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NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF
 
 
 
 
CYCLOPEDIA
OP THE
PRACTICE   OF  MEDICINE.
Edited by Dr. H. von ZIEMSSEN,
  PBOFESSOB OF CLINICAL MEDICINE IN HuWiUH, BAVARIA.
VOL. III.
CHRONIC  INFECTIOUS DISEASES.

       By PROF. CHRISTIAN BAUMLER of Erlangen, PROF.
         ARNOLD HELLER of Kiel, and PROF. OTTO
               BOLLINGER of Munich.
QpranHlatefc is
ARTHTJR H. NICHOLS, M.D., of Boston; WILLIAM ASHBRIDGE, M.D., of Philadelphia:
    JAMES G. HYNDMAN, M.D., of Cincinnati; and EDWARD B. BRONSON,
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ALBERT H. BUCK, M.D., New York,
      BDITOB OF AMERICAN EDITION.
£tet'M
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IS 74-
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In the Office of the Librarian of Congress at Washington.
ALL RIGHTS  RESERVED.
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         NEW YORK. 
BIOGRAPHICAL SKETCHES  OF THE  AUTHORS.
    Christian Baumler, Professor of Materia Medica  and Director  of the
Polyclinic at Freiburg (Baden), was born in  1836, at Buchau (Upper Fran-
conia).   His early education was completed at the High School of Nurem-
berg, and he studied medicine  in the  Universities of  Erlangen, Tubingen,
Berlin, Prague, and Vienna.  He graduated at Erlangen in I860, and for
over two years held  the post  of assistant-physician to the polyclinic  of this
university.  Afterwards  he  went to Paris and London,  and from 1863  to
1866 was resident  medical officer at the German Hospital, London.  In the
latter year he became a member of the  Royal College of Physicians, London,
and practised in London  from 1866 to 1872, at the same time acting as assist-
ant-physician to the German  Hospital and the Victoria Park Hospital for Dis-
eases of  the Chest.   In  1872 he  was called to a Chair of Medicine  in the
University of Erlangen, and  in the autumn of 1874 to Freiburg.
    He is the author of " A Thesis on the Function of the Intercostal Muscles,"
Erlangen, 1860;  of  papers  "On Coloboma Oculi," Wiirzb. med. Zeitschr.,
1862;  "On Tympanitic Resonance in Pneumonia,"  Deutsches Arch, fur
klin. Medicin, Vol. I., 1865; "On  Typhoid Fever in England," Ibid.,  Vol.
III., 1867;  " On the  Observation of Temperature as a Means of Diagnosis
in Cases of Syphilis," Ibid., Vol. IX., 1871 ; and of various other contributions
to the  same journal,  and to the Medical Times and   Gazette,  the British
Medical  Journal, the  Transactions of the Clinical and Pathological Societies
of London.   He was the translator of Niemeyer's lectures on Consumption
into English for the New Sydenham Society.

   Arnold Heller, Professor of General Pathology and Pathological Anatomy
at the University of Kiel, was born in the year 1840, in  Klein-Haubach-on-
the-Main in  Bavaria.    He studied medicine in Erlangen and Berlin, received
the degree of Doctor in 1866, and served as an  army surgeon  during the war
of 1866.  In further pursuance of his studies he visited Vienna,  Prague, and
Leipsic, in the  former working under Bokitansky, and in the latter under
Ludwig.   During the war of 1870-71 he was active as  a volunteer  in caring
for the sick and wounded.  During the interval  from  1866 to 1872  he was 
iv          BIOGRAPHICAL SKETCHES OF THE AUTHORS.

assistant at the Pathological Institute in Erlangen; in  1869 he received the
position of Private Instructor; in 1871 he visited  England and Scotland;  in
1872 he was called  to  Kiel.  He has  contributed  the following  articles  to
journals:  " On the Anatomical Grounds for the Disturbances  of Hearing  in
Cerebro-spinal  Meningitis,"  in  the  Deutsches Archiv f. klin. Med., Band
III.; "Pneumonia and Meningitis," Ibid., Band V. (written conjointly with
Professor Ziminermann, of Basle) ; " Metastatic Processes of the Liver," Ibid.,
Band VII.; " Skleroderma," Ibid., Band X. ; " Hydronephroses," Ibid., Band
V., VI. ;  " Multiple Neuromata," Virchow's Archiv, Band 44; " On Inflam-
mation and Suppuration," Erlangen, 1869, Ibid., Band 40; " On  Rhythmic
Lymphatic Pulse," Med.  Central-BL, 1869;  " On the Blood-vessels of the
Small Intestine,"  Arbeit, d.  Phys.  Instit.  zu  Leipsig, 1872.  He has  also
published a number of minor articles in the Deutsches Archiv f. klin. Med.,
in  Virchow's  Archiv, aud in the Sitzungsberichte d. physical, und medicin.
Gesellschaft of Erlangen.

    Otto Bollinger, the son of a Protestant minister, was born on the 2d of
April, 1843, at Altenkirchen, in  the Rhenish Palatinate of Bavaria.   After
completing his studies  at the High School  of Zweibriicken, he entered the
University of Munich  in the autumn  of 1862, and devoted  himself to the
study of medicine until 1868.  From the year 1863 to  1868 he also acted  as
assistant under Professor Buhl, of the Pathological and Anatomical Institute
of the University.  Without taking his degree or  passing the  state examina-
tion lie visited Vienna and Berlin, where, during the years 1868 and 1869,  he
completed his medical studies, and immediately commenced in those cities the
study of comparative  pathology and  veterinary  medicine.   Returning  to
Munich he continued his  studies at  the veterinary school of the latter city,
and in the summer of  1870 became Private Instructor in comparative path-
ology  at the University of Munich.  When  the  Franco-German  war broke
out he entered the  Bavarian service for the war, as a volunteer  surgeon of
a battalion.  In this capacity he served  during the whole campaign  in France.
After the war was ended he accepted a call, made before the war, and became
Professor  at the Veterinary  School  in Zurich, acting  at  the same time  at
the University as Private Instructor in Comparative Pathologv;  he also gave
instruction as Professor  of  Epidemiology in the agricultural department of
the Confederate Polytechnic Institute.  After three years of active devotion
to  these  subjects in Zurich,  he  accepted a call as Extraordinary Professor of
Comparative Pathology at the University of Munich,  and also as Professor
of  General Pathology at the Central Areterinary School of Munich both  of
which positions he  has been filling since the Spring of 1874.  The more 
           BIOGRAPHICAL SKETCHES  OF THE AUTHORS.           V

important of his scientific works  are  the  following: 1. "Contributions to
Comparative  Pathology,"  Part I.   " The  Colic of Horses  and Vermiform
Aneurism of  Enteric Arteries" (with 19 wood-cuts), Munich, 1870, Part II.
" On the  Pathology  of Malignant  Pustule " (with 3 plates), Munich, 1872.
2. " Statistics of  Changes of Old Standing in Human Bodies."  3. " On the
Pathological  Anatomy  of  Acute  Atrophy of  the Liver and Phosphorus
Poisoning."   4. " A Case of Phosphorus Poisoning."  Deutsches Arch. f. klin.
Med., Vols. V. and VI., 1869 and 1869. 5. « On Peculiar Bodies in the Miuute
Arteries of Horses," Virchow's Arch., Vol. 47, 1869.   6. "Mycosis of the
Lungs in Horses," Ibid., Vol. 49, 1870.  7. " A Contribution to our Knowl-
edge of  the Rinderpest," Arch. f. Thierheilkunde, Band 24, 1871.  8. " Con-
tributions to  Comparative Pathological Anatomy : " I. " On the Pathological
Anatomy  of Hydrophobia ;"  II.  " Miliary Tuberculosis   in  the  Cat,"
Virchow's Arch., Band 55, 1872.    9.  " On the  Tuberculosis resulting from
Inoculations  and Feeding with Tubercular Matter," Arch.  f. Exper. Path.,
Bd. I., 1873.   10. "A Contribution to our Knowledge of the Lameness of
Foals,"  Virchow's Arch., Bd. 58, 1873.   11. "On Epithelioma Contagiosa
in the Domestic  Fowls and the so-called Pox  in Birds," Ibid.   12.  "On
Leukaemia of Domestic Animals,"  Virchow's Arch., Bd.  59, 1874.   13.  " On
the Syphilis of the Wild Hares," Ibid., Bd. 59, 1874. 
EERATA.
                                    VOL.  II.

   On page 92, at the beginning of the fifth  line from the bottom, a comma  has been
omitted after the word '' bronchi."
   On page 231, fifteenth line from the top, the word  " chest " should be used instead
of "heart."
   On page 317, the word " modificaitons " should read " modifications."
   On page 538, sixth line  from the top, " (1 : 50-60) " read " (one grain to the fluid
drachm)."
   On page 662, foot-note,  for '' pills............doses,"  read " pills  containing equal
parts of sulphate of cinchona and saccharated carbonate of iron, of which from twenty-
three to thirty grains are taken through the day in hourly doses."
   On page 663, sixth line from the top, for " 180" read " 185 ; " seventh line from the
bottom, for "Barnatzik" read "Bernatzik."
   On page 664, last line  of foot-note, for " (10 lbs. 8 ounces  to the bath) " read " (one
hundred and twenty-nine American, or one hundred and forty-one British ounces to the
bath)."
   On page 665, second line from the bottom, for " chinoidine "  read " quinoidine " ;
in second foot-note, for " Quinodine " read "  Quinoidine."
   On page 670, eleventh line from the top, for " 180" read " 185."
   On page 677, in the foot-note, for " bebeerine " read  " berberine " ; and for " 3^- to
15 grains "  read " frcm three to fifteen grains."
   On page 737, at the top, for '' narcottic " read '' narcotic."


                                    VOL. III.

   On page 347, sixth text-line from foot,  " (bromide and iodide of potassium, chlorate
of potassa)," should read " (bromide,  chloride and iodide of potassium)."
   On page 370, second line from  the bottom, " bichlorate " should read " chloride ; "
and same page, last line,  "  potash" should read "potassium."
   On page 371, top line, " potash " should read " potassium."
   On page 452, lasli line, " disordered " should read " perverted." 
                                    T ■



CONTENTS.
                               BlUMLER.

                                Sypuilis.

                                                                          PAGE
Introduction.............................................................   3
History.................................................................   5
Geographical  distribution................................................  19
General considerations regarding the course of the disease....................  21
The stages of syphilis...................................................t.  26
General patlwlogical anatomy.............................................  33
Etiology................................................................  39
    The syphilitic poison..................................................  39
     Vehicles of the syphilitic poison........................................  42
        Hereditary transmission of syphilis.................................51
    The infection........................................................  57
        The transmission of syphilis by vaccination........................  61
    Susceptibility to the syphilitic poison ...................................  69
Pathology, symptomatology and pathological anatomy........................  74
    The period of incubation.............................................  74
    The primary affection................................................  77
        The doctrines of the unity and duality of the syphilitic and chancre
          poisons.......................................................  86
        Microscopic anatomy of the primary affection......................  109
    Enlargement of the lymphatic glands in the region of the primary affection..  117
    The so-called second incubation........................................  123
    The syphilitic eruption fever...........................................  125
    Location of the disease in the different organs...........................  129
    Skin and mucous membrane..........................................  129
        The different forms of the syphilitic affections of the skin and mucous
          membranes....................................................  132
            I. Circumscribed hyperemias with but slight infiltration. (Macular
                 syphilide, Roseola syphilitica.)............................  134
          II. Well-marked circumscribed infiltrations of the papillary body of
                 the cutis................................................  137
              1. In the form of papules.   (Papular syphilide.) ..............  137
              2. Infiltration of  the papillary body in large patches.  (Squamous
                  syphilide.) ............................................  146 
                              CONTENTS.
                                                                          PAGB
          III Location of the infiltration, especially in the walls of  the fol-
                                                                           147
                licles..............................................
             1.  Infiltration of the follicular walls', with only scanty or with no
                exudation in the follicles.  (Lichen syphiliticus.)  .......... 148
             2  Acute suppuration in the follicle.  (Acne syphilitica.) ...... 150
                                                                           151
             3.  Impetigo syphilitica......................................
           IV. Infiltration with subepithelial suppuration and superficial ulcer-
                 ation.  (Pustular syphilide.)............................. 152
               Ecthyma syphiliticum.................................... 1 53
               Rupia................................................... 154
            V. Deep infiltration and disintegration.  (Gummous formation.)  . 156
               Tubercular syphilide...................................... 156
The 7iair  and nails...................................................... *61
Subcutaneous and submucous cellular tissue, fascia,.......................... 164
Bones................................................................... 166
Ligaments, tendons, bursa,  and joints...................................... 175
Muscles................................................................ 179
The lymphatic apparatus................................................. 180
                  « (Translated by Edward B. Bronson.)

The liver................................................................. I85
Digestive tract........................................................... 194
    Mouth and fauces.................................................. 195
    Tongue............................................................ 195
    Teeth.............................................................. 197
    Palate.............................................................. 198
    Tonsils............................................................. 199
    Pharynx........................................................... 201
    Oesophagus....................................................  ... 202
    Stomach and small intestine.......................................... 203
    Large intestine and rectum.......................................... 204
    Salivary glands  and  pancreas......................................... 205
    Peritoneum........."................................................ 206
Respiratory  organs..................................................... 206
    Nasal cavities....................................................... 207
    Larynx, trachea, and bronchi.........................................  210
    Lungs..............................................................  211
 Circulatory system......................................................  215
    Heart..............................................................  215
    Blood-vessels.......................................................  217
Nervous system..........................................................  218
 Organs of the special senses...............................................  221
    Sense of smell.....................................................  221
     Eye...............................................................  221
     Organ of hearing.............¥......................................  225
 Urinary organs.........................................................  226 
                                CONTENTS.                               ix

                                                                          PAGE
    Genital organs.......................................................... 229
    Hereditary syphilis.......................................................235
        Syphilis of the placenta.............................................. 235
        Syphilis of the foetus................................................ 237
    Retrospect.............................................................. 244
    Diagnosis.......................................%....................... 254
    Prognosis............................................................... 259
    Treatment.............................................................. 266
        Prophylaxis......................................................... 266
        Treatment..........................»............................... 271
        Syphilization........................................................ 307
                        (Translated by William Ashbridge.)


                                 BOLLINGER.
                        Infection by Animal  Poisons.
                             (Diseases of Animals.
Glanders.
Glanders in Horses....................................................... 317
    Historical notice.......................................................... 317
    Etiology............................................................... 320
        Nature of the morbid poison of  glanders.............................. 330
        Communicability to other animals.................................... 332
        Distribution and frequency of glanders................................ 332
    Patlwlogical anatomy....................................................333
    Symptomatology, course, duration, and termination.......................... 343
    Diagnosis............................................................... 346
    Prognosis and treatment.................................................. 347
Glanders in the  Human Subject.
    Historical notice......................................................... 348
    Etiology................................................................ 349
    Symptomatology......................................................... 352
Acute glanders.............................................................. 354
Chronic glanders............................................................ 358
    Pathological anatomy.................................................... 361
    Diagnosis............................................................... 366
    Prognosis.............................................................. 367
    Treatment............................................................... 369
                        (Translated by Arthur H. Nichols.)
Anthrax.
Anthrax op Animals...................................................... 373
    History.................................................................373
    Etiology...................•............................................378
        Nature of the anthrax poison......................................... 385
        Appearance and spread..............................................394 
X                                CONTEXTS.
                                                                           PAGE
    Symptoms...............................................................  Jd
    Pathological anatomy.................................................... °Jc'
    Prognosis..............................................................
    Diagnosis and Prophylaxis...............................................40~
    Treatment.............................................................. 404
Anthrax in Man.   (Malignant Pustule.)..................................... 404
    Etiology...............................................................405
    Symptoms and course................................................... 411
    Pathological anatomy.................................................... 418
    Diagnosis................................... ........................... 4~4
    Prognosis............................................................... 426
    Treatment.............................................................. 427
                        (Translated by Edward L. Keyes.)

Hydrophobia.   (Lyssa.  Rabies.)
    Historical notice........................................................ 433
Hydrophobia in Animals.................................................. 435
    Etiology................................................................ 436
    Nature and mode of action of the virus..................................... 444
    Hydrophobia in other animals than the dog—Geographical distribution......... 448
    Symptomatology........................................................ 451
    The violent form of hydroplwbia in dogs................................ ... 452
    The sullen rabies  of dogs.................................................. 458
    Hydrophobia in other domestic and wild animals............................. 459
    Pathological  anatomy.................................................... 461
    Diagnosis............................................................... 467
    Prognosis and treatment.............................. ...................471
Hydrophobia in Man.................................................... 472
    Etiology...............................................................' 473
    Pathology............................................................... 481
        Frequency of hydrophobia in the human subject....................... 481
        Incubation.......................................................... 482
        Symptomatology.................................................... 483
            I. Premonitory stage........................................... 483
           II. Stage of excitement........................................... 485
                  Analysis of  the different symptoms.......................... 488
          III.  Stage of paralysis............................................. 492
                  Duration and termination.................................. 493
    Pathological anatomy....................................................495
    Diagnosis............................................................... 498
    Prognosis............................................................... 501
    Prophylaxis............................................................. 502
    Therapeutical treatment.................................................. 509
The  Foot-and-Mouth Disease.   (Aphthae epizooticaa.) 
                                  COXTEXTS.                              XI

                                                                           PAGE
The Foot-and-Mouth Disease in Animals................................  514
    Symptoms..............................................................  515
    Pathological anatomy....................................................  519
    Diagnosis, prognosis, and treatment.....................................  520
The foot-and-mouth disease in the human subject.......................  521
    Etiology................................................................  521
    Symptomatology.........................................................  525
    Diagnosis, prognosis, and treatment........................................  530
Infection by the Bite or Sting of Poisonous Animals.
    1.  Stings of insects.......................................................  533
    2.  Stings of bees, wasps, and hornets.......................................533
    3.  Stings of scorpions.....................................................  534
    4.  Bites of spiders.......................................................  536
    5.  Bites of centipedes.................  ...................................  538
          Treatment........................................................  538
    Snake-bites............................................................539
      A. Viper-bites.........................................................  541
            Symptomatology.................................................  543
            Treatment.....................................................   545
      B. Snake-bites......................................................  547
            Symptomatology.................................................  549
            Treatment......................................................  550
                        (Translated by Arthur H. Nichols.)

                                   HELLER.
DTSEASES FROM MIGRATORY PARASITES.
    In troduction............................................................  555
Eeiimococcus.
    History.................................................................  557
    Natural History........................................................557
    Pathology.............................................................  567
      I.  General pathology of the echinococcus..................................  567
          Diagnosis........................................................572
          Prognosis and treatment..........................................  574
          Etiology and prophylaxis..........................................  578
     II. Echinococcus of individual organs.....................................  579
          1.  Brain.........................................................  579
          2.  Spinal cord...................................................  581
          3.  Respiratory organs.............................................  582
          4.  Circulatory apparatus..........................................  586
          5.  Spleen........................................................  587
          6.  Kidney.......................................................  587
          7.  Suprarenal capsule............................................  589
          8.  Liver.........................................................  589 
Xii                             CONTENTS.



                                                                             PAGE



Cysticercus Cellulose.

    ™,                                                          .......... 595
    History...........................................................


    Natural history........................................................


    General pathology....................................................

                        .                                                     607
    Cysticercus of the brain..................................................




Trichinae.

    „.,                                                     .............614
    History..............................................................


    Natural history........................................................


    Trichinosis.............................................................. G30


    Pathological anatomy....................................................


    Etiology........................•....................................... 6^8


    Prophylaxis...............................•..............................


                       (Translated by James G. Hyndman.) 
SYPHILIS
BAUMLEE. 
 
INTRODUCTION.
Recent general works upon  syphilis:  Ricord,  Traitg complet des maladies veneli-
    ennes.  Clinique iconographique  de l'hopital des veneriens.  Paris, 1842-52.
    —Simon, Art. " Syphilis," in Virchow's Handbuch der spec. Pathol, u.  Ther.,
    Bd.  II., 1, 1855, p. 421.—Freeman J. Bumstead, The Pathology and Treatment
    of Venereal Diseases. 2 edit.  Philadelphia, 1864.—Michaelis, Compendium der
    Lehre von der Syphilis, 2 Aufl.  Wien, 1865.—Jonathan Hutchinson, " Constitu-
    tional  Syphilis," in J. Russell Reynolds' System of  Medicine, Vol. I. p. 287.
    London,  1866.—A. Geigel, Geschichte, Pathologie und Therapie der Syphilis.
    Wiirzburg,  1867'.—Berkeley  Hill, Syphilis and  Local Contagious Disorders.
    London,  1868.—Henry Lee, " Syphilis," in Holmes' System of  Surgery, 2d ed.,
    Vol. I. p. 395.  London, 1870.—C. v. Sigmund, Syphilis und venerische Ge-
    schwursformen.  Pitha and Billroth's Handbuch der allgem. u. speciellen Chi-
    rurgie, B. L, 2, p. 204, 1872.— H Zeissl, Lehrbuch der  Syphilis,  2 Aufl.
    Erlangen, 1872.—A. Foumier, Lccons surla syphilis etudiee plus particuliere-
    ment chez la femme. Paris, 1873.—E. Lancereaux, Traite historique et pratique
    de la syphilis, 2d edit., Paris, 1874, containing a very complete  bibiliography.

    By  the term syphilis we understand a  chronic, infectious
disease, whose course, though protracted, is not, on this account,
less typical than that  of other infectious  diseases.   But in syph-
ilis the different stages lie  so far removed  from each other that
the  connection between their symptoms is not at once manifest.
For this  reason,  certain symptoms of the disease were for a long
time not  recognized as belonging to syphilis.
    The disease consists, essentially, in an  intoxication,  which
proceeds  from a  local infection, and gradually pervades  the
entire organism, manifesting  itself in all the  various tissues of
the  body under the form of an inflammatory process, of greater
or less intensity,  which,  to a certain  extent, pursues a course
peculiar  \6 itself.
   The m ode  in which  the disease  commonly propagates  itself
has tended not a little to impede its study, and,  chiefly, because 
4
BAUMLER.—SYPHILIS.
in the past  attention  has been  directed solely to local pro-
cesses that take  place at the point  where the  poison gains
entrance, to the neglect of changes occurring in the body at large.
Furthermore, a number  of local affections, having no connection
whatever with syphilis, were for a long time confounded with it.
Etiologically speaking,  syphilis and  morbus venereus are  not
synonymous terms ;  syphilis may be a morbus venereus—as, in
fact, it is in  the  great majority of instances—but not necessar-
ily.   The  only conditions necessary  to  the inception of  the
disease  are the presence of the specific poison and its inocula-
tion at any part of the skin or mucous membrane of a  healthy,
that is, not yet syphilitic  person, though the  disease may also
be inherited.
   Whenever the meaning attached to a term is clearly defined,
the latter may be retained, even though its lack of intrinsic sig-
nificance or other considerations, such as, perhaps, apply par-
ticularly to the disease which we are now  considering,  might
seem  to render a change of name desirable.  The term " syphilis "
was probably invented  with reference,  etymologically, to  the
most  frequent mode  of origin  of  the disease,  and  was first
employed,  incorporated  in  a myth, by the Veronese physician
Hieronymus Fracastorius,1 who relates, in a poem concerning  the
disease, that  a herdsman of king Alkithous,  Syphilus  by name,
was afflicted with it by Apollo, in  punishment for pa}dng divine
homage  to  the king instead  of to  the  god.   Other names
employed in the fifteenth and sixteenth centuries were : Morbus
gallicus (by  the  Italians,  Germans,  and  Spaniards),  Morbus
neapolitanus by the French, who,  however, as early as at the end
of the fifteenth century, called the  disease " la grosse verole."
In Spain the popular term was ububas" (pox);  in Germany :
Welsche Bossen  or Purpeln, also  mala franzos.  The older
writers also employ  the  names Lues venerea (Fernelius,  1556),
mentagra (mentulagra), and Pudendagra, Patursa (passio tur-
pis Saturnina), and others.
  1 H. Fracastorii, Veronensis: Syphilis sive morbus gallicus. Lib. III. Written ir
1521.  Printed in the collection of A. Luisinus. F. does not himself give any etymol-
ogy of the term he employs, but Gabr. Fallopia, demorb. gall., Aphr. II. p. 763, says:
"Hie vocavit syphila morbum istum, quia ex amore... .ut plurimurn suboritur." 
HISTORY.
5
                                HISTORY.

Most of the writings which had appeared upon syphilis at the end of the fifteenth
    century, and up to the middle of  the  sixteenth century, are  collected in the
    work, first  published in 1566, in Venice, by  Aloysius Luisinus, De morbo
    Gallico omnia quae exstant, etc.  A third edition of this collection was prepared
    by Boerhaave under  the title, Aphrodisiacus  sive de lue venerea, etc.   Lugd.
    Batav., 1728.  A third volume, with other supplements, was published by Ch.
    G. Gruner, in 1788, and still later, up to  the  year 1802.—J. Astruc, De morbis
    venereis libri VI.  Paris, 1736.—Ch. Girtanner,  Abhandlung iiber  die vener.
    Krankheit.   Gottingen, 1789.—C. H. Fuchs, Die iiltesten Schriftsteller iiber die
    Lustseuche in Deutschland von 1495 bis 1510.  Gottingen, 1843.—Ph. G. Ilensler,
    Gaschichte der Lustseuche.  Altona, 1783.—J. Rosenbaum, Die Lustseuche im
    Alterthum.   Halle, 1839.—G.  L. Dieterich,  Die  Krankheitsfamilie Syphilis,  I.
    Band.  Landshut, 1842.—P. L. A.  Cazenave, Traitg des Syphilides. Paris, 1843.
    —F. A. Simon, Versuch einer kritischen  geschichte,  etc.  Hamburgh, 1830-46.
    —II Friedberg,  Die Lehre von den venerischen Krankheiten in clem Alterthum
    und Mittelalter.  Berlin,  1865.—H.  Haeser, Lehrbuch  der Geschichte der
    Medicin, 2 Aufl.  Jena,  1859.  3 Aufl., 1 Band, 1 Lief., 1874.—X  Ilirsch,
    Handbuch  der  histor. geograph. Pathologic  Erlangen, 1860.   1 Band.—
    F.  W. Mailer. Die venerischen Krankheiten im Alterthum.  Erlangen, 1873.—
    D. Bonifacio Montejo, La  sifilas y  las  enfermedades  que se han confudido con
    ella, Madrid, 1863-64 and 1870, was,  however, not accessible  to me;  refer-
    ences to it to be found in Notes on the History of Syphilis, by George Gaskoin;
    Medical Times  and  Gazette,  1876, Vol. II. pp. 62,  89, 115, 200, and in Die
    Deutschen Klinik, 1873.  Nos. 49, 50, and  51.— Edm.  Bassereau, Origine de la
    Syphilis.  Paris, 1873.

    The first knowledge  of syphilis,  as a  separate  and  distinct
disease, dates from  the end of the fifteenth century, from  that
notorious and epidemic-like  outbreak  of  the disease in  Italy,
between the years 1490 and 1500.    From  the  numerous writings
which appeared in the latter part of the fifteenth century, and in
the beginning of the sixteenth, it  is evident that the  physicians
regarded it as a new disease.1  Its origin is, by common consent,
traced by them to the army of Charles  VIII. of France, who had
been  in Italy since   September  1494, and 1494-5 was besieging

   1 Nicolaus Leonicenm writes in 1497: " Iusolita?  naturae morbus  Italiam et multas
alias regiones invasit."  Aphrodis..  I. p. IS.—Laurentius  Phrisius,iu 1530: "Nam
incognitus et invisus erat iste pestifer morbus non tantum  vulgo. verum etiam doctis
et in sacra medicina eruditis."  Aphr., I. p. 344. 
6
BAUMLEE. —SYPHILIS.
Naples.   The  disease is  reported (according to J. de Vigo, in
December, 1494) to have  broken out among the soldiers of the
besieging army to an alarming  extent, and in an exceedingly
severe form.
   The earliest description of the disease comes from Marcellus
Cumanus,  an army surgeon  from Venice, who observed  it in
1495 among  the soldiers besieging Novara.   He describes as
symptoms of the affection ulcers of the genitals, violent pains in
the arms and  legs, and  eruptions of the skin,  which, without
treatment, would sometimes last for years.
   Various attempts were made to account for the  apparently
sudden prevalence of  the disease.  While most physicians, as
Conradinus Gilinus, in 1497,' recognized the starting-point of the
affection to be in the genitals, and regarded impure sexual con-
gress as the most important element in  the etiology, yet this to
many seemed insufficient  to account for  the suddenness of the
outbreak, and  the rapid, universal spread of the  disease.  By
some the stars were blamed  as the source of the  evil, and since,
in the year 1483, an exceedingly ominous constellation had made
its appearance, they did not hesitate to ascribe the  origin of the
disease to  it (as  "Wendelin  Hock de Brackenau,  for example).
Corruption of the atmosphere was assumed by others to be the
cause  of the outbreak.   More especially, perhaps, in order to
account for the attacking  of monks and nuns, or persons of ele-
vated  rank in  the church, was the air considerately regarded
as the medium of  contagion.  Atmospheric conditions  were
advanced as the  source of the epidemic, by various writers, and
it was  especially noted that 1494 was an exceedingly wet year
during which  many regions  were flooded, and among others
Rome itself.2
   That such an event  as  the discovery of America should  have
been thought of, in the effort to explain the sudden outbreak of
a hitherto  unknown disease, is not at all strange ; on the con-

  1 Aphr., I. p. 343 : " TJnum tamen inter castera dico, morbum hunc contagiosum
esse : unde iterum atque iterum moneo, ne cum mulieribus hac perniciosa aeoritudine
laborantibus, aut eae cum viris hac asgritudine infectis, se commiserint." To th'
effect also J. de Vigo, 1503. Aphr., I. p. 450.
  2 Nic. Leonicenus, 1. c. 
HISTORY.
7
trary,  it  is  rather remarkable that so long a  time should have
elapsed before the two events were regarded in  connection with
each other.

   The earliest contribution of any physician, in reference to this point, was made
by Leonhard Schmaus, professor in Salzburg, who, in 1518, * wrote:  "Compertum
est jam  omnibus, occidentales Indos, per plurimos annos hoc morbo graviter labo-
rasse."  It appears, therefore (as is also evident from the letter of Jo. Manardus,2
written  in  1525), that this  view  was  already widely  entertained  at  the time,
although not one of the early medical writers mentions it; and even Schmaus is
disposed to regard  the origin of  the disease in Europe as due to the influence of
weather. R.  Diaz  de  Isla, whose writings, although not printed till 1539,3 were
probably written some time earlier (about  1510), claims  to have treated men from
the ships of Columbus, who were suffering from the disease before they landed;
and also that he had persons under treatment for the same  affection  in Barcelona,
before the King of France had come into Italy.
   In Barcelona the disease is said to have spread from the  soldiers  and sailors of
Columbus, they having brought it with them from Hispaniola (Hayti); and  that it
was raging there as  early as the middle of the year 1494, is shown by a letter of
Nicolaus Scyllatius4 that  was written on the 18th of June, 1494.   But it  is very
remarkable that Scyllatius makes  no mention  of an American origin of the pest
that  he found in  Barcelona, while  he  expressly states that the  physicians had
informed him that the disease had been imported from France.
   Diaz de Isla advances as an especial ground for  believing that the disease had
long existed in Hayti, the elaborate treatment in vogue  there, more  particularly in
the use of  the guaiacmn wood.   " How  could these  uncultivated people have
attained to such  a systematic method  of treatment unless the  disease had been
prevalent among them for  a long time ?"  Indeed it seems chiefly to  have been the
introduction of  the guaiacum wood into Europe—into Spain in 1508,  and into
Italy in 1517 (Delicado)—that gave currency to the theory of the American origin.
   Columbus  arrived in  Barcelona in  the middle of  April, 1493,  after  having
landed at Seville in the first part of the same month.  But inasmuch  as before  this
he had remained nine days at Lisbon, and was for some time detained by stormy
weather off the Azores, and furthermore, since one of his ships before joining him
at Palos, south of  Seville, had touched at the coast of Galicia, it  was  naturally
suggested that, supposing  the disease to  have been really brought from  the West
Indies, it should have broken out in all these places  before it did in Barcelona.
Montejo endeavors to show that this was impossible, since but a  few of Columbus'
men landed at the  Azores, and remained only for a short time, and that they were
cruising there in the storm but one week altogether; and  at Lisbon, he declares,
the crew did not go ashore, and  Columbus himself, accompanied only by  a pilot

  1 Aphrod., I.  p.  383.   2 Aphrod.,  I. p. 606.   3 Med. Times  and Gaz.,  1867, II. p. 90.
  * Friedberg, 1. c, p. 116. 
8                      BAUMLEE.—SYPHILIS
visited the King of Portugal, not in Lisbon, but at a country-seat  in Valparaiso.
In reference to Seville, Montejo shows that there was a hospital there as early as
1502, for the treatment of  syphilis, which was then called "Serampion  de las
Indias." ]
   From Spain the disease was carried into Italy, partly by Spaniards in the army
of Charles VIII.  and  partly by the Spanish army which was led by Gonzalo
Hernandez de Cordova into Italy to the assistance of King Ferdinand II. of Naples,
and landed at Messina in May, 1495.

    The contribution that did most to circulate  the theory of the
American origin of the disease was the work of Gonzalo Hernan-
dez de Oviedo,2 who, in 1513, was sent out to Hayti to inspect the
mines there, and in 1525 published a description of the country.
We find this  theory of tener mentioned or avowed by the medical
writers of the middle of the sixteenth century, as,  for example,
by Alfonso Ferro  (1537), J. Bapt. Montanus (1550), A.  Musa Bras-
savolus (1551), Gabr. Fallopia (1564).  Astruc's3 celebrated work
lent the theory weight in the eighteenth century, but at the  same
time, instigated the critical writings of Ant. N.  R. Sanchez,4 and
Hensler,5 which, in spite of the partially well-founded objections
raised  against them by Girtanner,  have  still  had  the effect of
depriving Oviedo's statements, with regard to the primary occur-
rence  of syphilis  in the West Indies,  of all credit,  even to the
present day.   Only recently has an effort  been made by Montejo,
Gaskoin, and Bassereau to re-establish them.    The latter urges

   1 Med. Times and Gazette, 1. c.
   2 Relacion sumaria de la historia general y natural de las Indias occidentales.   Toleti
1525.  In the editions of Ramusio and Barcia it is stated that the disease came from
India ;  on the other hand, in a transcript of the above passages that the Spanish monk
Francesco Delicado, introduced into his work on guaiacum, it reads that the disease was
very common amongst the Indians.  Moreover, this transcript from the Relacion, which
is probably the oldest in existence, differs essentially in other respects from both the
later ones, so that it seems as though alterations had been made in Oviedo's work that
is, that the whole history of the American origin of the disease had been fabricated.—
S. C H. Fuchs :  F. Delicado,  iiber den Guajak; Janus,  Centralmagazin  etc.   Gotha
1853.  S. 193—La historia general y natural de las Indias occid.  Sevilla 1535
   3 Joannes Astruc, 1. c.
   4 Dissertation sur l'origine  de la mal. vener.   Paris, 1752.  Examen historique sur
l'apparition, etc.  Lisbonne, 1774.   Vide Girtanner.
   6 Ph. G. Hensler, 1. c, and Ueber den westindischen Ursprung der Lustseuche
Hamburg, 1789. 
HISTORY.
9
that  during the  life of  Oviedo no opposition was raised to his
view, although, in other respects, his history of the West Indies
encountered no little hostility.  But, after  all,  that  does  not
appear so remarkable when we consider that this view  was an
explanation of  the outbreak  of the  disease (to  every one a new
and strange affection) which obviated all difficulties, and that the
Spaniards, and especially the  French, were  only glad to accept
a theory that relieved them from  the reproach of having them-
selves given birth to  the disease.   However, Oviedo's assertion
did encounter an  adversary even in the sixteenth  centunr, in
the already-mentioned Spanish priest, Francesco  Delicado,1 who
lived for a long time in  Italy, and who makes the statement that
the disease (with which he was acquainted from sad personal
experience) prevailed as early as 1488 in  Rapallo,2 and was con-
veyed to America by  Columbus'  men.

   Certain other alleged facts, in regard to the first outbreak of the disease, which
were used as objections to Oviedo, prove not to be authentic, as shown by recent inves-
tigations.  Thus, the  accuracy of the date of  the frequently quoted letter of Petrus
Martyr Anglerius to Arius Lusitanus, in Salamanca, was indeed suspected by Sanchez,
to whom this letter might have been of  material service, and it has recently been
called in question by Pellicier, Munoz, and Cantu.3  This letter is dated April 15,
1488, and commences: " In peculiarem tenostra; tempestatis morbum qui appelatione
Hispana Bubarum dicitur (ab Italis morbus Gallicus, medicorum Elephantiam alii,
alii aliter appellant) incidisse proecipitem, libero ad me scribis pede."   Against the
statement made by Caspar Torella,4 viz. :  " Malignam hanc aegritudinem incepisse
anno 1493, in Alvergnia et sic  per viam contagionis pervenisse in Hispaniam," etc.,
Bassereau5 contends that in the chronicles of Puy, which were written by a cotem-
porary and citizen of the town, De Meyes, it is particularly  mentioned that the
" verole " first showed itself in that city in the year 1496.

    There is no  doubt,  therefore, after what has been said, that
the disease was  in existence  in Spain before the campaign of

   1  Delicado, II modo di adoperare legno di India occidentale salutifero remedio, etc.
Venetiis, 1529, vid. Janus, Centralmagazin, etc.  Bd. II.  1853. S. 193.
   2 J. de Vigo, who was born in Rapallo, and wrote in 1503, does not mention this, and
makes the first outbreak of the disease occur in 1494.
   3  Guskoin, 1. c, p.  201.  G.  observes that Hallam (History of European Literature)
also regards the chronology of the letter of Petrus Martyr as unreliable.
   4  Aphrod., I. p. 494.
   5  L. c, p. 21 
10
BAUMLER.—SYPHILIS.
Charles VIII.  But there is in the dates thus far presented noth-
ing  inconsistent with  the supposition of  its  importation from
America.   Nevertheless, there are a number of descriptions and
historical  notices extant, which make it  probable that the dis-
ease was not unknown in certain portions of Europe, even prior
to the first  return of  Columbus from  the West Indies ; in-
deed,  the terms "morbus  gallicus,"  and  "mala franzos"  are
met with in some  chronicles before the Neapolitan campaign of
Charles VIII.

   Friedberg (p. 90-93) c: tes the cases of various persons of high rank, who were
affected by a disease, the description of which is a very fair representation of syphi-
lis ;  as, for instance, the case of the  bishop of Posen, Nicolaus von Kurnik. who died
the 18th of March,  1382, after having suffered first  from ulcers of the genitals and
afterwards of the tongue and throat, so that he was hardly able either to speak or to
swallow, and finally with ulcers upon the right side (latus quoque dextrum  per
scissuras penitus fuisse rupturn).
   Of far less value than these descriptions of  the disease, as it seems to me, are
certain citations from the older chronicles which occur in such an isolated manner
that one cannot refrain  from doubting their authenticity.  Thus Friedberg cites a
passage from the Annales Danicae of the year 1483 : " morbus gallicus saevit super
Christianos" (p. 95). Again, from the Chronisten des Saalkreises: "Anno 1493,
um diese Zeit hat sich zuerst die schadliche Seuche des morbi gallici oder sogenann-
ten, s. v. frantzosen in diesen Landen eraugnet" (p. 98).  In the  Stiftsprotokoll  of
St. Victor zu Mainz, of the year 1472, it is recorded that a chorister besought leave
of absence, in order that he might undergo treatment for the "mala franzos"
(p. 95).

   All things considered the probability is that syphilis existed
in certain portions of Europe, more especially in Southern Eu-
rope, prior to the epidemic  outbreak  of the disease  in Italy at
the end of the  fifteenth century, in the  same way,  perhaps, as  it
yet prevails in  certain  retired localities  in the form of an ende-
mic disease (vid. p. 18).   But at the end of the fifteenth century
various circumstances combined to favor a great general, epi-
demic outbreak.   The previous centuries, by means  of the cru-
sades  and the  peculiar  pilgrimages  of the  fourteenth  century,
had already set the people in motion,  and established  more inti-
mate  relations between  the different  nations.   The  unsettled
mode of life had tended to  deprave  the morals, and  the rough 
HISTORY.
11
bands  of soldiers roving  through the  country gave occasion to
all kinds of licentiousness.   In Italy, just before the outbreak of
the morbus  gallicus, an epidemic disease,  probably of typhous
character,  had been  raging  and destroyed many people,  the
affection having been imported with  the Jews (Marranen),1 who
were driven out of Spain;  besides, the years 1494-5 were marked
by great rain-falls,  so that floods occurred at Rome and  other
places.   All these circumstances, added to  the  pernicious mete-
orological  and hygienic  influences that always accompany war
and siege, would naturally impart to the already existing disease
an acuter,  severer character than it had before ; just as  we now
observe worse forms of the disease in persons reduced in health,
or living under unfavorable hygienic conditions.
    The campaign of Charles VIII. also contributed largely to
the spread of  the  disease in Italy, Spain, France, and Germany.
This spread during  the  last  ten years of  the fifteenth century
was extremely rapid and general.

   As early as 1496 measures were taken in the different cities of France and Ger-
many to  put a stop to the extension of the pest.  On the 6th of March, 1496,5 the
Parisian  Senate issued a decree designed to protect the inhabitants  from the epi-
demic ; it  began with  the statement  that a certain contagious disease, " la grosse
verole"  had  been raging violently in different parts of the  kingdom for two
years.  In Nuremberg3 the Rath passed an ordinance concerning the bath-keepers,
and in referenoe to the " new " disease of the " French."  In Frankfort, according to
J. Rohrbach, a cotemporary, the disease broke out in the summer or spring of 1496.
On the 9th of August of  that year the Rath decided to issue a jDroclamation to
the people, and on the 13th and 25th  of October passed decrees4 with regard to it.
The monk, J. Sciphover de Meppis,5 relates of this pest (pestis miseranda et lugu-
   1 These unhappy fugitives were also made responsible for the dissemination of
syphilis.  Compare Hirsch.—Jo Nauclerus. a cotemporary, states in regard to the pest
that broke out with the arrival of the Jews in Italy, that it destroyed many people, the
morbus gallicus but few (nonnullos), " plerosque inutiles  fecit."  Cited by Bassereau,
p. 39.
   2 Astruc, 1. c, p. 75.  According to our calendar, 1497.
   3 Wnldmi,  Vermischte Beitrage zur  Geschichte der  Stadt Niirnberg, B. IV. p.
409.
   4 G. L. Kriegk; Deutsches Biirgerthum im Mittelalter.
   6 Chronic, archicomit. Oldenburg, in Meibom. script, t.  II.,  1497.   Cited by
Gruner, 1. c, p. 116. 
12
BAUMLER.—SYPHILIS.
bris), existing in the principality of Osnabriick and in Westphalia, that the disease
came from Bremen and Hamburg.
   Medical writings on the subject first appeared in Germany in 1496-7.'

   The question as to whether syphilis towards the end of the fif-
teenth century was really a new disease, or was then for the first
time imported into Europe, has engaged  the attention of phy-
sicians  with greater  earnestness the farther  they  have  been
removed from that period.  To the cotemporaries, the influence
of the stars, war, famine, and flood  sufficed to account for the
production of a new disease.  Others contented themselves with
the theory of the American, or even of an  Ethiopean (Bapt. Ful-
gosius) origin.   Still,  even  at  that time,  there were  some  who
sought to trace a connection between it  and diseases with which
they were already familiar.  They were  especially disposed  to
trace the source of syphilis  to lepra—the leprosy—which was  at
that time becoming extinct. But the  efforts to identify these two
diseases were  opposed by  Nicolaus Leonicenus (1497).2  On the
other hand, again, Natalis Montesaurus  3 (1498)  declared  that
the disease was no new one, but had  already  been described
under  the names Bothor and  Asaphati; and  Sebastianus Aqui-
lanus4  (1498)   says that it is identical with  the elephantiasis
of Galen; but, in  this, is  sharply corrected  by Jacobus Cata-
neus5 (1516).   An attempt  has  been  made recently to establish
the theory of  the development of syphilis from leprosy.   A.  F.
Simon calls it the offspring of the leprosy, and claims, too,  that
under  certain  circumstances it may become its parent.6  What
we see of leprosy in  the  East and  various  other lands  at the
present day, certainly bears but slight  resemblance to syphilis ;
and it  is noticeable, too, that  in  the  commencement  of the six-
   1 Joseph Grunbeck, Tractat. de pestilentiali seorra sive mala de frantzos, etc.  (Vid.
Girtanner.)
   Johannes Widmann, professor in  Tubingen, Tract,  de pustulis et morbo, qui vul^ato
nomine mal de Franzos appellator.  (Vid. Astruc, p. 429.)
   The first French medical writer upon syphilis was Jaques de Bethancourt of Rouen :
Nova pcenitentialis Quadragesima necnon  purgatorium in morbum  gallicum  etc
Paris, 1527.  (Astruc, p.  450.)
   2 Aphr., I. p. 18.                       3 Aphr., I. p. 115.
   4 Aphr., I. p. 5, seq.                     5Aphr., I. p. 143.
   6 Virchow's Handbuch der spec. Pathol, und Therapie, II., 1, p. 429 and 1. c. 
HISTORY.                          13
teenth century, the lepers were evidently afraid of infection from
those who were syphilitic (leprosi  nolebant habitare cum  hoc
morbo infectis, says Laur.  Phrisius, Aphr.,  I. p. 344), and that
this was no groundless fear, that is, that lepra afforded no immu-
nity against syphilis, is shown conclusively by  the inoculation
tests of Danielssen.  Still it  is not impossible, or even improba-
ble,  that the term "lepra"  was made to  embrace  much that
properly belonged to other diseases, syphilis  included ; and  this
view is made plausible by E. Giintz1 from the descriptions given
of lepra by B.  Gordonius (1305).   So far as we know,  the leprosy
is not contagious, and  therefore such  passages as the following
of J. Gaddesden 2 have an especial significance :  " Ille qui con-
cubuit  cum muliere cum qua  coivit  leprosus  puncturas  inter
carnem  et corium (scil. virga?) sentit  et aliquando calefactiones
in toto corporo et postea frigus et insomnietates et circa faciem
quasi formicas currentes;"  and comparing  such passages with
others where lepra is  not directly referred  to, but rather  some
general  infection  of  the body  following impure  sexual inter-
course, the unavoidable conclusion is  that the implied disease is
syphilis.  The same is  true of the statement  of Gerard de Berry,
who lived in the  thirteenth century,  to which E. Littre 3 makes
reference:  "Virga patitur a  coitu cum mulieribus immundis
de spermate corrupto  vel ex humore venenoso in  collo matricis
recepto : nam virga inficitur et aliquando alterat to turn corpus."
    If we go still  further back  in the literature, the question
becomes  more  involved,  from the fact that in the  writers  of
antiquity and of the middle ages we rarely find such minute and
descriptive accounts of morbid appearances as are contained in
certain passages  from  Celsus and Oribasius  ;4 but the accounts
are mostly limited to descriptions of various local affections, for
   1 Archiv fur Dermatologie und Syphilis, B. II., 1870, p. 59.
   2 Rosa Anglica, lib. II. cap. 7, de lepra, cited by F. W. Mailer, 1. c, p. 113.
   3 Janus, Zeitschr. f. Geschichte u. Lit. d. Med., von Dr. A.  W. E. Th. Henschel,
B.  I., 1846, p. 594.  E. Bassereau (1. c, p. 12) says indeed that Littre has declared
this passage of Gerard, whom Bassereau calls G. de Nevers, to be apocryphal, but does
not tell where Littre has made this statement.
   4 Vid. the excerpts on condyloma and aphthae, by F. W. Midler, p. 37-42, and
p. 89. 
14
BAUMLER.—SYPHILIS.
which technical  names  are  employed, whose import, expressed
according  to  modern pathological views, is  not easy to deter-
mine.  The position  of  pathology, or of  any single prominent
investigator at any  period, has  a decided influence upon the
interpretation of such expressions.  We  only need compare the
historical researches  concerning syphilis for the last twenty-five
years to be convinced that the construction which is placed upon
these technical expressions varies essentially according as the in-
vestigator advocates the  doctrine of unity or duality in syphilis.
   For those  who made  syphilis arise  from the most  various
local  affections of the genitals, from gonorrhoea even, the fact of
there being evidence that such local affections had been observed
and unmistakably described in remote antiquity was quite suffi-
cient proof of the existence of  syphilis in those times ; while, on
the other hand, certain  adherents of  dualism saw only in  these
records descriptions of purely  local affections, such as are of fre-
quent occurrence at  the present day,  and have, in common with
syphilis, solely their frequent source in unclean sexual congress.
   It is  striking that in the  writers of  Grecian  and  Roman
antiquity, and in early mediaeval times,  we find no  accounts of
such affections as occur  in children with hereditary syphilis.   A
passage in Michael Scotus, de procreatione et hominis physiog-
nomia, which  Cazenave * cites, may possibly have  some reference
to this:  "Sciendum  est quod  si erat fluxus  quando erat facta
conceptio creatura concipitur vitiata in plus aut minus."  In the
Ajurveda of the  Indian  medical writer Susrutas,8 which  contains
throughout, very interesting  accounts of  affections that  owe
their  origin to sexual intercourse—and  can, therefore,  scarcely
be considered as anything  else  than syphilis—there occurs a
passage,  which also may refer  to hereditary syphilis; he  men-
tions  an  "atrophia  ulceribus  terribilis" of infants wdrich is
ascribed to the influence of demons.
  1 Cazenave, 1. a, p. 24.
  2 Susrutas, Ajurveda.  Translated into Latin by Dr. F. Hessler.  Erlangen 1844-50
B. I., cap. XII. and  XIII., p. 195, and cap. II. p. 175 ; II. p. 124.  Vid. also Fried-
berg, p. 33.  F, W. Midler, p. 14-19.  Regarding the age of the writings attributed to
Susrutas, see Haeser,  p. 17.  As the latest period of their production may be taken the
eighth century of the Christian era. 
                              HISTORY.                          15

    It is therefore in the highest degree probable, though difficult
 absolutely to prove, that, not  only local affections of the most
 varied description, due to unclean sexual connections, but also
 syphilis existed even in antiquity, both  in  the  East  and  in
 Europe.  But it was not recognized as a special form of disease,
 as a disease sui generis, until the close of the fifteenth century.
    It is a noticeable fact that, originally, various exclusively
 local affections of the genitals—ulcers  (caries, caroli) and dis-
 charges  (gonorrhoea)—were  distinguished from the   "morbus
 gallicus" "and were represented as  something  peculiar.   And
 there was considerable doubt,  with  regard to the epidemic out-
 break of the disease, as to whether its origin was not due to the
 action of general  causes.  Gradually, however, as  the most fre-
 quent source  of the  disease  came to be recognized, all affections
 of the genitals springing from sexual intercourse were included
 in common under morbus gallicus.

    As early as the sixteenth century infection was recognized as the cause of a blen-
 norrhoea of the urethra, while it had been hitherto regarded as a true gonorrhoea, as
 a superfluitas.  In the earliest descriptions of  morbus gallicus no mention is made
 of the gonorrhoea, and even in the petition (published  by Beckett1) of Simon Fish
 to Henry VIIL, in  the year 1530, the clap was distinguished from other diseases
 communicable through coitus, as appears from the  following extract: "... that
 catch pockes of one woman and bear them to another; that be burnt2 with  one
 woman and bear it to  another, that catch the lepry of one woman and bear it to
 another .  . ."

    Although  still  at the end of the sixteenth century Hierony-
 mus Capivaccius (1590)3 speaks of  a  " gonorrhoea citra luem
 veneream,"  we  find that such  a distinction was  more and more
 lost sight of, up to the end of the seventeenth century ; so that
 Sydenham4 wrote:  "cujus  (scil. morbi) virus cum per gonor-
 rhceam  non ejiciatur, sanguinis massam dicto  citius  pervadit
 inficitque."

   1 Cited by Friedberg, p. 72.
   2 The French synonym " chaude-pisse " occurs in the thirteenth century (E. Littre,
James I., p. 595) while "burning" appears in a decree as early as 11G2 (Friedberg,-p. 71).
   3 Ilieronymi Capivaccii, Acad.  Patav. professoris, de lue venerea acroasis.  Spira?,
1590.
   4 T/iom. SydenJmm, Op. universa. Epis. respons., II.  Lugd. Batav., 1726, p. 328. 
16
BAUMLER. —SYPHILIS.
   But in the second half of the eighteenth century voices arose
in England, demanding the separation again of gonorrhoea and
syphilis, as two distinct diseases.  In 1767, Balfour l in a disser-
tation upon the  subject, maintained their non-identity.   But
this view produced a less general impression than it would other-
wise have done, since so weighty an authority as John Hunter,3
supported by experiments, decided  in 1787 in favor of the iden-
tity  of gonorrhoea, chancre, and  lues venerea.   In May, 1767,
Hunter had inoculated (probably upon himself)  pus,  which he
considered to be gonorrhceal matter, on the surface of the glans
penis and prepuce.3 Ulcers  were produced, followed after  some
months by ulceration of the tonsils, and  a coppery skin-erup-
tion.   Consequently it  appeared to  Hunter that  the identity of
the  gonorrhceal,  chancrous,  and  syphilitic virus  had  been
clearly demonstrated.   Differences  in  the  manifestations  he
believed to  depend solely upon the difference in locality ; on
mucous membranes the venereal virus produced a blennorrhcea,
upon the  skin an ulcer.   On the other hand, Benj. Bell4 took up
the controversy in 1793,  and advocated (likewise supported by
experiments) the view of Balfour.  But the matter was only set-
tled definitively, in consequence of  the  numerous inoculations
made by Ricord,5 in the year 1831.   Out of many hundred inoc-
ulations of the skin with gonorrhceal secretion, Ricord did not
succeed in producing  a chancre or  constitutional syphilis in a
single instance ;  the contrary  results obtained  by  others  he
explained by supposing that in their  cases a chancre had been
concealed within the urethra.  Thus  gonorrhoea was finally once
more eliminated from  the definition of syphilis, and the latter
term  was limited to ulceration and certain  other  disease-pro-
cesses upon the genitals, and to those symptoms called,  since
  1 F. Balfour, diss, de gonorrhoea virulenta.  Edinburgh, 1767.  Cited by P. H. Wat-
son, The Modern Pathology and Treatment of Venereal Diseases.  Edinburgh Med
Journal, 1860 and 1861.
  2 The works of John Hunter, ed. by J. F. Palmer, Vol. II.  London  1835  p 143
  3L. c.,p. 417.                                           '
  4 Benjamin Bell, Treatise on Gonorrhoea Virulenta and Lues Venerea.  Cit by P
H. Watson.   See also Auspitz, das syphil. contagium. Wien 1866 52 f
  5 Ricord, traite pratique des maladies veneriennes.  Paris, 1838  Auspitz L
61.                                                     '   "' P' 
HISTORY.
17
Hunter's time, "constitutional."  A further  restriction  of the
term  was  proposed by Bassereau  in  1852, in separating from
syphilis the so-called soft chancres and the suppurating buboes,
to which they often give rise.  Concerning this point, which is
still regarded in many quarters as not yet settled, we shall come
to speak later more at length.
   Returning once more to the  first epidemic outbreak  of the
disease at the end of  the  fifteenth  century with which  we
started, it  remains to be observed that the character of the dis-
ease,  originally so malignant as to occasion  universal  alarm,
before long  grew milder.   Even during  the second decennium
of the sixteenth century the course of the disease had become
much  less severe,  other symptoms than those seen at first grad-
ually became prominent',  and by the middle  of  the  sixteenth
century we  find various physicians (Hieronymus Fracastorius
and Anton.  Musa Brassavolus amongst others8) expressing the
opinion that the  disease would continue to  grow  milder, and
finally become extinct.  To  be sure this  hope has not yet been
realized, but the  fact  of  there  having been  indications which
appeared to justify it then,  leave us to conclude that the disease
in the first half of the sixteenth century manifested much the
same forms and course as at the present day.
   But even now  we occasionally see a repetition upon  a small
scale  of this early epidemic outbreak, with  the virulence of the
disease at  the commencement and its subsequent gradual mod-
eration, in instances where syphilis  has suddenly invaded local-
ities previously exempt.  Such instances have been occasionally
observed,  in  late years, in consequence of the sudden invasion of
certain regions by troops and seamen.   Where the conditions
ar*1 particularly unfavorable and the locality retired, the first
outbreak of syphilis is apt to show a remarkable intensity ; but
after the more virulent forms of the disease have become extinct,
a certain hereditary taint is often left behind which manifests
   ' The historian Francesco Guicciardini says in Delia Istoria d'ltalia, lib. II.:  " At
length after many years the disease became milder and different from what it had been
at first." Cited in Girtanner, B. II. S. 9:52.
   8 Astruc, p. 71. cites a number of passages which refer to this subject.
          VOL. III.—2 
18
BAUMLER.—SYPHILIS.
itself amongst the later  generations in the form of manifold
chronic affections, these latter receiving the name generally of
the locality where they made their first appearance.  Endemic
diseases of this class, remnants  of-former  violent outbreaks  of
syphilis, are seen in the Radesyge in Sweden and Norway, the
Jutland Syphiloid, the Ditmarsch disease of Holstein, the Sib-
bens of Scotland, the Skerljevo of the lllyrian coast, and others '.
A closer study of  these forms of disease throws no  little light
upon the general  history of syphilis itself, since many interest-
ing facts regarding the  latter recur within circumscribed limits
in  these diseases, and can, therefore,  be more  conveniently
studied ; such facts,  for  example,  as the  novel and startling
character of the original  outbreak; the naming of the disease
from its locality or from that of its presumptive origin (usually
from the nation whence it was  imported); after  long continued
prevalence of the disease, the habit of including under the same
name the most diverse  affections, especially those of the skin ;
when widespread,  and, as often happens, when propagated  in
other ways than by sexual intercourse, the inclination to search
for other modes of origin than that by contagion.   Of the above-
mentioned  diseases the Radesyge and Skerljevo  have been the
most carefully studied, and these (excluding various common
skin diseases  which were also  embraced under these terms,  as
scabies, eczema, psoriasis,  lupus,  and in Norway the leprosy
(spedalskhed)) have been shown by the Norwegian  physicians
Boeck and Danielssen,  as well as by Hebra and  von Sigmund,
to consist really in acquired or hereditary syphilis,  which has
often become inveterate and been neglected.
   How widespread these diseases  may become,  is seen in the
case of the skerljevo, with which, according to medical statistics
in the year 1800, out of 39,000 inhabitants of the Hungarian sea-
board,  there were 6,000 affected severely  and 8,000 slightlya.
Furthermore, in the skerljevo we see how rapid an abatement of
the disease may be brought about  by judicious measures and
» Hirsch, S. 361 f.  Zeissl, S. 299.  Lancereaux, p. 25 s.
2 Cambiei'i, Omodei Annali univ. di medicina. Zeissl S. 299. 
GEOGRAPHICAL DISTRIBUTION".
19
the appropriate anti-syphilitic treatment,.  At the the present
time all of these diseases are in the course of extinction.

          GEOGRAPHICAL DISTRIBUTION  OF SYPHILIS.

   In  consequence of  the  active intercourse which  has been
maintained between different countries in  modern times we may
say that at the present day syphilis  is prevalent throughout the
world.  Its principal seats  are the  great  centres of traffic and
luxury, whence  the disease is continually being conveyed to
other and remote parts.   Especially is this  true  of  the great
seaport towns.  In many countries  the  coast is invaded before
the regions inland.  The fact that syphilis develops less readily
in one place than  another  is to be ascribed  solely to external
circumstances.   The mode of life, manners, and customs, material
prosperity, national temperament and the grade  of civilization
are the main points that influence the spread of syphilis.  Race
appears to have no particular bearing upon susceptibility to the
syphilitic  poison.  It is, therefore, so much the more remarkable
that in certain countries, although exposed to the infection,  the
disease has yet  made  no progress.  These countries are Iceland
and, according to Livingstone, a portion  of Central Africa.  Liv-
ingstone states that the natives who had contracted the disease
upon the West coast recovered, on returning home, without med-
ication. This peculiarity however was exhibited only by natives
of pure African blood ; mixed  breeds were affected by the dis-
ease  precisely as Europeans, and, moreover, negro tribes of other
regions did not enjoy the same immunity \
   The causes which  have hitherto  prevented  syphilis from
taking root in Iceland  are  still quite obscure; and,  moreover,
Livingstone's statements require confirmation.
   According to the testimony of various informers, the disease
appears to be more severe when communicated  to Europeans
from persons  of  another race.  Armand alludes to this in regard
to Europeans infected in China.  But in  this connection other
circumstances besides  difference of  race come into  account,  as
acclimatization, etc.
1 Zeissl, 1. c,
* HirscJi, 1. c, S. 372. 
20
BAUMLER.—SYPHILIS.
   Time would not permit to cite all the countries where syphilis
is  especially prevalent, or to relate what  is known concerning
the period of the earliest occurrence of the disease in the various
lands.   In  this connection we would refer to  the exhaustive
treatise of Hirsch.  We will only allude to the facts that in the
South Sea Islands the disease  threatens to exterminate the na-
tives, and that in South America, but still more so in Mexico, it is
extraordinarily prevalent.  At  the  end of  the previous century
the spread of the disease in America had been very limited, and
there are said to be to this day  certain  Indian tribes, living quite
apart by  themselves,  whom  the  disease has never reached.  In
the East its principal seats are the great seaport  towns of China
and Japan; in Africa, Egypt,  Abyssinia, and Algiers,  and also
the western  coast; in Europe, the northern provinces of Turkey,
the northern portion of European and Asiatic Russia.
   So far  as the influence of  climate upon the development and
course of syphilis is  concerned, it constitutes a factor of but
secondary moment in comparison with the  other outward influ-
ences which affect health and vitality.   According to Lagneau,1
the course of the  disease owes its character to the  temperature
of the region where it occurs.  In the warmer countries  it is
claimed that it runs a more rapid course than in  the colder.  In
regard to  the influence of  climate upon the severity of the dis-
ease, a number of statistics, intended to  indicate a favorable
influence  of mild climates, are  offset by  Hirscli with another
series,  equally large, which shows that even with the most favor-
able climate the disease may take a very malignant course.  The
more uniform the climate is, the less  unfavorable will the influ-
ence be from this particular source; but at the same time the
resulting  advantage may be  quite outweighed by other circum-
stances.   Residence in a region with  an excellent  climate, but
one to which the  individual is unacclimated, may  produce the
same result as though the climate were subject to the extremest
variations of temperature.
  1 G. Lagneau, Rech. compar. sur les mal. vener. dans les diff.  contrees. Annal.
d'hygiene publique et de med. legale, Ser. II. t. XXVIII.  Cited by Zeissl, S. 12, 
GENERAL FEATURES  OF THE DISEASE.
21
GENERAL CONSIDERATIONS REGARDING THE COURSE OF SYPHILIS.

