECTION. 
 
 precipitate” till salivation commenced. At the same time she used 
 some sort of a laxative decoction. 
 
 We prescribed iodide of potassium in 16 gr. doses. After using this 
 remedy four weeks, the ulcers were healed and cicatrized, and the pa- 
 tient feeling quite well, was discharged as cured. # 
 
 After eighteen months she returned again, in April, 1868 — aphonic , but 
 apparently healthy. 
 
 Laryngoscopic examination revealed that the vocal cords were round , pale 
 and swollen to such a degree that the glottis was narrowed in consequence. 
 They were deeply ulcerated in the vicinity of the left processus vocalis. 
 
 On the right arytenoid cartilage we could see a large swelling and redness of 
 the mucous membrane. On the lower part of the left vocal cord , a small flat 
 quilted prominence appeared, partially covered with an ulcer. The right vocal 
 cord stood with its free border nearly in the medium line , and remained sta- 
 tionary here during attempted phonaiion , and also with forced inspiration and 
 expiration. The movement of the right vocal cord which plainly appeared 
 with coughing , prevented a greater stenosis of the larynx. Deeper inspirations 
 were attended with a rough stridor. 
 
 The complaints of the patient were referred to deglutition and cough- 
 ing, especially on the right side of the larynx which seemed painful to 
 the touch. Cataplasms and inunction with gray salve over the larynx, 
 and -§ gr. doses of sublimate subcutaneously injected, were ordered. 
 Salivation being feared, we paused in the treatment two days, and after- 
 wards used only from -j- gr. to J gr. After using 3 gr. altogether, the 
 ulcers on the larynx healed, and the infiltration of the vocal cords and 
 the quilted formations on the left chorda-vocalis disappeared. Subcu- 
 taneous injections were further used which effected a perfect cure. 
 
 Lastly, I wish to direct the attention of my readers to 
 those cases of stenosis of the larynx which have had a long 
 existence, and in which by a deficient aeration, a blood alter- 
 ation, or almost blood poisoning is caused. Here tracheotomy 
 ought to be resorted to when impending suffocation occurs, 
 as the following case will show. 
 
 Case 40. — I was consulted by N., an army officer in 1862. He was 
 scarcely able to ascend the stairs on account of dyspnoea. The diffi- 
 culty in respiration was so much that he could utter only half sentences, 
 
MACULOUS EXANTHEM. 
 
 131 
 
 and being also interrupted by a persistent cough. He contracted a 
 hard ulcer in 1856, and mercurial pills were prescribed, he faithfully 
 carrying out the physician’s prescriptions. In the fall of 1860, he 
 noticed for the first time, a hoarseness, which, together with pain in 
 deglutition, increased in severity — later dyspnoea occurred, and as time 
 advanced, it became greatly augmented ; countenance rather livid ; the 
 pulse much flexed and small j and cough very frequent with a hoarse 
 dry sound. 
 
 Laryngoscopic examination revealed a stenosis of the larynx. The 
 infiltrated vocal cords, covered with a superficial ulceration, were but 
 little moved in inspiration — back of them red quilt-like formations ap- 
 peared. 
 
 Examination of the chest'revealed only 11 rales ” and a slight dullness 
 on the right front of the lung. I thought tracheotomy indicated, and 
 fixed the next day to operate. But when I made my visit the following 
 day, I found the patient already dead. Only ten minutes before, he had 
 drank beer brought to him by his landlord. Section revealed great 
 stenosis of the larynx. The sides of the laryngeal cavity, behind the 
 vocal cords, were swollen in such a manner that only a fissure re- 
 mained, and this was still more narrowed by the thickened mucous 
 membranes of the posterior wall of the larynx. The vocal cords were 
 infiltrated and showed superficial loss of substance. 
 
 Similar cases in suffocation occurring after a longer exist- 
 ing stenosis of the larynx are reported by Green (American 
 Jour. Med. Sciences, 1851) ; by Pravaz, (Lebert Traits 
 d’anatom, tom. I.) ; Tourdes, (Gaz. des Hosp., 1853, No. 
 12) ; Senn, (Jour, des Science Med., tom. V., p. 230), &c. 
 
 VI. SYPHILITIC SKIN AFFECTIONS. 
 
 MACULOUS EXANTHEM. 
 
 Before commencing upon the therapeutics of the diseases 
 of the skin , occurring in the first period of syphilis — that 
 extended territorium in which the dyscrasia of blood estab- 
 lishes disturbances of nutrition from a simple hypeaermia, 
 
132 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 as patches and erythema, up to the deeper gummous ulcera- 
 tions — I ^hall, irrespective of those cases in which the ex- 
 anthemata are only companions of other syphilitic affections, 
 and therefore to be classed under general therapeutics, place 
 the following principles the first in order. 
 
 If the exanthemata show only slight redness, if they do not 
 possess a specific character, if there are wanting these singu- 
 lar polymorphous skin efflorescences only seen in syphilis, 
 and especially if they have no explainable connection of the 
 lower formations to the higher ones, I always treat such 
 cases, at first, in the expectant method . 
 
 But if this is impracticable and energetic treatment seems 
 to be needed, then I inject, by way of trial, small doses of 
 sublimate. If they are well borne and show good result, I 
 even use for the entire curing of the exanthem further in- 
 jections till I have used at least 2J gr. of the sublimate. 
 But if no results are apparent then I lay aside the subcuta- 
 neous medication. 
 
 The diagnosis of a maculous syphiloid in its earliest com- 
 mencement, cannot be devoid of more or less difficulty, par- 
 ticularly if the characteristic coloring is absent, and the 
 hypersemic redness of the patches in contrast to the paler 
 hue does not appear. Even exposure of the body and the 
 coldness thereby produced, will often fail to bring out this 
 contrast in color. 
 
 In such cases, of diagnostic value are the complications with 
 other syphilitic symptoms , which occur at this period of syph- 
 ilis — as the connection of the mucosa of the pharynx, the 
 defluvium capillorum, and the swelling of the lymphatic 
 glands. But the first two symptoms are very inconstant, 
 and the third symptom is difficult to estimate on account 
 
MACULOUS EXANTHEM. 
 
 133 
 
 of not knowing the normal size and consistence of the 
 glands, and hence the three are often almost valueless. 
 
 A non-syphilitic roseola is a rarity . Roseola patches oc- 
 curring with exanthematous diseases, as morbilli, scarlatina, 
 typhus, have all characteristic differences, and besides are 
 accompanied with concomitant, febrile, catarrhal or angi- 
 nous appearances, which are in strong contrast with devel- 
 oping syphiloids. Roseola balsamica , which is formed some- 
 what similarly to the syphilitic, is generally combined with 
 hyperesthesia of the nerves of the skin, and it disappears 
 as quietly and suddenly as it appears. Substantive roseola 
 is a morbillous or scarlatinous process which almost in its in- 
 cipiency begins to disappear and cannot be confounded with 
 roseola syphilitica .* 
 
 I have very often noticed "that on the inside of the upper 
 thigh, the first signs of syphilitic eruption appeared, and 
 here showed the characteristic pale, copper-red color, pro- 
 duced by the change in the haematine of the blood, but 
 without developing itself afterwards to a clear roseola 
 elevata. 
 
 The therapeutic effect of the subcutaneously injected sub- 
 limate on the maculous syphiloid is generally a very satis- 
 factory and quick one, and compares very favorably with 
 the success of other standard treatments. According to 
 Zeissl (p. 103), “ erythematous syphiloid disappears with a 
 mercurial treatment in a fortnight .' 9 Engelsted* puts the 
 average time for treating the same complaint at four and a 
 half .weeks ; the shortest period three weeks, and the longest 
 six w’eeks. The chief remedies for these skin affections are, 
 according to Engelsted, calomel and sublimate, either alone, 
 
 * Constitutional Syphilis. Translated by C. Uterhart, Wurzburg, 
 
 1861, p. 10. 
 
 12 
 
134 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 or combined with iodide of potassium and decoctum sarsa- 
 parilla. 
 
 In the cases treated by me the amount, for complete 
 eradication, was from If gr. to If gr. of sublimate. 
 
 That there are exceptional cases where larger doses , and 
 a longer time , are necessary, I will not dispute. But never 
 was it necessary to use large doses for such a length of time 
 as I have mentioned, with the use of the decoctum sarsa- 
 parilla compositum, or as Engelsted notes for several of his 
 patients. 
 
 Those patients which came under my care in a relapsing 
 stage of syphilis, already having erythema annulatum , re- 
 quired larger doses. These cases had generally very bad 
 result on account of the syphilitic sequela always coming at 
 a certain period. In some cases the patches became redder 
 instead of paler after the first injections, and even more ele- 
 vated, but by steadily continuing the medication the eruption 
 disappears in due time. This is the case with all anti- 
 syphilitic treatments, either botanic or mercurial. Ac- 
 cording to Zeissl, “ all anti-syphilitic treatments caused an 
 increase in the development of the elementary formation of 
 syphilitic efflorescence.” 
 
 Lastly, I wish to direct the attention of the reader to a 
 new species of non- syphilitic maculous exanthema , which, 
 according to my knowledge, has not yet been described, and 
 to which I have been partly directed by Staff Surgeon Dr. 
 Lommer. The same manifests itself by a quantity of large 
 “ pea-sized” spots, of a peculiar pale blue color, which, for 
 this reason, we have named exanthema coeruleum . This 
 color is very dissimilar to the “ mulberry rash ” of the large 
 flecked syphiloid, unlike the ordinary copper-red hue, and 
 very different from the gray lead color of pigment spots. 
 
PAPULOUS EXANTHEMA. 
 
 135 
 
 Although we noticed this bluish maculous exanthem at 
 first only with syphilitics, later observations revealed that 
 quite as often it occurred with the non-infected, and that it 
 appears without a syphilitic blood-dyscrasia pre-existing. 
 
 As to the genesis of this singular exanthem, which I have 
 mostly observed on the sides of the chest, I can give only 
 this explanation, that I think it is produced by a venous 
 conglomeration and the blue pale color is caused by an over- 
 lying adipose covering. 
 
 PAPULOUS EXANTHEMA. 
 
 Diagnosis of the papulous syphiloid is, only in a few cases, 
 difficult. As with the maculous syphiloid, it is difficult only 
 in the incipiency of its formation, namely , when the dirty 
 brown red color , caused by the lenticular character of the 
 syphilis , has not yet appeared . And further , efflorescences 
 are present only in a few species . 
 
 In the obscure cases all the other data and symptoms 
 must be considered, in order to make out the diagnosis ; as 
 the concomitant symptoms, the date of the infection and 
 locality of the papules , &c. It is of importance to find out 
 whether they are seated in their favorite places, as in the 
 bend of the extremities, especially the plica cubitalis, fossa 
 poplitea, and near the hair on the forehead, neck, chin, &c. 
 
 The miliary species of this syphiloid is easily diagnosed. 
 They show their syphilitic character early, by a regressive 
 and progressive metamorphosis. Sometimes, however, the 
 diagnosis is embarrassed, inasmuch as often with the rapidly 
 appearing eruption of the small papules, febrile and nervous 
 appearances occur, which are generally absent in syphilitic 
 exanthemata, — the febrile first showing itself with a higher 
 
136 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 temperature and accelerated pulse, while the nervous is 
 attended with more or less itching of the skin in the affected 
 regions. In consequence of this pruritus , the small papules 
 are very often scratched open by the patient, so that the 
 efflorescences are subsequently covered with bluish-black 
 crusts. 
 
 The lenticular species progresses more slowly. Only after 
 a lapse of time, are a part of the efflorescences flattened, 
 desquamated and covered with their scabs. The more coni- 
 cal and pointed papules take on the vesiculous and pustulous 
 formations. 
 
 More difficult is the diagnosis in those cases in which the 
 papulous exanthema occur, and which is the only symptom 
 of relapsing syphilis. Here is a tendency for the efflores- 
 cences to group themselves in certain configurations, as in 
 an irregular, coil-like formation, or in a crescentic shape. 
 This occurring, forms a good basis for diagnosis. 
 
 With few exceptions have I noticed in recent cases of 
 papulous syphiloid, fine, circular formations only four or 
 five lines in diameter, which appear on the face and neck. 
 They consist of small narrow papules of the size of a pin’s 
 head, covering themselves quickly with pale red scales of 
 nearly the same dimensions. But care must be taken not 
 to confound such formations with a similar species of the 
 herpes circinatus . 
 
 Concerning the therapeutics , subcutaneously , of both de- 
 scribed species, I commence and conduct the treatment* in 
 accordance with the above-described principle. When the 
 diagnosis is so uncertain that even an experienced syphilo- 
 grapher would be in doubt, I inject then only small quantities 
 of sublimate by way of trial. 
 
 But I use the injection continuously, even after the pap- 
 
PAPULOUS EXANTHEMA. 
 
 137 
 
 ules show a tendency to desquamate and when they are 
 covered with fine lamellae, peeled off from the epithelial 
 scales, also even when some small papules increase in 
 volume. 
 
 It requires only a few days longer, and the treatment 
 with the sublimate will show its beneficial result on the 
 papulous efflorescences, they getting paler very quickly, 
 being soon after perfectly healed. 
 
 The healing of the papulous syphiloids require on an ave- 
 rage from J gr. to \ gr. more than the maculous . But in 
 some patients even greater doses are necessary. 
 
 The resistance to treatment of the named exanthema, in 
 certain cases, is known to all syphilographs. In former 
 years, when I relied more on the sarsaparilla sweat cure, I 
 met cases where, after months even, the papules were in 
 full bloom, and where a ‘repetition of the treatment, in com- 
 bination with iodide of potassium, effected no curative result. 
 Similar experience I have sometimes had with the inunction 
 cure, which was energetically applied, but without result. 
 And, indeed, it is surprising to witness the relatively quick 
 healing of this obstinate exanthema by the use of subcuta- 
 neous injections ; and we need not he satisfied with \ gr. 
 doses pro die , but may even risk larger quantities , as for 
 instance , J gr. or J gr. pro die. 
 
 In the following cases I shall show that while in some 
 patients neither a mercurial, nor the sarsaparilla sweat cure 
 treatment, energetically used, was sufficient to destroy the 
 papulous exanthem, and that finally subcutaneous injection 
 produced complete restoration. 
 
 Case 41. — Anna B., eighteen years old, was received August 22d, 1866. 
 Examination revealed a soft ulcer in the fossa naviculare vaginoe, va- 
 ginal discharge, urethritis and erosions on the clitoris. Although the 
 
 12 * 
 
138 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 erosions had a suspicious 11 look/’ yet no sure grounds for diagnosis of 
 syphilis could be detected, so I tried at first a local treatment only. 
 After four weeks syphilis manifested itself in the form of a maculous 
 exanthema , accompanied with pale red papules of the size of a pea situated 
 on the forehead , hack and. forearm. A large efflorescence had developed itself 
 on the upper lip cmd between the left nostril and angle of the mouth. On the 
 latter a condylomatous erosion was situated. The lymphatic glands in 
 the left inguinal region were swollen and painful to the touch. We 
 prescribed the sarsaparilla sweat cure. After using it for seven weeks 
 a number of desquamating papules still remained. On this account we 
 used the subcutaneous medication, and after a lapse of eight days, six 
 injections of \ gr. each, of sublimate, produced perfect recovery. 
 
 Case 42. — Louisa M., twenty-one years old, of healthy constitution, 
 but pale complexion, had already, June, 1866, on account of papulous 
 exanthema, undergone a sarsaparilla sweat cure of six weeks duration. 
 Three months afterwards the same appeared again, and similar treat- 
 ment was instituted. 
 
 Returning for the third time, April 20th, 1867, into the Charite, the 
 peculiar condition of the gums and breath aroused my suspicion that 
 she had taken mercury. By inquiry she owned that she had under- 
 gone Dzondi’s cure and had taken about 150 pills. 
 
 Status prsesens : Small erosions on the vaginal opening ; the vaginal 
 portion of the uterus much swollen, especially the posterior part of the 
 os , which was hard and superficially eroded. Tonsils largely swelled 
 and much reddened. In the neighborhood of the glutei there were 
 crusts resembling impetigo. On the body there were numerous papules , 
 particularly on the back , posterior surface of the arms ) forehead and neck . 
 Here they were aggregated into the form of half circles , one and a half inches 
 in diameter. The single efflorescences had the circumference of a lentil up to 
 the size of a pea ) being of a dirty brown hue and destitute of scales. The 
 papules were rather indurated. On the head there was occasionally a small 
 crust. Of the lymphatic glands, the cervical and right axillary and 
 cubital were very hard and greatly swollen. 
 
 To prevent further salivation we gave the patient chlorate of potassa 
 as a gargarism and internally. After all symptoms of ptyalism had 
 disappeared we began the use of hypodermic injections. After the sixth 
 injection of ^ gr. of sublimate each, the vaginal erosions were already 
 gone. Here we had to suspend the subcutaneous treatment on account 
 of symptoms of ptyalism, but resumed it after the lapse of four days, 
 
PAPULOUS EXANTHEMA. 
 
 139 
 
 giving -J- gr. pro die. The papules became more flat and some began to 
 desquamate. After the use hypodermically of 1 J gr. more ) the healing of the 
 papules was complete , and only small spots of a pale brown-red color remained. 
 The disappearance of the glandular swelling had not taken place in the 
 same proportion. 
 
 Case 43. — Augusta Schn., thirty-eight years old, received into the 
 Charite June 27th, 1866. 
 
 Patient says her present disease was discovered only some six weeks 
 ago, for which she had taken twelve sublimate pills and two bottles of 
 medicine, the ingredients of which she was ignorant. 
 
 Status prsesens : On the right labium maj. there was an ulcer of the 
 size of a Mexican dollar, with an indurated base, covered with a fatty 
 pus-like secretion. On the left labium min. there was an ulceration 
 of less extension but of the same character. Pale brown scabs were 
 visible on the right nostril. The skin of the whole body, especially on 
 the back, chest and abdomen, was thickly covered with a maculous exanthem , 
 irregularly scattered about. Some were topped with small scales , others were 
 metamorphosed ' into diminutive papules. On both tonsils and on the seba- 
 ceous glands at the root of the tongue, gray-white condylomatous ero- 
 sions could be seen. The lymphatic glands were much swollen in the 
 inguinal region, but only moderately in the submaxillary. 
 
 The patient was treated at her own request with the u sarsaparilla 
 sweat cure.” During the same, the maculae became more reddened, 
 although some of the spots got paler and still others lead-colored. To 
 our surprise , a lenticular papulous exanthem developed itself on the back and 
 upper arm. 
 
 After four weeks of the above treatment we suspended the same on 
 account of increasing weakness and a tendency to vomiting. After a 
 pause of eight days we observed an important increase of the papulous syphi- 
 loid; besides, we detected that the ulcerations at the labia majora were 
 not much softer, and therefore we determined to try the hypodermic 
 medication. 
 
 On account of the extreme debility of the patient, we injected only 
 
 gr. doses of sublimate, and soon increased to J gr., and then £ gr. 
 After using but 1 gr. the ulcers were cicatrized over and their hardness 
 very much diminished. 
 
 The papules , which were already considerably reduced when | gr. had been 
 usedj were entirely gone when 1 gr. had been administered , without leaving the 
 
140 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 usual pigment colored spots. But to eradicate the remainder of the indu- 
 ration, a further quantity, to the amount of grs. altogether, was 
 necessary. 
 
 • SQUAMOUS EXANTHEM. 
 
 This squamous syphiloid is mostly developed by cellular 
 proliferation from the papules, and on this account we find, 
 besides papules covered with scales, many which have not 
 yet taken on this metamorphosis, and hence diagnosis is 
 more easily made. 
 
 Besides this characteristic polymorphic of the efflores- 
 cences, this syphiloid is always preceded by, or simulta- 
 neously attended with, syphilitic processes in other organs. 
 
 The epidermic scabs in squamous syphiloid are disinte- 
 grated generally from the thicker scabs, as we see them 
 sometimes in genuine psoriasis, by being very thin, yellow, 
 red or shiny white, and appearing as if varnished. Their 
 seat is mostly in the centre of the papules, and seldom in 
 the periphery, having a wreath-like formation. 
 
 In some cases the character of the squamous syphiloid is 
 somewhat clouded — as, for instance, when the epidermic 
 scabs are not seated on the papule, but directly on the adja- 
 cent reddened cuticle, as it occurs in relapses after our sub- 
 cutaneous treatment. The scabs then are thicker and 
 cement-like, resembling psoriasis vulgaris in appearance. 
 The difficulty in diagnosis, under the circumstances, is 
 much lessened, when the locality and configuration of the 
 papules are considered. The size of papules varies between 
 the bulk of a lentil and size of a pea, seldom getting 
 larger. But, by confluence of the small efflorescences, 
 greater formations may be developed. 
 
 The scales of the genuine psoriasis, in opposition to the 
 
SQUAMOUS EXANTHEM. 
 
 141 
 
 syphiloid, very seldom remain in their primary smallness 
 (psoriasis punctata), but gradually acquire the size of a penny 
 (psoriasis numularis), soon assuming, by a central drying 
 process of the scabs, a circle-like formation (psoriasis annu- 
 lata). As characteristic of the squamous syphiloid, as well 
 as of all syphiloids, is polymorphic — i. e ., a simultaneous 
 appearance of more than one species of efflorescences, while 
 the genuine psoriasis has a tendency to variations in the 
 formations of the same efflorescence. 
 
 Among the syphiloids, the squamous shows the greatest 
 inclination for those regions for which the already named 
 papulous evince a predilection. The skin of the head is one 
 of these regions, and this valuable diagnostic singularit 
 predominates here, viz. : that generally the scabs change 
 themselves very easily into crusts, situated on ulcerated 
 bases ; but with psoriasis on the parts of the head covere 
 with hair, crusts do not form, but commonly only thin dirty 
 white gray scabs, and in such an abundance that they 
 strikingly remind us of the picture of the “ Tinea furfura- 
 cea” of the older authors.* 
 
 I used likewise for the squamous -syphiloid subcutaneous 
 injections, without any local treatment, as in the two already 
 described formations, with a generally curative result. In 
 only exceptional cases, when the exanthem was situated on 
 the face, neck or hands, did I use inunction, and then with 
 compounds of oleum cadini with hydrargyrum chloratum 
 mite, having a good result. 
 
 As is well known, the squamous syphiloid, and especially 
 
 • 
 
 * Tinea furfuracea, or Weichselzopf, is a disease met very frequently 
 in Poland, being caused by uncleanliness, and destroying the hair en- 
 tirely, leaving nothing but a mass of scab. In very rare cases the scabs 
 thicken, making a crust two inches thick. — Translator’s Rem. 
 
142 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 that which is called psoriasis palmaris and plantaris, is the 
 most obstinate, always resisting the older anti-syphilitic 
 therapeutics ; but I can assure you that with the subcuta- 
 neous injection, all formations improved gradually, healing 
 being the result in almost every case. 
 
 I have to add here that I do not, like many syphilographs, 
 hold the opinion that psoriasis palmaris and plantaris indi- 
 cate a quick removal, and therefore immediate and energetic 
 treatment. On the contrary, I have learned by my obser- 
 vations, that both of these affections may exist a number of 
 years, without evincing that the syphiloid is nourished by 
 any infection in the blood. 
 
 I allow T myself to give the following two interesting cases, 
 illustrative of my above remarks : 
 
 Case 44. — Carl S., tailor, twenty-six years old; received into the 
 Charite December 7, 1867. The recollection of this unreliable patient 
 failed to give us any sure data. He was of healthy constitution, but of 
 pale appearance. Status prsesens : On the skin of the penis and scrotum 
 and around the anus are broad condylomes ; on the prepuce an inflam- 
 matory phymosis is discernible. The whole surface of the body is 
 covered with an exanthem, which has a maculous, papulous and squa- 
 mous character . The exanthem has reached such an extension that only 
 on the thorax are there small spaces free from it, the remainder of the 
 skin having a spotted appearance. The face is especially noticeable, 
 being thickly flecked with papulous efflorescences. In both ears otor- 
 rhoea is present. On the left nostril are several large, moist papulous 
 efflorescences, almost like broad condylomes ; on the mucous membrane 
 of the nose, erosions ; on the left angle of the mouth, small ulcerations ; 
 and on the anterior roof of the palate, condylomatous ulcerations. On 
 the inside of the hand the syphiloid has the appearance of psoriasis. 
 There is defluvium capillorum jto a slight degree, and the right inguinal 
 glands are swollen to the size of a hazelnut, while the left are as large 
 as a walnut and very hard. The occipital, cervical and axillary glands 
 are swollen, but the cubital are intact. 
 
 We ordered the injection treatment, which, after being used twenty 
 
SQUAMOUS EXANTHEM. 
 
 143 
 
 days, resulted in a cure. We began with £ gr. doses. After using If 
 gr. — i. e., after the sixth injection — the condylomes had only slight ele- 
 vations remaining, a portion of the papules were healed and the scabs 
 on the face had disappeared, with- the exception of the few on the 
 nostril. The psoriasis of both hands was already gone at the fifth in- 
 jection. After the twelfth injection — i. e ., when 2f grs. of sublimate 
 had been used — the broad condylomes were entirely gone ; and so also 
 the exanthem, there only remaining a few pigment spots of a brown 
 coffee color on the nose and chin. After using -J gr. more, all the other 
 affections were destroyed. So that with fourteen injections, making a 
 total of 2f grs. of sublimate, the patient was discharged completely 
 cured. TJie patient for only a few days had a slight stomatitis. 
 
 Case 45. — Albert G., joiner by trade, thirty years old, was received 
 February 22, 1866, into the Charite. The patient says that about six 
 months ago he indulged for the last time in coitus, but some time subse- 
 quently he noticed his present disease. 
 
 Status prsesens : A partially eroded and partially ulcerated sclerosis on 
 the prepuce, nearly transformed into a cartilaginous ring, producing 
 such pressure on the glands that several ulcers are the result. Around 
 the anus and on the shin of the thorax and bach there is an exanthem of a 
 papulous-squamous character. There is light defluvium, and from both 
 ears a serous, pus-like secretion flows, and, according to the patient, 
 only during the last two days. He complains of a deafness, particu- 
 larly in the right ear, which had existed for the last two weeks. The 
 lymphatic glands in the inguinal and cubital regions are as large as a 
 walnut, while the cervical glands are less in size. 
 
 The patient first took a sarsaparilla sweat-cure. After using it six 
 weeks, and there being no material benefit following it, subcutaneous 
 injections were given, in the strength of f gr. per dose. The total of 
 2J grs. of sublimate, given in seventeen injections, was sufficient to es- 
 tablish a cure in three weeks. After the tenth injection (If gr. subli- 
 mate being used), the sclerosis of the prepuce subsided, the phymosis 
 having been previously operated upon. The deafness was also much 
 improved. After the eleventh injection (If gr. sublimate having been 
 used), the papulous efflorescences and a part of the squamous were 
 gone ; and after the last injection, they altogether vanished. 
 
144 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 CONDYLOMATOUS EXANTHEMA. 
 
 Closely connected with the papulous exanthem is a syphi- 
 loid, which in the first phase of its existence, stands on the 
 same histological basis as the lenticular species, but very 
 soon it oversteps the boundary and develops so rapidly that 
 penny and dollar sized efflorescences are formed, which later 
 resemble the broad condylomes on the genitals, and remind 
 one of their typical elementary formation, and therefore we 
 name it condylomatous exanthema . Having reached this 
 state of development, the efflorescences remain, only excep- 
 tionally, in an aggregated state, but they undergo a further 
 metamorphosis. Like all the products originated by syphilis, 
 they break down either spontaneously on their surface into 
 fatty, dirty, mush-like detritus, or change into dirty, brown 
 crusts, especially when the outward circumstances hasten 
 the molecular destruction. 
 
 I have observed in two individuals a further development 
 of syphilis in which ulcerations of the size of a walnut were 
 formed, they being partly destroyed in the above described 
 manner on their surface ; and partly having a glandular ap- 
 pearance, resembling, in consequence, monstrous w^arts. 
 
 Among the records of five hundred patients published in 
 my former work, I find that this condylomatous exanthem 
 occurred with eleven patients. 
 
 6 times with 356 women 
 
 5 “ 144 u 
 
 Concerning the statistics of accompanying symptoms in 
 women , it was present with 
 
 Affection on the genitals : 
 
 ^Condylomata lata, .... 5 times = 1.4 per cent. 
 
 Erosions, . . . . . 1 u = 0.69 “ 
 
CONDYLOMATOUS EXANTHEMA. 
 
 145 
 
 Affection of the skin : 
 
 Exanth. maculosum, 
 
 “ maculo-papulosum, . 
 
 “ squamosum, 
 
 11 maculo-pap-squam, . 
 
 u papulo-squamosum, . 
 
 11 papulo-impetiginosum, 
 
 1 time = 0.69 per cent. 
 ^ cc cc cc 
 
 X cc cc a 
 
 l u n a 
 
 l u cc cc 
 
 l cc cc cc 
 
 Affection of the fauces : 
 
 In all cases of condylomatous granulations, and mostly on the 
 tonsils. 
 
