SYPHILIS. 
BY 
HENRY ALFRED ROBBINS, M.D. SYPHILIS OF THE EYE, EAR AND THROAT. 
Washington, D. C. 
CLINICAL LECTURE DELIVERED AT THE SOUTH WASHINGTON (D. C.) FREE DISPENSARY, JANUARY 21, 1897. 
Henry Alfred Robbins, M. D,, 
eighth paper. 
Reprinted from the Maryland Medical Journal, May 8, 1897. 
This colored man, aged 50 years, is 
a veritable museum of syphilitic mani- 
festations. Dr. Arwine has presented 
him to us, so that we can observe every 
part of his body, and that is the proper 
way to study the polymorphous erup- 
tions of syphilis. The room is warm 
and there is no danger of the patient's 
taking cold. You notice that there are 
patches here and there of a pale maculo- 
papular syphiloderm. The patient first 
noticed the initial lesion-on the pre- 
puce-a year ago. Now there is simply 
a cartilage-like induration. You will find 
enlargement and hardness of the glands 
in the inguinal regions, also the epi- 
trochlear, and the post-cervical and 
the sub-maxillary. There are mucous 
patches in his mouth, and he complains 
of nocturnal headache and rheumatic 
pains. The patient is wearing dark 
glasses, and you will find that he has 
double iritis. 
The initial lesion of syphilis has been 
reported in the literature of medicine as 
occurring on the eyelids, most fre- 
quently upon the free border of the un- 
derlid, and at both commissures. I 
mentioned quite a number in a lecture 
called "Unmerited Syphilis" which 
I delivered to a class of students 
on April 12, 1893. They were acquired 
in an innocent way-as in using the 
public towel in a railroad wash-room, 
and from contagion from a buccal mu- 
cous patch, communicated by a kiss, or 
by the filthy practice of removing for- 
eign bodies from the eye by means 
of the tip of the tongue. The exquisite 
representation of chancre of the eyelid, 
to which I call your attention, I ob- 
tained in an old print shop in the Latin 
Quarter of Paris. Dr. Charles Stedman 
Bull reports a case of chancre that was 
confined to the conjunctiva. 
Syphilis may attack any part of the 
organs of sight, either directly or by 
impairing nutrition, resulting in opa- 
city of the lens itself. Syphilitic iritis 
is not uncommon in the secondary stage 
of syphilis. You may hereafter be lo- 
cated where there is no ophthalmologist 
to consult, and it is important to know 
what to do. Give mercury by the in- 
unction method until the constitutional 
effects are observed. Then follow the 
treatment of Dr. David Webster of New 
York City, given in a clinical lecture at 
the College of Physicians and Surgeons, 
1881. 
' ' Atropine, as I told you, is our sheet 
anchor in the treatment of iritis. Un- 
less it is used, adhesions are very apt to 
occur between the pupillary border of 
the iris and the anterior capsule of the 
lens ; such adhesions are called poste- 
rior synechiae. When formed, they in- 
terfere with the normal function of the 
pupil. If a healthy eye be exposed to a 
bright light, the pupil contracts; if 
darkness prevails, it dilates. When ad- 
hesions have taken place about the cir- 
cumference of the pupil, no such con- 
traction or dilatation can occur. If ad- 
hesions exist in the eye of a patient 
who has recovered from iritis, he will 
be much more liable to have recurring 
attacks of the disease than if there were 
no adhesions. The only way in which 
the recurrence of such attacks can be 
avoided is to perform an iridectomy- 
remove a part of the iris. By the vigor- 
ous use of a four grain solution of atro- 
pia we have prevented the formation 
of any permanent adhesions. Perhaps 
this would not have been accomplished 
had we used only atropine, or, in other 
words, except for the combined influ- 
ence of atropia and mercury." 
Allow at least a week to pass after 
giving mercurial inunctions for iritis 
before prescribing iodide of potassium, 2 
because the combination will produce 
coryza, conjunctivitis and salivation. 