   Before proceeding  further  we would call attention  to  the
general features  of  syphilis as they display themselves  in  the
ordinary course of the disease.  After the virus has been inocu-
lated,  whether by direct contact of some local lesion, secreting
the poison,  with  an abraded surface of skin or mucous mem-
brane, or by being carried  underneath the epidermis by means
of a  lancet, a period of several  weeks elapses usually before
anything  further is to be observed.  In artificial inoculations
a circumscribed redness of the part may appear, which will occa-
sionally develop  into  a little  pustule;  this,  however, dries up
in a few days,  and in a short time everything disappears.  As  a
rule, no changes will be observed before the lapse of three weeks.
Then a little red papule makes its appearance, which slowly in-
creases in elevation and circumference, and after a few days may
be felt by the finger as a distinct  induration.   The redness  and
hardness of this papule are quite sharply defined from the sur-
rounding parts.  The papule is termed the '•''primary lesion " of
syphilis, or, on account of its hardness, the  "induration" or
" initial sclerosis.''''
   A few days later than the first appearance of these changes
at the  point of inoculation, it is observed  that the lymphatic
glands, in whose district the infected part lies, are the seat  of a
slowly increasing swelling ; only one  gland is affected at first,
but afterwards several.  These swollen glands feel likewise strik-
ingly  hard   to the  touch,  are not  tender, are freely movable
underneath  the skin, and are known as indolent buboes.
   While now the  induration at  the point of inoculation in-
creases, there usually appears  upon its  surface a little scaliness,
or a thin crust is formed, which being removed displays  a shin-
ing surface  of a  bright red color,  exuding a scanty  secretion.
If the formation of the crust be prevented by a moist dressing, a
thin,  gray, diphtheritic-like deposit is formed over the secreting
spot.   Other forms  of the  primary lesion will be described else-
where under their appropriate head.
   Meantime,  while the  induration and  glandular  swellings
increase, the patient begins gradually to grow pale, to feel indis- 
22
BAUMLER.—SYPHILIS.
posed, and in the course of from six to eight weeks from the
commencement of the local manifestations, or nine to eleven from
the infection,  with or without febrile symptoms, an eruption
breaks out upon the skin, without itching, in the form of red spots
or papules.  Simultaneously with this, or usually somewhat later,
an inflammation begins in the throat, at first simply catarrhal, but
shortly leading in its further course to ulceration or to the pro-
duction of circumscribed flat growths upon themucous membrane.
   With  the access of these general  symptoms it is customary
to say that the syphilis has become " constitutional.'1'1
   A simple macular skin eruption is usually of short duration,
but  flat  papules often make their appearance, springing from
the maculae,  or else appearing from the very commencement,
and  these, under certain circumstances, may remain from two
to three months, meantime often undergoing various transforma-
tions.  More obstinate still than the papular skin eruptions are
thejiat condylomata of the fauces and larynx, about  the angles
of the mouth, the anus, or the female genitals.  These are gener-
ally present at the same time with the eruptions of the skin, and
are essentially papules of the mucous membrane, due to changes
similar to those of the skin, but modified by the locality.
   These  may persist  for months, ulcerating and manifesting,
during the first eight or  ten months after infection, a great dis-
position  to recur,  even in spite of proper treatment, and after
the external integument  has long  returned to its normal condi-
tion.   Simultaneously with  these affections of  the skin and
mucous membranes, there is often more or  less alopecia, occa-
sionally affections of the  nails, and very frequently a  periostitis
arises somewhere with exquisite tenderness on pressure, together
with violent pains, especially at  night.   In  addition to  these,
the eye is often affected within the first six months from  infec-
tion, in the form of an iritis or inflammatory process affecting
the deeper tissues of the organ, particularly the retina.
   Enlargement of the lymphatic glands belongs to the most in-
variable changes of this period.  They are similar to those  found
in the neighborhood of the  point of infection, and occur  in the
most various situations.  Of those accessible to the touch  the
cervical and cubital glands are the most commonly affected. 
GENERAL FEATURES  OF THE DISEASE.
23
   Now  the disease taking  a favorable course, all these signs
begin to subside, and in not a few cases, especially where  the
proper treatment has been pursued,  in ten  or twelve  months
from the infection the previous health is restored, the patients
recover their former aspect,  and in some  the disease is at an
end.  But in the majority of cases new crops  of eruption come
and go upon the skin and mucous membranes, as small papules
on the tongue or isolated patches of psoriasis upon the palms of
the  hands,  which often preserve a purely local character,  the
general condition being  thereby not at all affected.  But some-
times these  manifestations occur more extensively, and  are ac-
companied by general symptoms.
   As a rule, syphilis exhibits a great diversity as regards the
intensity of its attacks,  which to a large degree is determined by
individual peculiarities.  Although in a large number of cases
we see the disease following the course which we have depicted
above, in  certain patients of naturally feeble constitution,  or
else debilitated  by excesses or deprivations, suppurating erup-
tions of  the skin—pustules—sometimes develop, which  become
encrusted and are converted into  ulcers, that gradually increase
in size and finally heal by cicatrization.  They may occur at an
early stage of the disease, occasionally at  the first general at-
tack, but more  commonly as a consecutive symptom ; they are
often accompanied  with violent  fever, sometimes with chills.
Severe ulceration takes place in  the throat in these cases, and is
marked by a rapid destruction of tissue.  In the nasal  cavities
the bones are denuded in places by the ulcerative process, and
necrosed portions are expelled, followed by a sinking-in of  the
contour of the nose,  with permanent disfigurement.  The pains
in the bones, already alluded to,  are particularly severe in these
cases, and associated with marked swellings.  But in these cases,
too,  the symptoms  subside after a while, and the course of  the
disease is temporarily arrested.
   This period of latency has an exceedingly variable duration,
and  ensues upon manifestations, more or less severe,  in cases of
the most  varied intensity, after the first eight or ten  months
from the infection.   Now, symptoms appear  again, perhaps so
long deferred that the  former attack, particularly if it was a 
24
BAUMLER.—SYPHILIS.
light one, has long been forgotten.  It is only during the last
ten  years that  these  later symptoms  have been  regarded as
syphilitic, and referred to  their proper  source.  And even at
the  present  time,  in  spite of our more extended knowledge
of the disease, the  true nature of many of these manifestations
is too often misapprehended.   A part  of  them have mainly the
character of purely  local  affections,  as  those  relapses, for
instance, spoken of above ;  but,  on the other hand,  some of
them present themselves  under the form  of  a general affec-
tion,  of a deep-seated marasmus, often accompanied  by hectic
fever.
   The local affections are peculiar, on account of a marked
tendency to tumor  development not usually shown by the ear-
lier manifestations  of  syphilis, and the growths to which this
gives rise do not exhibit that  disposition  to undergo resorption
which is characteristic of  the inflammatory symptoms of the
previous stages of the disease, but a tendency rather to disinte-
gration and necrosis.   These growths,  which, as we now know,
may occur in any organ, were described by the earliest observers
of syphilis as occurring in the bones and  skin,  or subcutaneous
cellular tissue.   They present, at  first, hard elevations,  after-
wards gradually softening, and are termed,  on  account of  their
gummy-like, semi-fluid, grayish-yellow contents, "gummy tu-
mors,", or "gummata."   In the skin, mucous membrane, sub-
cutaneous cellular tissue and periosteum, the softening  and dis-
charge of the gummata is usually in the direction of the exter-
nal surface;  but in the internal organs the periphery of  the
tumor becomes thickened  into a fibrous envelope of connective
tissue, enclosing the contents of the original gumma, which have
now become condensed, fatty-degenerated, and dry.
   The disintegration of the gummy tumor of the subcutaneous
cellular tissue and  skin is attended with ulcerative processes,
which show a marked  tendency to constantly involve fresh por-
tions of  skin, gradually  invading the  surrounding integument
in serpiginous  ulcers, which  cicatrize   at one  extremity  while
the destructive action extends at the other.   If such ulcers are
situated over bone,  or  if the gumma have proceeded originally
from the periosteum, caries and necrosis take place. 
            GENERAL  FEATURES  OF THE DISEASE.          25

   The internal organs which are most commonly attacked by
gummy tumors are the liver, the testicles, and  the brain, with
its  membranes.  The  gummata  proceed  from  the  connective
tissue, and especially  from the  adventitia  of  blood-vessels;
they  not infrequently occasion grave symptoms, particularly
when occurring  in  the brain.   The  symptoms produced  by
gummata are  of  great variety,  depending  upon the impor-
tance of the organ implicated, and the seat  and extent of  the
tumor.
   Beside these local  processes, in numerous cases, though by
no means in all, a high grade of marasmus takes place, with
marked  pallor and great emaciation,  and often,  especially in
affections of the bones,  accompanied with fever of a decided,
remittent type. Though local manifestations upon the skin  are
absent in these cases, there are usually present tumefactions of
the bones  and joints,  and  the case may present many of  the
features of an acute articular rheumatism.  Or, in case there be
a cough and other signs of bronchial catarrh,  a suspicion of pul-
monary  phthisis might easily be  awakened, particularly on
account  of  the hectic fever that is present.  In  not a  few of
these cases  there is also albuminuria, with or without dropsy,
due to amyloid degeneration of the kidneys.
   At length the patients succumb either to anasarca,  sometimes
with  dysenteric affections, or to uraemia, or caseous pneumonia,
unless beforehand some syphilitic local process, implicating an
important organ, as the brain  or heart, puts a  speedier termi-
nation to life.
   The main points in the course of the disease which we have
just sketched may be recapitulated as follows:
   1.  The infection.
   2.  The local affection.
   3.  The acute general affection, the period of  whose manifes-
tations lasts for six or eight  months, and is then followed either
by a termination of the disease, or,
   4.  By a period of  latency having  a variable duration,  and
passing into
   5.  The period of gummous formations and ulceration.
   6.  Syphilitic marasmus. 
26
BAUMLEE.—SYPHILIS.
                   THE  STAGES OF  SYPHILIS.

   Suggestions with regard to a division of the course of syphilis
occur in  the writers of the  sixteenth century.  Thus De Vigo'
(1503)  contrasts  the Lues gallica recens with the  Lues gallica
confirmata.  Thierry de Hery2 (1552) divides the symptoms into
the antecedent (local), viz., ulcers of the genitals, clap, buboes;
the consecutive (suivants), viz., skin eruptions, affections of the
mucous membrane, alopecia,  wandering pains,  and the subse-
quent (sitrvenants), viz.,  the  fixed  pains with bony elevations
and caries or necrosis, ulcers of the  skin, marasmus—a division
that contains the nucleus of some of  the later divisions, particu-
larly that of Ricord.
   Ricord distinguishes
   1. A primary period, comprising the development of the
local process of infection and the indolent glandular swellings ;
   2. A secondary period, which  includes those early affections
that depend upon the general infection, and are  superficially
situated,  involving skin and mucous  membrane,  and comprising
alopecia,  disease of the nails, iritis, and affections of the testicles.
   Up to the year 1859, R. represented it as a radical mark of distinction between
the secondary  and primary periods that  the secondary manifestations were no
longer contagious, and that the disease  could only be communicated in this stage
by inheritance.  Subsequently, however, in consequence of the numerous convincing
inoculations with the secretion from " secondary " syphilitic affections, Ricord was
compelled to abandon this position.

   3. A tertiary period, the symptoms of which, besides occur-
ring late  in the course of the  disease, are severer in their mani-
festations, for  the reason that deeper tissues (the  subcutaneous
and submucous tissues, bones and joints, together  with the vis-
ceral organs) are implicated, chiefly in  the form  of gummata.
The disease  in this stage is not transmissible  by inheritance, but
may very likely give origin to  scrofula and  rachitis in the suc-
ceeding generations.

   1 Aphrod., I. p. 450.
  3 La methode curatoire de la maladie venerienne, etc.  Paris, 1552, p.  133.  Cited
by Fournier, Legons sur la Syphilis.  Paris, 1873, p. 308. 
THE STAGES OF THE DISEASE.
27
   This division of the course of syphilis, while having regard
mainly to certain relations of time,  has also in view the location
of the several derangements, and corresponds in general with the
clinical features of the disease.   But Cazenave, in 1843, objected
to such a division,  even from a clinical point of view,  contend-
ing that any consecutive manifestation of syphilis may, without
exception, appear at any time, whether more or less distant from
the period of infection, and one may precede the other indiffer-
ently.1  As soon as the different derangements are thoroughly
investigated in their pathological anatomy,  it becomes  manifest
that so sharp  a division as that of  Ricord is neither correct
chronologically nor  anatomically  admissible.   Virchow3  has
shown that both mild  and severe symptoms, or what Von Baren-
sprung represents as the critical events (Kriterien) of the second-
ary and tertiary periods—simple hyperemias and exudations on
the one hand, and tubercular formations on the other—can occur
together in all stages of syphilis and  that in hereditary syphilis
especially, the manifestations   of  Ricord's  secondary period
may be in progress while, simultaneously, the most  pronounced
changes  of the tertiary period are taking place in  the viscera.
Indeed, Virchow goes still  further,  for while admitting that the
gummy  tumors possess a certain specific character, not only as
regards their histological structure, but  in respect to the course
they  pursue, as distinguished  from  the purely irritative  pro-
cesses, he also insists upon the histological resemblance between
the initial sclerosis and the gummy tumors, and hence,  in a
measure, brings the beginning and end of  syphilis into immediate
relation with each other.
   While  we cannot but acknowledge the  justice  of the objec-
tions  urged to the divisions of Ricord on the score of the patho-
logical anatomy, it is  still not to be denied that from the stand-
point  of  clinical observation,  such a statement of the case as
Ricord has made is exceedingly attractive, and, relieved of its
manifest  inaccuracies, may be found yet of practical  value.
  1 L. c, p. 471. Compare also p. 317 and 207.
  3 Ueber die Natur der constitutionell syphilitischen Affectionen.  Arch.  f. path.
Anat, B. XV., 1858,  S. 217. 
28
BAUMLER.—SYPHILIS.
First of all, it is to be borne in mind  that so sharp a chronologi-
cal division as  that  of  Ricord does not in reality exist; that
there are cases of acquired syphilis whose course is so extremely
rapid and  severe that those profounder derangements of tissue,
which usually only appear during the later course  of  syphilis,
are developed in the very first months following the  infection.
In the great majority of  cases such a sequence in  the symptoms
is preserved that, during the early months, or even years, of the
disease only irritative  changes of a light character (adhesive in-
flammations) manifest themselves, not, as Ricord would have it,
on the surface of the body only, but in  all the organs and tis-
sues,  and later  the gummous  and destructive  processes begin.
Hence, according as  the type of  the lesion is more  strongly
marked in the one than in the other, we may distinguish  two
stages—the condylomatous and the  gummous, as  Zeissl1 and
others, have done.   Finally, there  exists in regard to the action
of therapeutic measures  a great difference between the mani-
festations of  the secondary and  tertiary periods, as  admitted
by Virchow.2   The facility with  which  the  manifestations of
Ricord's tertiary period yield  to the iodide of  potassium is
wholty disproportionate  to the effect of  this remedy upon the
manifestations of the secondary period, for the cure of which lat-
ter it is almost inert; and again, while mercury in the secondary
period acts very promptly, in cases of the tertiary class it occa-
sionally exerts an actually pernicious effect.   In -England the
opinion of the most experienced syphilographers is quite unani-
mous upon this point.   I will only mention J. Hutchinson, who
says :s "The marvellous  power of the iodide of potassium in the
cure of these affections (the tertiary) is universally admitted, and
has led to  the almost entire disuse of mercury in  their treat-
ment."  Hutchinson  also  points  out some  of  the  differences
between the symptoms of syphilis in the secondary and tertiary
stages, upon which not enough  stress has been hitherto laid, viz.,
the symmetry manifested by the secondary symptoms (the  skin
eruptions, ulcers of the tonsils, iritis, and retinitis), in contrast to
the marked asymmetry  of the tertiary symptoms, which often
1 L. c, s. 80.
2 L. c, S. 218.
3 L. c, p. 311. 
THE  STAGES OF THE DISEASE.
29
occur in quite isolated forms;  further, the disposition of the
secondary  affections to  heal  spontaneously,  while the tertiary
have a  progressive and  destructive  character.   Besides,  he
alludes to  the protection afforded against  new syphilitic con-
tagion being less  in the tertiary period,  while the probability
of  not  transmitting the disease  to  the  offspring  is greater.
Between the second and  the well-characterized third stages there
may be an  intermediate stage  of  latency or  relapses, of uncer-
tain and often  very prolonged duration.   The relapsing  affec-
tions of the skin during this  intermediate period are neither
so abundant nor so symmetrical as in the secondary.
    The marasmus  that persons who have had syphilis some-
times exhibit has often  nothing at  all directly to do with this
disease.  It is generally dependent  upon such changes as may
gradually take  place from other causes, particularly from long
protracted  suppurations.  Under  this head belong the amyloid
degenerations of the large  abdominal organs and of the lym-
phatic glands.   These marasmatic  conditions may be regarded as
sequelae of syphilis, or, with Von Sigmund,  as a fourth period of
the disease.
   Comparing syphilis with other  infectious diseases, particu-
larly the exanthemata, we find the secondary period of syphilis
to be the equivalent of  what  we are accustomed to regard as
the  disease proper  in these affections, that  is, it is  the direct
expression  of. the  general blood-poisoning.  Again, the tertiary
period of  syphilis  corresponds to  the sequelaB  of  the  acute
exanthemata, which are the result  of the previous action of the
poison upon the tissues.  During the secondary period of syphilis
we  may consider that all the tissues are subjected uniformly to
the action of the poison,  the vehicle  of which  at this  time is the
blood, as shown  by experimental inoculations.  But we must also
bear in mind that not only the organism as a whole, in  different
cases, but  also  different tissues of  one and the same organism
react differently when acted upon by the poison ; in other words,
that evidences  of  irritation are more easily provoked in one
tissue than  another.  Now gradually the poison  is eliminated,
but the tissues that have been temporarily under its influence, or
that were formed while its activity continued, though outwardly 
30
BAUMXER. —SYPHILIS.
exhibiting no morbid appearances, have in reality undergone a
permanent change, which on the one  hand  renders  them  insus-
ceptible to fresh syphilitic contagion, and  on the  other  leaves
them more disposed to inflammatory affections.   These inflam-
matory affections, by virtue  of the peculiar quality imparted to
the tissues by the syphilitic poison,  pursue  a  peculiar course
and thereby acquire,  in a measure,  a specific character  (gum-
mata).  It is often necessary  to the inception of  such inflamma-
tory processes that there  should  have been first  an  external
shock, an occasioning cause,  as an  injury, an  exposure to cold,
an  intercurrent  disease, or  some  powerful  emotional distur-
bance.  This predisposition, which is generated by the syphilitic
poison, need not  appertain  equally  to the entire  body  in all
its  parts.  From the  especially intense action  of  the poison
upon some particular organ or tissue,  the predisposition may
manifest itself there earlier than in others; thus in one  organ
a gummy  tumor may be developed,  while  elsewhere evidences
of the direct  operation of the syphilitic virus still remain, as
happens occasionally in very  severe cases  and in hereditary
syphilis.
  A similar view was taken of the sequence in the manifestations of syphilis by
Cazenave.1 Through the primitive symptoms (under which he includes the pri-
mary local affection and the acute manifestations of the secondary period (in the
ordinary sense) another " individuality " was impressed  upon the  person affected,
a latent condition developed that is no longer dependent upon the presence of the
virus in the system, and is first brought to notice through accidental external causes
in the form of morbid symptoms.  These symptoms are termed secondary by Caze-
nave, but under them he includes much that evidently belongs to the acute blood-
poisoning.

   Therefore we believe that a practical division of the symp-
toms of syphilis would be to separate them  into  groups accord-
ing to the order in which they gradually develop.  Hence we
distinguish
   1. The primary  stage,  beginning with  the infection  and
comprising the gradual development  of  the local symptoms at
the point  of infection and the indolent gland swellings  in the
1 L. a, pp. 177/207,483. 
THE STAGES OF THE DISEASE.
31
vicinity.  This stage therefore includes the  three or four weeks
of incubation, and is terminated at the breaking out of  general
symptoms.
   No absolute immunity from new infection with  the syphi-
litic poison.
   2.  The  secondary  stage.—Blood-poisoning  at  its  height.
Begins  six or eight weeks from the  first appearance  of the
primary affection;  accompanied  frequently  by  an eruptive
fever.
   As a rule, superficial eruptions of skin and mucous mem-
brane, distributed symmetrically over both  halves of the body.
Falling of the hair and  disease of the nails.  Often ansemia.
Lymphadenitis universalis.  Simple irritative processes in the
periosteum and  interstitial cellular tissue of internal  organs.
Disposition to heal spontaneously without loss of tissue,  though
under certain circumstances leading to  permanent derangements
of function, through adhesions of connective tissue or contrac-
tions.
   In exceptional cases (mainly due to a feeble constitution or
one that has  been debilitated  by accidental external  influences)
the more profound tissue derangements occur even in this stage,
bearing the same character which commonly distinguishes the
appearances of the subsequent stage.
   Immunity from  new  infection with the  syphilitic  poison.
Transmission of the  disease to offspring.
   Duration of this stage from several months to a year.  It
merges, without  definite  boundary, into an intermediate stage
of very uncertain duration, during which  the  disease  remains
quite latent, or  from  time to time various eruptions  appear
upon the skin and mucous membranes, which are usually more
limited in extent, less symmetrical, and not so acute as the first
general manifestations of the secondary period.  The continu-
ance of the blood-poisoning in this intermediate period,  though
in diminished  and with  steadily decreasing  intensity,  is still
evident in the immunity from new infection, and in the very
great likelihood of transmitting the disease to offspring.        '
   In these condary and  intermediate  stages the influence of a
mercurial course is decidedly  favorable. 
32
BAUMLER. —SYPHILIS.
   3.  The  tertiary stage,  characterized  by  local affections,
for the most part  asymmetrical, often occasioned by external
causes, and consisting  in cell-growths, having a tendency either
to disintegrate  or  to become  encysted with caseous metamor-
phosis and new formation  of  connective tissue.   Gummata of
the various organs, ulceration, necrosis, and caries of skin and
bone.  General state of  nutrition usually, though not always,
bad.
   Markedly favorable effect of the iodide of potassium.  Effect
of mercury often unfavorable.
   Since this stage is affected by all that has preceded it, by acci-
dental external influences, and also particularly by the constitu-
tion of the  patient,  its limits as to time are necessarily uncertain.
In the exceptional cases which have been already alluded to, it
may even  begin but a few months after the infection, and be
therefore concurrent with  the  secondary period.   But, as  a rule,
several years—often twenty  or more—intervene between the time
of contagion and the outbreak of tertiary symptoms.
   The blood-poisoning proper of syphilis is now either insignifi-
cant or entirely absent, so that offspring generated in this stage
usually escape infection.  The local manifestations, also,  of this
period are  incapable of conveying the syphilitic virus, and  im-
munity from new infection with the disease is diminished.
   This stage is either concurrent with or merges into
   4.  The  stage of confirmed syphilitic marasmus, or, more
correctly speaking,  marasmus  induced in  consequence of  syphi-
lis.  Irremediable changes, as amyloid degeneration, destructive
caseous pneumonias, dysenteric and other ulcerative processes.
   The two last-named stages are considered by S. Wilksl and
J. Hutchinson as sequelcB of syphilis.
   The variations with respect to the form and severity of  the
course pursued by syphilis,  which a large series  of cases present,
are very remarkable.   They may be  so great as to produce  the
impression of quite distinct diseases.  In general, the various
forms  may be divided  into  the mild and severe.  The character
of the latter has been already indicated.
1 Guy's Hospital Reports, -Ser. III., Vol. 9, p. 13. 
               GENERAL PATHOLOGICAL ANATOMY.            33

    The source  of these variations in  the form  of the disease
 might possibly lie in differences in the original virus (in respect
 to quantity and quality),  as claimed  by Carmichael,  of Dublin
 (1815), who maintained  that there were four different sorts of
 virus,  together with four different sets of primary and consecu-
 tive manifestations of the disease.  Or they may also lie in indi-
 vidual peculiarities of the infected person, as is often the case
 in other infectious diseases.   Of a number of persons exposed
 simultaneously to the infectious poison of measles,  scarlatina, or
 small-pox, that is,  to a poison of the  same kind and intensity,
 some will not be affected  at all, others onhy slightly, and some
 very seriously.   So it is with syphilis.   Frequently enough, the
 peculiarities of  constitution which determine a severe course are
 quite obvious.  It is in individuals who are  scrofulous, liable to
 inflammations,  debilitated  through deprivations  or excesses, or
 else naturally strong but living under  peculiar climatic or other
 outward conditions which are unfavorable—sailors, for example
 —that we observe  the severer forms  of the  disease which are
 often well pronounced, even in the early stages, as in the cases
 of phagedena.

               GENERAL PATHOLOGICAL ANATOMY.
 Lebert, Robin, Verneuil, Bullet, de la Soc. anatomique,  1855.—Lebert, Handb. d.
    prakt. Medicin,  1 Aufl., 1859, B. I., S. 370.—Virchow, Ueber. d. Natur der con-
    stit.-syphil. Affectionen.  Arch. f. An. u. Phys., B. XV. S. 217.— A. van Oordt,
    Des tumeurs gommeuses.  These de Paris, 1859.—Gros et Lancereux, Des affec-
    tions nerveuses syphilitiques.  Paris, 1861, p. 150.—E.  Wagner, Das Syphilom.
    Arch. d. Heilkunde, B. IV., 1863, S. 1; B. VII., 1866, S.  518.— Virchow, Die
    krankhaft. Geschwiilste, B. II. S. 387.—Cornil et Ranvier, Man. d'histol. pathol.
    Paris, 1869, V. I. p. 186.—E. Rindjieisch, Lehrbuch der path. Gewebelehre, 3
    Aufl. Leipzig, 1873, S. 92.
   The changes  which the syphilitic  infection induces in  the
humors of the body, particularly in  the blood, are  but little
known.  The investigations of Ricord  and Grassi,1 who found a
diminution in the red corpuscles and an increase in the albumen

   1 Bullet, de Therapeut., 1844.   Ricord. Lemons sur le chancre.  Lancereaux,  1. c.,
p. 96.
           VOL. III.—3 
34                  BAUMLER.—SYPHILIS.

of the serum, have really only proved the existence of what, in
many instances, is apparent to the naked eye, viz.,  oligsemia.
Besides, the fact is pointed out by Virchow, that when numer-
ous lymphatic  glands  suffer hyperplasia, in consequence of  the
irritation of this poison, there is a more abundant production of
white blood-corpuscles, that is, there is often produced a certain
degree of leucocythosis.   Hence these changes are by no means
either essential to or characteristic of syphilis.   No more  can
any organized components of the blood be shown to be charac-
teristic of syphilis, as  the researches of Lostorfer (to which we
shall again refer later)  seemed at first to promise.
   The local manifestations of the action of the syphilitic poison
upon the tissues at the point of infection, as well as in other
parts of the body, have been repeatedly and thoroughly investi-
gated.  Various sets  of  changes  are found, post-mortem, in
syphilitic subjects, but only a portion of  the changes have any
direct connection with the syphilitic infection ; cellular infiltra-
tions, fatty degeneration and atrophy of the tissues, and, finally,
amyloid degeneration  of  various organs,  are-the  most essential
of them.   Only the cellular infiltrations are properly character-
istic of syphilis ; these constitute the distinctive feature which
the most diverse local manifestations of  the disease possess in
common,  and the  connective tissue is the matrix in which the
cellular  growths  develop.   The  cells  composing  them have
generally a single large  nucleus, and bear a very close resem-
blance to the white blood-corpuscles, to  the cells of lymphoma,
and to those of the cell-growths in  typhus.   According as we
accept the position of  Cohnheim,  or adhere to the older views,
shall we regard the point of departure for these  cell-accumula-
tions  to be  in" the blood-vessels or  in the connective tissue.
Virchow compares the entire formation  to granulation tissue.
From the  fact of the  close resemblance of the cells which  per-
vade the tissues, or occur in the form of young  tissue-growths,
with the white blood-corpuscles, is it evident that, however much
they may characterize syphilitic new formations, they wholly
lack  specific microscopic characters.   Still,  their arrangement
and  the development and further course of the cell-growths
afford certain marks by means of which it is possible perhaps to 
GENERAL PATHOLOGICAL ANATOMY.
35
 distinguish the syphilitic new  growth from  every  other.  This
 is asserted by E. Wagner, and he has, therefore,  adopted the
 special name " Syphiloma."
    The most peculiar and striking of the local affections due to
 syphilis is the gummy tumor,  and it is to this especially that
 Wagner has applied the above term.
    Gabriel Fallopia has pointed out very clearly the main char-
 acters of gummy tumors, giving at the same time an explanation
 of  their name, in the following passage:l " Isti turn ores cum
 contineant materiam crassam, quae est veluti gummi eliquatum,
 ideo  gummata Gallica vocantur a medicis."   He  proceeds to
 describe the hard tumores tophacei and continues as follows  :
 "Secunda species tumorum est quando materia est mollis, quae
 tripliciter  apparet, nam aliquando est veluti  lardum, aliquando
 est minus  crassa  et est similis polentse et est atheroma Gallicum:
 tertia species est  sicut mel et dicitur meliceris Gallica."
    Tumors of this sort, varying in consistency, may develop in
 any organ in consequence of syphilis ; but their favorite seats
 are the subcutaneous cellular tissue, the skin, in and upon the
 bones, the liver,  the testicles, the brain, the kidneys,  and, espe-
 cially in children, the lungs.   According to  Wagner's  descrip-
 tion,  they  present the appearance  of a grayish-red, soft, homo-
 geneous mass, either without fluid contents  or else yielding a
 scanty  juice like mucus.  They may occur as infiltrations of
 microscopic size,  scattered throughout  the parenchyma of  an
 organ, and even  when  they appear as sizable tumors, as large
 as a walnut or more, they are not encysted  nor  sharply defined,
 but merge directly into the surrounding tissue.  In fact, some-
 times they occur more  in the form of a diffuse infiltration than
 of a distinct tumor.  Now, the development progressing, a soft-
 ening takes place in the  central portions, a metamorphosis into
 the above  gummous or honey-like substance, or, on the other
 hand, the  mass becomes drier  and firmer, showing on  section
in certain  places more  than others, a yellow color  and cheesyv
consistency.
   Microscopically a fresh syphiloma shows  nucleated  cells  of
Tractat. de morb. Gall. (1564), Aphrod., II., p. 826. 
36                  BAUMLER. —SYPHILIS.

the character  mentioned  above,  more  or less  closely  packed
together, and  so imbedded  in the  tissue that when the cells
are brushed away  little cavities remain in their  places.  Here
and there,  beside the round cells, spindle-shaped cells  may be
seen occasionally, an indication of commencing transformation
into connective  tissue.  The central softening is effected either
through a  simple atrophy and fatty degeneration, or through a
mucous metamorphosis, under which circumstances, according
to Rindfleisch, stellate branching cells are often formed.  Such
a gumma,  then, presents the appearance of a nodule, with more
or less fluid contents, enclosed in a dense cortical layer.  After
a  certain period fibrous tissue begins to be formed in  the pe-
ripheral layers of the nodule, owing to the fact, probably, that
nutrition is more active in  these portions.  This new connective
tissue surrounding  the  growth develops most rapidly after the
central  portions of the tumor, or several isolated spots, have
become caseous, in consequence  of fatty degeneration of the
densely crowded cells and of their intervening tissue ; the yellow
spots then appear  scattered throughout  an  exceedingly dense
structure.
   It is in the last-named form, which represents its final  stage of
development, and in which it may continue to remain for many
years,  that the gumma is  most  commonly found in the inter-
nal organs.  The parenchyma of the latter, in consequence of
the displacement, compression, and the cicatricial contractions to
which the organs are subjected, suffers various alterations.   The
effects of a gummy tumor  may extend to a great distance, in
case it has, caused contraction of the calibre of some vessel, espe-
cially  of a blood-vessel,  which is particularly liable to  occur
when the tumor has its seat in the adventitia of a vessel.  Fatty
degeneration and wide-spread processes  of  softening may be the
consequences  of a  tumor in itself insignificant, as occasionally
happens in the brain.
    When situated  in the skin, in the subcutaneous cellular  tis-
sue, upon  mucous membranes and superficial bones, the gumma
often makes its way to the  surface, since in these situations it is
not uniformly  enclosed upon all sides, but is exposed  to an
unequal pressure.   The entire infiltration then ulcerates. 
GENERAL PATHOLOGICAL ANATOMY.
37
   That which especially characterizes the gummy tumor is the
general course of development which the new-formed tissue pur-
sues ; for there  is nothing  that is specific in the separate pro-
cesses  of this development.  Virchow points  out as a special
characteristic the perishable  nature of the cells, their  dispo-
sition to become disintegrated through an incomplete fatty meta-
morphosis.   But the cells of the gummy tumor share this  nature
with those of numerous other new growths, notably with  tuber-
cle.  The resemblance of a cheesy gumma to cheesy tubercle,  in
certain parts of  the  body, may be so great that it becomes diffi-
cult to distinguish the one from the other.  Even Wagner, who,
in regard to the specific  character of "syphiloma" goes  much
farther than Virchow, does not look for its specific character in
its histological  constitution  at   any particular  period  of  its
development exclusively, but takes into account the mode of its
course, the  etiology, and even the action of remedies upon the
development and further course of the tumor,  to assist in char-
acterizing it.  The histology,  therefore, furnishes  scarcely any
more certain points for diagnosticating a new growth to be syph-
ilitic than may be obtained from a circumspect clinical examina-
tion of the case, together with a thorough investigation  of its
history.
   Still,  we may believe with Wagner that the cells of the syph-
ilitic new growths have in reality  a more specific character than
is apparent.  The whole course of their development points  to
such being  the fact; they owe this specific character to the tis-
sues—the soil in which  they develop—-and so, indirectly, to that
indefinable action of the syphilis poison upon the tissues, where-
by those properties  are imparted to the cells which determine
their future destiny.   These properties have undoubtedly  some-
thing specific about  them ; but their specificness is  not obvious
with regard to the single cell,  and can  only be inferred  from the
course pursued in the cellular growths.
   The close histological relationship between  the gumma tissue
and the primary affection to which Virchow has called attention,
and which we have already  alluded  to  above, consists  solely
in the  cellular infiltration that occurs in both, and is, in fine,
no more remarkable than  we meet  with elsewhere subsisting 
38                  BAUMLER.—SYPHILIS.
between  widely diverse pathological conditions.  Many of the
local processes of the secondary period  also present precisely
the same histological characters.  But what distinguishes these
processes from the gummy tumors is their tendency to wholly
disappear by resorption, or else to form  more highly organized
tissue;  that  is, to develop connective tissue, bone tissue,  etc.
The specific character of  these secondary processes, then, must
lie in something different  from that of the later events.  So Vir-
chow makes  the distinction between the merely irritative and
the gummous processes.  The primary affection, in our opinion,
is to be ascribed to the former, for the reason that in a large pro-
portion of cases it is a process which disappears in a compara-
tively short space of time without leaving a vestige of  it behind.
The source of the irritation to which  it is  due, viz., the  syphilis
poison,  is in this  instance brought from  without directly into
healthy tissue ; during  the irritative processes of the secondary
period the virus operates from within, i.e., from  the blood, upon
all the various tissues of the body.  But the tissues react under
it at first still as in a normal state.   During the period of gum-
mous development it is  probably no longer the action of  the spe-
cific poison  upon normal tissue with which  we have to do, but
with a sort of specific reaction of tissues, modified by previous
blood-poisoning, under some accidental irritation. 
SPECIAL   CONSIDERATIONS.
                          ETIOLOGY.

                    THE SYPHILITIC POISON.

 H. Auspitz, Die Lehren vom syph. Contagium.  Wien, 1866.—Concerning Lostor-
    fer's investigations,  vid. Archiv f. Dermatol, u. Syph., IV, 1872, p. 115 f.
    Schmidt's Jahrbiicher, B. 154, S. 170.  Zeissl, 1. c, S. 32.

    Our knowledge of the contagious principle of syphilis has
 been thus far limited to its effects.  Neither as  a chemically
 definable substance nor as a definitely formed body has it been
 possible yet to isolate  it.
    That some kind of  contagious principle lies at the bottom of
 the disease  was evident to unprejudiced observers even at the
 time of the first outbreak of  the  morbus gallicus.  The view
 that  arose in  consequence of its pestilential spread, viz., that a
 miasm, originating outside the  body, pervaded the atmosphere,
 did not long maintain its ground.   The very manner in which
 the propagation of the disease through  the medium of the air
 was spoken  of by the physicians J  of that  day, shows that the
 assertion was made oftentimes not wholly in earnest.  J. Ferne-
 lius2 expresses himself  in  the clearest manner concerning the
 syphilitic  poison, in comparing infection with it to  the bite of a
 mad  dog or the sting  of a scorpion,  and he also points out the
 fact that the fluids of the body serve as a vehicle for the poison.
    When  Liebig  compared the  nutritive  changes  caused by
 animal poisons with fermentative processes,  great stress was laid

  1 The Spanish physician, J.  Almenar, writes (1502):  il  . . .  aeris corruptio, per
quam causam evenisse, pie credendum est in religiosis."  And further below : '' Satis
est ut scias hunc morbum esse  contagiosum."  Aphrod., I. p. 361.
  2 Aphrod.,  I. pp. 610, 614. 
40
BAUMLEE.—SYPHILIS.
upon the chemical nature of the poisons to which the infectious
diseases were due, and these poisons were held to be analogous
to the ferments, to the nitrogenous substances.  But now, since
it  has been  shown,  chiefly by Pasteur,  that the presence  of
minute  organisms—fungi  and  bacteria—are necessary  to  the
production  of many  of  the so-called fermentative processes,
similar living organisms have been sought for as causes of the
infectious diseases.  The investigations of Salisbury concerning
the cause of malarial fever, and of Hallier in regard to cholera,
led the way to further researches in reference to other infectious
diseases, and it was not long before there was discovered not only
a  cholera fungus, but a fungus for measles, for scarlatina, and
even for gonorrhoea and  syphilis.   Salisbury and Hallier have
cultivated and described all these fungi.  But these discoveries,
unfortunately, could not be confirmed  by others.  Nevertheless,
both these investigators have earned the merit of opening up a
new field for research, and while  no very decisive results have
thus far been achieved, we have at least gained the advantage of
regarding the subject from some new points of view.
   The idea of living organisms—minute forms of life in active motion—being
the essential cause of syphilis, as, according to  Athanasius Kircher  (1659), they
were of the pest, was expressed in a rough form as early as the seventeenth century.1

    It was shown with regard to the vaccine lymph by Chauveau
and Burdon  Sanderson, that  the contagious element did not
reside in the fluid portion,  but  in minute, roundish, microscopic
bodies that  strongly  refracted the light.  Similar little bodies
were discovered by Lostorfer in the blood of syphilitic subjects.
Examinations of the blood, extending over several days, resulted
in the discovery of small,  strongly refracting corpuscles, which
made their first appearance on the third or fourth  day,  and
rapidly increased in  size during the days following.   This dis-
covery excited all the more interest, since Lostorfer, according to
report,  was  able  to  select correctly from among a number of
specimens of blood given him  those which came from syphilitic
persons.
1 Compare Astruc, 1. c, p. 91; Cazenave, 1. c, p. 67. 
ETIOLOGY.
41
   But the importance attached to Lostorfer's researches was
attacked by Wedl and Kobner, and it was not long before  these
corpuscles were  deprived  of  all claim to a specific character,
through the fact being proved that like bodies occur in normal
blood, and that they probably originate in the white blood-cor-
puscles, which, in certain stages of syphilis, are often increased.
   Since,  then, the syphilitic poison can be isolated by means of
neither chemical nor anatomical  tests, we come,  in the next
place, to inquire  in what constituents of an organism infected
with syphilis this poison resides,  and, in general,  what are the
relations which  it bears to this  organism or towards one not
infected.
   The question  whether the  syphilitic poison, that is, whether
syphilis may  be transmitted to  the lower animals, has been
the subject of  numerous experiments.   The attempts  made to
inoculate animals with the pus of chancre, by Auzias Turenne
and others,1 have determined nothing.   The famous ape from
which Dr. von Welz  inoculated  himself, had been  previously
inoculated with the pus of a simple contagious pustule devel-
oped in a syphilitic person, that is, from chancrous pus,  and had
afterwards a chancre only and no syphilis.   But a like result,
namely, the production of  simple  contagious ulcers, has also, in
numerous  experiments with  animals, followed  inoculation of
secretions from true syphilitic local affections.
   Only three  cases, so far  as I know, are on record where
syphilis has been actually communicated by inoculation to ani-
mals.   Two of these were reported by S. Messenger Bradley.3
He had previously made  numerous attempts at inoculation,
which had been either  quite fruitless or resulted only in the
production of soft  sores.   The cases were communicated to the
surgical section,  at the annual  meeting of the British Medical
Association in 1871.  "In  two cases (a guinea-pig and  a young
kitten) the inoculation was followed, in from two to three weeks,
by a local thickening at the point of inoculation, and afterwards
by  constitutional syphilis.  The  guinea-pig  died within one
1 Auspitz, 1. c, p. 293.
2 British Medical Journal, 1871, Sept. 30, p. 376. 
42
BAUMLER.—SYPHILIS.
month from the commencement of the induration, with destruc-
tion of one eye, and extensive ulceration of the mouth and soft
palate.  I killed the kitten at the end of the eighth week, and
found syphilitic gummata in the kidneys and liver."
   In a  third  case, Ch. Legros'  produced an indurated  ulcer
in a guinea-pig by inserting  a bit  of a syphilitic induration un-
derneath the skin of the leg.  During  cicatrization of the wound
the animal commenced to grow marasmic.  It died five and a
half months after the inoculation,  and at the autopsy there were
found extensive swellings  of the lymphatic  glands, enlarge-
ment of  the liver, with cicatrices upon its surface, and  little
cellular tumors in  its  substance, besides a number of gummy-
like nodules in the deeper layers of the cutis, and  a firm yellow
nodule the size of  a pea in one epididymis, an illustration of
which is given in  Lancereaux.  Lancereaux, however, in  view
of the marked predisposition of  guinea-pigs  to irritative con-
nective-tissue growths, expresses doubt  as  to the  syphilitic na-
ture of this  affection.   Zeissl8 made some experiments  with
syphilitic blood, with which he inoculated rabbits and doves, but
with a negative result.

             VEHICLES OF  THE SYPHILITIC  POISON.

   1.  It has long been a recognized fact that the primary affection
of syphilis, the ulcerating  sclerosis, bears the syphilitic poison;
that whether by contact in sexual intercourse, or by other mode
of contiguity, as well as in experimental inoculations, this poison
can  be  communicated  to  a healthy person from the primary
affection.
   2.  For a time  there was less  concurrence  of  opinion  with
regard to the infectious nature of the local manifestations belong-
ing to constitutional syphilis.  After  the opinion  expressed by
Hunter,3 based upon both theoretical and experimental  grounds
viz., that neither the local manifestations of constitutional syphi-
lis nor the blood and secretions of syphilitic persons are conta-
1 Lancereaux, 1. c, p. 597.                2 Lancereaux, 1 c, p. 42.
                  3 L. c, p. 383 and 384. 
VEHICLES  OF THE SYPHILITIC POISON.
43
 gious, had apparently been confirmed by Ricord in  more  com-
 plete experiments, it  doubtless seemed as though  the question
 had been  settled definitely in the negative.   In his Lettres sur
 la Syphilis, 1850 and 1851,1 Ricord makes the following state-
 ment : "The primary ulcer, in the period of  its extension, is the
 only source of the syphilitic poison."
    As early  as 1830-40 experiments  in inoculation  had  been
 made  which  yielded  quite a different  result—a result which
 was more consonant with the  numberless clinical  experiences
 that had been made ever since physicians first began to make
 syphilis a  study.   These experiences had attributed to the flat
 condylomata especially,  properties eminently contagious.2 These
 experiments differed from those of Hunter and Ricord in that
 instead of  inoculating the secretions from local affections in per-
 sons with constitutional   syphilis upon the bearers of these affec-
 tions,  or upon  persons already syphilitic, the inoculations were
 made  upon such as had been previously healthy.   Wallace, of
 Dublin, in 1835, was the first to make inoculations of this sort.3

   From a series  of experiments communicated by Wallace we select the following
 as the most instructive : On the 15th of November, 1835, W. inoculated both thighs
 of a healthy man with the contents of syphilitic pustules that had first appeared upon
 a patient fourteen days before.  The places healed with scars. In the second week in
 December there appeared at all  of the  points of inoculation upon  the right thigh,
 and in two of those on the left, little,  elevated, brownish-red papules with desqua-
 mating surface.  Some of these papules turned into ulcers,  which were covered with
 greenish-yellow scabs, and remained till  the 11th of  January, 1836.  At the same
 time there were enlargements of the lymphatic glands in both inguinal regions.  On
 the 21st of January general manifestations appeared, with a measly eruption and red-
 ness of the isthmus of the fauces.

   Wallace also alludes  to several successful inoculations with
the secretion  from flat condylomata, communicated to him by
some person not named.   But the communicability of syphilis
through these local forms of  the disease was more  forcibly illus-
   1 Union medicale, Eighteenth Letter.
   a In spite of the Ricord terrorism, some held firmly to this view, even in France,
(Baumes (1840), Cazenave (1843), 1. c, p. 176.)
   3 The Lancet, 1835 and 1836. 
44
BAUMLER.—SYPHILIS.
trated by cases of Waller,1 in Prague, and therefore we proceed
to his experiments.

   On  the 6th of August, 1851, a boy by the name of  Durst was scarified upon
the skin of the front part of the right thigh, with a clean  instrument, and pus from
fiat condylomata in a female patient  was smeared over the part, partly by means of
a spatulc and partly with a bit of charpie that had been dipped in the pus,  and  the
latter was then bound upon the wounds.  On the next day there were evidences of
slight inflammation, which, four days later, had entirely disappeared.  On  the 15th
of August several red spots made their appearance at the place that had been scari-
fied, from which by the 30th of August (i.e., twenty-five days from the inoculation)
fourteen tubercles, as large as peas, had  developed in the skin, most of them spring-
ing directly from the scars  caused  by the scarifications.  They were  hard to the
touch, partly of a dirty red color, others  of a dirty yellow, some of them desquamat-
ing.  During  the succeeding days they  became confluent, and had then the appear-
ance of a nodular place, the  size of a silver half-dollar, covered with scales.   Sep-
tember 27th (twenty-seven days after the appearance of the tubercles, and fifty-two
days from the  inoculation) a macular exanthem appeared upon the skin of the abdo-
men, chest, and  back, which during the following days extended and grew more
abundant, without evidence  of fever.  In the early part of October certain of the
maculae were changed into papules, others into tubercles, in short, into the charac-
teristic appearances of a syphilide.  There had  been no throat affection at the time
the case was reported.

    Amongst  others an anonymous  physician of  the Palatinatea
(1856), Gibert3 (1859),  Guyenot of Lyons,4 von  Barensprung4
(1859), von Hiibbenet6  (1859),  Lindwurm7  (1860-1), Hebra and
Rosner8 (1851 to 1862)  have  successfully inoculated persons pre-
viously healthy with syphilitic virus contained in the secretion
of condylomata lata.
    Thus by  experiment  was demonstrated what practice had
already taught in hundreds of cases.  Ricord, in order to account
for the above observed facts,  and  not  be inconsistent with  his
   1 Praeger Vierteljahrschrift, B. 29, 1851.
   2 Aerztl. Intelligenzblatt, 1856, No. 35.
   3 Bulletin de l'Academie de Medecine, t. 24, p. 881.
   * Gaz. hebdom., 1859, No. 15.
   6 Annalen des Charitekrankenhauses.  Berlin, 1860, B. IX., S. 110-208.
   6 C. von Hiibbenet, Die Beobachtung und das Experiment in der Syphilis.  Leipzig
1859.
   7 Wurzburger medicin. Zeitschrift, 1862, Bd. III., S. 146.
   " Auspitz, 1. c, p. 225. 
               VEHICLES OF THE SYPHILITIC POISON.            45

own former statement, that only the primary lesion can commu-
nicate syphilis,  was obliged to resort to the most forced assump-
tions.   Under the above class of inoculations belong the frequent
infection of  nurses through  suckling  infants, transmission  of
the disease in kissing, etc.—indeed, it  may be asserted that the
condylomata lata are the most common source of syphilitic con-
tagion.
    An experimental  inoculation has  also been made  with the
secretion from a constitutional affection of the tonsils, and was
performed by Dr. Lindemann upon himself.1

    In a friend of his, seven days after the breaking out of a syphilitic skin erup-
tion, a deep ulcer had appeared upon either tonsil.  On the twenty-second day after
the first appearance of these tonsillar  ulcers, Dr. L., having carefully cleaned the
left tonsil two hours before, inoculated himself, by means of a new lancet, with the
scarcely purulent secretion that had meantime again accumulated, in the skin of his
left forearm.  On the eleventh day following, a rose-colored, hardish papule, about
the size of a pin's head, without areola, made its appearance. It increased in size and
became covered with a crust, beneath  which  a  reddish fluid collected.  In a short
time the ulcerated papule  developed into a characteristic indurated chancre, and
three months later there appeared a papular syphilide  and swelling  of the cervical
glands.

    Yon  Rinecker,2 of Wiirzburg, inoculated a young physician,
Dr. R. W., who had never  had syphilis, with matter from  acne
pustules in a child forty-nine days old, which was aiiected  with
hereditary syphilis, on the 5th of January, 1852.

   By means of  a blister a bleb was raised upon  the forearm of  the physician, and
to the portion of skin thus  deprived of its ejndermis the pus from the acne pustules
was applied.  Jan. 10, the part had healed.  Jan. 15, desquamation and redness of
the inoculated place.   The skin felt tough and infiltrated throughout its thickness,
especially at the edges, and mostly at the lower  and inner angle of the rectangular
space corresponding to the portion of skin  that had  been inoculated, and to just
that portion of  it where the most matter was deposited. Just  at this point were
several rather resistant papular elevations, varying in size from a lentil to a pea.  By
the 10th of February the entire inoculated  space was occupied by brownish-red,
tough-feeling  tubercles, and on Feb. 15, some of these were  covered with  scabs,
underneath which suppuration was going on.  Under the influence of hydrarg. biniod.
and chloride of zinc paste this local affection disappeared with cicatrization.

   1  Bulletin de l'Academie de Medecine, Jan.  21, 1852.
   2 Verhandlungen der phys. med. Gessellschaft in Wurzburg, B. III., 1852, S.  391. 
46
BAUMLER. —SYPHILIS.
   June 12 (159 days after inoculation) there was malaise, and eight days later the
tonsils and front part of the velum palati were found dotted with red spots, which
afterwards ulcerated superficially, with the production of a grayish-white exudation;
later, upon the scrotum, red, infiltrated, moist, and superficial fissures.

    With the blood of persons suffering from constitutional syph-
ilis experiments have also been made, which  in some instances
have yielded decisive results.  The first  experiment of this  sort
was made by Waller.

   The person experimented upon was a boy fifteen  years of age, who was suffer-
ing from lupus exfoliativus of the cheek,  but had never had syphilis.  The skin of
the left thigh was scarified with a new instrument, and blood, taken by means of a
cupping-glass from a patient with constitutional syphilis, was applied to the scarifi-
cations, partly with a splinter of wood and partly by dipping a bit of charpie in the
blood, and then binding the latter upon the wounds (July 27, 1851).  The wounds
healed, but after thirty-four days (Aug. 31) W. noticed at the point of inoculation
two distinct tubercles as large as peas.  They increased in size during the days fol-
lowing, became confluent at their bases, and were surrounded by a red areola.   The
subjacent cutis, together with the subcutaneous connective tissue, was dense and
indurated, and ulceration commenced upon the surface of the tubercles, which were
covered  by a thin, brown crust.   October 1 (sixty-five days after the inoculation,
and thirty-two  days  from  the first appearance of the tubercles) an exanthem
appeared upon the skin of the abdomen, chest, back, and thighs, which, during the
subsequent days, extended over the entire  body. Meantime the point of inoculation
had become an ulcer as  large  as a half-dollar, with a  gray base and coppery-red
border.

   The anonymous physician of the Palatinate, mentioned above,
applied the  blood of  a  patient with constitutional syphilis to
ulcers  of the leg, in six  cases, and  thereby caused infection in
three of them,  without any special changes at the point of inocu-
lation,  but followed by the development of exanthems and  lesions
in the throat.   In  three other cases, which were inoculated with
blood  taken from one of the persons who had been infected in the
above manner, the result was negative.   On the other hand,  the
following case  reported by  Gibertl may,  perhaps, be regarded as
a positive success in the inoculation of syphilitic blood, although
the latter was mingled with some intercellular fluid, and, it may
be, with some  organized elements from a syphilitic  efflorescence :
i Auspitz, 1. c, p. 190. 
VEHICLES OF THE SYPHILITIC POISON.
47
   A patient at the Hopital du Midi, with  a  cicatrized  indurated chancre on the
outer surface of the foreskin, and  flat condylomata about the anus, had, upon the
forehead, a coppery, scaly, perfectly dry papule of the size of a ten-cent piece.  On
the 9th of February, the border of this papule was pricked with the point of a lan-
cet, and the latter having been thus moistened with a little serous blood, was imme-
diately introduced into the skin of the front of the forearm in a person affected with
lupus faciei.  In fourteen days every trace of the puncture had disappeared, and the
patient was discharged.  Much surprise was occasioned when the patient  re-entered
the hospital upon the  1st of April, showing at the point of  inoculation  a reddish
papule, which he  said had appeared there fourteen days before. Above and around
this  spot  there were  observed several  somewhat elevated, coppery-red  spots, the
beginning of a consecutive squamous syphilide, which  extended  afterwards over
the whole body.   In  the corresponding axilla a tender  glandular enlargement had
developed larger than a hazel-nut.
   Von Lindwurm injected blood  from a person  with constitutional syphilis, by
means of a Pravaz' syringe, underneath the skin between the shoulder-blades, in a
woman seventy-one years old, who was suffering from  a cancroid affection of the
skin of the forehead,  with necrosis and exfoliation of the frontal bone.   Li the
fourth week after the injection was made, a small red papule was formed  at the site
of the puncture, and  increased in size, becoming covered with  a thin,  yellowish-
brown scab.   It  reached  the size of a gold  dollar,   was  surrounded  by a red
areola, elevated at its  edges, excavated in the centre, and rested upon a  hard base,
and upon removal of  the scab showed a red, somewhat spongy surface, covered by
a  thin secretion  that  quickly dried into  another scab.  Eight days after, there
appeared, two inches  above the ulcer, between the spine and border of the scapula,
just beneath the cutis,  an enlarged lymphatic gland the size of a bean.
   Subsequently the occipital, cervical,  and cubital glands  became also  enlarged,
and a macular, papular, and squamous syphilide appeared upon the skin.

    The  most recent inoculations with syphilitic blood were made
by Pellizzari,1 of Florence  (1862).

   He had already twice made the attempt  before, but without  success.  On the
6th of February, 1862, he repeated  it upon three physicians, who voluntarily sub-
mitted themselves to  the experiment.  The blood was taken by venesection from a
woman, twenty-five years old, with constitutional syphilis,  who  was in  her sixth
month of  pregnancy.   The arm had been carefully washed beforehand,  and at the
point selected  there were no manifestations of syphilis.   The instruments employed
were all new.   As the blood  flowed from the vein a brush  of charpie was dipped
into it and applied directly to  the left arm of Dr. Bargioni at a point near the inser-
tion  of the  deltoid, where  the epidermis had been previously removed,  and three
transverse incisions made.
1 Gazette hebdom., 1862, No. 22.—Lancereaux, 1. c, p. 477. 
48                     BAUMLER.—SYPHILIS.
   The two other physicians, Drs. Rossi and Passigli, were inoculated in a similar
manner in the forearms, but the blood had then become cold and coagulated.  The
inoculation was successful only in  the case  of Dr. Bargioni.   On the third day
every trace of the local injury had  disappeared ;  on the twentieth day a papule
appeared, which for nine days remained dry, then became moist and began to
ulcerate.  An enlargement of the axillary glands preceded the ulceration.
   From the 4th to the 12th of April nocturnal  headache; general roseola and
swelling of the glands in the nape of the neck.

    At first Ricord maintained an  attitude of defence with regard
to the results of these experiments ; with brilliant logic, though
his objections were often trivial, he sought to  invalidate the evi-
dence of Wallace, Waller, and others.   It was not until the year
1859, after the question  had been discussed in the Academie de
Medecine, following the report of  a commission,  that he fin-
ally admitted the communicability of syphilis by  '' secondary''
lesions.
    3.  The physiological  secretions  of   syphilitic persons—the
milk, saliva, urine, perspiration, and tears—most probably are not
vehicles of the syphilitic  poison.  They may possibly contain it,
but in such an  exceedingly  dilute state as  to  be innocuous.
However, one of the physiological secretions, the semen,  seems to
form an exception to this rule (vid. p. 50).
    In reference to the milk,  there are a number' of instances on
record of  syphilitic  nurses suckling  healthy children for a long
time without  infecting them.    H.  Lee relates  an  interesting
instance of this kind.2

   A married woman  was admitted to St.  George's Hospital, October 5, 1864.
Since her last confinement she had taken another child besides  her own to nurse.
This strange child proved to be syphilitic, and, in consequence, the woman had an
ulcer of the breast, which was followed by a characteristic  eruption. The woman
had always nursed the children from different breasts, so that her own child did not
come in contact with the breast which was infected.  This child  remained healthy,
although the mother continued to nurse it for six months after the outbreak of the
eruption.
   1 Duges, de rinnocuite du lait des nourrices atteintes de Syphilis, etc.  These de
Paris, 1852.  Lancereaux, 1. c, p. 481.   Zeissl, p.  30.— Kobner, 1. c, p 60 98 100
110, 113, 130.                                                      '    '
   2 British Medical Journal, 1868, Nov. 28. 
VEHICLES  OF THE SYPHILITIC POISON.
49
    The frequent communication of syphilis from nurses to suck-
lings does not take place, then, through the medium of the milk,
but in  consequence  of  the accidental  presence of some local
syphilitic lesion upon the nipple.
    But Zeissl states  that in cases where syphilis in nurses had
become latent  in consequence of a  mercurial  course, so  that
neither  upon the nipples,  nor on the  lips, nor elsewhere were
there  any  outward  syphilitic  manifestations, he has, neverthe-
less, seen condylomata  develop upon the lips and anus  of the
suckling.   In regard  to the manner of transmission in such cases
Zeissl does not venture to express  a positive opinion.
    4. With regard to the infectious nature of pathological secre-
tions, not properly belonging to syphilis, a definitive  conclusion
is as yet impossible.   The successful inoculation of  syphilis with
gonorrhceal pus (Hunter), with pus taken  from chancrous pus-
tules  and buboes (Wallace), from chancrous pustules produced
by artificial inoculations (Bidenkap), the unfortunate accidents
where syphilis has been communicated from vaccine vesicles, all
apparently speak in favor of these pathological secretions being
vehicles of  the syphilitic poison.   However,  it  is very probable
that in all of these cases the communication of the syphilis was
due to the  admixture of blood with the secretions, or of disin-
tegrated portions of tissue from a syphilitic  local affection.