 WITH MEN. 
 
 Affection on genitals : 
 
 Ulcus durum, ..... 
 
 2 times 
 
 == 1.38 
 
 per cent, 
 
 Erosis dura, 
 
 1 “ 
 
 0.69 
 
 cc 
 
 Extensive condylomes, 
 
 2 “ 
 
 1.38 
 
 cc 
 
 Affections on the skin : 
 
 Exanth. maculosum, 
 
 1 time 
 
 c=9 0.69 
 
 cc 
 
 u 11 with purpura, 
 
 1 “ 
 
 cc 
 
 u 
 
 11 papulo-squamoso-lupos. . 
 
 1 “ 
 
 cc 
 
 cc 
 
 11 impetiginosum, . 
 
 1 “ 
 
 cc 
 
 cc 
 
 11 papulo-pustulosum, . 
 
 1 « 
 
 cc 
 
 cc 
 
 Affection of the fauces : 
 
 Broad condylomes with tonsils, 
 
 2 times 
 
 = 1.38 
 
 cc 
 
 The quantity of sublimate necessary for a cure was, on an 
 average, 2J grains. 
 
 To illustrate the different formations of the exanthemata 
 and the efficacy of my treatment, the following cases are 
 selected, of which the second is interesting, on account of the 
 already mentioned large tumors of a condylomatous char- 
 acter, which were formed in such magnitude as I have never 
 elsewhere seen nor found mentioned in medical literature. 
 At the same time the case is an evidence of the assertion 
 made that even with inebriates subcutaneous medication is 
 not contra-indicated. 
 
 13 
 
146 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 Case 46. — John R., coachman, thirty-eight years old, received into 
 the Charite Hospital July 9, 1866. The patient had contracted a hard 
 ulcer on the prepuce in 1865, and was treated for the same with the 
 sarsaparilla sweat cure, in our hospital. The result was not very lasting, 
 for a short time afterwards, he had a relapse of the ulcer. 
 
 He returned into our hospital, July 9, 1866, with the following status 
 prxsens : On the folds of the thighs are quilt-like elevations £ of a line 
 in height and same in width, in the shape of a horseshoe, consisting of 
 confluent condylomatous granulations, covered on the surface with a 
 fatty mush-like secretion. 
 
 On the dorsal surface of the penis were several serpiginous ulcerations, 
 which are partly surrounded by broad superficial eroded condylomes. 
 On the scrotum condylomata lata has a more mixed character shooting 
 out in pointed ulcerations, small bundles from the broad surface. On 
 the forehead we perceive a number of granulated places of the size of a penny, 
 having the above described character of the condylomatous exanthem. In the 
 middle of the forehead they have more of a warty appearance. On the border 
 of the hair they are already ulcer atively destroyed. On the thorax, abdomen 
 and lower extremities purpura-patches of the size of a pin’s head, are 
 scattered, and in the umbilicus is a moist granulated condylome. The 
 inguinal glands are the only lymphatics swollen, being of the size of a 
 walnut. 
 
 After ten injections (ljgr. subl. being used) the condylomatous ex- 
 anthema began to heal. After sixteen injections, the purpura patches 
 disappeared, also the lata on the genitals, bend of the thighs and umbi- 
 licus. The other symptoms disappeared also after the twenty-fourth 
 injection, 3 gr. of sublimate altogether having been used. 
 
 Case 4 1. — August. B., peddler, fifty-eight years old, received into the 
 Charite January 2, 1869. Patient says that seven months before his 
 entering the hospital, he was for the first time syphilitically infected. 
 At this time he noticed, two weeks after his last coitus, a superficial 
 peeling off of the glans which quickly healed with the use of chamo- 
 mile fomentations, without having to consult a physician. He noticed 
 seven weeks afterward scabs and crusts on his scalp, but he used no 
 remedy for them. Status prxsens : Patient has flabby muscles and 
 an oedematous appearance, making the impression of a u hard drinker,” 
 which is confirmed by his own statement, he twice having had delirium 
 tremens. 
 
 The whole back of his head , the skin of the body and lower extremities 
 
ULCEROUS EXANTHEM. 
 
 147 
 
 partly ; and the chin and nose are covered with indented tumors of the hulk of half 
 a walnut. On the back of the head they are so closely together that they form 
 a confluent tumor of the size of a small fist. The smaller tumors are of a pale 
 red color , covered with thin impetiginoid crusts. The somewhat larger tumors 
 have an intact surface of a wart-like glandular appearance. The largest show 
 thick black or brownish crusts , which being removed , an ulcerated surface ap- 
 pears, with pungent pus-like secretions. On the nostrils an ulceration goes 
 deeply into the tissue of the skin. Of other syphilitic affections there is 
 nothing to be seen except swelling of the submaxillary, cervical and 
 occipital glands. 
 
 Without any preparation, sublimate injections were used. Besides 
 a good diet, we ordered small doses of sweet wine, and later a bottle of 
 beer, daily. The patient withstood the deprivation of his accustomed 
 beverage better than we expected, also he bore the injections well. They 
 had a brilliant result. So that after giving twelve injections (J gr. 
 subl. each ) the tumors were lessened to half their size. After further 
 injecting of 2J gr. there was hardly anything left of the tumors. The 
 patient was rather pale, but felt quite well. 
 
 ULCEROUS EXANTHEM. 
 
 To the latter period of lues belong those skin processes 
 which come about by the ulcerative metamorphosis consisting 
 of vesicles and pustules , and which are named ecthyma and 
 rupia syphilitica . Here, during the ulcerative process of 
 the infiltrated cuticle, under the exposed epidermis are formed 
 those ulcers with deep flabby borders, being always repro- 
 duced by a concatenated after-development. This disease 
 resulting from extremely bad nutrition, does not always 
 contraindicate a hypodermic medication with a medicine 
 which has always been reproached, not only with producing 
 an analogous cachexia, but of producing ulcers similar to 
 those described above ; but I can say with satisfaction, that 
 all patients laboring under similar skin affections, and their 
 number has not been very small, have been healed with in- 
 jections of sublimate, and the cure has been effected in a 
 
148 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 relatively short time. Of a stay of months or even years, 
 as I have seen in other hospitals, and as patients have re- 
 lated, was never the case with us. After 'the use of only a 
 few small doses of the sublimate, the characteristic pyrimidal, 
 thick brownish black colored crusts, dried up; generally 
 beginning on the periphery, and soon after healing the mid- 
 dle, since here the crusts were the thicker. At the same 
 time the livid redness disappears, which encircles the infil- 
 trations of the ulcers. It is generally the consequence of a 
 venous stasis which escapes ulcerative destruction and thus 
 hinders the further ulceration of the skin. By lessening 
 the secretion of the ulcerated bases, and the presence of im- 
 paired material, the crusts become dryer, soon consolidate 
 and mostly dry up, leaving only a trifling moist, yet hyper- 
 plasic pale red color. To arrest this cellular proliferation 
 of the granulated tissue is the object of further injection. 
 
 In contrast to that very often rapidly healing process 
 sometimes these ulcerous crusts show a remarkable obstinacy, 
 not only the larger, but sometimes the very diminutive ones. 
 Occasionally reproduction begins in the form of single fresh 
 small pustules. They sometimes deceive the surgeon in their 
 first appearance, he taking them for a mercurial exanthem 
 consequent upon the injection of the sublimate; but very 
 soon they heal, thus showing the groundlessness of his 
 suspicion. 
 
 In the following, I shall present some of the species 
 “ rupia syphilitica” which maybe taken as an evidence, 
 that even this obstinate form of tertiary syphilis gives way 
 quickly to the injection treatment. 
 
 Case 48. — Carl P., shoemaker, 28 years old, of healthy and strong 
 build, but of very pale appearance, was received January 29th into the 
 Charite wards. The following is his deposition: suffered about four 
 
ULCEROUS EXANTHEM. 
 
 149 
 
 years ago with gonorrhoea, which soon disappeared, after using injec- 
 tions. Three months ago, a few weeks after his last coitus, he saw an 
 ulcer on the prepuce. Used for it borax and tar, with fasting. Two or 
 three weeks subsequently, the now existing exanthem made its appear- 
 ance. He dieted himself again, took sulphur internally, and externally 
 used a wash of borax, and later, tar soap : but the eruption did not dis- 
 appear. Some five days ago, hoarseness and weak eyes presented them- 
 selves. Status prsesens : On the prepuce can be felt a large and very 
 hard ulcer of the size of a walnut. The whole body is covered with a 
 polymorphous exanthema, consisting of papulous and squamous efflo- 
 rescences which are intermingled with a greater number of vesicles and 
 pustules. The vesicles are of the size of a lentil and close together in the re- 
 gion of the shoulder-blade and on the abdomen. There are a few on the face 
 and forehead with pustules of the size of a pea. On the left eye a specific 
 iritis in a mild degree has developed itself , which after using atropia showed 
 some adhesions. 
 
 Laryngoscopic inspection revealed redness and swelling of the mu- 
 cous membrane of the vocal cords besides single superficial erosions on 
 the mucosa of the anterior angle of the glottis. 
 
 We used the subcutaneous medication, beginning with -jL gr. doses. 
 The five following doses were about J gr. each, and the last five i gr. 
 each, so, that for complete cure, 3f gr. of sublimate were used. The 
 healing occurred in the following manner: After the fourth injection 
 (about If gr. sublimate being given) part of the vesicles on the back 
 were dried up and another part were metamorphosed into a puriform 
 condition. After the eighth injection the pustulous exanthem dried up 
 in crusts, which pealed off shortly after, leaving only superficial ero- 
 sions of the cuticle, which quickly cicatrized. It was singular that 
 after the described healing of these pustules, others were freshly devel- 
 oped but very soon dried up again. 
 
 After the fourth injection the subjective appearance of the iritis was 
 somewhat bettered, and the dilitation of the pupil was normal, but the 
 vessels of the sub-conjunctiva were so congested that we were compelled 
 to apply eight leeches. There was noticeable no stomatitis until after 
 the fourth injection, which resulted in salivation from the too frequent 
 injections, so that an interruption in the treatment of ten days occurred. 
 The stay of the patient in the hospital consisted altogether of twenty- 
 four days. 
 
 Case 49. — Philip W., farmer, 26 years old, received into the Charite 
 
 13* 
 
150 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 Oct. 26, 1867. He says that six years ago he had a chancre and bubo, 
 for which he used laxatives for quite a time. May, 1866, he contracted 
 chancre again, and was then homoeopathically treated. But in June 
 he noticed an eruption on the skin, for which he first used a sweat cure, 
 and afterwards an inunction cure, taking altogether eight weeks. But 
 seeing that his health did not improve he came to our hospital. 
 
 Status prsesens : On the prepuce there is an indurated cicatrix and a 
 slight erosion. On the surface of the left cheek we see an infiltration of the 
 size ■ of a penny , consisting of small confluent papules. Similar erosions we 
 find on the forehead, but here they are covered with yellow , green , impetiginoid 
 crusts. The skin of the scalp shows a greater number of deep-seated ulcers , 
 which are only partly covered by black , brown , moist crusts. On the right 
 arm there are four elevated red infiltrations , of the size of a penny , which show 
 on their periphery , more especially , thick crust formations. Similar efflores- 
 cences , with a pronounced rupia-like characteristic ulceration , are on the right 
 thigh and lower extremities. The very thin dry hair can be easily pulled 
 out. The lymphatic glands of the right inguinal region are more 
 swelled than the left, and still more tumefied are the right cervical and 
 left submaxillary. 
 
 The injections had the following effects : after the tenth injection, 
 (amounting to 2 gr. of subl.), the erosions on the prepuce and its indu- 
 rations had disappeared ; the crusts on the body and head, were gone, 
 and the slightly elevated places were infiltrated, as evidenced by the 
 touch, but were healed in the middle. After fifteen injections (3 gr. 
 subl. being used), the infiltrations were much softer. After twenty-five in- 
 jections slight stomatitis occurred, but nevertheless, the patient in a few 
 days was sent away cured. 
 
 Case 50. — Johanna S., 29 years old, wife of a cutler, was received 
 into the hospital March 7tli, 1867. Patient says but a very little about 
 her disease. She remembers having sore places on her genitals several 
 times. The present sores she had not particularly noticed. The erup- 
 tion on the skin dates back three months ago, and she states positively 
 that she never used any medication. 
 
 Status prsesens : The patient is very much emaciated, of a pale, dirty, 
 sallow color, cachectic habitus. On the left labium min. there is a 
 superficial erosion. A great part of the surface of the body , especially the 
 back , chest , the upper and lower extremities , are covered with a convolution of 
 vesicles and pustules , grouped together , with here and there papules covered 
 
KNOTTY SYPHILOID. 
 
 151 
 
 with a thin layer of scab. In the right scapular region are rupia crusts of 
 the size of a penny and pyramidal in shape. In removing them, the bleed- 
 ing surface appears deeply ulcerated. On the hand are ulcers covered with 
 crusts which have taken on an impetiginous character. Ulcerations of the 
 size of a Mexican dollar are visible on the lower part of the calf of the left 
 leg , with livid , flabby ) easy bleeding borders , encircled by varicose veins. 
 Between the third and fourth toe on the right foot, there is quite a 
 large ulceration with a fetid smell and covered with a dirty secretion 
 of a condylomatous character. In the left eye there is a well marked 
 iritis with several adhesions of the retina. The left tonsil is partly de- 
 stroyed by ulceration. The mucous membrane of the larynx is red and 
 swollen throughout. In the middle of both vocal cords, gray-white 
 patches are to be seen, produced probably by an ulcerative detritus. 
 The inguinal glands are but slightly swollen, but the cervical are very 
 much enlarged. 
 
 I used subcutaneous injections of sublimate with iodide of potassium 
 for about a week, but left the latter medicine out of the treatment at 
 this time. The first day we injected J gr. of sublimate in one dose in 
 order to combat energetically and quickly the iritis. Already on the 
 next day the gums were very much swollen and easily induced to 
 bleed. The eye was somewhat better. After the second injection of \ 
 gr. of sublimate, the patient complained, not only of the prodromes of 
 salivation, but also of mercurial ulcerations on the mucous membrane 
 of the cheek and borders of the tongue. Chlorate of potassa was used 
 both externally and internally for this, we stopping the treatment for 
 three days. 
 
 The iritis had nearly subsided and only small .adhesions remained 
 on the borders. By the following injections of J'gr. and sometimes J 
 gr. per dose, the above detailed symptoms vanished entirely, so that 
 we used in the whole seventeen injections of 4f gr. of sublimate. In 
 place of the crust-like exanthem intensely brown-colored pigment 
 patches appeared. 
 
 KNOTTY SYPHILOID.* 
 
 I discuss now a syphilitic formation of a disease which is, 
 especially in a morphological sense, of the greatest import- 
 ance, because a question has to be decided here, which in 
 
 * Knoten Syphilid. 
 
152 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 spite of our best authors on anatomy and dermatology, is 
 yet an object of a very spirited controversy — I mean the 
 lupus syphiliticus . 
 
 Among these authors there are some which go so far as to 
 assert that, between lupus and syphilis acquisita, all and 
 every feature is radically different. 
 
 They particularly assert “ that sufficient signs are wanting 
 by which the variety, lupus syphiliticus, can be distinguished 
 from lupus idiopathicus. In none of the cases of lupus, 
 they say, in which an autopsy was made, was a combination 
 with syphilitic affections of internal and external organs 
 distinctly found. The very slow progress of the lupus, 
 sometimes existing for years ; the limited seat of the same 
 in most cases ; the entire painlessness ; the small participa- 
 tion of the nutritive functions ; the absence of cachexia and 
 all swelling of the lymphatic glands ; the want of regularity ; 
 and lastly the smallness of the knots, compared with their 
 relatively long duration, and the non-appearance of the 
 caseous metamorphosis incident to gummy tumors ; all 
 certainly speak most emphatically against their identity. 
 Besides, very many defenders of the syphilitic nature of the 
 lupi, themselves acknowledge the anti-syphilitic treatment 
 without any result.” 
 
 I am induced by these remarks to make the following 
 observations : — 
 
 1. I first have to point out the fact that between the spe- 
 cific and idiopathic eruptions of the skin — as, for instance, 
 between the syphilitic macula and the ordinary — no histo- 
 logical difference till now has been discriminated. And so 
 it is between the small knots of the lupus idiopathicus and 
 those of the knotty syphiloid. No histological difference 
 
KNOTTY SYPHILOID. 
 
 153 
 
 has been found in them, both formations belonging to what 
 Virchow calls “ granulation tissue.” 
 
 2. As to the assertion that in no case of lupus, where 
 autopsy was performed, were other known syphilitic diseases 
 of internal organs found ; I must say that my clinical mate- 
 rial provided me with several cases in which, without doubt, 
 syphilitic affections, as rupia, tophi, ulcerations in the cavity 
 of the mouth, have been combined with lupus affection of 
 the skin. I have seen during the last four years about 
 twenty such cases, and at present I have in my wards three 
 remaining patients of this kind. I took occasion to present 
 one of them to several colleagues. 
 
 3. The chronological proportion is also in favor of our 
 view. Specific lupus never occurs in the beginning of the 
 syphilitic disease, where it might be taken as a coincidence, 
 but it always appears as the last link, in the latest phases 
 of the development of constitutional syphilis, being preceded 
 by a number of more or less severe processes, as maculo- 
 papulous syphiloid, iritis, rupia, sarcocele syphilitica, and 
 especially syphilitic affections of the bone. 
 
 4. Concerning the specific alterations of the lymphatic 
 glands not seen by some authors, I, on the contrary, can 
 point out clearly, in several cases, enlargements and indura- 
 tions ; and further I have to remark that often in the latter 
 stages of syphilis, the lymphatic glands are not only reduced 
 to their normal size, but even, in consequence of atrophy, 
 are hardly to be found, being below the normal size, as 
 Virchow has shown it to be, in a similar way, with the seba- 
 ceous glands of the tongue. 
 
 5. As to the assertion that anti- syphilitic treatment has 
 been of no avail against lupus syphiliticus, I will say in 
 opposition to it, that some of our medical literature mentions 
 
154 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 such cases, and besides, the subcutaneous injection method 
 which I instituted with a number of cases (from twenty to 
 twenty-four) in our hospital has never failed. 
 
 6. The assertion that the small participation of the nutri- 
 tive functions and the want of all cachectic symptoms, speak 
 against the syphilitic nature of lupus, is modified in two 
 ways by my experience. On the one hand, a great number 
 of patients, who are suffering under very active processes of 
 syphilis, seated on circumscribed localities, enjoy relatively 
 good health and appearance ; on the other hand, a part of 
 my patients affected with lupus syphiliticus show sufficient 
 symptoms of a deep-going cachexia. 
 
 7. It is granted that lupus idiopathicus has its seat in the 
 face mostly, just as lupus syphiliticus has its seat generally 
 on the back and extremities. But not only are cases known 
 and referred to by different authors where lupus appeared 
 not only in the face but also on the extremities, and I, 
 myself, and several other observers have had occasion to see 
 lupus syphiliticus seated on the face, where it generally does 
 not appear, and on the nose, forehead and cheeks. 
 
 8. I will not make any remark on the “ painlessness’ ’ 
 since a great number of syphilitically affected cases often 
 run a painless course. 
 
 9. Concerning the last point, that the syphilitic knotty 
 exanthema never enters into a caseous metamorphosis, as is 
 the case with lupus idiopathicus, this circumstance alone 
 will speak for it. As in all other exanthemata, we must 
 take a special species of lupus syphiloid, which must be 
 distinguished from idiopathic lupus. 
 
 From a number of nearly twenty cases lying before me, I 
 take the following case of lupus syphiliticus, which was so 
 typical in its total impression and its single appearance, and 
 
KNOTTY SYPHILOID. 
 
 155 
 
 was such a striking example of the disease, that I introduced 
 the patient to Professor Virchow's notice. 
 
 Case 51. — Wilhelm K., a stone mason, thirty years old, originated 
 from a family in which a dyscrasic habitus, especially tuberculous and 
 lupus, has never been noticed.. Married six years ago, but has had no 
 children, his wife being reported in good health. He was till that time 
 healthy and robust, but became sick for the first time in the year 1858, 
 with a glandular abscess on the left side of the neck. There yet can be 
 seen, above the insertion of the musculus sterno-cleido-mastoideus on 
 the sternum, a cicatrix of a star-like form. Eight years ago the patient 
 contracted a chancre on the penis, which, after a local treatment and 
 internal medication with pills, probably containing mercury, seemed to 
 heal after about four weeks. But a year later, already, ulcers in the 
 pharynx made their appearance, which, as reported, have been rather 
 deep-seated, and for which a long sarsaparilla sweat cure was ordered. 
 This had a result lasting only about a year, so that a repetition of the 
 treatment was necessary. The ulcers now present on the face, on the 
 scalp, and especially on the nose, appeared, as the patient said, in 1864, 
 for which, in our hospital, iodide of potassium and sulphur baths were 
 ordered, with good effect. But the healing was not complete and did 
 not last very long, the present diseased condition gradually coming on. 
 
 Status proesens , December 21st, 1868 : Patient has flabby muscles, 
 pale complexion, and very dry skin ; face very much disfigured by cicatriza- 
 tions and deep loss of substance . The scars extend partly over the cheeks , 
 chin and forehead , having a more or less rounded , oblong formation . The 
 roundness of the cicatrix shows a clearly defined atrophy of the cuticle , having 
 the character which is generally manifested by the cicatrized ulcers developed 
 by ulcerative , broken-down knotty lupus. The long cicatrices have a star-like , 
 bluish-white appearance. 
 
 The left eyelids, already retracted in their tissue by the great cicatrices, 
 are greatly swollen and firmly stretched over the eye, so that the latter 
 was neither completely shut nor widely open. By such a state of lag- 
 opthalmus, the cornea is obscured, and exudations are going on that 
 have nearly impaired the vision of this eye. On the nose the cartilages 
 of the nostrils are destroyed , more extensively on the left side. The point and 
 top of the nose and a greater part of the septum narium are wanting , from the 
 effect of a deeply-eating ulcer , it being nearly two inches long and one ahd a 
 half inches wide , having the characteristic appearance of idiopathic lupus. It 
 
156 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 extends down to the upper lip, of which a part is ulcerated away. The 
 remaining part of the upper lip is very much infiltrated, like lupus 
 hypertrophicus, showing the well-known livid-red color. On the scalp 
 in the vicinity of the parting of the hair, are crustous ulcerations 
 covered with amber-colored horny excrescences, and partially with 
 red-brown crusts as they appear in ecthyma and rupia. Both tibiae 
 have on their surfaces large hyperostoses, causing, nights especially, 
 severe boring pains. 
 
 The left testicle is of the size and form of a large pear, hard to the 
 touch, showing in the middle and on the border of the epididymis a 
 knotty circumscribed induration, which was glued anteriorly to the 
 inflamed, red, swollen and painful testicles. In the cavity of the mouth 
 a total destruction of the left tonsil and the anterior roof of the palate 
 is visible, in which region is stretched a small, ribbon-like, red strip of 
 mucous membrane, extending from the uvula to the side wall of the 
 pharynx. The right tonsil and uvula are intact. The lymphatic glands, 
 especially in the cubital regions, are slightly swollen. 
 
 The patient is, on account of his previously described condition and 
 the last preceding treatment, in a very weak state. Objections could 
 consistently be raised against a common mercurial treatment ; never- 
 theless, we began with him the injection cure immediately, with which 
 the strength of the patient gradually improved and the detailed symp- 
 toms lessened. 
 
 The dolores osteocopi (pain in the bones) was the first to leave him, 
 and consequently, by ability to get his rest at night, the patient gained 
 strength. The swelling on the left scrotum, together with the inflam- 
 mation and pain, already had subsided, after the use of J gr. of subli- 
 mate ; as also had the consistency of the scrotum likewise diminished. 
 The ulcers of the face became cleaner and cicatrized from the periphery 
 towards the centre; so that, after the further injection of 2J grs. of 
 sublimate, they were reduced to nearly half their original size. 
 
 Ulcerations on the nose and lips were cured after using 4 grs. of sub- 
 limate. The thick ulcers on the scalp showed the greatest resistance, 
 and they were healed only after the use of grs. of sublimate. The 
 cure then could be looked upon as complete, but still we used 1 gr. 
 more. The duration of our treatment, with the frequent interruptions 
 on account of salivation, lasted three and a half months. 
 
 As in the above described case, the following showed a 
 
KNOTTY SYPHILOID. 
 
 157 
 
 still more brilliant result of the subcutaneous method. In 
 spite of all kinds of medication during a ten months’ sick- 
 ness, syphilis could not be stayed in its ravages. Not only 
 was the patient emaciated to a skeleton almost, by the ulcers 
 covering so much of the surface of the body, death was also 
 almost unavoidable, on account of the fact that the syphilitic 
 process had drawn the kidneys into complication. 
 
 Case 52. — Augusta Fiehl, twenty years old, of quite a healthy con- 
 stitution, without any hereditary disposition to constitutional affec- 
 tions, had, at the time of her admission into the Charite, January 23, 
 1865, very hard erosions on the labia majora, accompanied, shortly 
 afterwards, with broad condylomes on the labia minora and majora, 
 plicae femorales and tonsils. The patient used then a sarsaparilla sweat- 
 cure, without staying the progress of the lues. On the contrary, after 
 the course of a week, roseola patches were formed — in the beginning, 
 only on the thorax and upper extremities ; later, in other different 
 regions. Besides, a papulous syphiloid was also formed, whose efflor- 
 escences were very soon developed on their points into small scales. 
 
 Not very long after, fever set in, with a temperature of the body of 39° 
 Cel., and with a frequency of the pulse reaching 100 per minute; and several 
 vesicles were formed, some soon becoming pustules, and some forming into 
 vesicles like those in pemphigus. The former of these were situated more 
 particularly in the bend of the lower and upper extremities, especially 
 in the fossa cubitalis and poplitea ; the latter were mostly on the ante- 
 rior part of the neck. Very suddenly pain appeared in the right eye, 
 extending to the depth of the orbit, and of a boring character. Intense 
 iritis, with great photophobia and flowing of tears, followed. By an en- 
 ergetically instituted antiphlogistic treatment, consisting of inunction 
 of unguentum hydrag., with opium, atropine, leeches, &c., the iritis of 
 the right eye disappeared, but shortly afterwards the same iritic process 
 was developed in the left eye, which required a still more energetic use of 
 the same antiphlogistic treatment for effecting a cure. 
 
 During this intercurrent episode with the eye, pustulous efflorescences 
 of the skin began to be very prolifically developed, increasing in size on ac- 
 count of confluency and destruction of the infiltrated ulcerations. The 
 always deeper-going ulcerations did reach not only the subcutaneous cellular 
 tissue, but even the fascia and muscles were reached and drawn into complied - 
 14 
 
158 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 tion. Especially was this the case in the region of the os sacrum and 
 the extremities. The ulceration on the os sacrum was particularly distin- 
 guished by its large circumference , it being six inches long and three inches 
 wide. Here the underlying bone could be plainly felt with the probe. A 
 smaller, more round-shaped, but as deeply-going ulceration was situ- 
 ated on the calf of the right leg, and the periosteum of the tibia could 
 be clearly seen in a circumscribed place. 
 
 To combat the above detailed condition, we used very many medica- 
 tions for months without any results. Besides the repetition of the 
 already mentioned sarsaparilla sweat-cure, which lasted for a few 
 weeks, inunction and different baths and ingredients in the same were 
 used. Later, sublimate baths and the wet sheet were employed, accord- 
 ing to Priesnitz. Internally we used iodide of potassium ; and lastly, 
 solutio arsenicalis Fowleri. 
 
 During the treatment, we used, for strengthening the system, quinine, 
 iodized iron, and later, cod-liver oil. 
 
 With this treatment, the patient was emaciated to almost a skeleton, 
 in the course of nine months. In this cachectic state I found her when I 
 tried for the first time on her my injection treatment. She was so weak 
 that she was compelled to keep in bed continually, not being able to 
 raise herself for a precise examination into her condition. In order to 
 see the skin affections, during my clinical lecture, I was obliged to have 
 assistants raise her from side to side. The ulcerations secreted a 
 profuse, pungent, purulent matter. On the face there was a lupus-like 
 syphiloid. On the arms , layers , in pyramidal formations , placed over each 
 other , could be seen ) which were composed of thick crusts of dark brown choc- 
 olate-colored appearance , under which purulent ulcers were situated. 
 
 TJrine was very albuminous — its specific gravity , straw color , all 
 pointing to severe renal disease. 
 
 Prognosis, under such circumstances, could but be very unfavorable ; 
 because all sorts of treatment had proved of no avail. The weakness 
 of the patient and the impending kidney affection were a contra-indication 
 to every new energetic treatment. 
 
