Compliments of the Author. 
SYPHILIS-THE IMPORTANCE OF A THOROUGH 
DIAGNOSIS AND LONG-CONTINUED 
TREATMENT. 
READ BY TITLE AT THE THIRTY-SIXTH ANNUAL SESSION OF THE MEDI- 
CAL ASSOCIATION OF GEORGIA, AT SAVANNAH, GA., APRIL 15 1885 
By J. C. LeHARDY, M. D., Savannah, Ga. 
Jas. P. Harrison & Co., Printers, Atlanta, Ga. Reprint from The Atlanta Medical and Surgical Journal. 
SYPHILIS-THE IMPORTANCE OF A THOROUGH 
DIAGNOSIS AND LONG-CONTINUED 
TREATMENT. 
READ BY TITLE AT THE 36TII ANNUAL SESSION OF THE MEDI- 
CAL ASSOCIATION OF GEORGIA, AT SAVANNAH, GA., APRIL 
15TH, 1885, BY J. C. LE HARDY, M. D., SAVANNAH, GA. 
In a paper, entitled " The Duality of the Syphilitic Poison," 
read before this Association in i 874, I briefly called the attention 
of the members to the pathological differences between syphilitic 
chancre and venereal ulcer, unwisely called by some authors 
" soft chancre " and " chancroids." Cases in illustration were 
cited, showing that the first is a constitutional disease having two 
different stages, one seemingly local (the chancre), the other 
general (secondary eruptions, etc.); that it is transmissible to pos- 
terity, and that mercury is the most potent remedy we possess 
for its cure ; while the second is a purely local disease, having 
but one stage, not hereditary, and mercury is useless and dften 
injurious in its treatment. I urged upon the profession the neces- 
sity of making an early diagnosis between these two diseases, in 
order to avoid the undiscriminating use of mercury, an error into 
which physicians have fallen, under the impression that they both 
originated from the same poison. 
The additional experience of eleven years in the daily treatment 
of syphilis has demonstrated to me still more fully the necessity 
for a thorough investigation and careful study of every case of 
suspicious ulcer before making a diagnosis. 
The exact nature of the disease should be so firmly fixed in the 
mind of the attending physician, that no after circumstance, not 
even the disappearance of all the symptoms, in a case diagnosed 2 
as syphilis, should shake his conviction or cause him to relax his 
efforts during the whole period necessary for the cure of that dis- 
ease. For I am fully convinced that most of the cases of uncured 
spyhilis, with their dreadful consequences, are the direct result of 
an insufficient treatment. The chancre being healed and no sec- 
ondary eruption appearing, the treatment is not persisted in, and 
the patient is allowed to marry whilst the poison is still lurking 
in his blood, to plague him in the future, or to infect his wife and 
curse his children with the hereditary form of the disease, the most 
disastrous perhaps of all in its effects upon humanity. This in- 
sufficiency may be due to the patients leaving the treatment as 
soon as possible, in order to save expense, or to the fault of the 
attending physician, who, through neglect, apathy or ignorance, 
will not rigidly enforce the necessarily long and wearisome treat- 
ment; or, again, it may be that through a lack of confidence in 
his own diagnosis, he allows his patient to discontinue a treatment 
which he does not deem necessary. 
A patient will often present himself to the busy practitioner, 
with a sore upon the penis, having the characteristics of a chan- 
cre. Upon inquiry, the doctor ascertains that it made its appear- 
ance ten or twelve days after coition. He concludes that it is a 
syphilitic chancre, and without further examination treats it as 
such. A course of mercury is commenced, together with local 
treatment. In two or three weeks the sore heals perfectly. The 
mercurial treatment is kept up regularly during four or five 
months, when, no secondary symptoms having occurred, the pa- 
tient being to all appearance perfectly healthy, the doctor con- 
cludes that he must have made a mistake, that the disease is not 
constitutional, and, yielding to the patient's importunities, dis- 
charges him as cured. In coming to this conclusion he may have 
committed a fatal error. Had he, in the first instance, made a 
careful study of the sore, and found under the microscope the 
syphilitic microbe, before and after cultivation, or had he inocu- 
lated the patient with its virus, without reproducing its like; had 
he made a thorough investigation of the surrounding parts and 
found the inguinal ganglia all enlarged, hard and painless on 
pressure, he would have been convinced that the case was one of 3 
syphilis, and never would have relaxed in his treatment for at 
least two years, and not then, unless the inguinal glands had re- 
turned to their normal condition, and all other symptoms had dis- 
appeared. 
With the universal dread of syphilis existing, at the present 
day, among civilized people, due in a great measure to the pam- 
phlets and other flaring advertisements of charlatans and patent 
medicine venders, any sore or abrasion upon the genital organs 
is regarded with fear and apprehension, and doctors are con- 
stantly called upon to give an opinion in cases where, if any dis- 
ease exist at all, the symptoms are not sufficiently developed to 
declare its true character. Many physicians, still believing that 
the early use of caustics will destroy the virus and prevent the 
development of syphilis, or, yielding tQ the importunities of the 
patient, who wants something to be done at once, or perhaps to 
the fear of losing a case, sear the parts with these agents to such 
an extent as to mask the true nature and destroy the diagnostic 
value of the lesions which may appear later. 