   The opinion has recently been expressed by certain English physicians that muco-
purulent,  urethral, or vaginal  discharges are not only vehicles of  the syphilitic
virus, but under certain circumstances also are direct manifestations of the syphi-
litic disease.
   H. Lee' believes that the secretion of any mucous membrane in  a syphilitic per-
son, if in a state of irritation, is capable of acting in this manner. According to
him, a slight muco-purulent discharge from the urethra, such as may occur  in a
person formerly affected with syphilis, after  immoderate sexual indulgence  (exclud-
ing the  possibility of a fresh  contagion with syphilis or gonorrhoea), may become
the medium of syphilitic contagion. And J. Morgan2 says that women having no
discharge from the vagina at the time of their admission to the hospital, in the first
stage of the disease, yet a few weeks later, when the secondary symptoms appear,
   1 H. Lee, Syphilitic Urethral Discharges, St. George's Hosp. Reports, Vol. VI., 1873.
—Art. Syphilis, in Holmes' System of Surgery, Vol. I., 1870, p. 477.
   2 On Syphilitic Gonorrhoea, Med. Press and Circular, Jan. 17, 1872.
           VOL. III.—4 
50
BAUMLER.—SYPHILIS.
very frequently have such discharges, which are then capable of communicating
syphilis.
   Discharges of this sort, in women with constitutional  syphilis would, therefore,
have to be regarded as a symptom of syphilis;  probably they are due to a catarrh
of the uterus.   A syphilitic  urethritis is admitted by Vidal 1  and also by Ham-
mond,2 of New York.   Such  a urethritis is to be distinguished from gonorrhoea  in
a syphilitic  person.   It was claimed that syphilitic urethritis can  communicate
syphilis much more readily than a simple gonorrhoea.
   Berkeley  Hill3 thinks it probable that blennorrhaic discharges in syphilitic per-
sons may infect with syphilis,  and Marston 4 has recently endeavored to establish this
view by a series of observations.   [Professor Tarnowsky, of St. Petersburg, has made
some experiments 8 which are interesting in this connection.   Eighteen inoculations
were performed by him, with blennorrhagic matter from the genitals of syphilitic
patients upon healthy persons, and in one instance with a positive result.  One  of
the persons so inoculated developed a well-marked induration, followed by general
syphilis.  The  experiments  were done under every precaution, any  jjossible  con-
tamination of the matter taken from syphilitic lesions or from admixture of blood
being carefully avoided.]6  Granting that pus-corpuscles  are white  blood-cells
which have escaped from the  capillaries, and the infectiousness of  the blood being
an  admitted fact,  there is really  nothing strange in supposing  that  these dis-
charges also  should be infectious.  Still,  the possibility that  some syphilitic lesion
may be deeply seated in the  urethra, where it is inaccessible to examination, and
so mingle its secretion with the urethral discharge, ought not  to be lost sight of.

    Pus from an acne pustule,  due  to  the use  of the  iodide of
potassium,  in a  syphilitic  person,  was  inoculated by  Biday7
but without effect.   The same was true of  serum from an eczema
in a person  affected with syphilis.
    5.  Whether the semen of  a man affected with  latent syphilis
may  be the medium  of  contagion to  the wife,  remains yet an
open question.   Von Barensprung8 claims  that  this  can  be  so
only when the wife conceives.    Others,  as Porter9 and Langston
   1 Auspitz, I. c, p. 280.
   2 Cited by Wilks, Med. Times and Gaz., 1865, Vol. I., p. 436.
   3L. c, p. 53.
   4 Med.-Chirurg. Transactions.  Cited by Lee, 1. c., p. 477.
   6 Vortrage iiber venerische Krankheiten, von Dr. B. Tarnowsky, A. Professor an d.
kaiserl. medic.-chirurg. Academie in St. Petersburg.  Berlin,  1872.
   6 Translator.
   7 Gaz. Med. de Lyon, Fevr., 1865.   Cited by Lancereaux, 1. c, p. 473.
   6 Die hereditiire Syphilis.  Berlin, 1864, p. 51.
   9 Dublin Quarterly Journal, May, 1867. 
            HEREDITARY TRANSMISSION OF SYPHILIS.          51

Parker,* have reported cases which tend to show that infection
of the  wife may take place without conception,  solely through
the  direct action of the  semen, and at the same time without
the  production on her  part of  any discoverable primary lesion.
The  difficulty experienced in  ascertaining the  real  facts  in
such cases is materially increased  from the  fact  (to be again
referred  to later) that the primary lesion upon  the internal
genitals of the female is  often  very superficial,  and lasts but a
short time.   H. Lee is of  the  opinion, however,  that in these
cases the semen does not cause the  infection of itself, but only
through  the  admixture  with  it  of syphilitic  virus  from the
urethral mucous membrane.
   On the other hand,  the virulence of the  semen of a syphilitic
father for the ch ild he begets is an unquestionable fact.
   In this connection  we proceed at once  to discuss the trans-
mission  of syphilis by inheritance, for, although this subject
belongs properly to the chapter upon Infection, it embraces cer-
tain important points of difference from other modes of infection,
which demand for it a separate  consideration.

           Tlie Hereditary  Transmission of Syphilis.
W. van Rosen, Om afkommet af Syphilitiske, etc.  Kjobenhavn, 1859, translated by
   Horning in Behrend's Syphilidologie, Neue Reihe, III., 1861.—von Barensprung,
   Die  hereditiire Syphilis.   Berlin,  1861.—Jonathan  Hutchinson, A Clinical
   Memoir on Diseases of the Eye and Ear, consequent on Inherited Syphilis ; with
   Commentaries on  the Transmission of Syphilis from Parent to Offspring, etc.
   London, 1863.—Ibid., On Inherited Syphilis.  London Hospital Reports, Vol.
   II.. 1865, p.  145.—Atispitz,  1.  c, S. 209.—Mireur, Essai sur l'hgredite de la
   Syphilis.  These de Paris, 1867.—Lancereaux, 1. c, p. 501.

   If a syphilitic father impregnates a healthy ovule, and the
foetus turns out to  be syphilitic without the  mother  becoming
similarly affected, it is  without doubt the semen that  served as
the vehicle1 of the syphilitic poison.   Again, the ovule  may be
developed in  the  ovary of a  syphilitic woman,  and having
received the germs of disease from  the mother-soil that produced
it, the foetus will be syphilitic, though  the ovule  was impreg-
1 Med. Times and Gazette, July 4, 1863. 
52
BAUMLER. —SYPHILIS.
nated by healthy semen.  Here we cannot speak of  an infection
properly,  since the  ovule  is merely a constituent  part of the
maternal organism, and as such has imbibed the disease-poison.
Finally, there is a third case, where the mother acquires syphilis
during the time of gestation,  and  infects the developing foetus
through her blood.
   The hereditary transmission  of syphilis was accepted as a
fact even by  the physicians  of the sixteenth  century.   John
Hunter,1 on the contrary,  did not admit it.   At the  most,  he
admitted  only that  the foetus in utero might become infected
with a portion of the same poison which infects and is absorbed
by the mother, but not that it was infected in consequence of the
maternal disease.  Hunter doubted the inheritance of syphilis
because he did not regard the  so-called constitutional syphilis as
infectious.   Ricord,  who shared Hunter's view with regard to
the latter point,  still admitted the hereditary  transmission of
syphilis as an exception to the rule.   Others, while granting
that children are sometimes  born with syphilis  which  they
appear to  have  inherited,  have supposed with Kluge2 that the
infection only took place during the act of delivery.  Kluge did
not regard the cases of  congenital syphilis, where the mother's
organs of  generation  were afterwards found free from  local
affections,  as really syphilis, but referred them to the uncertain
domain of scrofula.
   But unbiased observations  gradually again gave currency to
the views which had been already expressed by Paracelsus long
before, and again, in the beginning of this  century by Swediaur,3
viz., that  syphilis may actually be inherited; and moreover,
according  to  Swediaur, that  it is more commonly so from the
father only.   Vassal,4  Cullerier,5 and others asserted,  on the
other  hand, that  only  through the mother was syphilis trans-
mitted to the  foetus.  Quite recently this  subject has been more
thoroughly investigated, and  the conclusion arrived at has been,

   1 L. c, p. 383.                     2 Auspitz, 1. c, S. 209.
   3 Traite des mal. vener.  Paris, 1801, t. II., p. 177.
   4 Mem. sur la transmiss. du virus ven. de la mere a l'enfant. Paris, 1807. (Lan-
cereaux. )
   6 Mem. de la Soc. de chir., 1857, t. w. p. 230. (Lancereaux^ 
           HEREDITARY TRANSMISSION OF SYPHILIS.         53

that syphilis in the child may come from  the father alone, with-
out  any co-existent  disease  in  the mother.  Indeed,  the  re-
searches of von  Rosen and of Jonathan Hutchinson indicate
that the infection  of the child is most  commonly due to the
father alone.  E.  Frankel'  has also recently arrived at the same
conclusion from examinations  of  the placenta ; fourteen out of
seventeen mothers, whose placentae were found to be syphilitic,
appeared perfectly healthy.  This predominance of the paternal
influence is such, that  if the husband is healthy, but the wife
syphilitic,  the probability of the  succeeding offspring becoming
gradually free from syphilis is greater than when, on the  other
hand, the  wife is healthy and the husband syphilitic (Hutch-
inson).2  (Compare below.)   Further, the fact has  been  esta-
blished by numerous observations, that a man who at the time
is apparently free from disease, or has been so for a number of
years, but  at some former time was syphilitic, is still capable of
transmitting syphilis to the child he begets.
   According to  Hutchinson,3 syphilis of both parents  is more
certain to cause disease in the child than where but one of them
is affected ; in this case also  it is probable that  the  disease in
the child will be  severe.  Nevertheless, cases have been known
(Boeck, Kobner) where both parents were suffering from  general
syphilis, and yet produced healthy children.   The shorter  the
space of time since the infection, or since the outbreak of the
general symptoms  in the parent,  the severer is the infection of
the  offspring.  Hence children that are born later,  after the
lapse of a long interval from the above period, have a greater
chance  of  escaping the disease.  Hutchinson,4 however,  calls
attention to  the  fact that exceptions to this  rule occur where
the affected parent or parents  have become greatly broken down
under  the  influence of the disease, or else  where the mother,
through many successive  pregnancies, becomes more  and  more
infected, in a manner to be  described hereafter ; so that in the
later offspring it is not the influence of the diseased father alone

   1 E. Frankel, Ueber Placentarsyphilis. Archiv fur Gynaekologie, B. V., 1873, S. 45.
   2 L. c, p. 208.  Aphorism XI.
   8 L. c, p. 207.  Aphorism VII.
   1 L. c, p. 210.  Aphorism XVIII. 
54
BAUMLER. —SYPHILIS.
that comes into play, but that of the diseased mother also.   In
this way are to be  explained those cases where certain of the
children in  a family have shown  only slight evidences of infec-
tion, or perhaps none at all, while those born later have been pro-
foundly diseased.   Zeissl* even mentions cases where syphilitic
mothers have brought forth at one delivery healthy, and at the
next  syphilitic children.  But there is the possibility  here,  if
the first child were healthy,  that  syphilis had been acquired by
one of the parents  shortly before the procreation of  the syphi-
litic child.   Campbell (cited by von Rosen) has observed a case
in which a  syphilitic mother gave birth to twins, one of which
was dead and in a state of maceration, while the other at first
appeared quite normal, but a few weeks later showed symptoms
of syphilis.   Consequently both foetuses were in different degrees
syphilitic.
    Hence, in view of what has been said, syphilis may be trans-
mitted to the offspring either through the condition of the ovule
(syphilitic  mother),  or thruogh that  of  the  semen (syphilitic
father), or from a combination of diseased states in both.  Should
the father be healthy at the time of procreation,  and the mother
acquire syphilis during gestation,  the child will escape infection,
unless the mother becomes syphilitic before the seventh month
of pregnancy (Boeck,2 Frankel.3)
   Infection during the act of delivery does not properly belong here,  but rather
to the chapter on Infection.  Moreover, this mode of infection has not yet been
established with certainty, a fact which is pointed out by von Rosen,4 who, how-
ever, admits the possibility of such an occurrence. Frankel also is of the opinion
that it has not been clearly established.

    Whether the syphilitic poison can continue to exist in adults,
who in their youth suffered from hereditary syphilis, in sufficient
amount to transmit the inherited  disease to their  offspring, that
is, whether  syphilis is transmissible into  the  third generation,
must be regarded still as an open  question.  Hutchinson5 called
attention to this  point more particularly, and  with the exten-
1 L. c, p. 302.              2 von Rosen, 1. c, p. 183.  Auspitz, 1. c, p. 212.
3 L. c.,p. 48.               4 L. a, p. 185.
• London Hosp. Rep., Vol. II., p. 153.  Reynolds' Sys. of Med., I., p. 300. 
            HEREDITARY TRANSMISSION OF SYPHILIS.          55

sive material at his command he has made an effort to collect
cases  bearing upon  the question.   Out  of eight  instances in
which persons with evidences of inherited syphilis had children,
but one was found where the child  showed signs of  syphilis.  It
was the following  case :

   A respectable young woman came to him for an inflammation of the eyes.  She
had typical interstitial keratitis, the characteristic notched teeth, and the character-
istic physiognomy.  She  was  nursing  her first two-months-old child,  which, in
spite of the mother's assurance that it was perfectly healthy,  was found, upon
inspection, to be covered with coppery spots, and had condylomata about the anus,
and coryza.
   Hutchinson meets the possible objection that the father or mother of the child
might  have been suffering from acquired syphilis, with the statement that he had
had the father under treatment for a long time for a sycosis, which was not bene-
fited by the iodide of potassium, and the most thorough examination of the man for
syphilis showed no evidence of the disease.  With regard to the woman, there was
not the slightest ground for the suspicion of acquired syphilis,  and  moreover, the
fact of her having inherited the disease rendered an acquisition of it improbable.

   Therefore, Hutchinson  is disposed to regard this  case as an
instance of inheritance of syphilis in the third generation.
    The syphilis poison evinces a very peculiar modification of its
action  when it  operates through  the foetus, procreated by a
father affected with latent syphilis, upon the pregnant mother.
Women that go through a  number of such pregnancies begin
gradually to suffer an  impairment of health, without ever being
infected in  the  ordinary way.   A  modified  infection  ensues
which lacks the primary local affection,  together with the stages
of  eruptions and  condylomata.   Gradually  increasing pallor
and emaciation, alopecia, glandular enlargements, isolated bony
nodes, gummata of the cellular tissue, or ulcers of the  mucous
membranes, or  psoriasis palmaris, are the sole affections which
these women present  (Zeissl, Hutchinson).  Zeissl1 states  that
such women often complain of profuse menstruation, or abort
when they become pregnant.   Ricord, Diday, Depaul, as well as
Hutchinson, claim that this contamination of the maternal organ-
1 L. c, p. 43. 
56                   BAUMLEE.—SYPHILIS.
 ism, termed by the French writers '■'•choc en retour" is the result
 of a resorption of syphilitic embryonic fluids, the embryo owing
 its disease to the father.  According to HutchinsonJ  the symp-
 toms of a syphilis acquired in this way often do not appear before
 the climacteric, or even later.  This manner of becoming infected
 must not be confounded with the mode  of infection described by
 von  Barensprung, viz.,  that  which takes place through the
 semen, with coincident conception.   The latter is of  the  same
 nature as any ordinary infection,  and  von Barensprung states
 that in these cases manifestations of  syphilis generally occur in
 the tenth week of gestation.
   An event which is theoretically possible, but which, practically, has never been
 actually observed, remains yet to be mentioned,  viz.,  where a woman—who has
 escaped contagion before pregnancy, as well as infection during her gestation,
 through a foetus inheriting syphilis from the  father—becomes infected during the
 act of delivery, from some syphilitic lesion upon the child's body.

    This  somewhat obscure mode of infection, together with the
 inheritance of syphilis, constitutes the only really positive exam-
 ples  of  a syphilis without any manifest primary lesion, or the
 so-called syphilis dlemblee.

    The virulence of the syphilitic poison is not alike in all stages
 of the disease, nor is the virus uniformly distributed throughout
 the body at all times in the course  of  the  disease.   Else how
 were it possible to account for the fact of a father, affected  with
 latent syphilis, procreating at one time a healthy child, and next
 a syphilitic one ?
   As mentioned  already,   the virulence  of syphilis is most
 intense in the  primary lesion ; it is  of almost equal intensity in
 the various local  affections of constitutional syphilis,  as in the
 flat condylomata and the pustular syphilide.  So long as these
 manifestations of the disease  are present  in a patient, the disease
 may  be  communicated  in the ordinary  manner.  But whether
the contents of the gummy tumors, and  the secretions from the
ulcerating tubercles of the skin, or, in general, whether the local
affections of  the tertiary period are infectious, is a  question
1 L. c, p. 209.  Aphorism XVI. 
             THE DIFFERENT MODES OF INFECTION.           57

which has  not been satisfactorily determined.   Diday1  per-
formed inoculations with  the blood of persons in the  tertiary
stage of syphilis, and invariably with  a  negative  result.   Yon
Barensprung states that from observation  as well as experiment
he is persuaded that so soon as the syphilis has passed into the
destructive  forms of its tertiary stage, it  ceases to generate  an
inoculable virus; and clinical observation  seems to confirm this
view, both in respect to direct contagion  and with reference to
the inheritance of the disease.   Concerning the latter point,  no
great concurrence of  opinion prevails, though the tendency is to
regard the probability of hereditary transmission to offspring as
less in this  stage than in the secondary period.


                        THE INFECTION.

    In whatever way the poison of syphilis comes in contact with
a healthy body, it is necessary to  infection that it  should get
underneath  the  epidermis,  or beneath the epithelium of the
mucous membrane.   The  only real  exceptions  to this, so far as
at  present  known,  are  the modes of transmission mentioned
above, namely, by inheritance or the transmission of the disease
through an  infected foetus to the mother.
    That sexual intercourse was the  most frequent occasion of  in-
fection, was the almost universal belief of physicians and  laity,
even  at  the end of the fifteenth century, and  this still at the
present day continues to be  its most  prolific  source.   Conse-
quently the genitals are the most common seat of the infection.
The transmission of the virus from  diseased to healthy persons
is not always direct;  a  healthy person may act as conveyor of
the poison, and be  the means of its transmission, without this
person contracting the  disease.   This was  maintained  also  by
Cataneus,2 Fernelius,3 and other  writers of the sixteenth century,
and has been confirmed by many more recently.
  1 Gaz. med. de Paris, 1846.  Lancereaux, 1. c, p. 478.
  2 J. Cataneus (1504): Quarta causa poterit esse coitus cum sana cum qua de proximo
coiverit infectus, semine adhuc in matrix existente. Aphr., I. p. 140.
  3 Aphr., I. p. 613. 
58
BAUMLER.—SYPHILIS.
   But other locations and other modes  of  infection are suffi-
ciently common, particularly in females, and  information in this
regard  is especially important for the sake of effective prophy-
laxis.   It should be borne in mind that every part  of  the  body
accessible  to  the  contagion  may  afford a  lodgment  for the
poison.  Next to the genitals,  the commonest seat of infection
is the mouth, especially the mucous membrane of the lips, and
in the great majority of cases  the contagion  is effected by local
secondary lesions, communicated  from  one  mouth to  another
in kissing.  The comparative  frequency of infection  upon the
mucous membrane of  the  lips in  11,491  cases1 of  syphilitic
primary lesions,  arranged according to their situations, was com-
puted  at 3.2 per cent., while the seat of infection in 91.1 per
cent, of these cases was the genitals, or the parts in their imme-
diate vicinity, in 1.7 per cent, the anus, and in 3.9  per  cent.
other portions of the body.
   The poison may be inoculated by kissing, not only upon the
lips  or  tip of the tongue, but upon other parts of the face, as
the cheeks, the eyelids, forehead, etc.   Next to kissing, the most
common source  of  infection, where  the syphilitic poison is con-
veyed  directly to the lips or  other  parts  of  the  mouth, is the
custom of employing hired nurses.   Still there must be more
instances of the poison being communicated from the mouth of a
child with inherited syphilis to the breast of a healthy nurse2
than where a nurse with sj^philitic lesions of the nipple inocu-
lates the mouth of a healthy child.   Especially in  countries
where the custom prevails of having  infants  raised by nurses
in the  country,  numerous instances have recently been noted
where syphilis has been widely spread by a single diseased nurse
or a single  syphilitic infant.   Ricordi3  has reported  several
remarkable examples.  The danger of this mode of infection can
scarcely be overrated, and, in the choice of a nurse, renders the

   1 These figures are taken from a paper by Dr. F. R. Sturgis, in the Am. Jour, of Med.
Sciences, January, 1873, and were based upon observations  by Fournier, Bassereau,
Clerc, and Rollet.
   2 Even Torella says, in 1500 : " Ssepius vidi infantum infectum hoc morbo multas
nutrices infecisse."  Aphrod. I., p. 504.
   3 Ricordi, Sifilide da allatamento. Milano, 1865. 
            THE DIFFERENT MODES OF INFECTION.          59

most through inspection and the most searching  inquiries  an
imperative duty.
   Not only is  syphilis  communicated to women from suckling
infants, but it was not long ago that this frequently happened
through the custom, now almost  obsolete,  of  drawing out the
nipples of women, either just before or after delivery, by sucking
them,  or of emptying them in this manner when distended with
milk.  There was  formerly a class  of women who  made  this a
business, and in the writings of the sixteenth century, among the
different modes of infection, this is  mentioned almost invariably.
As late as 1825 F. Bourgoigne a  published an incident of this
sort in which  through  one  such woman a dozen  women were
infected.
   The mucous membrane of the  lips and mouth  is sometimes
infected also in mediate ways,  through the use of eating and
drinking  utensils,  tobacco  pipes,  and  cigar-holders  (indeed
through smoking  a cigar stump that had been  thrown away),
these articles having previously  been  used by persons with
syphilitic affections of the mouth.   The spread of the disease in
this manner in the glass factories where the custom prevails
of passing the  blow-pipe from one mouth to another, is a fami-
liar instance in point.
   If, in the event of an immediate or mediate communication
with the virus,  the  epidermis of  the lips is intact, but  there
happens to be a solution of  continuity in the epithelium  of the
mucous membrane upon the tongue or palate, with which the
poison is brought into contact by  some means, as  by  the food
for instance, infection may take place upon the tongue or  in the
deeper parts of the mouth, and the primary lesion develop  there.
Cases of this sort are reported by Rollet, Kobner,2 and Fournier,
and a  case in which a sugar pastil was passed  from one mouth
into another and caused infection, is said to have been observed
in Hardy's clinic in Paris.3
   Physicians  and midwives have not infrequently been inocu-
lated  upon the  fingers in cases where they  have undertaken
1 Fournier, 1. c, p. 54.             2Kobner, 1. c, 54 and 61.
       3 Brit. Med. Jour., 1872, VoL H. p. 606. 
60
BAUMLEE. —SYPHILIS.
obstetrical examinations with wounds upon these parts.   Anto-
nius Gallus '  related such a case in 1540.  Inoculations of the
fingers are also observed, now and then, under other circumstan-
ces.  An inoculation of the hand through the bite of an indi-
vidual with a syphilitic lesion of the mouth  was observed by
Hutchinson and  Sydney  Jones,2  and cases  have been  often
described in which the disease was communicated by a scratch of
a dirty finger-nail bearing the poison ;  infection in very uncom-
mon situations may perhaps be effected sometimes in this way.
   Surgical instruments have likewise  occasionally been the
means of conveying the syphilitic poison to healthy persons.  It
is reported than in the year 1577 an epidemic of  syphilis took
its origin from a public bathing-room in  Briinn, where over 180
persons were infected in the operation of cupping.  Such occur-
rences were by no means  isolated.3  Public attention was early
drawn to the  danger of infection at the baths, as appears from
the fact of  an ordinance being  issued by the Nuremberg  Rath,
which admonished the bathers to caution in this regard.4
   In several cases noted by Petry, of Gratz, syphilis was inocu-
lated in the operation of tattooing."   In the ritual circumcision
syphilis has occasionally been  communicated not only by means
of the instrument  employed,  but  through the mouth of the
operator in the act of completing the rite by sucking the wound.
   Infection by means of a Eustachian catheter, previously used
for syphilitic  persons, has been observed repeatedly, and sug-
gests the possibility of communicating the infection by means of
unclean tongue-spatulse, laryngoscopic mirrors, and  other like
instruments.
   There has  arisen in modern times, unfortunately, not a very
infrequent source of syphilitic infection, in the practice of vacci-
nation.  But  in view of the great importance that attaches to
this mode of transmission, it is proper to treat at some length of
the circumstances under which  it occurs.
'Aphrod., I. 463.
2Brit. Med. Jour., 1872, I. p. 14 and 313.
3 Hirsch, 1. c, p. 371.
4 Waldau, vermischte Beitrage zur Geschichte der Stadt Niirnberg B. TV. S. 409.
6 Auspitz, 1. c, p. 241. 
THE  DIFFERENT MODES  OF  INFECTION.
61
         Tfie  Transmission of Syphilis by  Vaccination.

Viennois, De la transmission de la Syphilis par la vaccination.  Arch, gener., 1860.—
    Auspitz, 1. c, p. 243;  and Lancereaux, 1. c, p. 490.—The very copious  litera-
    ture of this subject is given in full in the above works.

    Passing over  the  less  authentic  cases reported  in the first
decade of this century,  we shall confine  ourselves to well-estab-
lished and more recent instances.

   In the year 1849  a veterinary surgeon in  Coblenz vaccinated  twenty-six persons
from an apparently healthy child. . In nineteen of these the vaccine pustules turned,
in from three to four weeks, into syphilitic ulcers.  The child from which the virus
had originally been taken, broke out with a roseola a few days after the vaccination,
and ten days later died with hydrocephalus.1
    On the 16th of June, 1852,2 the public physician, Hiibner, in Hollfeld, Bavaria,
vaccinated thirteen  healthy children with lymph from  the three-months-old child,
Keller, regarding whose appearance we have no information, but which two months
after the vaccination died with atrophy.
    Eight months later the vaccinated children, which had meantime fallen ill, were
medically examined under a legal requisition; eight of the vaccinated  children and
nine of the mothers were suffering from lues universalis.
    From one  of the  syphilitic children between twenty-five  and thirty children of
another community had been vaccinated, and one of them had been infected; from
one of the first five who  remained  healthy twenty-five  others were vaccinated, of
which again one became syphilitic.
    A still  more unfortunate instance occurred  in the year 1861 in Rivalta,3 near
Acqui, in Upper Italy.  On the 24th of  May, 1861, the  surgeon Cagiola vaccinated
the eleven-months-old child, G. Chiabrera (both the  child and its parents appearing
healthy) with virus  from  the lymph  depot  at Acqui.  On the 2d of June, i.e., nine
days afterwards, forty-seven others were vaccinated from this child, and it is stated
that in this vaccination blood was noticed  upon the lancet.   Thirty-eight of those
vaccinated became affected with  symptoms of general syphilis.  One of these thirty-
eight (Luise Manzoni) was used on  the 12th of June to vaccinate seventeen other
children, of which seven became  likewise syphilitic.
    Subsequent investigation elicited the fact in regard  to the child Chiabrera, that
two months  before its vaccination it had  been in constant  communication with  a
   1  Wegeler, in the Prussian Vereinzeitung, 1850, 14.
   2 Aerztl. Intelligenzblatt,  1853.
   8 Pacchiotti, Sinlide transmissa per mezza  della vaccinazione in Rivalta.  Torino,
1862.  Auspitz, 1. c, p. 248. 
62
BAUMLER. —S YPHILIS.
woman  who  was evidently syphilitic, and had been nursed at her breast.  This
woman  had infected her sister's child by suckling it, and through it her sister also.
On the 8th of October  (over three months from the vaccination) the child Chiabrera
showed, besides  general debility and a diarrhoea, an erythema about the anus, an
excoriated tubercle  upon the foreskin,  and complete alopecia.   Its mother had an
ulcer upon one nipple, a fresh scar upon the other, and on the 7th of November,
flat condylomata upon the labia.  The father was  healthy, and showed no traces of
antecedent syphilis.
   With reference to the second child  from which  lymph  was taken, Luise Man-
zoni, it  appeared that at first she  had had ulcers at the point of vaccination, and
upon the 2d of August there was observed a papular exanthem upon the back  and
limbs, with flat condylomata about the mouth and genitals.  She died with maras-
mus on the 10th of September.
   For the sake  of  showing to what devastation  such an occurrence may give rise,
it may be mentioned that, altogether, eight children died, and twenty-six mothers
and nurses, five  husbands, and  three brothers  and  sisters  were infected in conse-
quence of these vaccinations.

    With reference to the mode  of  transmission  of syphilis in
vaccination the  following casex of Sebastian is  significant.

   On the 19th of March, 1863, from a ten-months-old child that  had been vacci-
nated itself eight days before, Sebastian, at the request of the child's mother, vacci-
nated the children of  two of this woman's friends.  As S.  was about  to make the
last puncture in the vaccination of the second of the two children, the child from
which he was taking  the lymph  made a sudden movement, and the  lancet was
driven in so deeply that a drop of  blood was  left upon the  point which was inocu-
lated with the lymph.
   In twenty-two days after, S. saw the  child again.   The vaccine pustules had all
run their normal course, but the point where the last puncture was made, the situa-
tion of which had been carefully noted by S., presented the appearance of a genu-
ine pseudo-chancre.  It was  covered with a dark conical scab, and around it  were
numerous lenticular papules.  Later, a considerable induration was  developed,
roseola and tubercles appeared, and finally swelling of the glands.
   S. now examined the child from which the  lymph had  been taken, whose vac-
cine pustules were quite cicatrized, and found upon it an extensive papular syphilide.
The cervical glands  were swollen, and  upon  the  genitals were several suspicious-
looking papules.  The child's father had formerly  had a chancre, and ever since
had had impetiginous  ulcers upon the  scalp, spots  on the  body, and flat condylo-
mata.
   The  other child vaccinated remained perfectly  healthy.
1 Gaz. des Hopitaux, 22 Oct., 1863.   Auspitz, 1. c, p. 250. 
               THE DIFFERENT  MODES OF INFECTION.            63

    Yery recently, too, observations  have been made with regard
 to the  inoculation of syphilis  in vaccination,  since  the latter,
 on account of the extensive epidemics  of small-pox of late years,
 has been practised more generally than formerly.

    A case which is interesting  in this connection, and noticeable also from the cir-
 cumstance of but one of  the  four vaccine pustules turning into  a syphilitic ulcer,
 was communicated by Thomas  Smith ' to the Clinical Society in London.
    In the section for public hygiene in the Natural Philosophy Association in Leip-
 zig (1872)2 Geh. M.-Rath Dr. Eulenberg, of Berlin, referred to a recent incident in
 the Rhine province  that came officially under his notice.  A  child, three months
 old, which appeared quite healthy, was  used  by  a physician for vaccination.  The
 child appeared to be such a fit subject for this  that the physician vaccinated sev-
 eral of his relatives from it.  Of one hundred  and  forty individuals who were vac-
 cinated with  lymph from this  child, fifty became syphilitic.  The local symptoms
 made their appearance in three  weeks, the general manifestations in from five to six
 weeks.  The  child itself, three months  later, had condylomata.   As subsequently
 ascertained, its parents had been syphilitic some  years before; the mother had had
 repeated miscarriages, and this child was the first that was carried to term.  E.
 remarks that  in the above case he was assured that only clear lymph without admix-
 ture of  blood had been used.

    A  number of cases,  which came under  Hutchinson's  notice,
 and were  reported by him  to the Medical and Chirurgical Soci-
 ety in London,3 are also  very instructive.

   In the first series of observations twelve persons had  been vaccinated from a
 child  that to all appearance was healthy.  The vaccina ran its usual course, but in
 ten of those vaccinated, indurated ulcers formed in the eighth week.  They were all
 treated with mercury, and  in four of  them symptoms of general syphilis appeared
 five months after the  vaccination.  The child from which the virus had been taken,
 at the  time  of the vaccination presented an  appearance of perfect health.  Two
 months  afterwards, when H. saw it, in addition  to certain other  rather suspicious
 appearances, there were five small, round condylomata about the anus, which the
 mother,  who was disposed to ridicule  the  idea of anything ailing her child, stated
 had not been there over one week.   The pock mark was  of normal appearance.
The child was unquestionably affected with inherited syphilis, although there was
no evidence of the mother's having had syphilis.  As to the  father's health, nothing
could be ascertained,  inasmuch  as he declined an examination.
1 Transactions of the Clinical Society of London, Vol. IV., 1871, p. 53.
2 Tagblatt, S. 194.
8 Medico-Chimrgical Transactions, Vol. LIT., 1871.—Lancet, April 7, 1873. 
64
BAUMLER.—SYPHILIS.
   In these observations it is noteworthy that the first two who
were vaccinated were not infected, and that the third, who was
vaccinated on both arms, had a syphilitic ulcer upon only one of
them, which developed in a vaccine scar; furthermore, that indu-
rated ulcers formed not  only in the scars of the vaccination, but
at points  of inoculation where there had been no vaccine pus-
tules.
   A second series of observations, concerning vaccinations  of
mostly older children, was reported at  the  same time, and is
worthy of mention inasmuch as in this instance  also the child
from  which the  virus was taken, when examined by H. three
months after the vaccination, excepting for a slight tendency to
hydrocephalus, together with one small condyloma near the
anus, might have been  taken for a perfect pattern  of health.
And he appeared  thus, at the time of the vaccination, to the
parents of several children that were vaccinated with his lymph.
   H. presented a third series of  cases before the same society in
the year  1873.  Of these cases we will call attention to one
instance where the  vaccine virus did not take, but in four weeks
afterwards one of  the spots inflamed, and  an ulcer followed,
which remained for three months, together with a skin eruption
and iritis.
   Besides these the English literature of the last three years
contains a number  of observations of the same class.
   From the observations reported the obvious conclusions are—
   1.  That syphilis can be transmitted by vaccination.
   2.  That the course  of the vaccine' pustules  in  children
already syphilitic at the lime of vaccination may be perfectly
normal and leave scars  of the usual appearance.
   3.  That in cases vaccinated from such children, unless the
inoculation fails altogether, either  the vaccina may take alone,
or the syphilis alone, or both may take  together and go  on to
their full development.
   If both take, then the vaccination runs its course in the usual
manner.   Then, either after complete cicatrization of the  vacci-
nated spot, or while the scab  remains  still  adherent, certain
changes take place (usually after a period of incubation of from 
            THE  DIFFERENT MODES OF INFECTION.          65

four to five weeks, reckoning from the time of vaccination) which
consist in induration and ulceration.
   If only the vaccine virus takes, the course is that of a normal
vaccination.
   If the syphilis only takes, there follows at the point of inocu-
lation, after a period of incubation of  some weeks,  a  syphilitic
primary lesion.
   Now, inasmuch as when healthy persons  are vaccinated with
lymph from a vaccine vesicle in a child, then  syphilitic,  these
persons do  not  all  acquire syphilis,  though  the vaccina per-
haps takes effect  in every case ; and furthermore, since in  those
who thus acquire syphilis all  of the vaccinated  points do not
develop syphilitic primary lesions,  the presumption is that in
such inoculations the vaccine and syphilitic poisons  are  trans-
mitted  separately,  that  is, the  syphilitic poison  is  not inti-
mately combined with the contents of the vaccine pustule, but is
only mingled with them mechanically and in small amount.  Or
perhaps both are not contained  in the vaccine vesicle together
at all, but are mingled together upon the lancet  purely by acci-
dent.
   The negative results of experimental inoculations of healthy
persons from vaccine vesicles in persons manifestly syphilitic, so
far as the transmission of syphilis is concerned, speak in behalf
of the supposition that the pure contents of a vaccine vesicle,
developed in a syphilitic child,  do not comprise the syphilitic
poison.  In these inoculations  nothing else than vaccina was
produced.'
    Certain  cases, particularly that  of Sebastian (vid. above, p.
62), appear to indicate that the syphilitic agent resides in a mix-
ture of blood with the vaccine lymph, but that the lymph by
itself is free from it.
   Hence we should expect that  the probability of transmitting
syphilis by vaccination was very slight; that  it is  so, and that
it may take place only under certain coincidences, we conclude
from the fact that such unfortunate events as we have just nar-
rated are of comparatively rare occurrence ; whereas, considering
            1 Auspitz, 1. c, p. 252.
VOL. III.—5 
66
BAUMLER. —SYPHILIS.
the commonness of  syphilis in large towns, it  can hardly be so
rare an accident that lymph is taken from children with  inher-
ited syphilis for vaccination.
   According to a  communication from Joukoffsky,1 fifty-seven healthy children
were vaccinated in the St. Petersburg Foundling Asylum, in the years 1865-7, from
eleven children,  which at the time of the vaccination were suffering from hereditary
syphilis, without one of the fifty-seven being infected with syphilis.  J., however,
remarks that the vaccinating physicians in this institution particularly avoid mix-
ing blood with the lymph.
   But the theory that syphilis is transmitted not by the lymph
of itself,  but through blood  being mingled with it, does  not,
after all, explain such cases as that of Luise Manzoni, who was
not  syphilitic when vaccinated, and  yet  out of seventeen  who
were vaccinated from her seven had syphilis in consequence.  It
is not supposable  that  ten days after she had been inoculated
her  whole blood had become infected with syphilis, and the
supposition  that a  hitherto latent  syphilis was reawakened in
consequence of the  vaccination is, in the present case,  purely
hypothetical  and without  foundation.  In the  latter event, by
analogy with other cases of latent syphilis, she would have had
no syphilitic local affection at the point of inoculation, whereas,
on the contrary, this affection ran its course in  her as in the in-
oculation of  syphilis upon a healthy organism.   At the most, we
may conceive of the syphilitic poison in this case beginning to
develop  in  the tissues locally, at the point  inoculated, with
greater rapidity than this  commonly happens,  though for this
theory also we have not all the necessary data from  the history
of the case.   This supposition is  the same in effect as that of
Gamberini,2 which Kobner3 also seems to entertain, namely,  that
in the vaccination-syphilis, generally, the base of the pustule
embraces a syphilitic local affection.   This theory would, how-
ever, apply to the few cases only in which the primary affection
is developed immediately  from  the vaccine pustule while the
scab is forming, and even then it does not wholly apply, since in

   1 St. Petersburger med.  Zeitschr., 1872, 1, p. 73.
   2 Auspitz, 1. c, p. 265.
   3 Dissertation by A. Rahmer.  Breslau, 1869.  Refer to Archiv f. Dermatologie und
Syphilis, B. II. p. 297. 
             THE DIFFERENT  MODES OF INFECTION.           67

these cases too, at  the time wdien the lymph is generally taken
for vaccination, that is, while the  vesicles or pustules are still
present, these latter differ in no respect from normal vaccine
pustules.  And as  several of the cases observed by Hutchinson
show more particularly, the vaccina often runs its course quite
normally to cicatrization, after which induration and ulceration
take place in the scars.

   Still greater difficulties present themselves with  regard  to the explanation of
Hiibner's case, where from one of the first vaccinated children, but which remained
healthy, twenty-five others were vaccinated, of which one became syphilitic;  unless
we suppose, considering that this is such an isolated instance, that the child had in
the interval after its vaccination acquired syphilis in some other way.

   Moreover, in those already affected with constitutional syphl-
is, the base of the vaccine vesicle is not the source of the syphi-
litic poison; but thin layers only of tissue and the walls of the
blood-vessels  separate  the contents  of   the  vesicle  from  the
blood, which latter contains the syphilitic poison, without doubt,
in certain periods  of the disease.   Therefore  many are of the
opinion—Hutchinson' among others—that when the vesicle has
been irritated for some time, the serum of the  blood transuding
from the vessels may contain the syphilitic poison, and is thus
capable of transmitting the disease in the same manner as the
blood itself.
   I have convinced myself repeatedly that a few blood-corpuscles, both red and
white, occur in the purest lymph that first exudes from a seven-days-old vaccine
vesicle.

   This supposition is  necessary to  the explanation  of those
cases in which we are assured that no admixture  of blood with
the lymph could have taken place.
   Two other possible events  in connection with the transmission
of syphilis in vaccination must be noted here.   It may happen,
namely, that a healthy child from whose arm lymph is being
taken, may be  infected by means of  the  repeated introduction
into the vesicle of a lancet,  which  has just been used to  scarify
» Lancet, April 7, 1873. 
68                     BAUMLEE.—SYPHILIS.
the arm of a syphilitic child, a portion of whose blood remaining
upon the instrument is deposited within the vesicle.
   Again, in vaccinating a large number of adults, one of whom
happens to have syphilis,  the disease may be easily communi-
cated both to the child furnishing the lymph, and to one or more
of those vaccinated immediately after this syphilitic individual,
by means  of the same instrument,  which has,  meantime,  not
been carefully cleaned.
    Finally, there remains to be mentioned an occurrence which,
especially with the laity, has sometimes given occasion to erro-
neous inferences :  An apparently healthy  child, five or six weeks
old, is vaccinated ; two or three weeks later it  is covered with an
eruption,  and  is evidently  syphilitic.   In this case the vaccina-
tion had nothing to do with  the  syphilis,  or, at the  most, it  but
hastened  the outbreak of  a  hitherto latent  inherited syphilis,
which would have manifested itself at any rate in a  few weeks.
This is the view maintained by Yiennois.
   In this connection allusion may be made, chiefly for the sake of their  historical
interest, to those cases where syphilis has been transmitted in transplanting a sound
tooth from the jaw of one person into that of another.  This operation seems to
have been pretty common in Hunter's time—at the end of the previous  century—
but is now no longer performed.  But inasmuch as  at the present day a decayed
tooth is sometimes removed, carefully cleansed of all its  diseased portions, filled
and replaced, it is not impossible  that the practice of transplantation may  be
revived.
   John Hunter 1 relates a number of cases in which  local and general symptoms
appeared  resembling syphilis, but which Hunter, on account of his prejudice in
favor of the non-contagiousness of constitutional syphilis, did  not recognize as
belonging to this disease.  The  circumstances upon which he based his doubts
mainly, were  that  ulceration about the  transplanted  tooth did not commence
till several weeks after the transplantation; then the sudden and rapid develop-
ment of general symptoms; the small  amount  of mercury that sufficed for a cure
in many of the cases; and, finally, the absence of ulceration in the mouth or dental
socket of the person from whom the tooth had been taken, as well as his freedom
from other manifestation of syphilis.
   Regarded in  the light  of our present knowledge  of syphilis, many of these
cases were unquestionably instances of syphilitic transmission.  Since the virulent
1 L. c, p. 483. 
                 SUSCEPTIBILITY  TO THE POISON.               69
 character of syphilitic blood has been demonstrated by experiment; since we have
 learned that in the course of syphilis periods of latency occur, during which out-
 ward manifestations, or those apparent to the eye, are absent; since we have learned
 to recognize a period of incubation in syphilis, these cases have lost much of that
 strange and unusual character in which they appeared to Hunter.

           SUSCEPTIBILITY TO THE SYPHILITIC POISON.
    We have already spoken of the influence which climate,  race,
 constitution, etc., have upon syphilis.  We now come to speak
 of those  circumstances that are peculiar to the individual, which
 may also influence  the liability to infection, such circumstances,
 that is, as tend  to decrease or augment the susceptibility to the
 syphilitic poison.
    1.  With regard  to the  disposition in general to incur infec-
 tion, it is to be observed, first, that there are persons who expose
 themselves repeatedly to contagion with impunity, under circum-
 stances where others would become infected at once.  We notice
 a similar immunity in  certain  people with  reference to other
 infectious diseases also.
    In  the vast majority  of cases this immunity is acquired
 through  some thorough  antecedent  infection with  the specific
 disease concerned.   Any one who has once had  small-pox,  scar-
 let fever, typhus, etc., is,  as a rule, not liable to these diseases
 again for the rest of his life.  The same is  true of syphilis.  Not
 only  while an individual is still  actually syphilitic, does he pos-
 sess an immunity with respect to fresh contagion,  but for years
 after all evidences of the disease  have disappeared.
   By means of this fact many exceptional instances of infection are made  expli-
 cable.  For example, the fact first remarked by Colles,l that a child with hereditary
 syphilis does not infect its mother, though a healthy nurse may  contract the disease
 from it.  Another instance is the failure of inoculations of the  syphilitic poison
 upon the person from whom this poison is taken ; which fact was made use  of by
 Ricord as an important point of distinction between a syphilitic and non-syphilitic
 ulcer.
   Yet this immunity is  by no  means so absolute as Ricord
 claimed.  Sometimes very shortly after the infection, before the
local affection has yet made its appearance, as well  as later, but

    'On the Venereal Disease, 1837, p. 385. Cited by Lancereaux, 1. c, p. 489. 
70                    BAUMLEE.—SYPHILIS.
before the  occurrence of general symptoms, it  happens that a
fresh inoculation of the syphilitic poison produces its local effects
the same as usual (see below, the cases of Bidenkap, p. 97).  An
instance of  this occurred  in an inoculation made  by H. Lee,1
upon a  patient in whom  the disease was already pretty well
advanced.1   In a girl who had had syphilis before, he produced
an induration five weeks after inoculating her with  pus from a
syphilitic  ecthyma  pustule.  Moreover,  second infections  fol-
lowed by such merely local effects are occasionally met with in
practice.  Diday and Kobner observed such cases.  But Hutchin-
son 2 has called attention to the liability to confound these cases
with the relapsing indurations which occur occasionally without
fresh contagion, and which he was the first to  describe.  Gener-
ally, however, the inoculation of secretions from syphilitic ulcers,
unless it fails altogether, produces a pustule without incubation,
and this pustule may turn into a common soft sore, which does
not become indurated.
   But a second infection may be followed by general effects
as well as local.   A large  number of cases of this '' reinfectio
syphilitica,"  first  described by Zeissl,3 have  been  published
(Diday,4 Hugenberger,6 Kobner,6 Hutchinson,7 H. Lee ).8  The fol-
lowing case (which is interesting  otherwise also)  came under my
own observation:
   W. L., a man well  on in the fifties, came under my care  in November, 1867,
affected with an icterus that had lasted for several weeks, and  was accompanied by
other symptoms which pointed to the presence of gall-stones or  of an ulcus rotundum
ventric. As the icterus increased, the liver gradually increased in size, and a tumor
as large as a goose's egg, not tender, and of an elastic feel, appeared just beneath the
lower border of  the  ribs, on the right side, near the mesian line, and was supposed
to be the gall-bladder.  Before the liver had become markedly enlarged, a transient
benefit was at first derived from the use of the Carlsbad  salts.  The symptoms
1 Holmes' Syst. of Surgery, I. p. 440.
2 Reynolds' Syst.  of Medicine, p. 294.
3 L. c, S. 58.  Zeitsch. d. k. k. Gesellsch. d. Aerzte in Wien, 1858, No. 52.
4 Archives gener., 1862, Vol. II. p. 26.
5 St. Petersburger med. Zeitsch., Vol. III., 1862, S. 161.
6 Berliner klin. Wochenschrift,  1872, No. 46.
' L. c, p. 293.
8 L. c, p. 440. 
SUSCEPTIBILITY TO THE POISON.
71
 increased gradually, and pains in the region of the stomach were particularly severe ;
 only by the subcutaneous injection of morphine could they be for the time allayed.
    I was aware that the patient had had syphilis in the year 1864, and that  he  had
 also infected his wife, whom I saw frequently at that time, and had treated her for
 iritis and condylomata of the vocal cords.
    The patient was very much debilitated, and as  the  symptoms showed no ten-
 dency to improve, the possibility of a syphilitic affection of  the hepatic duct occur-
 red to me, and therefore I resolved to make trial of the iodide of potassium.  This
 was begun on the 8th of February, 1868, and on the 12th inst. I learned that the
 pains had been  absent ever since an attack on the  7th, which was allayed by mor-
 phine.  Prior to this they had occurred every morning.  The icterus had, to be sure,
 somewhat increased;  but, on the other hand, the region  of hepatic  dulness did not
 extend as far downwards as upon  the 7th inst.,  and the elastic tumor was smaller
 and softer.  The  17th of February the icterus had  also diminished, and the liver
 was manifestly smaller'; the elastic  prominence could no longer be  felt.  The pains
 did not return, the icterus disappeared entirely in the course of the following weeks,
 and the patient was then lost sight of.  No passage of gall-stones was ever known
 to have taken place.
    February 7th, 1870, the patient again made his appearance, and  this time with a
 fresh syphilitic infection;  six weeks  before he had had a small ulcer upon the  fre-
 nulum, which healed in three weeks.  For fourteen days past he had  been  feeling
 very languid, and on the 6th of February he first remarked a red eruption upon the
 body. I found a slight induration upon the froenum, as if due to cicatricial tissue, a
 considerable indolent swelling of the inguinal glands of  the left side, and a roseola,
 consisting of slightly elevated  spots  and rings,  which  was  most marked in  the
 region of  the loins, and upon  the sides above and below  the crista ilei,  upon the
 back, especially  along the mesian line, upon the neck, and on the extensor surfaces
 of the arms and  legs. The face, breast, and belly were  free.  There were no mani-
 festations in the throat.  The cubital glands were not  enlarged.  On the 12th of
 February the eruption had  almost entirely disappeared, only  some very slight, no
 longer elevated  spots were still to be seen.  Moreover, the patient did not seem
 to have experienced  further annoyance from the affection,  for  he  did not again
 appear.  I met him  occasionally some years afterwards, and learned from him that
 he had had  no further symptoms.   If  any of importance  had  occurred I should
 at least have known of it, since during this time I  was treating several members of
 his family.
    Concerning the first  infection, my colleague,  Dr. A. Rasch,  of London, who
 treated the patient,  during  the  attack, in the  Eastern  Dispensary  of  the German
 Hospital, has had the kindness to supply me with the following  notes: "W. had in
 April, 1864, an indurated ulcer; in September, > affection of the  throat.  He took
 mercury from June,  1864, until  March, 1865; later, for some  time, the iodide of
 potassium.  "Whether he had  roseola at this time, I was unable to ascertain;  he
states himself that he  did have  a slight eruption.   He says  he has never suffered
from pains in the bones. 
72                   BAUMLEE.—SYPHILIS.
   Therefore, in this case we have an unquestionable instance of a second infection
about five and a half years after the first.  Its course was very mild.

   In  the majority of  cases  a  mild  course of the  disease  is
observed  after a second infection; still not  in all.    Diday de-
scribes two  instances of  second infection with severe course.
But, in general, we may say that a second attack of the disease
will be a modified one,  and will be milder  the earlier it takes
place after the first attack.  In both of Diday's cases the interval
between the two infections was  nineteen and a half years; nine
mild cases had an average  duration of forty-five months.
   Persons who  have suffered from inherited syphilis  in  their
childhood are in later years protected to a certain extent, and if
they become infected, the disease takes a modified course in this
instance also.  Hutchinson' met with a case of second infection
in a person who had inherited syphilis.
   It  is a very  important and interesting  question to decide
whether the children of  syphilitic parents inherit a certain degree
of immunity without having  actually had hereditary syphilis.
Ferguson2 has ascribed the remarkably mild course which the
disease pursues in the  inhabitants of  Portugal to the thorough
saturation of the population with syphilis, and to the immunity
thence acquired  or inherited; and H. Lee asserts that a similar
effect is observed in other  countries amongst  the common classes,
which are peculiarly exposed to syphilitic  contagion.   Lee re-
gards  it as probable that in a  family where some of the children
bear evidences of different grades of inherited syphilis, and the
rest remain entirely free, the  latter also inherit a certain degree
of protection against the syphilitic poison.
    Age  does not  essentially  modify  the susceptibility to  the
syphilitic virus.   Only in so far as the period  of  childhood is
marked by a greater tenderness and vulnerability of the  skin
and mucous membranes will the disease be more readily incurred
in the event of an exposure to infection.
    There is likewise no difference  in sex with reference to the
susceptibility to the poison.

       1 Reynolds' Sys. of Med., p. 295, Note. Lond. Hosp. Reports, Vol. II.
       2 Cited by H. Lee, 1. c, p. 455. 
SUSCEPTIBILITY TO  THE POISON.
73
   2.  The  local predisposition may  be influenced by certain
physiological  or pathological conditions.   Thus, during  preg-
nancy the liability to syphilitic infection  is usually increased
(von Sigmund),  and for the reason that a slight catarrh of the
genital mucous membrane is present.   And since such a catarrh
often exists after menstruation, infection may be incurred more
readily at this  time also.  This will be the case  still more  if
these conditions overstep the bounds of physiology, or if catarrhs
of the mucous membrane are present, which are true pathological
processes.
    Special conformation  of particular parts,  as a high grade  of
congenital phymosis, for instance, may augment the local predis-
position to receive the virus. 
PATHOLOGY.
(SYMPTOMATOLOGY AND PATHOLOGICAL ANATOMY.)

                 THE  PERIOD OF  INCUBATION.

   In the vast majority of pure,  uncomplicated cases of infec-
tion with the syphilitic poison,  especially therefore in the cases
of experimental inoculation of syphilis upon healthy persons, a
period  of  incubation occurs which has  pretty  definite limits.
During this period there are no symptoms of any kind, either
local  or general.  It is precisely like the period of  incubation
which we observe in other infectious diseases, in the acute exan-
themata for example.   The length of this period of incubation
in any  disease is not  solely determined by the specific  poison,
but is also more or less dependent upon various influences which
are for the most part obscure, and the longer the period of  incu-
bation pertaining to any disease-poison, so much the  more may
the duration be affected by these extraneous influences.  Never-
theless, so far as syphilis is concerned, a large series of observa-
tions, made with reference to this period,  show a remarkable
uniformity in their results.
   Generally from three  to four weeks  may be taken as  the
period  of  incubation for  syphilis—that is, the period elapsing
from the infection until  the first appearance of local symp-
toms.   In  private practice we  see  cases  now  and then which
enable us to fix the period of incubation exactly ; from my own
observation I will adduce the following examples :
   F. S. presents himself on the 18th of July with two hard papules, as laro-e as
pin-heads, upon the outer integument of the penis,  which, he states, have  been
there only a few days.  He has not exposed himself to the risk of infection  since
the end of June.   One of the papules shows a small black point in its centre, and 
THE PERIOD OF  IXCUBATION.
75
looks  like a hard sebaceous follicle; neither of them are red.   July 24, that is,
four weeks after the infection, the papule upon the right side is somewhat larger
and slightly reddened;  it is situated in the cutis, is isolated and slightly movable ;
the epidermis over it is smooth and unchanged.  July 30, this little papule has
grown larger, as well as the papule upon the left side, and the latter is covered by a
small  crust.  Swelling  of the inguinal glands on the left side.  Now, two flat
papular indurations were developed, of which one grew to the size of a three-cent
piece.  A few inguinal glands  became enlarged on the right side also, and on the
28th of August, about  two months after the inoculation, the first traces of the
roseola were visible, which was fully developed a few days afterwards.
   In  the two following cases the  periods could be precisely determined to the
day:
   K.  C, infected on the 6th of January; first local manifestation February 5.
   O.  J., infected on the 30th of January ; first local manifestation February 25.
   In  the first case, therefore,  the period of incubation  amounted to twenty-nine
days;  in the last, to twenty-five days.

   In the literature of syphilis will be found a number of similar
observations.   Of  especial value  are  two cases mentioned by
Fournier1 in his  paper  on the incubation of syphilis.  One  of
them concerned a pupil of the veterinary school,  the other a
physician, and both made accurate notes of their own cases.  In
one case the  length  of the incubation was twenty-eight, in the
other thirty-three  days.
   Of  still greater value in  this   connection than  the above
observations upon patients, are the results obtained from exper-
imental inoculations of syphilis upon healthy persons.  Out of
fifty-eight such  experiments with which I am acquainted,  in
thirty-one cases the dates are given with sufficient  accuracy to
determine the exact period of incubation.   These cases are  here
tabulated.
1 A. Fournier, Recherches sur Tlncubation de la Syphilis.  Paris, 1865, p. 20. 
76
BAUMLER.—SYPHILIS.
			Period of Incubation in Days.	
				II. From the
No.	Name of Observer.	Source and Mode of the Inoculation.	I. Until the ap-pearance of the local affection.	appearance of the local affec-tion until the outbreak of general syph-ilis.
1	Waller	Secretion from condylomata in scar-		
		ifications	24	27
2		Blood in scarifications	35	31
3	Lindemann	Secretion from tonsillar ulcer by a		
		lancet puncture	10	3 months.
4	Von Rinecker.	Pus from syph. acne pustule of a hered. syph. child upon a vesica-		
		ted spot.	20	139
5	<i	Secretion of prim, lesion of No. 4		
		upon vesicated spot	23	bet. 47 & 57
6	a	Secretion of prim, lesion of 5 upon		No constit.
		vesicated spot	27	syph.
	Palatinate			
7	Anonymous (l)1	Secretion of flat condyl. inoculated		
		by puncture	17	27
8	(2)	Secretion from fissures behind the		
		ear inoc. by puncture	23	107
9	(4)	u ti it	15	68
10	(5)	a u a	17	62
11	(7)	u a u	18	25
12	(8)	u <( it	25	49
13	(10)	u (( u	36	No general symptoms within a year.
14	(H)	u U ((	22	42
15	(12)	Pus from the prim, affect, of No. 7	23	45
16	(13)	u a a.	44	No erupt'n.
17	(14)	u u u	16	48
18	Gibert	Pus from flat condyl. upon vesicated	14 (redness)	
		spot produced by ammonia	18 (papule)	37
19	a	U I. U	25	12
20	G-uyenot	Pus from flat condyl. inoculated by		
		puncture	28	55
21	Von Barensprung	Secretion from an induration inocu-		
		lated by puncture	28	About 65.
22	u	Secretion from flat condyl. inoc. by		
		puncture	28	Not stated.
23	Von Lindwurm	Secretion of indurated ulcer, punc-ture	15	About 2£ weeks.
24	u	Secret, of prim, affec. in No. 23. Two inoculations		
		July 10	19 (29, VII.)	About 5
		" 12	24 (5, VIIL)	weeks.
25	Hebra and Rosner	Secret, of flat condylomata upon the		
		nipple	16	56
26	u <<	(( u u	21	52
27	Pellizzari	Blood in scarifications	25	About 5 weeks.
28	Cullerier2	Pus of an indurated ulcer	38	33
29	Auzias Turenne	Secret, of flat condyl. upon vesicated		
		spots produced by ammonia	18	) Not
30	u u	il n u	25	f stated.
31	Galligo (Florence)	Flat condylomata of the lips inocu-lated	17	
   1 The annexed figures are the numbers of the experiments in the original; they are
given for the sake of more easily identifying the cases.
   2  The cases 28-31 cited by Fournier, 1. c, p. 30-33. 
THE  PRIMARY AFFECTION.
77
   The shortest period of incubation, according to this table, was
ten days, which was, in fact, the only instance of an incubation
of less than sixteen days.  Most frequently the incubation lasted
between fifteen and twenty-four days, in a small number of cases
from  twenty to thirty days, and only in four over thirty.  The
longest period of incubation was forty-four days.
   In the cases not included in the table the period of incubation
was usually stated at from  three to four, or four weeks.  Fournier
collects from his clinical observations quite a large number of
cases, which lead  him to draw the inference that the  period of
incubation is oftener over than under three weeks; that not infre-
quently it is four, and is even  six weeks sometimes; and he
relates one case in which it  is  claimed to  have amounted  to
seventy days.  Von Sigmund * also states, that in a small number
of cases he has observed a period of incubation of from forty-two
to fifty-six days, while in  the vast majority of cases it was over
two and not over four weeks.
   It is apparent from the above experiments that the locality of
the body where the affection occurred had no influence upon the
duration of the period of incubation, and examples enough are
afforded in practice which go to show the same thing.  Especially
in the event of infection in  unusual situations, as upon the  lips,
the breast, or in  the vaccination-syphilis,  it becomes possible
often to fix the period of incubation with precision, and we then
see that this period is, generally speaking, everywhere of a uni-
form length.
   With regard to the circumstances which determine the dura-
tion of the incubation, we  may infer from the experiments given
in the foregoing  table that they reside rather in the person
infected than in  the source from which the poison is derived,
inasmuch  as the period of  incubation varies greatly when  virus
from one and the same source is inoculated upon different indi-
viduals (compare the cases seven to seventeen).

                  THE PRIMARY AFFECTION.
John Hunter, A Treatise on the Venereal Disease.  London, 1786.  Edited by J. F.
   Palmer.   Lond., 1835, Vol. II—R. Carmichael, An Essay on the Venereal Dis-

         • Wien. med. Wochensch., 1856, No. 77-80. Auspitz, S. 276. 
78
BAUMLER.—SYPHILIS
    eases which have been confounded with Syphilis.  Dublin, 1814.—Clinical Lec-
    tures on Venereal Diseases, reported by S. Gordon.  Dublin, 1842.—Ph. Ricord,
    Lecons sur le chancre, publiees par Alfr. Fournier.   Paris, 1858. Second edi-
    tion, 1860.—A. Fournier, Etude clinique sur Tinduration syphilitique  primi-
    tive.  Archiv. gener. de Medecine, 1867, T. II.  p. 503.—De St. Germain, De
    1'erosion chancreuse, rapport par Dolbeau.  Soc. de Chirurgie, Gaz. des hopit.,
    1867,  p. 94.—F. Hugenberger, Ueber die primitive Erscheinung der Syphilis.
    Petersb. med. Zeitsch., B. XIV, 5, p. 290.—G. Lewin, Vortrage. Berlin, klin.
    Wochenschr., F^br., 1873.—M. Kaposi, Die  Syphilis der Haut und der angren-
    zenden Schleimhaute.  1 Lieferung.  Wien, 1873.