 But, notwithstanding all that, I concluded to use with this patient 
 injections of sublimate, on account of the old adage u Melius anceps 
 remedium ) quam nullum in casibus desperatisT Because of the great pros- 
 tration, I began the treatment cautiously, with very small doses ; and 
 seeing no bad symptoms arise, but, on the contrary, a very slight and 
 hardly perceptible improvement, I began to give larger doses. 
 
GUMMATA OF THE CELLULAR TISSUE. 
 
 159 
 
 The great difficulty with the injection was, that the whole body was 
 so covered with broad and deep ulcerations that I had but very little 
 space of sound and healthy skin where I could make my punctures. 
 Another difficulty I found in the dislike of the patient, who refused, and 
 seemingly with a perfect justice, to undergo anew a painful treatment, 
 since all our endeavors had failed in restoring her health. But by and 
 by the feeling of the patient gave way to a better spirit, on account of 
 the improvement in her disease. 
 
 The result was indeed for me, and for all who witnessed it, a striking 
 one. I used about one hundred and fifty injections, amounting to a 
 total of about 15 grs. of sublimate, and the method being quite new 
 then, the case made considerable propaganda for the subcutaneous 
 treatment. A large circle of my pupils followed the case with apparent 
 interest, seeing how changed the patient became. She finally could be 
 discharged entirely cured , having quite a healthy countenance , herself being 
 astonished at the result. 
 
 , After a year, A. F. returned again, for a short time, to the Charite, 
 on account of some small ulcers, which appeared on the right forearm. 
 They quickly vanished with the administration of a few injections, and 
 the very healthy and almost blooming appearance of the patient was 
 really wonderful to us, who had seen her in her ghastly and emaciated 
 condition. 
 
 GUMMATA OF THE SUBCUTANEOUS CELLULAR TISSUE. 
 
 We may consider, very properly, those gummata which 
 develop themselves in the deeper cellular tissue , as a differ- 
 ent species from the above-described knotty syphiloid. They 
 are distinguished from them first especially by their greater 
 size, which comes about chiefly on account of their situation 
 in the subcutaneous cellular tissue, where they find in the 
 net-like texture more room for development than the lupous 
 knots which are imbedded in tense, unyielding layers of 
 cuticle. 
 
 Generally these gummous formations first commence 
 during the latest phase of lues, and mostly as final links of 
 the syphilitic dyscrasia. But contrary to this general obser- 
 
160 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 vation, I observed this appearance in two cases rather 
 sooner. 
 
 In one of these cases, which might properly be called 
 “ galloping syphilis,” this affection appeared almost as a 
 first symptom of relapsing syphilis, and accompanied mostly 
 with orchitis gummosa and rupia. In both cases, as also in 
 those patients where no ulcerative metamorphosis in the 
 gummous granulated tumor has taken place, I succeeded in 
 complete resorption by the subcutaneous treatment, so that 
 neither a scar nor depression of the skin remained, and not 
 even a discoloration showed the former seat of these so obsti- 
 nate tumors. 
 
 The first result was mostly visible in the lessened cir- 
 cumference of the ulcers, the consistency of them seemingly 
 increasing in hardness , but time alone will overcome that, 
 and complete restoration crowns the work. It may be ex- 
 plained thus : that with resorption, the softer contents of the 
 ulcer began to heal, and only later is it the case with the 
 peripheric surroundings which have a more or less sclerotic 
 taint. 
 
 It was singular to notice that the nearer lymphatics became 
 irritated and inflamed , being enlarged , reddened and painful 
 to the touch . It may be possible that, absorption in the 
 lessened gummy tumor carries along the detritus, and this 
 may be the cause of the irritative symptoms in the lymphatics. 
 
 But not always were the gummata in patients in a yet in- 
 tact state. Very often they presented thin open ulcers , 
 tvhich sprung from an ulcerative metamorphosis . 
 
 The ulcerative process may here be traced in most cases 
 to a mechanical origin, and it seems to be induced and 
 favored by the neighborhood of bones, especially epiphyses, 
 narrow folds of skin, &c., which may be easily irritated. As 
 
GUMMATA OF THE CELLULAR TISSUE. 
 
 161 
 
 in diseases of the larynx and pharynx, we must here also 
 be careful not to force the injection or prolong it. On the 
 contrary, it is necessary to institute here a surgical treat- 
 ment. 
 
 The quantity of sublimate necessary for the described 
 gummous tumor is generally very large. In lupous ulcer 
 sometimes 3 gr. were sufficient, but in the gummata from 6 
 gr. to 10 gr. of sublimate on the average were needed, but 
 cases occur in which even this amount must be increased. 
 
 Case 53. — Max. L., twenty-two years old, a cigar maker, was received 
 into the Charite Hospital October 9, 1868. Patient says he is of a healthy 
 family, and, with the exception of the ordinary diseases of childhood, 
 he was well up to his thirteenth year. In the following year he suffered 
 considerably with glandular swellings in the neck, which disappeared 
 with the use of cod liver oil. 
 
 The patient was infected eleven months ago with chancre, in London, 
 which seemed so insignificant that he consulted no doctor. Only five 
 months ago his present ailment began, but medical aid was of no avail. 
 The medication was a botanic one, as the attending physician did not think 
 it justifiable to use any mercurial preparation , on account of the ulcerative 
 character of the rupia which seemed to spread rapidly . But on the contrary, 
 as the ulcers enlarged more and more, healing of them was despaired 
 of, and his physicians advised him to leave England, and go back to Ger- 
 many, partly on account of the climatic change which might bring 
 about a better state of things. 
 
 Status prsesens: Patient is very much emaciated, of pale complexion, 
 blonde hair, cachetic appearance, and of a very delicate constitution. 
 I found him lying in bed at my first visit, he being unable to move, on 
 account of the great pain induced. Examination revealed rupia crusts 
 on both fore arms, on the forehead , the scalp , on the back and lower extremities , 
 of the size of a penny up to the size of a silver dollar. Beneath the thick brown 
 crusts , deep seated ulcerations are to be seen covered over with pus. On both 
 tibise we find diffuse, painful, gummous swellings, having an elastic consistency. 
 Similar swellings are on the left clavicle , especially at the acromial end. On 
 the left of the scrotum we can feel small tumors , but on account of too great 
 sensitiveness they cannot be plainly made out. After a few days , examination 
 
 14* 
 
162 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 showed that there are gummous tumors there of the size of a hazelnut . In the 
 subcutaneous tissue of the right sternal region in the vicinity of the nipple , and 
 on the left elbow , a little above the olecranon , painful , gummous ulcers are 
 found of the same size as above . The lymphatic glands in the submaxil- 
 lary region are not swollen, but in the cervical and inguinal they are 
 somewhat enlarged. Patient complains very much of acute pains in 
 the tibial regions during the night, and of an inability to move without 
 experiencing great suffering. On the inner lamella of the prepuce there 
 is a cicatrized place of the size of a pea, being devoid of pigment dis- 
 coloration. It is not at all hard to the touch, and according to the 
 patient, it is the seat of the original chancre. 
 
 On account of the great debility of the patient, I used only on alter- 
 nate days the subcutaneous injection in -J- gr. doses. This being well 
 borne, and the dolores nocturni also abating, we injected the same dose 
 of sublimate daily. Very shortly afterwards the ulcers were reduced in 
 size and depth. The prodromes of salivation appearing, we were com- 
 pelled to interrupt the treatment. After the twenty-first injection, the 
 patient complained of a cough, produced by a cold, and on account of 
 a lung complication we again suspended the injection for awhile. After 
 a treatment of three months with a few interruptions on account of 
 stomatitis, 6 gr. of sublimate having been used, the result was very 
 satisfactory on the described affections, besides the gummy tumors had 
 vanished. In the place of the rupia ulcers, cicatrices were visible on 
 the skin, of a livid color, a red quilted appearance with a cancroid 
 character. Patient gained so visibly and assumed such a healthy 
 countenance, that my clinical pupils were astonished to see so marked 
 a change. 
 
 About six weeks after his discharge from our hospital, he returned 
 again on account of ulcerations appearing. Examination of the patient 
 showed that several of the above described cancroid cicatrices were super- 
 ficially ulcerated and broken down , chiefly on the back and right shoulder. But 
 we were surprised to find gummata of the size of a hazelnut , situated about 
 three or four inches below the axilla , and on the anterior wall of the thorax , 
 one and a half inches beneath the right mamma. Aside from this, there was 
 nothing abnormal in the patient. We instituted the injections again, 
 beginning with £ gr. doses of sublimate per day, soon increasing to J gr. 
 doses. 
 
 The ulcers had already healed when 2 gr. of sublimate had been 
 used, but the gummata disappeared much more slowly. The glands around 
 
GUMMATA OF THE CELLULAR TISSUE. 
 
 163 
 
 the axilla on this same side , and later the glands about the nipple were much 
 swollen and painful to the touch. In addition to this, a bubo of the size 
 of a hen’s egg, made its appearance. We used for that gray mercurial 
 ointment, but without avail. Neither had the internal use of iodide of 
 potassium any Result. We began again, on this account, the sublimate 
 injections, and produced an entire healing of the gummata, but only a 
 trifling diminution of the lymphatic glands. But the sensitiveness of 
 the patient increased after the amount of 3 gr. sublimate had been used, 
 and we had to pause. These injections did no good ; the swellings 
 seemingly having no connection with syphilis. Therefore, I concluded 
 to use inunctions of iodide of potassium, which proved to be just the 
 remedy. 
 
 The now following case seems to have a double interest, 
 therapeutically and pathologically considered. It is of a 
 pathological interest, inasmuch as a number of intact gum- 
 mata occurred, and a gummy tumor already gone into a 
 deep ulceration, had involved the epiphysis of the bones, 
 while, as a general rule, they are situated on the diaphysis. 
 
 Therapeutically it is interesting, because here we see iodide 
 of potassium quickly healing a syphilitic ulcer on the pos- 
 terior wall of the cavity of the mouth, but after a year, a 
 relapse has already occurred that has developed dangerous 
 symptoms, and yet the case is fully cured by injections of 
 sublimate. 
 
 Case 54. — Augusta W., twenty-four years old, married, was received 
 into our hospital October 26, lSGT. The data remembered by the pa- 
 tient are rather meagre. She originated from sound parents, and says 
 that, with the exception of a slight inflammation of the eyes, she has 
 always been healthy, and denies that she ever had any disease on her 
 sexual organs. 
 
 Status prsesens : Patient of weak constitution, flabby muscles, gracile 
 habitus, and of very pale complexion. On the posterior part of the 
 cavity of the mouth there is an ulcer of the size of a large penny, 
 reaching deeply into the tissue and having very sharp borders. The 
 soft palate is mostly, and the uvula is entirely destroyed. 
 
164 
 
 SYPHILITIC SKIN AFFECTIONS. 
 
 We used daily for the patient about 50 gr. of iodide of potassium. 
 On account of so great a debility we prescribed also a weak decoction 
 of cinchona rubrum. The local treatment consisted of gargarism of 
 chlorate of potassa and painting the ulcerated surface with nitrate of 
 silver. Under this treatment the ulcers cicatrized o’ter, so that the 
 patient could be discharged at the end of the sixth week. 
 
 That the iodide of potassium treatment was only a palliative one was 
 shown by the return of the patient in about one year. The status prse- 
 sens then was as follows : The described ulcer in the pharynx remained 
 cicatrized, but the epiglottis was so much ulcerated that only a small 
 portion of it remained. The condylus externus and internus of the right 
 elbow was swollen and painful to the touch . On the external condyle there 
 could be plainly felt an enlargement of the size of a large penny. It was 
 distinctly circumscribed from the surroundings. The tumor was characterized 
 by its elastic and somewhat fluctuating consistence as a gummous formation. 
 On the clavicle and very close to the extremitas acromialis , there was situated 
 an ulcer two inches in diameter , which reached to the non-necrosed bone , 
 exposing two-thirds of an inch in length and one inch in breadth. It secreted 
 a thin pus , and was without doubt developed from the ulcerative destruction 
 of a gummy knot. Beneath the right patella there was a tumor , two inches 
 in length 1 which showed a division in its middle. Its consistence was still 
 more dense than the above described gummata . 
 
 We immediately began the injection treatment and prescribed for the 
 ulcer on the clavicle, irrigation with cold water by means of the atom- 
 izer, as already pointed out. Under this treatment the tumor under the 
 patella was the first to subside, so that after the use of lj gr. of subli- 
 mate it was entirely gone. The remaining required rather more ener- 
 getic doses. 
 
 The ulcer on the clavicle then diminished rapidly, granulation taking 
 place, so that the patient, after using 4 gr. altogether, during a stay of 
 five weeks, could be discharged as cured November 18th, 1868. 
 
 VII. SYPHILITIC AFFECTION OF THE EYE. 
 
 Syphilitic affection of the eye is an important disease. 
 It sometimes appears isochronal, with the earliest manifesta- 
 tions of syphilis on the skin ; sometimes it accompanies lues 
 
SYPHILITIC AFFECTION OF THE EYE. 
 
 165 
 
 in its tardy appearance, and sometimes, even, the disease of 
 the iris is the only syphilitic trace in the relapse. 
 
 The really syphilitic iritis is very difficult to discriminate. 
 Generally there is more or less injection of the conjunctival 
 and of the sub-conjunctival vessels which surround the 
 cornea ; there is opacity of the iris ; spotted appearance of 
 the same produced by sub-serous inflammatory action ; ad- 
 hesion of the pupils to the crystalline lens, resulting from 
 exudation ; and further, there are the subjective symptoms, 
 viz. : the intolerance of light and deep-boring pains of the 
 orbita shobting along the course of the supra- and infra- 
 orbital nerves; lachrymation and the lessening of vision. 
 Sometimes there are small tumors of the size of a mustard- 
 seed up to the size of a kernel of wheat, of a yellowish-red 
 color. These are generally situated in the middle of the 
 tissue of the iris, sometimes starting from the central border 
 and reaching into the aqueous humor. These tumors have 
 been considered by some authors as condylomes, by others 
 as gummata, and they are characteristic of the syphilitic 
 nature of the iritis. 
 
 The plan of treatment adopted by us for syphilitic iritis, 
 consisted in an energetic injection of sublimate adapted to 
 the case in question. When inflammation was very intense ; 
 exacerbations of fever at night ; penetrating pain not only 
 in the eye but also in the supra-orbital region ; increased 
 lachrymation with great intolerance of light; when there 
 was high graded opacity of the iris ; reddish appearances of 
 the same on account of sub-serous exudation, so that the 
 development of gummata was imminent, &c. ; then I began 
 immediately to inject ^ gr. of sublimate, repeating the 
 injection, according to the intensity of the iritis and the 
 individuality of the patient, so that sometimes already on 
 
166 
 
 SYPHILITIC AFFECTION OF THE EYE. 
 
 the first day § gr., and in one case even 1 gr., was injected. 
 The result was, in every case, very good, so that we had 
 relatively a quick and complete cure — in lighter cases 
 already after 1J gr., in harder cases after 5 or 6 gr. 
 
 The last-mentioned dose was particularly necessary with 
 three patients, in whom these characteristics in the iris were 
 formed. 
 
 Besides this general treatment, we used locally a weak 
 solution of atropia. Only in exceptional cases did we apply 
 leeches to the temporal regions. 
 
 It is remarkable that during and towards the end of a 
 subcutaneous treatment , used for something quite different , 
 an iritis may develop itself suddenly . This reminds us of 
 the already mentioned appearance of suddenly developed 
 broad condylomes on the pharynx. Such cases seem not to 
 be published in medical literature, and I shall relate some 
 of them by and by. 
 
 Concerning the prevalence of the iritis, I have a record 
 of twenty-five cases which came under my observation 
 during four years. In eighteen cases which were carefully 
 recorded I find the following complications were present : — 
 
 Broad condylomes on the genitals and surroundings, 7 times. 
 Superficial erosions at the same place, ... 6 u 
 
 Uulcus durum on the penis, 1 11 
 
 Condylomatous ulcers between the toes, . 1 “ 
 
 Maculous syphiloid, . . . . . . . 4 u 
 
 Squamous 11 4 11 
 
 Papuloso-vesicul. syphiloid, 2 “ 
 
 Pustulous “ 2 “ 
 
 Papuloso-pustulous 11 ..... 3 “ 
 
 Gummy knots on the scrotum, .... 1 11 
 
 Tophi of the tibia, I 11 
 
 In three patients every syphilitic complication was wanting. 
 
SYPHILITIC AFFECTION OF THE EYE. 
 
 167 
 
 In the following three cases, I give the first as an 
 example of an often-recurring relapse of an iritis produced 
 by syphilis, during a period of twenty-four years. The other 
 two cases are illustrations where condylomatous iritis was 
 quickly and thoroughly eradicated by injections of sub- 
 limate. 
 
 Case 55. — K., a merchant, forty-six years old, contracted in the year 
 1844 a hard chancre, and he underwent a long treatment, the details of 
 which he cannot remember. It was seemingly healed, but he had an 
 inflammation of the eye the year following, which was examined by 
 several oculists and pronounced syphilitic. In spite of all treatment 
 the iritis made its appearance every year until the year 1860, i. e. fifteen 
 times. The treatment each time required several months. The last 
 treatment he received from Dr. Koblanck, which was a mercurial one, 
 being very energetic and followed by a good result, since then there 
 has been no reappearance of iritis for seven years. In October, 1868, 
 the patient was again attacked, and sent to me by the above-named 
 gentleman. 
 
 Patient is somewhat weak and cachetic. The iritis is characterized neither 
 hy subjective nor objective syphilitic symptoms , but by great conjunctival and 
 sub -conjunctival injection , paleness of the iris, and dead appearance of the 
 pupil, which is polygonally stretched. Vision is very much impaired, and at 
 a distance of four feet it is nearly impossible for the patient to discern anything. 
 He complains of a fixed boring pain in the orbita and supra-orbital region. 
 
 I injected J gr. of sublimate in the back and 2 V g r * in the temporal 
 region, and the above symptoms quickly disappeared. The further use 
 of \ gr. lessened the inflammation, but produced toxical symptoms, as 
 active diarrhoea, abdominal pain, nausea, great prostration, &c., so that 
 we had to suspend injections for two days. We used after this f gr. of 
 sublimate in the next four days, which caused the inflammation to sub- 
 side so rapidly, that the patient thought himself well and he resumed 
 his work. But he caught cold, and the iritis got worse. On that 
 account I began again the injections, giving J gr. doses, and in the 
 course of ten days I succeeded in overcoming the affection of the eye. 
 In order to guard against further relapses, I injected 2 gr. more of the 
 sublimate. But whether we accomplished a radical cure or not the 
 future will show. It was noticeable that the patient, in spite of the 
 
168 
 
 SYPHILITIC AFFECTION OF THE EYE. 
 
 cold and stormy weather, attended his usual avocation without danger 
 and risk. 
 
 Case 56. — Louisa H., 22 years old, was received April 1, 1869, into 
 the Charite, and showed the following syphilitic affections : condylo- 
 matous erosions at the labia majora and minora ; pigment-colored ex- 
 anthem on the trunk, and iritis condylomatosa sinistra. The characteris- 
 tic appearances of the inflammation of the retina were the following: 
 great injection of the conjunctival and sub -conjunctival vessels , narrow and 
 stretched pupil, and small excrescences of angular appearance and yellow- 
 ish-brown color in the region of the pupil. In the upper segment of the iris , 
 we can see a prolific granulation of the size of a kernel of wheat , which rises 
 button-like over the tissue of the iris. 
 
 I used J gr. of subl. on the back and 2 V gr. in the temporal region by 
 subcutaneous injection, and I applied atrophia to the eye. Examina- 
 tion with the optlialmoscope revealed an irregular enlargement of the 
 pupil. There were especially two places glued together on the inside 
 border of the pupil, one below and inside, and the other above and outside. 
 
 In consequence of these adhesions the pupil looked like a figure 8. 
 On the whole inner border of the iris we see now plainly white-yellowish 
 exudation-plaques which overlap the pupil, in an angular and thread- 
 like manner. The yellowish prolific granulation on the outside free 
 borders of the iris is plainly visible over the tissue of the iris. 
 
 In the following three days we again used daily J gr. of subl., and 
 thereby produced strong salivation. The examination made April 6th, 
 showed that the condylomatous prolific granulations on the iris were 
 reduced to half their former size, and the other symptoms were much 
 improved. The pains in the orbita and the intolerance of light, had all 
 disappeared. Vision was better. Notwithstanding the existing saliva- 
 tion we again used J gr. of sublimate. The consequence of this forced 
 injection was that the adhesions were completely broken up. The iris 
 showed a normal lustre, and of the condylomes no trace could be 
 found. 
 
 To completely heal this case of condylomatous iritis 1J gr. of subli- 
 mate were sufficient. 
 
 Case 57. — Henrietta B., 29 years old, of weak and somewhat ansemic 
 appearance, and mother of a healthy child 2J years old, was already 
 treated one year ago in our hospital for a chancre, receiving only local 
 
SYPHILITIC AFFECTION OF THE EYE. 
 
 169 
 
 medication. Examination, Dec. 19, 1868, revealed the following symp- 
 toms : 
 
 Purulent vaginal discharge, urethritis, a pigmento-papulo-vesiculo- 
 pustulosum exantliem, especially on the back and abdomen. On the 
 fauces is erythema, the right tonsil being tumefied and eroded. There 
 is a double condylomatous iritis and keratitis punctata sinistra. 
 
 About both eyes there is great conjunctival and pericorneal injection. Both , 
 cornea are much clouded. The discolored iris, especially of the right eye , is 
 adherent to the crystaline lens at several points posteriorly . The polygonal 
 pupil has the shape of a vertical oval keyhole . From the border of the pupil 
 two prolific granulations are visible. They are of the size of a pin-head, with a 
 spongy appearance, reaching into the aqueous humor. The cornea itself is 
 reddened in three or four circumscribed places. With the iritis of the left eye 
 we also see prolific condylomatous granulations, but they are smaller than in 
 the right eye, and seem to be in a state of development. No dilation of 
 the pupil follows the use of atropia. 
 
 I prescribed injections of sublimate at once, using the first day J gr. 
 and the following three days, J gr. daily. After the use of J gr., the 
 pupil dilated nearly to its normal size ; the right but slightly, remaining 
 yet in its polygonal shape. After using 1 gr., intolerance of light and 
 the pericorneal redness disappeared in a great measure. The aqueous 
 humor of both eyes was clearer, and the condylomes of the left eye 
 disappeared ; those of the right eye were much subdued in appearance. 
 The conjunctival redness persisted, however, but in a lessened degree. 
 But on account of salivation, the injections had to be suspended. After 
 again using 3 gr. the condylomatous prolific granulations in the right 
 eye were entirely eradicated, the iris assumed its normal condition, only, 
 that the structure was a trifle faded in appearance. At the same time 
 the other symptoms of the patient disappeared, and she was dis- 
 charged cured. 
 
 The following three cases concern patients in whom iritis 
 appeared, either during an anti-syphilitic treatment, or after 
 a long duration of the same. 
 
 Case 58. — Augusta W., 27 years old, some eight months advanced in 
 pregnancy, mother of a healthy boy 4 years old, was received into the 
 hospital Oct. 22, 1866, with the following symptoms : condylomata lata 
 with erosions on the labia majora and minora, pudendi, at the anus, on 
 15 
 
170 
 
 SYPHILITIC AFFECTION OF THE EYE. 
 
 the plicae fermorales, and on the tonsils ; soft nicer on the thigh ; ingui- 
 nal, cervical and submaxillary glands tumefied. 
 
 We used at once injection of sublimate, but the affections remained 
 rather obstinate, so that about 5f gr. were used altogether. Suddenly , 
 after being seemingly cured , an iritis appeared in the right eye , characterized 
 by great conjunctival and sub-conjunctival injection, discoloration of 
 the iris, no reaction from light, great intolerance of the same, lachry- 
 mation and pain in the orbita. 
 
 I used at once J gr. doses of sublimate, following it up for five days, 
 at the end of which time the inflammation of the eye was entirely 
 gone. Very shortly after our cure the patient was delivered of a 
 healthy and robust boy. Soon after the child was taken with a severe 
 blenorrhoea of conjunctive, coryza, also broad condylomes on the anus, 
 and a papulous exanthem on different parts of the body. It died in 
 twenty-four days. 
 
 Case 59. — Fred. S., day laborer, 24 years old, received November 
 20, into the Charite, exhibited the following affections : Condylomata 
 lata and erosions on the nates; acuminata on the lamellae of the pre- 
 puce; condylomatous ulcer on the lips ; papulous exanthem, more espe- 
 cially on the nape of the neck. 
 
 The infection took place three months ago ; the specific symptoms 
 showed themselves only two weeks ago. I prescribed for the patient 
 inunction, with gray ointment, 4 grammes daily (64 gr). The broad 
 papules healed after the 10th inunction. The ulcers on the upper 
 lip began to cicatrize after the 16th inunction. But after a use of 64 
 grammes (lj oz. nearly ) of the ointment , an iritis of the right eye was devel- 
 oped. The appearances were so characteristic that I presented them to 
 my clinical students as clear distinct pictures of a syphilitic iritis. 
 
 I used injections of sublimate, which, after the use of J gr. during 
 four days, brought about a complete dissipation of the inflammation of 
 the retina, the other syphilitic complications disappearing at the same 
 time. 
 
 In the following case inflammation of the iris occurred in 
 spite of the subcutaneous injection ; a papulous exanthem 
 developing itself on the abdomen, neck and back of the 
 patient. 
 
SYPHILITIC SCROTAL TUMORS. 
 
 171 
 
 Case 60. — L. R., 15 years old, was received into our hospital on the 
 19th of February, 1865, in the following condition: 
 
 There were broad erosions on the labia minora, and plicae femorales ; 
 the left pudendum was tumefied. For these affections the patient had 
 already undergone before admittance into the Charite a very severe so- 
 called, u hunger cure,” of about five weeks duration. 
 
 After using in the course of four days J gr. of sublimate subcutane- 
 ously, the eroded papillary excrescences on the pudendal lips, which, 
 were till now flat, became larger, but they however soon diminished 
 after the use of 1 gr. of the same. The conjunctival and sub-conjunc- 
 tival vessels of the right eye suddenly became injected • the iris some- 
 what discolored ; the pupil stretched ; and great pain was felt in the 
 orbita, shooting towards the supra orbital region. At every trial to 
 fix the eye on an object great lachrymation ensued. At the same time 
 with this iritis, the already mentioned characteristic papules appeared 
 on the described places. 
 
 The further hypodermic doses of J gr. of sublimate caused in the 
 weak and young patient a quite severe stomatitis, on which account we 
 interrupted the treatment for about one week. To guard against re- 
 lapses we injected about \ gr. more, so that we used altogether about 
 If gr. with the patient. The patient returned twice to the Charite 
 after the lapse of fourteen or eighteen months, but with a most minute 
 examination, we could find no sign of any syphilitic affection; there 
 being nothing but blenorrhoeic processes. 
 
 VIII. SYPHILITIC SCROTAL TUMORS. 
 
 This organ, whose parenchyma is very rich in nerves and 
 capillaries, is quite often the seat of gummous processes. 
 The development of the process runs, like all gummous 
 affections, a very latent course, because the slow formation 
 of the tumors produce no disturbances in the sensibility. 
 And not very seldom it is the physician who first points out 
 to the patient this affection. And this is the more strange, 
 since the generality of men watch, as is well known, every 
 functional disturbance of the testicle with the eye of an 
 
172 
 
 SYPHILITIC SCROTAL TUMORS. 
 
 Argus. And I can aver that in my practice, in all cases 
 where I found these alterations of the testicle, the patients 
 did not consult me on that account, hut for some other 
 syphilitic process. Therefore, I could get but few data 
 respecting it from the patients themselves. But this latent 
 course seems to me a very valuable diagnostic sign, because 
 all other pathological processes in this organ produce very 
 much more pain than the gummous, and hence are much 
 sooner noticed by the patient — as, for instance, the tuber- 
 culous and carcinomatous formations. 
 
 Concerning these indolent gummy tumors, I have had 
 occasion to observe two different kinds. The one form is 
 characterized by circumscribed, semi-lunar, hard knots of 
 the size of a pea or hazelnut, reaching above the paren- 
 chyma of the scrotum. This formation is generally the 
 first state of the syphilitic sarcocele, where the scrotum has 
 already more or less enlargement. This is quite natural, 
 considering the development of the gummata of the scrotum, 
 which arise from the albuginea, in which the testicle is 
 wholly wrapped, and from the septa-testis, they being already 
 hyperplastically degenerated before becoming specific neo- 
 plasm. 
 
 In the second form of the gummous sarcocele on the 
 largely hypertrophied testicle, a few circumscribed tumors 
 of hard resistance were found ; hut generally the whole 
 testicle was changed into a knotty mass. 
 
 As to the therapeutics for this orchitis gummosa, it might 
 be well to preface the treatment with the internal adminis- 
 tration of iodide of potassium ; but with a long resistance, 
 and in relapses, I think it justifiable to use the injection 
 treatment. In the cases observed by me, we had generally 
 to treat very rebellious and obstinate affections, and some- 
 
SYPHILITIC SCROTAL TUMORS. 
 