Applications of caustics at this period therefore render the di- 
agnosis mere guess work and the treatment necessarily becomes 
hap-hazard. The effect of caustics upon a simple abrasion, exist- 
ing upon the penis, may be to produce an ulcer with infiltration 
of the sub-tissues, liable to be mistaken for a syphilitic 
chancre, or it may produce an ulcer, causing a painful inflam- 
mation of the inguinal glands, with or without suppuration, thus 
similating a venereal ulcer. The patient may then be subjected 
for years to a course of mercurials for the cure of syphilis when 
none exist; and again, he may be treated for venereal ulcer, with- 
out mercury, and told that he has no constitutional disease, when 
really he is infected with syphilis-the symptoms of this disease 
having been hidden by the use of caustics. Thus he is exposed 
to the risk of general syphilis and its consequences, and the doc- 
tor, who makes a diagnosis without a sure foundation, suffers mor- 
tification and well-merited loss of reputation, when such a patient 
turns up with secondary eruptions. 
The conscientious physician will not commence the treatment 
of any disease until he has made a satisfactory diagnosis, and it is 4 
especially important that this rule shall be strictly followed where 
such a serious malady is suspected. 
In every suspicious case, the subject should be kept under 
daily observation, using such local applications only as will not 
interfere with the natural development of the disease. While 
waiting for this development, the doctor should make his patient 
fully understand the necessity for a long-continued treatment of 
the case in the event it should prove to be syphilis. It is of the 
greatest importance that this fact should be thoroughly impressed 
upon his mind, because the success of the treatment depends en- 
tirely upon its regularity and long continuance. Subjected early 
to treatment, the primary symptoms of syphilis are usually mild; 
when mercury is used from the inception, the secondarv manifes- 
tations may or may not present themselves at the ordinary pe- 
riod, or never at all. When they do appear, it is generally 
in the form of superficial eruptions, which fade away in a 
short time, leaving the health of the patient seemingly unim- 
paired; yet, slight as these symptoms may be, unless a regular 
treatment be kept up, they will in most instances be followed, at 
some future period, by other and more serious exhibitions, which 
will undermine the constitution of the strongest subject, and carry 
his wreck to the grave. These are the cases which, to this day, 
lead many of us to believe that syphilis is not only incurable in 
this world, but that it will follow our shades into the next. 
The large percentage of mild cases occurring under the mer- 
curial treatment now in vogue, and the contrast between their 
symptoms and those of the same disease, as described by old au- 
thors, have led many prominent physicians and writers, both at 
home and abroad, to the opinion that syphilis is dying out by 
•" evolution," or by " dilution." They believe that the germ is 
gradually becoming weaker and less dangerous as it passes 
through successive generations. Herbert Spencer, in his " Study 
of Sociology," seems to lend the weight of his great name to 
strengthen this false opinion; but it must be remembered that his 
object was to fight against the passage (by the English Parlia- 
ment) of an act which he believed aimed at the exercise and 
consequent abuse of irresponsible power, and the testimony which 5 
he brings up to sustain the hypothesis that syphilis is diminishing 
in intensity and frequency in England is naturally ex parte. 
An experience of thirty years, devoted in great part to the 
study and treatment of syphilis, has taught me that it is to be 
found in all conditions of society, among the pure and the licen- 
tious, the young and the aged, the married and the single. Some- 
times, in its primitive form, with all the nauseous symptoms de- 
scribed by early writers; sometimes in a modified or mild form; 
sometimes so masked that its presence is not suspected until the 
disease for which the patient is under treatment, failing to yield 
to other measures, mercury is resorted to, when the benefit re- 
sulting brings the attention to syphilitic symptoms not before no- 
ticed. 
That it now exists in its most malignant form in many parts of 
the world cannot be disputed. Our worthy President, Dr. Fos- 
ter, proves this beyond a doubt in his essay, " Syphilis as a Socio- 
logical Problem," read before this Association last year, by co- 
pious extracts from the writings of men of recognized authority. 
My own observation also goes to prove that malignant syphilis, 
with the same symptoms of nauseating sores, phagasdena, gum- 
mous tumors, disfiguring skin eruptions, and loss of hair, the ex- 
cruciating night pains, the nodes and the various nervous affec- 
tions described nearly four hundred years ago, is still to be met 
with in this country, especially when the disease is badly treated, 
or not treated at all, as is often the case among backwoodsmen, sail- 
ors and unsuspecting married women, and again under certain 
peculiar conditions of health, even when the most careful treat- 
ment is pursued. 
That the mild form in which the disease is usually observed is 
the result of treatment is aptly illustrated by its history among 
the colored population of the Southern States. When the negroes 
were slaves they were well clothed, well fed and well housed; 
they were kept on the plantation under strict hygienic regulations; 
they were made to observe the marriage relations; when they be- 
came sick they were treated at once by competent physicians. 