    As a  rule, the  first manifestation of  syphilis  is,  as  already
remarked, at the point where the poison gained access.   Yet the
literature of the subject embraces records of cases  in which gen-
eral syphilis, so to speak, broke out all at once without any local
affection  ever having been perceptible.  The further our informa-
tion extends with regard to uncommon seats of the infection, the
rarer will such  instances become  ; and in  many cases  we  may
assume positively that a primary lesion has not been discovered,
simply because the examination was not circumspect  enough, or
not directed to the right places, or  else because local signs which
were present were  not  recognized  as  being really the  primary
affection.  But since we have  learned to avail ourselves of the
indolent,  glandular swellings as a guide to the situation of the
primary lesion, not infrequently have we discovered the latter in
places where we should least  have expected it.  Therefore, ex-
cepting the transmission of syphilis by inheritance, and from the
foetus to the mother, the possibility of syphilis occurring without
a primary local lesion has become very dubious.  Fournier de-
clares himself opposed to the idea of  the existence of a so-called
"syphilis d'emblee," y and he accounts for the cases which have
been  regarded as such, by  supposing that, for some reason  or
other, their course in the commencement was either  not recog-
nized or  not observed.  Still the opposite view has many advo-
cates, among whom H. Lee and Marston2 may be named.   Out of
all  the cases of experimental inoculation of syphilis upon healthy
persons,  made by  the anonymous physician of the  Palatinate
1 Lecons sur la Syphilis, p. 36.
2 Med.-Chirurg. Transact., Vol. XIV.  Cited by H. Lee, 1. c, p. 425. 
THE PRIMARY AFFECTION.
79
(who applied syphilitic blood to  common ulcers of the leg in
people otherwise healthy), local manifestations were wanting in
but three cases where general syphilis followed.   In these latter
cases certain  minute changes may still have taken  place in the
surfaces of the ulcers, which were not apparent  to  mere- ocular
inspection.
   The first sign observed at the  infected point in the experi-
mental inoculations (which  correspond  in this  particular  with
numerous observations where the contagion was effected in the
ordinary way) is a circumscribed redness, and shortly afterwards
an elevation of  the spot into  &jiat papule.   Inasmuch as the pri-
mary affection follows a somewhat different  course  upon the
outer  integument from what it does upon the  mucous  mem-
brane, we shall first follow its development as illustrated upon
the skin.
   The  papule which  has been formed  increases principally in
the horizontal plane, it grows a  little harder, and in from eight
to ten days from the first appearance it begins to become a little
scaly.  In this  condition, slowly increasing in size, and gradu-
ally becoming harder,  it may continue for  some  length of time,
or its centre becomes a  little moist, and the slight amount of
serum secreted  dries into a crust.  If this is removed, we find
upon the surface, which is of a bright red color, and  shining as if
it were  glazed, a very little pus, and when a moist dressing  is
applied  to the papule, so as to prevent the crusting, the very
scanty secretion  is  seen  to  consist of  a  gray,  slimy  deposit,
adhering to the central portion of the papule, which is here of a
livid  color.  By means of this  superficial ulceration the middle
of the tubercle becomes gradually excavated.
   Exceptionally a  more decided ulceration may take place, producing a  crateri-
form ulcer.  In individuals with bad constitutions, scrofulous  persons, or in those
much debilitated, in drunkards, and as a  consequence of neglect or of injudicious
and irritating treatment, gangrene sometimes ensues, and by this means not only
the entire  indurated tubercle, but  the  surrounding healthy tissues  may become
involved in a wide-spread destruction of tissue.  More especially does this happen
in that peculiar form of  ulceration which we term phagedena. The parts in the
vicinity of such a phagedenic ulcer are greatly swollen and very red, and  as the
tissue destruction advances, its limits are defined by a sharp border.  Besides, there
is usually a great amount of pain present.  Phagedena, as a complication of the 
80                  BAUMLER.—SYPHILIS.
syphilitic, primary affection, is, upon the whole, rare, and certain observations of
Hutchinson show that it is sometimes due to the infection of a syphilitic or chan-
crous ulcer with the poison of hospital gangrene.
   The ulceration in most  cases remaining quite  superficial, the
tubercle becomes gradually more and more  indurated.   This
induration is sharply defined from the sound skin in its vicinity,
and when its base is grasped between the fingers, it imparts  the
sensation of a hard disk, bevelled at its edges and set in the skin,
or that of a more roundish, hard body.
   If left to itself, the induration and superficial ulceration still
continue to extend, and then sometimes remain  in a certain con-
dition for  a considerable  time before a  process of resolution
begins to make itself perceptible.  The first signal of  the latter
is the disappearance of the  livid hue, and  the cleaning  of  the
ulcerated surface, which little by little becomes covered with
granulations and cicatrizes from the edges.
   The course upon the mucous membrane is  somewhat differ-
ent,  as, for example, upon the glans penis.  In protected spots,
as in the sulcus corona? glandis, the first thing  observed, after
the period of incubation has  passed, is  a very small, itchy vesicle
upon a reddened base, or an erosion, due to the bursting of  the
vesicle, which cannot be distinguished from the  erosion result-
ing from a simple herpetic vesicle, such as often occurs upon the
inner layer of the prepuce.
   Such  an erosion looks like a trifling affair, and many patients
scarcely notice it, especially if some weeks have elapsed since the
infection.  Only anxious patients, who are in the  habit of exam-
ining themselves critically,  under these  circumstances  present
themselves directly before a physician,  and then  we have an
opportunity  in a few days  to see  the small,  superficial ulcer
develop from the erosion, secreting a scanty amount of pus, and
soon  granulating.  The place having granulated may cicatrize
completely, and the induration gradually disappear;  or else, and
this is the case most commonly, the induration remains or con-
tinues to increase.
   If such an induration is situated upon the glans penis, it is
often perfectly flat, its hardness  only being perceptible when it
is grasped laterally, and resembles a piece of parchment (indu- 
THE PRIMARY AFFECTION.                  81
ration parcheminee of the French authors; Fournier terms the
lightest grade of it, induration foliacee orpapyracee).  In these
cases,  occasionally, the immediate vicinity of the place assumes,
in the course of a few days, a similar parchment-like thickening,
which, however, disappears earlier than from the original spot.
Such a parchment-like induration, or a simple flat, round, but
still dry papule, may bear the closest resemblance to a papular
syphilide  of  the secondary period, and they are, moreover, ana-
tomically identical.

   If the primary affection be situated in the sulcus, or just in the fold where the
prepuce begins, the induration is usually of considerable magnitude  and of a  carti-
laginous hardness; it also receives from the anatomical relations of  the part  some
especial peculiarities.  As the induration advances from the sulcus on to the  inner
layer of the prepuce, retraction becomes somewhat difficult;  but when the prepuce
is fully retracted, its posterior portion is tilted up, and the indurated place forms a
projection which looks exactly like the posterior border of the tarsus of an everted
upper eyelid.  The top of this projection is perfectly bloodless, on account of the
pressure to which the vessels are subjected  by the eversion, and has the appear-
ance of wax.  The cartilaginous character of the induration becomes now very
apparent.
   If the induration involves the orifice of the prepuce, a phymosis is gradually
produced as  the hardening increases, and when the lips of the urethra have been
the seat of infection,  the entire end of  the glans frequently becomes indurated,
and a considerable contraction of the urethral orifice may be the result.

    Occasionally, even  when the ulceration  has been slight, an
acute lymphangioitis is developed upon the dorsum of the penis,
accompanied by great swelling of the prepuce, and of the entire
skin of the penis; it,  however,  usually recedes in a few days.
This should  be distinguished  from  induration of a lymphatic
vessel between the primary affection and the nearest  lymphatic
glands, which is gradual in its occurrence, is usually nodulated,
and occurs without inflammatory swelling or redness of the skin
lying about it, and lasts for some weeks (see below).
    These  forms of the  primary affection,  just  described,  are
observed likewise  in females.   But in the female genitals, simple
erosions,  which patients  hardly notice,   with  parchment-like
thickening, are of more common  occurrence than  real  tubercular
indurations.   The thickening may be  tolerably  extensive upon
           VOL. II.—6 
82
BAUMLER.—SYPHILIS.
the edges of the labia minora, or upon the prseputium clitoridis.
The small and slightly indurated erosions have often but a brief
duration.  But the parchment-like, at first dry, indurations upon
the edges  of the labia minora, or isolated  papules  upon  the
inner surfaces of the labia majora,  where the  mucous membrane
is kept moist through opposite surfaces  lying in contact with
each other, or where the parts are constantly  moistened and irri-
tated  by pathological secretions  from  the  uterus  and vagina
(such as are commonly present under these circumstances), soon
assume  another  character, and are gradually transformed into
moist hyperplastic growths—the condylomata lata.

   As illustrated in a case of Von Lindwurm's,1 the primary affection in men may
also, though rarely, take the form of a flat condyloma. But this must not be con-
founded with an ulcus elevatum, that is, with exuberant granulations upon a simple
ulcer (chancre). One might fall into the error, in such  a case, of supposing that
a simple ulcer—a  " chancre "—had been transformed into a symptom of syphilis,
viz., into a flat condyloma.

    In women the primary affection has its seat most  commonly
on the labia majora and minora, or in the posterior  commissure,
extremely seldom in the  vagina, though not infrequently in the
portio vaginalis.
    With regard  to the occurrence  of the syphilitic primary affec-
tion in  other parts of the body, we still find its main characters
to  be papular development,  and  especially, under  all circum
stances, the characteristic induration, whether it  be the lips  or
cheeks,  infected in kissing, or the fingers of  a  physician or mid-
wife infected in a labor case.  Upon the lower lip  the  primary
affection usually occurs  in  the form of an indurated  fissure,
particularly if its seat is in the middle of the lip.
    Usually there is but  one place which can be regarded  as the
primary affection; but in the event of the poison having gained
access at several points, there may be two or more  such places;
and this is especially apt to be the case in women.

    The limitation of the  syphilitic primary affection to  the point of the original
infection essentially distinguishes it from the  simple chancrous  ulcers in which
L. c, p. 162. 
THE  PRIMARY AFFECTION.                83
multiplicity is almost the rule; for in these ulcers other places become infected by
contact, and by reason  of the short time required for a chancre to develop, they
attain their complete development almost as soon as the original sore.

   The  syphilitic  primary lesion  leaves  a scar only when the
rete  Malpighii or  the layers of the cutis or mucous membrane
have been destroyed.  In the one case  there remains only a pig-
mentless spot; in the other, a true cicatrix.  If there has been
merely  a thin parchment induration in the mucous membrane,
in the female genitals more especially, every trace of it may be
gone within a few weeks.   Upon the collum uteri particularly,
as stated by Fournier, the primary affection often heals with sur-
prising rapidity.
   The variations  presented by the primary affection—differences
in form, degree  of induration, and extent of ulceration—depend
far more upon  the seat of the affection  and upon such acci-
dental  influences  as its scabbing over, the  irritation of caustics
and  illy-applied dressings, and  upon the patient's constitution,
than upon the nature of the affection itself.
   The  first appearance and development of the primary  affec-
tion does not always answer to the description as given above.
Although in private practice, and in persons who  expose them-
selves but seldom to the risk of infection, we sometimes see the
disease follow what may be called  its normal  course, we meet
with cases in the hospitals, and particularly amongst the nymphs
of Venus vulgivaga, as well as in the  laboring classes,  which
differ from the above in this essential point, viz., that, according
to the  statements of the patients, the disease appears often but
a few days only after the infection.  But a day or two, as they
say,  after an exposure, a small vesicle perhaps appeared, which
in a few days became  an ulcer, and in  a few  more other such
ulcers made their  appearance in the vicinity or upon  parts  lying
adjacent.
   In men,  if sores form upon the prepuce or glands, it soon
becomes impossible to  retract the foreskin.  It is then, not un-
commonly,  that medical aid is first sought.   Under such circum-
stances we find the prepuce cedematous and greatly swollen, and
through the swelling a considerable  circumscribed hardness may
be felt.   If t"h.Q prepuce is divided,  so  as to lay bare the  glans 
84                   BAUMLER.—SYPHILIS.
penis, a large, deep ulcer, with hard base, appears in the sulcus,
encroaching  upon the mucous  membrane of the prepuce, and
which, if kept clean, soon  begins  to  granulate, although its
hardness still continues.
   When an opportunity is afforded to observe such a case from
the commencement, it is seen that  from a  slight  tear of  the
mucous membrane, sustained during coition, or, such not  being
perceptible, from a vesicle appearing a few days later,  an ulcer
develops, with sharp-cut edges and surrounded  by an inflam-
matory areola.   The ulcer increases in circumference and depth,
and when the purulent secretion is wiped away, displays a gray,
unhealthy base.   This ulcer has received, on account of its cor-
roding character,  the name of "chancre"  (from  cancer).  Its
edges and base are usually soft.   If the pus from this chancre
is inoculated upon a healthy person, or upon the bearer, there
results,  in twenty four  hours, a small pustule, which  forth-
with  turns into another chancre, with likewise inoculable  secre-
tion.   After it has lasted for three or four weeks a perceptible
induration of the base appears, and, as this increases, the sore
begins rapidly to granulate and cicatrize, unless through appro-
priate treatment it has  not already healed before,  in which
later case the induration  develops in the scar.   This induration
is the specific  mark  of the  primary affection, both  when it
follows this course and in the other case described above.   This
fact was pointed out, more  especially by Hunter,1 although he
was not  the first to do so, and since Ricord's  time this indura-
tion has been commonly known as the  " Hunterian indura-
tion."
   The induration of  the syphilitic primary affection was perfectly well known
even to the writers on syphilis in the fifteenth and sixteenth centuries.   Thus in a
poem  on  the disease by the Spanish physician, F. Lopez de Villalobos2 (1498),
  1 L. c, p. 316: "A chancre has commonly a thickened base, and although in some
the inflammation spreads much further, yet the specific is confined to this base," p.
320 : .  . . " but still there is a hardness peculiar to this poison surrounding the sores,
especially those upon the prepuce."
  2 "Mas quando en tal miembro esta buba ollaguita (wound) majormente si es sin
dolor y esta dura."   The Medical Works of Francisco Lopez de Villalobos, translated by
G. Gaskoin.  London, 1870, and Med. Times, 1. c., p. 200. 
THE  PRIMARY  AFFECTION.
85
we find especial mention made of the hardness of the ulcer.  J. de Vigo ' (1503)
speaks of pustules, " cum callositate eas circumdante,^ and Petrus Maynardus2 (1506)
of "pustulai induratce."  But the following passage by Gabr. Fallopiaa  (1564) is
especially noteworthy:  " Suboriuntur ulouscula in pudendis callosa, vel fiunt callosa
qua? inceperant.  Quoties videtis sanatam cariem et quod remanent calli circa cica-
tricem, tenete esse confirmatum Gallicum,  .  .  .  quoniam  calli illi sunt  manifes-
tissima et demonstrantia signa morbi confirmati."  Hence we might with  as much
propriety speak of the Fallopian induration as of the Hunterian.

    Until within the  last  ten  years, the course of  the disease
which has  just been  described—namely, ulceration commencing
a few days after  the  infection,  and  later  induration  of  the
ulcer—was supposed by the majority of physicians, mainly under
the influence of Ricord's  authority, to be the ordinary course,
or, so to speak, the normal one.

   We see how much biassed opinion and the  reverence for authority hindered
ingenuous inquiry, when we reflect that not only in this century have unprejudiced
observers like G. Babington shown the induration  to be the most essential part of
the primary affection, and  that  it often precedes ulceration, but physicians even
in the sixteenth century, as was known by Hunter4 too, were perfectly well aware
that the  syphilitic primary lesion often made its appearance  only after a  con-
siderable period of  incubation.   In  this connection the  following passage  from
Hieronymus Capivaccius6 is very interesting: " Quibusdam simulac venere sunt usi
eo ipso die caries erumpit;  nonnulli  post coitum non  corripiuntur  carie nisi  post
30 aut 40 dies."  So C.  was well aware of the period of incubation in syphilis, and
distinguished the two  courses pursued by the  primary affection  described above,
while Ricord still, in 1851,  made the  induration begin in three days, as a minimum,
and invariably in the course of the first or  second week, and declared  the opposite
views, viz.,  that the induration may precede ulceration,  and that sometimes  the
chancre does not become indurated before the third or fourth week of its existence,
to be erroneous.  Ricord came to these conclusions mainly through his experimental
inoculations; but  inasmuch  as  these were only made upon the bearers and  not
upon  healthy subjects,  they became, of course, the source of false inferences,  not
only with reference to the  primary affection but with regard to the question of
the inoculability of the syphilitic secondary lesions.

    According  to Ricord's  earlier  representations the induration
1 Aphrod., I. p. 450.                               ! Ibid., p. 392.
3 Ibid., II. p.  781;  see also Auspitz, 1. c, p. 30.
4 L. c, p. 319.                                    6 L. c, p. 20. 
86
BAUMLER.—SYPHILIS.
of a chancre appeared as a  constant  occurrence in the course of
all venereal sores  of  the genital  organs.   But in  his  letters,
published in 1850-1,  a division  of the chancres was made into
such as  become  indurated  and  those  that  do  not,  and to  the
former only was ascribed the power of infecting the entire body,
that is, of causing general syphilis.  As to which of  these  alter-
natives should take place was referred to pure chance.   It was
supposed to depend  mostly upon the character  of the soil in
which  the  ulcer develops,  that  is,  upon  peculiarities in  the
individual infected.    Thus  was  the .first  step taken  towards
founding the  doctrine of  duality in syphilis—in other words,
towards  the theory that syphilis and chancre  owe their  origin
to distinct morbid poisons.


The  Doctrines  of  the  Unity and  Duality of the Syphilitic
                       and Chancre Poisons.

Ph. Ricord, Traite" prat, des malad. vener., recherches crit.  et expenmen. sur l'in-
    oculation.  Paris, 1838.—Lettres sur la Syphilis.  Union Mgdicale, 1851, 1852,
    2d ed. Paris, 1856.—Lecons sur le chancre, redig. par A. Fournier.  Paris,
    1858.  2d ed., 1860.—Leon Bassereau, Traite  des affections de la peau, symp-
    tomatiques de la Syphilis.  Paris, 1852.—Clerc, Du chancroide syphilitique
    (Moniteur des Hopitaux).  Paris, 1854.— Cullerier, Rapports a la SocieTe1 de
    Chirurgie.  Bulletins, 1855-57.—M. A. Dron, Du double virus  syphilitique.
    These  de  Paris, 1856.— V. de Meric, On the Unicity  or Duality of the Virus in
    Syphilis.  Lancet, Aug. 21,1858.—Diday, Exposition critique et pratique des
    nouvelles doctrines sur la  Syphilis.  Paris, 1858.—Rollet, De la plurality des
    maladies vener., 1858.  Etudes sur le chancre produit par la contagion de la
    Syphilis secondaire.  Archiv. gengr.  de M6d., Febr., 1859.  Recherches clin.
    et experim. sur  la  Syphilis, etc.  Paris et Lyon,  1861.— Von Barensprung,
    Annalen des Charitgkrankenhauses, 1860.— Von Lindwurm,  Wiirzb. med.
    Zeitsch., 1862, B.  IH., S. 146.— Von Sigmund, Ueber Verschiedenheit der
    Ansteckungsstoffe, etc.  Wiener med. Jahrb., 1861. H. IV.  and  numerous
    articles in the different Vienna medical journals of the years 1860-70.—F.
    E. Friedrich, Ueber  die Lehren vom Schanker.  Erlangen, 1861.— W. Boeck,
    Recherches sur la Syphilis.  Christiania, 1862.—H. Kobner, Klin. u. experim.
    Mittheilungen aus der Dermatologie und Syphilidologie.   Erlangen, 1864.—H.
    Auspitz, Die Lehren vom syphilit. Contagium.   Wien, 1866.—J. Cooper For-
    ster, Syphilis and Chancre.  Guy's Hospital Reports,  Series IH.,  Vol. XV.,
    1869,  p. 159.—J. Morgan, On the Nature of the  Vener.  Poison.  Med. Press 
              DOCTRINES OF UNITY AND DUALITY.           87
    and Circular, 1871.  Brit. Med. Jour.,  1871, Vol. I. p. 94.— F. J. Bumstead,
    On the Present State of the Question  of the Unity or Duality of Syphilis.
    Amer. Jour, of Med. Sciences, April, 1873, p. 321.—if. Kaposi, 1. c.
    It was Leon Bassereau, a pupil of  Ricord,  who, in 1852,
treading in the footsteps of his master, and dividing the chancres
into two varieties,  the hard and  the soft, as Ricord had done,
first made the division complete  with respect  not to their form
merely  but  to  the sources from which they  spring.  Having
made inquiry in a large number of cases of venereal disease as to
the source from which the  infection was derived, he ascertained
that in every instance patients who had  hard  sores traced their
infection to persons who were syphilitic, that is, who still bore
evidences of  primary or  secondary disease;  while sores that
remained local—simple chancres—only produced their like when
transmitted ; in other words, only  produced sores which remained
permanently local,  with or without suppurating buboes.
    The  new doctrine soon  met with support  founded on fact,
especially from Clerc.  But it was Ricord again who, in his lec-
tures on chancre in 1858, through the weight of his  authority
and by  his brilliant eloquence, secured approval for the new doc-
trine  and gave it  currency.  Ricord  had meantime learned to
distinguish the inflammatory hardness  of a chancre from  the
specific hardness of a syphilitic  induration.   He  had likewise
abandoned the idea of the unity of the two kinds of sores, and
accepted  the  doctrine of Bassereau, in so far as to  adopt the
principle that each variety  of sore propagates only its own
kind; the soft chancre  operating upon all alike,  both healthy
and syphilitic,  but the hard syphilitic sore  only upon  the
healthy.  For both he and Hunter had established the fact, by
experimental  inoculation,  that the secretion  of  the  syphilitic
hard  sore is  not inoculable  upon the bearer nor upon others
already syphilitic.
   Meantime the doctrine had received  material  support from
numerous inoculations of syphilis  upon healthy subjects (see p.
42 et  seq.), inasmuch as in the great majority  of  these inocula-
tions  it was shown that a period of incubation of some weeks
occurs before the appearance of the primary affection.  On the
other hand, the numerous  inoculations  of  Ricord and others, 
88                   BAUMLEE.—SYPHILIS.

with  the secretion of soft chancres, had shown that in twenty-
four  hours a redness appears, and on  the third  day  a vesicle,
which in a few days more turns into an ulcer.  Therefore it could
no  longer be supposed, with Ricord,  that infection  with  the
syphilitic virus is always followed a few days after by a chancre.
The syphilitic poison has a period  of incubation, the chancre
poison has not.
    But in order to account for cases occurring in practice,  where,
a few days after an infection, a sore is formed, with all the char-
acteristics of a chancre, but which after  the  lapse of a certain
time, begins to  become indurated, and is followed by general
syphilis, the hypothesis  of Rollet  (1858) became  necessary,
namely, that different poisons may be inoculated simultaneously,
and will be followed by a complex result.   Thus gonorrhoea and
chancre may coexist in the same individual, and  both be trans-
mitted together, and so, also, with chancre and syphilis.   If in
the latter case both poisons are transmitted at the same point,
a mixed chancre is the result, that is, there is developed  first a
chancre,  and  after  a  time, sometimes not until the sore  has
healed, an induration takes place.

   In  another way, too, may the action of both  poisons be evinced at  the same
point of the body, as, for instance, where chancre virus is inoculated upon an existing
syphilitic  induration.  This has been demonstrated experimentally by Laroyenne,
Basset, Melchior Robert, and others with positive results.1  The converse of this,
viz., inoculation of syphilitic poison upon a soft chancre, is likewise possible; but
practically the occasions for its occurrence must be extremely rare, inasmuch as per-
sons who have soft chancres are not so ready to  expose themselves to another infec-
tion as those with syphilitic indurations which cause but slight annoyance.

    An important question  is, whether from such  a mixed sore,
following a double infection, it is  possible  to produce by inocu-
lation upon a healthy person another sore with the same mixed
characters ? The possibility of transmitting both poisons simul-
taneously was demonstrated in an  experiment by  Hebra,2  which,
however, was not entirely satisfactory,  for  the reason that blood
was inoculated together with the secretion from the sore.   There-
1 Lancereaux, 1. c., p. 74.
2 Auspitz, 1. c., p. 227. 
              DOCTRINES OF UNITY  AND  DUALITY.            89

fore it really does not prove that both poisons were contained in
the secretion, and in  this respect is analogous to  a  number of
the observations  made with regard to vaccination which  have
been already cited.
   Secretion from a soft chancre was inoculated upon tubercles about the size of
peas, which were scattered  over the body of  a syphilitic patient.  Ulcers formed,
and from this secretion, mingled with blood, another person was inoculated.  Two
days later, pustules appeared at the places inoculated, which turned into ulcers, one
of them healing in four weeks, while the other grew larger and became indurated.
Subsequently symptoms of general syphilis appeared.  (Compare also Case II., on
page 95).
    In Germany, through the researches of  Waller and  others,
the way had already  been prepared for the new doctrine, and it
therefore soon found  adherents, among whom von Barensprung
gave  it a more precise interpretation, in transferring the essential
ground of distinction  from the difference in the  forms of  the
sores to a difference in the poisons to which the sores are due.
    In the study of these questions  the mistake has always been
made of generalizing  too  hastily,  and  this criticism  applies
especially to  Ricord.   Thus, certain points were laid down  by
him as characteristic of the syphilitic primary affection, which
failed to bear the test of further experience, and  the same  thing
happened again in regard to the separation of the soft chancre
from the syphilitic indurated sore.   Not only was  undue weight
laid upon certain signs, whose recognition  was always more or
less dependent upon the subjective appreciation of  the observer,
as in deciding between the hardness or softness  of a particular
ulcer, but other characteristics  were affirmed of  the ulcers with
too great  positiveness, and from inadequate observations.  In
this category belongs the assertion,  dating from an  earlier period
of Ricord's teachings, that a soft chancre never occurs upon the
head, or, in other words, an infection  upon the  head is  always
followed by an induration.1  This question  elicited considerable
controversy, but  was first answered by means of experiment by
Rollet,  in 1857,  and by some  others  later, and  since  then by
means of numerous  clinical observations, the import of this  tes-
1 Atispitz, 1. c, p. 108.  Lancereaux, 1. c, p. 81. 
90
BAUMLEE.—SYPHILIS.
timony being that the head possesses no immunity with regard
to the soft  chancre, the rarity of its occurrence in this situation
being solely due to the infrequency of the occasions for trans-
mitting chancre poison to  this part, while indurations may be
often produced upon  the head in consequence of the transmis-
sion of syphilitic poison, from secondary lesions upon the mouth,
usually in the act of kissing.
   On  the  other hand, the opponents of dualism have thought
that because  a single such  position  had been  successfully
attacked, the whole doctrine might be  overthrown in the  same
way.
   The principal point against which the  attacks upon the doc-
trine of dualism are concentrated is the proposition that each
kind of sore propagates only its own kind.  The  results of con-
frontations and experiments are adduced  in opposition to this.
Clinical experiences are called in, with  instances where fre-
quently nothing but soft chancres were found as the source of
characteristic  indurations.   Quite recently J. Morgan1 called
attention to the fact that in the Westmoreland Lock Hospital a
hard sore  was scarcely ever  observed  in  the female patients,
while in the men, who  had  been infected from this same class of
women, such sores were by no means  rare, and that in certain
cases, where the infection could be traced directly to its source,
he had found  a hard sore  in the man and a soft sore in the
woman.  We  shall take occasion later (compare page 114) to
refer again to this point, as well as to the statement, often made,
that in a given instance constitutional syphilis has succeeded to
an undoubtedly soft  chancre.  For the present  we proceed at
once to those objections which the opponents of dualism derive
from the results of experimental inoculations.   These objections
are comprised in the following propositions, viz.,  that by means
of experiments in which the  secretions of indurated sores and
flat condylomata were inoculated, it has  been proven  that the
syphilitic virus,
   1. Contrary to the assertions  of  Ricord  and  von Baren-
sprung, is  inoculable  both upon  the  bearer  and  upon others
1 Brit. Med. Journ., 1871, Vol. I. p. 94. 
              DOCTRINES  OF UNITY AND  DUALITY.           91

syphilitic; but in this case,  almost without exception, a soft
chancre with all its characteristic marks—absence of incubation
and inoculability in generations—will be  produced; and,
    2. That  in rare cases,  when inoculated upon healthy  sub-
jects, it has immediately produced a soft chancre both with and
without subsequent syphilis.
    1. The non-inoculability of the syphilitic indurated sore upon
the bearer or upon other syphilitic subjects was regarded for a
time as a cardinal point of  distinction between this sore and the
soft chancre.   Then, in consequence of Clerc's researches,1 some
exceptions to this rule were learned.   In inoculating  the secre-
tion of an indurated sore upon the bearer, Clerc obtained a posi-
tive result in producing not an indurated but a soft sore.  From
this experiment, joined to another  observation where a typical
indurated sore, situated  upon the scrotum and afterwards fol-
lowed by a  papular syphilide, caused the production of a soft
sore upon the skin of  the  penis lying in contact with it, Clerc
concluded that the pure, soft chancre is, in fact, the result of
inoculation  from an  infecting sore, that is, the effect of  the
syphilitic virus upon an  individual  already syphilitic.  By vir-
tue of the immunity conferred by the disease, a syphilitic per-
son did not  acquire an indurated sore from a second inoculation
of  the virus; but, if  the  inoculation took at all,  only a soft
chancre, to which Clerc, as Maratray had done before him, gave
the name of "chancroid."  This stands in the same relation to
the infecting sore as the varioloid to variola, or the abortive to
the typical vaccine pustules.
    Although these observations (to which belongs one made by
Fournier2 in 1856, who made such an inoculation with positive
result) were somewhat  isolated, yet their  numbers were increased
as soon as certain experimenters succeeded in exciting syphilitic
indurations  to  a  copious secretion  of pus by artificial means.
Henry Lee 3 used for  this purpose savine ointment, and  with
  1  L. c, in Auspitz, p. 104.
  2  Auspitz, 1. c., p. 113.
  3 Brit, and Foreign Med.-Chir. Review, 1859.  The Lancet, 1856,1859-61. Ampits,
p. 310 et seq. 
92                  BAUMLER. — SYPHILIS.
the pus produced under its irritation he and others (Melchior
Robert, in Marseilles,1 for example) succeeded in producing upon
the bearers of indurations, without incubation, ulcers which bore
the characters of soft  chancres, and were further  inoculable.
Kobner2 obtained a like result by inoculating the  secretion of
flat condylomata which had been irritated with savine ointment
or powder.  These investigators, therefore, succeeded in making
the syphilitic virus auto-inoculable.  The greatest  number of
inoculations of  secretion from  indurated sores was performed
by Boeck  and  Bidenkap3  in Christiania,  who, in their  recent
attempts at curative syphilization, employed only the secretion
of indurated ulcers.
   In  the  above experiments the secretion of soft chancres did
not come into play at  all, but solely  the, in some way, aug-
mented secretion of syphilitic primary lesions, or  of later local
affections, as flat condylomata or tubercles, in which, by  means
of  savine ointment, or even by mechanical  irritation,  as by a
seton (Pick4), a profuse suppuration had been induced.  Can we
thence infer that it was the syphilitic virus  in these cases that
produced the soft  chancres, which were inoculable  in genera-
tions \  Certainly not.  For, in  the first place, in this secretion
produced by irritation, we have to do with a very complex pro-
duct,  which can by no means be regarded as identical with
the syphilitic poison.   It may, in many instances,  contain  the
syphilitc virus,  but  its chief component is pus.  In the  second
place,  there are a  number of  facts that go to show that  the
secretion  of a syphilitic local  affection is not at all necessary
to the production,  upon a  normally appearing portion of skin
in a syphilitic subject, of a sore which  is  inoculable in a series
of generations.
    It  has been  shown, namely, that perfectly ordinary, non-
specific pus,  inoculated upon  syphilitic subjects,  causes soft
ulcers which may also be inoculated in generations.   At Zeissl's
1 Melch. Robert, Nouv. traite' des mal. ven., 2 ed. Paris, 1861.  Auspitz, p. 315.
2L. c, p. 77.
3 Auspitz, 1. c, pp. 239, 325.
4 Auspitz, 1. c., p. 335. 
DOCTRINES OF UNITY AND DUALITY.            93
suggestion,  Pick'  inoculated  pus from  scabies, pemphigus,
and acne pustules  (which pus, when inculated  upon the bear-
ers of these affections or other non-syphilitic persons, gave a
negative result) upon syphilitic subjects,  with the  result of pro-
ducing soft sores from which still other  inoculations could  be
made.  Kraus and  Reder obtained with the pus of scabies, and
Henry Lee2  with  pus  from  a non-syphilitic child, the same
result.   Therefore  it appears that the skin of  syphilitic indi-
viduals possesses a marked vulnerability, a peculiar aptitude to
become inflamed when  acted upon by irritants.  We find this
peculiarity, too,  in many individuals  who are not  syphilitic.
Every physician  has met with such persons, in  whom  the most
trifling injury  results in  suppuration.    Moreover, this suscep-
tibility of  the skin  to  irritation  is by no means uniform  in
syphilitic subjects (Berkeley Hill,3 Bidenkap).   It  remains to be
seen if in the syphilitic subjects manifesting  this disposition, a
more simple irritation, continued for some length of time, as the
introduction  of clean  needles, for instance,  or electricity, is not
likewise capable of producing sores similar to the soft chancre.
   Here evidently belong the results obtained by Michaelis,4 by cauterization of
'■'■indolent buboes" with Landolfi's caustic paste, and inoculation of the pus formed
after separation  of the slough.  Pustules followed without a period  of incubation.
Only one of those so treated became undoubtedly syphilitic, that is, had secondary
symptoms.  In this instance the communication of  the pus to  a healthy subject
might possibly have produced a mixed result.

    The last-mentioned experiments did  much  to deprive the
virus of  the soft  chancre of its alleged specific  character.  But
there still remained the notion that there must be a syphilitic
soil for it to originate in, ulceration having been first excited in
the former by means of  the inoculation of various purulent
secretions.  But  quite  recently Kaposi6  has  published certain
investigations, the results of which divest the soft  chancre of  its
1 Zeissl, Lehrbuch, B. I. p. 176.
2 Med.-Chir. Transactions, 1867.  Lancereaux, p. 88.
8L. c, p. 256.
4 Auspitz, 1. c., p. 307.
BL. c, pp. 47 and 57. 
94
BAUMLEK.—SYPHILIS.
specific character completely, and, should they be substantially
confirmed hereafter, the doctrine of the identity of the syphilitic
and chancre poisons, or even of a relationship between them, will
lose its principal support.  Kaposi says :
   " My own experiments have taught me that  non-syphilitic pus, such as we find
in acne and scabies pustules in non-syphilitic persons, when inoculated upon the
bearer, as well as upon other non-syphilitic persons, produces pustules whose pus
proves to be inoculable in generations; that loss of substance was  caused by the
pustules, which healed by cicatrization, and that with the increase in the number of
pustules produced by the inoculations the contagiousness of the pus diminished,
and finally became quite extinguished."
    These  non-specific  inoculated  ulcers  had  therefore all  the
characters of the soft  chancre.  Kaposi's results, which go far
beyond those obtained by Pick,  are analogous  to the results
which L. Vidal * has recently obtained, in  inoculating pus from
ecthyma pustules in typhoid fever and ecthyma simplex.   This
pus was found to be auto-inoculable, and that, too, in three or
four generations of  pustules; but it was not inoculable upon
healthy persons, only upon the bearers.
    So  long as its corroding  character and  the inoculability in
generations are accepted as the decisive characteristics  of  the
chancre, we must admit the ulcers  produced  by Clerc,  Lee,
Boeck, as well as now those of Pick and Kaposi, to have  been
soft chancres.  The necessary conclusion then, is, that the poison
of  the soft chancre  may, under certain  circumstances, be pro-
duced de novo without the intervention of the syphilitic virus,
while the syphilitic  poison propagates itself only in one contin-
ued series.  Hence the chancre poison, or whatever in the above
experiments produced the chancre-like pustules,  cannot even be
compared with the syphilitic poison, to say nothing of regarding
them as identical.  As implied in what  has been already said,
and as was assumed by Rollet, and  confirmed through experi-
ments by Kobner,2  it is  the pus to which the irritant property
that generates  the  ulceration pertains;  and according to the
source and mode of its origin, as well as according to  the suscep-
1 Annales de Dermatologie, 1873, No. 5.  Ref. in Gazette hebdomad., 1873, No. 45.
2 L. c., p. 86 et seq 
               DOCTRIXES OF  UNITY AND DUALITY.             95

tibility of the individual affected, will the pus possess and evince
this property in greater or less degree.   Whence the pus derives
this property, in what it consists, and why all pus does not pos-
sess it alike, are questions not yet solved.
    Whether  the soft sores which can be produced  in syphilitic
persons, either by means  of  true syphilitic secretions (to which
belong purulent vaginal secretions in syphilitic subjects, accord-
ing to John  Morgan) or by means  of non-specific pus—in other
words, whether the chancroid of Clerc,  when communicated to a
healthy person, is capable  of producing syphilis, or  only local
sores which remain soft and  are further inoculable,  has not been
positively determined.   Up  to  the present time but  two experi-
mental observations have been  made with regard to this point,
and  these with contrary results.   They are  described  by Biden-
kap,' and are the following :

   Case I.—A young woman, admitted for vaginal and urethral blennorrhcea, Oct.
9, 1862, out of curiosity inoculated herself by means of a needle with the pus from
artificial sores in a  patient who was being treated by syphilization.  These artificial
sores sprang originally, though conducted through many generations since, from an
infecting sore which had been inoculated by Bidenkap.
   A few days after the inoculation,  according  to the patient's statement, there
resulted a pustule, which turned afterwards  into an ulcer that  lasted for two
months.  This produced another in its vicinity; both healed without leaving indu-
rated scars or enlarged glands, and  were not  followed by constitutional syphilis.
One and a  half years later she acquired syphilis  through a fresh sore upon  the
genitals, which was obtained in the usual way.
   Case n.—A young woman, affected with eczema of the forearm, who had never
suffered from venereal  affections, inoculated herself, like the previous patient,  out
of caprice, with eighteen chancres, to which were added, since the manner of their
origin was at first  uncertain,  twelve others, inoculated from  the first, in order to
test their character.  The sores from which she  had inoculated herself likewise
sprang originally from the secretion of infecting sores, which secretion, however,
had passed through many generations and individuals.
   The pustules became transformed  into tolerably large ulcers.  Two of them felt
somewhat hard,  but in most of  them there was not a trace  of induration.  At a
little distance from certain  of the  sores, a small, somewhat tender glandular
enlargement could  be felt. January 27th.   All the ulcers healing.  Two of  the
largest were seated upon a hardish swelling, which was pretty well defined, and
1 Wiener med. Wochenschr., 1865, No. 34.  Auspitz, 1. c, p. 236. 
96                     BAUMLEE.—SYPHILIS.
felt like the half of a little sphere.  Four others were somewhat hard,  but their
hardness was not so sharply defined.
   February 17th. Slight symptoms  of fever appeared, and there was redness of
the fauces, with whitish exudation  upon the left tonsil and  over a part of the
velum.  She was ordered, internally,  chlorate of potash, and in a few days all the
symptoms had disappeared.  The exudation upon the tonsil  reappeared several
times, but  always went away again  without treatment.  At the end of February
and the beginning of March  she had some derangement of digestion and  hysterical
symptoms; meantime the ulcers healed and left behind bluish or brownish scars;
those of the two most markedly indurated ulcers were somewhat hard.
   April 23d. In the right axilla a swollen gland could be felt, as large as a hazel-
nut, which was hard, movable, and not tender.  April 24th there appeared upon
the abdomen  several isolated pustules, as large as a flax-seed, with red areola.
Besides these, no  other symptoms of syphilis.  On the 29th the pustules had
increased in size and number; the largest were nearly the  size  of peas, with
depressed centre, and the region about was bluish and somewhat swollen.  One or
two glands were also perceptible.   Inoculations from the pustules gave a negative
result.  Several  more of them appeared  upon the back and breast, and  she com-
plained of headache, especially'towards  evening.  In the course of some days
these symptoms vanished, the pustules dried up, and the patient appeared quite
well.
   One month later, that is, five months after the inoculation, as no new symptoms
appeared she was discharged as recovered.

   Now in the first of these cases the result of the inoculation
was simply  local;  in the second, however,  the  course  was
exactly what  it  would have been after the  inoculation  of two
poisons ; that  is,  what is  required  by  the hypothesis  of the
mixed  chancre.   Induration  followed the  ulceration,  which be-
gan at once, without a period  of incubation, and later came the
general syphilis.   The  physicians who observed  the symptoms
developed—Boeck and Bidenkap—did not regard them as syphi-
litic.1   Kobner, on the  other hand, also an  opponent of dualism,
recognizes them as such unconditionally.4
   But the  statement  that the syphilitic sore  is  not inoculable
upon the bearer, has been subjected to  a  still further qualifica-
tion.  Not only have  soft chancres been  produced in inocula-
tion experiments upon syphilitic persons, but in  some instances
the  inoculation of syphilitic secretions upon a syphilitic  subject
Auspitz, 1. o., p. 239.
2L. a, p. 77. 
DOCTRINES OF UNITY  AND  DUALITY.
97
has been  followed,  by  the development  of a papule,  after the
lapse of a considerable  {from three to four weeks) period of
incubation.
    The cases which  bear  upon this  point  were  all  observed by
Bidenkap' and Boeck.  . They are the following :

   Case I.—O. C, who had never before had constitutional syphilis, came into the
hospital on the 26th of August, 1861,  with  a slightly indurated ulcer  upon the
orifice of the urethra and two erosions upon the left  labium.  From the ulcer in the
commissure the skin of the thigh was artificially inoculated.   For the first fourteen
days nothing further  was noticed  at the inoculated place, and consequently  no
further examination was made of the patient  until the 27th of September.  There
now appeared at the  point inoculated an ulcer of the size and shape of a split
almond, which was seated upon a deep and extensive  induration.  This had there-
fore taken fourteen days at least to develop, and, according to the patient's state-
ment, nearly three weeks.  The ulcer having healed, the patient was discharged
upon the 14th of October, but returned  February 22d, 1862, with the  symptoms of
constitutional syphilis.
    Case II.—J.  S. entered the hospital January 3d, 1863, with an  eroded well-
marked induration  in the retropreputial fold, slight swelling of  the  inguinal
glands, but  presenting otherwise no  symptom of syphilis.   The disease  had been
contracted towards the middle of December, and the  girl, from whom he acquired
it, was admitted into  the hospital  December  10th, 1862,  with moist  papules upon
the genitals.  On the 9th, 10th,  and  11th of January, inoculations were made upon
the side of the thorax, with the secretion of the chancre, but without any immediate
effect.
    January 12th, pulv. sabinse was  strewn upon the chancre, and by  this means in
a few days a copious suppuration was induced.  The pus thus obtained being inocu-
lated in the left side of the thorax, caused, at first, only little pustules, which soon
dried up; but, January 17th, an inoculation made from this pus produced a large
pustule surrounded with a red areola, which in a few days turned into  an ulcer. An
inoculation performed on the 24th of January had the same result.    February 5th.
" The artificial ulcers are healing. At the places where inoculations were made upon
the 9th January, and the  days following, only pale red papules are to be seen.  At
the place that was inoculated upon the 9th, the papules are of the  size of a pea, at
the other places smaller.   At those made on the 12th they are the size of pin-heads.
These papules were seated regularly in threes, at the points inoculated, and at places
even where it was supposed the inoculation had failed.  The papules increased daily
in size, became more prominent, were surrounded by a red  areola, were themselves
of a more livid color, and finally showed at the top a commencing  desquamation."
    On the 9th of February a small, movable, hard, not tender gland was discovered
Wiener med. Wochenschrift, 1865, Nos. 31-34.   Auspitz, p. 321.
  VOL. III.—7 
98
BAUMLER.—SYPHILIS.
above the largest of the papules mentioned.  The 11th of February a slight roseola;
later, moist papules on the scrotum and erosions in the  mucous  membrane of  the
pharynx.  Expectant treatment.
   "For some weeks  the papules increased in size, the  scabs became thicker, and
on the 22d of February the oldest were covered with a thick, reddish-brown scab,
which, upon being removed, revealed a dark red,  slightly moist surface.   April
22d. The scabs had fallen off and  the papules were somewhat  flatter  and of a
browner color.  The longest had a diameter of from three to four lines.   From the
indolent glandular swelling in the right side of the thorax, a hard cord could be dis-
tinctly felt extending upwards to the next gland, which  was likewise enlarged, and
from this another cord led as far as to the axilla, where it was lost in a large, some-
what movable glandular swelling.   Brown-colored spots were left by the papules.
   Case III.—A. A. was admitted January 5th,  1863, with a  sore  on the collum
glandis,  seated upon  a cartilaginous induration.   In  both inguinal regions,  but
especially the right,  hard, swollen glands.  Infection  about five  weeks  before;
according to patient's statement, there were small erosions in the situation  of  the
sore eight days before. "With the scanty, thin transparent secretion which could be
scraped from the moist surface, inoculations were made upon the thorax on the 9th
of January, and every second day afterwards.  January  25th,  as  no  effect was
observed at the inoculated places, pulv. sabinae was strewn upon the ulcer, and the
purulent secretion thereby produced was inoculated upon the arm, which caused,
upon  the 29th  of January,  characteristic pustules, which were inoculable in  ten
generations upon the bearer and other patients.
   " In the last few days pale-red papules had made their appearance at the places
first inoculated, those, namely, from the  9th to  the  13th of January.  On the 29th
those  inoculated upon the 9th  of January had reached a  diameter of two lines.  On
the same day, traces of a commencing roseola were observed.  The cervical  glands
were also enlarged."
   February 3d. Papules were forming at all of the points inoculated.   They fol-
lowed the same course as in the preceding case.   The resolution began towards the
end of March.   On the 5th of March, the patient was attacked by a  diffuse erysipelas,
which proceeded from one of the artificial chancres upon the left arm.  During this
intercurrent affection,  which lasted  one week, all the artificial  sores dried up, the
papules became  even with the surface  of the skin, and looked finally like brown
maculaj. Afterwards, when  the  erysipelas  had disappeared,  the papules became
again elevated.
   "April 22. The following was noted : For several weeks the indolent glandular
swellings have been perceptible along the border of the mus. pector. major.—At one
point the connecting lymphatic vessel can be felt as a hard  cord.   In the  axillae,
groups of similar enlarged glands are felt."
   Case IV.1—P. A. F. entered the hospital February 22d, 1867, with an indurated

   1  W. Boeck,  Ueber syph. Infectionsweisen, etc.  Archiv fur Dermatol,  und Syph-
ilis, I., 1869, 2, p. 177. 
                  0CTRINES OF UNITY AND DUALITY.              99

sore of the corona glandis.  Inoculations made with pus, obtained by sprinkling
savine powder over the ulcer.  March  23d. No effect yet observed.  March 25th.
Roseola.   May 23d. At the point of the test inoculations eight papular elevations
of a brownish-red color, and desquamating.  How long they had been there cannot
be stated,  since the places had not been  examined  for some time.   June 17th, they
had disappeared.
    Case V.—A patient had connection for the last time six weeks before  admis-
sion to the hospital, and a few days before his entrance (October 3d), had noticed
a small excoriation upon the glans penis, and inner surface of the prepuce.   Indu-
ration not perceptible.   Inguinal glands on the left side somewhat swollen.  Inocu-
lations were made, sometimes daily, sometimes on alternate days, but did not appear
to take.   November 2d. Marked induration and profuse suppuration.  Inoculation
of the pus upon the bearer, as well as upon other syphilitic subjects, caused, in two
days,  typical pustules.   Beginning of November,  roseola.  " At the same time the red
spots  on the breast, which had remained from the inoculations of the first three
weeks, which appeared to have failed, having meantime somewhat increased in area,
began to rise above the skin and rapidly developed into papules, or rather into tuber-
cular  elevations of a bright red color, and as large as small peas.  The  largest had
developed from the oldest inoculations, made at the beginning of October."
    Besides these,  several other such cases  have been observed in the last few years
at Christiania, and some of them are briefly reported by Boeck.1  In two cases the
course was exactly like that in those which we have given in detail; in a third there
was this  difference—that the patient  had already, when  the  inoculations were
begun, tubercula  mucosa genitalium  et ani.  In this  instance, also, papules were
formed in the situation of the inoculations; but these inoculations were not made with
the secretion of the  indurated chancre, but from a pustule which had  been produced
by  inoculation of  its secretion.   Moreover, the case is  not  very fully or clearly
reported, particularly with regard to the chronology; it is  not stated whether or
when  the  roseola appeared, and with  regard to  the  "papules" mentioned,  it is
remarkable to  see the  statement made  that reinoculations were made  from these.
The case is in many respects, therefore, unique.

    We  shall  recur to these very important cases elsewhere ;  for
the  present let them  merely serve  to show  that real syphilitic
virus, that is,  the  scanty,  thin,  transparent secretion  of  an indu-
ration, when inoculated upon the bearer, has  really a quite differ-
ent effect from that produced by the abundant purulent discharge
which is excited in the sore by means of artificial or other irrita-
tion.   These cases also show the  rashness  of denying absolutely
the proposition  that the  syphilitic  poison is inoculable upon a
subject who already has a syphilitic sore,  or, as  Ricord  calls  it,
1 lb., B. IV., 1872, p. 491. 
100
BAUMLER. —SYPHILIS.
an "infecting chancre," in other words, denying that there may
be a multiple syphilitic primary affection.   It  should  be well
observed that, with  a  single  exception, in  all those  cases in
which a second inoculation of the virus produced its usual effect
after the  syphilitic  primary  affection had already been devel-
oped,  this inoculation  was made before the disease  had  pro-
gressed  so far as  to  involve the whole organism.  In not one of
the more  carefully reported cases had a longer  period than six
weeks elapsed from the time the disease was contracted.
    It has  been urged as a  serious  objection to the doctrine of
dualism,
    2. That in  experimental  inoculations with the syphilitic poi-
son upon healthy  subjects, ulcers have sometimes resulted, with-
out a period of incubation—soft chancres therefore—which were
either followed by syphilis or remained as local affections.
    The  experiments which  are alleged in support  of this state-
ment are meagre and inconclusive.  In fact, but  a  single experi-
mental  observation  has  been  found  which  might be  cited as
an instance of syphilitic transmission under  the form of a soft
chancre, with  subsequent constitutional syphilis, notwithstand-
ing the  assertion  that  such instances are clinically of very com-
mon  occurrence.  This observation,  therefore,  must  be  here
related.
    Danielssen' of  Bergen, who, with the idea  of thereby benefit-
ing the  Norwegian leprosy (Spedalskhed), treated a number of
lepers by syphilization,
   Inoculated A. J., a man thirty years of age, who had never had syphilis, with
matter from  a hard chancre.  This man had previously, during  five months, been
inoculated with the pus of soft chancres without constitutional symptoms having
shown themselves.  From April 25th until the middle of September he had had 287
chancres, after 393 inoculations, and by the middle of September had apparently
acquired immunity.  On the 28th of September he was inoculated with new matter
from a chancre which later became indurated.  In three days a characteristic pustule
developed, and with pus from this, inoculations were continued.   But it was only
possible to produce a few small pustules.  In a short time the immunity was com-
plete, and  at the end of October all the ulcers had healed.   November 15th, a scar
   1 Deutsche klinik, 1858, p. 322.  Behrend's Syphilidologie, B. III.,  1861, p. 353.
Auspitz, 1. c, p. 181. 
              DOCTRINES  OF UNITY AND  DUALITY.           101
upon the right leg, where one of the former ulcers had been, broke open again, and
in the course of eight days an ulcer had developed, of oblong shape, with sharp
edges and uneven, but not very deep base, which yielded a scanty, thin secretion.
The region about was red, very hard, and rather tender on  pressure.  The inguinal
glands of the corresponding side were swollen but indolent.  " The ulcer healed
under warm fomentations by the middle of December; the scar was somewhat hard
without my noticing it particularly, since I did not apprehend any accident."
   January 5th, 1858, an exanthem  upon the scrotum. Beginning of February,
manifest symptoms of constitutional syphilis, ulcers in the throat, etc. He was now
syphilized once more, and this time with success

    We  are  obliged  here, with  Auspitz,  to  suppose that the
patient  acquired syphilis through the  inoculation  which was
made  Sept.  28th,  for there  is  not the  least  ground to support
Boeck's  assumption  that it was in  consequence  of the  first
attempt at  syphilization.  The  most  difficult  fact to explain,
from the standpoint of  dualism, is that a pustule was developed
only three days  after the inoculation of  secretion  from a hard
chancre.   We might assume that there was  an infection with
both poisons,  the chancrous and syphilitic,  but  too  little  is
stated regarding the  source from which  the  inoculated matter
was taken to fully justify such an  assumption;  neither are we
justified  in  assuming that  the lancet used was  soiled  with
chancrous matter,  though it may be presumed that the inocula-
tion was made with  the same lancet that was used  in  the pre-
vious case,  since Danielssen believed  at the  time that  he was
taking  matter from a soft chancre.   Bnt the probability is,  that
the  affection from which he  took the matter was suppurating
profusely on account of its  being in a state of  abnormal irrita-
tion ; for  it  has  been already shown that such copious purulent
discharges are capable of exciting  ulceration.   Moreover, the
production  of pustules,  or  inflammatory  local  manifestations
without incubation, after the inoculation of real syphilitic secre-
tions upon healthy persons  is,  after all, not,  a very rare occur-
rence.
   In one case of Vidal's,1  after inoculation of the secretion of a pustule, due to
constitutional syphilis, an inflammation  appeared at the place inoculated on the
very day of the inoculation,  with suppuration  and ulceration, which healed in
1 Auspitz, 1. c., p. 151. 
102
BAUMLER.—SYPHILIS.
about fourteen days, to be succeeded thirty-four days after the inoculation with a
fresh development of pustules, which was followed by constitutional syphilis.  In
this instance purulent secretion was used in the inoculation, and the person  inocu-
lated seems, moreover, to have been especially disposed to  suppurations, for the
local appearances that followed, after a rather long period  of incubation, also
assumed the form of pustules.

    Furthermore, there  have been  a number of instances where
persons  who  had  never  had  syphilis  were  inoculated  with
undoubtedly syphilitic  secretions,  and the  result was  the  pro-
duction of  merely  local evidences of irritation, varying  from
insignificant  pustules  to phagedenic  ulcerations, without  any
symptoms of general  syphilis following.

   Among the experiments of the anonymous physician1 of the Palatinate, there
are three in which  the inoculated places  became at once inflamed;  two of them
healed after suppurating for from eight to ten days; in the third, pustules filled
with sanious pus appeared in four places two days after the inoculation.  On the
following day they became confluent, and  were accompanied  by violent inflamma-
tion of the surrounding cellular tissue; on the sixth day a slough formed.   None
of the three cases were followed by constitutional symptoms.

    Whether  these  pustules and  ulcers  had  the character of
soft chancres, with  regard to  further  inoculability,  wTas a point
not tested.   The test  was  applied, however,  in  the following
case of Boeck's :a

   A woman suffering from chronic eczema, who had never had syphilis, had been
treated by B. by syphilization (i.e., inoculation of soft chancres).  Upon a relapse
of the eczema, five  years  afterwards, she was to have been syphilized again. But
at B.'s desire  she was inoculated  by  Bidenkap with the secretion of a charac-
teristic hard chancre (whether after it  had  been excited to profuse suppuration
or not, is not stated).  There  resulted  large pustules with quite superficial ulcera-
tion. The pus from these took  in only three generations, and afterwards only
produced abortive pustules.   General syphilis did not occur.

    In  this case,  as  well as  in  the three previous ones, I think
that we  must  assume  that the  peculiar result  of  the  inocula-
tions  is  to be  ascribed to  a  constitutional peculiarity in the
individuals,  and  that  through   the  suppurative  action   that
occurred  the syphilitic virus  was destroyed.  Moreover,   sup-
1 Vid. Table on p. 76.
2 Auspitz, 1. c, p. 182. 
DOCTRINES OF UNITY AND  DUALITY.
103
posing that  Bidenkap inoculated the  secretion of a  hard  sore
which had been artificially irritated, it is a question whether  the
syphilitic poison may not have been too much diluted with  the
pus to take effect.
    Finally, there are  a number of cases on record where, after
experimental inoculations of the syphilitic poison upon healthy
subjects,  the  usual  local  symptoms   appeared after a  con-
siderable period  of incubation,  and yet no general infection
occurred.

   The first case of this sort was observed by von Rinecker.1  A boy, twelve years
of age, who was suffering from chorea, was inoculated  March  17th, 1852, upon a
blistered spot on the back, with pus from a primary lesion, which was covered with
a scab and had likewise been produced by artificial inoculation.  In  twenty-seven
days a portion of the sore from the blister was converted into an indolent tubercle ;
that became gradually covered with thin scabs, and, without treatment, was replaced
in four weeks by a slightly depressed scar.   There were no constitutional symptoms.

    Among the experiments reported b}^ the  anonymous phy-
sician of the Palatinate,  there are two which are here pertinent.

   Case X. was that of a young woman, twenty-five years of age, who was inocu-
lated with the secretion from moist condylomata  and mucous patches in  an indi-
vidual suffering from secondary syphilis, September 29th, 1854.  In thirty-six days
tubercules of the skin had formed on the arm. which after a time began to suppu-
rate. November 27th, they had begun to recede ; there still only remained  a slight
desquamation.  Up to the 20th of September, 1855, no general symptoms.
   In Case XIII., in which a woman thirty-five  years old was inoculated  October
5th, 1854,  with secretion from ulcers in case No. I.  (see table, p. 76), ulcers formed
in the places inoculated in forty-two days, and by the end of November were cica-
trized.  No eruption.  With regard to other constitutional symptoms nothing is
stated.

    These  seven cases are  the  only instances  where,  after the
inoculation of healthy subjects with the  syphilitic poison, any
manifestations at  all  appeared, and  general syphilis remained
absent.   And it is  obvious from a simple comparison between
them  that  these cases,  in  many respects, do not coincide with
each other.  The failure of  the inoculation to produce general
syphilis  in the first series was owing  to an  entirely different
1 Wiirzburger Verhandl., B. III. p. 37. 
104
BAUMLER.—SYPHILIS.
cause from that in the second (where it is wholly obscure).   In
the former case we may suppose that the inflammation and sup-
puration which ensued rendered an infection from the syphilitic
virus wholly impossible, or that the latter was immediately
destroyed, together with the infected portion of tissue.
   Weighing together all the facts thus far collected, with refer-
ence to the question at  issue, we cannot but regard the chancre
as a purely local,  contagious  affection, and that while it may
stand in some remote  relation to syphilis,  it does not so neces-
sarily.   Granting that  the  inoculable sores produced by other
secretions than genuine chancre-pus, in the above detailed ex-
periments upon syphilitic and non-syphilitic subjects, were really
the same thing as the typical soft chancre,  representing it, per-
haps, only in a modified degree, we can only say that under cer-
tain  conditions it is  possible for a soft chancre to  occur in a
syphilitic subject in consequence of the inoculation of the syphi-
litic  poison.  But, supposing even that this Clercian chancroid
were the effect of the syphilitic poison, modified by the syphilitic
soil upon which it  operates, ought we not, from the standpoint
of the unity doctrine, to expect that, were such a sore inoculated
upon a healthy person,  syphilis would follow %  The only obser-
vations which give us a clue to the answer are those two cases of
Bidenkap, related above, where two girls inoculated themselves,
out of caprice, with pus from  inoculated chancres in syphilitic
persons.
   Although these  cases lose a portion of their value  from the
fact  that the inoculations were not performed by a physician,
nor the  cases observed from the start, the  mere lack of uni-
formity in  the results  ought not to throw discredit upon the
accuracy of the observations.  For really both cases are possible,
the transmission both of a permanently local sore, and of a sore
which is followed  by induration  and general syphilis, and  we
have no doubt but that it was  this latter event which obtained
in the second case.
   We hold—to be more explicit—that the chancroid of Clerc (which occurs, indeed,
in the ordinary way of infection often enough), even supposing it to be produced 
               DOCTRINES OF UNITY  AND DUALITY.            105

by the true syphilitic poison, is not a syphilitic local affection, which does not mani-
fest itself  in the usual form, merely because the bearer  is already saturated with
the disease; and so also do we not believe that the poison remains in the insuscep-
tible organism unchanged, to develop its usual effects upon a susceptible one which
happens afterwards to be inoculated with it.  We  suppose, rather, that it does not
develop its specific action at all  upon an  insusceptible (because already syphilitic)
organism,  but  is probably quickly destroyed in the  acute sujjpuration induced
either in consequence of pus being inoculated at  the same time with the poison, or
else in consequence of some indefinable peculiarity in the syphilitic organism. The
result of such an inoculation is, therefore, something entirely different from the
syphilitic local affection.  Although an infection with syphilis may follow the inocu-
tion of a healthy subject from such a sore, there  is another reason for this than in
supposing  that  the previously inoculated syphilitic poison has again become active.
The infection in this case is due rather to the syphilitic poison which pervades the
entire syphilitic organism (with all its fluids) of  the individual in whom the chan-
croid was developed, and inoculation from the chancroid produces a syphilitic infec-
tion only when blood or its serum are inoculated with the pus;  in the same manner
as in the vaccination from  a vaccine vesicle in a syphilitic subject where the contents
of the vesicle are mingled with portions of blood that have exuded from the capil-
laries.