Then begin with iodide of potassium, 
saturated solution, five drops in water, 
three times a day; increase drop by 
drop until the patient has had as much 
as he can tolerate. Apply leeches to 
the temples, where there is much pain, 
or where the progress is slow. 
Many physicians pay little, if any, 
attention to the eyes in syphilitic cases 
they treat. Others, at most, look only 
for specific iritis. That there is a long 
list of such diseases liable to occur in 
connection with syphilis is often for- 
gotten. Dr. Jonathan Hutchinson, in 
his little work on syphilis, gives the 
following list of these diseases : In ac- 
quired syphilis are the following : 
1. Acute iritis; usually symmetrical; 
always in the secondary stage ; of fairly 
common occurrence. 
2. Inflammation of the vitreous body; 
often an accompaniment of iritis in its 
severe forms. 
3. Diffuse keratitis. This is very 
rare in connection with acquired syph- 
ilis. It occurs in the secondary stage, 
chiefly, if not exclusively. 
4. Neuro-retinitis. A primary in- 
flammation of the ocular portion of the 
optic nerve and retina, attended by 
general haze, but without evidence of 
choked disk. It is usually seen in the 
secondary stage. It may affect only 
one or both eyes. Not common. 
5. Scattered choroiditis ; gummata of 
the choroid ; choroiditis disseminata. 
This affection is rare and is seen only 
in connection with the late secondary 
stage. It may be attended by neuro- 
retinitis, or may occur alone. Usually 
it is almost wholly confined to one 
eye. 
6. Optic neuritis, with swollen or 
choked disk ; usually seen in the terti- 
ary stage and in association with men- 
ingeal gumma. It is rare, affecting 
both eyes at once. 
7. Serpiginous choroiditis. In this 
form large patches of absorption are 
seen, which slowly spread at their edges. 
8. Aquo-capsulitis, a form of insidi- 
ous and chronic iritis, of which the 
most conspicuous phenomenon is the 
dotted condition of the posterior lamina 
of the cornea. 
With inherited syphilis we have- 
1. Acute iritis. It is rare ; occurs at 
about the fourth month as one of the 
secondary class. It is very dangerous 
to sight. 
2. Interstitial keratitis ; tolerably 
common ; usually affects both eyes ; 
often attended with slight iritis and 
sometimes by choroiditis. Remarkable 
for its tendency to recover in most cases. 
3. Choroido-retinitis; usually chronic 
and attended by atrophy; most frequent 
at periphery ; may simulate the results 
of retinitis pigmentosa or approach 
choroiditis disseminata. 
4. Optic neuritis, followed by white 
atrophy ; very rare and almost never 
recognized, excepting in the atrophic 
stage. It will be observed that most of 
these forms of eye diseases are rare in 
syphilis, but their possible occurrence 
should always be kept in mind. 
On October 20, 1881, Dr. C. S. Bull 
read a paper before the New York 
Academy of Medicine on "Lesions of 
the Orbital Walls and Contents due to 
Syphilis," in which he restricted his 
remarks to the study of the lesions of 
the bones and the adipose and connect- 
ive tissues of the orbit. These lesions 
were not a common, though by no 
means a rare, manifestation of syphilis. 
The lesions considered were osteitis, 
periostitis, singly and combined, peri- 
ostosis, hyperostosis, exostosis, of which 
two or more might coexist, caries and 
necrosis involving perhaps only a small 
portion and possibly the entire thick- 
ness of the bone invaded. According 
to most authorities these lesions be- 
longed to the late manifestations of the 
disease, but Dr. Bull thought that they 
might occur earlier than had usually 
been supposed. They were more com- 
mon in hereditary than in acquired 
syphilis and in warm than in cold lati- 
tudes. The earlier periostitis was much 
less indolent than that which appeared 
later and was never followed by exosto- 
sis or hyperostosis. 