Almost every Southern doctor knows how rare were the cases op 
syphilis among the slaves. When, however, through the result of 6 
the war, these people were set at liberty, a different state of 
things commenced. Large numbers left the plantation to follow 
the army. Many of the women contracted syphilis from the sol- 
diers. Naturally careless and lazy, ignorant of all sanitary laws, 
perfectly demoralized, they huddled together in filthy, unventi- 
lated shanties and huts. Unrestrained in their sexual intercourse 
the disease became epidemic among them. Few escaped it in 
some phase or other, and the malignant form was the most pre- 
dominant, and proved very fatal. Deprived of the fostering care 
of the master, ill fed, badly clothed, with little or no medical at- 
tention, the mortality was very great; much of it was due to 
syphilis, although not often attributed to it. When the disease 
attacked the lungs, the brain, or other vital organ with fatal re- 
sults, the cases were recorded in mortuary reports, if recorded at 
all, under the name of consumption, paralysis, convulsions, etc. 
While this epidemic existed among the negroes, syphilitic cases 
also increased in number, in the surrounding white population, 
but it is to be noted that although the virulence of the primary sores 
was greater than usual, and the secondary manifestations more 
frequent and persistent, still under strict and regular treatment 
the disease was cured in the ordinary time. 
To the sociologist and statesman a fact of importance to be 
observed in relation to this disease is, that, whether in its mild or 
in its aggravated form, syphilis is equally dangerous, if we con- 
sider its influence by heredity upon the constitution and the health 
of the masses, a subject which is beginning to attract the atten- 
tion of medical investigators. From this point of view, perhaps 
the milder form is the most dangerous of the two, because a per- 
son with malignant syphilis is personally disagreeable; he shuns 
the society of others, and being avoided by every one is not lia- 
ble to propagate the disease through contact; moreover, a severe 
case is likely to be treated with all the necessary care long enough 
to eradicate the poison from the system; while the milder form, 
on account of its very mildness, is liable to be neglected and re- 
main uncured. Unrestrained in his social intercourse, such a 
person can readily transmit it through the lips, in the act of kiss- 
ing (as he may have mucous patches in his mouth or throat, un- 7 
known to himself the most frequent mode of transmission in the 
secondary form among young people), by contact with objects 
used in common (among cigar-makers, glass-blowers, etc.,) or, if 
he marry, he may infect his wife by actual intercourse, or through 
the foetus; and, again, his child, if born alive, may become a cen- 
ter of infection. 
'Since this disease, then, is not confined to the vicious and the 
depraved, but may affect virtuous women and innocent children 
as well; since it does not depend upon licentious and debauched 
habits for its propagation, but may be spread by the most inno- 
cent social intercourse, it is evident that all attempts to prevent 
its ravages by means of laws to license and control prostitutes 
must necessarily prove futile. It has passed beyond the reach of 
the law, if indeed history does not prove that it never was within 
its reach. So, then, I agree with Herbert Spencer in his opposi- 
tion to such laws, but it seems astonishing, indeed, that so clear 
and deep a thinker should have supported this opposition in any 
part by an argument attempted to be drawn from a comparison of 
the mortality from syphilis andfrom other diseases. Such an ar- 
gument is unphilosophical and vicious in its tendencies; it belittles 
the importance of the disease as an element in the problems of 
sociology, and blinds those who accept his reasoning to the vast- 
ness of the evil. To make it sound, we must be able to say in 
every case that death was or was not the result of syphilis, either 
directly or indirectly, and that is impossible. 
Like malaria, but in a different manner, syphilis poisons the 
system, undermines the constitution, saps the vital strength, and 
diminishes the power to resist the attacks of other diseases. It 
complicates or masks the symptoms of other diseases. It im- 
presses upon them its own refractory and malignant character, 
and thus many deaths, attributed to other causes, ought to be 
charged to syphilis, but are not, if it can possibly be avoided. (In 
the mortuary records of this city may be found the names of 
hundreds of persons reported as having died of consumption, 
softening of the brain, locomotor ataxia, convulsions, paralysis, 
scrofula, rheumatism, etc., etc., who, to my knowledge, were the 
subjects of general or of inherited syphilis.) 8 
It may even be that in the process of " evolution," so much 
prated about at the present day, many diseases which now baffle 
the skill of the physician are the direct product of the syphilitic mi- 
crobe. If such be the case, the dilution of the poison, like the 
homoeopathic dilution, must increase its potency the further it is 
carried, if we consider the numbers who die from these diseases. 
But this question, like all others pertaining to the operations of 
nature, can only be settled by the close and laborious study of an 
immense number of recorded facts, collected for years from a wide 
and varied field, and to this work it should be the pride of every 
physician to contribute his share. 