    Hence in Clerc's chancroid there has been no transformation,
as  the unicists claim,  of  the  syphilitic poison into  some  modi-
fied  poison, which only produces  local effects, and which may
either be transmitted  in  this modified form  to healthy persons,
or, under certain circumstances,  be transformed back again into
real  syphilitic virus;  but  the resulting sore, the chancre, is  a
thing  by itself,  and when only  a  simple chancre  is  produced
by the inoculation of a healthy person with  pus  from a chan-
croid,  there is no danger afterwards of transmitting syphilis in
any further inoculations which may be made from this simple
chancre.  For there  has never yet been a single  instance where
syphilis was caused by the inoculation of chancre-pus from an
individual who  had only chancre, and  not syphilis.

   Two inoculations of healthy persons, performed by Wallace1, with the pus from
ulcers of the genitals of a man otherwise apparently healthy at the time (Experi-
ment VII.), and from a suppurating bubo due to pustular ulcerations (Experiment
VIIL), which in both instances were followed by general syphilis, cannot be urged
to the contrary of what has been said, since  it was not stated whether  the persons
1 Auspitz, 1. c, p. 139. 
106
BAUMLEE.—SYPHILIS.
from whom the pus was taken did not become syphilitic themselves later, or were
not already suffering from latent syphilis.

    On the other hand, syphilis has followed  almost invariably
when the secretion of primary or secondary affections in syphi-
litic persons has been inoculated, whether upon such as had been
formerly " syphilized" with chancre pus, or upon those perfectly
healthy.
  In Dr. Lindmann's case the inoculations of chancre pus had been continued for
two  months without symptoms of constitutional syphilis occurring during the four
months following.  In the case described by Danielssen (see above, p. 100) 287 chan-
cres  were developed after 393 inoculations, without syphilis being produced.  But
as soon as secretion from a really syphilitic source was employed for inoculation,
general syphilis followed in both cases.

    The number of cases in which syphilis has not developed after
the inoculation  of  non-syphilitic  persons with unquestionably
syphilitic poison, is extremely small.
    The objections  to dualism have,  as a  rule, been  directed
mainly to secondary considerations, particularly  concerning the
form and general character of the  sores, and with a certain jus-
tice too, inasmuch as the doctrine of dualism was founded upon
the existence of a difference in the sores themselves.  Instances
are adduced in support of these objections, of  syphilis occurring
in the bearer of a soft  chancre; we are confronted with cases
where soft  chancres were  found as  the source of hard sores ;
stress is laid upon the fact of the secretion  of a profusely sup-
purating induration producing a soft chancre, when inoculated
upon the bearer, and so it  is concluded that the  poison that
causes syphilis, and the  agent that produces  only permanently
local sores, are in reality  one and the same.   But as Bumstead
shows (in  the  very interesting article cited  above), the main
point in Bassereau's distinction between the two kinds of sores
lies not  so much in their difference in form, as in the fact that,
according as any sore from which an infection is derived, remains
local, or is accompanied or  followed by constitutional symptoms,
so also will the sore in the individual infected remain local, or
be followed by constitutional syphilis.  In any given case, then,
the inquiry should be : Was there any syphilis in the infecting 
              DOCTRIXES OF  UNITY AND DUALITY.          107

source?  To this question the confrontations of Bassereau and
of many others, and indeed daily experiences give  the most
unmistakable answers.  And the results of experiment will tend
far more to sustain than controvert the inference.
   Practically, the doctrine of unity can only mean that the
venereal poison is capable of producing syphilis, whether the
primary affection appears  under the form of a soft chancre,  or
after a considerable  period of incubation under the form of a
papule, with subsequent superficial ulceration and  induration ;
and  hence, that an infection from the secretion of a soft chancre
may be either followed by a soft chancre again, or by an indura-
tion and constitutional syphilis ; and that,  on the  other hand,
an infection from the secretion of an induration or other syphi-
litic local affection may be followed by a simple soft chancre.
The  doctrine of  unity therefore  affirms that, under whichever
form the poison  manifests itself, this  form may become again
converted into the other.   There is a certain degree of truth in
this, so far as the forms of the sores are concerned, but not with
regard to the whole  disease  process.  The rule is, and this  is
admitted, too, by believers in the unity of  the  poisons,  " that
between healthy individuals the  soft chancre and constitutional
syphilis are transmitted separately as such, with the same effects
in the infecting party as in the party infected"  (Kobner).1    In
many of the cases observed clinically which  appear  exceptional
to this rule, is it not  reasonable to question  the accuracy of the
observations, or to doubt  the inferences drawn  from  the facts,
when we daily witness the  confirmation of facts now,  which
some few years ago  were never mentioned  even,  were  in fact
entirely  overlooked, as the incubation of syphilis for instance.
Should not the apparently exceptional cases rather be made  to
conform  to the rule?  The theory of the transmission simulta-
neously of two species of infectious matter, each of  which devel-
ops effects peculiar  to itself,  seems to me far less difficult  of
acceptation, and to accord better with observed facts than the
hypothesis that the syphilis poison and the contagious principle
of chancre are one and the same thing.
'L.c, p. 73. 
108
BAUMLER.—SYPHILIS.
   In view of the facts which we have now learned, the  theory
of chancre and syphilis, and their relations to one another, may
be formulated as follows :
   1. The  chancre (soft  chancre)  is  a contagious local affec-
tion which is inoculable upon  the bearer, and upon others, both
healthy and syphilitic, to an almost unlimited extent.   It devel-
ops  without incubation in twenty-four hours.  Through resorp-
tion an irritation of the  adjacent glands takes place, which has
an acute inflammatory character, and usually leads  to  suppura-
tion, but  is not followed by constitutional syphilis.   This pus
has the same properties as the chancre pus.
   By reason of the facility with which inoculations are effected,
several chancres often  occur  in the  vicinity of each  other by
direct communication.
   Sores, more or less resembling the chancre, perhaps  identical
with it, and likewise inoculable in generations, may be artificially
produced  by the inoculation of syphilitic subjects with syphili-
tic,  or even  non-specific purulent  secretions,  and  as  it  seems,
too,  through the inoculation  of non-specific pus upon healthy
subjects.  The ulcerative action is probably due solely  to the
pus, though its activity may be increased by means  of the pecu-
liar constitution of the subject inoculated.
   2. The syphilitic poison contained in the secretion of a syph-
ilitic primary affection,  in that of the various syphilitic local
manifestions,  and in the blood,
   a. When  inoculated upon  healthy subjects causes  at the
inoculated point, after a period of incubation of three or four
weeks, a papule, which becomes gradually indurated and often
superficially ulcerates.  After  a further incubation-period there
follow  the general symptoms of syphilis.
   In very rare and  exceptional cases the  local primary mani-
festations  recede without general symptoms  following.
   In another class of no less  exceptional cases, probably under
the influence of a personal predisposition, there occurs, immedi-
ately after the inoculation, a  local inflammatory process, with
ulceration, as in the soft chancre, by means  of which the devel-
opment of the syphilitic poison is, very likely, counteracted  in
the part infected, and the poison may be thus destroyed.  But 
          MINUTE ANATOMY OF PRIMARY AFFECTION.       109

under certain  circumstances, where,  notwithstanding  this, the
syphilitic poison takes, induration will follow later, together
with general syphilis.
   b.  When inoculated upon those already syphilitic the syphi-
litic poison either cannot be inoculated with any effect at all, or
else a small abortive pustule is produced, or there results a soft
sore, with  all the characters  of the  chancre (Clerc's chancroid).
This result is  obtained with certainty if the secretion is taken
from  a  syphilitic  primary  affection, or a constitutional  local
manifestation,  which has  been artificially irritated into a pro-
fuse  suppuration.
    3. When the induration has been developed gradually in a
chancre, or where syphilis follows the latter without any indu-
ration having  been perceptible, it  is to be supposed, in the great
majority of cases, that a double  infection has taken place,  on
the one hand,  from an intensely irritating pus—chancre poison
—and on the other, from true syphilis poison.   The parent sore
was either  double (chancre and syphilis), or it was such a sore
as we have just considered (an indurated chancre), or possibly a
chancre in a person already syphilitic,  that is, a chancroid of
Clerc.
    When we remember the multiplicity of secretions which are
often mingled  together at the  infecting  source, there is no won-
der that, in practice, syphilitic infection does not preserve the
pure  and  simple character which is observed in  pathological
experiments.
    Hence we accept only one  syphilitic poison, but in another
sense from  that given to it in the doctrine of unity.  We do not
regard the contagious principle of chancre as identical with this
poison.  It is  a pathological agent  by itself, but a far less con-
stant and uniform one than the poison of syphilis, since we have
seen that it may be generated de novo under the co-operation of
certain influences, and quite independently of syphilis.

      MICROSCOPIC  ANATOMY  OF THE PRIMARY AFFECTION.

   Robin et Marchal de Calvi, Acad, des Sciences, 2 Nov., 1846.— Virchow, Tageblatt
der Naturforscherversammlung in Tubingen,  1853.   (Canstatt's Jahresb., 1853, 
110
BAUMLER.—SYPHILIS.
II., S. m).—Buhl, cit. by v. Lindwurm, Wurzb. med. Zeitsch., III., 1862, S. 154.
—Auspitz, Ueber die Zelleninfiltrationen der Lederhaut bei Lupus,  Syphilis und
Scrophulose.  Zeitschr. d. Gesellschaft d. Aerzte in Wien, Med. Jahrbucher, XX.,
2, 1864. S. 222.— A. v. Biesiadecli, Beitr. z. phys. u. path. Anat. d. Haut.   Sitz-
ungsber. d. kais. Academie zu Wien.  Math, naturw. CI., 1867, S.  2ZS.—E. Ver-
son, Zur Lehre der syph. Indurationen.  Virchow's Archiv, B. 45, 1869, S. 117.—
A. v. Biesiadecli, Ueber d. Verhalten der Lymphgefiisse im harten Schanker.  Unters.
aus cl.  path.-anat.  Institut in Krakau, 1872, S.  1.  Schmidt's Jahrbucher, B.
160, 1873, No. 10, S. 60.—M. Kaposi, 1. c.  (See also the literature on p. 3.)

   The microscopical examination of the syphilitic primary af-
fection shows the tissue of the cutis and mucous membrane to
be filled with great numbers of nucleated cells,  which  are very
closely crowded  together  between  the otherwise   normally
appearing  connective-tissue bundles and with especial density in
the adventitia of the blood-vessels.   The capillaries  also show
numerous  cells in their markedly thickened  walls.   According
to von Biesiadecki, whose description we follow mainly, where
the primary  affection is distinguished by a very pronounced
induration, these  cellular infiltrations in the walls of  the  blood-
vessels extend far beyond the deposit proper.  The calibre'of the
considerably thickened blood-vessels is diminished, though  the
vessels still  remain pervious.  The mucous layer of the epider-
mis is not at first involved, but as the cells keep on accumulat-
ing they gradually  encroach upon the mucous layer also, so that
the boundary between this and the corium becomes more and
more indistinct, and  the epithelial layer  becomes  constantly
thinner.  In  this way the regeneration of the  horny  layer is
impaired,  and  molecular  disintegration and  ulceration take
place.  The  disintegration  may  remain  quite  superficial  or
extend deeply, even encroaching upon the tissue of the cutis,
in which case its connective-tissue fibres become  transformed
into a granular mass.
   The changes in the blood-vessels explain the remarkable dry-
ness and rigidity of the tissues in the syphilitic  initial sclerosis,
as well as the waxy whiteness that takes place upon slight pres-
sure.   But the peculiar, often cartilage-like, hardness of the pri-
mary affection in many cases is not fully accounted for  in the
above description;  for,  according  to Auspitz,  a quite similar 
          MINUTE ANATOMY OF PRIMARY AFFECTION.       Ill

cell infiltration obtains also in certain cutaneous diseases, as in
lupus for example, where no such hardness is manifested.  Aus-
pitz  regards  as the  chief cause  of the hardness an amorphous
substance, first described by him, which is interposed between
the cells and the normal tissue elements.  But in many cases a
true new formation of  connective tissue from the infiltrated cells
seems  to be  the  source of the hardness in  the higher grades of
the induration, as was shown by Verson, and again recently by
von Biesiadecki.   This new formation of  connective-tissue fibres
occurs particularly, according to the latter, in the peripheral
portions, where, in consequence of  the  collateral hypersemia, an
oedema has taken place.
   Von Biesiadecki found the lymphatic vessels within the mor-
bid  deposit enlarged,  when, in consequence of  an extension of
the disease to the walls of  one of the main branches of the lym-
phatics, the  latter had suffered  a  contraction of its  calibre or
was plugged by a coagulum.
   The inquiry naturally suggests itself here as to how the mi-
nute anatomy of the  soft chancre is related to the above pro-
cesses.   Buhl found the tissues spongy, and likewise (though
less densely) infiltrated with cells, and  the  blood-vessels were
enlarged.  On the contrary, von Biesiadecki did not find any
such very marked differences as might have been expected.  Of
five cases, four showed  decided infiltration of  the walls of the
blood-vessels, but in less degree than in the hard sore.  In one
instance his  results agreed with those of Buhl, in that the infil-
tration of the walls of the blood-vessels was wanting, the vessels
enlarged, and the tissue of the cutis and the cells of the mucous
layer were swollen up.
    Since the cells which infiltrate the tissue are doubtless de-
rived from the blood-vessels, it is not strange that,  under certain
circumstances, the chancre and the syphilitic primary affection
should present  almost  identical appearances,  especially with
regard to the accumulation of cells in the sheaths of the vessels.
In the soft chancre, where the entire process of infiltration runs
an extremely acute  course, it makes a  great difference at which
stage the examination is made, as to whether we shall find the
walls  and sheaths of  the  blood-vessels filled with cells  or free 
112
BAUMLER.—SYPHILIS.
from them.   But in the syphilitic initial sclerosis, which runs a
decidedly chronic course, there will be a greater accumulation of
cells, and when the process continues for a considerable length of
time, the cells in  places develop  into connective tissue.   The
higher  grades  of  the induration,  which depend probably, as
already mentioned, upon the formation of new connective tissue,
only occur when the process has a considerable intensity and has
been of long duration. Moreover, outward influences are doubt-
less not without their effect; hence, we see the induration reach
its highest grade in places that are exposed to external irritations,
as the orificium prseputii and urethra?, the borders of the  labia
majora and the lower lip.   But very  marked indurations occur
also on the posterior fold of the prepuce and in the sulcus coro-
na? glandis.  From these cartilaginous indurations  to  the flat,
paper-like thickenings of the mucous membrane, where the  in-
creased resistance is perceptible only in feeling of it sideways, all
imaginable intermediate stages occur, the one thing common to
them all being the dense cellular infiltration  of the tissue of the
cutis or mucous membrane.
   Induration has therefore  been often  taken in  too narrow a
sense, only pronounced types  being regarded as  indurations,
while sores in which only a slight degree of  hardness could be
felt, were held to be simple chancres.   Slight thickenings of the
mucous membrane belonging to the category of the parchment
indurations were, therefore, not looked upon as syphilitic pri-
mary affections at  all. Many apparent inconsistencies in the
doctrine of the primary affection or seemingly exceptional cases
are the  result of such misapprehensions  of the real facts.  For
besides the multiform  character of the anatomical appearances,
it must be remembered that the opinions of different observers
are often at variance with  regard to  the signs present in any
particular case.   When  we  reflect that Ricord, with  his un-
doubted faculty for observation, and with the immense material
at his command, made every chancre,  in spite of numerous inoc-
ulations, become indurated by the fifth day, we can partly appre-
ciate how often less experienced observers may have claimed  an
induration where none existed, and been unable  to detect one
really present.  But in many cases the signs do not admit of a 
          MINUTE ANATOMY OF PRIMARY AFFECTION.       113

positive decision.   If an affection is  seen  to begin as a papule,
at a certain time after a possible occasion for infection, and after-
wards gradually enlarging, there is, to be  sure, but little diffi-
culty in determining the true nature of the case ;  but if, follow-
ing immediately after an infection, a pustule appears, with subse-
quent ulceration, which is, perhaps, afterwards neglected by the
patient, or irritated in various ways, as by improper treatment,
it is often impossible to decide whether it is a specific induration
or a mere inflammatory infiltration.  Such a simple inflammatory
thickening, with slight oedema, sometimes forms at a point where
the preputial ring has become gangrenous in an irreducible para-
phymosis,  or upon a torn frenulum, simply due  to an extreme
derangement of the local circulation.   In such cases it is often
quite impossible during the first few days to say whether a syph-
ilitic induration is not in process of development.  Therefore,
ulcers may occur on the genitals which show a  distinct hardness,
but  which are not followed by  syphilis,  and for  the  simple
reason that they were not produced  by the syphilitic poison.
Cauterizations  of  soft chancres, or simple applications of the
nitrate of  silver, are especially apt  to be the  occasion  of  such
thickenings.
   On the other hand, the induration may be very inconsider-
able or obscure in local affections which are  followed  by con-
stitutional syphilis.   Particularly is  this  said to  be the case
in the female genitals ; indeed, it is asserted  by a large num-
ber  of notable syphilographers,  that an induration  upon  the
female genitals is, in fact, a rare occurrence. From my own
experience I cannot concur in this opinion.   In the vast majority
of cases in which a recent syphilis came early enough under my
observation, the primary affection was present as a dry or ulcer-
ating induration upon one of the labia majora, or else as a simple
parchment-like thickening upon the borders of  the labia minora,
or in the form  of  several papules in  process of conversion into
flat condylomata.   Fournierl very  properly calls attention to
the fact that the induration in females often cannot be felt, for
the simple  reason that in  certain places,  as in the  introitus
               1 Lecons, p. 46.
VOL. III.—8 
114
BAUMLER.—SYPHILIS.
vagina?, it is impossible to make the examination by touch in
the proper manner.  Nevertheless, I have been able in one case
to demonstrate an unmistakable induration in a superficial sore
in this situation.  Cooper Forster is also of  the opinion that  in-
durations occur much oftener in women  than has been supposed.
Typical indurations may be observed  in various  situations in
the external organs of generation, and also upon the os uteri.
They occur in the form of dry or moist papules (condylomata
lata) or extensive parchment-like  thickenings, or of merely small
and superficial erosions, in which a slight degree of hardness
may  be felt by  pressing from the  sides.  It is, moreover, in
females that multiple  venereal  affections are most apt to occur,
and these may  give  rise to a false conclusion.   Thus  a soft
chancre may appear upon the vulva, while a syphilitic primary
affection has its seat upon the  collum uteri, where it  might be
easily overlooked.
   Absence or indistinctness of the induration may  be  owing
to the fact of ulceration ensuing and extending so rapidly as to
entirely obliterate a very superficial or parchment-like syphilitic
induration.   Notwithstanding this, the  poison may penetrate as
far as the lymphatic glands and so produce  its effect.   Thus
one might think that  constitutional syphilis had succeeded to a
soft chancre.  According to Henry  Lee,1  the  number of cases
where syphilis ensues upon unquestionably soft chancres, does
not  exceed the number of those in which the way  of  access
generally of  the  syphilitic poison into the system is not dis-
coverable.  Thus we see how the views of syphilographers differ
in regard to such an  apparently  simple question, and  we thence
draw our inferences  of what  value is to be  placed  upon  the
alleged numerous clinical proofs of the  doctrine of unity, based
upon the occurrence  of constitutional syphilis following a soft
chancre.
   When left to itself the  indurated primary affection,  if  the
induration is extensive, has a  very protracted course. Months
are necessary to  its involution, even where a specific treatment
has been pursued.  In large flat  indurations upon the external
1 Brit. Med. Journal, 1868, VoL II. p. 568. 
          MINUTE ANATOMY  OF PRIMARY AFFECTION.       115

integument of the penis, the process of involution may be fol-
lowed very closely.   The elevation  gradually decreases, and as
the softening goes on, it becomes somewhat hollowed or umbili-
cated, and as it falls more and more to the level of the surround-
ing skin, the redness disappears and is succeeded by a brownish
pigmentation, which at the periphery is uniform  and pretty
sharply defined, while in the centre, where slight ulceration has
been, pale cicatricial lines traverse it in a reticulated form.  The
pigmentation disappears in the course of time, but is often to be
seen for years afterwards, notably towards the edges.
   In large indurations upon the glans, first the cartilaginous
tubercle softens,  the pale, waxy hue gives place to a decided
vascularization, and,  even after the total  disappearance of the
hardness there remains for a long time a considerable  degree of
sponginess in the tissues, with marked distention of the blood-
vessels.  Pigmentation  does not take place  upon the mucous
membrane.
   The turning-point in the  softening  of  an induration,  when
left to itself, is generally coincident with the outbreak of general
constitutional symptoms, and the commencing involution is per-
haps  partly due  to  the influence of a febrile determination of
blood to the surface,  through which  a more active vital process
is induced in the indurated  spot.   In  case  a mercurial course
has been commenced before  this, its influence is quickly mani-
fested upon the induration ; but if for any reason the treatment
is suspended, the place  soon recovers its former hardness again.
If there was ulcertaion which had been benefited, it again begins
to increase, and an already commencing cicatrix may break out
afresh.  Such oscillations in  the course of the affection  occur
sometimes also where expectant treatment is  continuously pur-
sued,  or even where a mercurial course has not been interrupted.
   In several  cases in which  a mercurial course was  begun as
soon as the induration was well pronounced, and in which I was
able to watch the course of events closely,  four months elapsed
before the induration wholly  disappeared.   In  one  case  with
very marked induration in the sulcus glandis, the induration,
under the use of mercury, began rapidly to diminish in the  third
month of its existence, but had not  entirely disappeared before 
116
BAUMLER.—SYPHILIS.
seven months from  the infection.   Zeissl' never saw an indura-
tion under the action of mercury disappear entirely before ninety
days, but Clerc2 relates a case in which the  induration disap-
peared completely in twelve days.
   When an induration has entirely receded, the syphilitic pri-
mary affection is at  an end, often without a vestige of it remain-
ing ; but  more commonly it leaves a scar and a spot of pigmen-
tation.   But Hutchinson3 has made  the  observation  that the
induration, after it  has long been cicatrized, may relapse in the
same spot.  The scar becomes inflamed and hardened,  and may
even ulcerate without  a new infection  having  taken place.   In
one case this happened in four successive years.
   But these are extremely rare and exceptional cases.  Where
the point of infection, as in  a case that Eicord relates, can be
recognized after thirty years, through the presence of a distinct
tubercle,  it is no longer the original  induration which is present,
but a knot of cicatricial connective  tissue.   In case the ulcera-
tion has  extended uncommonly  deep,  the  loss of substance is
filled up  by  fibrous connective tissue, and that such a place
should for years afterwards be distinguished from the surround-
ing parts by its superior hardness is  not  at  all strange.  But
there often remains from the syphilitic primary affection either
no  scar at  all, or a very superficial and  perfectly  pliable one.
Large cicatrices are much oftener  the sign of a previous chancre
than evidence of syphilis.  Where there is a suspicion of antece-
dent syphilis, the discovery of a scar upon the genitals is there-
fore of but slight importance to the diagnosis, and  the hope of
ascertaining anything  from the presence or  absence  of  an indu-
ration in  a scar that has existed for  years cannot but lead to
erroneous inferences.

   A syphilitic primary  affection, characterized by a well-pronounced induration,
may sometimes be obscured through certain accidental conditions, which may stand
in a more or less close relation to the syphilis, or,  indeed, have nothing at all to do
  1 L. c., p. 55.
  2 Cited by Berkeley Hitt, p. 74
  3 London Hospital Reports, Vol. III., 1866, p. 378.  Compare also Fournier, Du
pseudochancre indure des sujets syph.  Arch, gen., 1868.  Lecons, p. 592 s. 
             ENLARGEMENT  OF NEIGHBORING  GLANDS.          117

with it.   It has been already mentioned that a laceration of the frenum, or  gan-
grene at the preputial ring in paraphymosis, due to inflammatory and cedematous
infiltration, may produce an effect simulating the syphilitic induration.  This is
sometimes the case in a still greater degree in fistulous ulcers, such as occur in the
glands of Bartolini.  Such callosities may develop about fistulous sinuses of the most
various description, having no connection with syphilis whatever.  Papulae upon the
genital mucous membrane, belonging to a general papular eruption on the body,
may bear a very deceptive resemblance to a primary papule, especially where in cer-
tain favorable localities they ulcerate superficially or become (as is apt to occur in
the female genitals) indurated.   In this situation the transformation into condylo-
mata lata is of the  most  common occurrence.  To  the conditions simulating the
primary affection belong, also, cancerous new growths, particularly epithelioma, it
being often necessary to resort to the microscope before making a positive diagnosis.
    Sometimes in patients who have already been syphilitic for a long time, a fresh
infection causes at first a soft chancre, in which gradually a certain degree of hard-
ness is developed, so that it might be regarded as the primary affection of the exist-
ing disease, or as a fresh syphilitic infection. Henry Lee,1 who has called attention
to this occurrence more especially, thinks  that in these cases the induration is due
to the  influence  of the  already existing constitutional  syphilis.  Finally, in the
later periods of the disease gummata may develop upon the genitals, which, either
with or without ulceration, may bear the greatest resemblance to a syphilitic pri-
mary affection.


ENLARGEMENT OF THE  LYMPHATIC  GLANDS  IN  THE REGION  OF
                      THE PRIMARY AFFECTION.

    This is one of the most constant as  well as, in a diagnostic
point  of  view, the  most  valuable  of  all  the symptoms  of  the
syphilitic  infection.    Fournier2  found it missing  in only three
cases out of 265 men, and three out of 223 women.  The route by
which the virus  reaches  the glands may sometimes be  traced
through a portion of  its course by a thickening of the lymphatic
vessel, which can be felt beneath the normally appearing skin
as  a  narrow  and exceedingly  hard cord.   Von Biesiadecki3
found  the  muscular  fibres in such lymphatic  vessels enlarged,
through the presence of  numerous exudation cells; the adventi-
tia was contracted, containing only a few of these cells ; the ves-
1 Holmes' Syst. of Surg., I. p. 439.  Conip., too, Fournier, 1. c.
2 Legons, p. 201.
8 Schmidt's Jahrb., 1873, B. 160, S. 60. 
118
BAUMLEE.—SYPHILIS.
 sel was in places plugged by a coagulum or  closed by a thicken-
 ing and  folding of the intima.   The immediate  vicinity of the
 lymphatic vessel was but little changed;  rarely a few exuda-
 tion cells  appeared between the  fat cells.   Yon B. believes he
 has discovered the explanation of the fact that the changes in
 the lymphatic vessels are independent of any infiltration in their
 vicinity, in the presence of a few blood-vessels in the walls of the
 lymphatic vessel;  the cells  found in the walls of the  lympha-
 tics are probably derived from these blood-vessels.  The course
 of this chronic lymphangioitis is very slow, and invariably ter-
 minates in resolution.
    When the primary affection is situated upon the genitals the
 intumescence of the lymphatic glands takes place very gradu-
 ally, and is never perceptible before  the primary affection ; usu-
 ally, not until several days after the latter  has appeared.  In a
 few cases, which I had the opportunity of observing from the
 start, at least from five to six days elapsed from the first appear-
'ance of the primary affection before  a slight glandular  enlarge-
 ment could be perceived ; usually of  but a single  gland at  first.
 In several cases where the syphilitic poison was inoculated artifi-
 cially, and attention was directed to this point, the swelling of
 the lymphatic glands was not observed before from the eighth to
 the eleventh  day  after the  appearance  of  the primary papule
 (von Barensprung, Hebra).
    The glandular  swelling  attains  no  very great magnitude.
 The  inguinal  glands become  as large  as from  a hazel-nut to
 a pigeon's egg,  are  not usually  tender  on  pressure, and gen-
 erally occasion  the patient  no  annoyance, even  when fully
 developed. For this reason they are termed "indolent" bu-
 boes.  Only very rarely have patients who were  in the  habit of
 closely observing  their bodily  condition  complained  to  me,
 from the commencement of the glandular swelling, of difficulty
 in walking.
    It is not a single gland only that becomes enlarged in the
 inguinal  region,  but those adjacent also become gradually swol-
 len, though  not always in regular succession, sometimes skip-
 ping over one ; this being due to the manner in which the sev-
 eral  glands  are  connected with  the lymphatic  vessels of the 
           ENLARGEMENT OF NEIGHBORING GLANDS.        119

genitals.1  After a time a bundle or chain (une plejade, Ricord)
of such swollen lymphatic glands make their appearance, vary-
ing in size, hard to the touch, slightly movable underneath the
integument, which  is  neither  reddened  nor  otherwise altered.
When the glands affected in the inguinal region are both nume-
rous and  very much swollen, the skin appears  noticeably ele-
vated above a smooth,  somewhat nodulated tumor.
   The swelling of the glands is not always  symmetrical when
the infectious matter has been deposited upon the genitals, nor
does it always occur first upon the side corresponding to the seat
of the primary affection.  I have  repeatedly seen a lymphatic
gland upon the opposite side, contrary to  expectation, become
enlarged before those of the same side with  the primary affec-
tion.  Considering the  multitudinous anastomoses of the geni-
tal lymphatic vessels, this is no more to be wandered at than
that the lymphatic glands in both inguinal regions  should be
attacked in spite of  the primary affection being  situated only on
one side.
    This enlargement of the  lymphatic glands, which  is due, as
may be inferred from the period at which  it takes place,  to a
resorption from the primary affection, is, moreover, of very great
value practically,  since it often gives the first clue as  to the
point where the syphilitic poison was first deposited.  While the
inguinal glands of one or both sides will be attacked, if the seat
of infection was upon  the genitals, the submaxillary glands will
be swollen if the infection occurred upon the lips.  I have seen
several cases where, in the presence of an induration upon the
lower  lip, a  gland underneath the chin has become enlarged
almost  to the  size  of  a pigeon's egg.  Where  the infection is
upon one of the fingers, the  corresponding cubital glands swell,
or a number of the axillary glands become also swollen, or, as I
remarked in one case, the glands  in both these situations  may
become enlarged at the same time.  If the  nipple has been the
seat of infection, a swelling takes place in certain glands on the
side of the thorax below  the  pectoralis major, or in the deeper
  ■  Compare figure in H. Auspitz, Die Bubonen der Leistengegend.  Arch. f. Dermat.
u. Syph., V., 1873, S. 453. 
120
BAUMLER.—SYPHILIS.
glands of the axilla.  The older writers, as Astruc,1  have also
directed  attention to  these glandular  swellings in the various
situations of the primary affection.  It occasionally happens that
there has been only a slight erosion at the point of infection, or a
small papule only, which became but slightly indurated or has
already vanished by the time the case is examined, and then the
discovery of an indolent, glandular swelling may become of the
greatest assistance in finding the obscure vestiges of the primary
lesion.
   Histologically these glandular  swellings represent a hyper-
plasia of  the  cellular  gland-elements.   According  to Rind-
fleisch,2 the chronic  induration  of  the  glands  is due "not  so
much to a hardening and enlargement of the reticulum, as to a
very uniform,  though by no  means  exuberant  production  of
young cells in all portions of the gland."  The involution is
effected through fatty metamorphosis and absorption.   Under
certain circumstances  caseous and calcareous degeneration may
take place.
   The course is always very tedious.  If left to itself the glan-
dular swelling will  continue  to increase for  weeks,  and  even
under an anti-syphilitic treatment it is long before a diminution
in size is perceptible.  In one case that was under my observa-
tion, where there was a moderate glandular swelling in the ingui-
nal regions, which was treated internally with mercury (bichlo-
ride) and followed a  mild course, on apparent diminution in size
took place before eight months from the time of  the infection ;
the swelling persisted, therefore, for more than six months.
   In  individuals of  a so-called  scrofulous  constitution, the
swellings of the lymphatic glands may  attain a much higher
degree.  Such  persons are usually predisposed to considerable
glandular enlargements, after even slight peripheral irritations,
which often go on to suppuration,  or even caseous degeneration.
In such persons the syphilitic poison, too, may occasion a suffi-
cient irritation for such marked changes.
   Exceptionally, in persons with good constitutions,  from  an
unfavorable mode of  life, or through walking too much,  or in
1 L. c, p. 94.
2 L. c, p. 177. 
            ENLARGEMENT OF NEIGHBORING GLANDS.        121

consequence of other bodily exertions, the cellular tissue in the
vicinity of an indolent glandular swelling may become inflamed,
and the  overlying skin  show  a considerable  redness.   If the
patient remains quietly in bed,  such an  inflammation  quickly
recedes.  Actual suppuration of a syphilitic bubo is  extremely
rare.   Fournier observed it in but three cases out of 265 syphilitic
men,  and in five out of  204 women.  Such a bubo suppurates,
then, as any ordinary  glandular abscess.   No chancre  sore  is
developed.
   The acute  lymphadenitis, by which  the soft chancre is followed, is essentially
different from the glandular swelling that accompanies the syphilitic primary affec-
tion. In the former only a single gland (rarely are several swollen) becomes enlarged
in the course of a few days, with great pain and other inflammatory symptoms. The
inflammatory process extends rapidly to  the surrounding cellular tissue, and to the
skin lying above it, so that the gland beneath is no longer movable.  An erysipela-
tous redness often extends over a considerable region.  After a few days, fluctuation
becomes perceptible, and a collection of pus is present.  The pus from such  an
abscess is also inoculable, like the preceding chancre, and often exhibits this prop-
erty upon the wounded skin covering it,  which is converted into a true chancre sore,
and this may involve the parts adjacent to a considerable extent and depth.

    The syphilitic, indolent,  glandular swelling does not  remain
confined to the gland that lies nearest the point of primary infec-
tion,  but others lying  in the  course of the  lymphatic vessels
become also involved.  Thus far this has been demonstrated only
as  far as the  glandula? iliacse; but theoretically  the glandula?
lumbales should next gradually become infected, and so the poi-
son passing thence  through  the truncus lumbalis  to the ductus
thoracicus  finally arrive in the  general circulation ; but we  have
no  anatomical proof as   yet with regard to  the entire route.
Henry Lee,1 however, affirms, with much  positiveness, that the
glands of the second order, that is, such as receive their lymph
from  other  glands, never  become affected through  resorption of
the specific poison of the primary disease,  and thence  concludes
that the  syphilitic poison does not,  as has been generally sup-
posed since Hunter's time, infect the body by way of the  lym-
phatic system, but  through  the blood circulating  either in the
»L. a, p. 413 and 418. 
122
BAUMLEE.—SYPHILIS.
primary affection or in the primarily affected gland.  But among
the reported  cases  of  artificial inoculation of syphilitic poison,
there are two where,  the inoculation having been made upon
the chest, not only were the first group of  glands enlarged, but
also those of the second and third order, an indurated lymphatic
cord connecting them with each other (vid. Cases II. and III. of
Bidenkap,  p.  97).   Moreover,  Fournier1 has  reported  certain
observations  which tend  decidedly  to sustain the Hunterian
view.
  In the collection of the Hopital de Lourcine there are three preparations of women
who died of intercurrent diseases while affected with syphilitic sores on the vulva.
In these preparations not only the inguinal glands are swollen, but there is a hyper-
plastic enlargement of a number of glands above Poupart's ligament. In the second
case there occur in the fossa iliaca, along the blood-vessels, nine enlarged glands,
arranged, in three groups, one above the other, the uppermost at the origin of the
art. hypogastrica.  The enlargement of the glandula? iliacac had attained nearly the
same degree as that of the gl. inguinales, among which one or two  on  each of the
three preparations were distinguished through their greater size as the  ones first
attacked.
    The fact that hitherto there have been so few careful anatomi-
cal investigations with reference to this point, is doubtless to be
attributed to the rarity of opportunities for such  examinations ;
there has also been a lack of  microscopical examinations of the
more centrally situated glands, which, while appearing intact  to
the naked eye, might reveal certain  changes to  the  microscope ;
for we have seen how it has enabled us to follow the cellular infil-
trations extending from the primary affection over large tracts of
the blood-vessels.   As  soon  as attention  has once been fairly
directed  to this  point, advantage will be  oftener taken of the
opportunities occasionally afforded for anatomical examinations
of  syphilitic  subjects who die during  the development  of the
disease, or just at the outbreak of general symptoms, in order to
decide the question on strictly anatomical grounds, whether the
infection of the  organism takes place by way of  the lymphatic
system or not.
    It is  not  to be disputed that a portion of the poison may be
taken up directly by the blood-vessels circulating in the primary
1 Lecons, p. 213. 
THE  SO-CALLED SECOND INCUBATION.
123
affection and in the indolent buboes.  In behalf  of the theory
that the entire blood infection takes place only in this way, may
be alleged the fact that the period which elapses from the first
infection to the outbreak  of  general symptoms is of about the
same length, whether the point of infection had its seat upon the
upper arm or upon the genitals,  in which latter situation there
are several groups of glands which have first to be passed.
   It remains to be mentioned that Bassereau and Clerc main-
tain,  that in certain  rare cases  the  lymphatic glands do not
show any alteration at any period of the disease.  This  applies
probably  only  to  extremely mild  cases.  Where the glandular
affection is very slight, it may be exceedingly difficult to decide
whether there is any enlargement or not, as in very fat persons
especially, where it is often absolutely impossible.
   The question as to whether a lymphatic gland may be imme-
diately attacked without a previous primary affection upon the
skin—the  so-called bubon d'emblee of the French—has been
already considered above  (vid.  p. 79) in speaking of infection
without primary lesion.


             THE  SO-CALLED  SECOND INCUBATION.

    The period between  the  first  appearance of the  syphilitic
primary affection and  the eruption of general symptoms is some-
times designated  as the second incubation;  this is the period
which is  required by the  syphilitic  poison so  to increase as to
gradually infect the total mass of fluids throughout the body.
One may imagine that not only from the first infected point, but
from all the lymphatic glands, acting as depots in which the virus
accumulates, does the  blood gradually become saturated with the
syphilitic  poison.  It  is not until this saturation has reached  a
certain degree, which  differs  in different cases, according to the
irritability of the  particular organism concerned, or of certain of
its tissues, will symptoms appear  at remote points or throughout
the system.  It is obvious, then, that the diffusion of the poison
through  the  body takes place  very slowly.   Several weeks
always elapse from the first  appearance of  the local  affection
before the point  is reached where general symptoms break out, 
124
BAUMLEE. —SYPHILIS.
and this circumstance speaks also in favor of the theory that the
poison advances by way of  the lymphatics, and the slowness of
this advance finds its explanation in the hindrance  offered to
the passage of the virus by the lymphatic glands.
   On an average, the duration of the second period of incubation
is from six to seven weeks; the whole time from  the infection
to the outbreak of general symptoms, from nine to eleven weeks.
In a few cases that came under my observation, in which I was
able to determine accurately the limits of the second incubation,
it amounted to thirty-five, forty-four, and fifty-four days.  In the
cases  of experimental inoculation (vid. table, p. 76) the shortest
period noted is twelve days (Gibert's case), the longest, 139 days
(case of von Rinecker); it may therefore vary, within very wide
limits, between two and twenty weeks.  The causes of these vari-
ations are for the  most part unknown.   It is commonly stated
that a mercurial course begun  immediately after the appear-
ance of the primary affection may prolong this period. It is said
also that  the general symptoms then not only occur later,  but
are more  isolated and present  a less  typical  picture  of  the
disease.  On the contrary, a shortening of the second period of
incubation is sometimes caused  by certain unfavorable  influ-
ences  acting  upon  the system,  such  as deprivations, excesses
(notably in the use of alcoholic drinks), great physical exertions,
and mental and emotional  disturbances, in  short, debilitating
influences of all kinds.
   As the poison thus  increases in  the  body, and  gradually
becomes diffused, in many patients, besides the changes at the
point  of infection and the enlargement of the lymphatic glands,
no further derangement of the general health is apparent; they
retain their  normal color and do not feel ill.  But in  many
others, especially weakly subjects, and  in females particularly,
a gradually increasing anaemia makes its appearance, and  the
patients complain of a sense of indisposition, languor, and  like
symptoms, and there is developed a sort of condition like chlo-
rosis.   The alteration in the constitution of the blood upon which
this condition depends, stands in  a close relation to the  hyper-
plasia of  the lymphatic  glands,  which latter deliver a  larger
number of white  corpuscles into the circulation  than  usual; 
               THE SYPHILITIC  ERUPTION FEVER.            125
but  it  is also connected  with certain other, as yet unknown,
processes in the development of the blood (vid. above, p. 33).
   In  many cases the  commencement  of  general symptoms,
together with  the termination  of the second period of incuba-
tion and the  primary  stage  of the disease, is very  sharply
defined ; quite as sharply as in one of the acute exanthemata.
As in small-pox or measles,  so in syphilis also, may an eruption
fever suddenly occur, as the precursor of, or as an introduction
to further symptoms.
               THE SYPHILITIC ERUPTION FEVER,

 J. E. Giintz, Das syphilitische Fieber.  Kiichenmeister's Zeitsch., Neue Folge, n.,
    1863, p. 123 ;  IV., 1865, p. 192. Extract from it in J.  E. Giintz, Das syphi-
    litische Fieber.  Leipzig, 1873, p. 56 and 63. The last-named work contains
    an almost complete compendium of all the information concerning fever in the
    course of syphilis that occurs in the literature up to  the  year 1873.—A Four-
    nier, Lecons, etc., p. 854.

    Mention  is made  of the eruption fever  of  syphilis  by the
 oldest writers on the morbus gallicus, many  of them  calling
 especial attention to the fact of its occurring under the form of
 repeated rigors  or  of evening exacerbations of fever.   But the
 febrile attacks that usher in  the  period of eruption in syphilis
 were not always distinguished  from  those  which occur some-
 times in the later periods  of the disease.   Hunter refers  to this
 distinction, however, in remarking that, at first, the fever  bears
 a close resemblance to a rheumatic fever, but later is more like a
 hectic fever.  We are indebted to J. E. Giintz for more accurate
 investigations concerning  the eruption fever.  By means of the
 thermometer he  succeeded in demonstrating the fact that the
 fever most frequently precedes the appearance  of any manifes-
 tations upon the skin, and  this has since been repeatedly con-
firmed by others.   Hence the relation is similar  to that which
 obtains  in the  acute exanthemata, where  the fever also pre-
cedes the eruption of the exanthem either  by one (scarlet fever)
or several (measles, small-pox)  days.  The morbific agent is
already  present in the body, but  different tissues and  organs 
126
BAUMLER. —SYPHILIS.
react towards it with  different degrees of  susceptibility, and
the  nervous system (upon which the occurrence  of fever is
mainly dependent) is  affected earlier and with greater facility
than the skin and other organs.
   In the rise of the bodily temperature we have a criterion for
determining with precision the period at which the general affec-
tion takes place.  Giintz states that the syphilitic fever com-
mences, most commonly, between fifty and sixty-five days from
the time of  infection (with a single exception it did not occur in
any of his cases before the  fortieth day); the period may also
be deferred till the ninetieth day.
   According to Giintz,  the fever may  consist  of a sudden,
marked  elevation of temperature occurring but once,  or it may
continue  for days,  during  which time  the  temperature  may
reach nearly 104° F., and then rapidly fall again.   This recession
of the fever is  often only temporary, however, and  merges into
remittent fever  of  a  ver}^ moderate grade, which  may last
for weeks.  As  in one case1 that  I observed thermometrically,
this remittent fever may also show very marked variations in
temperature, and, according to the  accompanying symptoms,
may present the most striking  resemblance to an intermittent
fever.   Similar cases have been  described  by the  earlier writers
also, as Cazenave,2 Yvaren,3 Zambaco,4 Lancereaux,5 and  many
others.
   As already remarked, the eruption fever is  not an invariable
occurrence.   According to Giintz, it appears in about twenty per
cent, of  the cases ; but this seems to me to be too low an esti-
mate.  According to Fournier it is commoner in womeii than in
men.
   The symptoms that accompany the eruption fever are of great
variety.   Apart  from symptoms which  pertain  to every more
  1 Ueber d. Verhalt. d. Korperwarme als Hiilfsmittel z. Diagn. einiger Formen syph.
Erkrankung. Deutsch. Arch. f. klin. Med., B. IX., 1872, p. 403.
  2L. c, p. 488 and 491.
  3 Prosper Yvaren, Des metamorphoses de la Syphilis.  Paris, 1854, p. 173.
  4 Zambaco, Des affect, nerveuses syphilitiques.  Paris, 1862, Case 74,
  6 L. c, p. 10y.  See also Giintz and Fournier, 1. c. 
                THE SYPHILITIC ERUPTION FEVER.            127

 marked elevation of temperature,  such as pains in the back and
 limbs, general lassitude, and a feeling of dulness in  the head, it
 is principally functional disturbances of the nervous system that
 occur here ; and these are commoner again, and of a severer form,
 in women than in men.  A very  remarkable  disturbance of this
 sort, to  which certain writers at  the time of the syphilis epi-
 demic, Petrus Pinctor (1500), for example, also  called  attention,
 is the craving appetite that  many syphilitic persons  manifest,
 notwithstanding the fever present.   Again,  violent headache,
 resembling in its course an intermittent neuralgia, and character-
 ized by nocturnal exacerbations,  belongs to  the commonest of
 these symptoms.  The pains in the limbs are  not infrequently
 confined  to particular joints, and, in fact, are sometimes associ-
 ated with swelling of certain articulations, so that under these
 circumstances the disease may simulate,  very  deceptively, an
 acute articular rheumatism.   R.  Volkmann' observes that he
 has once or twice seen cases which, at  the period of the  acute
 invasion  of syphilis, together with  an unusually marked syphi-
 litic exanthem and violent fever, manifested the above similarity
 to acute  articular rheumatism ; and he  also  states that  mono-
 articular hydarthroses,  particularly of  the  knee, commencing
 acutely, and then becoming very persistent, have  been  observed
 repeatedly.   Often but a single joint is affected, as, for instance,
 the  carpo-metacarpal joint of  the thumb ; and it is often this
 affection that  first brings  the patient  to the  physician; upon a
 careful inspection then, a roseola is found, with other symptoms
 of syphilis.   Treatment directed to the latter is usually followed
 by a rapid disappearance of the joint affection.
   Sometimes the symptoms—the violent headache, dizziness,  and fever—are of
 such  a kind that, without  careful attention,  an abdominal typhus might be in-
 ferred ; and in several cases I have observed  an enlargement  of the spleen where
there had been no malaria, in the stage of the syphilitic eruption.  The further course
of the affection, perhaps even one day more, renders the diagnosis  clear. The
breaking out of the exanthem shows that it is no simple catarrhal, or rheumatic, or
typhous fever, but the syphilitic eruption fever. If, as sometimes happens, the exan-
them  in syphilis breaks out suddenly, and in a very pronounced form, and particu-
1 Pithau.. Billroth, Handb. d. allg. u. special!. Chirurgie, B. II., 2, p. 504. 
128
BAUMLER. —SYPHILIS.
larly where the outbreak of the eruption occurs just at the acme of the fever, it is
possible to commit the mistake of confounding the disease with measles, the erup-
tion possibly resembling  that  of the latter disease, and the periods of time  with
reference to the occurrence of the exanthem corresponding in the two affections.
Should the eruption consist of disseminated tubercles, one might  easily think of
varioloid, especially if a rapid recession  of the  fever has taken place just as the
eruption made its appearance.   These are by no means  mere imaginary cases.  It is
not uncommon that the patients have not the least idea that the febrile symptoms
for which they seek medical aid have anything to  do with the perhaps insignificant
or (as is often the case in women) unnoticed affection upon the genitals; or  they
may intentionally conceal the  latter; or, in case the primary affection has an  unu-
sual situation, they may not even be aware  that they are infected.  A careful obser-
vation of the mode in which the exanthem appears, remembering that in syphilis a
much longer  period is required for its development, together with accurate  ther-
mometry observations of the course of the fever,  will  tend to render mistakes of
the above description infrequent.


   With the  access of  the  eruption fever,  or, in the absence of
this, with  the outbreak of an exanthem or affection of the ton-
sils and the parts in their vicinity, the  general infection is com-
plete,  and the disease has  entered upon its secondary stage, or,
according to Hunter1 s mode of expression, the syphilis has become
"constitutional."   The entire system is now under the influence
of the syphilitic poison, and every organ and tissue may suffer in
consequence.
   The various forms under which all  these parts  may become
affected will  occupy us in what follows,  the separate  organs
being  considered in  succession.  We here take leave of the  clini-
cal  course, which  our  discussion has  hitherto  pursued,  and
proceed  to  treat successively of the various series of pathological
changes, as observed in  each organ separately, either  during  the
course or in consequence of syphilis, together with the symptoms
thereby  occasioned. This  is mainly for the  sake of avoiding
repetitions, since otherwise a portion of the organs would  have
to be considered both in connection with the so-called  secondary
and  tertiary  symptoms; moreover, in  regard  to certain of  the
changes, it has not been positively determined to which series
they properly belong.   For the purpose of locating the symp-
toms with reference to the course of the disease, the  above gen-
eral  sketch may serve as our chart. 
      AFFECTIONS OF  THE  SKIN AND  MUCOUS MEMBRANE.    129

    LOCATION OF THE DISEASE IN THE  DIFFERENT ORGANS.
                 SKIN AND  MUCOUS  MEMBRANE.

Albers, Ueber d. Erkenntniss u. Natur der syph.  Hautkrankheiten.  Bonn,  1832.—
    P. L. A. Cazenave, Traite  des Syphilides.  Paris, 1843.—Bassereau, Traite des
    affect, de la peau, symptomatiques de  la Syphilis.   Paris, 1852.—H. Auspitz,
    Ueber d. Zelleninfiltr. d. Lederhaut, etc.  Wiener med.  Jahrbucher, XX., 2.
    1864,  p. 222.—A. v. Biesiadecki, Beitr. z. Phys. u. Path. d.  Ilaut. Sitzungsber.
    d. kais. Akad. zu Wien, 1867, S. 233.—J. Neumann, Ueber Syphilis der Haut.
    Wien. med. Presse,  IX.,  1868,  No. 7, 9.—Id., Lehrb.  d.  Hautkrankheiten,
    3 Aufl.  Wien, 1873.—M. Kvhn (Kaposi), D. Syphilis d. Schleimhaut d. Mund-,
    Rachen-,  Nasen- und  Kehlkopfshohle.  Erlangen, 1866.—Id.,  Die klin. u.
    histolog.  Charaktere der Syphiliden.  Wiener med.  Wochensch., XX., 1870,
    No. 55-57.—M. Kaposi, Die Syphilis der Haut u.  d. angrenzenden Schliem-
    haute, 2 Lief.  Wien, 1874.—The general works on syphilis given on p. 3.

    The affections of the skin, as the most apparent of  the  mani-
festations of  syphilis,  have  always  played a  very  important
role in  the  descriptions  of  the  disease.  The  earlier writers
embraced them all under  the name  of  "pustulce."   Still, they
described the various  forms under which they appear with  toler-
able  clearness.  Biett was the  first  who clearly delineated the
characters  of the different forms, with  reference  to elementary
changes in the  skin, and he adopted  the term "syphilide,"
previously employed by Alibert.
    The  skin undergoes certain general alterations in syphilis,
as in other chronic diseases, with respect to its lustre, softness,
and the amount of blood it contains.   We notice, particularly
in  the tertiary stage, or where there  is  a pronounced syphilitic
marasmus, a sallow, harsh, and flabby  skin.  But besides  these
a great number of special forms of skin affections  are  caused by
syphilis, and while a  part of these may be produced by  other
causes, many of  them are quite peculiar to syphilis.   But even
to  the  forms which are not  peculiar to this  disease, there  are
joined certain characters,  when  owing  their  origin to syphilis,
which  render them  immediately recognizable  as  syphilitic.
These peculiarities were recognized long ago;  not infrequently
there has  been too much stress laid  upon  them.   The  most
important of them are :
           VOL. III.—9 
130
BAUMLER.—SYPHILIS.
   1.  The Color—A. syphilitic efflorescence, after continuing for
several days, or especially where  it has lasted for a longer time,
often  assumes a peculiar red color, which Gabr. Fallopia com-
pared to the color  of  ham.  Swediaur chose the color of cop-
per for comparison, and a coppery red hue has, ever since, been
universally accepted as a characteristic  mark of the  syphilitic
eruptions.  The peculiarity of this  color consists in a combina-
tion of  yellow and brown, with the more or less dark red of
the efflorescence.  On inquiring into the source of  this peculiar
color, we find  that it is not an  exclusive mark (and therefore
not a specific one) of the syphilitic eruptions.  In every syphi-
litic efflorescence there is  a  circumscribed dilatation  of blood-
vessels,  together with a certain amount of exudation of,  mainly,
white blood-cells into  tlue  sheaths of the vessels merely, or also
into the surrounding tissue.   The  greater in degree the stasis,
the more abundant will the exudation also of red corpuscles
be,  and it is the alteration of  the  coloring matter in  these red
globules which imparts to the color of  the  syphilides, after they
have  remained  for  some  time,  their yellowish  or  brownish
shades.   These shades are  more distinct  in proportion as the
congestion of  the  vessels  and the  redness  thereby occasioned
recedes,  and they are more pronounced,  also, the longer  the
stasis has  continued.   In the same  way any efflorescence, or
its  immediate vicinity, or  scars  following ulcers on the lower
extremities, not due to  syphilis, may also assume this color.
Long-continued dilatation of capillaries and stasis  of the blood
is all that is  necessary to produce the  pigmentation.   When,
in addition, there is  such a  state of the blood as favors extra-
vasation of its corpuscles through the vascular walls, or capillary
hemorrhages such as exist in scorbuta, and occasionally  in mea-
sles and small-pox, the eruptions of these  diseases may present
a coppery color quite as marked as in the syphilides.
    The pigmentation left by  syphilitic eruptions is the result of
the conditions already stated.    The pigment of the  rete  Mal-
pighii becomes increased through  direct transformation of the
exuded coloring matter of  the  blood, or perhaps also in conse-
quence  of an alteration in the nutrition,  due to the influence of
the blood stasis.  If the rete Malpighii  has been destined by 
      AFFECTIONS  OF THE SKIN AND MUCOUS  MEMBRANES.   131

 ulceration, the scar is not pigmented, and its whiteness  is in
 striking contrast to its deeply pigmented border.   The pigmen-
 tation gradually becomes paler, and, unless unusually marked,
 it may entirely disappear.

   Pigmentation occurs also in the skin without a local hyperemia having preceded
 (ephelides, chloasma, Addison's disease). Likewise there may occur, in consequence
 of syphilis (almost exclusively in females, according to Fournier),1 irregularly
 shaped, grayish-brown pigment spots, especially upon the skin of the neck, which
 develop very gradually and continue for a long time in spite of anti-syphilitic
 treatment.

    The coppery coloration does not pertain to all forms of the
 syphilitic eruptions  in an equal  degree.   A certain intensity in
 the local  process and prolonged continuance  are  requisite.  In
 persons with very pale skin, and  particularly in such as, at the
 time of the eruption, are very anaemic, it is often wholl}^ wanting
 or makes  its appearance  only as  the exanthem begins to wane,
 with a yellowish color.  In persons with dark complexions  it is
 often very pronounced.
    2. Polymorphous character of the  exanthem.  In the syphi-
 litic eruptions it is very common to see  macules, papules, vesicles,
 and pustules side by side.   The reason of this lies in the chronic
 course of the syphilides.
    Notwithstanding  the anatomical basis is the same  for all of
 them, namely, a cellular infiltration  proceeding from the blood-
 vessels, different grades of the process  are sometimes attained in
 different  situations, corresponding to which different forms are
 exhibited.  Or the most different initial  forms may finally lead
 to one ultimate form ; thus, for instance, syphilides of the most
 various description may gradually all assume the form of ulcers.
 Where the course of  the skin affection is chronic, and the separ-
ate points of efflorescence do not make their appearance at  the
same time, different stages of development will be present simul-
taneously.
   Moreover, this polymorphous character is not peculiar exclu-
sive! y to  syphilis,  but occurs, though  in much less degree, in
1 Lemons, p. 422. 
132
BAUMLER.—SYPHILIS.
other chronic diseases of the skin (for example, in  eczema and
scabies).
   3.  The annular  form  of  a syphilitic efflorescence,  or  the
grouping together of several points of efflorescence, to form either
perfect circles or  segments of circles similar to those observed in
herpes circinatus.  This form  occurs  rarely in simple macular
eruptions, oftener in the papular, tubercular, and vesicular.   A
considerable  length  of time is  necessary to its production in  a
single efflorescence, and it is only in such as have a long duration,
as,  for example, a  papule or  an ulcerating  tubercle, that we
observe this  peculiar form, its development depending upon  a
gradual receding of the disease process in the centre, while at
the periphery it continues to advance  upon the  surrounding
sound  skin.   So the circle gradually extends,  or  its progress
being irregular or interrupted, only segments of circles are pro-
duced, or several  circles near each other may approach and inter-
sect, giving rise to extremely complicated forms.  A grouping of
several points of  efflorescence in the form of a circle also occurs,
sometimes, even at the very first eruption.
   Isolated eruptions, appearing after the acute period  proper
has passed, so-called relapses,  are especially prone  to take this
form either from the very  commencement or through a series
of gradual changes; it is also very pronounced in  syphilitic
ulcerations, notably  in the serpiginous  ulcers.
  The annular form is often very distinct, too, on  the mucous
membrane, especially upon the tongue, on  the hard and soft
palate, and on the glans penis.
   4.  The absence of itching  of the skin affected  with  syphi-
lides.   Very  often every  sensation that could be occasioned
by a skin eruption is so completely wanting in the syphilides
that many patients  are not  even aware  that they  have  any
eruption.   But there  are also exceptions where pretty violent
itching is present, especially where the exanthem comes on very
acutely.

The Different Forms of the Syphilitic  Affections  of the Skin
                  and Mucous Membranes.

   The syphilides are still classified,  with but slight modifica- 
     AFFECTIONS  OF THE SKIN AND MUCOUS  MEMBRANES.   133

tions, according to the following division of Biett, also adopted
by Cazenave:
                1. Exanthematous syphilides.
                2. Vesicular          "
                3. Pustular           "
                4. Papular           "
                5. Squamous         "
                6. Tubercular        "
   This division has reference exclusively to the external form,
and  since  the microscopical  change in the  cutis and  mucous
membrane in all  these different forms is essentially the same,
namely, cellular infiltration, the differences between the separate
forms are better characterized by the gross appearances than in
their minute anatomy.  But  nevertheless some  regard should
also be paid to anatomical conditions in the classification, espe-
cially to the greater liability of certain components of the tissue
of the cutis or mucous membrane to become attacked  in some
affections than in others.   The very numerous  forms to be dis-
tinguished  may be thus better classified at the same time that
the superabundant nomenclature is somewhat abridged.
   Keeping  the fact  in view that intermediate varieties may
occur, we may range the different forms in the following groups:

  I.  Circumscribed Hyperemias  with but slight Infiltration.
                Macular syphilide, Roseola.
       II.  Marked Infiltration of the  Papillary Body:
   1. In the form of papules:
                Papular syphilide.
   2. In large patches:
                Squamous syphilide.
   On mucous membranes, or at favorable points in the cutis:
                Moist papules (condylomata lata).
 III. Especial Implication of the immediate Vicinity of the
            Follicles (Hair and sebaceous follicles).
   1. Simple infiltration, with either scanty or no exudation in the follicles:
                Lichen syphiliticus.
   2. With acute suppuration in the follicle:
                Acne syphilitica. 
134                 BAUMLER.—SYPHILIS.
   3. Exudation into small, markedly infiltrated groups of follicles, with rapid for-
mation of crusts:
               Impetigo syphilitica.
IV.  Infiltration with  Subepithelial Suppuration and Superfi-
                       cial  Ulceration.
        Pustular syphilide:
              Varicella syph.   Pemphigus syph.
              Ecthyma syphiliticum.
              Rupia syphilitica.

 V.  Infiltration with  Disintegration to a considerable  depth
                   {gummous development).
           Tubercular syphilide (lupus syphiliticus).
   I. Circumscribed hyperemias with but slight infiltration.