 173 
 
 times very long-standing relapses. On this account I was 
 obliged to use greater doses, and repeat them quite often. 
 But, after all, in some cases I failed entirely to effect a 
 cure. The tumors were considerably swollen, but once in a 
 while there were on the testicle small elevations, having a 
 hard resistance ; and here I used Fricke’s method of band- 
 aging with adhesive straps, which sometimes had a good 
 result. 
 
 Of my numerous cases, I shall give the following marked 
 case, with a view to show, on the one hand, the good effects 
 of the subcutaneous method ; and further, that in a syphilitic 
 patient, after a lapse of ten years, a relapse may occur, and 
 too in a very dangerous form, which is attributed by anti- 
 mercurialists to the administration of quicksilver ; but here 
 the patient himself was a follower of Baerensprung, and 
 never had used, for his first syphilitic affection, nor for his 
 secondary symptoms, a grain of mercury. 
 
 Case 61. — St., a merchant; from a healthy family, and of a robust 
 constitution ; always healthy ; was, in the year 1856, syphilitically in- 
 fected. His physician diagnosed a soft chancre ; but a year after, 
 symptoms of constitutional syphilis made their appearance, showing 
 the error committed. Professor Bserensprung was then, consulted, and 
 that gentleman, just having begun his metamorphosis as an anti-mercu- 
 rialist, prescribed for him for a length of time, with seemingly good re- 
 sults, the decoctum Zittmanni, and to be sure of its efficacy, he ordered 
 iodide of potassium to be used for some time also. The patient 
 returned the next winter from a voyage to Norway, where he made the 
 acquaintance of Professor Boeck, and delivered this gentleman’s known 
 works to Yirchow and Bserensprung. The latter assured him, after 
 repeated examination, that he was sound, not only for the present, but 
 healed from the effects of syphilis for the future, as the patient himself 
 told me particularly , because, according to Baerensprung’s opinion, the 
 time 11 necessary for a relapse” was already overpassed, since the pa- 
 tient had lived during a cold winter in the North. Suspicious erosions 
 on the penis, probably of a condylomatous nature, were treated only 
 
 15 * 
 
174 
 
 SYPHILITIC SCROTAL TUMORS. 
 
 with nitrate of silver, locally — together with iodide of potassium inter- 
 nally. This cure lasted for a few years ; but, as we shall see, a relapse 
 proved the cure to be only temporary. The patient suffered for quite a 
 time with an obstinate cold in the head, as he thought ; but in the 
 year 1867 the quantity and quality of the secretion were so augmented 
 that great masses of mucus and pus, intermingled with blood, were 
 secreted. The nostrils became stenosed, and the voice had that pecu- 
 liar nasal twang. The snoring during sleep was so peculiar and loud 
 that it could be heard at quite a distance. “ My whole nervous sys- 
 tem,” added the patient, “was by that heavy cold and an awful head- 
 ache so affected, and I was so weak, that I hardly could keep awake.” 
 
 I examined the patient in June, 1868, and found the following status 
 prsesens : On the velum and palate-roof shallow , not deep-going , ulcerations ; 
 and on the epiglottis I perceived an ulcer of the size of a small penny . The 
 cavity of the nose was filled with a yellow , dirty , thick-flowing secretion from 
 ulcers reaching far into the swollen mucous membrane . The face of the pa- 
 tient appeared bloated , especially around the eye and nose. In a further ex- 
 amination , I found, to the surprise of the patient , verg large gummous knots 
 on both testicles , of the size of hazelnuts , which had so changed the right testicle 
 into a bulky , elevated mass that it resembled a fist in shape . 
 
 I began the subcutaneous injection at once, and after a lapse of eight 
 days, there was a visible change for the better in the affection of the 
 mucous membrane of the nose. In three weeks the same was again in 
 its normal state. 
 
 The knots upon the testicle were more unyielding. Even after the 
 lapse of two and a half months, after using 5J grs. of sublimate subcu- 
 taneously, small remnants of the tumors were yet present. The pa- 
 tient was much delighted with the result, and broke off the treatment ; 
 but after seven weeks, the right testicle was again tumefied, several 
 of the elevations being felt much less plainly than before. The secre- 
 tion of the nose was somewhat augmented and tenacious, being occa- 
 sionally streaked with blood. 
 
 I prescribed now iodide of potassium, and for the nose I used Weber’s 
 nasal douche, with chamomile decoction. At the same time, I band- 
 aged the scrotum, lege artis , with straps of emplastrum hydragyrum. But 
 all this was without avail, and I was obliged to use again injections of 
 sublimate. And I had the satisfaction to notice, after the use of 5 grs. 
 of sublimate, that the testicle was reduced to its normal size, and that 
 also the last remnants of the affection in the vicinity of the mouth had 
 disappeared. Up to the present time (June, 1869), no relapse has yet 
 oecurred. 
 
SYPHILITIC AFFECTIONS OF THE BONES. 
 
 175 
 
 IX. SYPHILITIC AFFECTIONS OF THE BONES. 
 
 The affection of the bones is the most latent and obsti- 
 nate effects of syphilis. In no other system of the human 
 organism does lues, at the same time, so often show its 
 polymorphous character as in the osseous. 
 
 These processes generally begin with irritative diseases of 
 the periosteum, but gradually rise, by hyperplasia, into pro- 
 lific granulations. They show their culmination by forma- 
 tions of elastic gummous tumors, which change either into 
 real hyperostosis, or go into a metamorphosis, finally re- 
 sulting in caries and necrosis, thus displaying their malign 
 nature. 
 
 The first commencement of syphilis in the bones consists 
 in a swelling of the periosteum, which can hardly be de- 
 tected by an examination, and which, according to high 
 authorities, does not form a flat swelling, but “is elastic 
 under pressure/ ’ It is commonly concomitant with super- 
 ficial affections of the skin and mucous membrane, and is 
 accompanied with lancinating pain. They are distinguished 
 in a characteristic manner from the rheumatic pains caused 
 by an eruptive fever, which pains are sufficiently marked by 
 their fixed and circumscribed seat, and by the sensitiveness 
 of the fibrous periosteum to every pressure. 
 
 Later, there are more palpable changes of the bone, especi- 
 ally in those flat, unossified intumescences of an elastic con- 
 sistency. They occur on the tubera frontalia, diaphysis of 
 the tibia, and frequently on the sternum, clavicle ribs, &c., 
 and in the latter places are very often seated near the articu- 
 lations. Quite frequently I have found the disease in ques- 
 tion having its seat on the processus mastoideus. Here I 
 
176 
 
 SYPHILITIC AFFECTIONS OF THE BONES. 
 
 would discover just behind the ear — sometimes already after 
 the expiration of three or four months, and sometimes still 
 later — flat swellings painful to the touch ; even swellings of 
 the size and form of an almond, which could very easily 
 be confounded with swelled lymphatics. In some instances 
 they would be sensitive to only a small extent and were 
 hardly noticed by the patient; in other cases they had 
 spontaneously more or less painfulness. 
 
 In the later course we see the periosteal gummy tumor, 
 with simultaneous action of the upper layer of the bone, take 
 on an ossified condition, changing into plano-convex hyper- 
 ostosis or exostosis and osteophytes. 
 
 All these formations are characterized by a boring pain, 
 which prevents sleep, and consequently affects the nutritive 
 system very much. 
 
 The changing of the periosteal gummous tumors into 
 ulcerative metamorphosis, i. e., the development of an ulcera- 
 tive periostitis — I never noticed in my patients because those 
 processes were already healed by my subcutaneous injection 
 treatment. In some cases I have had occasion to observe 
 caries and necrosis which existed with the patients when 
 they were brought into our wards, and I thought it justifiable 
 to regard suppurative periostitis as the exciting cause, be- 
 cause the initial affections on the bones were yet visible. 
 
 The therapeutics of the syphilitic diseases of the bones has 
 the same indication as in the already described gummous 
 processes. The same principles exist here, as there, to dis- 
 tinguish, for iodide of potassium or injections of sublimate. 
 The effect of the latter depends on the state of the bone 
 affection. In the first described state, the lancinating pain, 
 and the periosteal tumefaction disappear after small doses of 
 sublimate rather quickly. The characteristic elastic tumors 
 
SYPHILITIC AFFECTIONS OF THE BONES. 
 
 177 
 
 require larger doses. They are absorbed in a short time 
 without a depression of bone remaining on the affected places. 
 And it seems as if the apparently dead and partially broken 
 down tissue is reducible by a fatty metamorphosis, and can, 
 therefore, be absorbed. In already new formations, from 
 the really sclerotic bone development, the results of the in- 
 jection are not so favorable. Even in long standing cases 
 where different treatments failed, and where great meta- 
 morphosis of form and texture had already taken place, I 
 succeeded in effecting a complete disappearance of the already 
 mentioned pain in the bones. 
 
 In quite a number of cases, a decided lessening of the 
 volume of the tumors took place on account of resolution of 
 the remaining gummous formation, but the hyperostosis did 
 not diminish, which was produced by hypertrophy of the ex- 
 terior of the bone, and the chalky process which the peri- 
 osteum underwent. To restore such a bone to its integrity 
 could not be expected from any treatment. 
 
 Concerning the ulcerative process of the bone, produced 
 either by periostitis or osteitis, or resulting from the ulcera- 
 tive process of the soft parts reaching into the bone, the 
 same rule holds good that has been laid down respecting 
 ulcers on the skin, reaching down to the bones. They need 
 a special surgical interference to remove the sequestra, even 
 if the syphilitic dyscrasia has been eradicated by sublimate 
 injections. 
 
 We have already published cases with affections of the 
 bones, and in the following cases I take those showing the 
 different periods of the disease, beginning with the first state. 
 
 Case 62. — Julius W., blacksmith, twenty-six years old, was received 
 into the Charite wards February 22, 1867. Eight weeks previously, he 
 
178 
 
 SYPHILITIC AFFECTIONS OF THE BONES. 
 
 had gonorrhoea, two weeks afterwards a hard ulcer on the glans, which 
 caused, in about eight days, phymosis. 
 
 Patient is of fair constitution and muscle. His chief complaints are 
 shooting pains in the region of the right musculus pectoralis . Examination 
 revealed that the seventh rib , near its junction with the sternum is but little 
 swollen , yet very painful to the touch. Of further syphilitic processes, we find 
 glandular ulcers ; induration of the lamellae of the prepuce ; the right 
 tonsil swollen and maculous exanthema. The inguinal glands were 
 principally swollen. 
 
 We injected for the first three days T 7 g gr. doses of sublimate. Already 
 after the third injection, the ulcers on the glands were healed, and the 
 phymosis gone. We reduced the doses one-half to -fo gr. After the 
 seventh injection, the induration on the prepuce was nearly gone, and 
 the exanthem entirely vanished. After the ninth injection (3 gr. having 
 been used) the periostitis on the seventh rib had also subsided. 
 
 The patient was discharged cured, April 12, 1867. 
 
 It was remarkable that after the second and fifth injections, the al- 
 ready described symptoms of intoxication appeared under the form of a 
 gastritis with colic pains, bloody diarrhoea, which passed away without 
 any interference by pausing for a few days with the subcutaneous medi- 
 cation. 
 
 Case 63. — Johanna M., twenty-three years old, was received January 
 14, 1867. The patient was already in our syphilitic wards four years 
 ago, suffering from broad condylomes and condylomatous angina, be- 
 sides she had a squamous exanthem, ‘ and was treated with a five weeks 
 sarsaparilla sweat-cure. At present she suffers from lupus syphiliticus 
 and rupia. On the shoulder, hip, thigh and right tibia, there are places 
 partially round and oval, and of a brown pigment color, which are ele- 
 vated somewhat above the skin, showing some infiltration. With some 
 the centres are deepened, the periphery being covered with a brownish 
 white, and somewhat leaf-like crust, by the removal of which bleeding 
 ensues. On the moist places the developments could be traced to 
 efflorescences. Besides, here and there over the body there were several 
 cicatrices of the size of a penny, which resembled brown circles with 
 lighter centres. The right tibia was swollen to a great extent , also the left 
 metacarpal bones. Both places were very painful to the touch. At the same 
 time the patient complained of extreme boring pains during the night at the 
 same localities. 
 
 The treatment consisted of sublimate injections, with the simultaneous 
 
SYPHILITIC AFFECTIONS OF THE BONES. 
 
 179 
 
 use of very small doses of iodide of potassium. After the sixth injection 
 the lupous places were covered only with small squamae, soft to the touch. 
 On the extremities there yet were some infiltrations, and a large crust 
 in the vicinity of the left knee. After the tenth injection (1J gr.) the 
 lupous ulcers were entirely healed, the pigment in the centre of the 
 respective places pale. On the left lower extremity there was a thin 
 rupial crust, beneath the same were prolific granulations of the corium 
 in the surrounding smaller crusts. The swelling of the tibia and meta- 
 carpal bones was lessened and they were painless. After the eleventh 
 injection, the former infiltrations vanished, and the swelling on the 
 tibia was very much less. After the twelfth injection (l£ gr.) the tume- 
 faction had also disappeared. 
 
 The patient was discharged, cured, February 23, 1867. 
 
 In the following patients there were greater affections of 
 the bone, which remained healed after a treatment with the 
 subcutaneous injection, notwithstanding several relapses of 
 rupia, which probably were occasioned by the voluntary in- 
 terruption of the treatment by the patient. 
 
 Case 64. — William R., baker, thirty-five years old, was received into 
 the Charite Hospital November 19, 1865. His former history showed 
 that the patient had, two years ago, ulcers on the frenulum, for which 
 he used some mercurial pills. About seven weeks ago, he contracted 
 again a new ulcer on the same place, which has been accompanied by 
 an eruption on the skin. Again mercurial pills were used which caused 
 salivation. Status prsesens : An induration near the destroyed frenulum ; 
 eroded lata near the pharyngeal palate roof; a papulous squamous ex- 
 anthem over the whole body entirely, more or less of them having scab 
 formations ; tophi on the forehead and tibia ; boneache (dolores osteocopi), 
 and slight tumefaction of the inguinal, cervical, submaxillary and 
 cubital glands. 
 
 The patient received twenty-four injections during seventeen days, 
 amounting to 3 gr. of sublimate. After using 2 gr. the elevation on the 
 frontal bone, and the night pains were already gone, but the exanthem 
 was not quite healed. The patient, nevertheless, left the hospital by 
 his own choice, but returned within a month. Examination then re- 
 vealed, that of the former affections, only the papulo-squamous ex- 
 
180 
 
 VISCERAL-SYPHILIS. 
 
 anthem on the face, neck and on the extremities, were yet present, and 
 that also the above mentioned glands were still swollen. I prescribed 
 a sarsaparilla sweat-cure, but being without result after a six weeks’ 
 use, injections w r ere again instituted, which caused a partial recovery, 
 after the use of If gr. of sublimate, but no complete healing. 
 
 In spite of our warning, the patient left again, but returned once more 
 to the hospital after three and a half months. Besides superficial ero- 
 sions of the internal lamellae of the prepuce, we found only several 
 papulous efflorescences of the size of a pea on the forehead, neck and 
 right upper arm which were quite soft to the touch. We treated him 
 locally only, and discharged him soon afterwards. 
 
 He sought relief again in our wards two and a half years afterwards. 
 He told us that up to July, 1868, he felt quite well, having suffered much 
 affliction and perplexity in obtaining a livelihood. He was obliged to 
 go for quite a time without any animal food. At this date horny ex- 
 crescences had developed themselves on the scalp, which soon ulcerated. 
 
 The patient was very much emaciated and cachectic. We found by 
 examining, that the head, as well as the back and right arm, was covered 
 with rupia crusts of the size of a penny. On the uvula and epiglottis 
 there were ulcerations as large as a pea. 
 
 We first prescribed a good strengthening diet with wine and beer, and 
 after a fortnight, we commenced our injection treatment, healing all the 
 ulcers and eruptions completely with 4 gr. sublimate. But to guard 
 against relapses, we used 2 gr. more of sublimate, and had the satis- 
 faction to discharge the patient completely cured and strengthened. 
 Quite recently he sent me a letter telling me of his complete health. 
 
 X. VISCERAL-SYPHILIS. 
 
 In consequence of the high interest which latterly is cen- 
 tred voluntarily upon the teachings on syphilis of the internal 
 organs, I regret very much that I have but a few cases 
 wherein I have made any observations. These cases of vis- 
 ceral syphilis do not occur as often as the specific diseases of 
 the external and more superficially situated regions of the 
 body, but after all they are not quite so rare as generally 
 supposed. Very many of the cases are wrongly diagnosed, 
 
SYPHILITIC DISEASES OF THE LIVER. 
 
 181 
 
 and therefore but sparsely seen in our syphilitic wards of 
 the Charity. 
 
 That the internal organs are quite frequently syphilitically 
 affected, is well authenticated by careful post-mortem exami- 
 nations, especially in pathological anatomical institutions. 
 Syphilitic diseases have been observed very frequently, 
 particularly in the brain, liver, kidneys, and even in the 
 lung itself, and we are compelled to feel thankful to Virchow 
 for this careful dissection and examination, which has made 
 such researches famous throughout the world. 
 
 The difficulty of diagnosing visceral syphilis, intra vitam , 
 is very great, arising out of the long interval of years be- 
 tween the infection and the outbreak of the disease inter- 
 nally, and from the deficiency of a specific group of symptoms 
 which distinguish internal syphilitic formations sharply from 
 the syphilis vulgaris. 
 
 A. SYPHILITIC DISEASES OF THE LIVER. 
 
 The liver is generally the chief organ affected in the 
 greatest number of cases of visceral syphilis. 
 
 Although immediately after the appearance of syphilis in 
 the fourteenth century, the liver was looked upon as the or- 
 gan primarily attacked by the syphilitic contagion, seemingly 
 poisoning the circulation, it is only recently that a sound 
 pathology of syphilitic disease has been established. It is to 
 be regretted that clinical observation has not kept pace, in 
 this respect, with pathological anatomy. 
 
 Although pathology has pointed out the more or less 
 characteristic symptoms of a syphilitic perihepatitis of a 
 simple syphilitic interstitial, gummous and amyloid hepatitis, 
 we do not possess a single pathognomonic sign by which we 
 16 
 
182 
 
 SYPHILITIC DISEASES OF THE LIVER. 
 
 can distinguish, during life, these diseases, caused by syphilis 
 in the liver, from diseases of the same organ, from other cases. 
 Neither the subjective nor objective symptoms, detected by 
 palpitation, percussion, &c., nor even microscopic examina- 
 tion, nor chemical analysis of the secretions and excretions 
 themselves, can furnish us evidence for a diagnosis. Diagnosis 
 will always have to be based on the fact of a syphilitic in- 
 fection, together with the simultaneous symptoms of perhaps 
 a yet existing syphilis, and the exclusion of other sufficient 
 causes. Another help for diagnosis is generally and mostly 
 overlooked, I mean the therapeutic experiment. We abstain 
 from a mercurial cure on account of the cachectic state of 
 the patient, which we regard as a contra-indication for this 
 venenum frigidum. A good treatment instituted, would, in 
 many cases, not effect a radical cure, hut would prolonglife. 
 The subcutaneous treatment with the sublimate would not 
 restore the parenchyma to a normal structure, which had 
 been vitiated by an amyloid process, nor the liver-acini which, 
 by the retraction of the tightened tissue are atrophied, but 
 used at the proper time, the inflammatory process which is 
 more or less connected with the shrinking, would be stayed, 
 and thus the hyperplasia, the prolific growth of tissue, 
 would be anticipated. But how seldom with such diseases 
 a suitable antisyphilitic cure is instituted, is shown by a 
 careful perusal of our medical literature. The cases are not 
 very rare where only on the dissecting table the right diag- 
 nosis is made. 
 
 We grant that in recent times a certain progress has been 
 made in the diagnosis of syphilitic cirrhosis, but we cannot 
 say the same of that affection which, according to my obser- 
 vations, often has more of a specific character than we sup- 
 pose, I mean the syphilitic icterus. 
 
SYPHILITIC DISEASES OF THE LIVER. 
 
 183 
 
 There is certainly not a sure diagnostic sign between 
 icterus and syphilis of the liver, and in our cases we could 
 detect none, because clinical observations, as has already 
 been said, have not as yet established them. 
 
 But the following points seem to us of more or less im- 
 portance in designating an icterus a syphilitic one, viz. : 
 
 1. The relatively often appearance of icterus with syphilis. 
 
 In the last four years I have observed nineteen cases of 
 
 icterus. Among these sixteen were syphilitic, and the other 
 three were not affected with secondary syphilis. The number 
 of this latter class is generally, in my wards, twice as large 
 as the number who have constitutional syphilis. 
 
 2. The coincidence of the icterus with the syphilitic affections 
 of the skin and mucous membrane . 
 
 In fourteen syphilitics, the icterus was accompanied 
 
 9 times with broad condylomes on the sexual parts and surroundings. 
 
 hard ulcers on the same. 
 
 ulceratively destroyed condylomatous granulations on 
 the pharynx, 
 maculous exanthem, 
 maculous squamous exanthem, 
 maculous papulous exanthem, 
 papulous exanthem, 
 pustulous exanthem. 
 
 3. The simultaneous swelling of the lymphatics , which, in 
 all cases, is more or less characteristic. 
 
 4. The therapeutical result of the subcutaneous injection . 
 Of sixteen syphilitics suffering with icterus 
 
 4 patients were treated with the sarsaparilla sweat-cure. 
 
 12 “ 11 11 sublimate injection. 
 
 It was noticeable that with the first class the healing pro- 
 cess of the icterus was slower, and accompanied with great 
 
184 
 
 SYPHILITIC DISEASES OF THE LIVER. 
 
 prostration, nausea, vomiting, vertigo, &c. But on the con- 
 trary the icterus run a quicker course in those persons 
 treated with the injection, and no untoward symptoms were 
 noticed. I never observed any toxicological effect of the bile 
 on the blood or nervous system. No patient had convulsions 
 or delirium. All improved quickly; the appetite reap- 
 peared, and the strength in due course of time ; the painful 
 symptoms of the disease, as unquiet sleep, headache, flatu- 
 lency, prurigo and constipation, were soon gone. 
 
 I further made this observation, which is worthy of remark, 
 and may lead to additional investigation : as is well known, 
 patients with icterus proper, emaciate quickly, but our pa- 
 tients, on the contrary, had not a rapid loss of strength or 
 flesh. One could judge of the case in this respect by fre- 
 quently weighing the patient. My patients kept their strength 
 and flesh, in spite of my giving relatively large doses of sub- 
 limate subcutaneously, and further on account of our pecu- 
 liar system in the hospital, a dietetic regime could not be 
 very well executed. 
 
 Case 65. — Thresa B., seventeen years old, of a robust constitution, 
 was received into the Charite wards February 17, 1867, and showed the 
 following symptoms : There were ulcerated lata at the labia majora, on 
 the tonsils and mammas ; also squamous exanthem near the upper ex- 
 tremities. On the chin, cheeks, upper lips and on the sides of the nos- 
 trils, we saw remarkable fine drawings (squamae gyratae) of greater or 
 smaller circles, which reminded one of herpes circinatus and gyratus. 
 A close examination revealed small epidermic scales, seated on the sur- 
 face, which was swollen into minimum papules. The inguinal, cervical 
 and cubital glands were enlarged. The color of the skin and conjunctiva 
 is yellow with a shade of brown. The hue of the visible mucous membrane , 
 especially on the hard and soft palate , is a dirty yellow. Laryngoscopic 
 examination shoived the vocal cords to be discolored in the same manner. 
 Tongue coated ; the dullness of the liver , commencing at the sixth rib , is not 
 very intense , and overreaches in the parasternal and mammillar line , the lower 
 
SYPHILITIC DISEASES OF THE LIVER. 
 
 185 
 
 border of the ribs , a little more than usual. The region of the liver is some- 
 what painful under touch , also the epigastrium which is a little swollen. The 
 dullness over the spleen is not enlarged. Percussion on the abdomen is 
 loud, deep and symptomatic. Only in the left iliac region was the sound 
 less prolonged and fuller. The whole abdomen is somewhat enlarged. 
 
 The patient complains of general malaise, loss of appetite, bad taste, 
 increased thirst, restless sleep, and a feeling of heaviness in the region 
 of the stomach and right hypochondrium. The itching is not very sig- 
 nificant. Since two days there has been no stools. There is voided 
 daily of urine sixteen hundred cubic centimeter in quantity, of a specific 
 gravity of ten hundred and twelve, of a very yellow color ; a chemical 
 analysis revealing much biliary coloring matter in the same. 
 
 We first prescribed an infusion of rhubarb, and as the subjective and 
 objective symptoms of the icterus did not disappear, I began to suspect 
 the disease to be syphilitic icterus, and therefore commenced the sub- 
 cutaneous injections of sublimate. The first three days we injected 
 doses of gr. each, and the following three days doses of J gr. each. 
 The treatment had a good result. After the use of lj gr. the skin lost 
 its brown color, and after the further use of the same quantity, it as- 
 sumed its natural appearance. The patient gained right along, so that 
 with 2 gr. used, she felt quite well. After using still another 1J gr. of 
 sublimate, the biliary coloring matter could not be anywhere more de- 
 tected, and she was discharged after three weeks, cured. 
 
 Case 66. — Mary H., twenty-one years old, of a gracile habitus, and a 
 weakly constitution, always healthy, says that about two weeks before 
 her admission into the Charite, she suffered from indigestion. 
 
 On December 2, 1868, the following was revealed by examination : 
 condylomata lata at the labia majora which is tumefied ; soft ulcer on 
 the posterior commissure of the vagina ; acuminata in the same place ; 
 an ulcerated anal fissure ; elevated lata near the tonsils and the posterior 
 roof of the pharynx , and icterus. 
 
 An accurate examination failed to reveal any demonstrable physical 
 changes of the liver or abdominal organs. The pulse was rather slug- 
 gish, being sixty-five per minute. The color of the skin and conjunctiva 
 was somewhat like mahogany ; the urine contained biliverdine ; the 
 stools were of a clay color ; the appetite was small ; the feeling of 
 strength about normal ; the sleep at night undisturbed. 
 
 During the instituted sublimate treatment the patient gained con- 
 tinuedly; the appetite increased; the icteric color of the skin and urine 
 
 16 * 
 
186 
 
 SYPHILITIC DISEASES OF THE KIDNEY. 
 
 diminished ; the faeces assumed more and more their natural hue, and 
 lastly, the subjective and objective symptoms of the icterus disappeared 
 after the injection, subcutaneously, of 1J gr. of sublimate. Also the 
 plaques mucqueuses of the pharynx entirely vanished, but the condy- 
 lomata on the labia pudendorum increased so that it was necessary to 
 inject 3 gr. more of sublimate. 
 
 B. SYPHILITIC DISEASES OF THE KIDNEY. 
 
 There is yet a certain obscurity about the syphilitic diseases 
 of the kidney which remains to pathological anatomy to ex- 
 plain more fully, but we are able already to point out with 
 certainty a syphilitic interstitial and gummous nephritis , and 
 even an amyloid degeneration of the kidney ; not only Vir- 
 chow in his lectures, but also the dissertation of Barde,* * * § ap- 
 pearing under his presidium. Also, Arn. Beer,f and the 
 French authors, especially CornilJ and Lancereaux,§ have 
 shown important necroscopic facts bearing on this form of 
 disease of the kidney. To use for these syphilitic affections 
 of the kidney a mercurial treatment, especially the subcu- 
 taneous injection of sublimate, might look, at the first glance, 
 rather improper, since Wells, Blakall and Gregory, and re- 
 cently Pavy and Sackowsky, have stated that mercury not 
 only induces albumirmria , but also causes grave disease , as 
 parenchymatous and amyloid degeneration of the renal or- 
 gans. 
 
 As older authors, so in recent time, Kussmaul defended 
 mercury against this imputation, and has shown that, with 
 
 * De Syphiliticis Renum AfFectionibus. Berolini, 1863. 
 
 j* The Interstitial Syphilis. Tubingen, 1867. 
 
 J Memorie sur les lesions antomiques du rein dans Palbuminurie. 
 These de Paris, 1864. 
 
 § Traite de la Syphilis. Paris, 1866, p. 289. 
 
SYPHILITIC DISEASES OF THE KIDNEY. 
 
 187 
 
 workmen who manipulate quicksilver, no albuminuria could 
 be found, and those workmen who applied the quicksilver to 
 looking glasses, laboring under disease of the kidney, had 
 their renal affection as a consequence of an already existing 
 tubercular process of the lungs. To detect albumen in the 
 urine, and to settle the question, I examined the secretion 
 from fifty patients, taking those who received the relatively 
 greater doses of the sublimate subcutaneously. The ex- 
 amination was made at different stages, in the beginning and 
 the further development of the disease, and even at the end 
 of the treatment. Among the patients there were even such 
 as had more or less salivation, and even some of them showed 
 appearances of intoxication consequent upon abnormally 
 large doses of the sublimate being subcutaneously injected. 
 