Let the practitioner consult his records of pastyears, let him 
fathom the recess of his memory, and tell to the world how many 
of his patients have left treatment before they were cured ; how 
many discharged as cured (stating length of treatment) have 
returned with the secondary or tertiary form of the disease ; how 
many have called upon him to attend their wives for syphilis or 
abortions induced by it; how often, after the birth of a child, he 
has found it syphilitic. Let him give his experience of mothers 
infected bv their own offsprings, of nurses, or friends infected by 
the nursling. Let him also recount those unaccountable com- 
plications which have appeared in the ailments of those who had 
been previously infected with syphilis, and the proportion of cases 
of consumption, scrofula, softening of the brain, paralysis, ataxia, 
etc., which present a syphilitic history. Let such similar infor- 
mation be gathered from the records of hospitals, civil, military 
and naval, public and private. In the mass of fact thus collected 
materials will be found for the building up of the true theory of the 
pathology of syphilis, and when the investigations, now in progress, 
into the natural history of the syphilitic microbe, shall have given 
us a correct knowledge of its growth and mode of propaga- 
tion, the means of destroying this germ will, I doubt not, also be 
discovered, and we shall, without the aid of the law, have full con- 
trol of the disease before it can become constitutional and heredi- 
tary. Thus our children will be protected against the infernal 
taint which now permeates all civilized society. 
But that part of the subject is beyond the scope of this essay ; 9 
my object is simply to give our Southern country doctors, who 
have but rare opportunities of seeing cases of syphilis and of 
studying the disease, a few practical directions which will, I hope, 
enable them to recognize it when they see it, and guard their 
communities against its spread. 
DIAGNOSIS. 
Even to one who is in the daily habit of seeing the disease, the 
diagnosis of some cases of chancre is very difficult to make; hence 
it is not to be wondered at that mistakes are frequently made 
by the general practitioner. Thus it often occurs that cases come 
to me in which pimples, insect bites, herpes, venereal ulcers, 
warts, gonorrhoeal infiltration of the prepuce, etc., had been cau- 
terized and then treated as chancres. On the other hand, I often 
see patients with syphilis in its various forms, who had been 
treated for other complaints, as in this case now under treat- 
ment : A negro woman, with a chancre involving the pharynx, 
was treated for ulcerated sore throat, getting worse every day ; 
she consulted another doctor, who, finding the woman's health 
broken down, and the glands of the neck much enlarged, treated 
her for scrofula, with iron tonics, continuing to cauterize the 
throat. Not improving under this treatment, she was brought to 
me by her employer, whose children she was nursing all the time! 
I found, on examination, a large, angry ulcer in the throat, with a 
peculiar grayish slough at the bottom, all the lymphatic ganglia 
on the scalp, neck, axillae and groins enlarged, hard, movable 
and painless. There was also a well-defined specific eruption 
between the shoulders, on the back and chest (a papular syphi- 
loderm), one mucous patch on the pharynx, a fissure at one 
corner of the mouth, and three patches at the of the anus. 
In addition to these symptoms, the temperature was 970, the skin 
mealy, and she looked very badly. With these unmistakable signs 
before me, I pronounced the case one of general syphilis, and 
treated her for it with favorable results so far. 
In the investigation of any suspicious sore or erosion upon the 
genital organs of man or woman, or, indeed, upon any part of the 
body, let me advise you to be always guarded in the expression 10 
of an opinion. Take ample time to complete your investigation, 
and do not commit yourself until you are fully satisfied of its na- 
ture. Should any caustic application have been made, use a 
water-dressing or other placebo, and allow all of the effects of the 
cauterization to pass away; then wait upon the development of 
the ulcer. Never tell a patient, who has had an ulcer or abrasion 
or fissure upon the genitals, that he has not syphilis until after 
the expiration of several weeks, and not then, if you find the in- 
guinal glands enlarged. 
The chancre is always the result of an inoculation with the vi- 
rus from a chancre, or from some of the secondary manifestations 
of syphilis, or from the blood of a person suffering with general 
syphilis. It is usually conveyed from man to woman, or woman 
to man, in the act of coitus; but maybe in kissing, by the saliva, 
or by actual contact with a sore. It may be propagated from the 
nipple of the infected, from the foetus in utero and the new-born 
babe. The knife or other instruments of the surgeon, the finger 
of the gynecologist, or of the accoucheur, may all be the vehicle 
for conveying the virus. Hence, the doctor must not conclude 
that his patient has no syphilitic disease because there is no evi- 
dence of his ever having had a primary sore on the genitals or an 
impure coition. 
By far the most common site of inoculatiou is on the glans, or 
on the prepuce near the corona glandis, above or below; at the 
fourchette or the introitus vaginae; but I have seen it on every 
part of the penis and its the labia and mons ven- 
eris, in the vagina, the uterine neck, inside and outside, the ure- 
thra, the anus, in the rectum, on the toes, the legs, the thigh, the 
groins, the fingers, the hand, the nose, the lips, the tongue, the 
throat, the evelid, the forehead, etc. Therefore, the search for a 
primary lesion should extend over the whole body, mucous mem- 
brane and skin alike. 
The true chancre is almost invariably single; if ever multiple, 
all arise from one inoculation and appear at or nearly at the same 
time, in contrast with the venereal ulcer, which reproduces itself 
by new inoculations, and appears on successive days. 
Its characteristic beginning is that of an elevated papule, which, 11 
after two or three days, becomes cup-shaped, from the dying and 
shrinking of the tissues at the centre. It may, however, first ap- 
pear as a simple erosion or fissure, or a superficial ulcer, which 
may heal without leaving any cicatrix or induration behind, 
in which case, of course, they have no diagnostic value of their 
own, but when followed by an induration of the tissues beneath 
this fact is of the greatest importance. 