          Macular Syphilide,  Roseola syphilitica.
   This is the earliest and most common  form of the syphilitic
skin affections.  It is, as a rule, the first of all the various mani-
festations upon  the integument,  making its  appearance  not
infrequently after an eruptive fever  of several days' duration,
and does not then become very abundant  at once, but so gradu-
ally  that fourteen  days  or more elapse before  the  eruption is
at its height.  The exanthem  consists of perfectly  even, rose-
colored, or darker  colored spots, of a size varying usually from
that of a lentil to that of a pea, with a roundish or irregular
shape.  At  first it disappears entirely under the pressure of the
finger, but when it  has lasted for several  days, and especially if
the color is rather dark, on withdrawing the pressure a yellowish
discoloration remains behind, and the exanthem has already, to
a certain degree, the characteristic coppery hue.
   Very often at this time the infiltration of the  cutis (which,
according to Biesiadecki, consists in  an  accumulation of cells
along the capillary vessels and a growth of nuclei in  their walls)
begins to be perceptible, on account of a certain elevation of the
spots of e'fflorescence, which does not yield to pressure.
   A syphilitic roseola may present the  greatest diversity with 
AFFECTIONS  OF THE SKIN AND MUCOUS MEMBRANES.   135
regard to the abundance of the maculae, as well as in their form.
Sometimes it  is with difficulty that a few spots can be detected
upon  the sides of  the chest and in the  groin, and again,  some-
times, they are disseminated over the whole  body like  the erup-
tion of measles.  If  certain spots are elevated, we speak of it as
an erythema papulatum.   Occasionally,  along with a few small
maculae,  there may  be a number of  large,  isolated,  smooth
prominences, with  a diameter of from one to two cm., presenting
very markedly the peculiar coppery coloration, and resembling
sometimes the spots of erythema nodosum.
    If the eruption is  only scanty, it may disappear pretty rapidly
in the course of from one to two weeks ; but with especial rapid-
ity if  the patient  has  been subjected to  a  mercurial course.
When left to itself, it remains, as a rule, for several weeks, and,
where  it has already lasted for  some time, there may be seen
spots of  efflorescence in the most various  stages of development
—fresh, red maculae  or papulae,  together with both pale-colored
and pigmented spots.  Vesicles and pustules develop very rarely
during the existence  of a roseola.

   Eruptions that are due to other causes than syphilis may, under  certain circum-
stances, be confounded  with the  syphilitic roseola.  The roseola of typhoid fever
can only give rise to such a mistake when it is exceedingly abundant, as happens
in mild cases occasionally; but even then the face is always free from the eruption,
which in a syphilitic  roseola  equally extensive would never be the case.  The
syphilitic roseola would scarcely appear in the form of isolated lenticular papules,
developing gradually and leaving  behind somewhat pigmented and slightly shining
spots, as in the case of  the roseola of typhoid fever; and  furthermore, the rest of
the symptoms tend to prevent a mistake.
   In children a syphilitic  roseola may be mistaken for measles or for rubeola ; for
the former particularly, if the syphilitic exanthem was preceded by a violent erup-
tion fever.  Inasmuch as rubeola frequently runs its course with but slight and
rapidly disappearing fever, or with none at all, its resemblance to mild cases of rose-
ola syphilitica is very great. Circumspect examination and  observation of the case,
with careful noting of the temperature, the absence of red spots upon the mucous
membrane of the mouth and throat in the  syphilitic affection; further, the absence
of any catarrhal affection of the respiratory passages, such as is invariably observed
in measles, the discovery of other symptoms pertaining to syphilis—the primary
lesion, enlargement of the lymphatic glands, and the affection of the throat—will
render it a matter of but little difficulty to establish a diagnosis of syphilis.
   Certain medicaments, jtarticularly copaiba balsam, may cause  skin eruptions, 
136                      BAUMLEE.—SYPHILIS.

which, though really having but slight resemblance to the roseola syphilitica, may
nevertheless sometimes be confounded with it, for the reason that the affection of
the genitals, for which the copaiba balsam has perhaps been used, is apt to arouse
suspicion in this  direction.  The eruption of  erythema balsamicum (which is much
more like an urticaria or a lichen  urticatus than the syphilitic roseola) consists of
flat elevations and of smaller or larger papules that are often confluent, and which
occur more especially upon the extensor surfaces of  the extremities,  on the backs of
the hands, and  about the joints.   According to Zeissl,1 large confluent patches are
particularly apt to occur in places where the skin is continually subjected to  pres-
sure.  This affection runs its course without fever, and is  also distinguished by the
intense itching  accompanying it.
    This eruption is  produced under  the influence of the balsamic remedies (espe-
cially of copaiba and of cubebs also), only in persons especially predisposed to it,
whether these remedies have been employed in  the treatment of gonorrhoea or of
some other  affection.  Even  though  the peculiar characteristics of this eruption-
location, form, and  itching—should  not  be well pronounced, the diagnosis may
nevertheless be made from the history of the case, that is, from the evidence of these
remedies having  been employed  within  a short  time;  from the discovery of the
violet-like odor in the urine, or from  the detection of the resin in the latter through
a precipitate being produced on the addition of N0B, and afterwards clearing up on
boiling; or, in those who have taken cubebs, from the peculiar odor in the breath.
    The internal use  of mercury, too, appears to cause an erythematous eruption in
many persons, as  shown in a case of ZeissFs,2 where, after taking different mercurial
preparations, as calomel, the yellow iodide,  etc., an  extensive erythema was pro-
duced, chiefly on the flexor sides of the legs and arms, but also upon  the trunk.  I
have observed a very similar eruption, unlike the eczematous eruption sometimes
caused by the external use  of mercurial ointment, in a patient who had been treated
by inunctions.  The  frictions were  made in  the usual manner during ten  days,
when, one morning,  a fine, papular, measly exanthem made  its appearance upon the
front and  sides of the chest, as far down as the lower border of- the  ribs, in the
groins, in the  flexure of the left  elbow, and upon the right wrist.   The back and
other portions of the body were  entirely free.   He had  anointed the  calf of the
left leg the evening previous, the evening before  that the  calf of the right leg, and
the third evening before, the left thigh, and the gray  color  of the  ointment was
still to be  seen  in  the last-named situation at the time the  exanthem appeared.
Hence the eruption occurred  in  situations that either had not been touched for
 several days,  or  had never been  anointed  at  all.  The  night after the  eruption
 appeared the patient had  a slight fever, and was unable to  sleep on account of the
itching.  Two days later the eruption (it having  meantime  appeared slightly upon
 the abdomen) had become quite  even with the surface, and  darker colored;  was
 somewhat ecchymotic.   In eight days it disappeared.  At the outbreak of the exan-
 them the  mercuiial inunctions were stopped, and a week  later the  bichloride was
'L.c, p. 110.
2  L. c, p. 111. 
      AFFECTIONS OF  THE SKIN AND MUCOUS MEMBRANES.   137
commenced internally, but similar appearances were not again observed.  The con-
nection of this eruption with the administration of the mercury cannot be very
strongly insisted upon ; and were it not for Zeissl's observations, where, on account
of the oft-repeated occurrence of the manifestation, the connection between the
two can scarcely be doubted, I should not have ventured to allude to the above
case as I have.1
   The roseola  syphilitica is sometimes  the sole eruption that
occurs during the entire course  of the disease.  Very rarely no
eruption occurs at all, but merely certain trivial affections of the
throat,  especially of  the tonsils.  But in a disease with  such a
protracted course, in which slight and isolated eruptions of the
skin  may so easily escape the notice of both the patient and the
physician, it is  impossible to speak very positively upon this
point.  On the other  hand, the roseola may recur a number  of
times in the course of one and the same syphilitic attack.   Such
relapses are commonly  marked  by  certain  peculiarities.   The
spots are paler, of a more grayish red, and are very  few in num-
ber ;  the separate spots of efflorescence  are larger, and  exhibit
more frequently the annular  form, or  the grouping together  of
several spots in a ring shape,  than at the first  occurrence of the
eruption.   With  the  exception of the  annular  variety, the
relapses are usually of short  duration.  An erythema annulare
may  appear as a relapsing syphilide as late as  twelve months  or
more after the infection.
    The erythematous syphilide is not, as a rule, perceptible upon
the  mucous membranes (at  least not as a macular eruption),
with the exception  of  the  mucous membrane of  the  throat.
When it occurs in the throat  it is in  the  form of a diffuse, more
or less pronounced redness, sometimes accompanied by  a slight
oedema of the mucous membrane.

II. Well-marked circumscribed infiltrations of the papillary body
                          of the cutis.
                       1.  In the form of papulae.
                      Papular Syphilide.
    Papules, from the size of a barley-corn to that of a split pea,
   1 With regard to mercurial dermatitis, compare also A. KussmauVs Untersuchungen
iiber den constitutionellen Mercurialismus.  Wiirzburg, 1861, p. 303 f. 
138                 BAUMLEE.—SYPHILIS.

varying in color, according to their age, from red to brownish red,
rather hard to the touch, and smooth upon their surface, or else
slightly desquamating, constitute this variety of the exanthem.
In this  form the separate  points of efflorescence  are most fre-
quently about  the size of  a lentil;  hence the name lenticular
syphilide.  The separate papules are sharply circumscribed, at
first smooth,  later covered  with loose epidermis,  or, the latter
having been  rubbed off,  the summit of  the  papule presents a
dark-red and shining appearance, and soon covers itself with a
thin scab through the oozing from it of a little serum.   Around
the base of the red summit, or the scab, is the ragged, slightly
raised edge of  the epidermis.  Occasionally  the epidermis over
the papule becomes loosened (in consequence,  probably, of a
very slight exudation underneath it) in  the form of a yellowish
unbroken pellicle, which is a little thicker in  the centre,  and this
is more apt to occur in places where the epidermis is somewhat
thickened.
   The  central loss,  or at least a marked thinning of the epider-
mis, may remain for some  time  after the papule has receded
and become perfectly level  with the surface of the skin.   On the
palms of the hands and soles of the feet, where (on  account of
the thickness of the epidermis probably) the papular elevation
is never very marked, there often  occur,  in  connection with a
papular syphilide over the rest  of  the body, certain perfectly
level places,  with a  circular  loss of epidermis,  which look as
though the cuticle had been punched out with some instrument.
Places  so deprived  of their epidermis,  or which  may  be still
desquamating in the centre, represent the situation of former
papules.  These  papules appear at first in  the form of circular
red spots, darker in the centre, which become gradually denuded
of their epidermis within the entire area occupied by the infiltra-
tion. This  affection is  still often  incorrectly represented as  a
special  variety of syphilide,  and is usually designated by  the
name psoriasis palmaris and plantar is.
    Sometimes we find only round places of this sort,  of from
one-half to one cm. in diameter ; in the furrows of the hand they
are  of a more oblong shape, and fissures may  form, extending
into the papillary body ; the latter then remains exposed,  or be- 
       AFFECTIONS  OF THE SKIN  AND MUCOUS MEMBRANES.   139

 comes covered with a scab.   Sometimes a number  of  such spots
 coalesce, or they may enlarge separately.   The latter is more apt
 to be  the case where (as often happens) papules occur as relapses
 upon  the palms and soles,  the process then  advancing at the
 periphery, either  uniformly  or  irregularly, while it  gradually
 heals  in the centre.  In this way the affection may  assume a
 rather diffuse form, but  can be  distinguished from other affec-
 tions  resembling it—as  psoriasis  vulgaris,  chronic eczema,  or
 keratosis of the palm of the  hand—from  the  fact that we find,
 beyond  the defect in the epidermis,  on the advancing edge, the
 flat, often coppery-colored wall of  infiltration  (Kaposi).1  But
 where the process is decidedly chronic in its course, and the pro-
 gress is  very slow,  the advancing zone of  infiltration is not well
 marked, is almost quite even with the surface,  and the  desqua-
 mation  may extend to the  extreme periphery of the  affected
 spot.

   In such cases it may be very difficult to diagnosticate it from a chronic eczema.
 The latter, however, usually extends over the entire surface of the palm, and, while
 extensive  patches of psoriasis palmaris syphilitica are often confined to one hand,
 eczema  usually occurs on both hands,  and is more common in corpulent or gouty
 individuals,  or those well advanced in life.  From psoriasis vulgaris, which, by
 the way, could scarcely  occur  exclusively upon the palms and soles, the chronic,
 palmar  and  plantar, papular syphilide (frequently the only manifestation of  the
 disease) is distinguishable, inasmuch  as the  former extends usually from the wrist,
 or from the borders of the foot, and the scabs are smaller, whiter, and more thickly
 piled up ;  there is, in fact, a true hypertrophy of the epidermis, while in the psori-
 asis syphilitica the pieces of epidermis which are separated appear almost quite
 normal.

   A different mode of development  of the papules takes place
 in parts  of the body where surfaces  of skin lie  in contact with
 each other.   Under the influence of the warmth  and moisture
 thereby  produced, and especially where there is friction between
 the  parts, or  the irritation of various secretions, the papules
develop  exuberantly, become moist upon their surface, and run
together in patches of large size.  The papillary bod}^ (where the
cellular infiltration  has its principal seat) becomes hypertrophied,
»L. a, p. 103. 
140
BAUMLER.—SYPHILIS.
 the epidermis becomes macerated, exudation cells are also depos-
 ited in the rete Malpighii, and thus the surface of the papules, or
 of the patches, which often presents a papillous appearance, falls
 into molecular disintegration,  and is covered with a grayish,
 slimy secretion.  So the papule comes to present  that form of
 development which has received the names of moist or mucous
 patch {plaque muqueuse), mucous tubercle, fig-wart, or fat con-
 dyloma.
    The  papule appears  in the form  of  the mucous  patch on
 mucous  membranes most  commonly,  and  especially in such
 places as are exposed to frequent irritation, as  at the mucous
 orifices  of the body, or in the isthmus faucium.  But lower
 grades of development of the papule are also met with upon  the
 mucous  membranes, together with  all  possible  intermediate
 stages, from  a very slight cloudiness and thickening of the epi-
 thelium over a somewhat reddened spot, to the thick and super-
 ficially ulcerating infiltration.  While the lightest forms appear
 upon the  genital mucous membrane as superficial  erosions,
 there occur upon the  mucous  membrane of  the  mouth more
 frequently, especially as chronic and  relapsing manifestations,
 circumscribed thickenings,  with an anomalous  formation and
 amassing of the epithelium, producing opalescent or milk-white
 spots {plaques opalines), which bear the greatest  resemblance to
 the effect produced by a very superficial cauterization  of the
 mucous membrane with the nitrate of silver.   These spots may
 occur singly  or in a more diffuse form, and  are peculiar  to the
 mucous membrane of the lips, cheeks, and tongue. The derange-
 ment of nutrition is often permanent,  so that  these places may
 last  for  years, or  even  never disappear.   (Psoriasis membr.
 mucosae, von Sigmund, Kaposi.)  Upon the  mucous membrane
 of the tongue the  acute syphilitic  papule  usually forms circular
level spots, which often enlarge at the circumference  while the
process recedes in  the centre, so gradually assuming the annular
form; and the same thing occurs  sometimes upon  the hard
palate.  On the soft palate and upon the palatine arches the
entire free border  maybe infiltrated and  superficially ulcerate,
or upon the mucous membrane of the soft palate elevated  thick-
enings of a gray or grayish-yellow color may occur. 
      AFFECTIONS OF  THE  SKIN AND  MUCOUS MEMBRANES.   141
   The mucous membrane  in the introitus vaginas and on the carunculae myrti-
formes sometimes presents  a swollen,  cloudy,  scalded-like appearance, which is
very similar to that of the mucous patches, but they must not be confounded with
each other.  The former is observed in persons not syphilitic, in connection with a
fluor albus, and is doubtless the result of a superficial maceration of the epithe-;
lium.

   The minuter anatomy of the syphilitic papule has been given
already in that of the  primary affection (see p. 110).  Indeed,  it is
often impossible to distinguish an isolated secondary papule by
its gross appearances from  a  commencing primary  affection.
With regard to  the  mucous  patches (condylomata lata), whose
identity with the dry papules of the  skin is evinced in  the fact
that  by simply keeping them dry they change back into  dry
papules again,  the investigations of von Biesiadecki  and Los-
torfer have shown  that the changes  in  the epithelial layer are
to be regarded as purely passive, caused by  the hypertrophy
which the papillae of the cutis undergo  in  consequence of the
cellular infiltration.   Auspitz,l on  the contrary, ascribes a more
active part in these changes to  the epidermis, asserting that as
the latter  becomes thickened  it grows in between the papillae,
occasioning an apparent lengthening and narrowing of them, and
splitting them up into  arborescent forms.   Lostorfer has called
attention especially to  the alterations in the vessels, consisting
in a  hypertrophy of the  endothelium and thickening  of  the
adventitia through a  network of branching cells, whose meshes
are filled with the round cells usually found in syphilitic affec-
tions ;  L.  supposes that  a  portion  of these   round  cells are
derived from the branched cells of the vascular sheath.
   The so-called acuminate condyloma (mucous papilloma), which has nothing at
all to do with syphilis, and  is caused by irritation of the skin or mucous  membrane
from different secretions  (particularly gonorrhceal pus), and moreover is con-
tagious,2 must not  be confounded with the  flat condylomata.   Its anatomical
structure is essentially different, since in the one case there is a marked hyper-
trophy of the rete Malpighii, in consequence of a division of its cells (Lostorfer),
and in the other an upward growth and branching of the papillae,  with new
formation of connective tissue and dilatation  of the vessels.  Where extensive
1 Arch. f. Derm. u. Syph.. II., 1870, p. 54.
2 Kranz, Deutsch. Archiv f. klin. Med., II., 1867, p. 85. 
142
BAUMLEE.—SYPHILIS.
groups of acuminate condylomata are flattened, from being situated upon opposing
surfaces, as on the labia majora, in the  preputial sac,  or in the folds of the anus,
they may very closely resemble the flat condylomata, and, on the other hand, where
in condylomata lata there has beeu a considerable hypertrophy of the papillae, a
more crested or cauliflower-like appearance may be assumed.  In such cases the
accompanying manifestations together with the history of the case, will deter-
mine the diagnosis.

   The condylomata lata  not infrequently  become  ulcerated
upon the surface, the molecular disintegration not being con-
fined to the cells of the  epidermis,  but encroaching upon the
papillary body also,  and so we have the condylomatous ulcer.
Pressure  and irritations of  all kinds—from secretions  present,
through walking, etc.—either favor this ulcerative process or are
its  exciting  cause.   This process may even  assume  a  specific
character in the event of  the  condyloma having been accident-
ally inoculated  with the poison of a chancre;  indeed,  through
auto-inoculation chancre-like ulcers may be produced from it, as
in the artificial auto-inoculations of the purulent secretion from
condylomata, which have been described above (compare above,
p. 92).  A rapidly extending ulcer then results.
   In  unclean  or  very corpulent  persons  flat  condylomata
increase very rapidly in places where surfaces lie in  contact with
each  other.   In women the  primary  affection becomes often
transformed, as already mentioned above, into a flat condyloma,
and again a mucous patch on  the female  genitals, after having
remained for a  considerable time,  may become indurated at  its
base, and this secondary lesion come to similate a primary affec-
tion very deceptively.  This is not to be surprised at when  we
reflect that the  primary affection is in every respect  indentical
with the  syphilitic papule which forms the basis of the condy-
loma,  and that secondary syphilis,  generally, is nothing more
than the  primary affection  generalized throughout the system
in consequence  of the blood infection.  The  diagnosis  in these
cases will depend mainly upon  the chronological relations.
   The secretion of  the  condylomata lata is infectious in the
highest degree.  At the point where transmission is effected in a
previously healthy subject, there is developed, after  the ordinary
period of incubation, an indurated primary papule, or, the cir- 
      AFFECTIONS OF THE SKIN AND MUCOUS MEMBRANES.   143

cumstances being favorable,  another condyloma.  Great auto-
inoculability has been attributed to the flat condylomata, and,
in fact, nothing is commoner than to see a portioff of skin that is
in continual contact with a moist condyloma become  gradually
affected in the same way.  There is no doubt that such a direct
local infection may take place in the earliest weeks following the
contraction of the disease, before the system at large has become
saturated  with the  poison.  The  primary  lesion is first  trans-
formed into a flat condyloma, which causes the  development of
a new infectious deposit upon  a  surface lying contiguous; for
auto-inoculations from  the  primary  affection have been also
successfully made with the lancet (see above, p. 98).  But much
more frequently  does  the multiplication of condylomata (appa-
rently due to direct contagion) depend upon an existing general
disease ; or, in other words, it is due to  the exposure of a tissue
(the papillary body), in which infected blood is already circulat-
ing, to the constant irritation of a secreting condyloma lying in
contact with it; hence, the syphilis has  merely come to a devel-
opment in a new  place.
    From the foregoing  description it is obvious that the condy-
lomata lata belong to an early stage of syphilis,  to the primary,
or  particularly to the  secondary stage, and indeed are so char-
acteristic  of the  latter  that several  writers have proposed even
to designate this  stage as the  " condylomatous"   Condylomata
lata are exceedingly prone to relapse, and frequently they are
the only form under which relapses occur at all,  or, indeed, the
sole manifestation of the disease within the first year  after the
acute period.  They are not apt to appear  later  than  this, and
are never seen in  connection with the gummy tumors (Zeissl.1)
   The part of the skin or mucous  membrane  which is more
especially  assailed  by  the syphilitic  papule is  the papillary
body.  Even where  the  papule  has apparently  developed in a
follicle, the affection consists in an  infiltration  of  the papillae
forming the edge  of the follicle, and is not an affection of the fol-
licle itself.  Zeissl2 makes the syphilitic papules develop mainly
from the sebaceous follicles, excepting when  they occur in the
L. c, p. 140.
2L. c.,p. 114. 
144
BAUMLER.—SYPHILIS.
hollow of the hand or in the sole of the foot, and  in support of
this view he refers to the syphilitic miliary papule, in which,
after resorption has taken place, the excretory ducts of the dis-
eased follicle appear very distinctly as little depressions the size
of pin  heads, surrounded by a dark brown border.  This is per-
fectly correct for this particular form, or so far as certain  situa-
tions in the  body are concerned, as in the dent of the chin and
in the depressions behind the alae nasi, where almost solely mil-
iary papules  occur ;  but for  the most common  form of the
papule it is  inapplicable, and for this reason we have separated
the miliary form from the papular syphilide, and placed it under
acne syphilitica (see below).
   Certain peculiarities are presented by the papular syphilide when occurring on
the negro skin.  The papulae are ordinarily more strongly pigmented, the furrows
of the epidermis form whitish lines, or wherever there is a loss of the epidermis the
dark papules are bordered by a gray, ragged fringe of epidermis.  As observed in
two cases by R. W. Taylor,1 the papule sometimes  loses its pigment during the
development, and becomes  white ("in certain places they were  snow-white with
slight desquamation ").  The papillae and the deeper layers of the epidermis were
found  by microscopic examination infiltrated with  the  round cells  of syphilitic
growths; the pigmented layer, with  the exception of a few pigmented cells, was
wanting.

   The papular syphilide may occur anywhere on the surface of
the body, but it has certain favorite seats where it may be found
even when very sparingly developed.  These are, more particu-
larly, the  borders of the  scalp, the forehead, where it is often
arranged  in the form of a continuous band (corona veneris), on
the back of the neck (especially  in women), and finally in all
places where the skin forms folds or depressions,  as on the chin,
in the angles formed between  the alae nasi and the cheeks, on the
borders of the axillae, in the elbows, in the hollows  of the knees,
and behind the ears.  In a few of  the last-named  situations,  and
in all places generally where folds of skin are in continual con-
tact with each  other (either  normally or through  an excessive
development of the adipose  layer or other pathological altera-
tions in the form of the  skin), and therefore, more  especially on
1 Amer. Journ. of Syph. and Dermat., Vol. IV., No. 2, 1873, p. 107. 
      AFFECTIONS OF THE SKIN AND MUCOUS MEMBRANES.   14o

 the external female genitals, the scrotum, beneath the dependent
 breasts,  in the navel, about the anus, at the preputial orifice, the
 angles of the mouth, between the fingers and toes,1 the papules
 are very apt, after a short time, to assume the form of condylo-
 mata lata.
    Upon the hairy scalp and the bearded portions of the face the
 papules  soon become covered  with crusts,  which is obviously
 due to the  external irritations to which they are subjected from
 being often wounded in these situations  in  combing or scratch-
 ing.
    The papular syphilide sometimes breaks out with symptoms
 of  violent fever, but usually there  is only a slight elevation of
 temperature,  or the eruption may make its appearance very
 gradually without perceptible fever  at  all.  Where a violent
 eruptive fever precedes the outbreak of the syphilide, the appear-
 ance of the papules might suggest  small-pox.  But the attend-
 ing symptoms and the  further course of the .disease will soon
 reveal the true state of things.
    The papular  syphilide is very often accompanied by violent
 pains in  the bones, and one of the most  common  affections at
 this time is iritis.  After the  syphilide has continued for a con-
 siderable length of time, alopecia and disease of the nails  are
 very commonly associated with it.
    The  earliest appearance of the  papular syphilide may take
 place at various periods in the course of the disease.   Sometimes
 it is the  very first skin affection, either because the disease has
 been left to itself, or because, as is usually the case  under  these
 circumstances, the patient has been subjected to an insufficient
 course of treatment at the commencement; in other  instances it
 develops gradually from a roseola syphilitica, or does not appear
 until some weeks after this has disappeared.
    The duration is much longer than that of the macular syphi-
lide.  If  left to itself it may last for many months, and a mercu-
rial course  even does not pause its disappearance  before sev-
eral weeks have elapsed.   The places on the palms of the hands
and soles of the feet are especially obstinate.
1 Zeis, Deutsnh. Archiv f. klin Med., B. II., 1867, p. 271.
VOL. III.—10 
146
BAUMLEK.—SYPHILIS.
   Relapses of the papular  syphilide may occur a  long time
after the  commencement  of  the  disease.   In  the late relapses
usually only isolated papules appear, and  these are very apt to
group themselves together in  an annular form.  The papulae are
especially prone  to relapses upon  the  palms and  soles;  but
while the eruption, as an early manifestation, or at an early stage
of the syphilis, usually affects both hands or both feet alike, the
later relapses are mostly confined  to particular spots  upon one
hand or one foot, and are not apt then  to present the circular
form,  but, as they do not spread uniformly, they become irregu-
larly shaped, and are often more like simple fissures.
   The involution of the syphilitic papule is first announced by
its growing  paler and becoming level with  the surface.   As the
redness decreases the pigmentation becomes more evident,  and if
the eruption has been of long duration, dark pigment spots are
left which are very slow  in  disappearing.  The  moist papules
upon the  mucous membranes leave  no scars, unless  there has
been deep ulceration;  upon the skin they leave either a  slight
pigmentation, or, on the genitals  especially, or about  the anus,
large unpigmented spots remain,  surrounded by  a very narrow
pigmented border.  Such   scars  often, after  many years have
elapsed, are  still present,  the evidences of former condylomata
which occupied these situations.
           2. Infiltration of the papillary body in large patches.

                    Squamous Syphilide.

   The  coalescence  of  several papules, or  the gradual enlarge-
ment of a single papule, is sometimes associated with extensive
infiltrations  in the cutis, and when the desquamation upon their
surface is considerable, may bear a very close resemblance  to the
patches of a common,  non-syphilitic psoriasis.  Therefore this
form of syphilide may  be  termed,  with a certain propriety, pso-
riasis syphilitica.  Such  infiltrations are of  a dense structure,
and are especially apt to develop upon the forehead, on the back
of the neck, on  the  hairy scalp, the mons  veneris,  the labia
majora, and upon the scrotum; but they  also occur  upon the
extremities,  flexor and extensor  surfaces alike, and over other 
      AFFECTIONS OF THE  SKIN AND  MUCOUS  MEMBRANES.   147

portions of  the  body.  This  eruption  occurs  commonly as a
relapsing syphilide, appearing in isolated situations and assum-
ing the circular or kidney form.  It  advances at the edges, and
is covered, especially towards the borders, with loose  epidermic
scales, which, however, are more apt to take the  form of thin
yellow crusts, and are thus distinguished from the white  thick
desquamation of psoriasis  vulgaris.   Besides, the favorite situa-
tions of the latter,  namely,  the knees and elbows, are usually
avoided in the syphilitic psoriasis.
    Hie earliest period at  which I have ever observed this form
of eruption was in the fourth month from the infection.  Well-
marked  infiltrations of the above  description were situated
upon the head, while upon the trunk there  were  only maculae
scattered here and there.   In  the  recession  which followed
pretty promptly  upon a mercurial course, the pigmentation was
very well marked and was  slow in disappearing.
   Like the previous variety, this form of syphilide also becomes
often transformed, in favorable situations, into flat condylomata,
and is  accompanied with the same affections of  the mucous
membrane as the papular syphilide.

III.  Location of  the infiltration, especially in the  walls  of  the
                           follicles.

   The  appearances of the skin eruption vary according to the
grade of the cutaneous disease.  But in the forms  which  we are
now to  consider, it is evident  that the walls of the follicles  are
mainly implicated, in the fact  that a hair penetrates each of  the
separate points of efflorescence, or at least the excretory duct of
the follicle may be recognized as a minute, dark spot in its cen-
tre.  Notwithstanding the similarity in their situation and in the
anatomical processes by which they are produced, each  of  the
several forms of  the syphilitic skin  disease coming under this
head  usually preserves its distinctive characters  throughout;
thus miliary  formations run their course from beginning  to end
as such, and  although they differ from the  syphilitic  acne pus-
tules only in  degree, they do not turn in to these, but either form
preserves its  own peculiar course. 
148                 BAUMLER.—SYPHILIS.
1. Infiltration of the follicular walls, with only scanty or with no exudation in the
                           follicles.

                    Lichen Syphiliticus.

   The simplest form most resembles those enlargements of  the
follicles which occur in  many persons upon the dorsal surface
of the upper arm, in consequence of an accumulation and desic-
cation of the secretion.  Hard granules, resembling dried gum,
are situated beneath the epidermis, which can be excavated with
the finger-nail, leaving  little cicatricial  depressions.  But  the
similarity is confined to the external appearances, for in the  one
case it is dried secretion  and an obsolete sebaceous follicle that
are concerned, while in the  other there is an infiltration in  the
follicular walls.  On account  of this outward  resemblance this
form of syphilide might be termed milium syphiliticum.   How-
ever, it is not  desirable to increase the nomenclature, and there-
fore the name lichen syphiliticus, adopted for this form by most
writers, had better be retained.
   Papules  of this  class  rarely occur only singly; usually they
stand ranged in  groups  of a  dozen or more.  At first they are
slightly reddened, but they soon assume a shade of yellow, and
may remain for a long time of the same form and size, but gradu-
ally they become flattened in  consequence of the desquamation,
and leave no pigment spots behind.
   If the process is more acute, an exudation takes place into
the follicle,  and groups of little vesicles are formed, which, their
contents becoming  cloudy, soon turn into pustules.  Moreover,
the contents are so scanty that  even in closely crowded groups
of such vesicles  the little scales  or crusts  that are left after their
desiccation  remain discrete.   When these crusts  fall off, small,
darkly pigmented scars are left,  which at first are depressed,  but
soon, through the increased fulness of the blood-vessels, become
distinctly prominent, afterwards becoming flat again.
   The further development of many of the papular groups may
be varied in still another way: The papillae of the  cutis, lying
between the papules,  become also  infiltrated, causing the entire
surface of skin which was occupied by the papular group to be
converted  into  a  desquamating,  psoriasis-like patch, as illus- 
      AFFECTIONS OF THE SKIN AND MUCOUS MEMBRANES.   149

trated in  the following case,  which in  other respects  presents
an example of the ordinary course of lichen syphiliticus:

   H. J., an anaemic-looking man, twenty-five years of age, three months after the
infection, and while the induration still remained, together with an open bubo in the
left groin, had an exanthem consisting of very small papules, vesicles, and pustules
ranged in groups, the contents of which dried up into little, bright-red scaly crusts.
These groups occurred most abundantly upon the lower portions of the back and
on the abdomen, and also upon the face, where the  points  of efflorescence were
crowded together more than elsewhere.   The upper half of the chest was noticeably
free.  In fourteen days, under the  use of the yellow iodide of mercury, several
groups upon the  face and on the back of the neck had become transformed into
infiltrations  of a circular  shape, or in the form  of  plaques, which assumed the
appearance of a  squamous syphilide.  The patient now interrupted the treatment
for three weeks, and when he  again made his appearance a new eruption of vesi-
cles had developed on the face and on the neck, while upon the arms there were a
number of scaly  red  miliary papules.  In a week the newly formed vesicles had
turned into pustules, whose contents dried up afterwards, beginning in the centre.
After the crusts had fallen off, markedly pigmented and somewhat elevated, slightly
desquamating places remained, which gradually became flatter, so that then, besides
the psoriasis-like  places upon the neck, there were left scattered over the body spots
of various sizes  composed of closely aggregated brown points the size of pin-
heads.

   This acute form of the lichen syphiliticus is so well character-
ized by the  grouping,  and  by the constitution and course  of
development  of  the  papules composing the groups, that  it can
hardly be confounded with any other form of cutaneous disease.
And  the more chronic  forms may also usually be distinguished
without difficulty from  the  somewhat  similar  affections  of the
skin follicles which occur in scrofulous and cachectic individuals
(lichen  scrofulosorum) by taking into account the rest  of the
symptoms (throat affections, etc.).
   The  syphilitic exanthem  under consideration may be vari-
ously designated, according to the different states of development
under which  it may appear,  as  a miliary papular syphilide
(Zeissl), or, with marked exudation into the follicles, as a herpes
syph. (Ricord),  or  where more  extensive  regions of  skin  are
implicated, as an eczema syph. (Cazenave).  In case the  exuda-
tion into  the  follicles is very abundant, and where the affected
points  are somewhat isolated, pustules are often formed which 
150
BAUMLER.—SYPHILIS.
resemble the pustules of varicella (varicella syph.) or those of
simple acne.
   The  miliary  syphilide  which we have  just  described  often
makes its appearance with pretty violent febrile symptoms.  It
usually occurs at the commencement of the  secondary period,
though also, occasionally, as a relapsing exanthem, and is  then
rarely very extensive.  There may be present,  at the same  time,
the ordinary forms of psoriasis palmaris and  plantaris, together
with the affections of the mucous  membranes  that commonly
accompany the papular syphilide.
                 2. Acute suppuration in the follicle.

                      Acne Syphilitica.

   When suppuration develops  in  the follicle  rather acutely,
in connection with the infiltration, acuminate pustules  upon a
red or coppery-colored base are produced, which  bear a close
resemblance to  the pustules of acne  vulgaris.  Therefore, this
form may be termed acne syphilitica.   Like the previous form,
the acne syphilitica has its favorite seat also in the face, upon the
back, and especially upon the shoulders, on the hairy scalp, par-
ticularly at the edges of  the hair, on the buttocks, and upon the
extensor surfaces of  the thighs and  legs.  The pustules  may
develop in great  numbers,  in groups or quite  singly, and some-
times in such small number as to be counted.  When numerous
acne pustules develop all  at once, there may be pretty violent
general symptoms, while if but a few appear at a time,  these
symptoms are entirely absent.
   The single pustules do not become very large ; they are  usu-
ally about the size of pin-heads.   The contents of the pustule dry
up, and after the crust has fallen off a cicatricial  depression is
left, which remains  visible for some time as a pale spot sur-
rounded by a border of pigment, but gradually entirely disap-
pears.  Exceptionally the pustules enlarge  to the size of a pea.
   The distinction of acne syphilitica from  acne vulgaris,  in cases where only
single points of efflorescence appear, just in the favorite seats of the latter, will
rather  depend  upon other symptoms present at the same time, which point to
syphilis, than upon any outward characteristics of the eruption, since under certain 
      AFFECTIONS OF THE SKIN AND MUCOUS MEMBRANES.   151
circumstances the eruptions in the two diseases may be exactly alike, though in the
syphilitic acne the inflammatory areola is  ordinarily more pronounced, and it is
characterized also by a more coppery coloration.

   A third form of the syphilide,  with especial implication of the
skin follicles, but which, on account of  the formation of thicker
and larger  crusts, conies nearer to the following group, is pecu-
liar  from the fact that  the  intermediate spaces between the
affected follicles  do not remain intact, as in the lichen and acne,
but  become infiltrated at once, the same as the  follicles.  The
hair follicles appear as vesicles lying very near each other or con-
fluent, resting upon an infiltration varying in size from a lentil
to a bean.  The  vesicles quickly desiccate, and greenish-yellow
granular  crusts  are formed which cover the whole surface of the
infiltration.  This  crust can be removed  without  difficulty, and
beneath it is found a loss of substance with an uneven surface.
This form is called

                     Impetigo Syphilitica.

    Very  similar crusts  and ulcers may be produced in syphili-
tic eruptions which follow another course of development, the
pustular  formation not  proceeding so directly from the follicles ;
these eruptions belong to the next following group.  But in these
the  eruption usually develops in isolated spots, while the  form
just described occurs more like an acute exanthem, with tolera-
bly copious eruption, and pretty early after the infection, fre-
quently as early as in the third or fourth month.
    The outbreak of the eruption is sometimes accompanied by
violent fever,  which may have a markedly remittent  character
and be ushered in with  chills and sweating.  In addition to this,
periosteal swellings may be present at the same time, with violent
pains, and notably with pains in the head, which, on account of
their occurring regularly every evening, often resemble a typical
malarial  neuralgia.  This form of eruption is most apt to occur
in  persons of poor constitution, or in individuals whose health
has been  broken down through previous  diseases.
    The favorite seats of  impetigo syphiltica are the  face, the
hairy scalp, in the beard, and in  other regions where thick hair 
152
BAUMLER. —SYPHILIS.
 grows, as in  the middle of the breast.  The extremities usually
 remain free, or only isolated spots occur upon them.  The affec-
 tion  could scarcely be mistaken  for  a non-syphilitic impetigo,
 since  in  the latter the crusts do not rest  upon infiltrations.
 Moreover,  the attending symptoms,  particularly the primary
 affection, which is usually still present, will tend to facilitate the
 diagnosis.
    The loss of substance caused by impetigo  syphilitica heals
 either with the production  of a scar, which is at first uneven and
 pigmented in places, and afterwards becomes smooth, thin, and
 white, like the pit from a small-pox pustule,  or else it continues
 for some time to enlarge on all sides, or  only in one  direction,
 the ulcerative process  advancing at the edges, leaving irregular
 and disfiguring cicatrices.

 TV. Infiltration with subepithelial suppuration and superficial
                           ulceration.

                     Pustular Syphilide.
   In the eruptions of  this group  the pus is not situated in the
 cutaneous follicle, but  underneath the epidermis, independently
 of the follicle.  The pustules develop rapidly, are rather small
 in size, and may look very much like those of the previous group,
 and we may have the production again of  eruptions, resembling
 varicella,  herpes, or acne.   But the points of predilection for the
 pustules  of this group differ from those of acne syphilitica and
 of the form of impetigo just described, being situated chiefly in
 places where the skin  is tender,  namely, beside  the face,  the
 flexor surfaces of the extremities and the sides of the trunk, and,
 indeed, in places where there  are no follicles  at all, as the'palm
 of the hand.  Moreover, these pustules are much more super-
 ficially situated than those which proceed from the follicles, and
 consequently  leave  only very shallow depressions,  even imme-
 diately after the crusts have fallen off.
   Zeissl» calls the large-sized pustules (which  by others, especially the French
writers, are  designated as pemphigus syphil.) varicella confluens, and he reports two
rare gases, one from his own practice, and  the other  from the Hop. St. Louis, in
L. c, p. 147. 
      AFFECTIONS OF  THE  SKIN AND MUCOUS MEMBRANES.   153
which the palms and fingers of both hands were covered with pustules as large as
split peas.  In his case they appeared like  poorly developed variola pustules with-
out the areola.  At the tips of the  elbows the pustules developed upon places which
were at first of a dark red color, with some thickening.
   If, not contented with the  simple "pustular syphilide,"-we are to preserve any
special name for this form, I should prefer the term pemphigus syphiliticus to vari-
cella,  since the disease has a greater resemblance to the pemphigus of non-syphilitic
persons, and moreover, the very similar form in new-born children with hereditary
syphilis is commonly known as pemphigus syph. (neonatorum).

                     Ecthyma Syphiliticum.

   The ecthyma  pustule  is  the typical  form  of  the  pustular
group.   It may be described as an elevation of the epidermis by
a cloudy fluid,  which  soon  becomes  purulent, and not  infre-
quently is tinged with blood, over a reddened base.   Ecthyma
usually appears in isolated spots, the pustules being separated by
wide interspaces, in contrast with the  pemphigus  syph.  neona-
torum, and with the  form  in adults just mentioned, as well as
with the ordinary form of varicella syphilitica ; these all occur-
ring more  as an acute  exanthem.  Though it  may occur in any
part of the  body, its favorite seat is  the legs below the knees.
The pustules develop very quickly, following a hyperaemia of the
affected spots  that has  existed for a short  time previously.  In
other cases this prodromal stage lasts  for a longer period, and
the  pustule  does not make its appearance until the skin at this
point has become more or less infiltrated.
    The same diversity may be presented by the affection in its
further course, inasmuch as we find after desiccation of the pus-
tules quite superficial excoriations beneath the scabs, or in other
cases deep ulcers may  be developed, which extend at the edges
and occasionally assume a serpiginous form.  Hence many writ-
ers  describe an ecthyma superficiale and pro/yundum.
   The lesser forms of ecthyma may present a very marked  similarity to the above
described  impetigo syphilitica after the scabs have  formed.  But the crust of
ecthyma is generally darker colored, especially if the contents of the pustule were
bloody; the crust, too, lies deeper in the cutis than in impetigo, where, on the con-
trary, it is somewhat raised above the level of the skin, on account of the infiltra-
tion beneath it; finally, the ulcer underneath the scab in ecthyma has a sharply cut
edge, in impetigo the edges are  elevated and like a wall, and while in the former 
154
BAUMLER.—SYPHILIS.
the bed of the ulcer is composed of disintegrated tissue, in the latter it often pre-
sents the aspect of an irregularly granulating surface.

   The scars of ecthyma are generally round, and remain pretty
red for  a considerable  time;  later they are either  (depending
upon the depth to which the  destructive action has extended)
slightly  pigmented or  perfectly white ;  they are somewhat de-
pressed,  and surrounded by a border of pigment.
   Ecthyma is a  manifestation  more  especially of the later
periods  of  syphilis, as  evinced  in the unsymmetrical and dis-
persed manner of its occurrence.   Furthermore, it is an evidence
of a poor constitution, and one  generally disposed to suppura-
tion, and this disposition may show itself  in similar ecthyma
pustules which are not due to syphilis (e. cachecticum).  In such
as are thus predisposed to it, ecthyma may make its appearance
quite early in the course of syphilis, even within the first half
year. Bad  hospital influences, which give  rise to  scurvy and
hospital  gangrene, may  also  have something to do with  the
development of the severer forms of ecthyma profundum.
   The affections of the mucous membranes, which are present at
this  time, likewise show a proneness to  suppurative disintegra-
tion ; small aphthous-like sores appear in the mouth, deep ulcers
of the tonsils, or destructive ulcerations upon  the soft  palate.
Moreover, suppurative processes in the bones often accompany
this  form, together with  febrile  symptoms  of a pronounced
remittent type, which may continue for weeks.  In such cases it
is often difficult to decide whether  the disease is in its secondary
or tertiary stage.  Gummata of  the skin or subcutaneous cellu-
lar tissue may  also be  present  at the same time with  the
ecthyma.
   Pustular exanthems with very large  pustules were formerly
termed bullous syphilide.  Such large pustules commonly give
rise  to that  form of the syphilitic  cutaneous  affection  which
bears the name of

                          Rupia

(from /W09, filth).  By  it we understand large,  dirty, brownish-
green, stratified crusts in the shape of a cone, resting upon a per- 
      AFFECTIONS  OF THE SKIN AND  MUCOUS MEMBRANES.   155

fectly flat, ulcerated surface.  The conical shape is produced in
the following way : At  first only a  small  scab forms, perhaps
the size  of  a gold dollar, but the ulcerative  process beneath
advances slowly beyond its edge, and so each successive layer of
the scab  gives a little broader base to the crust, at the same time
that it gradually increases its height.   If the ulceration advances
uniformly at all parts of the periphery, the  summit of the cone
will always remain in the centre ;  but if it advances irregularly,
or only in one direction, the  top of the scab gradually assumes
an  eccentric position, and this latter  is the more usual  case.
These crusts are very much like oyster shells.
   The purulent bulla, out of which the summit of  the rupial
crust is formed, develops from an infiltration of the cutis, which
takes place very rapidly, and while the crust  increases  in size
this infiltration slowly advances at the periphery.  The epidermis
around the edges of  the crust is elevated by the pus to a slight
distance beyond  the scab,  and as this ring of pus  dries, the
crust enlarges in circumference.   It may  attain  the size of  a
half-dollar,  but is rarely larger.  When the crust is removed,
a livid-red ulcerated  surface appears, which  in very large rupia
spots is  usually somewhat filled out in the  centre, and a moist
dressing being applied,  this part is  soon covered with epider-
mis.   Towards the  circumference  the  ulcer grows  gradually
deeper,  and has  sharp-cut  edges.   Thick   crusts,  resembling
rupia, sometimes  form from other syphilitic ulcerations, which
follow a different course of development from  that of rupia, as
from  impetigo,  ecthyma, or  from a disintegrating tubercular
syphilide.
   The process of cicatrization does not always go on with per-
fect regularity, but  the ulcer  may cicatrize earlier in one place
than in another, and after a time the previously circular  spot,
covered  by a  conical crust,  becomes converted into a kidney
or  horseshoe-shaped ulcer that cicatrizes  on its  concave side
while it  slowly advances on the convex, and is covered  with a
narrow scab, which at the convex border is bevelled to  a thin
edge.   Such ulcers, proceeding originally from  rupia, may con-
tinue  to  extend for years, and convert  extensive tracts of skin
into cicatricial  tissue ;  they  may also, however, develop  from 
156
BAUMLER. —SYPHILIS.
 other pustular syphilides, and owe  their origin  to  a disinte-
 grating tubercular eruption far oftener than to rupia.
   The cicatrices, whether due to simple, roundish, rupial spots,
 or to serpiginous ulcers,  are permanent.   They become gradu-
 ally very white,  are usually quite smooth, sometimes are  tra-
 versed by small blood-vessels, and are surrounded at first by a
 pigment border that in time disappears.
   Rupia was formerly classed with the syphilitic manifestations
 of the tertiary group.   It breaks out sometimes, however, within
 the first six  months after infection,  in a  tolerably acute form,
 and, indeed, not  only, though in by far the greater number of
 cases, in persons of very poor constitution;  but  it  is often  a
 manifestation of the later periods, and is associated with marked
 syphilitic marasmus, gummy  tumors, and necrosis in the mucous
 membranes and bones.   Fever does  not often attend the rupia
 of the later stages  of syphilis, though a violent remittent fever
 accompanies  its  acute and premature occurrence, the same as
 other syphilides which tend to ulceration.
   Rupia is  generally unsymmetrical upon the extremities, as
 well as upon  the back, breast, and head.  It may not be exclu-
 sively rupial spots which are  present, but other suppurative
 forms of  syphilitic skin  eruption, as acne and ecthyma, may
 exist at the same  time.   In the event  of an improvement in  the
 constitution,  the  rupia may heal spontaneously.  But it always
 lasts for a good many months.

 Y.  Deep infiltration and disintegration.  {Gummousformation.)

                   Tubercular Syphilide.

   The  gummy tumor (see  above, p. 35)  may develop in  the
 skin in the form of roundish  tubercles, or of tolerably large
tubercular groups, which present the often-mentioned crescentic
or circular  arrangement.   At a certain stage  of their develop-
ment these groups may appear precisely like those of the papu-
lar syphilide; still, their manner of  development is  different,
their color usually  darker, and in their course they differ very
decidedly.  The syphilitic cutaneous tubercle begins its develop- 
     AFFECTIOXS OF  THE SKIN AND MUCOUS MEMBRANES.   157

ment usually in the deeper layers  of the cutis, and not in the
papillary body.   Therefore at the commencement, only a papule
can be felt in the skin, and there is  no redness present.   The lat-
ter only appears as  the  tubercle approaches the surface  and
begins to cause  some elevation; then, the redness increasing in
extent and intensity, we can almost mark the gradual ascent of
the tubercle through the  integument.   Gradually the  papillary
body becomes involved in the advancing process,  and the epider-
mis above participates now in different  ways,  either  in the form
of desquamation  merely, or a scanty  serous exudation takes
place,  which, drying, forms together with the epidermis a small
crust,  resting upon the summit of the tubercle.
   In  contrast  with these tubercles, which tend to resorption
without ulcerating, and occur, usually, in the form of isolated,
semicircular  groups, especially upon the shoulders,  on the face,
and on the extremities, there is another form, in which disinte-
gration and ulceration ensue very rapidly.  These latter  pro-
cesses  take place through the epidermis being raised  above the
tubercle in the  form of a pustule  which quickly desiccates, the
ulceration extending underneath the crust;  and such a place
may occasionally resemble a rupial spot, or it assumes at  once
the form of  a serpiginous ulcer.   Or  the process of  softening
may be similar to the development of a furuncle, as is more apt
to be  the  case in the larger  isolated tubercles which grow up
from the subcutaneous cellular tissue.  Such a tubercle looks
then like a  furuncle, about the size of a pea  or hazel-nut; it
becomes gradually of a bluish red  color, and, when  it breaks,  a
grayish yellow, gummy-like matter is  discharged, not a kernel
of  connective tissue,  as  in  the true  furuncle.   An  ulcerating
cavity remains  behind, which either little by little  is filled by
granulation and cicatrizes, or it continues to enlarge,  becoming
a flat,  encrusted ulcer with  swollen  edges,  which commonly,
through healing in one part and advancing in another,  assumes a
serpiginous character.
   The scars  left by the  dry tubercles  of the tubercular syphi-
lide, after resorption has taken place, even when the  epidermis
over the tubercles has remained intact,  or has merely  suffered a
slight  desquamation,  are somewhat depressed,  and—since the 
158                   BAUMLER.—SYPHILIS.
 rete Malpighii is involved in the disturbance of nutrition—devoid
 of  pigment,  although  occasionally in certain spots and at the
 edges especially,  the pigmentation may be  very marked.   The
 softening and disintegrating tubercles  invariably lead  to the
 production of connective-tissue cicatrices, which are, at first, of
 a livid hue,  but gradually become paler, and  are surrounded by
 a brownish  border.   After a few years they form a striking con-
 trast with  the  sound  skin  around  them, on account of  their
 whiteness, smoothness,  and dryness.  Unlike other scars,  they
 undergo  but little contraction, so that  even large cicatrices of
 this  sort lead  to no deformities  from  mechanical distortions,
 except in case of extensive destruction of the subcutaneous cel-
 lular tissue.
    Sometimes the process  of ulceration and  cicatrization in the
 tubercular   syphilide is very  irregular.   A group of closely
 aggregated tubercles becomes disintegrated in spots, giving the
 whole a riddled  appearance ;  then bridges form, as in scrofulous
 ulcers, of infiltrated or cicatricial tissue, with little follicle-like
 cavities between, which are  filled with  pus,  beneath which the
 destructive action continues.   I have often observed such forms
 upon  the backs or borders  of the feet.   They often prove  very
 intractable.   The  cicatrices  that  are  left  are also  irregular,
 uneven,  traversed by thick bands, and show a marked  prone-
 ness to break down in ulceration again.
    The above forms of the syphilitic tubercles, as well as the dry
 tubercular patches, present a marked similarity to different forms
 of lupus ; whence the name lupus syphiliticus, with the various
 qualifying phrases  (exulcerans,  serpiginosus, etc.) with  which
 these forms have been designated.
   This resemblance may render the diagnosis a matter of some difficulty.  A single
small tubercle, or a group of dry tubercles extending peripherally, or even ulcerat-
ing  tubercles of lupus vulgaris may, at first sight, have the exact appearance of a
 tubercular syphilide.  If the history of the case affords no ground for a diagnosis, or
if the earlier periods of a syphilitic attack have left no traces behind, or where there
are no collateral manifestations pointing to syphilis, it remains only to decide the
case ex juvantibus. The various forms of the tubercular syphilide undergo from the
use of the iodide of potassium a marked change for the better, while the same treat-
ment in lupus vulgaris is without effect. This was well illustrated in a case of mine,
where a lupus vulgaris of the cheek, in a young girl, on account of its eccentric 
       AFFECTIONS OF THE  SKIN AND MUCOUS  MEMBRANES.    159

spreading, and the brownish color of its tubercular edge, offered the greatest simi-
larity to a lupus syphiliticus.  Sometimes we can ascertain something from the course
pursued by the affection; this is much more  protracted in the lupus vulgaris than
in the tubercular syphilide.  The markedly ulcerative forms of lupus vulgaris of the
face are more apt, as Zeissl' has shown, to be accompanied  by decided evidences of
reaction, by extensive redness, or even oedema  of  the surrounding  parts, while the
margin  of  infiltration  in an ulcerating  syphilitic tubercle is generally sharply
defined against the adjacent healthy-looking skin.
    Ulcerating tubercular  syphilides are distinguished from  scrofulous ulcerations
through the absence in the former of reactionary manifestations in their vicinity, but
especially through their different behavior under treatment with the iodide of potas-
sium.  Moreover, the scars from scrofulous ulcers differ materially from those of a
tubercular syphilide in'their elevation and livid color.
    Cancer of the skin, under certain  circumstances, may simulate a  tubercular syph-
ilide, especially on account of the cachetic appearance presented by the patients in
both affections.  The very rare multiple, cutaneous cancer,  whose tubercles  have a
certain resemblance  to the slowly growing syphilitic tubercles of  the skin, is, per-
haps, less liable to  give occasion to an error in diagnosis  than epithelioma, which
might readily be mistaken  for an  ulcerating tubercular syphilide, when situated
upon the nose, lips, or genitals.  But the associated manifestations, the frequently
marked  enlargement of the  lymphatic  glands in the vicinity  of  an epithelioma,
together with the facts elicited from the history of the  case (which should always, in
such doubtful cases, be ascertained with especial care), the microscopic examination,
and, finally, the therapeutic test (also of great importance  in doubtful  cases) with
the iodide of potassium will tend to prevent any such  errors in diagnosis.
    It is chiefly upon the nose that other conditions are  met with which may simulate
a tubercular syphilide.  To such conditions belong certain very inveterate forms of
acne rosacea with marked hypertrophy.  On close examination, however, the more
livid than brownish-red  colored acne tubercles, commonly traversed  by varicose
blood-vessels, may be  readily distinguished  from the smooth, coppery,  sharply
defined tubercles of syphilis.

     The formation of syphilitic tubercles in the mucous membrane
is  associated with a more decided hyperaemia of the surrounding
parts than in the cutis.  It is very seldom that  an opportunity is
afforded to observe  a tubercle of the  mucous membrane, of the
soft palate, or of the posterior wall  of  the  pharynx,  for example,
before it has reached the surface.  A marked prominence is then
noticed,  with an intense redness,  which gradually shades off into
the hue of the  surrounding membrane.    Usually the affection is
not seen before ulceration has taken  place.  The ulcer has sharply
1 L. a, p. 174. 
160
BAUMLER. —SYPHILIS.
cut edges, a yellowish, purulent base, and the parts about are
swollen and intensely red.  Such ulcers in the throat often become
very extensive, particularly upon the posterior pharyngeal wall.
They occur also in the large intestine,  especially in  the  lower
part of the rectum, and, through their cicatrization there, occa-
sion  considerable stenosis, which  is  also  the case  when they
occur in the mucous membrane of other passages, as the trachea,
for instance.   Sometimes upon the genitals such ulcerations pro-
ceeding from tubercles of the mucous membrane are so very like
phagedenic ulcers or chancres, that only the most careful scru-
tiny of everything relating to the case will prevent mistakes.
   The tubercular syphilide belongs to the tertiary group of the
syphilitic manifestations;  amongst the  concomitant  symptoms
gummous processes may be present in the subcutaneous  cellular
tissue, in the periosteum,  or in the bones, in  the testicles and
internal organs ; upon the skin isolated pustular eruptions may
be associated with it, especially rupia.  Condylomata lata do
not appear as late as this, and  this fact may be made available
in determining the true relations  of extraordinarily developed
papules in a papular syphilide which may look like a tubercular
syphilide.
   The course  of  the tubercular  syphilide is  very protracted,
and  in cases  even that are very amenable to treatment, this
form  is  exceedingly prone  to relapse.  Fever  is not  present
usually in  this form,  unless  some other  associated process,
such as bone affections, should give rise to  it.  Even very  ex-
tensive serpiginous ulcerations run their course without febrile
symptoms.
   The patients suffering from a tubercular syphilide are gener-
ally more or less cachectic ; amyloid degeneration of the  abdom-
inal  organs often coexists.  Usually,  a number of years have
elapsed since the acute stage of the disease.   Zeissl, however, saw
a case in  which an ulcerating  tubercular syphilide occurred in
four  months after the infection.  The earliest period at which I
have observed it, was at eighteen months from the contraction of
the disease, in a man twenty-two years of age,  in whom,  besides
disease of both testicles, slight icterus,  tenderness of the cervical
vertebrae  and fever,  a pustular eruption appeared  upon  the 
             AFFECTIONS OF THE HAIR AND NAILS.         161

skin, and in the subcutaneous  cellular tissue there were devel-
oped a number of roundish tubercles, extending to a  greater or
less extent through the whole thickness of the skin—so that
over some of them the skin was  already reddened, while over
others it  appeared unchanged.  A two months' treatment with
the iodide of mercury caused all manifestations to disappear.
                   THE HAIR AND NAILS.

   These appendages  of the skin likewise exhibit changes, not
infrequently, in consequence of syphilis.  A relatively common
occurrence  is loss of the  hair—alopecia.   In an extreme
degree of  the affection it may implicate every hair in the body.
Even  the  old writers used to make merry over the ridiculous
appearance  presented by such hairless individuals,  and  they
remark that this symptom,  which at the time of the syphilis
epidemic was not known, first made its appearance towards the
end of the sixteenth century.  (A. Musa Brassavolus, 1553.)'
   It is obvious that the hairs will be destroyed when the deeper
forms of syphilitic skin disease, the ulcerating forms particu-
larly, affect or perhaps destroy the cutis  in its entire thickness.
Upon scars produced in this way the hair never grows again,
leaving bald spots of greater or less extent upon the scalp, in the
beard,  or the eyebrows.
   The alopecia  which  was mentioned above,  however,  occurs
without any visible change in the skin having taken place.   The
hair merely loses its lustre, becomes dry and often discolored,
and upon  combing it the hairs easily fall out.   Upon the  head
this may occur to a pretty large extent, though at first there is
only a thinning  of the hair in certain spots.   Even in  nearly
total  baldness (which,  by the  way, is a  very  rare  occurrence)
the scalp has almost a perfectly normal appearance ;  the follicles
may be even more distinct than usual.  The skin is not smooth
and shining,  as in the common calvities.
   This variety  of  syphilitic  alopecia is  very much like that
             1 Aphrod., I. p. 659.
VOL. Ill—II. 
162
BAUMLER. —SYPHILIS.
 which occurs in consequence of  certain acute diseases, and is
 one of the  early manifestations  of general syphilis.  It begins
 usually  at  the  time when  the languor, headache, pallor,  etc.,
 announce the approaching  outbreak of an eruption fever  or a
 skin affection, and lasts for a number of months; but young
 persons,  as  a rule, regain their former luxuriance of hair.   In
 the  advanced secondary period, too, the alopecia may still occur
 in connection with relapses  upon the integument, scarcely later,
 however, than in the  second year  after infection.  Finally, it
 may occur as a concomitant symptom in the syphilitic  maras-
 mus.  The local condition  to which it is immediately due  is,
 doubtless, a  derangement of nutrition in the hair papilla, per-
 haps a scanty cellular infiltration  of the papilla.   It is not
 always especially anaemic individuals in whom the highest grades
 of alopecia are observed.
   There is a prevalent opinion, which has been handed down
 from remote times, that the use  of  mercury favors or actually
 causes falling of the hair.   This  assumption is without founda-
 tion, the fact being that under a judicious mercurial course we
 see the growth of hair in syphilitic subjects rapidly improve.
   The nails show alterations in their texture, either  indepen-
 dently of any obvious  affection of the matrix, or else in conse-
 quence of  such affection.   Accordingly,  the  first form  of the
 syphilitic affection of the nails corresponds to that form of alo-
 pecia which we have just described ;  the second, to the oblitera-
 tion of the hair through  the grosser  morbid processes in  and
 about the hair follicles.
   When the nail by itself is diseased it  presents either merely
a lustreless surface, or numerous white spots appear, such as are
very commonly  seen in young  persons in normal health; or a
number of parallel  rows of  little  furrows are observed, at  first
separated by  rather wide interspaces,  afterwards approaching
gradually closer to each other.   In  this  way the nail  becomes
thinned at its posterior extremity at  first, so that  here it can  be
easily dented.  As this  thinned spot extends forward, the entire
nail becomes gradually thinner and wavy.  This condition, which
is termed onyxis or onychia sicca, is uncommon.  According  to
Fournier's  statements  it must  occur much more frequently in 
             AFFECTIONS OF THE HAIR AND  NAILS.         163

Francex  than in England.   In one case of  it that I saw, there
was marked alopecia of the hair of the head,  beard, eyebrows,
and cilia ;  but in another case the hair showed no alteration and
the secondary symptoms were almost entirely limited to a very
obstinate affection  of the mucous  membrane.   In this case the
affection of the nails occurred in the  eighth month after infec-
tion, did not implicate all of the nails, and in eight months more
it had disappeared.  The onychia occurs under other forms also ;
for instance, a great frangibility of the  nails may be produced,
especially of the finger-nails, so that they are constantly split-
ting off at the ends (the so-called psoriasis of the nails), and this
is met with most frequently in women.  The development of the
nails, however, may not only be more or less interfered with  in
its  superficial layers, but their growth may cease entirely, and,
in this case, the nail gradually advances  forward with a posterior
free, jagged edge, and thus  at length becomes wholly disengaged
from its  bed.  As stated by Fournier,2 a toe nail may be lost in
this way without the patient's knowledge. A new nail is gradu-
ally produced,  which may either be normal in its appearance,  or
present various degrees of deformity.
    The coarser processes which take place in the matrix, and
which, according to their  situation, may or may not be accom-
panied by alterations in the  nail, are designated by the term
paronychia.   Most frequently an efflorescence  of  a papular
syphilide, developing on the fold of the  nail, or alongside of  it,
is the source of the paronychia in its lighter forms.  On the nail
wall [the skin projecting over the root] it generally merely leads
to a  slight desquamation  and to  some  alteration of the nail,
while papules at the lateral  edges are  sometimes converted into
condylomata lata, which crowd the nail,  laterally, from its bed.
Such moist papules of the matrix are more commonly observed
upon the toes  than the fingers, and  may resemble closely an
ulcer from an  ingrowing  toe-nail;  they often  owe their  origin,
indeed, partly  to  the  same cause, namely,  pressure.    Severer
forms are produced by pustular or tubercular syphilides upon
1 Compare also B. Bergh, Behrend's Syphilidol., III. p. 426.
2L. c, p. 469. 
164
BAUMLER.—SYPHILIS.
the fold of the nail.  Suppuration or ulceration then takes place,
wliich interrupts the nail-growth, or  the fold of the nail may be
entirely destroyed.  In  the  latter case no new nail grows,  but
merely irregular islands  of horny substance are developed upon
the matrix.  Such ulcerative processes are accompanied by con-
siderable swelling and great  pain usually, on the big toes espe-
cially.
   Finally, both matrix and nail may be implicated in the for-
mation of a gummy tumor proceeding from the cellular tissue or
periosteum of the same member.