 Not in one of all these cases could I detect a trace of albu- 
 men, and furthermore I will remark that I also failed to find 
 any trace of sugar in the urine . 
 
 And, therefore, I am justifiable in making the assertion, 
 that hypodermically injected sublimate produces no affection 
 of the kidney which could be detected by the presence of 
 albumen in the urine. 
 
 Since I consider myself justifiable by the facts, in not 
 attributing to mercury a deleterious effect on the kidney, my 
 therapeutical results give me on the contrary, the conviction 
 that the subcutaneous method in the first state of syphilis 
 might be of a beneficent character, and as evidence of this 
 view, I produce the following cases, which might be aug- 
 mented by further illustrations. 
 
 Concerning the cure in the later stages, I am not able to 
 give any proofs. That the sublimate is not able to restitute 
 the cicatrized tissue of the kidney as detected by Virchow, 
 nor bring about the functional integrity of an amyloid de- 
 
188 
 
 SYPHILITIC DISEASES OF THE KIDNEY. 
 
 generated tissue, holds good with the kidney as with all other 
 organs. 
 
 To state that a better success attends the subcutaneous 
 method, than any other antisyphilitic treatment of these 
 affections, is impossible, since a greater number of patients is 
 necessary wherewith to make a reliable comparison. 
 
 I will only mention that before introducing my method, I 
 treated two patients with a long course of the sarsaparilla 
 sweat-cure , the one being in the early and the other in the 
 advanced stage of the disease. The result was rather a 
 pitiful one. Both died, and a post-mortem examination re- 
 vealed a diffuse nephritis with the one, and the other had an 
 amyloid degeneration of the kidney. 
 
 The following are cases treated subcutaneously : 
 
 Case 67. — Ann A., twenty-one years old, was received into the 
 Charite on the 17th July, 1866. The patient, already in 1865, had been 
 in our wards, on account of erosions on the labia minora, a vaginal dis- 
 charge and small soft ulcerated patches at the vaginal introitus ; she 
 was locally treated for three weeks, March 10th, 1866, on account of diph- 
 theric ulcerations on the left pudendal lip ; maculous exanthem on the 
 trunk. The sarsaparilla sweat-cure was also used during the same 
 time. Twelve weeks ago, she was confined in her eighth month of 
 pregnancy, with a child, which lived six weeks. 
 
 Status prsesens : the patient is of delicate, feeble constitution, looking 
 care-worn and pale. The face is someivhat tumefied , especially beneath the 
 eyes , besides there is slight oedema near the joints of the lower extremities . 
 The following syphilitic appearances are present : condylomata lata 
 covering the pudenda, at the left angle of the mouth, and near the 
 tonsils, and on the roof of the mouth ; maculous exanthem ; loss of 
 hair; vaginal discharge ; urethritis, and some swelling of the inguinal 
 glands. 
 
 Examination of the chest showed the existence of a slight bronchial 
 catarrh. The urine was acid , containing much albumen , a little blood , 
 bladder epithelium , fibrine cylinders and oil globules. Temperature 37.6 
 Celsius, pulse 84, appetite, bowels and sleep, normal. 
 
SYPHILITIC DISEASES OF THE KIDNEY. 
 
 189 
 
 We used at once subcutaneous injections of sublimate, giving gr. 
 doses for two days. The quantity of urine passed in twenty-four hours , 
 consisted of 1500 centimeters with a specific gravity of 1013. Afterwards we 
 gave £ gr. doses. 
 
 The patient complaining of great pain in the kidney regions, we ap- 
 plied six cups. Up to the twelfth injection (1J gr. sublimate being 
 used nearly) no change for the better was visible. Also in the quality 
 and quantity of urine there was no alteration. 
 
 But soon the oedema disappeared, and we could detect no fihrine or blood 
 corpuscles in the urine . The albuminous ingredient was lessened. After 
 the thirteenth injection salivation had already occurred. At the same 
 time the patient complained of great headache, nausea, vomiting and 
 vertigo. The urine was again tinged with blood and albumen , the specific 
 gravity being 1012 and the quantity 1600 cubic centimeters. 
 
 On the following day, the blood increased in the renal secretion, and 
 also the headache, with severe pain in the knee joint. The patient was 
 very feeble ; restless sleep ; appetite and stools were wanting. Again 
 six cups were applied to the sacral region, and I prescribed confection 
 of senna for the bowels and used tannin and opium. 
 
 After the fourteenth day, the condition of the patient improved. But 
 on account of the non-disappearance of the syphilitic symptoms we 
 used again the hypodermic injections, besides the tannin. After the 
 third injection of gr., the blood and albumen in the urine disappeared. 
 The quantity increased to 2000 cubic cent., the specific gravity being from 1015 
 to 1010. The color was a pale yellow. The maculous syphiloid faded 
 out, and I discharged the patient after using altogether 3 gr. of the sub- 
 limate. Several months after, the patient returned again to our wards, 
 November 10, 1866. Her appearance was healthy, and she said she had 
 been well since her discharge. Of constitutional symptoms of syphilis, 
 no trace was left. There was only acuminata on the labia, an ulcus 
 molle on the introitus vaginae, besides fluor vaginalis and urethritis. 
 The urine was of normal consistency and free from fibrine cylinders , albumen 
 and blood. Two days after admission, the patient was taken with a pro- 
 fuse diarrhoea which was checked by opium. We discharged her Nov. 
 24th. 
 
 After six months, Anna A., was again received into the Charite on 
 June 6, 1867. 
 
 An examination of the quite healthy appearing patient, revealed 
 eroded condylomes, like excrescences, on the labia majora, and in the 
 vicinity of the anus ; vaginal discharge ; an abcess on the right gland 
 
190 
 
 SYPHILITIC DISEASES OF THE KIDNEY. 
 
 of Duverney ; the lymphatic glands only in the inguinal region were 
 swollen. On account of the not well marked character of these excres- 
 cences, we used only a local treatment of argentum nitricum, which 
 produced, in three weeks, a complete cure. 
 
 It is noticeable in this case, that the patient was suffering from a 
 stomatitis which had the character of a mercurial one, although the 
 patient denied having used any preparation of mercury. Gargarisms of 
 chlorate of potassa cured this affection. 
 
 Case 68. — Fred. S., a laborer, eighteen years old, was received April 
 1, 1868, into our wards. Patient says he had a chancre four months 
 ago, and a skin affection following in two months thereafter. 
 
 Status prsesens : The patient has flabby muscle and a delicate habitus; 
 looks pale, and the visible mucous membrane seems anaemic. He com- 
 plains of a frequent desire to urinate ; shooting pains in the lumbar 
 region, and a dizziness and pain in the head. He particularly complains 
 of a lack of air which he feels once in awhile. Examination revealed oedema 
 of the face, arms , feet and moderate ascites. The quantity of urine daily passed 
 is from 800 to 900 cubic cent., with a specific gravity of 1019, of a brown 
 color. Microscopic examination shows it to contain blood corpuscles, albumen, 
 and fibrine cylinders quite abundantly. Of syphilitic appearance, I found 
 on the back, the upper and lower extremities ecthymatous ulcers of the 
 size of a penny, which did not reach very deeply into the skin. The 
 inguinal and cervical lymphatic glands were much swollen. In the nose 
 were superficial ulcerations, on the mucous membrane which secreted 
 profusely pus and mucus. Exploration of the chest and abdomen revealed 
 nothing abnormal. The heart’s sound at the apex was very loud and 
 strong; vesicular respiration is sometimes augmented; liver and spleen 
 normal. 
 
 Although the patient was dropsical, we thought the use of the subli- 
 limate was indicated because we had the opinion that syphilis was the 
 cause of the nephritic affection. 
 
 We used at once J gr. subcutaneously, the next day reducing the dose 
 to l gr. After the sixth injection, or the use of 1 J gr. of sublimate, the 
 general feeling of the patient was better, the dyspnoea, especially, being 
 diminished. The anasarca and ascites were considerably reduced; urine 
 was voided more profusely , and increased after the use of 2\ gr. to 4000 cubic 
 cent., the specific gravity being 1021. The color was yellow, but somewhat 
 clouded on account of mucus being present . Albumen or fibrine cylindroids 
 could not be detected nor blood corpuscles . 
 
SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 191 
 
 A continuation of the injections completed the cure, the subjective 
 and objective symptoms entirely disappearing. The ozaena and ecthyma 
 were healed, and we were able to discharge the patient after the use of 
 2f gr. of the sublimate. 
 
 C. SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 What we have asserted of syphilis in general, holds good 
 concerning syphilis of the brain. 
 
 It exists much oftener than is generally supposed. If we 
 take the many post-mortems and the lesions found there in 
 the central nerve apparatus, which can be pronounced with 
 more or less certainty as residues of a preceding syphilitic 
 process, the opinion will force itself upon us, that in the ma- 
 jority of cases, a wrong diagnosis allowed the fatal issue. 
 Among the instances are to be classed apoplexy, hemiplegia 
 paralysis, epilepsy and even psychosis, mania, hallucinations, 
 melancholy, &c. Prof. Jaksch of Prague, says, in his valu- 
 able paper* on syphilis of the internal organs, in a very 
 characteristic way, that “a revision of the hospital and in- 
 sanity cases would show that syphilis is too little looked upon 
 as a cause of mental derangement.' ’ 
 
 Concerning the pathological and anatomical changes in 
 the brain suffering from syphilis, the symptoms are more 
 manifold even than they are in syphilis of the skin. But it 
 is to be regretted that they are not yet known in their 
 characteristics, nor anatomically specified. 
 
 In recent times again, Virchow has been the first to clear 
 up the obscurity in this branch of science, which may give 
 rise to still more important developments in the future. The 
 gummata are not to be looked upon as the only manifestation 
 
 * Prager Medicinische Wochenschrift. 1864, No. 1-50. 
 
192 
 
 SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 of syphilis. We know that the disease holds on to its poly- 
 morphous character, causing not only specific irritations in 
 the form of thickenings, vegetative growths, granulations, 
 and even condylomatous excrescences. Besides these mani- 
 fold syphilitic processes, we find that even the different parts 
 of the brain may be the seat of syphilitic degeneration. 
 
 Not only the dura mater on its outer and inner surface, 
 and semilunar prolongation is visited by syphilis, but also 
 the pia mater, arachnoidea, ependyma and even the greater 
 and lesser brain. And here the syphilis is not only concen- 
 trated on the one or the other part, but it may attack the 
 substance of the hemispheres, also the large ganglions, thala- 
 mus opticus, pons varioli, pedunculi cerebri and cerebelli. 
 
 The danger of brain syphilis does not wholly consist in 
 the fact that a single part of this organ suffers disorganiza- 
 tion, but that a disturbance is also caused in the nearest sur- 
 roundings, thus complicating the affection. We see that the 
 single tissue by the exudative inflammation, may take on the 
 growing process here, the fatty metamorphosis there, and 
 the nerves which are exposed to pressure will become atro- 
 phied, and the blood-vessels §lso obliterated. By this latter 
 process, we may explain the apoplexies which have always 
 been witnessed with syphilis, as existing in some mysterious 
 manner. Such revelations belong to recent investigations, 
 and Virchow was the first who proved an obliteration of the 
 carotis cerebralis. Similar cases may be found in^the pub- 
 lications of this distinguished author, especially in his work 
 on Malignant Tumors, Vol. II., p. 451. 
 
 It is not the place here to detail those pathological pro- 
 cesses occurring in the central nervous apparatus. But I 
 will not omit this occasion to repeat again that pathological 
 anatomy, coupled with clinical observations, will be able to 
 
SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 193 
 
 contribute to a better knowledge of brain syphilis. It will 
 be able to do it very often. In post-mortem examinations 
 w r e generally find the last products of syphilitic degeneration, 
 L e.j the coarser material changes, while on the other hand 
 the finer beginnings may be found, very probably, by the 
 help of clinical observations. 
 
 We must consent that a peculiarly formed tissue like the 
 syphilitic does not cause a difference in the quality of the 
 functional disturbance produced by it, but there are always 
 starting points which may assure, either in a positive or 
 negative manner, a diagnosis in syphilis. To the former be- 
 long the antecedents of the patient, the coincidence of syphi- 
 litic affections in other organs, their development, chronolo- 
 gical data, the intensity of single symptoms, the remission 
 and exacerbation as to headache, especially at night. The 
 negative points are the exclusion of all etiological symptoms 
 based on an accurate examination of all organs of the patient. 
 
 As to the therapeutical indications for brain syphilis, res- 
 toration of the destroyed nerve tissue is out of the question. 
 A nerve cell destroyed by inflammation, or on account of 
 pressure or fatty metamorphosis, cannot be restored ad in- 
 tegrum; neither can a brain mass despoiled by haemorrhagic 
 detritus be replaced in its normal condition. The same is 
 the case with vessels which have become impermeable by an 
 adherent thrombus. We are glad to say, however, that these, 
 described processes are the last phases of syphilitic disease. 
 In the earlier stages treatment may cause a certain healing 
 by involution and absorption after a regressive metamorphosis, 
 or at least it may stay the further development of the affec- 
 tion. It seems that the connective tissue of the brain, 
 encircling it in its coarse and fine rugae, and its pathological 
 proliferation may take on a retrogressive metamorphosis in 
 17 
 
194 
 
 SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 consequence of a therapeutical treatment, just as do the 
 outer integuments of the body which are histologically similar 
 in tissue. As the inflammatory, exudative and condylomatous 
 prolific granulations of the skin and mucous membrane, and 
 even the periosteal layers of bone are undergoing changes by 
 the absorptive process, so also, the histologically similar 
 tissues of the brain, pia and dura mater, arachnoidea, 
 ependyma, &c., or the adventitious tissue of the vessels in 
 the cranium may undergo the same pathological processes. 
 That “ absorption may diminish and eradicate the gummy 
 knots in the brain,” Virchow has already pointed out. It 
 almost seems, according to his researches in pathology, that 
 gummous formations in the brain, change not so frequently 
 into the more dangerous puriform metamorphosis as the same 
 constructed tumors of the skin and bones, and that here fatty 
 metamorphosis is always favorable in prognosis. 
 
 This view might be taken at first glance as a hypothetical 
 one, but it is fully confirmed by many clinical cases, well 
 authenticated, in which cerebral syphilis was healed by a 
 timely antisyphilitic treatment. Our medical literature con- 
 tains the record of very many syphilitic brain affections, 
 which either by mercury or iodide of potassium have been 
 wholly eradicated. Among these are paralysis, epilepsy, and 
 psychosis of every description. I refer to Yvaren, Sandras, 
 Brach, Baumes, Romberg, Trousseau, Jaksch, &c. 
 
 I will remark here, a very significant fact for practice, 
 that all those remedies which had a result, especially the 
 mercurials, have been used not only once, but frequently and 
 energetically. Romberg, in his work on “ Diseases of the 
 Nervous System,” p. 918, says emphatically, “If anywhere 
 a correct diagnosis may save a patient, it is especially true 
 with these paralyses. The specific remedies are mercury and 
 
SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 195 
 
 iodide of potassium , which accomplish ivonders here ; but 
 their use must be persevered in sufficiently long. Also the 
 decoctum Zittmanni is a suitable remedy here.” The fear 
 that a forced use of these remedies might be dangerous to the 
 nerve apparatus, seems to be without foundation. Ottensee 
 has, in one of his works, a hesitancy in regard to the dele- 
 terious effects of these drugs, but it has not been verified in 
 the least, and the most accurate observers have failed to find 
 any evidence to substantiate his statement. 
 
 My own cases, where I have had opportunity to observe 
 the effect of the sublimate, subcutaneously used, have not 
 been numerous, because, as already said, the patients having 
 these diseases were sent, very frequently, to other wards on 
 account of a wrong diagnosis. 
 
 I never saw, in my patients, syphilitically affected, even 
 in those grave forms which are apt to be connected with 
 syphilis of the nerves, a transformation of the disease to the 
 nervous apparatus, which may be owing to the quick regres- 
 sive course of the syphilis caused by the subcutaneous in- 
 jections. 
 
 How and in what manner my method excels other ordinary 
 treatments for syphilis of the cerebral organs, I cannot de- 
 cide for want of comparing material. I had several patients 
 in my private practice, especially with hemiplegia, but on ac- 
 count of their leaving town, I cannot give any accurate 
 statement concerning their recovery, and therefore I must 
 fall back on my few cases in the Charity. I must say here 
 that, although my patients improved rapidly, I have not a 
 single case of a total cure to chronicle, probably because 
 several were satisfied with their improved condition, and left 
 the hospital, while others were sent by us to other wards as 
 
196 
 
 SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 nervously and mentally deranged patients, where was abetter 
 convenience for those of this class. 
 
 The following are the cases in question : 
 
 Case 69. — E. F., a merchant, thirty-one years old, descending from a 
 healthy family, suffered, in 1863, from a hard chancre, and used for the 
 same inunction for three weeks. Two months after he had a papulous 
 exanthem on the forehead, for which he took, during five weeks, Dzondi’s 
 pills, and later iodide of potassium. He noticed, eight weeks afterwards, 
 a hoarseness and a painfulness in deglutition. He now used Zittmann’s 
 treatment as prescribed. During the war in Schleswig-Holstein, 1864, 
 after a great deal of service, he suffered suddenly from paraplegia of the 
 lower extremities. After a number of foot-baths, and the use of mineral 
 water, the paralysis of the right foot disappeared, the left remaining in 
 its paralyzed condition. He had great torpidity of the bowels ; catarrh 
 of the bladder, and paralysis of the same. At his admission, July, 1865, 
 we found the following conditions : feebly built, flabby muscles, and a 
 paleness of the visible mucous membrane ; myopia of both eyes ; senso- 
 rium perfectly clear ; no paralytic symptoms in the region of the nerves 
 of hearing ; tongue has a yellowish coat ; appetite good ; abdomen 
 tympanitic ; stools produced only by laxatives ; dullness over the hepa- 
 tic region ; spleen normal ; thorax well built and normal ; respiration, 
 costo abdominal. Auscultation and percussion does not reveal anything 
 abnormal. Dullness of the praecordial region of normal extent. Heart 
 sounds clear. Pressure over the well proportioned spinal column not 
 painful. Both lower extremities were of the same length as shown by 
 accurate measurement from the spinae il. ant. sup. The malleoli and 
 knee-joint were upon the same level. When lying quietly on the back, 
 the use of both extremities is not affected with the exception of a slight 
 impairment of the left. Sensitiveness is normal. In the erect position , 
 the patient rests more on the right than on the left foot ) in consequence of which 
 the whole of the left side of the body seems somewhat lax. The left shoulder 
 is some lower than the right. Pressure on the spinous processes of the 
 sacral region causes no pain. In walking the left foot is raised but a little 
 from the ground. Patient drags the same , assuming thereby a shuffling gait. 
 The mentioned paralysis of the bladder still exists , the patient being unable to 
 retain his urine. Constipation still obstinate and only by strong laxa- 
 tives can the bowels be moved. Pressure over the region of the bladder 
 causes no pain. On the scrotum and penis there are several erosions. 
 
SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 197 
 
 In catheterizing the patient with an elastic catheter, we encounter a 
 hindrance in the vicinity of the prostate gland. By an examination, 
 per rectum, we find the middle lobe of the prostate some swollen and very 
 sensitive to the touch. Urine is alkaline, of a clay color, with a milky 
 white sediment. Electricity is more sensibly felt on the paralyzed ex- 
 tremities than on the sound. 
 
 We believed, from the previous history, we had to deal with a syphi- 
 litic paralysis, and our opinion was strengthened in this view by the 
 absence of other etiological momenta tending to a different diagnosis. 
 But I resolved not to use the sublimate injection at once, and, there- 
 fore, prescribed iodide of potassium internally with galvanism. This 
 treatment resulted in bettering the condition of the paralyzed bladder. 
 But the paresis of the loiver extremities existed in the same degree, therefore, 
 
 I thought myself justified in using the sublimate injections . We injected 
 daily gr. sublimate hypodermically. After the use of twenty injections, 
 or 2} gr. of sublimate, a decided improvement in the movements of the 
 lower extremities could be seen. After the further injection of 1 gr. 
 more, the movements were almost normal. The patient was, unluckily, 
 satisfied and left. 
 
 Case 70. — H., a druggist, forty-one years old, was received into out- 
 wards January 1, 1866. The antecedent history of the patient, on ac~ 
 count of indistinct utterance from paralyzed vocal cords, proved very unsatis- 
 factory. Only after improvement had taken place, could we get the 
 following from the patient : In May, 1865, he contracted a hard chancre 
 on the prepuce, and used as a remedy about 50 gr. calomel, according 
 to his statement. But the syphilis reappeared, under the form of a 
 maculous exanthem, in October of the same year. He used, without 
 consulting a physician, hydragyrum iodatum rubrum etflavum. But seeing 
 no result from this treatment, he used iodide of potassium, and a certain 
 
 II wood tea.” Shortly after he had loss of memory and confused thoughts , 
 accompanied with aphasia, so that his relatives brought him to the hospital 
 in the following condition : 
 
 Feeble, emaciated body ; flabby muscles ; a paleness of the visible 
 mucous membrane ; apathetic expression of the countenance, with a 
 somewhat fixed gaze ; pupils of equal size, reacting normally to the 
 light ; patient follows the movements of objects placed before him only 
 for a short time. In the nerves of the face no paresis is discoverable. 
 
 Physical examination of the organs of the chest and abdomen reveals 
 nothing important, only the sound in the left supraclavicular region is 
 
 17* 
 
198 
 
 SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 rather higher than normally it should be, while the sound of the left 
 regio-supraspinata is a trifle duller. Auscultation shows nothing very 
 abnormal, excepting the breathing is irregular and feeble. The mani- 
 fold entreaties made to the patient for deeper respiration are not no- 
 ticed ; mucus sputa is expectorated ; no abnormal sensibility of the 
 spinal column can be made out ; during the decubitus of the patient, 
 the left upper extremity is straight, while the right is moderately flexed, 
 and sometimes is taken with clonic twitchings. Similar convulsive movements 
 are noticed with the right lower extremities , especially in the vicinity of the 
 musculus rectus femoris. The arm and foot being lifted , they both fall down 
 helpless. But the patient himself is able , after repeated urging , to raise these 
 extremities , but visibly , with great exertion. The right could , after repeated and 
 fruitless efforts , be slightly raised. To flex the arm is impossible , and he al- 
 ways fails with this arm in reaching objects placed before him. The right lower 
 extremity is colder to the touch than the upper one . Requesting the patient to 
 make pressure with his hands , it is evident that the left is weaker than the right. 
 
 The sensitiveness to electricity is very much lessened in the muscles 
 of extension, so that only with a strong current can the right leg be ex- 
 tended. Only after several trials is the patient able to raise himself from the 
 bed , and this is generally effected by the help of the left arm. He can stand 
 erect , but very imperfectly . With closed eyes , he staggers and falls if unas- 
 sisted. In trying to micturate in an erect position he falls to the left side. He 
 urinates very slowly, and after finishing, quite a quantity drips away. 
 The urine is weakly acid, rather cloudy, but contains no abnormal in- 
 gredients. Asking him about pain, he points to his forehead, and never 
 gives any other details respecting pain. Deglutition is good ; the uvula 
 hangs down lax and straight ; the tongue, when pointed from the mouth ) 
 has a tremulous, unsteady motion ; the functions of mastication are 
 normal. 
 
 As to syphilitic appearances, a small papulous exanthem coveied with 
 small scales is remaining partly in an aggregated and partly in a dif- 
 fuse configuration. On the forehead, besides the single papules, there 
 are dark-brown pigment patches. There are small erosions on the right 
 tonsils. The inguinal and cubital glands are much swollen, but the 
 cervical only slightly. 
 
 The instituted therapeutics consisted of the administration of iodide 
 of potassium, electrifying the paralyzed parts together with good diet. 
 But these symptoms were becoming more aggravated. One morning, 
 we found the patient helpless upon the floor. Probably he fell while 
 trying to urinate. He could not relate why he was out of the bed, but 
 
SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 199 
 
 pointed to the urine vessel. By long standing and with efforts to urinate , 
 tremor and twitching occurs on the right side, especially in the right arm , 
 which, with this exception , seems less sensitive . The dribbling away of the 
 urine has caused several excoriations on the scrotum. On the sacral 
 region, bed sores have formed. 
 
 After using ljg of iodide of potassium during twelve weeks, the 
 faculty of speech was improved, but not very greatly, so that he could 
 utter single words, but no coherent sentences. The hemiplegic ap- 
 pearances were not much changed. 
 
 Five months after admission, we began the use of subcutaneous in- 
 jections of sublimate in gr. doses. Already after the use of 1 gr., the 
 patient was able to elevate the right arm and flex it . But the right leg did 
 not improve so much. In the ankle joint particularly, he could make 
 no spontaneous movement ; but he could open and close the right hand quite 
 well. He could stand erect but for a short time only . The faculty of speech 
 improved , but it was not quite normal. Examination now of the mentally 
 improved patient, revealed that the functions of the right eye and right 
 ear are impaired, as compared with the left. The bones of the head 
 are not very sensitive. On all parts of the body he feels quite readily a 
 pricking with needles, and locates the points very well. The tempera- 
 ture of both sides of the body is the same. 
 
 After the use of 1 gr. more of the sublimate, the patient himself 
 notices his improvement. With the right arm and leg all movements are 
 made , although rather slowly yet correctly. There was improvement daily. 
 The articulation was better, so that he could speak slowly, but co- 
 herently. In this condition he was taken home by his friends. We 
 used, altogether, with this patient, 4J gr. of sublimate. 
 
 Case 71. — Martin Sch., day laborer, twenty-seven years old, was re- 
 ceived into the Charite Jan. 29, 1869. I did not see the patient myself 
 when received. He said that he contracted a chancre, which disap- 
 peared itself after the use of mercurial pills. The patient is of medium 
 size, and of a very strong constitution. Concerning the syphilis per- 
 taining to him, we found on examination, a great portion of the surface 
 of the body, especially the trunk and extremities, covered with a lenti- 
 cular, papulous exanthem in the desquamative stage, with occasionally 
 dark pigment patches. On the prepuce in the neighborhood of the 
 sulcus retro glandularis, there was a cicatrix, rather soft to the touch. 
 The hair easily came out. The lymphatics were swollen in the inguinal 
 and cervical region. 
 
200 
 
 SYPHILITIC AFFECTIONS OF THE BRATN. 
 
 Ophthalmoscopic inspection revealed a specific retinitis , on account of 
 which the patient was sent to the ophthalmic wards of Dr. Yon Graefe, 
 where he also complained, for the first time, of nausea and general 
 weakness. The ophthalmoscopic examination showing an inflammatory 
 action of the eye, the application of an artificial leech was prescribed. 
 Before commencing this small operation, the patient was suddenly taken 
 with dizziness , swooning away , but soon recovered his consciousness . The 
 artificial leech was applied, extracting, however, but little blood. In 
 returning the patient to the syphilitic wards, he was again taken with 
 vertigo , which soon subsided , but according to the nurses accompanying him ) he 
 was unable to utter a word. 
 
 In our wards , shortly after , the patient was taken with paresis of the right 
 facialis and hypoglossus. The expression was rather apathetic , the right angle 
 of the mouth being drawn down in a lax manner , and the right nostril was 
 narrowed , and did not dilate with respiration. The nerve fibres belonging 
 to the musculus orbicularis, palpebrarum, corrugator supereilli and 
 frontalis, were not so much paralyzed. In asking him to show his tongue 
 the same could be done only very imperfectly , the point being extended towards 
 the right . Our efforts to make the patient speak were fruitless. It was im- 
 possible to get any sure evidence as to the integrity of the psychical functions , 
 on account of this decided glosso-plegia. Every admonition for him to exe- 
 cute voluntary muscular movements had to be repeated before it was 
 obeyed, and the movement then was of an unsatisfactory character. The 
 condition of the patient changed during the day very much. First paresis of 
 the right arm occurred , with complete sensibilty and reflex action remaining. 
 Afterwards cataleptic symptoms were present. In telling the patient to do 
 something, he executed the request, but remained in the same position 
 till changed by some one else. 
 
 The following day nothing more of these appearances was present, 
 but paresis of the right arm was developed to complete paralysis ex- 
 tending to both right extremities. Also the partial paresis of the region 
 of the face was increased and fully developed, the next day. All the 
 other functions of the body were entirely normal. Examination of the 
 organs of the chest and abdomen revealed nothing out of the natural 
 order. The heart sounds were especially clear, and the extent of dull- 
 ness normal. Urine was acid, of a pale brown color, containing nothing 
 abnormal. Temperature 38.2 Cel., pulse 94. 
 
 On account of the named syphiloids and the retinitis, and a deficiency 
 of any other etiological cause for the apoplectic symptoms, I thought 
 myself justifiable in diagnosing syphilitic disease of the brain , and there- 
 
SYPHILITIC AFFECTIONS OF THE BRAIN. 
 