The symptomatology of these differ- 
ent lesions was illustrated by cases and 
the treatment of each variety was con- 3 
sidered in detail. Mercury and iodide 
of potassium were the drugs chiefly 
used in the medicinal treatment and in 
some cases it had been found necessary 
to reach very large doses of iodide of 
potassium before the symptoms of the 
disease began to yied. Dr. Bull (Mor- 
row, in Dermatology and Syphilology) 
gives beautifully colored plates and ac- 
curate descriptions of gummata of the 
conjunctiva and a well-marked example 
of gumma of the sclera or episcleral tis- 
sue on the temporal side of the eyeball, 
sometimes called scleritis gummosa. 
Also gumma of the iris pathognomonic 
of acquired syphilis. 
East eveni-ng at the Medical Society 
of the District of Columbia, Dr. Swan 
M. Burnett exhibited the pathological 
specimen of an eye in which there was 
a gummatous infiltration in the ciliary 
region. The patient, a young negro 
boy, had the history of an initial lesion 
dating back one year. Dr. Burnett re- 
ported several other similar cases, all 
occurring in young negroes, in whom 
the eye had to be enucleated. All began 
with iritis, which did not yield to treat- 
ment, such as inunctions of mercury 
and hypodermics of the bichloride of 
mercury. 
Gumma is considered to be a tertiary 
manifestation, but syphilis is some- 
times so rapid in its evolution that we 
are amazed to see the primary symp- 
tom and a tertiary product. Dr. Henri 
Roger, in 1863, presented to the Soci- 
6t£ Medicale des Hopitaux a little girl 
two years old, on whom could be ob- 
served simultaneously all the symptoms 
of syphilis ; the primary lesion, a chan- 
cre on the upper lip communicated by 
her mother who had at the time a chan- 
cre on the lower lip ; secondary symp- 
toms, specific roseola and mucous 
patches on the vulva and anus ; tertiary 
symptoms, periostoses of the cranium, 
the humerus and both tibiae. 
It is our object in these clinical lec- 
tures to turn syphilis inside out, as it 
were. We will drive the evil spirit out 
of his hiding places in the internal and 
vital organs. We have shown you how 
it attacks the eye. Now let us take up 
the ear, and you will perceive that it 
sometimes finds an abiding place there. 
I have, in private practice, two patients 
who suffer from deafness caused by 
syphilis. Both have histories of having 
had the disease for eight or ten years. 
One of them is being treated by my 
friend Dr. John H. Metzerott, and his 
hearing has been remarkably improved. 
This is a case of disease of the middle 
ear. The other has impairment of the 
auditory nerve, and these cases are al- 
most hopeless. 
The external ear may be attacked 
with gummata, papules and condylo- 
mata. These sometime escape recogni- 
tion by the general practitioner, who is 
not familiar writh the masquerading pro- 
clivities of syphilis. In 1888, Dr. Law- 
rence Turnbull of Philadelphia wrote an 
article on syphilitic ear diseases, which 
is the best and briefest that I am famil- 
iar with. I take the liberty of quoting 
his conclusions: 
1. That syphilitic diseases of the 
ear are less numerous in the United 
States than in great Britain or Eu- 
rope, and that it is not so frequently 
a cause of deaf-mutism. 
2. In almost all constitutional syphi- 
litic diseases of the ear in children and 
young persons, it is associated with 
some affections of the eyes, throat and 
nose. The deafness which often follows 
the improvement in the eyes is some- 
times profound. 
3. Persons who have suffered from 
constitutional syphilis, especially young 
persons and children, have great im- 
pairment of conduction of sounds 
through the bones of the head. Even 
in adults with constitutional syphilis 
the tuning-fork in some instances can- 
not be heard on the bones of the head 
or face. 
4. In a few cases the first indication 
of a syphilitic diseased ear is a primary 
ulcer in the throat, naso-pharyngeal 
space, or in the auditory canal, or near 
the membrana tympani. 
5. Purulent otitis media, or otitis media 
serosa syphilitica, may occur in utero, 
or in very young infants, while in young 
persons and adults we may have con- 
gestion of the tympanic mucous mem- 
brane from the same cause, anchylosis 4 
of the bones of the ear, with bands of 
adhesion in the middle ear, by extension 
from the throat to the Kustachian 
tubes. 