The papule is usually small and flattened, but the resulting 
chancre may grow to the size of a ten cents piece. A chancre 
very rarely suppurates unless irritated or inflamed by some arti- 
ficial cause. 
Its contents are the disintegrating tissues, grayish in color, elas- 
tic, are tough, with a tendency to separate from the living tissues. 
At the line of demarkation there is an oozing of serum, which 
spreads over the surface of the ulcer and keeps it moist and 
shiny. 
It is painless and heals rapidly as soon as the dead tissues are 
detached. If not irritated by treatment, it will be entirely covered 
with epithelium in one to three weeks, leaving a persistent discol- 
oration above and an induration beneath, which may last for 
months. When situated on a mucous membrane, the papule 
and the resulting chancre are flat; the induration beneath is thin 
and parchment-like. 
The erosion or fissure may involve only the epithelium and un- 
derlying cellular tissue; if the specific induration follows, it usually 
extends into the cutis vera. 
The chancre, beginning as a papule on the skin, penetrates into 
the cutis vera and the induration into the loose tissues beneath. 
When on a mucous membrane it involves its whole thickness and 
the induration is in the connective tissue beneath. 
In any of its forms, the chancre may become phagedenic; then 
all the tissues, including the induration, die and slough out. 
The induration may begin with the papule, or may be devel- 
oped during the ulcerative process. Sometimes, however, it is 
only discovered after the healing of the chancre. 
In a case of erosion or fissure, it only appears after they are 
healed, if at all. 12 
The chancre has always a period of incubation-that is, a cer- 
tain time elapses between the moment of inoculation and the ap- 
pearance of the papule this time varies considerably. It is 
rarely less than ten days, and is generally much longer. I have 
seen a case, that of a sailor, who was on board ship sixty-five 
days between Havre and this port. Two nights before leaving 
Havre, he cohabited with a prostitute, and discovered the " pim- 
ple," as he called it, only five days before reaching Savannah, 
so that the time of incubation in this case was sixty-two days. 
The length of the period of incubation is of great importance 
in forming the diagnosis of chancre, for in any other inoculation, 
the parts will frequently present an inflamed appearance from the 
very first. 
But the most reliable sign of syphilitic infection, in my opinion, 
is the enlargement of the lymphatic ganglia nearest to the point of 
inoculation. The poison spreads along the lymphatic vessels to 
these ganglia, and causes them to enlarge. They become hard, are 
movable, have a peculiar elastic feel to the touch, and are perfectly 
painless on pressure, unless inflamed. If the point of inoculation be 
on the face, mouth or throat, the ganglia of the neck will always be 
found affected, with perhaps those about the jaws or any other 
part of the head. If it be on the hand, those on the arm and in 
the axilla of the affected side; if on the genitals, the inguinal 
chain in both sides; if on the foot or leg or thigh, those on the 
limb and the groin. 
In non-specific ulcers and in venereal ulcers, one gland usually, 
with sometimes the lymphatic vessel leading to it, becomes enlarged 
in one or both groins, but it is always inflamed, always painful, 
and usually suppurates in the end, when produced by a venereal 
ulcer. In the chancre, on the contrary, many glands will be 
found enlarged ; they will be small, painless and never suppurate 
except in broken down constitutions, or where the sore becomes 
inflamed by the treatment or some other cause. 
Should the patient under your examination have a non-infec- 
tious excoriation, cut, fissure, pimple or wart upon the penis, 
there will be no enlargement of the chain of inguinal ganglia ; 
one or two of them may become tumefied, but this tumefaction 13 
will, under the application of water-dressing to the sore, disap- 
pear along with it, in a few days, never to return. 
If the case be one of herpes, three or more watery pimples will be 
found in a cluster, at one or several different points, on the glans, 
the prepuce, or any other part of the penis. Herpes is seldom at- 
tended by any enlargement in the groin, unless-irritating applica- 
tions are used, and will under simple dressings disappear in five 
to seven days, but will frequently recur afterwards. 
In syphilis the enlargement of the lymphatic ganglia may be 
so trifling that the most delicate manipulation only will detect it, 
and it may even be that a person not having much experience can- 
not detect it at all. In this case, as in all others in which there 
is a doubt as to diagnosis, the doctor must next resort to inocula- 
tion of the patient with the unmixed serum from the suspected 
sore, somewhat in the same manner that vaccination is made with 
the unmixed lymph. 
If this inoculation produce the like of the original sore, and 
can be repeated with the same result, then the case is not 
syphilis. 
But great care is required in getting only the pure virus on 
the point of the lancet,and in introducing it, so as not to cause 
unnecessary irritation, for the introduction of decaying tissue into 
the skin might be a source of danger in itself, and irritation might 
prevent the inoculation. 
Where, in cases of erosion, tissue, etc., there is no reliable secre- 
tion to inoculate with, and the enlargement of the ganglia can- 
not be demonstrated with certainty, nothing is left but to wait 
and watch for the appearance of secondary symptoms. 