   SUBCUTANEOUS  AND SUBMUCOUS CELLULAR TISSUE, FASCIAE.

   In considering the tubercular syphilide it was  observed that
gummy tumors, which gradually extend through the  skin or
mucous membrane,  originate in the subcutaneous  or submucous
cellular tissue.  They occur  underneath the skin as flat, round-
ish,  and (when not proceeding from  the fasciae) movable  and
perfectly painless tumors, which are  often  discovered only  by
accident by  the patient or  physician.   Gradually  adhesion of
the integument takes place, then the latter  becomes red  and
painful, and  the tumor softening, the skin breaks, as in a cold
abscess or a furuncle, from which deep  ulcers proceed of the
character already described.  These  tumors may vary in  size
from a pea to a goose's egg.   Sometimes several of them in the
subcutaneous cellular tissue  coalesce,  so that the infiltration has
more of a diffuse character.
   The minute  anatomy  of these  growths  has been already
given (see p. 35).   According to its  stage  of  development the
tumor on  section has a grayish-red, in certain places  a more
grayish-yellow,  exsanguinated appearance, and is either  soft-
ened in the centre to a gummy-like mass, or is partly or entirely
dry, resembling colorless fibrine, as illustrated in a very notable
case described by W. Adams.,
   In a lady, thirty-one years of age, there were developed within nine years, at dif-
ferent times, upon the right leg—and with a single exception only in this situation
   1 Transact, of the Pathol. Soc. of London, Vol. XX., 1869, p. 309.  Compare also a
case of Dittrich. Prager Vierteljahrschrift, 1850, 2, p. 49. 
     AFFECTIONS OF THE SUBCUTANEOUS  CELLULAR TISSUE.  165

—more than one hundred tumors, which at first continued to increase for from
three to six, or even to twelve, months without pain, then became inflamed, swollen,
and ulcerated, and when left to themselves gradually disintegrated with the pro-
duction of an excessively foetid discharge.  The exposed tumors had a yellow color,
and the consistency of a cow's udder.  They were not vascular, and consisted of an
indistinctly fibrillated, partly finely granulated basement tissue, in which, besides
fibres of connective tissue, with numerous nuclei, there were imbedded a large num-
ber of fat-cells.  This unusual constitution appeared to A. Bruce, who examined the
tumors microscopically, to be owing to the fact that the tumors proceeded from the
adipose tissue.
   The patient, whose husband had been syphilitic, but who herself, so far as  could
be ascertained, had never during twelve years of sterile married life presented symp-
toms of the earlier stages of syphilis, had been suffering during the last three years
from affections of the periosteum and joints, besides a deep ulcer in one tonsil.  The
above-described affection was not at first regarded as syphilitic, and therefore the
patient was not placed under specific treatment.  Later, mercury in any form always
had a good effect, and especially upon the bony and articular  affections.   The
iodide of potassium invariably induced a great depression in the patient, and for
this reason could not be used.  Nevertheless, at the end, under the use of the iodide
of ammonium for  about three months, the tumors disappeared, and did not return.

    If gummata of the  subcutaneous cellular tissue, or of  the fas-
ciae occur singly, without  other manifestations  or  evidences  of
syphilis,  their diagnosis  may be doubtful;  and when they soften
and the skin above them is thinned, they may be taken for  sim-
ple  cold  abscesses.  I have seen such a tumor, distinctly fluc-
tuating, proceed from the  tendinous expansion of the occipito-
frontalis muscle upon  the forehead of a young person.   It devel-
oped without pain, and disappeared in a very short time entirely,
under the experimental use of  the iodide of potassium.   A care-
ful inspection of the  patient,  which was made  at  the time, re-
vealed the presence of an old node on the right tibia.
    A large number of  still hard subcutaneous gummata may be
mistaken for multiple subcutaneous cancers or fibromata;  and
in the absence of any circumstances  in the history of the  case,
or of associated manifestations which  might throw light upon
the diagnosis, the decision will  have to depend upon the course
which the disease pursues, or upon the result of an anti-syphi-
litic treatment.
    In infants with hereditary syphilis, the  by no means  rare
subcutaneous gummata described by von  Rinecker as  syphilis 
166
BAUMLER. —SYPHILIS.
nodosa, and-anatomically examined  by Virchow ' and Forster,'
are precisely like the furuncles of atrophic children, but their
contents, however, do not consist of  pus or a kernel of cellular
tissue, but of a muco-purulent fluid which contains chiefly gran-
ular detritus.   Other signs of syphilis,  such as these children
invariably present, the gradual development of  the tumors from
the subcutaneous cellular tissue, and the character of their con-
tents—will insure the correct diagnosis.
   Gummata  developing in  the  subcutaneous cellular  tissue
cause extensive ulceration of the mucous membrane, particularly
when they occur in the throat.

                            BONES.
Virchow, Archiv,  B.  XV.  p. 237 s.  Die krankh. Geschwiilste,  B.  II. p.  398 s.—
    B.  Volkmann, Pitha und Billroth's Handbuch d. Chirurgie,  B. II., 2, p. 262 s.
    In these works the literature of the subject  is given in full.

   In the  first description of syphilis by  Marcellus  Cumanus
(1495), mention is made of the pains in the limbs, and in various
writers of the fifteenth and sixteenth centuries we find minute
accounts  of the anatomical  changes to which  the pains  in the
bones are due (see citation from Fallopia, p. 35, where reference
is made to gummata of the bones).
    Pains in the bones begin to occur as early as  at the period of
the  eruption  fever,  causing  the patients sleepless nights.  On
account  of their frequently widespread, sometimes wandering
character, and their tendency to occur only in the regions  of the
joints, these pains are known  as "rheumatic."  But a careful
examination of the skeleton shows the joints to be often entirely
unaffected, and that the points from which the  pains really pro-
ceed are certain sensitive spots at the articular ends of the bones,
especially bony  prominences to which muscles are attached,  a
fact to which my attention was first  directed by my colleague, A.
Burger,  of London.  At this early stage no other  changes are
usually to be discovered in the affected bones.  The pains may,
however,  be associated with a flat elevation at the place affected,
1 Gesamm. Abhandl., p. 595.  Archiv f. Anat. u. Phys., B. XV. p. 262.
2Wiirzb. med. Zeitsch., B. IV. 1863. 
AFFECTIONS OF THE BONES.
167
 to which the tenderness on pressure is limited.  When this ele-
 vation is marked and situated on flat surfaces of bone, as on the
 top of the skull, or the inner surface of the tibia, a certain elas-
 tic resistance or a peculiar sense of fluctuation may be percepti-
 ble to the touch.  After some length of time this gives place to
 an increasing hardness,  so that finally a more or less even, hard,
 and permanent prominence is left behind.  Such ossified promi-
 nences  were termed by the old writers tophi,1 and were distin-
 guished from  the gradually softening gummy tumors  of  the
 bones.
    The latter belong mostly to the later periods of syphilis, gen-
 erally appear in isolated form, without other symptoms  often,
 and the prominences grow pretty rapidly into roundish  tumors,
 or, upon the top of the skull, remain  flat.  Only exceptionally,
 and then in connection with destructive,  pustular eruptions, do
 these tumors occur in the acute stage  of syphilis.   They have  a
 pretty  firm, but elastic consistency when fully developed, and
 afterwards  the course wliich they  pursue  differs in different
 cases:  either resorption  gradually takes place, which leaves  a
 depression  behind,  surrounded by a hard wall-like rim,  or else
 the tumor advances in the direction of the skin, which it perfo-
 rates in the same way as the subcutaneous gummata.   The ulcer
 resulting in the latter case is, however, not confined to the skin
 and subcutaneous cellular tissue, but  from the very first begins
 to encroach upon the bone, the destruction of which commences
 before the perforation of the skin ; different-sized pieces  of very
 porous  bone are thus exfoliated.  Upon  the  top  of  the skull,
 especially, extensive  destruction is often the result of this pro-
 cess, wliich may even  go on  to  a perforation of  the bone.  If
 such  ulcers  heal, radiating,  contracting  cicatrices are formed,
 which are adherent to the irregularly nodulated surfaces of bone
 beneath.
   These processes occur not only on the surface of the bone in
the periosteum, they may also develop in the medulla.  For a
long time deep-seated, violent, boring pains in  the bone  are the
  1  G. Fallopia, 1. c, " tophacei (sc. tumores) sunt constantes ex materia penitus lapi-
dosa et videntur veluti tophi ossei vel materia ilia qua ligantur ossa fracta." 
168
BAUMLER.—SYPHILIS.
only symptoms.   Gradually the bone becomes swollen at  a cer-
tain spot,  or, it may be, in its entire circumference, where a thin,
long bone is concerned, as the fibula, or one  of the phalangeal
bones of the fingers, and the like.   Finally, only a thin, cortical
shell surrounds the gummy tumor, yielding to pressure with cre-
pitation ;  at last it is broken through and the perforation of  the
skin soon  follows.

   It is this process which obtains in one form of the so-called dactylitis syphilitica^
where a roundish, nodular swelling of  one  phalanx gradually develops, and the
skin over it  becoming  finally red, is broken through in one or more places, giving
exit to a gummy-like  fluid, mingled occasionally with lumps of whitish, caseous
matter.   This affection is not very common, and though occurring in adults,  it is
observed particularly in children with hereditary syphilis, in the first few years of
life, and constitutes a variety of the so-called spina ventosa.  Its outward appear-
ances may be produced also  by tuberculosis, enchondroma or sarcoma  of the bone
marrow.2   Anti-syphilitic treatment is speedily efficacious in dactylitis syphilitica.
In Bergh's and Morgan's cases a cure was soon brought about by the use of mercury,
while in several cases of mine I have seen perfect recovery take place, within a few
months, through the iodide of potassium.
   In an eighteen months' old, well-nourished boy of healthy appearance, who had
an induration, opening externally, of the left testis and epididymis, and slight
hydrocephalus, there were developed  upon the fifth metacarpal bone of the left
hand, on one of the right metatarsal bones, and upon  the lower end of the radius,
swellings of the  character above described.  The one on the radius had opened.
The child presented no other symptoms of syphilis.   Complete  cure followed the
use of the iodide of potassium, within five months, an interruption of the treatment
for  several weeks having previously been followed by a renewed increase in the
osseous swellings.   The ulcer in the testicle healed much less rapidly than  the
ulcer in the  radius, and both healed with  sunken cicatrices which  were firmly
adherent to the parts beneath.
   Dactylitis syphilitica does not always originate in the bone:  similar  appear-
ances may be produced through gummous formation in the sheaths of the tendons
and in the fibrous structures of the finger.

    The  syphilitic  bone  affections have  certain special points of
   1 Compare  Lucke, Berl. klin. Wochenschr., 1867,  No.  50 and 51.—Archambault,
l'Union med., 1869, No. 140.—#. Bergh, Archiv f. Dermat. u. Syph., II., 1870, p. 223.
—J. Morgan, Med. Press  andCirc, 1872, Dec, 1873, Jan., and Dublin Journ. of Med.
Sci., 1873, April, p. 354.—#.  W. Taylor, Arch, of Scien. and Pract. Med., New York,
1873 No. 4. : reference to in the Centralblatt, 1874, No. 5.
   2  Virchow,  Die krankh. Geschw., II. p. 405.   Comp. also pp. 6, 29Q, 703. 
AFFECTIONS OF THE BONES.
169
predilection.  Such bones are first attacked as are  covered only
by the integument, and are thus more exposed to external trau-
matic  accidents  and to the changes of temperature,  as,  for
example, the  skull, the clavicles,  the  tibiae,  the ribs, and  the
sacrum.   Then come the bony processes, as already mentioned,
and  especially the points of muscular  attachment,  which  are
subjected to a strain during contraction of the muscles.  In con-
tradistinction to these situations, bones which are  enveloped in
the  soft parts are but rarely attacked; nevertheless, even  the
vertebral column is not always spared, and when this is assailed
it must  be esteemed a fortunate circumstance for the  patient
when bony elevations coexist in places accessible to inspection,
thereby directing the physician's attention to the true nature of
the affection, which might otherwise betray its syphilitic char-
acter by no sign whatever.
   The most  painful of the  syphilitic bone affections are often
the  very  slight periosteal swellings  of  the secondary  period.
The  sensitiveness of the affected  part may be so extreme that
even the  pressure  of the bedclothes cannot be borne.   Gum-
mata, whether proceeding from  the periosteum or  the medulla,
may run their course with but insignificant pains, or with pains
wliich are violent and persistent—dolores osteocopi.  The pain of
syphilitic bone affections  has the peculiarity of occurring with
its greatest vehemence at night.  During  the day it may be
totally absent.   Ricord thinks that it is the warmth of the bed
that causes the pains, and he makes the statement that persons
who stay up during the night remain then free from  pain, but
suffer if they lie  in bed during the daytime.  It is very prob-
ably alterations in  the fulness of the blood-vessels which either
occasion or at least aggravate these pains; and another  point
which  seems to me equally, if not more  important, with respect
to their cause, is the existence of an evening exacerbation of  t?ie
fever, although it may be only slight in degree.  It has  seemed
to me,  in fact, that the  patients who had  fever complained
more of  periodically recurring pains than those in whom bone
affections ran their course without febrile symptoms ; and more-
over, that the pains did not begin at so late an hour of the night
as is generally stated—eleven o'clock—but commenced  gradu- 
170
BAUMLER.—SYPHILIS.
ally to increase from  the  latter part of the afternoon.'  And the
fact of the pains ceasing with an attack of sweating in the early
morning hours, as  mentioned  by numerous  writers,  speaks in
favor of their connection with variations in the bodily tempera-
ture.   This connection  appears to me to be  something  as  fol-
lows :  Under the influence of the febrile rise in temperature the
peripheral blood-vessels gradually dilate, and at the  same time
there is a determination  of blood to  those parts of the perios-
teum and bones which lie nearest the skin, a tumefaction being
thereby produced in the places affected.
   Anatomically all  the  syphilitic affections  of the  bones are
owing to  changes either in the periosteum or in the  medulla,
and indeed, whether the processes are irritative, hyperplastic, or
gummous, they may develop in one as well as in the other of
these situations.
   The very painful though scarcely perceptible swellings which
occur principally in the early periods of syphilis, as early often
as the fever of eruption, though by no means  excluded from the
later periods, belong to  a  simple periostitis.   This, after  lasting
for a certain length of  time, leads to  a deposition of  new bone
substance and to a thickening of the adjacent cortical  portion—
to a hyperostosis.   In this way there are formed, especially upon
the long bones,  but on  the skull  also, often considerable eleva-
tions, which, after the  acute process has spent itself,  constitute
the painless tophi.  At  first such  portions of bone (or it may be,
the whole extent of a  long bone), are of ivory-like hardness ; but,
according to Virchow, medullary spaces  gradually appear in the
sclerosed portions in the same way as in the normal osseous de-
velopment, so that in the course of time the thickened bone may
become even more  porous than natural.  In  this variety of the
periosteal affection, suppuration  occurs very rarely,  though it
doubtless might take place in the severe forms, such as are of
much more frequent  occurrence,  according  to C. Mauriac, in
South America and Africa, and likewise in that form of the bone
affection which  has been recently shown by  G. Wegner2 to be
„________.__________________•_____________________i  ____
   1 Even Fallopia says : " XXII.  Hora incipit dolor, non pervenit ad mediam noctem
et clamor percutit auras." L. c., p. 781.
   2 Virchow's Arch., B. 50, 1870, S. 305. 
                        FFECTIONS OF THE  BONES.                  171

peculiar to hereditary syphilis,  of which it is a pathognomonic
symptom.

.   This form of the bone affection occurs at the margins of ossification in  the epi-
physes and in the cartilage of the ribs.   It was described by Valleix,1 Bargione,2
Ranvier,3 and Gueniot,4 but has only been carefully studied in the last few years by
Wegner, Waldeyer and Kobner,5 and  Parrot.6  Its course is marked by thickening
of the periosteum, formation of osteophytes, and by a speckled discoloration and
softening of the spongy tissue of the bone in the  neighborhood of the epiphyses.
The cartilage layer is enlarged  and softened, the zone of ossification is thickened,
and projects with irregular prolongations into the cartilage layer, the union of the
two becoming thereby less firm, so that  the epiphysis  is liable to  become entirely
separated  from the shaft of the bone,  or the rib from its cartilage.  Suppuration
frequently takes place in the tissues surrounding such markedly altered bones, and
occasionally in the adjoining articulation.
   This affection generally exists in several bones at the same time,  as may often be
demonstrated at the autopsy, even though during life the affected extremity may
apparently have been quite normal.  Moreover, where changes  to the naked eye
appear exceedingly minute and insignificant, with  the  aid of the microscope they
may be recognized  as the characteristic marks of the  affection—diminution or
absence of the osteoblastema at the margins of  ossification, and  a filling of the
medullary spaces with granulation—(gumma—) tissue.   The knowledge which has
been gained of  this affection must be regarded as an extraordinarily valuable con-
tribution to the diagnosis of inherited  syphilis.  It is not infrequently the only
symptom of it,  and, inasmuch as it begins even in uterine life, its presence  may be
demonstrated in still-born children  as well as in those that live for several weeks.
Whether it occurs also in children with hereditary syphilis, in whom the disease
does not manifest itself until later, has  not been determined, but it appears to be
absent when the syphilis is acquired in infancy;  at least  Kobner,7 in a  case of vac-
cination syphilis, was unable to find any changes in either the cartilaginous  ends of
the ribs or in the epiphyses of the long bones.

    Gummy tumors not infrequently  develop in  the periosteum
in the later  stages  of the  disease.   Their development is  slow,
often attended with but  little pain, and  they may be  either small
and  circumscribed,  or (as  upon the cranial  bones,  especially)
1 Bull, de la Soc. anatom. de Paris, IX., 1834, p. 169.
2 Lo Sperimentale, Juli, 1864.
3 Gaz. medic, 1864.
4 Gaz. des Hop., Feb. 9, 1869.
» Virchow's Arch., B. 55, 1872, p. 367.
6 Archives de Physiol., 1872. Nos. 3, 4, 5.
T Arch. f. Derm u. Syph., B  III., 1871, p. 148. 
172
BAUMLER.—SYPHILIS.
their occurrence may be more diffuse.   These periosteal thicken-
ings have a lardaceous appearance on section, or they may be
still softer,  with the consistency partly  of mucous tissue or
pus, and are composed of a delicate, fibrillar groundwork, with
round  and  spindle-shaped (or together with  some stellate,
branching) cells, frequently mingled with a finely granular detri-
tus. In the early stages  of the process it  is impossible  to fix
upon any anatomical difference between a simple inflammatory
or hyperplastic growth and gumma tissue.   There are obviously
transitional  forms,  since the gummy tumor differs only in the
peculiar change which the cell-growth undergoes in its subse-
quent  course, from the processes of the primary and  secondary
period which run their course more after the manner of a simple
hyperplasia.
    The change which is wrought in the bone where these growths
develop, and which was first accurately described by Virchow, is
a double one.   In the  centre, an ulceration, a caries sicca takes
place,  which leads  to a superficial excavation, and to a porous
condition of the bone, while at the periphery, a hyperostosis is
in progress,  so that the central depression, which is often radiated
or  star-shaped,  comes to be  surrounded by a hard bony  wall.
During the  extension  of the process the periosteal hyperplastic
growth can be lifted out of the depression, and its identity with
gumma tissue has  been  demonstrated microscopically by Vir-
chow.1   Rindfleisch2 has shown that the adventitia of the
blood-vessels, in this  instance also,  forms the  matrix of the
hyperplastic growth.  By this means the encroachment  of the
growth upon the bone tissue, with atrophy of the latter, is made
explicable.  After the hyperplasia has undergone complete reso-
lution, the depression  still remains,  with the but little altered
periosteum  firmly adherent to it.   The secondary changes  at the
periphery are not confined to the surface of  the bone, but the
subjacent spongy tissue, or, in the  skull,  the diploe,  becomes
sclerosed in like manner ; indeed, effects may be seen upon the
inside  of the cranium, of a process taking  place upon the out-
side, in the form of thickenings or osteophytes, and  even upon
1 Archiv. B. XV. p. 243.
aL. a, p. 568. 
AFFECTIONS  OF THE BONES.
173
the  inner  surface  of the  dura mater, in fibrinous or slightly
hemorrhagic spots.  This  process may extend still farther in-
ward, as illustrated by a case, the autopsy of which I witnessed
at the German Hospital in  London, June 9th, 1872:

   A man, about forty years of age, who for some time had suffered from dropsy,
but in whom no syphilitic affection had been suspected, died rather suddenly in an
attack of convulsions, which were  said to have been confined to the face upon the
right side.  Besides amyloid degeneration of the spleen, liver, and kidneys, there
were found certain marked changes in the cranium, namely, several roundish atro-
phic spots upon the outer surface of the calvarium, among which was a uniformly
atrophied spot, the size of a silver dollar, in the  left half of the frontal bone, near
the mesian line.  The cranium at this spot was thinned, and  corresponding to the
middle of this thinned place, in the dura mater,  there was found a yellow, caseous
patch, one mm. thick, and of the size of a twenty-five cent piece, to which the pia
mater was firmly attached.  The latter also could not be separated, without tearing,
from the gray substance of the brain, which  was somewhat softened and  dotted
with various-sized brownish-yellow points.

   In the medulla of the  bone the syphilitic changes  also  pro-
ceed from hyperplastic cell growths, as already mentioned with
regard to the form occurring in hereditary syphilis.   But while
in the medullary  cavities  of  the long bones the osteon^-elitis
appears in  the form of  circumscribed tumors,  in  the  spongy
tissue of the flat bones, and especially in the diploe of the cra-
nium, it  forms a  sort of infiltration.   The cell growth causes an
enlargement of the canaliculi and  lacunae  of the bone, and in
this way it may happen that a piece of bone is entirely separated
from its  osseous union with  the surrounding  bone.  Such an
exfoliation  occurs  frequently  upon the  skull,  and the  seques-
trum  is  marked by a great  porosity,   corresponding  to  the
processes which  led to its separation.  The actual separation
takes  place in consequence of the  purulent or muco-fatty dis-
integration of the gumma growth,  and before this has progressed
far, inflammatory processes commence in the layers above, which
are soon followed  by perforation of  the  skin.   At  the margin
of the diseased  bone there occur in  this  instance  also, in the
bone as well as proceeding from  the periosteum, hypertrophic
processes, sclerosis, and osteophyton formations.   In small long
bones the gummous formation in the  medullary cavity causes a 
174
BAUMLER.—SYPHILIS.
bulging of the bone, with gradual atrophy of the cortical sub-
stance, which finally encloses the growth as a mere thin shell;
the most marked form of which is seen in the above-described
dactylitis syphilitica.
   We must mention, finally, the changes produced in the bone
secondarily, through ulcerative processes in the  overlying soft
parts.  Under this head  belong  especially the necroses of  the
bones in the nasal cavities and of the hard palate,  which proceed
mostly from ulcers of the mucous membrane; here belong also
necroses of superficially  situated bones, due to ulceration in
the skin.
   The sequela? to syphilitic bone affections are of great variety.
Not only may permanent  disfigurements result, as, for example,
a sinking-in of the ridge  of the  nose,  bulgings of the facial
bones, protuberances and  hollows upon the forehead, but bones
may be so impaired in their strength that fractures are produced
upon the most trivial occasions (as observed in one case of  the
humerus,  by Hutchinson,1 and of the  radius, by Volkmann);
or, through defects in certain bones,  the safety of vital organs
may be imperilled, as that of the brain; or  organs may have
their functions seriously  impaired, as on account of defects in
the palate.   Again, those bone affections which are attended
with enlargement  and hyperostosis may occasion symptoms of
compression of vessels and nerves.   Cases in which the latter are
involved occur frequently, and are of great importance, particu-
larly where the cerebral nerves suffer in this way.
   In the diagnosis it is  important, first, in any given case, to
decide whether an existing bone affection is really syphilitic or
not.  The syphilitic are distinguished  from  other affections of
the bones through their  points of predilection,  the nocturnal
pains, the slight tendency to suppuration, and their disposition
to hyperostosis and  anastosis ; in  necrotic processes, on account
of the porousness  of the  sequestrum and the slight reaction in
the surrounding parts.  Next, the form of the affection is to be
ascertained, whether simple or gummous periostitis or  gum-
mous osteomyelitis ; and here the relations as to time have to be
1 Lond. Hosp. Reports, Vol. III., 1866, p. 381. 
          AFFECTIONS OF THE  LIGAMENTS AND  JOINTS.      175

principally regarded.  Gummous processes proper, that is, such
as  tend to mucous softening,  suppuration,  or caseous degen-
eration,  belong, with few exceptions,  to the tertiary  stage of
syphilis ; in the secondary stage,  processes occur which undergo
spontaneous resolution or lead to  simple hyperostosis.
    There yet remains a single question to  be alluded to, wliich
for centuries has been revived time and again, namely,  whether
the bone affections which we have just described occur most
frequently in  those patients who have taken mercury, indeed
whether they are not exclusively due to the action of mercury,
and have nothing  at all to do with syphilis.  J. Griinbeck J as
early as 1503,  and  again G. Fallopia (1555)2 more particularly,
ascribed affections of the bones to the use of mercury in the form
of inunction, and  the latter even  claims to have found the metal
in excised gummy tumors of the bones.  But,  on the other hand,
U.  Von Hutten (1519)3 and L. Botallus (1563)4 maintained that
bone  affections  occurred in those  also  who had never  taken
mercury; and  now,  after the  experiments  of Overbeck upon
animals, together with the profound studies of  Kussmaul6 con-
cerning the hydrargyriasis acquired by workers  in mercury, we
may rest assured that, while caries and necrosis of the maxillary
bones  may take place in  consequence of mercurial stomatitis,
other bone affections, such as are observed in syphilis,  are  not
produced by mercury.

          LIGAMENTS, TENDONS, BURS^E,  AND JOINTS.

    Syphilitic gummata sometimes develop in the fibrous cap-
sules  and ligaments of the joints, indicating their presence by
tumors which  are  but slightly painful, though associated with
more or less disturbance  of function, depending upon their situa-
tion.
1 Comp. J. K. Proksch, Der Antimercurialismus.  Erlangen, 1874, p. 10.
2 Aphrod., II. p. 809.
3Ibid., I. p. 280.
4Ibid., II. p. 896.
"Untersuch. ub. d. constit. Mercurialismus.  Wiirzburg, 1861. 
176
BAUMLER. —SYPHILIS.
   According to Verneuil'  and Fournier2 the sheaths of the
tendons either become the seat of mere circumscribed effusions,
which form painless, occasionally fluctuating swellings, an affec-
tion  which is not uncommon in women,  chiefly in connection
with the extensor tendons of the hands and feet,  or inflamma-
tory appearances  are superadded, with all the symptoms of an
acute tenositis—tumefaction,  redness of the  skin, tenderness,
pain, and a sense  of friction on motion.  According to Fournier,
the extensors of the thumbs, the tendons of the biceps and of the
peronei, and the extensors of the fingers  are the most frequently
attacked, though  the affection is also met with upon the ligamen-
tum  patellae, the tendo Achillis, and in other situations.  When
the inflammation  is situated near a joint, it may easily simulate
an affection of the latter or of the periosteum, but a careful ex-
amination will almost always lead to the correct diagnosis.
   But true gummata  may also  develop in the sheaths of the
tendons.   In a case of Munn's'a palish-yellow tumor, of the
size  of a half orange,  formed above the tendons on the back of
the foot, in a man forty-five years old, who for twenty years had
been suffering from  syphilis.  The skin ulcerated, and the con-
tents of  the tumor were  evacuated.  Something similar had
taken place over  the tendons at the inner side of the knee some
time before.
   In the  bursas,  also,  serous effusions may take place, and the
walls of  the bursa, like the tendinous sheaths,  may become the
seat  of a gummous growth.
   Of more  frequent  occurrence than  the  affections  just de-
scribed are syphilitic diseases of the joints.  Although not a few
of the painful affections,  appearing at first  sight like  joint
affections, are found on closer examination to be inflammations
of the periosteum,  or  affections  of the ligaments or  tendons,
there still remain  a number of cases of true disease of the joints,
either of  the subserous connective tissue and synovial mem-
brane only,  or  even of the  articular  cartilage.  It has  been
1 Gaz. hebdom., 25, Sept., 1868, No. 39.
2Lec,ons, p. 703 ; Gaz., hebdom., 9, Oct., 1868, No. 41.
3 Transact. Path. Soc. London, Vol. XVII., 1866, p. 437. 
          AFFECTIONS  OF THE LIGAMENTS  AND  JOINTS.       177

observed (p. 127) that, at the time of the eruption fever, articular
pains, with  serous effusion into the joint, together with inflam-
matory  symptoms resembling an acute articular  rheumatism,
are not of very rare occurrence.  Babington has called attention
to the  difference between this form, which generally occurs at
the  beginning of  the secondary stage,  and  the chronic forms
which develop  without  inflammatory  symptoms  in the later
stages of  the disease.  The  acute  forms  may,  however,  also
occur later in the course of syphilis,  as shown by two cases of
Duffin's' and one which 12 reported.
   An exceedingly important and  invariable indication (first
pointed  out  by Duffin) of the  syphiUtic nature of such articular
affections  (which,  by the way, may also be  called  "syphilitic
rheumatism," or in case it is more of a periostitis or an affec-
tion of the fibrous structures  outside the joint, Fournier's term,
" pseudorheumatism," maybe employed) is the decidedly remit-
tent fever,  which, together  with  the joint affection, responds
with remarkable rapidity to anti-syphilitic treatment.3  This is
illustrated in the following tracing, taken from my work cited
above:
   The case was that of a person, twenty-eight years of age, who was suffering
from ozaena, and had an old perforation of the hard palate, but presented no fur-
ther symptoms of syphilis.  She had been suffering for a few days from rheumatic
symptoms, and at the time of admission there was a swelling of both ankle-, knee-,
and elbow-joints, and of the left wrist and shoulder. There was profuse perspi-
   1 Transact. Clin. Soc. London, Vol. II.. 1869, p. 81.
   2 Deutsches Archiv f. klin. Med., IX., 1870, p. 408, Fall 2.
   3 Schuster, Ueber Fiebercomplicationen bei Syphilitischen.   Archiv f.  Derm. u.
Syph., B. V., 1873, p. 283, reports a case in corroboration of the above. 
178
BAUMLER. —SYPHILIS.
ration, as in rheumatism.  The urine contained abundant albumen.  Very small
doses of the iodide of potassium had, in a few days, as appears from the tracing,
a perceptible influence upon the course of the  fever and upon the other symptoms
as well, and when the remedy, on account of a diarrhoea, was  interrupted, the
temperature rose again at once.  Further observations were  precluded by the
patient's leaving the hospital.
   Sometimes the affection is confined to a single joint, and in
case it is long persistent, it may be attended with  considerable
effusion—hydarthrosis.  But even old joint troubles of this kind
yield relatively quickly to anti-syphilitic treatment.   I have seen
several cases where patients had been confined to their beds for
months with  such articular affections of the lower extremities,
and yet,  by means of the iodide of potassium, regained the use
of their limbs within a few weeks.
   Of the anatomical changes, upon which the  syphilitic joint
troubles  depend,  we have very imperfect knowledge.  In the
acute form, post-mortem examinations are  totally lacking.  On
the other hand, a few cases of chronic affection of the knee-joint
have been  examined by Lancereaux'  and  Oedmanson * who
found a gummous growth in the subserous  connective tissue at
the side  of  the patella, together with secondary changes  of the
articular cartilages, in the form of  superficial erosions ; in the
synovial membrane there was merely thickening  and injection.
Coulson 3 observed perforation into the knee-joint of  a gumma,
which had  originated in its vicinity.   In like  manner—per con-
tiguitatem—a joint may  become the  seat of inflammatory mani-
festations when a bone which enters  into the composition of the
articulation is attacked by a syphilitic affection, as in the above-
mentioned instance of the peculiar epiphyseal disease in children
with  hereditary syphilis.  Moreover, where a simple syphilitic
periostitis occurs  in the immediate neighborhood of a joint, an
effusion may take place  into the latter, since  the subserous tis-
sue and synovial membrane participate in the inflammatory flux-
ion to the part.
  1  L. c, p. 203 s.
  2  Nordisk Med. Archiv, I., 4, 1869. Cited by Bergh, Archiv f. Dermat. u. Syph., H.,
1870, p. 232.
  3  Lancet, 1858.  Cited by Lancereaux. 
AFFECTIONS OF THE MUSCLES.
179
                            MUSCLES.
 Ricord, Clin, iconograph— Buisson, Turn. syph. des muscles. Gaz. mgd. de Paris,
    1846.—Notta, Sur la retraction muscul. Syph. Arch, gen., 1856, Dec.—Nelaton,
    Turn. syph. muscul.  Gaz. des Hopit., 1858,  No. 6, 1861, No. 59.— Virchow,
    Archiv, B. XV. p. 282;  Geschwiilste, B. II.  p. 437.—Sidney Jones, Transact.
    Path. Soc, Vol. VII., 1856, p. 346; Vol.  XL, 1860, p. 246.— Murchison,Ibid.,
    Vol. XIII., 1862, p. 250  (Diaphragma).—J. Hutchinson, Reynolds' System of
    Med., p. 304.—Lancereaux, 1. c, p. 211.

    Under the influence of syphilis the  muscles may become dis-
 eased, either in a somewhat diffuse manner, or in the form of  a
 subcutaneous myositis, accompanied  by considerable  pain on
 motion, and tending  to atrophy of the muscular  bundles and
 fibrous  degeneration  of  the  portion of muscle  affected ;  or  a
 gummy tumor  may develop in the interstitial connective tissue
 or  in the muscular sheath, consisting  in its fresh  state of an
 accumulation of single nucleated cells, in its  later  stages  of
 amorphous, fine granular substance.    In  this latter  case the
 muscular fibres are likewise destroyed.   The course of the affec-
 tion in  the latter form is more insidious, pain is wanting, and
 frequently the  contraction which characterizes the first form is
 also absent.  Gummata of the muscles  may also undergo soften-
 ing, and break externally,  after the  manner of subcutaneous
 gummy tumors ; intractable fistulous ulcers may thus result.
    The syphilitic disease  may locate itself in the  most various
 muscles.  The diffuse  form has  been found more  especially in
 the flexors of the upper  extremities, while the gummy tumors
 occur in  the gluteus, trapezius, sterno-cleido-mastoideus,  in the
 tongue, the muscles of the soft palate, and in the fleshy substance
 of the heart.
    A gummy tumor of  the muscle, grown to a large size, might
 readily be mistaken for a malignant  growth, especially if it pro-
 jects  much above the  muscle.   But in cases  even where other
 evidences of syphilis fail, we may always have recourse  to the
 therapeutic test with the idodide of potassium' as an aid to the
 diagnosis.
  1 As early as 1845, Tatum, in a paper read before the Med. Chir.  Society in London,
but which was not printed in their Transactions, called attention to the efficacy of the 
180
BAUMLER.—SYPHILIS.
                  THE  LYMPHATIC APPARATUS.

Lymphatic  Glands,  Follicles,  Tonsils,  Spleen,  and other  so-
                    called Vascular  Glands.
Virchow, Archiv, B. XV. p. 315-20, Geschwiilste, B. II. p. 416.—Lymphatic glands:
   v. Sigmund, Wien. med. Wochenschr., 1859, No. 23 u. 25.— Fournier, 1. c, p.
   613.—Spleen: E. Wagner, Archiv d. Heilk., B. IV.,  1863, p. 430.—A Beer,
   Die Eingeweidesyphilis.  Tubingen, 1867,  p. 24, 110,  134, 160.—S. Gee, Brit.
   Med. Journal, 1867.—& Wills, Transact. Path. Soc, Vol. XII., 1861, p. 216.—
    W. Moxon,  Ibid., Vol. XXII., 1871, p. 274.—Suprarenal capsules: v. Baren-
   sprung, Hered. Syph., p. 56.—IF. Moxon, Guy's Hosp. Rep., Vol. XIII., 1868, p.
   339.—Huber, Deutsches Archiv  f.  klin. Med.,  B. V., 1869, p.  270.— Hennig,
   Jahrb. f. Kinderheilkunde, 1872, p. 109.—Thymus: P. Dubois, Gaz. Med. de
   Paris, 1850 et 1851.— F. Weber,  Beitr. z. path.  Anat.  d. Neugeb.  Kiel, 1852,
   II., p. 75.—C. Hecker, Verh. d. Berl. Ges. f. Geburtsk., B. VIIL, p. 117, 122.—
   Lehmann Ibid., B. X., p. 29.— Weisflog, Beitr. z. Kenntn. d. Dubois'schen Thy-
   musadscesse bei angeb. Syph.  Inaug-Diss.   Zurich, 1860.

   Lymphatic  Glands.—In the same  manner as we  saw the
primary affection attended by an indolent swelling of the corre-
sponding lymphatic glands,  so we find the same occurring after
infection  of   the  entire system, when  the syphilitic poison has
caused  multiple deposits  throughout the  body  in  which the
virus becomes  augmented.   From  the  local affections of the
skin, of the mucous membranes, of the bones, etc., the  poison is
conveyed in larger quantity to the next lymphatic glands, excit-
ing  in  them the same changes  which we have studied in  the
indolent  buboes of the  primary period.  Thus,  in  connection
with affections of the  mucous membrane of the mouth, we find
the  submaxillary  glands enlarged ; with  eruptions  upon  the
hairy scalp,  the cervical glands; with papules of the  palm of
the  hand, or with paronychiae, the cubital glands.  But this is
not  the only way in which the lymphatic  glands  of all  the
different  regions of  the body are made to  sympathize in  the
disease.  It  is probable that the poison circulating in the blood
iodide of potassium in the treatment of muscular tumors.  (Referred to by Prescott
Hewett, in his Inaugural Address, as President of the Clinical Society.  Transact., Vol.
VI., 1873.) 
           AFFECTIONS OF THE LYMPHATIC GLAXDS.         181

may cause hyperplasia of the lymphatic glands directly, for
sometimes  we see these glands reacting to the poison before the
skin or mucous membranes.  The glands of the nape of the neck,
those above the condylus int. humeri, or the small glands at the
side of the breast often  become enlarged before the skin erup-
tions make their appearance, or without any source of peripheral
irritation being discoverable.  Von Sigmund, who was the first
to direct attention to the universal character of the glandular
affection in the secondary period of syphilis, and to its great
practical significance, is disposed to admit only this last mode of
origin, observing that the glandular swellings precede  the  syph-
ilides of  the  skin  and  mucous membrane, and are to be found
in new-born  children before any manifestations of the inher-
ited syphilis  have yet made their appearance.  From this stand-
point,  however, it is  still  unexplained  why,   when the  total
volume of  the blood contains  the poison in sufficient quantity
to irritate  the lymphatic glands, this irritation  manifests itself
only upon  certain ones ; for that this is a fact I have been con-
vinced by a number of observations, directed to  this  particular
point;  in  many  individuals  who  had  been  unquestionably
syphilitic for some time,  the  glandular affection was  absent
from, certainly, a  large proportion of the glands accessible to
inspection ; indeed,  only here and there were certain glands or
groups  of  glands  found to be enlarged, and even the cubital
glands were not affected with any such uniformity as claimed by
Von Sigmund.  The fact is, that the individual disposition comes
here into account, and, while in one person it is  the integument
which reacts first  to the irritation of the syphilitic  poison, in
another it  is the lymphatic glands.  It is, moreover,  to be ob-
served further, that, even with peripheral local lesions existing,
the corresponding lymphatic glands  do  not necessarily become
enlarged, and that in any two persons, the conditions in other re-
spects being about the same, the glandular enlargements may be
greater and more permanent in one than in the other.  The terti-
ary local affections are said not to be attended by swelling of the
glands, but yet it  depends mainly upon whether these affections
are accompanied with  suppuration or not.   In the former case
the glands become tumefied as in any ordinary suppuration. 
182
BAUMLER—SYPHILIS.
   With regard to the secondary stage, I have a general impres-
sion that there is usually some intervening local lesion between
the blood-poisoning and the glandular swellings.  Berkeley Hill,'
too, is of  the opinion  that this is more commonly the case.
Sometimes  the lymphatic vessels in the vicinity of these glands
also become affected, feeling like hard cords.
   This affection  of the glands (which is peculiar to the secon-
dary period, beginning to develop from the sixth week after the
appearance  of the  primary lesion)  attacks by preference  those
glands which have  been already named, but most commonly of
all  the posterior cervical,  in the vicinity of which an occipital
or mastoidal gland is occasionally enlarged.   Its occurrence in
the lymphatic glands in the interior of the body, also, has been
verified in post-mortem examinations by von Barensprung2 and
Virchow.   The course of the secondary affection is quite as pro-
tracted as that of the primary indolent buboes, from six to eight
months passing before resolution begins; according to von Sig-
mund, the  glandular affection may  even last for  a  lifetime.
Inasmuch  as, when  dependent upon  local  lesions,  different
glands may vary considerably in their development as to time, it
is occasionally possible to find swollen glands here and there for
years, although the course of development for any single gland
is comprised within months.
    Resolution is  not the only issue in which the hyperplasia of
the lymphatic glands may terminate.  The  cell-growth may ex-
ceed its usual limits, and swellings result like those of  scrofula ;
and, as in  the  latter, suppuration or caseous degeneration may
ensue.  Fournier states that this process is pretty common, only
it is frequently not referred to  its real source.  But the events
just mentioned may assume a more peculiarly syphilitic charac-
ter ; the hyperplasia may take  the course of a gumma,  and a
fluctuating  tumor become  gradually developed which does not
contain pus but  a gummy-like mucous fluid.  Finally, in  the
later course of syphilis,  the  lymphatic glands, together with
other glandular organs may,  as shown by Virchow,  suffer an
amyloid degeneration.
1 L. a, p. 76.
2D."ehered. Syph., p. 17. 
           AFFECTIONS OF THE LYMPHATIC GLANDS.        183

   A hyperplasia perfectly analogous to that which  occurs in
the lymphatic glands may be sustained also by the follicular
apparatus  at the root of the tongue, in  the tonsils, and on the
posterior pharyngeal wall; and Virchow calls attention to the
fact that where  the  cell-growth is tolerably abundant a disinte-
gration, culminating in a sort of follicular abscess or ulcer, may
be  the result.   The  tonsils are especially apt to be the seat of
such gummous  ulcerative processes.  Certain  peculiar  changes
in Peyer's patches will be mentioned further on.
   That the spleen may become enlarged  in the acute stage of
syphilis has been already mentioned (p. 127),  and Weil *  has
recently discovered that this enlargement may begin even during
the primary period.  The affection of the spleen is related, on the
one hand, to that which occurs in this organ in other blood-poi-
sonings, and, on the other, to the lymphatic glandular enlarge-
ments.  It is probably purely hyperplastic in its nature, since
it disappears rapidly under  anti-syphilitic  treatment.   But
where it has existed for a considerable time, an induration may
doubtless develop  in the hyperplastic  spleen tissue.  These
events are the same as those described under Virchow's two ana-
tomical forms of the syphilitic enlarged spleen, which he terms
respectively the  soft and the indurated.
   Gummata are frequently observed, too,  in the spleen. They
appear in the form of isolated or quite numerous nodules, vary-
ing in size from a millet seed to a walnut, in a spleen that is, gen-
erally, enlarged.  If  they lie near the capsule, the latter becomes
cloudy and  thickened.   According  to Wagner, recent syphilo-
mata are grayish-red in color, tougher than the normal tissue of
the  spleen from which they project;  the older ones  are gray,
sprinkled  with yellow, dryer and harder.   The vessels of the
spleen and its septa, within  the growth, mostly disappear with-
out any traces of them remaining to be seen, and it is the same
way often with  the Malpighian bodies, though  in other cases
they are present.   In other respects  the sharply defined,  but
not  usually encapsulated tumor, shows  the finer  anatomical
structure of the syphiloma, namely,  the cellular hyperplasia,
1 Centralblatt, 1874, No. 12. 
184
BAUMLER.—SYPHILIS.
with various grades of atrophy and fatty degeneration, together
with the formation of new connective tissue.  In consequence of
these processes a gradual shrivelling takes place, with cicatricial
contraction, similar to what occurs in healed hemorrhagic infarc-
tions.   Zenker  found  numerous cholestearine  crystals  in  a"
tubercle of the spleen, which was enveloped in a distinct fibrous
capsule.
   Still other pathological changes in the spleen are regarded by
different observers as related to syphilis. Thus A. Beer describes,
besides a diffuse cellular infiltration of  the arterial sheaths in
the spleen, certain peculiar deposits, which he regards as very
characteristic;  they are paler than the normal tissue, from which
they do not project at all, merge diffusely in the  surrounding
spleen tissue, contain  but little blood and few cells, and, in the
centre, consist of a finely granular material in which a few cells
and nuclei are imbedded.
   Gummous disease of the spleen can only be suspected during
life when the tumor lies  near the capsule, and through irritation
of the latter, pain or symptoms  of a  circumscribed peritonitis
are occasioned.  The enlargement of the spleen which is usually
present in the early stages of syphilis would only admit of the
diagnosis of a hyperplasia ; in the later periods it would be amy-
loid degeneration, which  is very apt to occur in the tertiary stage
and in the stage of sj^philitic marasmus, in connection with amy-
loid degenerations of other organs.
   Moreover,  the rest of  the so-called  vascular  glands—the
thyroid, the suprarenal  capsules, the glandula pituitaria, and
thymus gland—occasionally present  more  or less characteristic
changes in syphilis.   In  the thyroid gland Lancereaux found
enlargement with varying degrees of fatty degeneration ; gummy
tumors have not been found in it, though they doubtless occur
in the gland, pituitaria (Virchow, Lancereaux).8  In the supra-
renal  capsules, besides enlargement  and gumma-formation
(Virchow, Moxon), a total fatty degeneration was found in one

   1 Private communication, supplementary to a short reference to the reported case in
the yearly reports of the Gesellsch. f. Natur- u. Heilkunde in Dresden f. 1851 u, 52, p.
15.
   • Gros et Lancereaux, Affect, nerv. syphil. Paris, 1861, p, 247. 
AFFECTIONS  OF THE LIVER.
185
case, by Virchow.1  The thymus,  an  organ which  gradually
undergoes atrophy in developing children, can only be of inter-
est in this connection in the foetus  or in infants—particularly,
therefore, in cases of hereditary syphilis.  P. Dubois was the first
to call attention to  the  fact  that in the thymus  of new-born
children, with inherited  syphilis, collections  of pus are to be
found, with which, however, as Virchow observes,  the ordinary
secretion of the  gland must not  be  confounded ;  and the ques-
tion is suggested by  Lancereaux, whether in these cases it was
not really softened gummata which were present,  since Lehmann
in one case, has found a  gumma-like  formation  in the thymus.
Eberth2 also found,  besides abscess-like deposits, certain dry,
caseous tubercles in this gland.

                          THE LIVER.
Dittrich, Prager Vierteljahrschrift, 1849,  B. I. p. 1, 1850 ; B.  n. p. ZZ.—Gubler,
   Mem. sur une nouvelle affect, du foie liee a; la Syphilis hergdit.   Gaz. med. de
   Paris, 1852.—Budd, Diseases of the Liver, 2d ed., 1857.—Virchow, Archiv, B.
   XV., 1858, p. 2m.—Frerichs, Klinik  d. Leberkrankh., 1861, B. II. p. 152.—S.
    Wilks, On Syph. Affections of Internal Organs.  Guy's Hosp. Reports, 3d Ser.,
   Vol. IX. 1863.—E.  Wagner, Das Syphilom der Leber.  Archiv der Heilkunde,
   B. V., 1864, p.  121.—v. Barensprung,  Die hereditare Syphilis.   Berlin,  1864.
   — Virchow, Die krankh. Geschw., B. II. p. 423.  See further references in the
   last-named work; also in Lancereaux, 1. c, p. 259.

   The discovery of  syphilitic disease of the  liver, by Dittrich,
marked a turning-point in the pathology of syphilis,  since here
properly began the study of visceral  syphilis.   For, although
the earlier writers upon syphilis regarded the liver  as the proper
seat of the  disease,  this was a mere  supposition, based upon
dogmas  of Galen,  and had been attacked  by Pr. Borgarutius
(1566),s in  consequence  of the  negative results which he  had
obtained from numerous post-mortem examinations.  The patho-
logical  changes  to which Dittrich  was the first to  attribute a
syphilitic origin had  been already described by Budd, and  also
by Oppolzer and Bochdalek, the former regarding them as due

                 1 Wiirzburger Verhandl., B. III., p. 368,
                 a Virchow's Archiv. B. 40,  1867, p. 326.
                 3 Aphrod., II. p. 1127. 
186
BAUMLER.—SYPHILIS.
to the obstruction of dilated hepatic ducts with cheesy matters,
while the two  latter ascribed them to cancer of the liver, which
had  healed.   In consequence  of the numerous  investigations
which  have since been made with reference  to syphilis of the
liver, we have learned that the forms of disease wliich, under the
influence of syphilis, may  attack  this organ (though some of
these affections are better known to us in their final stages  than
in their entire  development)  are the following :
   1. Diffuse Infiltration (Wagner's diffuse syphiloma)—a  form
which has thus far been observed almost exclusively in infants]—
was  first described  by Gubler,  and is  marked by an increase in
the size and weight of the liver.   Its color resembles that of flint;
the acinous structure may  be  more or less obliterated or, per-
haps, quite indistinguishable to the naked  eye, as was the case
in the liver of  a child, one month old, examined by Wilks :2 The
liver was increased in size, was flattened and very dense,  and no
traces  of hepatic tissue were visible to  the naked eye.  Under
the microscope,  however, in spite of  the extensive infiltration,
hepatic cells  and  blood-vessels  were found, presenting  their
normal appearance.
   According  to Wagner, in livers of this  kind the connective
tissue between the acini is found thickened in  most places, some
portions being in a state of simple hypertrophy, while others are
studded with numerous cells and nuclei, which also appear with-
in the acini, arranged in groups corresponding to the capillaries.
Sometimes only  connective tissue is seen.  As to the hepatic cells
themselves, they are at one time in their normal state, while at
another they show various stages of molecular disintegration.
   The state  of things here, then,  is quite analogous to what
occurs in the syphilitic  changes in the skin and other tissues,
viz.,  there is  a  proliferation of cells from the connective tissue
between the acini, or from the adventitia of  the interlobular ves-
sels, and this growth  may  become transformed  into connective
tissue.
   2. In a more circumscribed form this variety is doubtless of
commoner occurrence, and particularly in adults.  Since the pro-
       1 Wagner, 1. c, p. 145, describes a case in a man fifty-four years old.
       2 Trans.  Path. Soc, Vol. XVII., 1866, p. 167. 
AFFECTIONS OF THE LIVER.
187
cess runs the course of an interstitial  hepatitis, it is  usually
recognized only by the  cicatrices which it leaves.  But  in most
of the cases, if the process has reached a considerable extent, the
larger masses of  cicatricial  tissue are found to include portions
of tissue which have undergone cheesy degeneration, similar to
those left by true gummous hepatitis, which,  from the first,
occurs more in the form of circumscribed tumors.  It is possible
that such cheesy tubercles may gradually decrease in size by
resorption of the fatty material, and  thus, with the interstitial
hepatitis, lead the way to those very  remarkable  changes  in
form which  are sometimes observed in the liver.  By means of
deep cicatricial contractions,  the organ may be divided into  a
number of distinct, roundish lobes or prominences, the liver be-
coming often much diminished in size, or it may be reduced to a
roundish, nodular mass, not larger  than the fist.   When cut,
dense bands of fibrous connective tissue, that grate under the
knife, are found,  corresponding to the external constrictions, and
at some points they  may enclose masses, which have undergone
cheesy degeneration.  The intervening hepatic tissue is either of
normal  character, or frequently in  a   condition of vicarious
hypertrophy, or  sometimes in a state of amyloid degeneration,
and this degeneration may be limited to particular  places, and
be  of such  a high grade as  to resemble gummy tubercles,  as
described by Virchow,1  Grainger Stewart,2 and Moxon.3
   As a rare consecutive affection, partial acute yellow atrophy
may develop in livers of this kind (Andrew,4 Hilton Fagge).5
   The peritoneal coating of such a liver shows, besides the con-
strictions, traces  of perihepatitis, in the form of thickenings or
adhesions with the diaphragm, the anterior walls of the abdo-
men, or with some of the other abdominal viscera.
   3. The true gummy tumor of the liver  (the large nodular
syphiloma of Wagner)  usually presents  an irregularly circum-
scribed mass  of  connective tissue, from which prolongations
1 Geschw., II. p. 430.
2 Brit, and For. Med.-Chir. Rev.. 1864. p. 512.
3 Trans. Path. Soc. London, Vol. XX., 1869, p. 431.
4 Ibid., Vol. XVII., 1866, p. 158.
6 Ibid., Vol. XVIII., 1867, p. 136. 
188
BAUMLER.—SYPHILIS.
often  extend  into sound hepatic  tissue,  with  grayish-yellow
cheesy deposits scattered through it, which  are more  sharply
defined, the denser the  connective tissue has  become.  Some-
times, however, it takes the form  of a  well-defined tumor of a
roundish form, enclosing a dry, firm, cheesy matter in a fibrous
capsule.  Deposits in  the midst of dense masses  of connective
tissue are most apt to occur beneath the  suspensory ligament,
from which a  broad fibrous  mass  often extends  through the
entire thickness of the  isthmus between  the two lobes of the
liver.  Virchow calls attention to this, and he observes that it has
an appearance  as though the  traction of the heavy organ upon
its supporting  ligament  exerted a strain upon the  tissue which
had had some influence upon the development of these changes.
   As  a  rule, gummy  tumors  in the  liver are isolated,  but it is
possible  for their number to be very large, and when this is the
case  they present the  utmost  diversity as to size, varying from
that  of a millet-seed (miliary syphiloma, Wagner) to that of a
walnut, and are  even  greater.   They were very numerous in a
case observed  by  Prof. Zenker'  in Dresden in 1851,  of which he
has had the kindness to  give me a full report.

   In the liver of  a man, forty-one years of age, upon whose skull and shoulder-
blades were also distinct marks of syphilis, were found, especially upon the right
lobe, numerous round tumors of a size varying from a pea to a moderate-sized apple,
which were for the most part spherical, but in many cases were aggregated in masses
of irregular shape. With the exception  of two large, soft tubercles, which con-
tained a pultaceous substance enclosed in a dense  fibrous capsule, they were very
hard and dry, of a yellowish-white color, and in a few of them a distinct, concentric
lamination was visible, and it was possible even to peel off the substance in con-
centric layers.  The tumors were separated from the normal hepatic tissue by a pale
gray fibrous capsule of considerable thickness, some of them being of a homogene-
ous consistency, while others  showed at the centre of the yellowish-white substance,
or in some  part of the periphery, one or  more irregularly shaped, pale grayish-red
spots, which in comparison with the rest of the cut surface were somewhat depressed
and softer,  but much tougher.  In some  of the tumors very small calcareous con-
cretions were also found.  One tubercle was discovered in the spleen, of the same
appearance  as the tumors in the liver.
   Under the microscope the  pultaceous contents of the softened tubercles were
found to consist mainly of finely granular corpuscles, resembling pus-cells but  yet
1 Citat. on p. 184. 
AFFECTIONS  OF THE LIVER.
189
not perfectly round, of free fat, fat cells, and cells with fatty nuclei.  In a light
yellow mass which lay in the midst of one of the reddish gray spots, fat cells and
numerous small acicular crystals were  found. These reddish gray spots presented
the appearance of indistinct  fibrillation, with a few scattered islands of small cor-
puscles of irregular form, and not strongly refracting the light.  At the boundary
of these two substances were found a great number of non-transparent, large, round
cells, from which issued, on pressure of the specimen, a quantity of short, needle-like
crystals, while more deeply in the yellowish-white matter these  cells were found
more  isolated.  In addition to this, the tubercles  everywhere contained a large
amount of amorphous, finely granular matter.

   So far as the more essential microscopical characters of these
tumors are concerned, they have already been given in the above
description.  While in  the yellow spots it is possible  only  to
demonstrate a finely granular detritus within a fibrous substance,
towards the periphery,  nuclei often appear,  and sometimes cells,
wliich anastomose in a reticular form.  The development of these
tubercles probably proceeds  from the  interlobular vessels,  as
stated above with regard to the diffuse affection.  Corresponding
to this, too, the tumor does not  develop  regularly  and present a
rounded  surface on all sides, simply crowding the  hepatic tissue
away, but  it grows into and between the acini in such a manner
that liver tissue is sometimes surrounded and shut in by it.  A
very accurate description of the microscopic appearances is given
by J. F.  Payne,1 and he makes it appear  probable that  gum-
mata can continue to grow at the periphery, on account of the
continued proliferation of the nucleated interstitial and inter-
lobular tissue, while at the centre they have already become
amorphous, and  in  the intermediate  layer  have degenerated
into fibrous  connective  tissue.   Payne calls attention to  the
fact that the  growth  has but  little vascularity,  and  in this
respect is in marked contrast with  the ordinary interstitial hepa-
titis (cirrhosis).
   The study of the larger tubercles in the earliest phases of
their development has not been more closely pursued, because as
a rule,  they are only met with  at autopsies after  the processes
have run their entire course.   One of the earliest  steps of their
development is shown  in von Barensprung's first plate, which
» Trans. Path. Soc, Vol. XXL, 1870, p. 207. 
190
BAUMLER.—SYPHILIS.
represents the liver of an infant which was probably prematurely
born and which lived but sixteen hours.

   "The liver is of a bright red color, but with dark, greenish-brown spots, which
are sharply defined, and some  of them are round in form, while others have an
irregular kidney shape, occasioned by the coalescence of one with another.  In these
spots are seen numerous white granules, which are as large as corn-grits, and slightly
prominent.  The liver is large and  flabby;  on section, it is of a reddish-yellow
color, but also spotted, since the spots noted on the surface extend one or more lines
in depth into the substance of  the organ.  Roundish deposits are also seen, which
do not reach the periphery, are of a greenish-yellow color, surrounded by an area of
marked hypersemia, and at some portions contain also the white granules mentioned
above.   These  last show, under the microscope, a finely granular,  molecular mass,
while at the discolored spots  there is everywhere an abundant proliferation of cells
and nuclei between the liver cells, which have been pushed aside and have in part
disappeared.

    A case observed by H. Weber,1 in  an adult,  communicated by
him to the  London Pathological  Society, and which  I  had the
opportunity of  examining with him, presents certain points of
outward resemblance to the case just  described.