6. Syphilitic disease may affect the 
most vital part of the internal ear, 
labyrinth, semi-circular canals and 
cochlea, with hyperemia, marked thick- 
ening and dryness of the membranes of 
the round and oval windows and ves- 
sels which supply the internal ear. 
There is also disease of syphilitic na- 
ture in the auditory nerve, also the 
brain itself, in the formation of dissem- 
inated small nodules within the nerve 
centers. This form of disease of the 
ear is most successfully treated by the 
combined use of pilocarpin and mer- 
cury. Another valuable preparation in 
obscure syphilitic cases is the follow- 
ing: 
B.-Hydg. bichlor gr. j 
Acid, arseniosi .... gr. j 
Ferri pyrophosphat. . . gr. vj 
M. Ft. Pil No. xxiv. 
Sig.-One three times a day. 
Care must be exercised in the use of 
powerful drugs, as there have been cases 
of jaborandi and pilocarpin poisoning. 
Two cases have been reported of poison- 
ing; one from two drachms of the fluid 
extract of jaborandi (which required no 
antidote), and the other from swallow- 
ing a considerable dose of the fluid so- 
lution of pilocarpin used for stimulating 
the hair, instead of a solution of qui- 
nine. In both cases the symptoms 
were profuse perspiration and salivation, 
dimness of sight, prostration, a sensa- 
tion of cold tremor and extreme general 
debility. The treatment of the pilocar- 
pin case was with atropine, which is the 
antidote. 
It is my intention to make you ac- 
quainted with all the forms of cures and 
treatment that have been tried or sug- 
gested. I found in a very old scrap 
book of mine an article on the " Influ- 
ence of Febrile Diseases on Syphilis," 
in which it was stated that it is per- 
fectly certain that several grave febrile 
diseases may modify the course of con- 
stitutional syphilis so as to change, or 
even cause the complete disappearance 
of the external manifestations of the 
disease. Dr. Petrowski ( Vratsch, No. 
22) reports three cases of this descrip- 
tion. 
In the first, the patient had con- 
tracted the chancre six months pre- 
vious to entering the hospital. He had 
an indurated chancre of the prepuce, 
balanitis, mucous patches on the glands 
and scrotum, ulcerations in the throat 
coincident with a scaly, syphilitic erup- 
tion on the face and scalp. A six 
weeks' mercurial course produced but 
slight amelioration. While at the hos- 
pital he fell sick with the smallpox; the 
attack was of exceptional gravity, but 
when the crusts of the smallpox eruption 
had fallen, no trace of the syphilitic 
eruption remained; the patient was un- 
der observation for several years, and 
none of the syphilitic manifestations 
reappeared. It has been suggested by a 
pupil of Dr. Hardy to inoculate the 
poison of smallpox in cases of syphilis 
which have resisted all other methods 
of treatment. (Garrigue, Del'influence 
des maladies aigues sur les diatheses, 
These de Paris, 1870.) 
The second case is less striking; the 
patient had a syphilitic gumma at the 
angle of the jaw, and after an attack of 
typhoid fever, this gumma suppurated, 
leaving a cicatrix which bore no resem- 
blance to ordinary syphilitic cicatrices. 
The third case was that of a power- 
fully built soldier, twenty-three years 
old, who was found while suffering with 
facial erysipelas to have a superficial 
sore on the penis, swelling of the in- 
guinal and cervical glands, erythema- 
tous redness of the pharynx, and broad 
condylomata on the soft palate, and on 
the pharyngeal wall. The erysipelas 
lasted fourteen days, and the fever was 
severe. With its subsidence, and with- 
out any mercurial treatment having 
been employed, all the manifestations 
disappeared, and none others ever made 
their appearance. This patient Dr. 
Petrowski also had under observation 
for several years. 