A case of venereal ulcer presents a strikingly different appear- 
ance from the chancre or any other lesion. It first appears 
as a vesicle or pustule, inflamed all around and attended with 
burning and itching, in from one to five days after the coition 
which caused it. This rapidly changes into an open ulcer, irreg- 
ular in form, with ragged, well-defined edges, forming a red, 
angry areola. (Sometimes the ulceration begins with a vesico- 
pustule). The surface of the ulcer is usually flat; its cavity con- 
tains yellow pus mixed with the gray disintegrating tissues. If 14 
some of the pus be taken on the point of a lancet and inserted 
under the epidermis, on any part of the patient's body, it will be 
followed in a few hours by an inflammation, and shortly after- 
wards by an ulcer of the same kind as the original, and this pro- 
cess may be repeated ad infinitum with the same results. 
The venereal ulcer is frequently multiple; two or more may 
commence at the same time, or one after the other from self-inoc- 
ulation. (If three or more appear in a cluster, they may be mis- 
taken for herpes). They are always painful, and the patient is 
anxious for relief. 
The ulcer has a tendency to spread, and, unless the virus be 
destroyed by early and deep cauterization, may get beyond con- 
trol, even under the most careful treatment. It is almost always 
found on the genitals, but is sometimes seen in other situations, 
though not so frequently as chancre. 
As the ulcerative process goes on upon the penis, the labia or 
contiguous parts, one, or rarely two of the ganglia in the super- 
ficial inguinal chain, on one or both sides, becomes inflamed, 
much enlarged and very painful. 
The inflamed ganglion is always tender on pressure, and not 
movable as in syphilis; it increases rapidly in size, and this increase 
is often attended by a rise in the temperature and pulse, which 
may amount to a fever, continuing until suppuration takes place, 
and the pus evacuated. 
Although the venereal ulcer may sometimes spread over a large 
portion of the body, it always remains a local disease. It is never 
constitutional, and mercury is contra-indicated. 
Perhaps my country brother may be called upon to diagnose a 
case which presents all of the symptoms of a venereal ulcer, as 
above described; but let him beware of rashly telling his patient 
that he has no constitutional disease. For it sometimes happens 
that the virus of the chancre and that of the venereal ulcer have 
been inoculated together at the same spot. Then the venereal ulcer 
takes the lead, and progresses in its usual manner, but after ten 
days or more, the symptoms of syphilis can be discovered by close 
examination. Those ganglia of the inguinal chain, which have 
not been affected by the venereal ulcer, will be found enlarged, 15 
movable, painless, with the peculiar, hard, elastic feel before de- 
scribed. At the same time the button-like induration of a chan- 
cre will make its appearance under the ulcer, elevating it above 
the skin. If these symptoms escape notice, the doctor will be 
greatly mystified, at the end of six to ten weeks, by the discovery 
of a very significant eruption; or the patient may consult him for 
some trouble about the throat, when, upon examination, he may 
find one or more mucous patches staring him in the face. 
Therefore, I repeat, be very guarded in expressing an opinion; 
be verv slow in making a diagnosis. 
Insisting again upon the necessity of examining the entire skin, 
and, as far as may be, the mucous membranes of the patient, in 
the search for a primary lesion, in every suspicious case, I now 
give the differential diagnosis between syphilis and venereal ul- 
cer, because they are frequently mistaken the one for the other. 
THE CHANCRE. 
1. Is always the result of inoculation 
with virus from a chancre, or from one 
of the syphilo-dermata, or with the 
blood of a syphilitic. 
2. Has a long period of incubation, 
usually more than ten days. 
3. Ispain ess and will generally heal 
without treatment; gives rise to no fe- 
ver. 
4 Is generally single; if multiple, al- 
ways so from the original inoculation. 
5. Begins as a papule without an in- 
flamed areola, or as an erosion. 
6. When fully developed, its form is 
that of a round or oval, cup-shaped ul- 
cer, with a iherent sloping edges. 
7. Its contents are serum, and the dead 
tissues gray and tough, like wet parch- 
ment, which will si >ugh out without 
suppuration or inflammation. It has an 
indurated base which elevates it above 
the surrounding skin, or mucous mem- 
brane. Induration button like in shape 
and feeling, painless, non-inflammatory 
and very persistent. ihe indurated 
chancre involves the whole thickness of 
the skin and of the areola tissues be- 
neath. As an erosion, it has no definite 
shape, and may have no induration. 
8. Rarely becomes phagedenic; usually 
follows a regular course until cured. 
9. The virus can rarely be re-inocu- 
lated on the patient. 
THE VENEREAL ULCER. 
1. Is always the result of inoculation 
with the virus from a venereal ulcer or 
from its suppurating bubo. 
2. Has no period of incubation ; may 
appear within twenty-four hours or after 
a few days. 
3. Is always p inful, has a tendency to 
spread, requires careful treatment, gives 
rise to febrile excitement. 
>. Is generally multiple from the be- 
ginning, or by fresh inoculations. 
5. Begins as a pustule with an inflamed 
areola, or as an erosion. 