 201 
 
 fore I began at once the antisyphilitic cure with injections of sublimate 
 in doses varying from J gr. to \ gr. each. 
 
 After using 2 gr. I could notice some change for the better. The 
 sensorium was free ; the patient could execute movements in the sound 
 part with quick and exact cordination of the muscles ; the function of 
 speech returned, but in a slight degree. Single, short words like “ good,” 
 and “ thank,” he could speak plainly without stammering ; also the 
 paresis of the facialis was greatly diminished, the corrugator supercilli 
 and frontalis regained their function. The right eyelid from long closure 
 trembled and had an unsteady motion. The muscles, labii superioris, 
 alaeque nasi, zygomatici, &c., were still under the influence of the paresis. 
 The point of the tongue was still a good deal drawn towards the right 
 when thrust from the mouth. The movement of the right lower extremi- 
 ties was somewhat improved, but the left less so. Vision in the affected 
 eye was much better, and the mental capacity almost wholly restored. 
 After using 2 gr. more the patient was able to flex the right forearm to 
 a right angle, but he could not raise the upper arm himself nor bend a 
 finger in the hand. The patient was not able to stand erect. He can 
 take only a few steps when supported on the right side ; tongue drawn 
 towards the right when extended ; articulation in short sentences, slow 
 but indistinct. The alphabet he repeats to the letter U T,” when he gets 
 uneasy, moves the head in an unquiet way, and afterwards the whole 
 body trembles. The situation of the mouth is a trifle one-sided, and 
 the right nostril slightly dilatable. All the muscles about the face 
 work, excepting the musculus risorius santorini. After using 4 gr. more, 
 the retinitis was completely gone ) and the yet existing paresis appearances of the 
 facialis and tongue had entirely disappeared , but articulation was rather 
 difficult. The muscles which elevate the arm, and the extensors of the 
 fingers were not quite restored, notwithstanding the use of electricity. 
 The right foot also was dragged along in walking. 
 
 As I did not expect a further result from my antisyphilitic treatment, 
 
 I sent the patient for further faradisation to the nervous wards of Pro- 
 fessor Westphal. 
 
202 
 
 RESPECTING SUBLIMATE INJECTIONS. 
 
 VI. — CONSIDERATIONS RESPECTING SUBLIMATE 
 INJECTIONS. 
 
 Haying already considered the general pharmacodynamic 
 effect of sublimate on the healthy and diseased organs, and 
 the eventualities of a pernicious effect of this medication on 
 the blood, nervous system and other organs, it seems, at a 
 first glance, unnecessary to discuss again the question of 
 contraindication. But I consider it necessary to name here 
 special momenta in which injections of sublimate are either 
 partly or wholly contraindicated. These momenta are espe- 
 cially age, sex, dyscrasia or already existing diseases. 
 
 Age. — Generally I never treated children in their first 
 years of life with injections, although such experiments 
 have been made, I hear, in Vienna with complete success. 
 I refrained here from giving the injections, because a part 
 of the advantages to be gained with the adult — as the ability 
 to work, &c. — does not pertain to the age of childhood ; and 
 the pain of the operation is to be borne in mind, on account 
 of the will power to withstand it being absent in the young 
 organism. As yet, I have only treated one child, a girl of 
 seven years, with the injections, and seeing that I would 
 need to use a large number of them, I desisted on account 
 of her great sensitiveness. 
 
 The Sex deserves some consideration, the female organ- 
 ism requiring less than the male. But I have frequently 
 observed elsewhere as here, that women generally withstand 
 and endure the pain better than men. Considering men- 
 struation and pregnancy , and the effects of injections as 
 connected therewith, I will describe them more fully in 
 another chapter. I can say that menstruation is not at all 
 
RESPECTING SUBLIMATE INJECTIONS. 
 
 203 
 
 a contraindication for the subcutaneous treatment, since the 
 catamenia are neither increased nor diminished thereby. 
 Neither can I say that the hypodermic medication will 
 either induce, or augment an already existing irritability of 
 the ovaries and uterus. 
 
 Acute Diseases, which happened to syphilitics — as, for 
 instance, inflammation of the respiratory, circulatory and 
 digestive organs, exanthemic fever, &c. — are always a con- 
 traindication for the injection. Chronic or acute diarrhoea, 
 or a disposition towards it, must be taken as a contraindica- 
 tion, or at least the utmost care and judgment are necessary, 
 if the hypodermic medication is employed, bearing in mind 
 that relatively small doses of sublimate may produce here 
 toxicological effects — as when abnormally large doses are 
 taken by a healthy, robust individual. 
 
 Acute Articular Rheumatism is not a contraindica- 
 tion. Several observations have revealed the fact that the 
 curative effects of the injection were as favorable in rheu- 
 matic as in syphilitic ailments. In Case No. 9 I have men- 
 tioned such a result, and I have treated two similar cases 
 with the same good results. 
 
 In cases where a dyscrasia combines syphilis with itself, 
 it is necessary to make a thorough examination, as ought to 
 be done before using any antisyphilitic cure, in order to 
 ascertain whether the dyscrasic condition appeared before , 
 simultaneously or after the manifestations of syphilis . This 
 examination requires much care, because it is well known 
 that other pathological diseases originate from different 
 causes, and that they are very difficult to distinguish from 
 the polymorphous lues, e. g . syphilitic adenitis, resembling 
 scrofulosis. Anaemia, chlorosis, leucaemia and other patho- 
 logical changes in different organs, as already stated in the 
 
204 
 
 RESPECTING SUBLIMATE INJECTIONS. 
 
 chapters on visceral syphilis, give but little margin for a 
 differential diagnosis from syphilitic blood alteration and 
 disease. The therapeutics should be modified according to 
 the diagnosis. Here my method has a great advantage over 
 others, since I may combine with it any other treatment ; 
 as, for instance, in a combination of scrofula with syphilis, I 
 may use at the same time iodide of potassium, cod-liver oil, 
 &c. ; or, with anaemic females, I can use relatively smaller 
 doses of the sublimate, and conjointly give internally iron, 
 &c. ; use baths, &c. Concerning the disease commonly 
 called tuberculosis , I have but three cases that I shall 
 report : 
 
 Case 72. — Herman B., a cigarmaker, was received into our wards 
 August 5th, 1868, he having suffered three years previously from a 
 hard chancre, and using only local remedies for it. Later, spots ap- 
 peared upon the body ; slight scaling off of the epidermis on the penis ; 
 pain in the throat also, which complaints were but little heeded by 
 the patient, and therefore they received no treatment. Two years sub* 
 sequently the patient was attacked with inflammation of the lungs, in 
 consequence of which a cachectic and tuberculous condition was de- 
 veloped. During the last six months he has had ulcers on the skin, for 
 which he used, with good result, mercurial pills. Patient has now a 
 cachectic appearance ; flabby muscles ; dull eyes ; stooping gait ; a flat 
 paralytic thorax ; but little adipose tissue, and is a complete picture of 
 phthisis. On the described paralytic thorax , near the fifth and sixth right 
 ribs , there is a flattened depression. Here percussion gives the 11 cracked pot” 
 sound , and auscultation detects mucous rales. . Of syphilitic appearances we 
 see on the skin a great number of ulcers, of the size of a penny, covered 
 partly with pyramidal rupial crusts and partly with dried pus. On the 
 scalp the ulcers are of less size, but reach deeper into the tissue. The 
 hair is but sparsely present. The erythema of the fauces and the ero- 
 sions of the mucous membrane much resemble a stomatitis produced by 
 mercury, which also may have caused the swelling of the mucous mem- 
 brane about the teeth. 
 
 Notwithstanding the existence of vomicse of the lungs, we did not 
 hesitate to use the sublimate injections with the patient, and began the 
 
RESPECTING SUBLIMATE INJECTIONS. 
 
 205 
 
 same August 5th with the relatively large doses of \ gr. We were soon 
 compelled to pause on account of salivation, and when we resumed 
 treatment we reduced the dose to J gr. We paused but once again (for 
 four days), when we detected blood in the sputa. After using 3J grs. 
 of sublimate, we had the pleasure to see the patient rid of all syphilitic 
 affections. During the whole period the patient felt very comfortable. 
 Only once did the cough increase, on account of taking a cold, but it 
 soon assumed its normal character. The appearance of the patient was 
 improved, and his weight, which, at the beginning of the treatment, 
 diminished a trifle, soon increased to its former standard. His lung 
 difficulty remained unaltered by the cure. 
 
 Although I remarked, page 41, where I treated of diet- 
 etic rules at length, that inebriates seemed to withstand the 
 injection treatment quite well, and therefore alcoholism is no 
 contraindication , giving Case 47 as an example, — I wish 
 also to publish here a second case, in which the patient, 
 an inebriate, suffered from caries that might have been 
 syphilitic. 
 
 Case 73. — John K., a laborer, thirty-eight years old ; from a healthy 
 family; is, according to his own testimony, very intemperate, having 
 been already twice treated in our hospital for delirium tremens. 
 
 His first syphilitic infection dates back to the year 1862. It vanished 
 entirely, except leaving a syphilitic induration. For the ulceration, 
 and also for the later arising relapses, in the form of exanthema, he 
 used here in the Charite nothing else than a botanic treatment. At 
 the time of admission, the patient has a crustaceous exanthem, which 
 is over the entire body, in the form of small efflorescences ; also psoriasis 
 palmaris and plantaris. Two weeks before, the patient had inflamma- 
 tion of the joint between the first and second phalanges of the little 
 finger on the left hand, which was excessively painful. Examination 
 here reveals much swelling, and crepitation by rubbing the second and 
 third phalanxes together. 
 
 Although the patient suffered a week prior to admission into our wards with 
 delirium tremens, and was directly transferred from the so-called A delirium 
 room ” I used at once the hypodermic injections of sublimate , without allowing 
 him any alcoholic drinks. We used altogether twenty injections of J gr. 
 
 18 
 
206 
 
 QUANTITY OF SUBLIMATE TO BE INJECTED. 
 
 of sublimate each, which produced the disappearance of the described 
 exanthem, while the disease of the joint did not increase nor materially 
 abate. 
 
 VII.— quantity op sublimate to be injected. 
 
 Having, in my therapeutical endeavors, the principal aim 
 to find a method for the sure and quick healing of syphilis, 
 I have not restrained myself, in my experiments, to the 
 trial of subcutaneous injections of sublimate alone, but have 
 combined it also either with the internal use of iodide of 
 potassium , or with a sarsaparilla sweat-cure, preceding the 
 injection treatment or simultaneously ivith it. Besides, I 
 have given some patients chlorate of potassa, and others, 
 tannin, in order to prevent the troublesome and deleterious 
 effects of salivation. 
 
 For each of these combination cures a number of patients 
 were selected. 
 
 The following tabulated statement is the best proof of the 
 results obtained, by means of the combined methods, in 
 eight hundred cases (six hundred being women and two hun- 
 dred men). These eight hundred patients are the material 
 from which the following statistical tables are arranged. 
 
 I have taken only these eight hundred patients, because 
 their treatment commences in the year 1865 and continues 
 to the end of 1867, thus giving me, since their treatment, 
 up to the time of the publication of this work, three years, 
 two years and one year, respectively, in which I have had 
 opportunity to observe a greater number of possible relapses 
 than I possibly could have had, had I tabulated cases treated 
 since 1867. 
 
QUANTITY OF SUBLIMATE TO BE INJECTED, 
 
 207 
 
 QUANTITY OF SUBLIMATE. 
 
 
 
 WOMEN. 
 
 
 
 MEN. 
 
 
 CLASSES. 
 
 Number 
 
 of 
 
 Cases. 
 
 Total of Sublimate 
 
 Injected. 
 
 Average Quantity- 
 
 Injected. 
 
 Number 
 
 of 
 
 Cases. 
 
 Total of Sublimate 
 
 Injected. 
 
 Average Quantity 
 
 Injected. 
 
 I. Cases in which subli- 
 mate alone was injected, 
 without any other medi- 
 cation 
 
 134 
 
 336} 
 
 Grains. 
 
 2} 
 
 34 
 
 103| 
 
 Grains. 
 
 3 
 
 II. Cases where the sub- 
 cutaneous injection was 
 preceded by a sarsapa- 
 'rilla sweat-cure . . . 
 
 58 
 
 122J 
 
 2* 
 
 33 
 
 70} 
 
 2J 
 
 III. Cases in which the so 
 called hunger-cure pre- 
 ceded the subcutaneous 
 injection method . . 
 
 
 
 33 
 
 79} 
 
 2§ 
 
 IY. Cases in which the 
 subcutaneous injection 
 was used simultaneously 
 with the sarsaparilla 
 sweat-cure 
 
 24 
 
 55} 
 
 a* 
 
 14 
 
 33 A 
 
 2f 
 
 Y. Cases in which iodide 
 of potassium was used 
 internally, in addition 
 to the subcutaneous in- 
 jection of sublimate . . 
 
 90 
 
 151f 
 
 i} 
 
 12 
 
 27} 
 
 2} 
 
 YI. Cases in which the 
 subcutaneous injection 
 was used with internal 
 use of chlorate of po- 
 tassa 
 
 185 
 
 400} 
 
 2} 
 
 34 
 
 86 
 
 
 VII. Cases in which mor- 
 phine was used with the 
 injected fluid and tannin 
 internally 
 
 62 
 
 116} 
 
 1t 9 (T 
 
 25 
 
 41} 
 
 if 
 
 VIII. Cases in which the 
 internal use of iodide of 
 potassium with the sub- 
 cutaneous injection was 
 preceded by a sarsapa- 
 rilla sweat-cure . . . 
 
 34 
 
 50} 
 
 i} 
 
 
 
208 
 
 QUANTITY OF SUBLIMATE TO BE INJECTED. 
 
 QUANTITY OF SUBLIMATE — continued. 
 
 
 
 WOMEN. 
 
 
 
 MEN. 
 
 
 CLASSES. 
 
 Number 
 
 of 
 
 Cases. 
 
 Total of Sublimate 
 
 Injected. 
 
 Average Quantity 
 
 Injected. 
 
 Number 
 
 of 
 
 Cases. 
 
 Total of Sublimate 
 
 Injected. 
 
 Average Quantity 
 
 Injected. 
 
 IX. Cases where the in- 
 ternal use of chlorate 
 of potassa, with subli- 
 mate injection, was pre- 
 ceded by a sarsaparilla 
 sweat-cure 
 
 13 
 
 28J 
 
 Grains. 
 
 21 
 
 5 
 
 101 
 
 Grains. 
 
 2?V 
 
 X. Cases in which the use 
 of iodide of potassium, 
 with injection of subli- 
 mate, was preceded by 
 the so called hunger- 
 cure 
 
 
 
 
 10 
 
 161 
 
 It 
 
 Total 
 
 600 
 
 1272 
 
 21 
 
 200 
 
 4681 
 
 21 
 
 The quantity of the injected sublimate with two hundred 
 male patients was 468J grs., or for each patient m g^., 
 or about 2J grs. of sublimate was used, by which the visible 
 symptoms of syphilis were destroyed. 
 
 The quantity of sublimate given to six hundred female 
 patients was 1272 grs., or for each patient 2 5 3 g grs., or 
 about 2^ grs. of sublimate. 
 
 This difference of it gr. about \ gr. (equal to two syringes 
 full of the solution No. 2) in favor of the female patient, is 
 augmented from £ gr. to J gr., when we consider the re- 
 latively great quantities of sublimate, which was necessary 
 for some female patients, on account of their very extensive 
 and very obstinate syphilitic formations. 
 
QUANTITY OF SUBLIMATE TO BE INJECTED. 
 
 209 
 
 The therapeutical result varies in the different classes , ar- 
 ranged according to the different combination cures employed. 
 Here, however, we should naturally consider the greatness or 
 smallness of the treated affection to fully judge of the produced 
 effect. A glance at the tables shows the average quantity 
 necessary for a cure ranges between the amount of 3 grs. and 
 1} gr. We see further that, patients of the first class, i. e. y 
 such as were treated with the subcutaneous injections alone, 
 needed a larger quantity of sublimate to effect a cure, the 
 female patients receiving 2J grs., and the male 3 grs. 
 
 By the remaining eight classes, females as well as males, 
 the quantity of injected sublimate is somewhat reduced in 
 those patients who had previously to the injection undergone 
 a sarsaparilla sweat-cure. Although these same patients, as 
 we will show further on, had somew T hat fewer relapses, this 
 advantage, together with the small fractional amount of sub- 
 limate saved, is so insignificant, that it would be more than 
 irrational to subject a patient, before using our sublimate 
 injection method, to that cure which takes about four weeks. 
 Aside from its costliness, and the length of time necessary, 
 it rather weakens the patient and subjects him to colds, as 
 we have had occasion to notice. 
 
 The class in question contained, to a large extent, patients 
 who suffered but slightly with syphilis, or with the affection 
 of that type which was readily amenable to treatment. 
 
 The most favorable results we see in those patients who 
 used either iodide of potassium , or tannin in conjunction 
 with the hypodermic medication , (classes v., vii. andix.) The 
 latter had the addition of morphia to the sublimate. But as 
 iodide of potassium augmented the disposition to salivation, 
 and the inclination to relapses, and as tannin may produce 
 disturbances in the digestive apparatus, their advantages are 
 
 18 * 
 
210 
 
 RELAPSES OF SYPHILIS. 
 
 balanced by their disadvantages, and, therefore, the final con- 
 clusion is that, with the simple subcutaneous injection neither 
 another cure ought to precede nor be combined with it , but for 
 lessening pain and relapse, small doses of morphia may be 
 added to the sublimate. 
 
 YIIL— RELAPSES OF SYPHILIS. 
 
 “ Relapses occurring after every treatment, are not the 
 exception , but the rule . Yes, for a century, investigation 
 has been going on, and in recent times, as in the times of 
 Ulrich von Huttens, the frequency of relapses is the worst 
 curse appertaining to this disease.” 
 
 This saying of Yon Bmrensprung, is almost identical with 
 the assertions of French syphilographs, and stands as a fixed 
 law concerning the frequency of relapses, (la loi des recidives) 
 which is not only a constant threat for the layman, filling 
 him with gloomy forebodings of the future, but is the great 
 complaint of the physician, and robs him of the satisfaction 
 he might feel in the accomplished cure. 
 
 To solve the question how the number of relapses occur- 
 ring with my treatment, compares with other antisyphilitic 
 treatments, a statistical basis is particularly demanded. But 
 to obtain statistics in this particular branch of medicine, 
 syphilis, is not very easy. The great difficulty arises from 
 the fact, that the largest number of patients who suffer from 
 a syphilitic relapse, condemn the formerly received medical 
 treatment and go to other doctors, hoping thereby to get 
 radically cured. There are certain classes of persons who 
 are obliged to undergo in sickness a special treatment in 
 hospitals set apart for them, I mean those persons under 
 police surveillance, the puellae publics, and soldiers; but even 
 
RELAPSES OF SYPHILIS. 
 
 211 
 
 here circumstances happen which make the gathering of 
 statistics difficult or even impossible. 
 
 As to the mentioned prostitutes, they know only too well 
 how to evade a police control; and in the larger cities, with 
 the exception of Berlin, there are more syphilitic hospitals 
 than one where the patients have their choice — indulging 
 very readily in the tempting principle of change. 
 
 Concerning soldiers who are obliged to undergo treatment 
 in military hospitals, their time of service is too short to give 
 clear and sufficient observations for studying syphilitic re- 
 lapses. 
 
 The first statistical resources that we find in our medical 
 literature have already these shortcomings. They are the 
 published records of French military surgeons of the begin- 
 ning of the present century, as Devergie, Barthelemie, Des- 
 ruelles, &c., about relapses occurring with mercurial or anti- 
 mercurial treatment in soldiers treated by them. But the 
 soldier remains only two years in Paris in garrison. There 
 is another momentum to be considered, which further dam- 
 ages the value of their statistics. The authors were earnest 
 adherents to Broussais ’ Inflammatory Theory , taking lues 
 for an inflammatory process, as they did every manner of 
 genesis and duration of the disease. They stated no dis- 
 tinction between a primary and a well marked constitutional 
 syphilis, and as a consequence they had really syphilitic re- 
 lapses equally divided for patients of every description. 
 Among the 6000 patients whose cases were tabulated by 
 Devergie for proving his assertion of the favorable circum- 
 stances resulting from the antisyphilitic treatment, there are, 
 in point of fact, nearly 5000 who were affected only with 
 gonorrhoea, epididymitis, acuminata, &c., in whom relapses, 
 in one sense, are not to be mentioned. By reduction of the 
 
212 
 
 RELAPSES OE SYPHILIS. 
 
 patients from 6000 to 1000, the percentage of Devergie’s 
 relapses will rise from 7 per cent, to 35 per cent. But even 
 this high number is not yet free from error, because those 
 syphilographs, the images of our present anti-mercurialists, 
 combated, in abstractor against the use of mercury, but never- 
 theless, not only used it in such cases, as we to-day see an 
 indication for its use, for instance, “if, during the simple 
 treatment, red spots, papules or pustules appear,” but even 
 they employed it in local affections which “have. arisen after 
 a very short state of incubation,” or “which have withstood 
 other local treatment for quite a time.” (Desruelles.) 
 
 The same error we find in the statistical references of the 
 English physicians. All through, like a red thread, we find 
 the mistake between primary and secondary syphilis. We 
 find always the contradiction of charging mercury to be the 
 cause of “the malignant course of syphilis and relapses,” 
 and after all proclaiming it as the ultimum refugium for the 
 malignant forms. 
 
 But how far a partisan predilection and one-sidedness may 
 bring about real drastic delusions, we see in the well known 
 statement of Fergusson’s, during his stay in Spain and Portu- 
 gal, which paints up the result of the non-mercurial treat- 
 ment in a very rose-colored way, so that it has caused the 
 quick-spreading of the so-called “simple treatment.” But 
 even now the small remaining number of Furgusson’s ad- 
 mirers do not yet see that he not only observed very super- 
 ficially, but also that his assertions were in complete contra- 
 diction with his own English colleagues serving in Spain, as 
 well as with the native Spanish physicians. 
 
 Concerning the statements of other English physicians 
 serving in the army , they, too, are not of any real value. 
 This is the case with the official statement of Thom. Clarke, 
 
RELAPSES OF SYPHILIS. 
 
 213 
 
 about 338 patients treated by him, during the years 1829 to 
 1832, of whom only 46 persons suffered with real syphilis ; 
 so also with other pamphlets published by Gregor & W. 
 Franklin. 
 
 But we must recognise, too, that English surgeons sooner 
 abondoned the anti-mercurial treatment than the continental 
 physicians. The discussion of the Medical Society of London, 
 on the 9th December, 1839, is indicative of this change of 
 opinion. Dendy, one of the warmest defenders of a dietetic 
 treatment, asserts that he has arrived at the conclusion that 
 mercury is the surest remedy for the healing of syphilis, and 
 against relapses, — an assertion which was accepted by all 
 medical authorities of that time, without much opposition. 
 
 As to other countries on the continent, the Swedish sur- 
 geons give the most minute details in reference to relapses 
 after different antisyphilitic remedies. The Royal Sanitary 
 Commission tables comprise 46,687 cases. But even here 
 we miss the distinction between local and syphilitic affections, 
 and therefore, those published tables where, after a non- 
 mercurial treatment only, 16 per cent, of relapses occurred, 
 are of no value whatever, and we meet here at the same time, 
 the curious final assertion that in a great number of cases, 
 mercury was equally useful and important. 
 
 Of Italian surgeons , only Calderini, hospital surgeon at 
 Milan, has published a statistical work based on cases 
 treated there. There were 1050 patients, of whom 524 were 
 treated with mercury, and 526 according to the antisyphilitic 
 method. 
 
 As we have seen, in all these statements there is no reli- 
 ance, and even our most recent investigations have either 
 given very scant statistical tables, or they have been actuated 
 by a partisan spirit. This is particularly the case with Her- 
 
214 
 
 RELAPSES OF SYPHILIS. 
 
 mann, of Vienna, so that his assertions cannot claim a scien- 
 tific consideration. In the beginning of his work, entitled, 
 “The Mercurial Diseases,” (Vienna, 1865,) we find the fol- 
 lowing curious statement : 
 
 “ Of the whole number of patients treated in the years 
 from 1856 to 1864, amounting to 7796 patients, there came 
 during a period of six years 335 persons twice, 70 persons 
 three times, 30 persons four times, 8 persons five times, and 
 3 persons six times to our hospital. In all these cases fresh 
 infections took place , and in none was there a real relapse , or 
 a higher degree of development of the existing forms of syphi- 
 lis ” 
 
 Diday,* who advocated a modified mercurial treatment, 
 and an expectant kind, is rather small concerning statistics, 
 but after all has a certain significance : 
 
 “ Of 43 patients accurately watched and expectantly 
 treated, 3 patients, 7 per cent, did not relapse ; 40 patients, 
 93 per cent, did relapse, to whom there occurred two re- 
 lapses to 17 patients, three relapses to 12 patients, four re- 
 lapses to 4 patients, and seven relapses to 6 patients. With 
 these relapsing patients syphilis ran in a mild form in 23 
 cases, 57.5 per cent. ; in a severe form in 17 cases, 42.5 per 
 cent. ; in a tertiary form in 4 cases, 4 per cent. So that 
 finally as an ultima ratio, mercury was taken; il avait finale- 
 men t fallu y avoir recours.” 
 
 Yvaren’sf statistical material comprises 150 relapses in 
 the form of inveterately severe lues, 35 cases were treated 
 without mercury; in 31 cases mercury was given irregularly 
 
 * Historie Naturelle de la Syphilis. Paris, 1863, p. 138. 
 
 | Yvafen, Traite sur les Metamorphoses de la Syphilis, Paris, 1854 ; 
 Kussmaul, p. 24 ; Bazin, p. 130. 
 
RELAPSES OE SYPHILIS. 
 
 215 
 
 and insufficiently; in 17 cases it was given in appropriate 
 doses. 
 
 But how little mercury was the cause of the severity of 
 the lues was clearly shown by the fact that, by the repeated 
 use of mercury 80 patients of the above number were com- 
 pletely cured. 
 
 A further proof that mercury does not cause relapses in 
 syphilis we find by the well known Danish author, En- 
 gelstedt. He says that the severest and the most obstinate re- 
 lapses occur only in persons in whom the primary constitu- 
 tional symptoms, light in themselves, were not treated with 
 an energetic, especially a mercurial medication, “ and the 
 disuse of mercury favors the relapses of syphilis .” In the 
 translation of Uterhardt,* numbers are rather uncertain in 
 their expression of percentage of both the relapses, and the 
 absolute cures, and therefore valueless. He says relapses 
 occurred, after using sublimate, 55 times; after using calo- 
 mel, 35 times; after using inunction cure, 4 times, and after 
 using an undescribed mercurial preparation, 20 times. 
 
 A work which, by its great exterior, captivates for the 
 first moment, but by a more careful perusal loses its signi- 
 ficance for our purpose, is that one written with so great 
 diligence, viz.: “Recherches sur la Syphilis appuj^es de 
 tableaux de statistique tir£s des archives des hopitaux de 
 Christiania, par W. Boeck.” But those 3000 cases were 
 written in a time when an exact observation according to 
 the present state of science was impossible. The Norwegian 
 author has, in publishing his work, the object to popularize 
 the excellency of his method, “syphilization,” as may be seen 
 by the following table, which one of the most enthusiastic 
 
 * Hie Constitutionellc Syphilis nacli klinischen Untersucliungen. 
 Uebersetzt von C. Uterhardt, Wurzburg, 1861 . 
 
216 
 
 RELAPSES OF SYPHILIS. 
 
 admirer-s of the method, Auzias Turenne, has published in 
 his “Recueil des travaux de la -Society medicale allemande 
 de Paris,” (1865): 
 
 & 
 
 o 
 
 i — i 
 
 EH 
 < 
 I— I 
 
 3 
 
 P-l 
 
 t* 
 
 U1 
 
 Therapeutics. 
 
 Number 
 
 of 
 
 Cases. 
 
 Average 
 
 duration. 
 
 Relapses. 
 
 Deaths. 
 
 Number 
 
 of 
 
 Cases. 
 
 Percentage. 
 
 Number 
 
 of 
 
 Cases. 
 
 Percentage. 
 
 
 
 days. 
 