Dr. Rudolph of Magdeburg reports 
two cases that illustrate the temporary 
subjugation of syphilis by an erysipela- 
tous attack. In the first case, that of a 5 
man fifty-two years old, the syphilis 
was of twenty-nine years' standing. The 
syphilitic manifestations observable at 
the time of his attack of erysipelas were 
two sores, one on the ala nasi and the 
other on the supra-orbital margin of the 
right side. On the ninth day of the 
erysipelas the sores had entirely healed. 
The patient was not seen after that, so 
it cannot be said that he continued free 
from syphilitic manifestations. 
The other case was that of a young 
woman who had had syphilis for four 
years, had undergone three courses of 
mercury, one by inunction, and two by 
hypodermic injection, and had taken 
great quantities of potassium iodide. 
For all that, she was found to have sev- 
eral glands enlarged to the size of a 
pigeon's egg under the lower jaw on 
each side, and posterior cervical glands 
varying in size from that of a pea to that 
of a hazel-nut. She was very weak and 
emaciated, and, in consequence of rheu- 
matic pains in the knees, accompanied 
by well marked inflammatory thicken- 
ing, could walk but little. This rheu- 
matic trouble, she said, had been pres- 
ent ever since she had syphilis, also ex- 
ceedingly severe headache. There was 
paresis of the left half of the face, and 
occasionally there were spasms of that 
side of the face. In spite of her weak- 
ness, she was given another course of 
mercurial inunctions-a drachm of mer- 
curial ointment being used daily for 
thirty days. The effect was nil and she 
declined to submit to further treatment. 
In about a year Dr. Rudolph was 
called to attend her again. She was 
then extremely cachectic; she had been 
bed-ridden most of the time on account 
of great debility and pains in the knees, 
and her headaches had never left her. 
Moreover, her former manifestations of 
syphilis were still present. She was 
now in the early stage of what proved 
to be a severe attack of erysipelas, 
which spread from the face over the en- 
tire head. In ten days the fever and 
theexanthema hadentirely disappeared; 
not only that, but she was apparently 
cured of her syphilis. The clusters of 
submaxillary glands, that had threat- 
ened to suppurate, melted away entirely 
as the inflammation disappeared ; there 
was no more headache or articular pain; 
the facial paresis and spasms gradually 
ceased, and her general health was so 
rapidly restored that in the course of a 
month she was able to return to work 
as a tailoress. A relapse occurred, howr- 
ever, at the end of a year. 
Dr. John Noland Mackenzie (in Mor- 
row's work on Dermatology and Syph- 
ilology) says: "This remarkable in- 
fluence of the febrile state upon syph- 
ilitic inflammation and ulceration of the 
nasal passages and throat is also in a 
measure true of simple inflammatory 
conditions of these cavities. It were for- 
eign to the purpose of the present article 
to elaborate this latter and cognate sub- 
ject, and I shall therefore simply offer 
for consideration the fact that simple 
catarrhal inflammation of these regions 
occasionally disappear completely, and 
is permanently cured during the course 
of an acute febrile disease. Whether this 
occurs as a phenomenon of so-called 
substitution, or as the result of a pro- 
found impression made upon the nutri- 
tion of the parts by virtue of which ab- 
normal secretion is arrested and the in- 
flamed tract placed in a condition favor- 
able to resolution, can only be deter- 
mined by the accumulation of more 
exact scientific data concerning the 
reciprocal antagonism of pathological 
processes." 
Not long ago, a new cure for cancer 
was announced. It was inducing ery- 
sipelas, by injecting its micro-organism 
into the substance of a malignant 
growth. This streptococcus of Fehlei- 
sen (named in honor of the bacteriolo- 
gist who discovered it), it was supposed, 
made war upon and destroyed the can- 
cer germs. I was investigating this 
subject, and had collected the above- 
mentioned cases, when day before yes- 
terday I received a copy of the New 
Albany Medical Herald (December, 1896) 
in which there was a most able article 
from my friend Professor J. Abbott 
Cantrell of Philadelphia. The article 
was entitled, " Does the Streptococcus 
of Fehleisen exert a Curative Influence 
Upon Syphilitic Ulcerations ? " He re- 
ported a case of apparent cure of syph- 6 
ilis in a patient who was attacked with 
erysipelas. " The case, in fact, pre- 
sented a picture which is rare to behold 
in this disease, which often shows such 
multiple disfigurements, and so varied 
were the appearances in this young 
man's case that it had been arranged to 
photograph it at my next visit, but, 
upon arriving at the hospital, I was in- 
formed that in some manner or other 
the young man had contracted erysip- 
elas and consequently we were obliged 
to postpone our operations until a future 
visit. 