6 When fully developed, its form is 
that of an irregular, flat and deep ulcer, 
with overhanging, ragged edges, forming 
a red, angry areola. 
7. Its contents, yellow pus, mixed 
with disintegrating gray tissues ; has no 
induration at the base beyond the line of 
inflammation; rarely involves the tissues 
below the skin ; is not elevated above the 
surrounding skin or mucous membrane. 
Beginning as an erosion, it soon takes 
the definite shape of the ulcer. 
8. Has a tendency to phagedena; ex- 
tensive ulcerations are relatively fre- 
quent; has an irregular course, and is 
stubborn to treatment. 
9. Can always be re-inoculated on the 
patient any number of times. 16 
10. Always affects all the surrounding 
superficial, lymphatic ganglia. The en- 
largement usually trifling. These gan- 
glia are hard, painless, freely movable, 
and do not suppurate. 
It. Is always constitutional, db initio. 
12. When left to nature will heal, but 
after a length of time will be followed 
by other lesio' s upon the skin and mu- 
cous membranes. Later on every organ 
of the body may become affected by the 
disease. 
13. Mercury is the best remedy known 
to affect a cure. 
10. Never affects all the surrounding 
ganglia; one or two become inflamed, 
greatly enlarged and very painful. They 
generally suppurate; the pus often inoc- 
ulable. 
11. Alwtiys remains a local disease. 
12. When left to nature the ulceration 
extends. It may spread over a large sur- 
face of the skin and become formidable, 
but once healed is not followed by any 
other manifestation. 
13. Mercury is useless, and often injuri- 
ous in the treatment. 
PROGNOSIS. 
There is no single symptom, nor group of symptoms, in a case 
of primary or secondary syphilis, which will justify us in pro- 
nouncing a positive opinion as to the final result. It may be stated 
as a general rule, that when the primary symptoms are severe, 
the secondary manifestations will fallow promptly, and be strongly 
marked, and when mild in its first stage the disease will be mild 
in the second. 
But it must not be concluded that the mild case is more likely 
than the other to have a favorable termination. For, no matter how 
small the amount of the disease lingering in the system, it will cer- 
tainly manifest itself in some way or other. Either the patient will be 
overtaken sometime during his life by so-called tertiary syphilis, 
or will be liable to complications in any disease by which he may 
be attacked, or to obscure diseases of the brain and nervous sys- 
tem, or remaining to all appearance healthy himself, his children 
may inherit constitutional syphilis. 
Prominent syphilographers have held that the disease is « self- 
limited," and that it will disappear without treatment after 
an indefinite number of years, the patient being restored to per- 
fect health. My own experience, however, is that in most cases 
where this appears to have occurred, the disease is not cured, but 
merely held in abeyance, to manifest itself when,either by the en- 
ergy of its own poison, or by that of some other disease, the 
patient's vital force has been reduced. 
I have seen numerous cases in w'hich the patients left treatment 
before I thought them cured, and yet afterwards showed no symp- 
toms, married, had healthy children and died of some other dis- 17 
ease ; others, who, after several relapses and many doctors, have 
apparently gotten well after leaving all treatment. 
On the other hand, cases, which had been treated and pro- 
nounced cured by eminent specialists in Europe and in America, 
have come under my observation at a later day with well-defined 
constitutional symptoms. It is then safe to assume that, without 
any treatment, the termination will be unfavorable ; that, under 
proper treatment, faithfully and persistently carried out, the dis- 
ease will, in the great majority of cases, disappear in from eighteen 
to thirty-six months, never to return, leaving the patient in per- 
fect health and not liable to infect his children. 
There are, however, a small percentage of cases in which, 
even with the greatest skill on the part of the doctor, whether 
from neglect by the patient (which I believe is the most frequent 
cause), or from some peculiarity of constitution, skin manifesta- 
tions, at times mild, at times inveterate, will return. In others, 
the patient, after remaining to all appearance perfectly well for 
years, will have his life ended by some obscure disease, which I 
consider as a result of syphilis. 
I advise you, therefore, whenever called upon to give a prog- 
nosis in a case of syphilis, to do, as many years of experience 
and many disappointments have taught me to do-tell your pa- 
tient that if he will faithfully carry out your directions, the chances 
of a cure are in his favor ; that the great majority of cases get 
well in this climate in about two years, under skillful treatment, 
but that you cannot promise a cure, because there are some cases 
which defy all treatment. 
OUTLINE OF TREATMENT. 
As it is now well understood that, during the incubation of the 
chancre, the syphilitic microbe travels along the lymphatic ves- 
sels into the ganglia, and at the time of the first appearance of 
the papule has already affected a lodgment in the system, it seems 
unnecessary for me to say, that all attempts to abort the disease 
by cauterization of the chancre will be ineffectual. Repeated ex- 
periments have shown that deep cauterization of the sore, even a 18 
few hours after its first appearance, fails to prevent constitutional 
symptoms. 
The disease must be cured, if cured at all, by remedies which 
affect the general system. 