 
 
 
 
 Mercury 
 
 3200 
 
 125 
 
 1036 
 
 32 
 
 108 
 
 Q3 
 
 
 
 
 
 (32.375) 
 
 
 
 Iodide of Potas’m 
 
 186 
 
 108 
 
 40 
 
 21 
 
 2 
 
 1 
 
 
 
 
 
 (21.5) 
 
 
 
 ' Without the pre- 
 
 ) 
 
 
 
 
 
 
 ceding use of 
 
 V252 
 
 134 
 
 23 
 
 H 
 
 
 
 mercury 
 
 J 
 
 
 
 (9.127) 
 
 
 
 In relapses after 
 
 \ 54 
 
 191 
 
 10 
 
 18 J 
 
 
 
 using mercury 
 
 / 
 
 
 
 (18.33) 
 
 
 
 Without result 
 
 I 
 
 
 
 
 
 
 after using mer- 
 
 r 6 
 
 347 
 
 2 
 
 33* 
 
 
 
 cury 
 
 J 
 
 
 
 (33.33) 
 
 
 
 Tartarization 
 
 157 
 
 178 
 
 31 
 
 20 
 
 
 
 
 
 
 
 (19.745) 
 
 
 
 Syphilization is, according to its author in regard to re- 
 lapses, almost a preventive, but the contradiction of it is 
 apparent when we read Turenne’s assertion, “En outre de 
 cette maniere les chances de r^cedive sont reduites a presque 
 rien ; car dans les trois dernieres ann£es pendant lesquelles 
 M. Boeck s’est born£ a l’inoculation de la matierede chancres 
 indures, iln’a pas mentionne une seule recidive tandis que 
 dans sept ou huit annees precedentes . . . . le nombre des 
 recidives montait &neuf et demi pour 100,” and more so 
 when we compare it with other reliable authors. But Boeck, 
 
KELAPSES OF SYPHILIS. 
 
 217 
 
 in a conversation with Lancereaux (Traite histor. et prat de 
 la Syphilis, Paris, 1866, p. 749), says that the number of 
 relapses are about twelve or thirteen per cent., and that ac- 
 cords with Boeck’s own statement in the year 1860 : “De 
 la Syphilisation etat actuel et statistique.’ , 
 
 A. Oewre (Med. Times and Gazette, 1868, p. 929),* bases 
 his assertion that syphilization exerts no influence over 
 syphilis, chiefly on the fact of so frequent relapses of syphilis. 
 
 In recent times Depres has spoken emphatically against 
 the use of mercury in the discussions of the Societe Im- 
 perial de Chirugie at Paris, in 1867, and imputed to mer- 
 cury the most obstinate and frequent relapses. Full of zeal 
 for statistical arguments against this drug, he undertook 
 several raids upon the different hospitals of Paris, but neither 
 in the “ Hospital de Lourcine,” nor “ Hospital de St. Louis,” 
 could he find any statistical proof. His travels were a piti- 
 able odyssey. Against his own statistical observations which 
 he made, during eighteen months at the “ Lourcine, ” im- 
 portant objections were made. The statistics he made at 
 Hillairet’s wards in the “ St. Louis Hospital,” were disavowed 
 by Hillairet himself. As to the conclusions which Desprds 
 drew from two hundred and forty-seven cases observed, 
 which observations he received from Laillier, chief surgeon 
 at the “ St. Louis Hospital,” the latter wrote a letter to 
 Blot, in which he denies all responsibility. 
 
 As conclusively shown, there is an evident lack of reliable 
 statistical references, and therefore I am obliged to get 
 comparative starting points for my method, procuring the 
 material in my own way. For this end I have used the 
 extensive material of the “ Registration of the Berlin 
 
 * Archiv fur Dermatologic und Syphilis von Auspitz und Pick, 18G9, 
 1 Jahrg, 1 Hft. S. 135. 
 
 19 
 
218 
 
 RELAPSES OF SYPHILIS. 
 
 Charity” in which the history of all cases for the last 
 twenty years is fully preserved. From out of this abun- 
 dance I have selected only two thousand suitable cases, 
 which I have rearranged in tabular form, showing the affec- 
 tions, the instituted treatment and the intervals between the 
 single relapses. 
 
 With such a clear pathological curriculum vitae of two 
 thousand patients, I could follow syphilis from its very 
 incipiency to its later stages of development — from the 
 sclerosis on the genitals to the final phases of visceral 
 syphilis and forms producing a fatal issue. I have only 
 taken female patients for my statistical material, because 
 the male patients are free from all police surveillance, and 
 therefore could not be as reliable as to estimating the pro- 
 portion of relapses. 
 
 By a closer examination of this female material, I found 
 some errors ; as, for instance, a lack of precision in diag- 
 nosis and therapeutics, as recorded ; so that, with the cases 
 where care was taken, I could use only 1420 patients for 
 the purpose of my statistics. One-half used the sarsaparilla 
 sweat-cure .* 
 
 The statistical results from this treatment, in reference to 
 relapses of syphilis, are as follows : 
 
 Of the 710 patients who have used a sarsaparilla sweat- 
 cure, 456 women, or 64.22 per cent., had relapses of 
 
 * Von Baerensprung used generally a decoction of 
 R. Rad. sarsaparillae ; 
 
 Spec, ad decoct, ligni, aa 5ii 5 
 Rad. caricis, 5 SS 5 
 Fol. sennae, gj ; 
 
 Aqua distill, lb.j. 
 
 After using this decoction, the patient must remain, in the morning, 
 wrapped in woollen blankets, and sweat for one or two hours. 
 
RELAPSES OF SYPHILIS. 
 
 219 
 
 syphilis — occurring once in 260 patients, or 36.62 per 
 cent. ; twice in 81 patients, or 11.4 per cent. ; three or 
 more times in 115 patients, or 16.19 per cent. 
 
 Patients who were treated with mercurial preparations,* 
 there occurred, in 710 patients, relapses with 464 persons, 
 or 65.35 per cent. ; once in 203 patients, or 28.6 per cent. ; 
 twice in 116 patients, or 16.34 per cent. ; three or more 
 times in 145 patients, or 20.42 per cent. 
 
 According to this we perceive that, after a mercurial and 
 a botanic treatment, the relapses are almost equal, i. e. on 
 an average of about 65 per cent. 
 
 This number, high as it is, may not, after all, give the 
 right proportion. Among these 1420 patients, nearly 350 
 were women who came of their own accord , without any 
 interposition of the police, to the Charity. They were partly 
 servants and partly married women. Of this number only 
 50 persons, or 14J per cent., returned, on account of a 
 recurring sickness, into the Charite ; so that the remainder, 
 if they had a relapse, probably sought relief outside of the 
 hospital. 
 
 Deducting these 350 women, and we see that in 1070 
 patients, 870, or 81.3 per cent., w T ere taken with relapses. 
 But if we consider that even surgical surveillance may over- 
 
 * The preparations of mercury were different. We mostly used it 
 internally, as hydrargyrum iodat. flav. (Simon, V. Baerensprung) ; hy- 
 drargyr. chlor. mite (Simon) ; hydrargyr. bichlorat. corrosiv. (V. Bae- 
 rensprung) ; hydrarg. albuminat. (V. Baerensprung) ; unguent, hydrarg. 
 cinererum. The ratio, as given, are about as follows: 
 
 Hydrargy. iodat. flav. to of the cases ; 
 
 11 bichlorat. corrosiv. to A of the cases ; 
 
 11 chlorat. mite to of the cases ; 
 
 “ albuminat. to ^ of the cases ; 
 
 Inunction cure to ^ of the cases. 
 
220 
 
 RELAPSES OF SYPHILIS. 
 
 look certain syphilitic affections, e . g . small hidden plaques 
 muqueuses on the pharynx, or some syphiloid may not be 
 recognised ; and again, some prostitutes evade, for a longer 
 or shorter time, police surveillance by sharp practice. We 
 do not think the figures too high, when we fix the percentage 
 of relapses from 81 to 90 per cent. 
 
 The small difference of 1.4 per cent, in favor of the 
 botanic treatment is more than overbalanced when we con- 
 sider the circumstance that the latter treatment has been in 
 vogue only since the year 1858 ; so that all the relapses 
 following this treatment could not have taken place in the 
 relatively short period of five years. 
 
 But patients treated, between the years 1845 and 1858, 
 with mercury, we can assume with certainty that with them 
 the syphilis is entirely eradicated. 
 
 The numerical proportion of the patients who not only 
 once, but several times have been attacked with syphilis, is 
 the following : 
 
 Of 456 persons who have been treated with mercury, 1010 
 relapses have to be divided, so that two relapses occur to 
 each individual. Of 430 persons who have been treated 
 botanically, only 859 relapses take place ; so that here there 
 are two relapses for every patient. 
 
 A second important question is, in what length of time do 
 relapses appear after a botanic and after a mercurial cure ? 
 This examination is, aside from its absolute value, in refer- 
 ence to the relatively high value of each. 
 
 We commenced our injection treatment already in the 
 year 1865, but we treated then only 41 persons. The 
 remaining 560 patients, who are counted in the relapses, we 
 used this treatment upon in the following years, 1866 and 
 1867. But as in the expired time of respectively four, three 
 
RELAPSES 
 
I. 
 
 II. 
 
 Patients who received only 
 sublimate injections. 
 
 Patients with the subl 
 mate injection and sa 
 8aparilla sweat-cure. 
 
 Total. 
 
 When received. 
 
 
 No. of patients. 
 
 No. under police 
 surveillance. 
 
 No. of relapses. 
 
 Percentage. 
 
 No. of patients. 
 
 No. under police 
 surveillance. 
 
 No. of relapses. 
 
 Percentage. 
 
 6 
 
 ) 
 
 l 
 
 C 
 
 No. of relapses. 
 
 Percentage. 
 
 A. 
 
 
 
 
 
 
 
 
 
 
 
 
 From Oct. 1st, 1865, to 
 
 
 
 
 
 
 
 
 
 
 
 
 June 30th, 1866, 
 
 19 
 
 15 
 
 7 
 
 46f 
 
 22 
 
 18 
 
 9 
 
 51 
 
 3 
 
 16 
 
 48J 
 
 
 
 
 (8*) 
 
 (53*) 
 
 
 
 (10) 
 
 (55 
 
 
 (17) 
 
 (54) 
 
 From July 1st to Dec. 
 
 
 
 
 
 
 
 
 
 
 
 
 31st, 1866, 
 
 88 
 
 71 
 
 24 
 
 33| 
 
 36 
 
 29 
 
 12 
 
 41 
 
 2 
 
 46 
 
 38 
 
 
 
 
 (27) 
 
 (38) 
 
 
 
 (13) 
 
 (45 
 
 
 (53) 
 
 (43) 
 
 From Jan. 1st to June 
 
 
 
 
 
 
 
 
 
 
 
 
 30th, 1867, 
 
 
 
 
 
 
 
 
 
 0 
 
 62 
 
 36£ 
 
 
 
 
 
 
 
 
 
 
 
 (75) 
 
 (44) 
 
 From July 1st to Dec. 
 
 
 
 
 
 
 
 
 
 
 
 
 31st, 1867, 
 
 27 
 
 23 
 
 10 
 
 43J 
 
 
 
 
 . . 
 
 9 
 
 48 
 
 304 
 
 
 
 
 (12) 
 
 (52) 
 
 
 
 
 ’ 
 
 
 (75) 
 
 (47) 
 
 Total, 
 
 134 
 
 109 
 
 41 
 
 33 
 
 58 
 
 47 
 
 21 
 
 44 
 
 4 
 
 172 
 
 351 
 
 
 
 
 (47) 
 
 (43) 
 
 
 
 (23) 
 
 (49 
 
 
 (220) 
 
 (45) 
 
 * Of the nun 
 
RELAPSES OF SYPHILIS. 
 
 221 
 
 and two years not all the relapses have yet occurred, we 
 have been compelled to estimate those which might occur. 
 
 For this end we selected cases from all the “ sick jour- 
 nals” of the Royal Charite, in which the most accurate 
 observations upon occurring relapses are stated. Of these 
 patients, 456 persons were treated in the years from 1846 
 to 1858 with a mercurial medication, and 404 persons from 
 1858 to 1863 with the sarsaparilla sweat-cure. 
 
 An exact tabular statement of the ascertained result I 
 have published in my former work (Charity Annals, Yol. 
 XIV., p. 556). 
 
 The 780 relapses occurring after botanic treatment were 
 divided into eight different numerical groups , according to 
 the state of the patient between the first treatment and the 
 first relapse, or between the first and second relapse, or 
 between the second and third relapse, &c., up to the eighth. 
 
 The other 1010 relapses , which occurred many years ago , 
 and on account of the instituted mercurial treatment , have to 
 be classed into ten numerical groups , since many of the pa- 
 tients had eight , nine or ten relapses. See Table of Re- 
 lapses. 
 
 For a precise calculation of the intervals occurring be- 
 tween the single groups of relapses, the already mentioned 
 classes were divided into fifteen subdivisions. 
 
 The results which are interesting are the following : 
 
 1. The by far greater number of relapses appeared during 
 the first year after all antisyphilitic cures, and especially 
 after the botanic treatment, in the proportion of 91 per 
 cent. ; mercurial, 83 per cent. Of 11 remaining classes, 
 respectively, 17 per cent, of relapses occurred during the 
 second year. Still, after a mercurial treatment, there is yet 
 
 19 * 
 
222 
 
 RELAPSES OF SYPHILIS. 
 
 seven per cent. ; after a botanic treatment, twelve per cent. 
 The two yet remaining classes, respectively, develop five per 
 cent, of relapses during intervals of many years. According 
 to analogies as to these ascertained results, we calculated 
 what percentage of relapses, after our subcutaneous injec- 
 tions of sublimate, had occurred till now, and what and how 
 many would probably occur. 
 
 In the foregoing table on relapses we show all the relapses 
 occurring till the year 1867, together with the probable total 
 of the yet occurring relapses. To show the result of the 
 combined treatment, we also gave a table. The result as 
 there exhibited, where even the most unfavorable chances for 
 our cure have been given full consideration, is that with a 
 high probability, the number of relapses following the subcu- 
 taneous sublimate injection is , at the highest estimate , but 45 
 per cent ., or 85 per cent . less than with a treatment either 
 mercurial or botanic. 
 
 We separate in this manner & progressive from a regressive 
 syphilis. The latter is always of a milder character and 
 lighter form, as, for instance, the more or less eroded broad 
 condylomes on the genitals, erosions of the mucous mem- 
 brane of the pharynx, superficial disturbances of the skin, 
 especially erythematous and maculous exanthema, and the 
 moderate loss of hair. But the progressive kind to syphilis 
 always takes a deeper hold of the tissues. The broad condy- 
 lomes do not only show superficial erosions, but also deep 
 ulceration. Papulous and squamous infiltration attack the 
 skin, and sometimes gummous iritis develops. But as the 
 farthest progressed, besides visceral syphilis, we must desig- 
 nate those external progresses in which new formations of a 
 gummous nature arise, and the infiltrations show already a 
 tendency to an ulcerative destruction. In this category we 
 class the pustulous efflorescences as occurring in the form of 
 
RELAPSES OF SYPHILIS. 
 
 223 
 
 ecthyma, and rupia ; lupus and deeper diseases of the bones, 
 parenchymatous astitis, gummous orchitis, and affections 
 with which, not very rarely, destructive ulcerations of the 
 pharynx and larynx exist. 
 
 Which character the relapses, after our subcutaneous in- 
 jection have shown, whether they have assumed the character 
 of progressive or regressive syphilis, must be solved by the 
 import of our registered material. 
 
 These records of the ailments of such females as have been 
 visited by the severest forms of syphilis, particularly the 
 tertiary , are of considerable importance. From their thera- 
 peutical anamnesia, I hoped to give some valuable confirm- 
 ations of my object. But my efforts have been crowned only 
 with poor success. The registered records of such patients 
 were in surprisingly small numbers, only 39 being present. 
 These were very incomplete, and very often for fixing the 
 more important anamnestic and therapeutical points, the 
 necessary numbers of the record were wanting.* This was 
 
 * Yon Baerensprung, says, (Annals of the Charite, vol. ix., 1860, p. 191,) 
 li if I overlook the 150 cases of inveterate syphilis which developed into 
 tertiary formations, whose history I have gathered, I find among them 
 122 in which the patient was repeatedly treated with mercury; in four 
 cases nothing could be definitely made out from the anamnesia ; only 
 four cases are among them in which we could assume with any degree 
 of certainty that no mercury at all was used.” 
 
 These 122 cases Yon Baerensprung has probably gathered in* his pri- 
 vate papers. I did not find them among the documents of the Regis- 
 trar’s office ; on the contrary, the number of female patients in whom no 
 mercurial treatment could be made out, I find to be already greater than 
 given by Yon Baerensprung. In the report of the physicians of the Im- 
 perial Royal Hospital at Yienna, of the year 1867, we read on the con- 
 trary, as follows: u Diseases of the bone were observed in cases of 
 secondary syphilis fourteen times in men, and twice in women, among 
 703 patients, of whom only four men had gone through a mercurial 
 treatment, the remainder being treated only locally.” 
 
224 
 
 RELAPSES OF SYPHILIS. 
 
 particularly the case with such persons as never underwent 
 a treatment with mercury, hence I am justifiable in making 
 assumptions according to minute examinations and researches. 
 
 These records of the 39 sick, which I found in the Regis- 
 trar’s office, cannot all be classed as clear cases, because the 
 treatment was partly mercurial and partly botanic. 
 
 But if we calculate these mentioned cases on the basis of 
 the 1420 cases, we see that with the older cases , 2.74 per 
 cent, of the relapses occurred in the character of tertiary 
 syphilis , a proportion which, according to the already men- 
 tioned reasons, does not come up to the percentage there 
 obtained. 
 
 In the following table we see, excepting those cases of 
 serious disease, how the relapses are — whether of the char- 
 acter of progressive or regressive syphilis. 
 
 A. Sarsaparilla Sweat-cure (456 Cases). 
 
 Affection at relapse. 
 
 1 Eel. 
 
 2 Rel. 
 
 3 Rel. 
 
 4 Rel. 5 Rel. 
 
 > Rel. 
 
 7 Rel. 
 
 Affection when first treated. 
 
 1. Condylomata lata on the geni- 
 tals (148 cases), 
 
 2. Throat affections (36 cases), 
 
 3. Exanthema maculosum (165 
 
 cases), 
 
 4. Exanth. papulosum (s. maculo- 
 papulosum), (65 cases), 
 
 5. Exanthema squamosum (s. pap- 
 ulo-squamosum), (42 cases), 
 
 38 64 
 
 ii 13 
 
 66 
 
 56 
 
 22 
 
 19 
 
 10 14 
 
 27 
 
 7 
 
 4 15 
 
 2 3 
 
 25 
 
 18 
 
 9 10 4 
 
 7 10 
 
 1 
 
 1 
 
RELAPSES OF SYPHILIS. 
 
 225 
 
 B. Mercury Cure (408 Cases). 
 
 Affection when first treated. 
 
 Affection at relapse. 
 
 1 Rel. 2 Rel. 3 Rel. 4 Rel. 5 Rel. 6 Rel. 7 Rel 
 
 a a 
 
 c5 a 
 
 gs 
 
 V Q 
 
 a S 
 
 •*-' i> 
 
 co 
 
 a 
 
 £ a 
 
 1. Condylomata lata on the geni- 
 tals (296 cases), 
 
 2. Throat affection (9 cases), 
 
 3. Exanthema maculosum 
 
 cases), 
 
 4. Exanthema 
 cases), 
 
 5. Exanthema 
 cases), 
 
 6. Exanthema 
 cases), 
 
 papulosum 
 
 squamosum 
 
 pustulosum 
 
 (63 
 
 (14 
 
 (14 
 
 (12 
 
 175 
 
 l 
 
 42 
 
 7 
 
 8 
 6 
 
 64 
 
 1 
 
 C. Subcutaneous Sublimate Injection (800 Cases). 
 
 Affection at relapse. 
 
 Affection when first treated. 
 
 Condylomata lata on the £ 
 genitals. ® 
 
 to 
 
 Throat affection. W 
 
 CO 
 
 Exanthema maculosum. W 
 
 Exanthema papulosum ^ 
 
 (s. maculo-papulosum). 
 
 Exanthema squamosum ^ 
 (s.papulo-squamosum). 
 
 Exanthema pustulo- ^ 
 
 ulcero-crustosum. 
 
 1. 
 
 Condylomata lata on the genitals, . 
 
 11 
 
 2 
 
 3 
 
 2 
 
 2 
 
 2 
 
 2. 
 
 Throat affection, .... 
 
 5 
 
 7 
 
 1 
 
 1 
 
 1 
 
 
 3. 
 
 Exanthema maculosum, . 
 
 16 
 
 25 
 
 11 
 
 5 
 
 2 
 
 
 4. 
 
 Exanthema papulosum (s. maculo- 
 
 
 
 
 
 
 
 
 papulosum), ..... 
 
 18 
 
 12 
 
 5 
 
 3 
 
 3 
 
 1 
 
 5. 
 
 Exanthema squamosum (s. papulo- 
 
 
 
 
 
 
 
 
 squamosum), ..... 
 
 6 
 
 12 
 
 4 
 
 1 
 
 3 
 
 1 
 
 6. 
 
 Exanthema pustulo-ulcero-crusto- 
 
 
 
 
 
 
 
 
 sum, ...... 
 
 
 3 
 
 1 
 
 1 
 
 
 2 
 
 Total, 109 Regressive, 37 Identical, 26 Progressive forms of Relapse. 
 
226 
 
 RELAPSES OF SYPHILIS. 
 
 This tabular statement exhibits what syphilitic affection 
 existed at the first treatment, and what forms of relapse 
 appeared, whether treated with the mercurial, botanic, or 
 subcutaneous injection cure. The full-faced figures designate 
 the number of those patients who had a relapse of the same 
 form of syphilis as existed at the first treatment. The figures 
 on the right side of these , show the higher developed , while 
 those on the left show the less developed forms of syphilis in 
 the relapse. 
 
 In order to compare the character of the relapses after the 
 different treatments, I give the following : — 
 
 
 Regressive 
 
 Form. 
 
 Identical 
 
 Form. 
 
 Progressive 
 
 Form. 
 
 I. Botanic Treatment, 
 
 47 per ct. 
 
 21 per ct. 
 
 32 per ct. 
 
 
 68 per ct. 
 
 
 II. Mercurial Treatment, 
 
 18.6 per ct. 
 
 46.6 per ct. 
 
 34.8 per ct. 
 
 III. Subcutaneous Injec- 
 
 65.2 per ct. 
 
 
 tion Cure, 
 
 61.7 per ct. 
 
 20.9.per ct. 
 
 17.4 per ct. 
 
 
 82.6 per ct. 
 
 • 
 
 The result is therefore that those relapses , which occur 
 after the subcutaneous sublimate injection method , show : — 
 
 17 per cent, of less progressive forms 
 25 per cent. 11 11 adequate u 
 
 43 per cent. 11 more regressive 11 
 
 than the other methods of treatment which have heretofore 
 been used in the Charite . 
 
 Of the patients with progressive relapses after the subcu- 
 taneous injections, none were taken with a bad form of 
 tertiary syphilis. 
 
RELAPSES OF SYPHILIS. 
 
 227 
 
 Only in a few patients, which showed already before the 
 sublimate injection malignant formations, did a malignancy 
 appear in the relapse, and then in a mild manner. 
 
 Of the remaining patients of the category of progressive 
 relapses, not one was really taken with a severe affection. 
 The following cases I show as examples : 
 
 1. Carol B., received July 9, 1867, the first time into the Charite, 
 affected with condylomata lata at the genitals, angle of the mouth and 
 between the fingers and toes ; a light papulous exanthem on the thigh. 
 She received 3f gr. of sublimate hypodermically, and was discharged 
 cured. 
 
 She returned in five and a half months with the single affection, 
 condylomata lata at the entrance of the vaginae, erosed considerably. 
 There were injected If gr. sublimate, which dispelled the affection. On 
 the 9th December, 1868, L e., nine months subsequently, she came back 
 again, having the following, viz. : ulcerated condylomata lata at the 
 labia, nates and left thigh ; great crusts at the nates , crust-like formations 
 on the leg and right fore arm. The inferior and superior extremities were 
 quite covered with a maculous cicatrized pigment colored eruption At 
 the posterior commissura was a large putrid ulcer. We repeated the 
 subcutaneous injections. At the 9th injection (1J gr. having been 
 used) so severe a salivation occurred (lasting four weeks) that we sus- 
 pended the injection treatment entirely. We used for two weeks iodide 
 of potassium, and finally a sarsaparilla sweat-cure for four weeks, and 
 thus we were able to discharge the patient, after four months, as cured. 
 
 2. Auguste, E., was in my wards from June 15, till July 15, 1867, for 
 ulcerations in the fossa navicularis and erosions. She was treated with 
 sublimate injections, receiving 1 gr. hypodermically. Four weeks later 
 she returned to the Charite with crustaceous erosions on the left labium 
 min. with soft ulcers on the fossae, and a papulo-pustulosum exanthema 
 on the back, abdomen, and lower extremities. After injecting lj- gr. of 
 sublimate subcutaneously, the exanthem disappeared. 
 
 3. Anna H., was received November 12, 1866, for lata at the genitals 
 and fossa, erosion on the nose, psoriasis palmaris, rhagades between 
 the toes of the left foot and a pustulous exanthem about the head. She 
 received 2 gr. of sublimate subcutaneously, and the exantliem disap- 
 peared, pigment patches only remaining. 
 
228 
 
 KELAPSES OP SYPHILIS. 
 
 On account of a primary affection, she returned five times to the hos- 
 pital, and returned once again January 23, 1869, i. e., two years and 
 three months after her first discharge, this time having crustaceous 
 ulcerations, ecthymatous eruption on the lower extremities, crusts on 
 the nates. She received subcutaneously J gr. of sublimate. A stoma- 
 titis mercuriales ensued, and she was then treated with a sarsaparilla 
 sweat-cure, and received thereafter \ gr. of sublimate more, and was 
 discharged cured. 
 
 4. Mrs, Kl., twenty-one years old, already four times treated for 
 primary syphilitic processes, was again received into the hospital Oc- 
 tober 3, 1866, with condylomata lata near the anus and on the tonsil, 
 maculous exanthem, loss of hair and adenitis. She was treated subcu- 
 taneously, and was discharged cured after using 2f grs. of sublimate. 
 She returned again, after four and a half months, to the Charite, with 
 eroded tonsils and three pustules, of the size of a pea, on the left fore- 
 arm. They dried up, after the use of f gr. of sublimate, hypodermi- 
 cally. When If gr. had been used, the crust fell off, and the patient 
 was discharged cured. Subsequently she returned to my wards several 
 times, but I could not detect anything of these syphilitic formations. 
 
 5. Emilie Sch., twenty-one years old, received into my wards Feb- 
 ruary 24, 1867, with indurated ulcers on the right of the labia 
 minora, condylomata lata on the tonsils, papulous exanthem over the 
 whole body ; was discharged cured after the injection of 1-g- gr. of sub- 
 limate. She returned in the course of a month, and we found eight 
 crusts, of the size of a pea, of yellow color, resembling impetigo, seated 
 on a superficially eroded cuticle upon the neck and abdomen. After 
 the hypodermic injection of If gr. of sublimate, we discharged her 
 cured, and when last heard from she remained perfectly well. 
 
 6. Augusta L., eighteen years old, received into the Charite April 
 18, 1866, with condylomata lata on the genitals and maculous exan- 
 them ; was treated for six or seven weeks with the sarsaparilla sweat- 
 cure. During the while, papules developed themselves on the back. 
 An injection treatment was instituted, which resulted, after using 3 grs. 
 of sublimate, in a cure. After six weeks, the patient returned with the 
 following symptoms : eroded condylomata on the left arcum palato- 
 pharyngeum, impetiginous exanthem on the lower extremities, psoriasis 
 palmaris and adenitis. This time the use of 2 grs. was sufficient. But 
 the patient came back again, three months subsequently, with an ulcer 
 on the lower eyelid, which had caused some loss of substance. Also, 
 
RELAPSES OF SYPHILIS. 
 
 229 
 
 the epiglottis exhibited superficial erosions. All of these processes did 
 not appear to me evidently of a syphilitic character, and I prescribed 
 iodide of potassium. After the use of gii, a healing was effected. 
 
 7. Fred. H., eighteen years old, received into my wards January 27tli, 
 1867, with eroded condylomata on the left of the labia minora and 
 urethritis; was discharged cured after the use of % gr, of sublimate. 
 After the lapse of three months, he returned to the hospital, with a 
 papulous exanthem on the face and extremities. We used again the 
 subcutaneous sublimate injection cure, 5 grs. completing the cure. 
 
 Among the remaining cases in which a progress of syphilis 
 was stated, in twelve cases the most significant affection was 
 a papulous exanthema, and in six cases a squamous exan- 
 thema. Subcutaneous injections of sublimate, to the amount 
 of from 1 gr. to 2| grs., always brought these syphilitic 
 processes to a stand-still. 
 
 In the remaining progressive relapses, after broad condy- 
 lomes on the genitals or superficial erosions in the pharynx, 
 a maculous exanthem was the result. 
 
 It is of importance that, for the cure of the relapses gen- 
 erally , only from half to three-fourths the quantity of subli- 
 mate is necessary to eradicate the first eruptions of syphilis, 
 as is shown by the following tabular statement : 
 
 23 
 
230 
 
 RELAPSES OF SYPHILIS. 
 