During the course of the next few 
days the erysipelas was noted to have 
reached its height and what was 
more peculiar was that as the time pro- 
gressed the ulcerating lesions were 
noticed to be becoming smaller each day 
until finally when the erysipelas was 
entirely relieved, these syphilitic points 
were found to be entirely healed and 
presenting the cicatricial condition only 
that is usually found after the removal 
of the effect of syphilis." 
He says, ''The impression of the 
writer is that the effect was not acciden- 
tal. That the same effect may be pro- 
duced in any case in which erysipelas is 
accidentally contracted. Another point 
to answer is: Is the effect entirely 
curative, i. e., has the disease been for- 
ever cured, or is it likely to return ? 
In answer to this I may say that it is 
probable that it will, and therefore the 
effect is probably not lasting." 
Dr. Cantrell gave the report of the 
committee appointed by the New York 
Surgical Society to investigate the 
value of the streptococci of Fehleisen, 
that vegetable germ to which erysipelas 
is due, in cases of malignant diseases 
(Annals of Surgery, July, 1896). 
" We believe that in the instances of 
apparent cure or marked improvement 
the correctness of the diagnosis is open 
to doubt." 
" We therefore submit : 
" 1. That t ie danger to the patient 
from the treatment is great. 
" 2. Moreover, that the alleged suc- 
cesses are so few and doubtful in character 
that the most that can be fairly alleged 
for the treatment by toxines is that it 
may offer a very slight chance of ameli- 
oration. 
"3. That valuable time has often 
been lost in operable cases by postpon- 
ing operation for the sake of giving the 
method of treatment a trial. 
"4. Finally, andmostimportant, that, 
if the method is to be resorted to at all, 
it should be confined to the absolutely 
inoperable cases." 
After reporting the curative action of 
erysipelas upon syphilis, it is well to 
''give the devil his due," and report 
cases where syphilis has been reported 
in taking a hand in curing the most 
dreadful scourge of this country-pul- 
monary tuberculosis. Dr. R. Abrahams 
Record, December 28, 1895) 
reported the case of a man aged 35, who 
was far advanced in phthisis pulmonalis. 
He acquired syphilis. Under prompt 
and energetic anti-syphilitic treatment 
every symptom of syphilis and tubercu- 
losis vanished. Five years later he was 
perfectly well. Dr. Ross Rec- 
ord, February 15, 1896) reported a simi- 
lar case. Seven years later the patient 
was enjoying perfect health. Fournier 
reports the case of a man who was given 
up to die, who had every symptom of 
pulmonary tuberculosis. Syphilis was 
diagnosed. Iodide of potassium was 
given, resulting in a rapid and perma- 
nent cure. Brambilla reports the fol- 
lowing : '' In a hospital a phthisical 
patient occupied the adjoining bed to a 
syphilitic. The first was extremely 
ill and there was little hope of his re- 
covery. Through a mistake of the 
apothecary, the mercury which was or- 
dered for the syphilitic was given to the 
one with phthisis. He soon recovered 
his former health and vigor and left the 
hospital." 
More than twenty years ago I re- 
ported the case of a man who was far 
advanced in pulmonary tuberculosis. 
He became interested in daguerreotyp- 
ing and passed hours every day in the 
dark room, inhaling the fumes of the 
iodides. In a few months he had en- 
tirely regained his health. 
In my next lecture I shall take up 
some of the syphiloderms and then show 
you cases as they come in.