It is desirable, of course, to heal the chancre as soon as possi- 
ble, and to do this all irritant applications must be avoided. If, 
from any cause, there be irritation or inflammation around it, 
water dressing, or weak astringent lotions, should be constantly 
kept applied to the parts, until it has disappeared, then a dry 
dressing of pulverized iodoform, clay, chalk or bismuth, etc., must 
be used night and morning, after carefully washing and drying 
the ulcer. By this treatment cleanliness is secured, the dead tis- 
sues will slough out readily, and the sore will then heal rapidly. 
The enlarged ganglia require no treatment unless inflamed, 
still, it may be useful, in order to interest the patient in the treat- 
ment, or to relieve his apprehensions, to make him rub them over 
with some non-irritating ointment. But when the patient fully 
understands the dangers of neglect, it is always better to allow 
the absorption to be effected by the internal treatment, because 
the condition of the ganglia is a sure index of the progress of the 
cure. 
The effect of the syphiliic microbe upon the human blood, seems 
to be, to cause the destruction of the red corpuscles. Almost 
every individual suffering from the first or second manifesta- 
tions of syphilis, is anaemic. If the blood be examined under the 
microscope, it will be seen that the proportion of the large white 
corpuscle to the red, is much greater than in health. 
Under the use of small doses of mercury and proper hygienic 
treatment, the red corpuscles increase rapidly, and the pale hue 
of the surface is replaced by a natural complexion. 
The entire treatment then, of a case of syphilis, consists, ac- 
cording to my experience, in such hygienic measures as will bring 
the general health of the patient up to the highest standard pos- 
sible, together with the administraion of that salt of mercury, 
which will increase the number of the red corpuscles. 
The first duty of the physician, when the diagnosis of a case of 
syphilis is made, is to fully instruct his patient in all matters per- 19 
taining to the disease, warn him of its deplorable consequences, 
impress upon him the necessity of adhering rigidly to the treat- 
ment until a cure is effected, and get his promise to do so. But 
this promise alone avails nothing. I can recall many instances of 
young men of a class who would naturally be supposed to feel 
most fully the weight of a moral obligation, but who, while un- 
der such promise, have left the treatment as soon as the promi- 
nent symptoms had subsided, to die afterwards a miserable death 
from some of the sequelas of the disease. After suffering many 
disappointments from this cause, the idea occurred to me of put- 
ting my patients under a money obligation to adhere to the treat- 
ment to the end, and I have found this plan to work very well as 
to results. 
Next, a mode of life should be prescribed which will improve 
the patient's general health. Such diet only should be allowed 
as will build up the strength and not overtax the digestive pow- 
ers. Alcoholic drinks and tobacco should be absolutely forbid- 
den, as either of them will greatly interfere with the treatment. 
Then the doctor must find, by repeated trials, that preparation 
of mercury which will improve the patient's blood, and the dose 
which he can take three times a day, for any length of time, with- 
out disturbing his digestion, and without inducing salivation, or 
tumefaction, or even reddening of the gums. 
Individuals are met with, who cannot take mercurials with ad- 
vantage at first. Here we must alternate a tonic treatment with 
trials of the various salts of mercury until some one is found suit- 
able to the case. 
On the appearance of secondary symptoms, such non-irritant 
local application should be made to the affected parts as the 
judgment of the doctor may dictate, and the treatment previously 
pursued, should be continued. 
If constipation occur during the treatment, it should be relieved 
by a cathartic dose of calomel. When, after the disappearance 
of the secondary symptoms, the patient is restive under treat- 
ment, and irregular in taking his medicine, we may be obliged 
to produce an eruption of the skin, by the use of large doses of 
the iodides, in order to bring him under control. 20 
It is never safe to discontinue the regular treatment in less than 
eighteen months after its commencement. If, at the end of that 
time, the patient has been free from all symptoms for six months, 
and the ganglia have returned to their normal size and condition, 
the mercury may be intermitted for longer and longer periods 
during the next six months, and then discontinued altogether, but 
the patient must be kept under observation for six months longer, 
when, if still free from symptoms, he may be discharged as 
cured. 
It is always advisable to keep up the treatment for six months 
after the disappearance of the last symptoms, no matter how long 
the case may have lasted. 
If the red corpuscles do not increase in number under mercury, 
it must be stopped for a while. If the general health does not 
improve, a change of air and climate must be tried. 
Whenever the disease recurs after an apparent cure, the treat- 
ment indicated above must be resumed, as in a new case. 
In cases where the deep tissues, or the internal organs, or the 
bones are involved, and swelling, or deposits are present, the 
iodides should be used to cause absorption, and stopped so soon 
as this result is reached. 
It will be observed that my opinion of the value of the iodides, 
in the treatment of syphilis, differs from that usually entertained. 
I have found that when their use is pushed to any extent, they 
impoverish the blood and impair the vital powers of the patient, 
while the theory of treatment on which I practice is, that all our 
efforts should be directed to building up. 
In giving these simple directions, I think I have discharged the 
self-imposed duty of putting it in the power of a country physi- 
cian to control any ordinary case of syphilis, and to conduct its 
treatment to a successful issue. For the details of treatment of 
the many complications, which may arise during its progress, or 
which may otherwise come before him, I must refer him to works 
upon the general subject.