 P 
 
 m 
 
 Ph 
 
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 At th© fifth Re- 
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RELAPSES OF SYPHILIS. 
 
 231 
 
 Concerning the question ivhether a too small quantity of 
 injected sublimate may cause the appearance of relapses , it 
 is very difficult to answer, since we saw no deviation, the 
 quantity for relapses being a trifle less than for other 
 cases. With several relapses the average quantity of the 
 injected sublimate is less than when but a single relapse 
 occurs, as shown. That my figures concerning quantity and 
 quality of relapses after subcutaneous injections have not 
 been taken too favorably, can be seen from the following 
 statement of the present status of my wards for syphilis . 
 
 Number of prostitutes subcutaneously treated during the years from 
 1865 to 1869, between ....... 1300 and 1400 
 
 Number of relapsing women in my wards,* . . . . .20 
 
 And they suffered as follows : — 
 
 From condylomata lata on the genitals or surroundings, 
 
 11 11 11 and erosions on the tonsils, 
 
 11 11 11 11 and exanthema maculosum, 
 
 Exanthema papulosum, 
 
 “ papulo-squamosum, ..... 
 u 11 11 and ulceration on tonsils, 
 
 u 
 
 u 
 
 u 
 
 crustosum, 
 
 u 
 
 u 
 
 and periostitis, 
 u retinitis, 
 
 10 
 
 2 
 
 2 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 * I point out here again that my wards probably represent the full 
 contingency of all syphilitic women in Berlin, and for that reason give 
 a fair estimate of all the relapses after the sublimate injection cure. 
 Not only are the prostitutes examined weekly by proper sanitary in- 
 spectors, but also they are sent immediately to my wards. No other 
 hospital is allowed to receive persons so diseased. Only a few of the 
 better situated puellae publicae have been allowed to be treated in their 
 homes, but these have not been subcutaneously treated by me. Con- 
 cerning the other wards of the Charite, in which sometimes women 
 with visceral syphilis are found, only one patient in the insane ward ot 
 Professor Westphal has been treated subcutaneously. Diagnosis here 
 is not quite certain, but it seems that a hemiplegia induced by syphilis 
 exists with the patient. 
 
232 
 
 RELAPSES OF SYPHILIS. 
 
 INTERVALS BETWEEN THE SINGLE RELAPSES. 
 
 It would be advantageous if we could use the intervals of 
 the single relapses as a prognostic mean in reference to the 
 further course of the syphilis. All the views and assertions 
 of former syphilographs are lacking a reliable statistical 
 basis, and are therefore only subjective in their origin. 
 Hence the contradictions of the authors. For instance , 
 Von Bcerensprung regards longer intervals , especially after 
 mercury , as a less favorable prognostic significance . Diday 
 reverses the matter , and regards short intervals as unfavorable 
 in a prognostic point of view . 
 
 In my work in the Charite Annals, I have pointed out 
 the non-correspondence of the views of Yon Baerensprung 
 with the result of his own records in his “ Sick Journal , 99 
 besides showing the insufficiency of the material of Diday. 
 The observations of the 39 cases of tertiary syphilis which 
 are found in the records of my predecessors, induced me to 
 think that the character of the relapsing syphilis does not 
 depend on the intervals between the outbreaks. 
 
 As to the intervals in which the simple relapsing affections 
 occurred in the patients of my predecessors, and as to the 
 intervals occurring after my subcutaneous injection cure, I 
 have taken of the former 912 patients, observing them more 
 minutely, and of the latter 800. When compared, the 
 result is as follows : — 
 
 A. Sarsaparilla Sweat-Cure. 456 Cases. 
 
 At the first treatment were : 
 
 I. Condylomata lata on the genitals, ... in 148 cases. 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals . . . “ 38 “ 
 
INTERVALS BETWEEN THE SINGLE RELAPSES. 233 
 
 Condylomatous erosions and ulcerations in the 
 
 pharynx 
 
 Exanthema maculosum 
 
 during 5 months . 
 
 “ 11 “ 
 
 Exanthema papulo-squamosum 
 
 during 5 months . 
 
 “ 11 “ 
 
 II. Condylomatous erosions and ulcerations in the 
 
 pharynx 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 Condylomatous erosions and ulcerations in the 
 
 pharynx 
 
 Exanthema maculosum 
 
 They were divided as follows, occurring during 6 mos. 
 Exanthema papulo-squamosum . 
 
 III. Exanthema maculosum with or without affec- 
 
 tions of the Category I. and II. 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 They were divided as follows : during 9 months . 
 
 “ 28 “ 
 
 Condylomatous erosions and ulcerations in the 
 
 pharynx 
 
 They were divided as follows : during 8 months . 
 
 “ 24 “ 
 
 Exanthema maculosum 
 
 during 7 months. 
 Exanthema papulo-squamosum . 
 
 during 8 months. 
 
 IV. Exanthema papulosum with or without the affec- 
 
 tions of Category I. to III 
 
 Relapses 'occurred as : 
 
 Condylomata lata on the genitals 
 
 during 11 months . 
 
 Condylomatous erosions and ulcerations in the 
 pharynx during 10 months . 
 
 Exanthema maculosum 
 
 during 11 months . 
 
 20* 
 
 in 64 cases. 
 u 27 “ 
 
 “ 25 u 
 
 a 2 “ 
 
 “ 15 “ 
 
 “ 13 “ 
 
 u 2 “ 
 
 “ 12 “ 
 
 “ 11 “ 
 
 “ 13 “ 
 
 u 12 “ 
 
 u 5 “ 
 
 “ 165 “ 
 
 “ 66 “ 
 
 “ 59 “ 
 
 u y a 
 
 “ 56 “ 
 
 “ 50 “ 
 
 U 6 (4 
 
 “ 25 “ 
 
 a 18 a 
 
 “ 165 « 
 
 a 22 11 
 
 a 19 a 
 
 a 9 a 
 
234 
 
 RELAPSES OF SYPHILIS. 
 
 Exanthema papulosum 
 
 during 12 months . 
 Exanthema papulo-squamosum 
 
 during 4 months . 
 
 Exanthema pustulosum 
 
 during 2 months . 
 
 Y. Exanthema squamosum with or without the affec- 
 tion of Category I. to IY. . 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 
 during 5 months . 
 
 Condylomatous erosions and ulcerations in the 
 pharynx during 5 months . 
 
 Exanthema maculosum 
 
 during 12 months . 
 Exanthema papulo-squamosum 
 
 during 13 months . 
 
 Exanthema vesiculosum 
 
 during 18 months . 
 
 in 10 cases 
 u 4 u 
 
 u i u 
 
 “ 32 “ 
 
 “ 10 “ 
 
 “ 14 a 
 
 U >J li 
 
 u 10 « 
 
 <• l « 
 
 B. Mercury Cure. 456 Cases. 
 
 4.t the first treatment were : 
 
 I. Condylomata lata on the genitals 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 
 Condylomatous erosions and ulcerations in the 
 pharynx ........ 
 
 Exanthema maculosum 
 
 during 9 months . 
 
 “ 48 “ 
 
 Exanthema papulosum 
 
 during 9 months . 
 
 “ 30 “ 
 
 Exanthema squamosum 
 
 during 4 months . 
 
 “ 14 “ 
 
 Exanthema pustulosum ..... 
 
 during 7 months. 
 
 “ 296 « 
 
 “ 175 “ 
 
 « 64 “ 
 
 “ 30 “ 
 
 u 24 “ 
 
 a 6 11 
 
 u 13 “ 
 
 u 9 u 
 
 u 4 u 
 
 u 6 a 
 
 “ 5 “ 
 
 U l u 
 
 “ 6 “ 
 
INTERVAL BETWEEN THE SINGLE RELAPSES. 
 
 235 
 
 II. Condylomatous erosions and ulcerations in 
 . pharynx ....... 
 
 the 
 
 in 
 
 93 cases. 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 
 
 it 
 
 1 
 
 tl 
 
 Condylomatous erosions and ulcerations in 
 pharynx ....... 
 
 the 
 
 it 
 
 1 
 
 it 
 
 Exanthema maculosum .... 
 
 
 tt 
 
 5 
 
 tl 
 
 during 6 months . 
 
 
 tt 
 
 3 
 
 It 
 
 “ 18 “ 
 
 
 tt 
 
 2 
 
 It 
 
 Exanthema papulo-squamosum . 
 
 
 it 
 
 1 
 
 It 
 
 during 7 months. 
 
 Exanthema pustulosum .... 
 
 
 it 
 
 1 
 
 it 
 
 during 3 months. 
 
 III. Exanthemata maculosum with or without 
 affections of Category I. and II. 
 
 the 
 
 it 
 
 63 
 
 tl 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 
 
 a 
 
 42 
 
 It 
 
 during 9 months . 
 
 . 
 
 it 
 
 37 
 
 a 
 
 “ 36 “ 
 
 
 It 
 
 7 
 
 tt 
 
 Condylomatous erosions and ulcerations in 
 pharynx ....... 
 
 the 
 
 it 
 
 8 
 
 tt 
 
 during 6 months. 
 
 Exanthema maculosum .... 
 
 
 It 
 
 5 
 
 tt 
 
 during 8 months . 
 
 
 It 
 
 4 
 
 it 
 
 “ 13 “ 
 
 . 
 
 It 
 
 1 
 
 it 
 
 Exanthema papulosum . 
 
 
 It 
 
 3 
 
 tt 
 
 during 6 months. 
 
 Exanthema pustalosum . . . 
 
 
 It 
 
 2 
 
 it 
 
 during 11 months. 
 
 Exanthema tuberculosum .... 
 
 . 
 
 it 
 
 3 
 
 tt 
 
 during 36 months. 
 
 'IV. Exanthema papulosum with or without 
 affection of Category I. to III. 
 
 the 
 
 (l 
 
 14 
 
 it 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 
 
 It 
 
 7 
 
 a 
 
 during 10 months . 
 
 
 It 
 
 4 
 
 it 
 
 “ 17 “ 
 
 
 tl 
 
 1 
 
 tt 
 
 Exanthema papulosum .... 
 
 . 
 
 It 
 
 o 
 
 it 
 
 during 10 months. 
 
236 
 
 RELAPSES IN SYPHILIS. 
 
 Exanthema vesiculo-pustulosum ... in 4 cases, 
 
 during 10 months. 
 
 Y. Exanthema squamosum with or without the 
 affection of Category I. to IV. 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals ... u 8 “ 
 
 during 13 months. 
 
 Erosions and ulcerations in the pharynx . . “ 1 “ 
 
 during 3 months. 
 
 Exanthema maculosum u 2 11 
 
 during 19 months. 
 
 Exanthema papulosum ..... a 1 a 
 
 during 1 month. 
 
 Exanthema squamosum “ 2 11 
 
 during 4 months. 
 
 YI. Exanthema pustulosum with or without the 
 
 affections of Category I. to Y. . . . “ 12 “ 
 
 Relapses occurred as : 
 
 Condylamata lata on the genitals . . . 11 6 “ 
 
 during 20 months. 
 
 Exanthema pustulosum “ 4 “ 
 
 during 24 months. 
 
 Exanthema luposum 11 2 “ 
 
 during 10 months. 
 
 C. Subcutaneous-Injection-Cure. 182 Cases. 
 At the first treatment were : 
 
 I. Condylomata lata on the genitals and surround- 
 
 ings “ 22 “ 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals ... 11 10 11 
 
 during 8 months. 
 
 Erosions and ulcerations in the pharynx . . 11 3 u 
 
 during 2 months. 
 
 Exanthema maculosum u 3 u 
 
 during 4 months. 
 
 Exanthema papulo-squamosum .... 11 4 11 
 
 during 4 months. 
 
 Exanthema pustulosum “ 2 “ 
 
 during 3 months. 
 
INTERVAL BETWEEN THE SINGLE RELAPSES. 
 
 237 
 
 II. Erosions and ulcerations in the pharynx with or 
 without the affections of Category I. 
 
 in 
 
 14 cases 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 
 ll 
 
 5 
 
 u 
 
 during 5 months. 
 
 Erosions and ulcerations in the pharynx . 
 
 it 
 
 1 
 
 ii 
 
 during 6 months. 
 
 Exanthema maculosum 
 
 Cl 
 
 1 
 
 ii 
 
 during 3 months. 
 
 Exanthema papulosum 
 
 u 
 
 1 
 
 ii 
 
 during 14 months. 
 
 Exanthema squamosum ..... 
 
 Cl 
 
 1 
 
 ii 
 
 during 7 months. 
 
 III. Exanthema maculosum with or without the 
 affections of Category I. to II. ... 
 
 ll 
 
 55 
 
 ii 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 
 Cl 
 
 15 
 
 ii 
 
 during 12 months. 
 Erosions and ulcerations in the pharynx . 
 
 u 
 
 23 
 
 ii 
 
 during 9 months. 
 
 Exanthem maculosum ..... 
 
 ll 
 
 10 
 
 ii 
 
 during 9 months. 
 
 Exanthema papulosum ..... 
 
 ll 
 
 5 
 
 i 
 
 during 8 months. 
 
 Exanthema squamosum 
 
 ll 
 
 2 
 
 ii 
 
 during 4 months. 
 
 IY. Exanthema papulosum with or without the 
 affections of Category I. to III. 
 
 It 
 
 41 
 
 ii 
 
 Relapses occurred as : 
 
 Condylomata lata on the genitals 
 
 ll 
 
 16 
 
 ii 
 
 during 17 months. 
 
 , Erosions and ulcerations in the pharynx . 
 
 It 
 
 13 
 
 it 
 
 during 11 months. 
 
 Exanthema maculosum ..... 
 
 ll 
 
 5 
 
 ti 
 
 during 21 months. 
 
 Exanthema papulosum 
 
 ll 
 
 3 
 
 ii 
 
 during 15 months. 
 
 Exanthema squamosum 
 
 It 
 
 3 
 
 u 
 
 during 2 months. 
 
 
 
 
238 
 
 RELAPSES IN SYPHILIS. 
 
 Exanthema pustulosum 
 
 during 16 months. 
 
 Y. Exanthema squamosum with or without the 
 
 in 
 
 1 cases. 
 
 affections of Category I. to IY. 
 
 Relapses occurred as: 
 
 u 
 
 30 
 
 ii 
 
 Condylomata lata on the genitals 
 
 during 10 months. 
 
 ll 
 
 8 
 
 u 
 
 Erosions and ulcerations in the pharynx . 
 
 during 13 months. 
 
 it 
 
 13 
 
 ii 
 
 Exanthema maculosum 
 
 during 9 months. 
 
 ti 
 
 3 
 
 it 
 
 Exanthema papillosum 
 
 during 7 months. 
 
 it 
 
 2 
 
 u 
 
 Exanthema squamosum 
 
 during 7 months. 
 
 it 
 
 3 
 
 u 
 
 Exanthema pustulosum 
 
 during 6 months. 
 
 VI. Exanthema pustulosum with or without the 
 
 ll 
 
 1 
 
 u 
 
 affections of Category I. to Y. 
 
 Relapses occurred as : 
 
 ti 
 
 10 
 
 u 
 
 Condylomata lata on the genitals 
 
 during 8 months. 
 
 ll 
 
 1 
 
 n 
 
 Erosions and ulcerations in the pharynx . 
 
 during 8 months. 
 
 ti 
 
 3 
 
 u 
 
 Exanthema maculosum 
 
 during 2 months. 
 
 a 
 
 1 
 
 u 
 
 Exanthema papulosum 
 
 during 8 months. 
 
 u 
 
 3 
 
 u 
 
 Exanthema pustulosum ..... 
 
 during 15 months. 
 
 u 
 
 2 
 
 it 
 
 Following are two tabulated statements, of which the first 
 shows, how many relapses those patients had, who were sub- 
 cutaneously treated ; in the second it shows the difference 
 in intervals with such patients, who have undergone one or 
 more relapses . 
 
RELAPSES OF SYPHILIS. 
 
 239 
 
 Manifold Relapses. 
 
 Categories. 
 
 1st Relapse. 
 
 2d Relapse. 
 
 3d Relapse. 
 
 4th Relapso. 
 
 5th Relapso. 
 
 I. (41 cases) 
 II. (21 “ ) 
 
 IH.a (7 “ ) 
 
 111 . 6(26 “ ) 
 III.c (53 “ ) 
 
 III .d (9 “ ) 
 
 IY.a (10 “ ) 
 
 IY.6 (5 “ ) 
 
 in 1 9 cases. 
 “ 11 “ 
 
 “ 3 “ 
 
 “ ^ ci 
 
 “ 26 “ 
 
 “ 3 “ 
 
 u 7 U 
 
 u 3 It 
 
 in 12 cases. 
 
 “ 8 “ 
 
 u 2 11 
 
 u y a 
 
 u 15 II 
 
 u 4 it 
 
 u ^ 11 
 
 u 2 11 
 
 in 10 cases. 
 
 it 2 11 
 
 it 2 u 
 
 u 2 
 
 “11 “ 
 
 « 2 u 
 
 it 2 tl 
 
 it it 
 
 in 1 case.- 
 
 n 2 tt 
 
 in 1 case. 
 
 a 2 it 
 
 Total 
 
 in 89 cases. 
 
 in 50 cases. 
 
 in 29 cases. 
 
 in 2 cases. 
 
 in 2 cases. 
 
 This statement shows, besides the important fact, that in 
 the greatest number of patients only one or two relapses 
 occur ; three relapses are rare, but four and five the excep- 
 tions. To show the intervals of manifold relapses, the 
 following table is inserted. 
 
240 
 
 RELAPSES OF SYPHILIS, 
 
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 bo C 
 
 03 o 
 
SUBCUTANEOUS INJECTIONS IN PREGNANCY. 241 
 
 As seen by this table the intervals are longer with those 
 patients in whom but one relapse occurred, and shorter in 
 those in whom several relapses followed. 
 
 IX. EFFECT OF SUBCUTANEOUS INJECTIONS IN 
 PREGNANCY. 
 
 Dr. Jul, Loewy publishes from Siegmund’s Clinic at 
 Vienna some very valuable points thereon. From January, 
 1868, till April, 1869, 99 syphilitic pregnant females were 
 treated: 58 expectantly, 37 with inunction. 
 
 With the .58 pregnant females of the first class, abortion 
 or premature delivery occurred 17 times, or 29 per cent. ; 
 with the 37 of the second class, abortion or premature deli- 
 very 5 times, or 13.5 per cent. 
 
 The number of syphilitic pregnant females treated by me 
 subcutaneously since 1865, up to April, 1869, were 85. In 
 this number abortion or premature birth occurred but 8 
 times, or with about 10 per cent. The result therefore is, 
 that with the subcutaneous sublimate treatment, abortion 
 and premature delivery took place 19 per cent, less fre- 
 quently than with the expectant treatment, and 3 per cent, 
 less frequently than with the inunction cure. 
 
 I do not put much value on this latter circumstance of 3 
 per cent, for my method, since changeable factors might 
 have caused the variation. 
 
 Tbe 85 pregnant females were in all stages of gestation 
 during the hypodermic treatment, as here seen: 
 
 21 
 
242 SUBCUTANEOUS INJECTIONS IN PKEGNANCY. 
 
 In 
 
 the 3d or 4th lunar 
 
 month 
 
 . 13 
 
 u 
 
 u 
 
 5th 
 
 ll 
 
 u 
 
 7 
 
 a 
 
 Cl 
 
 6 th 
 
 Cl 
 
 ii 
 
 . 12 
 
 u 
 
 u 
 
 7 th 
 
 It 
 
 u 
 
 18 
 
 n 
 
 u 
 
 8th 
 
 u 
 
 ll 
 
 . 17 
 
 a 
 
 u 
 
 9th 
 
 u 
 
 ll . 
 
 8 
 
 u 
 
 u 
 
 10 th 
 
 i: 
 
 ll 
 
 . 10 
 
 Accordingly we perceive that 
 
 20 were in the first half of gestation. 
 65 “ “ “ second “ “ 
 
 Abortion or premature birth occurred respectively, 
 
 In the 3d lunar month with 1 person. 
 u u 4th u u u 2 u 
 
 “ “ 5th « “ “ 1 « 
 
 “ 7th “ “ “ 1 - 
 
 “ “ 8th “ “ “ 2 “ 
 
 u u 9th tt « “ 1 “ 
 
 Here we see that women in the earlier months of preg- 
 nancy, who are more disposed to abort, bore the subcutaneous 
 injections of sublimate without any bad result. 
 
 Concerning the second important question, as to hoiv 
 gestation proceeded after the injection treatment , I cannot 
 give so large a statistical exhibit, because a part of the 
 patients left our hospital before confinement, and therefore 
 did not, come under my observation. 
 
 Of 50 patients I can make the following statement : 
 
 16 women were, from 1 to 1J months after the treatment, 
 delivered, in their 7th or 8th months of pregnancy. 
 
 14 women were, from 1 to 2| months after the treatment, 
 delivered, in their 8th or 9th months of pregnancy. 
 
 20 women were delivered at full term. 
 
SUBCUTANEOUS INJECTIONS IN PREGNANCY. 243 
 
 Concerning the influence of our cure on the life and 
 health of the foetus , 
 
 43 pregnant females gave birth to 32 living and 11 dead 
 children. 
 
 Of the 32 living children, 20 children, or 62J per cent, 
 died. 
 
 The remaining 12 were discharged with the mother, and 
 for only 2 children was an inunction cure thought necessary. 
 
 Of these 12 children, discharged seemingly healthy, I 
 have been able to ascertain nothing of but 5 : 2 died ; 3 are 
 yet alive and well. 
 
 Of 9 children who died in the Charity, a post-mortem 
 examination showed the existence of 
 
 Encephalitis I. ... 2 times. 
 
 u with Hepatitis 1 “ 
 
 Peritonitis with Hepatitis and Atelectasia Pulmonum . . 1 “ 
 
 Ostitis gummosa multiplex, Rhachitis, Thrombophlebitis . 1 11 
 
 Ostitis gummosa multiplex, Hepatitis gummosa, Broncho- 
 pneumonia 1 “ 
 
 Ostitis gummosa multiplex, Hepatitis gummosa, Pemphigus, 
 
 Abcessus glandulae Thymus 1 11 
 
 Atrophia universalis, Exanthema squamosum Furunculosis . I “ 
 
V 
 
INDEX. 
 
 PAGE 
 
 Abscesses, formation of . 21 
 
 Acute diseases 203 
 
 Age 202 
 
 Alopecia, mercurial 33 
 
 Appearances of places injected 20 
 
 Blood, formation — disturbances of ..... 33 
 
 Bones, syphilitic affection of 175 
 
 therapeutics of ........ 17G 
 
 Cases 62-64 177-180 
 
 Brain, syphilitic affection of 191 
 
 therapeutical indications ....... 193 
 
 Cases 69-71 196-201 
 
 Bubos, ulcerated 61 
 
 Circulation, disturbances of 32 
 
 Combination cures, most desirable 209 
 
 Condylomata lata 47 
 
 seat of (in women) 51 
 
 with other exanthemata . . . 53 
 
 seat of (in men) 54 
 
 with other exanthemata . . . 55 
 
 therapeutics of 56 
 
 verrucosa 60 
 
 mixta ......... 60 
 
 local treatment of 60-63 
 
 Condylomatous exanthema 144 
 
 its frequency 145 
 
 treatment 145 
 
 Cases 46-47 .... 146-149 
 
 Condylomes in larynx , 108 
 
 21* 
 
246 
 
 INDEX, 
 
 PAGE 
 
 Definition .......... 14 
 
 Depres 217 
 
 Desruelles 212 
 
 Devergie 211 
 
 Diday ........... 214 
 
 Dietetic rules . . . 39 
 
 Digestion, disturbances of . 25 
 
 Doses, generally used . . . 19 
 
 after relapses 230 
 
 Dyscrasia 203 
 
 Engelsted 215 
 
 Eye, syphilitic affections of . 164 
 
 complications with other affections 166 
 
 iritic inflammation of 167 
 
 Cases 55-60 167-171 
 
 Fergusson 212 
 
 Fovae tonsillares 73 
 
 Glands, lymphatic 63 
 
 mucous 69 
 
 Glandulae acinosae . . . 69 
 
 Gummata of subcutaneous tissue 159 
 
 Cases 53, 54 . . . 161-164 
 
 Gummy tumors, knots 82 
 
 Case 12 90 
 
 Hermann 213 
 
 Icterus, syphiliticus 182 
 
 with other syphilitic affections 183 
 
 effect of sublimate injections on 183 
 
 Cases 65, 66 184-185 
 
 Idiosyncrasy of patients . . . 0 24 
 
 Infectio per os 95 
 
 diagnosis of 100 
 
 Cases 19-26 98-102 
 
INDEX. 
 
 247 
 
 PAGE 
 
 Infection of nurse via child, &c 102 
 
 Case 27 103 
 
 Infiltration, submucous 106 
 
 gummous ........ 128 
 
 Injection, place for 15 
 
 mouth affections from 26 
 
 strengths of 17 
 
 inflammation from 20 
 
 general symptoms after ....... 25 
 
 abscesses from 21 
 
 indications for 43 
 
 respiratory disturbance from 32 
 
 considerations respecting ...... 202 
 
 interruption of sensibility from .... 223 
 
 effect in pregnancy 229 
 
 on foetus 243 
 
 Intoxication from sublimate 37 
 
 Iritis, syphilitic . 167 
 
 Kidney, syphilitic affection of . . . . . . 186 
 
 Cases 67, 68 . . . 188-19,1 
 
 Knots, gummous, in scrotum 174 
 
 Knotty syphiloid . . 151 
 
 Larynx, syphilitic affections of . . . . . . .104 
 
 catarrh of 104 
 
 stenosis of . . 106 
 
 condylomatous granulations in 107 
 
 inflammation of 110 
 
 therapeutics of 116 
 
 Cases 28-40 . . . . . . . . 118-130 
 
 Liver, syphilitic diseases of 181 
 
 Lupus syphiliticus 152 
 
 Cases 51, 52 155-157 
 
 m 
 
 Maculous syphiloid 132 
 
 effect of sublimate treatment on . . 133 
 
 Manner of using 14 
 
 Menstruation 202 
 
248 
 
 INDEX. 
 
 PAGE 
 
 Mercurial eczema 33 
 
 Mercury, physical effect of . . . 36 
 
 Mouth effects, syphilitic 66 
 
 Nervous system, disturbances of 35 
 
 (Edema of labia majora 59 
 
 Oewre, A 217 
 
 Osseous system, disturbances of 33 
 
 Papulous exanthema 135 
 
 miliary species ...... 135 
 
 lenticular species 136 
 
 therapeutics of 136 
 
 Cases 41-43 137-140 
 
 Pavement epithelium 108 
 
 Pharynx, syphilitic affection of 66 
 
 therapeutics of ........ 87 
 
 Cases 1, 2 . . . 70-72 
 
 Cases 9-11 88-90 
 
 Playnes opalines 72 
 
 Pregnancy . ... 202 
 
 Prophalaxis of mercurialism 28 
 
 Psoriasis oris 73 
 
 Psychical considerations ........ 42 
 
 Ptyalism proper 27 
 
 Relapses of syphilis 210 
 
 percentage of 216 
 
 Table of (vide) ........ 221 
 
 intervals between 221 
 
 after hypodermic injections 222 
 
 sarsaparilla sweat-cure 224 
 
 mercury cure 225 
 
 subcutaneous cure ....... 225 
 
 Cases of . • . . . . . . . . 227-229 
 
 Rheumatism, diminished by injection 88 
 
 acute articular 203 
 
INDEX. 
 
 249 
 
 PAGE 
 
 Scrofulosa, diagnosis of, from tertiary ulcers . . . .115 
 
 Sex 202 
 
 Skin affection, syphilitic 131 
 
 Spray atomization 61 
 
 Squamous exanthema . 140 
 
 treatment of 141 
 
 Cases 44, 45 142-144 
 
 Statistics of 800 patients ........ 207 
 
 Syphilis, spontaneous cure of 46 
 
 initial 44 
 
 progressive and regressive 222 
 
 visceral 180 
 
 Teeth, care of 20 
 
 Tonsils, hypertrophy of 31 
 
 Cases 72, 73 204-205 
 
 ulcerated 75 
 
 Cases 3-8 76-81 
 
 Tuberculosis, &c. 204 
 
 Tuberculous ulcers diagnosed 116 
 
 Tumors of scrotum 171 
 
 therapeutics of . . . . . .172 
 
 Case 61 (gummous knots) .... 174 
 
 Ulceration of false vocal cords Ill 
 
 petrolus Ill 
 
 epiglottis Ill 
 
 vocal cords 115 
 
 Ulcerous exanthema and rupia 147 
 
 Cases 48-50 . . . 148-150 
 
 Urinary organs, disturbances of 32 
 
 Yelum, ulcerative processes of 85 
 
 Vessels, injury to . 22 
 
 Warts, slender 48 
 
 Yvaren 214 
 
 Zettman’s decoction 46