   C. F., a  ship-carpenter, aged twenty-eight years, lay from December 21, 1865,
until January 10, 1866, in the  German Hospital in London,  suffering  from rheuma-
tism.  The elevation of temperature was only moderate, but to the other symptoms
were soon added great depression of the sensorium, pain in the head, stiffness of the
neck, slowness of the pulse, and on the 7th of January a state of coma supervened,
from which the patient could be aroused only  with  great difficulty. On the next
day it was no longer possible  to arouse  him, and  death occurred on the evening of
the 10th.
   At the  autopsy  the  head presented nothing abnormal externally, but upon
opening the calvarium, firm adhesions were  found between  the dura mater and por-
tions of  the frontal, temporal, and parietal bones.  These having been  torn away,
the internal table of the skull presented a worm-eaten appearance, and was covered
with small osteophytes.   Along the venous sinuses was found a growth of very vas-
cular spongy tissue, a portion  of which remained upon the dura mater.  This mem-
brane, so far as  these portions were concerned, was considerably thickened,  and
numerous ecchymoses were found upon it, while the other membranes were slightly
adherent to the dura mater, were somewhat opaque and thickened, but left a smooth
surface when separated from the brain.  A microscopic examination revealed in the
growth on the dura mater, large cells and nuclei, which had undergone some fatty
degeneration.   In the brain substance no changes were discovered with the excep-
1 Trans. Path. Soc, Vol. XVII., 1866. 
AFFECTIONS  OF THE  LIVER.
191
 tion of some hypersemia and ecchymosis of the pons and the crura cerebri.  The
 liver was of  normal size, but copiously studded with tubercles of large and small
 size, but for the most part of a round form.  At the middle of those tubercles,
 which reached the surface of the liver, a depression was seen, and  the  centres,
 which were of a darker color and strongly injected, were surrounded by  a wall
 varying  in width from 0.05 to 1 cm. in thickness, and of  a more yellowish tinge.
 In such  parts of the liver  as were apparently in a normal condition, examination
 with the microscope showed the hepatic cells to be enlarged, and filled with a finely
 granular substance,  but the arrangement of  the liver cells at the edges of the tuber-
 cles  was normal.  Toward the edge of  the yellow  zone there was an increase in size
 of the liver cells, as well as in the quantity of granules contained by them ; while at
 the  edge of  the  tubercles  the  cells appeared to  be pressed  closer together, and
 between  them was a dark granular substance, and  some large cells and free nuclei.
 Finally, in  the very vascular centre there were but few hepatic cells, and between
 them was a  growth of spindle-shaped cells, which were to some extent granular,
 some of them having very long processes.
   The condition of the lungs was quite  remarkable, both their surface  and the
 parenchyma  being  traversed with a network of lymphatic vessels, which appeared
 as if injected with a milky fluid.1  Some of the bronchial glands presented evidence
 of degeneration.  In these, as well as in the contents of the lymphatic vessels, were
 found large  cells, mostly round in form, but  also spindle-shaped, with a sharply
 defined contour, and containing  one  or two strongly refracting nuclei.   In the
 lymphatic vessels and glands were seen numerous fatty granules and much free fat.
   The spleen and kidneys, with the exception of  some contracted cicatricial spots
 upon the last-named organs, were healthy.
   In addition to the changes noted in the cranial bones, there was a flat periosteal
 growth on the posterior face of the sternum; but, with these exceptions, there were
 nowhere  either bony  elevations or gummata,  nor were any  traces of ulceration
 found on the skin.   The diagnosis  of syphilis, in the absence of  all anamnestic
 signs, rested upon the  presence of scars upon the palatine arches, enlargement both
 of the follicles at the root of the tongue, and also of the inguinal, cubital, and cer-
 vical glands,  together with a small scar upon the penis.  The testicles were  found
 to be entirely normal.
   The disease of the liver had run its  course without giving rise to a single symp-
 tom.

    The changes in  the  liver in this case present so little resem-
 blance  to  those observed in  other  cases, that,  in spite of the
 many  circumstances  favoring  the supposition,   I am not  fully
 convinced  that they  were  due to  syphilis.   The appearances

   1  W. Moxon describes a similar condition, which he found in a case of pneumonia, in
which there were also typical gummata of the liver, and a peculiar hemorrhagic affec-
tion of the spleen.  Trans. Path.  Soc, Vol. XXII., 1871, p. 274. 
192                 BAUMLER.—SYPHILIS.

found in the above case differ from those usually present in cases
of syphilitic origin, from the fact that round and spindle-shaped
cells were present of much larger size than are commonly seen in
gummy tumors.  The fatty degeneration, too, was more marked
at the periphery of the tubercle, while  in cases of  undoubtedly
syphilitic origin this change is usually found to be in its most
advanced stage at the centre.   In  fact, the description of this
case, when considered in all its bearings, suggests  some form of
sarcoma rather than syphilis.  But inasmuch as the early stages
of syphilitic  affections of the liver have been so little studied, it
is worth while  to note  this case, although as yet it stands alone
and its real nature remains doubtful, in order to compare it with
others of a similar character which may be observed hereafter.
   Softening of gummata of the liver must be regarded  as of
exceedingly rare occurrence.  With the exception of Zenker's
case, detailed above, I am acquainted with but one other, which
was reported by Moxon,1 and in which  the inner portion of some
of the tumors had the consistence of brain, and some perforations
into the hepatic ducts had occurred.
   4. Amyloid degeneration of the liver, in consequence of syph-
ilis, may involve the whole organ, as well  as portions of  it, as
already described.  This change usually starts from the  small
interlobular branches  of the hepatic artery, and it may, in fact,
be limited to the coats of  the arteries.   It  is always associated
with amyloid  degeneration  of  other abdominal organs,  as the
spleen and kidneys.
    The signs of syphilitic disease of the liver are, as a rule, so
vague that changes of a  high grade may be  found upon the
cadaver, without a single symptom during life having pointed
to the existence of hepatic disease.   Especially is  this  true of
gummata of the liver, which in many cases  run their  course
without giving rise to any symptoms whatever.  On the other
hand, no pathological changes have as  yet been found to account
for the  icterus, which occurs in the secondary period of  syphi-
lis—usually, in the eruptive stage.  Gubler2 was the first who
   1 Trans. Path. Soc, Vol. XXIII., 1872, p. 153.
   2 Mem. de la Soc. de Biologie, 1853. Gaz. med.  de Paris, 1854.  {Lancereaux, L c,
 p. 149.) 
AFFECTIONS OF THE LIVER.
193
attempted to prove that this form of icterus was not an acciden-
tal complication, but a characteristic  symptom of syphilis, and
he asserts  that it appears either with the first syphilitic erup-
tion or with the later relapses.   As a rule, it is not very marked,
nor does it continue for any great length of time,  so that we can
scarcely attribute  it to a compression of the gall-ducts  from a
syphilitic cell-growth.   It is more  rational to look upon it, with
Gubler, as  a congestive icterus due  to hypersemia of the liver, or
it may be  regarded as a simple catarrhal jaundice, which de-
velops under the influence of the fever, in the same way as the
catarrh of the stomach, which is sometimes present.  Lancereaux
alludes to  the  possibility of its being due to a swelling of the
lymphatic  glands at the  transverse fissure  of the liver.   How-
ever, it should  be observed that icterus at this period of syphilis
may also  be a matter of more serious  import.   Goodridge'
reports a case  of  acute yellow atrophy of the  liver in  a man
twenty years of age,  two months  after infection, while  roseola
and the syphilitic affection of the throat were still present.
   The symptoms of the  syphilitic affections of the liver, whose
morbid anatomy has  been  ascertained,  are  referable  to the
changes  in the size and form of the organ, to derangements in
the portal  circulation and in the escape of the bile, and,  finally,
to involvement of  the peritoneal coating.  Whether any or -all
of these symptoms display themselves, depends entirely upon
the location  of the process.  The increase in size of the  liver is
a constant symptom in the diffuse hepatitis, both of hereditary
and acquired syphilis, and also in amyloid degeneration, when
it involves the  entire organ.  If, in the progress of the disease,
interstitial contraction takes place, symptoms  of cirrhosis of
the liver will be developed.  When a circumscribed formation
of tubercles (gummous  formation)  takes  place, the gradual
change in  shape  of the liver—the  lobulation  of its tissue—
becomes one  of the most marked  symptoms, and, according to
the seat of the process, icterus or ascites,  together with other
evidences of a disturbed portal circulation, will be present.  The
diagnosis of a syphilitic cirrhotic liver, especially in patients of
      'Brit. Med. Journal, 1871, Vol. I. p. 609.
VOL III—13 
194
BAUMLER.—SYPHILIS.
advanced age or who  suffer from marasmus to a marked degree,
may be attended with some difficulty, since the projecting nod-
ules upon  the surface of the liver bear a marked resemblance
to those which occur  in cancerous disease.   As a rule,  however,
a syphilitic cirrhotic liver at this stage of the disease is smaller
than  normal, while a cancerous liver is apt to be enlarged, and
by careful observation the  increase  in size may be  verified.
Moreover, the  rest of the symptoms, especially the marasmus,
increase with great rapidity if the  disease is cancerous, but if
these  symptoms owe  their origin to  syphilis,  they are  apt  to
remain stationary for  a long time.   Of  more importance,  of
course, in making  a diagnosis, is the discovery of other symp-
toms pointing  to syphilis, or at  least  evidences of their  former
existence.
    Implication of  the peritoneal coating  of the  liver may  be
recognized by the pain in the hepatic region.  In new-born chil-
dren, unless, possibly, there may be some  enlargement of  the
liver, the  only local symptoms, often,  are  those due to the peri-
tonitis—the  screaming,  drawing up of the  legs, and vomiting.
In these cases  it is not rare for the peritonitis to become diffuse.


                        DIGESTIVE TRACT.

Mouth and Fauces, Tongue : M. Kohn  (Kaposi), 1. c—v. Sigmund, D. papul. Syph-
    ilid am weichen Gaumenu. d. Mandeln. Oesterr. Zeitschr. f. pract. Med., 1858,
    N0. 35.—Lagneau,  Des turn. gomm. de la langue.  Gaz. hebdom, 1859,  Nos.
    32, 33, 35. Archiv. gen., 1860,1., p 361.—Teeth : Marslon, Med.-Chir. Transact.,
    vol. 45.— J. Hutchinson, Trans. Path. Soc, Vol. IX., 1858, p. 449.  Ibid., Vol. X.,
    1859, p. 287.—Nunn, Ibid., vol. XII., 1861, p. 239, Vol. XIIL, 1862, p. 258.—/;
    Hutchinson, A Clin. Memoir, etc., 1863, p. 203 s.—Oesophagus: S.  Wilks, Guy's
    Hosp. Rep.— West, Dublin Quarterly Journal, Feb. and Aug., 1860.—Intestinal
    Canal:  E. Muller, Ueber. d. Auftreten d.  constit. Syph.im Darmkanal.  Inaug.-
    Diss. (Dittrich.)  Erlangen, 1858.—Meschede, Virch. Archiv, B. 37,  1866, p. 565.
    —E.  Wagner, 1.  c, IV., p. 368 u. 370.— Forster, Wiirzburger Med. Zeitschr., B.
    IV., 1863, p. 8.—Eberth, Virchow's Archiv, B. 40, p.  326.— Schott, Jahrb. f.
    Kinderheilk., lmi.—Both, Virchow's Archiv, B. 43, 1868, p. 299.— Oser, Archiv
    f. Derm. u. Syph., B. III., 1871, p. 27.—Schwimmer, Ibidem., B. V., 1873, p. 247.
    —Rectum: Gosselin, Archiv. gen., 1854,  II., p. 666.—v. Barensprung, Ann. d.
    Charite'krankenhauses,  B. VI., p. 18.—E. Hu'et, Behrend's Syphilidologie.  N.
    Reihe, B. II., 1860, p.  l.—J. Bpjrf. Med. Times and Gaz., 1865, I., p. 279.— 
           AFFECTIONS  OF THE MOUTH AND  FAUCES.        195
   A. Behr, Eingeweidesyphilis. Tubingen, 1867, p. 7.—Discuss, in the Soc. de
   chirurg. de Paris, Jan., 1873.  (A. Guerin, Despres, Verneuil.)  Gaz. hebdom.,
   1873.

   The mouth and fauces may not only be the seat of  the pri-
mary infection, but they are  also the  localities which are most
frequently affected  in  the secondary  and tertiary periods  ot
syphilis.  The elementary forms of these affections have  been
already described (pp. 137 et seq.), and it is here only necessary to
call attention  to certain peculiarities which are derived from the
locality.
   In the secondary period, superficial erosions or considerable
ulcerations are common on the inner side of the  lips, and they
are especially apt to occur when an  irregularity of  the teeth
keeps  up a constant irritation  at  one spot.  In the advanced
stages of secondary syphilis, the above-described plaques  opa-
lines occur upon the mucous membrane of the lips  and  cheeks,
and  are  often very obstinate  affections.  In the  posterior  por-
tion  of the mouth, the parts just in front of the half-arches, and
between  the upper and lower last molar teeth,  are most com-
monly the seat of  changes  in  the  mucous membranes, which
are most apt to take the form of papules.  Small erosions occur
also  frequently on the gums, back of  the central  incisors of the
upper jaw.  During the administration of  mercury,  the swelling
of the gums  due to this drug,  in  conjunction  with  syphilitic
changes  in the  mucous membrane,  may add much to the dis-
comfort of the patient.  In some of these cases, it is not an  easy
matter to decide exactly what is due  to mercurial stomatitis,
and what to syphilis.
   The tongue, during the period of eruption, especially when
there is  a  papular eruption on the skin,  is the seat  of  round,
circumscribed, slightly elevated  spots, which frequently  extend
at the periphery, assuming a ring or horse-shoe shape.   At the
borders of the tongue, above and below, isolated  erosions occur,
having the form of small fissures,  which are often caused,  or
at least  maintained,  by  sharp  edges of the teeth; and when
these are present the fissures may be converted into crater-like
ulcers, of greater or less depth,  with  hard, gray  edges.  Small
papules,  too,  often occur at or  near the tip of  the  tongue, 
196
BAUMLER.—SYPHILIS.
 appearing as very late relapses, and often having the form rather
 of a small, red surface than of a red papule.  When these pap-
 ules occur in great smokers (in whom, in fact, they are generally
 found), they are extremely slow in disappearing.
   At the anterior portion of the tongue the papules are usually
 flat,  and even sometimes seem to sink beneath the level of the
 surrounding mucous membrane, having the appearance of bright
 shining spots, deprived of  their  epithelium, and in this respect
 present a certain analogy to papules upon the palm of the hand.
 But  at the  back part of the tongue  the  papules project more
 prominently, and, becoming confluent, form large, elevated condy-
 lomata.  Some of the follicles  at the base of the tongue may be
 swollen at the same time,  or they may even become converted
 into  elevated papulae.  Under unfavorable circumstances,  par-
 ticularly in patients who  have defective teeth and are  not careful
 to cleanse them,  the entire tongue may be covered with papules,
 and  look as though covered with a grayish membrane, showing
 the impressions of the teeth at the sides.
   The tongue may, however, be the  seat of disease at a later
 stage of the syphilis, since gummata may also develop here. A
 tumor  of  this character may develop out  of an ulcer, which,
 though at first superficial, has long been subjected to the  con-
 stant irritation from the sharp point of a tooth.  More com-
 monly,  gummata originate in  the substance  of the tongue, be-
 neath the mucous membrane,  or in the  intermuscular  connec-
 tive tissue, in the form of tumors varying from the size of a pea
 to that of a hazel-nut, which gradually  increase in size  and
 approach nearer the surface till  they finally burst and leave an
 ulcerating cavity.
   Before these tumors  break, they annoy the patient more on
 account of the interference with the free motion of the  organ than
 from the pain, and may  then be easily confounded with cancer
 of the  tongue.   The points of  distinction, as commonly stated,
 are the greater amount of pain and the more marked  swelling of
the lymphatic glands in  cancer,  and these sometimes suffice to
make the diagnosis clear;  but it is often difficult to decide the
question, for after a gumma has  broken it may become painful.
 Under  these circumstances the result of treatment alone can be 
AFFECTIONS OF THE TEETH.
197
 depended  upon to  clear up the point.   Finally, there remains
 the possibility, to which Hutchinson' calls attention, that a can-
 cerous  affection may develop  from syphilitic ulcerations of the
 tongue.
   The teeth are sometimes  lost in consequence of syphilitic
 disease of  the gums; but their loss is more usually due to stoma-
 titis,  resulting from the injudicious use of mercury.   It appears,
 however, that disturbances in the nutrition of the teeth may be
 due entirely to syphilis, and not to the abuse of mercury.  Mars-
 ton2  describes a very  peculiar decay of the teeth, in  a  soldier
 affected with syphilis, which could not be ascribed to mercurial
 stomatitis  :  About  one and three-quarter years after infection,
 there made its appearance upon the superior lateral incisors a
 dark spot, which soon  became a carious  cavity,  increased in size
 and separated the crown of the tooth from the root.  The patient
 lost his upper teeth in this way,  and  those of the lower  jaw
 began to be affected in  a similar manner.
   Syphilis  causes various deformities in the upper central
 incisors, a fact which  was first  noticed by J. Hutchinson, and
 by him brought forward as a diagnostic mark of an antecedent
 inherited syphilis.   Hutchinson has shown that children affected
 with  hereditary syphilis frequently  suffer in their earliest in-
 fancy from a stomatitis due to that disease, and that, in conse-
 quence  of  this, the  development of  the permanent incisors is
 hindered.  This arrest  of  development  makes  itself manifest,
 soon  after  the appearance  of  the teeth,  in a very characteristic
 deformity.   Children affected  with hereditary syphilis, who do
 not have the stomatitis which we have mentioned, do not exhibit
 this deformity.3  It is therefore necessary to its  occurrence  that
 there should be  a certain  intensity in  the  manifestations  of
 hereditary syphilis, and, in accordance  with this view, Hutch-
 inson asserts that this change in the  teeth is  usually  found
 only  in young children, conceived soon after the infection  of
 the parents;  those born  later  have symptoms of  a lighter

   1 London Hospital Reports, Vol. III., 1868, p. 385.
   2 From H.  Lee, 1. c, p. 481.  Marston states further that Dr. Roberts, in Manches'
ter, and Dr. Todd have seen similar cases.
   3 Lond. Hosp. Rep., Vol. II., 1865, p.  145. 
198
BAUMLER.—SYPHILIS.
grade, and do not have the  characteristic syphilitic teeth.   It
is not possible for the milk-teeth to be involved in this affection
of the jaw, since they are formed in the earlier months of life;
but an  inflammatory affection or a cellular  infiltration of the
soft parts of the jaw may readily influence the early growth  of
the permanent teeth, wliich are still quite soft, especially in the
peripherical portions, that is in,  the enamel.   The incisor teeth,
since  they are  the most advanced in  their development, are
therefore in the most danger, and were investigation especially
directed to this point, it would be ascertained why the upper cen-
tral incisors are the teeth which are almost exclusively affected.
These teeth  are either stunted  in  their  growth, or more fre-
quently their  lateral borders,  instead of  being parallel, are con-
vergent, and there is a defect in the development of the central
portion of the free edge, which is often  serrated (Fig. I).1  This
central  portion  soon becomes worn  off by use, and  the edge  of
                  the tooth  then presents  a  slight concavity.
                  After the tooth  is fully developed it has a
               |  wedge shape, with a roundish notch in the
                  free edge (Fig. 2), and is usually shorter than
                  the adjacent lateral incisors.  In consequence
                   of the convergence of the sides  of the teeth
                  there is usually a considerable interspace left.
                     This very characteristic deformity, due to
                  hereditary syphilis, does not appear to occur
                   with equal frequency  in different countries,
                  being much more commonly found in England
than  in Germany.   From statements  upon  this  point which
appear  in German works, it is evident that the authors have not
seen this affection in its typical form.
   The isthmus faucium is one of the principal seats of syphi-
litic disease.  The earliest and  least  severe of the  syphilitic
cutaneous eruptions are accompanied by an erythema of the soft
palate and pillars of the fauces, and soon, either accompanying a
roseola or some other syphilide,  graver  and more characteristic
lesions  make their appearance upon these parts.  These lesions
  1 These two cuts, as well as a third, which is given below, are taken from Hutchinson,
and are used with his permission. 
       AFFECTIONS OF  THE SOFT PALATE AND TONSILS.    199

are either  superficial erosions wliich  often occupy a consider-
able space upon the soft palate,  or, more frequently, mucous
patches, which,  however,  are  rarely seen in the form of  round
elevations, but more frequently as gray thickenings in the form
of ridges, which may border the free edges of the arches of the
palate as  far as the uvula, and sometimes,  indeed,  may cover
the uvula also to a greater or less extent.   These growths usu-
ally undergo  a superficial disintegration,  and in  exceptional
cases there is deep ulceration,  and the affected portions then look
as if gnawed out, and have a  gray unhealthy  appearance.  It is
rare, however, for extensive loss of substance to occur under this
form of the disease, some little depressions only usually remain-
ing, though the  ulceration may possibly destroy the base of the
uvula.  These affections leave behind them very superficial cica-
trices, with but  slight  contraction, so that even after extensive
processes  of  this  sort  only  slight changes  are  produced, fre-
quently leaving  only a  slight bending of the uvula or  a deflec-
tion to one side or the other.
   The tonsils, when superficially affected, are most commonly
the seat of mucous patches, which are very apt to become disin-
tegrated, giving rise to ulcers  of greater or less extent, which are
frequently quite deep and crater-shaped.   Ulcers of this kind
have  irregular edges and a  grayish (lardaceous)  appearance.
But the tonsils, which  consist of a conglomeration of follicular
glands, suffer other  changes  during the secondary period  of
syphilis.  The tonsil increases in size, from swelling of  the folli-
cles and hypertrophy of the intervening tissue, and projects  as
a  round,  hard tumor,  which  is intensely red and  shining ; dif-
fering from the ordinary form of chronic hypertrophy only in its
redness and smoothness.  I  have, several times, seen this form
of hypertrophied tonsil  in secondary syphilis, in  conjunction
with papules in the palms of the hands.   Some of the follicles
of the gland may become filled with a mass of yellow  detritus,
and thus present  the appearance  of a tonsil, hypertrophied  in
consequence of acute catarrhal inflammation.  Tonsils which are
thus  affected  by syphilis gradually  diminish to a certain size,
but always remain somewhat larger  than they normally were.
Sometimes they  show a  delicate whitish or bluish-white coating, 
200                 BAUMLER.—SYPHILIS.
or spots of a roundish or irregular shape,  wliich resemble the
plaques opalines of the mucous membrane of the mouth.  On
tonsils  which had  been for a long time the seat of  syphilitic
changes I have several times seen, after the lapse  of  years,
superficially situated cysts, looking like atheroma cysts, filled
with fatty detritus, and varying in size from a lentil to a pea.
   It is not yet definitely settled whether gummata occur in the
tonsils in the form of large, circumscribed tumors or not.   It is
to be supposed that they would  occur, from the fact that,  in
the vicinity, submucous gummata undoubtedly develop.  Some-
times a part of a tonsil is seen to  swell to  a considerable size,
and  then rapidly become disintegrated, giving rise to an irregu-
lar, ragged ulcer, with  swollen and intensely red edges,  which
spreads both in circumference and  in depth.  But  such  ulcers
also occur, sometimes, in the  secondary period, without similar
processes taking place  elsewhere, and  they occur also in non-
syphilitic cases, in consequence of acute  inflammation  of an
hypertrophied tonsil, in a form that might readily be confounded
with that under discussion. I have often seen, in  young people
who were not syphilitic, but had  hypertrophied tonsils, a part
of one of the glands—usually  the most  prominent one, and  in
one case a projecting portion that remained after  an  excision  of
the tonsil—begin rapidly  to  ulcerate,  in the manner just de-
scribed, with the production of an ulcer,  which on account of its
ragged, purulent base,  and bright scarlet  and  swollen edges,
resembled very closely, for some days, a syphilitic ulcer of the
tertiary period.  A few days more served to show the real nature
of these ulcers, for  under simple  treatment  they soon took on a
more healthy action and cicatrized.  Such cases are especially
liable to cause an erroneous diagnosis, since ulcers of  the tertiary
period may also be confined to one tonsil,  and it is therefore
always advisable to examine the patient with particular care.
   At an early period of syphilis, in those who are of bad consti-
tution, with pustular eruptions upon the skin, ulcers may form
in the throat which resemble those just described, and which are
distinguished from the  common forms (which originate in thick-
enings of the mucous  membrane,  remain superficial,  and run
a chronic course) by the rapid purulent disintegration accom- 
AFFECTIONS OF THE PHARYNX.
201
panying them.  In the course of a few days the uvula, part of
the soft palate, the palatine arches, or the  tonsils  may  be de-
stroyed.  This ulcerative process, however, always extends to
the parts on both sides of the fauces and pharynx, while those
ulcerations which belong to  the tertiary period, are more local
in their character and  are limited to one tonsil or to one side
of the palate.
   Gummata of the soft palate  are  sometimes visible as round
prominences before they ulcerate.  But they  may  also emerge
and ulcerate upon the  upper side of the palate, in the posterior
nares, and then, on looking  into the mouth, nothing is seen but
a diffuse swelling of the soft palate.
   Under these circumstances, by the use of the rhinoscope, it is
sometimes possible to see  the place  where  the  gumma  has
broken, or the ulcer which has resulted from it.
   The  mucous membrane of the pharynx is usually implicated
in the erythema of the early affections of the skin and mucous
membranes.  Sometimes, papules are also situated here, wliich
are usually in the form of round, smooth elevations, having the
typical  appearance of  flat condylomata.  I once saw a condy-
loma of this character,  on the posterior wall of the pharynx, and
opposite to it, one, upon the posterior surface of the epiglottis.
If mucous patches are situated at the orifice of the Eustachian
tube they may  be  the cause of deafness, which is not of rare
occurrence among those affected with syphilis.
   Ulcerations upon the walls of the pharynx, during the secon-
dary period, are of much more  rare occurrence than upon the
structures of the  palate.  On the  other hand,  ulcers, origina-
ting in the disintegration of gummata of the submucous connec-
tive tissue, are frequently seen in the tertiary period, and indeed
may be the only symptom of it.  It is  rare that gummata are
seen in  the stage of tumor-development, since patients usually
do not  seek the aid of the physician until they are annoyed by
pain or  difficulty in swallowing, and then ulceration has already
begun, in the  form of a sharply defined loss of substance of the
mucous membrane, with a yellow suppurating base and intensely
red edges.  The destruction  to  which ulcers  of this character
give rise is often very extensive, and is followed by scars whose 
202
BAUMLER.—SYPHILIS.
contractions give rise to displacement of the parts as well as to
occlusion and constriction of passages.   Through the contrac-
tion of  the cicatrices, the orifice of the oesophagus may be con-
stricted, or, if the ulcer was situated just at its orifice, complete
adhesion may result, closing it entirely.
   Gummata which thrust forward the posterior wall of  the
pharynx may originate in the periosteum  of  the vertebrae, and
therefore, when tumors of the. posterior pharyngeal wall occur in
adults, we should always think  of syphilis; while in children,
retropharyngeal  abscesses are more apt to be due to tubercular
disease of the spine.  Gummata of the vertebral column may, as
shown in a case reported by Maisonneuve, and quoted by Lan-
cereaux,1 attain  large size and be confounded with sarcomatous
or cancerous tumors.  Through their degeneration necrosis of the
vertebrse may result, which may extend into and expose the ver-
tebral canal.
   Syphilitic affections of the mouth and pharynx, with  the
exception of  solitary papules or condylomatous growths on the
soft palate, cause, as a rule, great annoyance to the patient. This
is  especially  true of  some forms  of fissures,  of small recurring
papules  on  the tongue, and  of  ulcerations belonging to  the
secondary period;  while tertiary ulcers  in  the  posterior part
of the mouth and  pharynx  often occasion but little trouble.
When lesions occur in the posterior nares, the patient complains
of sensations  of pain at the base of the skull, which radiate from
thence towards the ears.
   Extensive affections of the mouth are  usually accompanied
by a hypersecretion  of saliva, due to reflex irritation,  and
this is also  true of  lesions of  the palate  and pharynx, where
the excessive secretion renders deglutition difficult.  Ulcerative
processes belonging to the secondary period are characterized by
the fetid odor imparted  to the breath, which is quite different
from that of mercurial or any other form of stomatitis.
   With regard to syphilitic  disease of the oesophagus, a num-
ber of instances have been recorded of cicatricial strictures occur-
ring in syphilitic subjects ; but, in a part of these instances, there
1 L. c, p. 245. 
        AFFECTIONS OF THE STOMACH AND  INTESTINES.     203

is some doubt as to the syphilitic nature of the affection.  Vir-
chow ]  reports that he has met with one case, where he saw yel-
low  gummy  spots  undergoing fatty degeneration, from which
ulceration  proceeded.  Still more  doubtful  is the  syphilitic
nature of the ulceration or  chronic thickening in the mucous
membrane of the stomach,  which has been attributed to this dis-
ease.8
   Solitary ulcerations  in  the small intestine, which some-
times occur in syphilitic patients, can with much more probabil-
ity be referred to syphilis, for the reason that similar ulcers from
other causes hardly ever occur, and if of typhoid or tuberculous
character, other symptoms would be present to render the diag-
nosis certain.  All these affections, however, are of more interest
in an anatomical than in a clinical point of  view, for the symp-
toms which they cause are not especially noticeable,  and even
such cases  as that reported by Schwimmer, where an infant with
an obstinate intestinal catarrh,  which resisted all the ordinary
medication, but was cured  with the yellow iodide of mercury,
only admit the  diagnosis of intestinal  syphilis with  a certain
degree of probability.
   In a case wliich was examined by Meschede numerous ulcers,
with a black pigmented base, were found in the ileum ; at some
points were fibrous  cicatrices, and on the peritoneal surface  of
the intestine, small fibrous tubercles.  Oser found infiltration of
Peyer's  patches with central  ulceration and  a thickening  of
the lymphatic  vessels in the adjacent  peritoneum.   Wagner3
noticed,  in the  lower part of  the ileum, a round  spot, about
which  the mucous  membrane was  thickened  and sharply de-
fined from the  surrounding surface1, while  the central  portion
showed numerous  little holes.   The mucous  and  submucous
coats formed a grayish-yellow,  soft, homogeneous mass, and
sent numerous prolongations into the muscular coat, which was
in a  condition of simple hypertrophy.  The  serous coat was irre-
gularly clouded.   With the microscope, it was  seen that the
affected  place was infiltrated with  cells.   In  Eberth's  case  (a

       'Geschw., p. 415.
       2 Wagner, 1. c., B. IV. p. 225, Case XVI. Lancereaux, 1. c, p. 248.
       8 Arch. d. Heilk., IV. p. 370. 
204
BAUMLER.—SYPHILIS.
new-born child with pemphigus) numerous spots  of thickening
(gummous  deposits) were found in the intestinal walls, and the
mucous membrane covering them was swollen and ulcerated.
   Forster  met  with a characteristic fibrous  alteration of the
glands of Peyer, in a  child who died  of  hereditary syphilis.
All of Peyer's patches had lost  their villi, they were  hardened
and of a grayish-red hue, having a prominence at the  centre,
while most  of them were covered with  a little slough in the
middle.  A microscopic examination showed that they consisted
of a dense  network of connective tissue, which extended to the
muscular coat, and toward  the centre had degenerated into a
finely granular detritus.  On the upper surface was found, also,
an abundance of cells and nuclei.  Eoth found a similar indura-
tion in the intestine of a child five days old, but it was not con-
fined to the glands of Peyer, and there were scattered ulcera-
tions, with sloughs, in both the small and large intestine.
   Of much greater clinical importance  are the syphilitic affec-
tions of the large intestine, and especially those of the rectum.
The ulcerative process in the large  intestine,  which is attended
with dysenteric symptoms, is mostly a terminal affection, which
stands only in an indirect relation to syphilis,  and is sometimes
dependent upon uraemia or amyloid degeneration  of  the  arte-
ries of the mucous membrane.    Clapton1  has seen attacks of
obstinate diarrhoea cease after the internal use of  the iodide of
potassium,  and from this infers that they were due to syphilis,
and Cullerier attained the same results in dysenteric attacks or
obstinate diarrhoea, from rectal injections of the iodide of potas-
sium, and drew the same inference as to the nature of the affec-
tion.
  The rectum, and more especially the lower part of it, is quite
commonly  the seat  of  syphilitic ulceration,  which may either
be the  primary sore or belong to  the secondary or tertiary
period.  These ulcers gradually lead to stricture of the rectum.
From the pretty copious literature of this subject we will merely
refer  to  the points that strictures  of the  rectum occur much
more  frequently in women than in men, and that when they are
1 St. Thomas's Hospital Reports (London), New Ser., Vol. III., 1872. 
AFFECTIONS OF THE RECTUM.
205
not due to cancerous  disease,  they most  commonly occur in
women  between the ages of seventeen and thirty years.  The
greater  frequency of  this affection in the female sex would
imply that the anatomical relations have much to do with  its
causation; in other words, that  the  secretions from the genitals
flowing over the anus may give  rise  to the ulcers in the rectum.
Gosselin and Erskine  Mason,1 to whom we are indebted for a
recent discussion of the whole subject, regard stricture of the rec-
tum as  a consequence, not of syphilitic affections, but of chan-
cres.  Mason  observed fifteen  cases in which  there were  no
symptoms of constitutional syphilis; in two cases,  the formation
of the  stricture preceded  the appearance of  secondary symp-
toms.   But while a number of authors look upon chancre as the
sole cause  of the  stricture, others, among whom are  A.  Guerin
and Verneuil, urge  the syphilitic nature of the  process upon
which the  disease depends.  Virchow, looking at the question
from an anatomical standpoint, leaves it undecided, since he has
had no opportunity to examine  the early stages of the process.
It must, however, be admitted that secondary ulcerations of the
rectum  may extend upward from affections about  the anus, and
also that gummata may occur in the rectum.   Gummata, and
the strictures resulting from them, will be distinguished from the
affections of more frequent occurrence, which are due to chancre,
on  account of the greater distance from the anus at which they
may occur ;  chancres being usually within four or five cm. from
the anal orifice.  Moreover, strictures which are due to gummata
will be more apt to occur late in  life,  and may therefore be easily
confounded with cancer.   If  stricture of the rectum is found in
young women, it is probably due to chancre cicatrices ; if it is
met with in old women and men, the inference should  be that it
is either caused by cancer or by a syphilitic  infiltration, with its
consequences.   Only in those cases in which no cicatricial tissue
has been formed, that is, where the contraction is due to the infil-
tration alone, will the results  of  an antisyphilitic treatment con-
tribute anything toward rendering the diagnosis more certain.
   In regard to the salivary glands and the pancreas,  which,
1 Amer. Journal of Med. Sciences, Jan., 1873. p. 22. 
206
BAUMLER.—SYPHILIS.
as appendages of  the digestive tract,  may be mentioned here, it
can  only be said that it is  extremely rare for them to undergo
any characteristic  alterations.   With the exception of a case that
was under the care of Rostan, and mentioned by Lancereaux, in
which,  in addition to gummata  in the  muscles,  two  were also
found in the pancreas, no changes in these organs are reported,
except in their parenchyma (submaxillary gland,  Lancereaux)—
fatty degeneration of the pancreas  in  infantile syphilis (Vir-
chow),  or an increase in  the consistence of the glands.
   The peritoneum is not uncommonly involved when it covers
the liver,  spleen,  ovaries, or other  organs  which have  become
diseased in consequence of syphilis ; and in such cases it is usu-
ally the seat of an adhesive inflammation, giving rise  to  adhe-
sions of the above organs with the diaphragm, the omentum, or
with  a fold of the intestine.   Sometimes  these adhesions may
be very extensive, so that, as in a case reported by Lancereaux,
the  peritoneal  cavity may  be obliterated.   Universal  adhesive
peritonitis is, however, more frequent  in syphilis  of infants than
in that of adults.
   That ascites may result as a consequence of interference with
the portal circulation, from pathological changes in the liver due
to syphilis, has already been stated.

                     RESPIRATORY ORGANS.

Nasal Cavities : M. Kohn (Kaposi),  1. c.—Larynx and Bronchial Tubes : L. Turck,
   in Zeissl, 1. c, p. 205 and Klinik d. Krankh.  d. Kehlk. u. d. Luftrohre.   Wien,
   1866, p. 377.—Gerhardt u. Both, Virchow's Archiv, B. XX.,  1860, p. 402 ; XXI.
   p. 7.—E. Wagner, 1. c, B. IV. p. 221.—Virchow, Geschw., B. II. p. 413.—Ger-
   hardt, Deutsches Archiv f. klin. Med.,  B. n.,  1867, p. 537; III. p. 292.  (On
   syphilitic disease of the air-passages.)—Morell Mackenzie, Transact.  Path. Soc,
   Vol. XXIL, 1871, p.  33.—A.  Thierfelder,  Path.  Histologic d. Luftwege  u.
   Lunge, 1 Lief., Leipzig, 1872, Taf. II., Fig. 1 u. 2.—Lungs: P.  Yvaren, 1. c, p.
   307 (Phthisic syphil.).—S. Wilks, Trans. Path. Soc, Vol. IX., 1857, '58, p. 55.
   —E. Wagner, 1. c, p, 356.— Virchow, Archiv, B. XV. p. 310; Geschw., B. II. p.
   463.— Forster, Wiirzb.  med. Zeitschr., B. IV., 1863, p. 3.— Wilson  Fox, Syph.
   Affect, of the Lung.  Reynolds' Syst. of  Medic, Vol. III., 1871, p. 792.-4.
    Thierfelder, 1. c, Taf. V., Fig. 3. 
AFFECTIONS OF THE NASAL PASSAGES.
207
   Nasal  Cavities.—The nasal mucous membrane, during the
eruptive period of syphilis, is affected by a catarrh of greater or
less intensity, but which is usually subacute in character, and is
not marked by any special symptom except its long duration.
This affection  plays  a very important role when it occurs in
young children.  The secretion is  then  more plentiful, causing
a snuffling noise in breathing, and interferes greatly with the act
of drinking, since inhalation through the closed nasal passages
is rendered extremely difficult.   On account of the constant wet-
ting to which the alse of the nose and the upper lip are exposed,
excoriations and papules in these situations are of frequent
occurrence.  When the nasal catarrh is very severe,  and par-
ticularly in young children, it is highly probable that there are
mucous patches on the nasal mucous membrane.  In these cases
the  secretion becomes  purulent.  Under the conditions wliich
favor the  occurrence  of ulcerative processes on  other mucous
membranes, erosions, or even deep ulcers, also  occur upon the
mucous membrane of the nose, which readily involve the perios-
teum and perichondrium, and lead to necrosis.  But  such pro-
cesses are  rare in the  secondary period  of  the  disease.   They
usually first appear in conjunction with gummata of the skin
or bones, and in a portion of the cases they are also due to simi-
lar deposits in the nose.   The appearance  of these destructive
processes in the nasal cavity is marked by a purulent discharge,
which  is often  mixed  with  blood, and  possesses  an  intensely
offensive odor,  which  is exhaled with the expired air, rendering
the patient an object  of aversion to any one near him  (ozsena
syphilitica).  The secretion remaining on the ulcerated parts of
the mucous membrane, or on  such  portions of  bone  as are
denuded, becomes dry by the passage of air through  the  nose,
and  forms  thick, brownish-yellow  scabs, which are not  easily
removed.   These crusts are sometimes attached  to fragments of
necrosed bone.   Finally, perforation of the bony or cartilaginous
septum  of  the  nose, or of the  floor  of the nasal cavity, takes
place, or changes in the contour of  the nose make their appear-
ance.  If there is destruction of the  cartilaginous septum,  the tip
of the nose sinks in and becomes flattened, while if  the vomer is
destroyed,  the ridge of the nose becomes sunken, causing the tip 
208
BAUMLER. —SYPHILIS.
of the nose with the nasal opening, to turn  upwards.  The rav-
ages caused by necrosis may involve the superior maxilla, the
ethmoid bone, and the pterygoid plates of the sphenoid.   Even
a slight defect in the nasal septum gives the voice a nasal tone,
and any other changes which interfere with the  free  passage of
air have the same effect.
   The lachrymal canal is frequently implicated  by extension of
the ulcerative process from the  cavities of the nose.   This gives
rise to symptoms  of dacryocystitis, and usually to necrosis of
the lachrymal bone.
   When  the mucous membrane of the superior portions of the
nasal cavities is affected, the terminal filaments of the olfactory
nerve are  often involved,  and the sense of  smell is impaired or
destroyed.   This is sometimes seen as a result of  the catarrhal,
or, more probably, papular affections of  the mucous  membrane
in the secondary period of the disease. Loss of the  sense of smell
may result also from other causes originating in  syphilis, but
which cannot usually be diagnosticated.  In regard to this point
nothing certain is  known, except  that after an  antisyphilitic
treatment the sense of smell may return after having been for
some time in a state of abeyance.  I myself have seen one case, in
which, after the perception of odors had been lost for two years,
it was regained after treatment with the iodide of potassium,
which had been administered in consequence of other sympto
which gave rise to a suspicion that syphilis was present.
   Anosmia may  also  be  due to a deformity, with displacement
of the nasal openings, or with  the destruction of the entire nose,
by means of which the current of inspired air passes from before
backward by too  direct a course.  There is a case,  briefly de-
scribed by Hutchinson,1  in which, while  an artificial nose was
worn, the patient  had the sense of smell, which, however, was
lost when this appendage was removed.  The explanation of this
appears to be, that, by means of the artiflcial nose, the inspired
air was forced in such a  direction as to pass up to the distribu-
tions of the olfactory nerves.
   The larynx is an organ which is frequently affected, both in
1 Lancet, 1874, Vol. I. p. 233. 
                 AFFECTIONS  OF THE LARYXX.             209

the early and later stages of syphilis.   The harsh voice of syphi-
litic patients,  the raucedo syphilitica, is a symptom to which
attention was long ago called, and the laryngoscope has  fur-
nished us with a knowledge of the anatomical changes to wliich
it  is  due.   The  form of laryngitis which corresponds to the
syphilitic nasal  catarrh,  and to the ordinary  form of angina
syphilitica, has no special characteristics, and is, like ordinary
laryngitis, a rather rare affection.  It is more common to  meet
with a chronic catarrhal process which  has become fixed in the
inter-arytenoid space, and which leads to thickening of the mu-
cous membrane.  In this early period it is possible, especially at
the posterior  commissure, to find erosions or ulcerations, which
begin in the  mucous  glands.  But these have nothing about
them which is pathognomonic of syphilis, and their nature can
be  determined only from other concomitant symptoms.  Flat
condylomata of the laryngeal  mucous membranes are more  char-
acteristic, and these may be  situated  on the epiglottis, at the
entrance of  the larynx, or even upon the vocal cords.  The con-
dylomata, as well as simple  chronic growths of the mucous mem-
brane, may either vanish completely after the administration of
anti-syphilitic remedies, or they may leave behind them changes
in the membrane leading to  permanent alteration of the voice.
    In the later stages of syphilis the laryngeal mucous mem-
brane may be  the seat of ulcers, which cause rapid destruction of
tissue, and are surrounded by an intensely red and swollen edge,
similar in every respect, in fact, to the tertiary ulcerations of the
pharynx wliich  were  described above.   The  ulcer  may be
situated  on the epiglottis, on  one of the false cords, in the pos-
terior commissure of the vocal cords, or upon one or the other of
the cords themselves,  though it is more apt to occur  on parts
above the cords.   Although the ulcers are usually attended by
deep and extensive  swelling of the mucous membrane, they are
not easily confounded with ulcerations of  the larynx of tubercu-
lous origin.  The oedema attendant upon syphilitic ulceration is
more limited ; but still, under certain circumstances, it may pro-
duce  such a  high degree of  stenosis  as to cause  suffocation.
The influence of  antisyphilitic treatment upon  such ulcerations
is very striking.  Even in cases which present a very unpromis-
        VOL. III.—14 
210
BAUMLER.—SYPHILIS.
ing appearance, the administration  of the iodide of potassium
soon produces  a marked diminution of the swelling, and causes
speedy  cicatrization of the sore.  This may, of course, be at-
tended  by the  formation of cicatrices,  with  various  effects,
depending upon their location.
   These ulcers also  frequently involve  the cartilages which
make up the larynx.   Necrosis of the cartilages results from an
extension of the process to  the perichondrium, and may  give
rise to abscesses which break externally, with the formation of
fistulse.
   If these ulcerative processes  have been very extensive, or if
they have recurred many times,  the  shape of the larynx may be
so altered as to be scarcely recognizable with the laryngoscope.
The  epiglottis  may be entirely  wanting,  or  its place  may be
marked only by a small,  irregular projection, and the cavity of
the larynx may be converted into  a cicatricial cone,  with an
opening not larger than a quill ; or sometimes the passage may
be reduced to a mere fissure, on account of a partial adhesion of
the vocal cords.   According  to the degree of  the  destruction
will the disturbance of different functions vary, as of phonation,
respiration, or deglutition.  In regard to the performance of the
last-named function, it may be  observed  that total  loss of the
epiglottis does  not lead to any  difficulty  in swallowing nor to
any choking sensation.
   The same processes, which have been described as occurring
in the larynx, are met with also in  the trachea and bronchi.
Those which  are of the most  serious import in these localities
are the  ulcerative processes  of the character  just  described.
According to Gerhardt, the entire mucous membrane of the tra-
chea may be the seat of ulceration ; but it is much more usual
to see the lowest  portion, just above the  bifurcation, alone
affected.   In the beginning, the  symptoms are those occasioned
by tumefaction of  the mucous membrane, moderate stenosis, a
tickling  sensation, pain back of the sternum, inclination to
cough, and coarse, moist rales;  later, the symptoms are those
of a constantly  increasing stenosis, which can sometimes be  seen
by the laryngoscope, but which, according to Gerhardt, may be
diagnosticated  from stenosis  of the larynx  by the fact  that 
                  AFFECTIONS of the lungs.               211

 during the convulsive  inspiratory efforts there  is but a  slight
 motion of the larynx downwards.
    The ulceration may lead to  other complications, to perfora-
 tion into neighboring organs, for example, into the aorta * or into
 the pulmonary artery.4
    Syphilitic diseases of the lungs were described by most of
 the physicians of the last century as a peculiar form of phthisis
 (phthisis a lue  venerea), but no anatomical lesions which were
 characteristic of  this form of lung disease were discovered, and
 Morgagni asserted  that  syphilis  merely  predisposed  to  the
 development  of  ordinary phthisis.  It is  only  in  the  last few
 decades  that the  fact  has  been established, chiefly from  the
 examination of  the lungs of new-born  syphilitic  infants, that in
 syphilitic disease of the  lungs  changes  take  place wliich  are
 similar to those seen  in the liver  and other internal organs.
    From  a purely clinical standpoint this much might be urged
 in favor of the supposition (as held in former times) of a syph-
 ilitic phthisis, namely, that in a certain number of cases of well-
 marked pulmonary phthisis  the  administration of anti-syphilitic
 remedies was  followed by a  rapid recovery.  A number of cases
 of  this character have been  collected by Yvaren.  It is possible
 that in some of these cases  there was really no  affection of the
 lungs at all, though  one was simulated  by the  high degree of
 ansemia and a laryngeal affection, with a cough and hoarseness,
 caused by the syphilis.   The liability to  commit such a mistake
 is greatly increased in those cases where a hectic fever is also
 present, as it often is  in syphilis.   A case which I reported3 is an
 illustration of this ; here all  the  general appearances of  phthisis
 were presented,  while the physical signs of pulmonary disease
 were wanting.  The discovery of  a node aroused a suspicion that
 the patient was suffering from syphilis,  and the administration
 of  the iodide of  potassium  was followed  in a few days  by
the disappearance of the  hectic fever and an amelioration of
the general symptoms.   This case was one  in which the  infec-
1 & Wtlks, Trans. Path. Soc, Vol. XVI., 1865, p. 52.
2 C. Kelly, Ibid., Vol. XXIIL, 1872, p. 45.
3 Deutsches Archiv f. klin. Med., B. IX., 1872, p. 419, Case V. 
212
BAUMLER. —SYPHILIS.
tion had  taken place long previously;  but syphilis during the
eruption  stage, and especially  in young women,  is  sometimes
attended  by symptoms which give the impression  that pulmon-
ary phthisis is developing.
   On the other hand, in the advanced stages of the disease, in
addition  to  other symptoms of  syphilis, signs of pulmonary
infiltration may develop, and if  hereditary predisposition can be
excluded, and there have been  no special causes for  the occur-
rence of destructive processes in  the lungs, then there would seem
to be some direct connection between the pulmonary disease and
the syphilis.  I have described a case of this kind in my paper,'
cited above; but since  there  were no pathological  changes
characteristic of syphilis found,  there is some doubt as to its
syphilitic nature, although  the  favorable effect of the iodide of
potassium upon the thoracic symptoms,  as well as upon  the
fever, was very marked.

   The patient was a woman, twenty-nine years old, of small stature, but well nour-
ished, who, in addition to small ulcers upon the soft palate and the posterior wall
of the pharynx, necrosis in the nasal cavities, and later serpiginous ulcers, which
originated in a subcutaneous gumma and  in ecthyma pustules, had symptoms of
infiltration of the superior lobe of the left lung and  diffuse bronchitis, together
with an enlargement of the spleen and intermittent slight albuminuria.  The remit-
tent fever, which had lasted with no interruption for two months, disappeared for a
few days, after administering the iodide of potassium, and the temperature rose
when this remedy was suspended.   Under the  same treatment the  symptoms of
pulmonary trouble, with the exception of those due to the bronchitis, vanished.

   Prof, von Ziemssen recently communicated  to me a case in
his own practice in which a deposit at the apex of the lung,
accompanied by hectic fever, in a patient with  syphilis, yielded
to mercurial treatment.
   It is desirable in every case of this character to  be able to
decide  whether the  pulmonary symptoms are directly due to
syphilis or are only a chance  complication.  The results of  an
antisyphilitic treatment  in cases of long  standing may  not
always  permit a diagnosis to be made, for it is possible that the
symptoms may be due to cicatrices which cannot  be removed.
1 L. c, p. 423, Case VL 
                  AFFECTIONS OF THE LUNGS.               213

 The influence of anti-syphilitic treatment upon the course of the
 fever  in these cases is of  much  importance  in forming an
 opinion; for if the fever is  solely due to syphilitic changes, it
 will yield in a few days to mercury, and especially to the iodide
 of potassium.
    Syphilis can indirectly cause destructive bronchopneumonic
 processes in the lungs, either through the injury to the constitu-
 tion, or more especially, by  means  of obstinate laryngeal affec-
 tions attended with ulcerations, secretions from which enter the
 lungs by aspiration.
    The  pathological changes wliich are found in the lungs of
 syphilitic patients, and  which may be  looked upon as  direct
 evidence of the disease,  are  of various forms.  In the lungs of
 new-born children, with  hereditary  syphilis, a very characteris-
 tic  change  is  found, in  the form  of a diffuse  infiltration of
 the  alveolar septa, which was  described by Virchow1 and F.
 Weber,a as "white hepatization during uterine life," but  was
 first shown to be of syphilitic origin by Hecker.3  Later, others,
 and more especially Wagner, have described cases of this kind,
 and Moxon4 has shown that it is probable that the same change
 occurs in adults.  The lungs thus affected are large, very heavy,
 and of a whitish color, the  alveolar septa being much thickened
 by  a cellular infiltration, with abundant fat  granules, so that
 the alveoli, in some parts,  are quite obliterated, while at others
 they are much  diminished in size.  Wagner6 rarely found  any
 organized elements in those alveoli which  were  of  normal or
 of reduced size  ; but Virchow,6 on the other  hand, found them
 crammed with  epithelium  and the  cells were sometimes filled
with fat.  Lorain and Robin,7 and also Forster, make the same
statement in regard to the affection, which is called by the first
 "epithelioma of the lungs," and by Forster "epithelial indu-
1 Archiv, B. L, 1847, p. 146.
2 Beitr. zur path. Anat. d. Neugeborenen.  Kiel, 1852, 2 Lief., p. 47.
3 Verh. d. Berliner geburtshilfl. Gesellschaft, VIIL, 1854, p. 130.
4 Guy's Hospital Rep., 3d Ser., Vol. XIII., 1867.
6 L. c, p. 359.
6L. c, p. 469.
7 Gaz. med. de Paris, 1855, 12. Cit. in Forster, 1. c, p. 4. 
214
BAUMLER.—SYPHILIS.
ration;"  but it probably is not  identical with  the affection
described by Wagner.  In the lungs  which Wagner  examined,
the smaller blood-vessels and capillaries were no longer visible,
and  the  interlobular connective  tissue was, for the most  part,
entirely  free.  This affection involves either  a portion  or the
whole of the lungs.   In some situations in the bronchial tubes,
especially in their finer ramifications, he found the same infiltra-
tion  of cells in  the mucous membrane  as existed in the lung tis-
sue.   The bronchial glands, too, showed cellular infiltration, and,
in one case, in the form of deposits  with yellowish centres.
   Either in connection with, or without these diffuse syphilitic
infiltrations, there are found,  scattered through the lungs of new-
born  infants, nodular  infiltrations — gummy tubercles — which
are mostly without capsules, and vary from the size of a hazel-
nut  to that of  a walnut.  These were described by Depaul,1 in
1837, and have been figured by Lebert  and Lancereaux.
   According to Forster, syphilis may also manifest itself in the
lungs of  infants, in the form  of unusually dense deposits, which
when cut with a  knife, present a smooth lardaceous surface;
but these are always accompanied by an abundance of spindle-
shaped and oval cells in the thickened interstitial tissue.
   Gummy tubercles  have,  moreover, been repeatedly demon-
strated  in  adults ; but when  the tubercles  have undergone
cheesy degeneration, it is exceedingly difficult to decide whether
they are  due to a syphilitic process, to tuberculous disease,  or to
catarrhal pneumonia.   Even with the aid of the microscope this
discrimination is rendered difficult, from the fact that, in tuber-
culous and chronic pneumonic processes, the alveolar tissue may
also  be infiltrated with cells.
   There is a more  or less diffuse form of chronic interstitial
pneumonia, which leads to the formation of fibrous cicatrices in
the lungs,  which has been referred, by several authorities, to a
syphilitic origin.   Of this kind are the cases described by Vidal,'
Dittrich,3 and Moxon ;4 and Wagner alludes to the possibility of

               1 Lancereaux, 1. c, p. 429.
               2 Ibidem, p. 329.
               3 Prager Vierteljahrschr., 1850, II. p. 42.
               4 Trans. Path. Soc, Vol. XXII., 1871, p. 38. 
AFFECTIONS OF THE IIEART.
215
the cicatrices being due to the absorption of syphilomata in the
lungs, in  the same way as in the  liver and spleen.   But  very
similar changes may occur independently of syphilis—particu-
larly in consequence  of the inhalation of irritating dust.
   Virchow: mentions, finally, a peculiar condition which he has
found several times in adult females, which resembles  the brown
induration of the lungs that occurs in connection with valvular
lesions of the  heart.  In  these  cases,  without there being any
obvious  impediment  to the circulation, a large  amount of pig-
ment  was  found  in  the lungs—especially  accumulated in the
alveolar epithelium, which  was unusually luxuriant.

                      CIRCULATORY SYSTEM.
Heart:  Ricord,  Gaz. des  hop., 1845, 101.  Clin, iconograph.,  pi. 29.—Lebert,
   Traite d'anat.  path., T. I., p.  470, 570, pi. 68.— Virchow,  Archiv, XV. p. 282.
   Geschwiilste, B. II., p. 441.— Haldane, Edinb. Med. Journal, Vol. VIIL, 1862,
   p. 435.—£. Wilks, Guy's Hosp. Rep. III. Ser. Vol. 9,  1863.—E. Wagner, Archiv
   d. Heilk., B. VII., 1866, p. 52L—M. Morgan, Dublin Quart, Journ., Vol. 52.
   1872,  p. 42.—J. Hutchinson,  Lond.  Hosp. Rep., Vol. III.,  1866,  p. 382.—
   Blood-vessels:  Dittrich, Prager Vierteljahrschr., 1849, I. p. 21.—N. Friedrich,
   Herzkrankheiten, 2 Aufl.,  167, p. 194, Note.  (Gummous  Myocarditis, fibrous
   Pericarditis, Pleuritis und Mediastinitis).—Muller, Die Syph. cl. Circul.-Organe.
   Inaug.-Diss. Berlin, 1868.—a 0. Weber, Verh. d.,  niederrh. Gesellsch., 1863,
   p. 171 (Exstr. in Wagner, 1. a, p. 530).—IF". Moxon, Lancet, 1869, ll.—Heubner,
   Archiv d. Heilk.,  B. XI., 1870,  p. 272.  Tagblatt der Naturforscherversamml.
   zu Leipzig, 1872, p. 167.

   The action of  syphilis  upon  the heart  is manifested, some-
times, in the form  of gummy  tumors, and, sometimes, in the form
of an indurated myocarditis.  These changes are either found
by chance at the autopsy, or the mode of death may have pointed
to some  cardiac trouble, though, during life, not diagnosticated
nor recognized as due to syphilis.    The s}Tmptoms are the same
as those  met with in the usual form of myocarditis, or such as
pertain to any disturbance  in the function of the  muscular tissue
of the heart.   Therefore, when a syphilitic  patient  has suffered
for a long time  from pretty severe palpitation, irregularity of the
heart's action, and symptoms of  derangement of  the circulation,
1 L. c, p. 470. 
216
BAUMLER.—SYPHILIS.
we can merely surmise that the symptoms are possibly due to a
cardiac affection of syphilitic origin, and  the  probability of this
being the case would be strengthened, were there no history of
antecedent rheumatic disease.  But since rheumatoid affections
are of such common occurrence in the course of syphilis,  the
history of the case will not assist us much—the cases of  syphilis
which present these symptoms being  usually of long standing.
The gummata of the heart are, anatomically, very characteristic.
They are found in varying numbers in all parts of the muscular
tissue, varying in size from a pea to a pigeon's egg, and if they
are situated near the endo- or pericardium these  membranes are
thickened, and often as hard as cartilage.  If the gumma is cut
open, it is found to consist of a pretty homogeneous mass, of a
yellowish-white  or brownish-yellow color, sometimes dry and
sometimes moist, movable, and enclosed in a capsule which is
composed of  fibrous, or softer  and vascular connective tissue
(Virchow).  These tumors  are composed largely  of small cells,
resembling in their structure many sarcomata, from which they
are distinguished, according to Virchow, by  a tendency to the
formation of large cheesy spots, with  amorphous basement sub-
stance.  Large phthisis  tubercles  may also  bear a very close
resemblance  to them; but  the presence or absence of general
tuberculosis must be relied upon to determine the diagnosis.
   Bundles of fatty muscular fibres are found both at the pe-
riphery and in the interior of the muscle of the heart.  Fibrous
indurations generally occur in the cardiac tissue  at  the same
time,  or they may be the  sole changes  present.  If fatty or
cheesy masses are found in the indurations, the question may
arise as  to whether the changes are not due to a gummy tumor
in process of resorption, and it might be even possible that all
the indurations were the remains of such tumors.   At all events,
these cicatricial indurations may be looked upon as a metamor-
phosis of an interstitial growth of cells, but at present  it is
unknown whether this cellular growth is diffuse from  the very
beginning,  or whether  the cells are, from the first,  massed
together in the form of a tumor.  In addition to these cicatricial
and  fatty changes,  Lancereaux mentions a waxy or  amyloid
degeneration, which he met with in two cases. 
         AFFECTIONS OF THE LARGER BLOOD VESSELS.      217

   The changes wliich the heart, as a whole, undergoes in conse-
quence of these affections are,  principally : enlargement from
dilatation of  its cavities,  and a  more or less  extensive  fatty
degeneration ;  but, whether gummata may soften and discharge
into  the  cavity  of  the heart,  has never been  certainly ascer-
tained, though a case reported by Oppolzer appears  to render
it  probable  that  this majr take place.  But embolic processes
may occur  in  other ways,  since gummy tumors in  the walls of
the heart, which project into one of its cavities,  when associated
with a partial dilatation,  consequent upon cicatricial  degenera-
tion of the cardiac walls, may lead to spontaneous coagulation of
the blood at the points where the tumors are situated.
   On the pericardium, in addition to cicatricial induration over
gummy tumors, or  in  connection with  cicatrices due to myocar-
ditis,  miliary  granules may be  found, which  the microscope
shows to be composed of indifferent cells, and may be therefore
regarded, like the well-marked gummy tumors, as  products of
syphilis (Wagner).
   Changes in the  larger  blood-vessels, which may with cer-
tainty be attributed to syphilis,  have thus far been observed
very  seldom.  C. O. Weber  described a, case  of stenosis of a
branch of the  pulmonary artery,  caused  by a  soft, gelatinous
nodule, of  the size of a bean, growing from the middle  coat of
the artery,  and  associated  with   a  diffuse  thickening of the
media.   Wagner also found,  in one case, changes in the pulmon-
ary artery, in the form of smooth tubercles, wliich, upon section,
were  found to be grayish red in color and soft.   Virchow' saw,
in one case,  a small, hard, bluish tubercle, which was close above
the valves  of  the pulmonary artery, and at the  post-mortem
examination of a girl nineteen years of age, a  growth of small
warts was  found upon the  semilunar valves and  the adjacent
portions  of the pulmonary artery.  Atheroma   of  the  arteries
has, however,  in many respects, so much similarity to the new
growths due to syphilis, that (especially in such cases as the one
described by Virchow,2 in wliich, in early youth, atheromatous
changes of  a high grade were found, with well-marked evidences
•Archiv XV., p. 253.
2 Geschw., p. 444. 
218
BAUMLER. —S YPHILIS.
of syphilis) it seems to be allowable to suppose a connection
between these changes and that disease.   It has been attempted,
at various times, by Morgagni, Wilks,  and others, to establish
a connection between the formation of aneurism of the aorta, or
of other arteries, and syphilis; and this seems  to be quite pro-
per,  in  so far as this disease  is the cause of atheromatous  or
other degeneration of the arterial walls.
   Contractions of  the carotid arteries,  occasioning considerable
disturbances in the  cerebral  circulation,  have  been observed
repeatedly,  and if more attention were paid to this point in case
of other such symptoms, it is probable that it would be found
that similar alterations take place in other vessels.  Lancereaux,
in connection with a case observed by him, calls attention to the
circumstance that the change which had taken place was not of
the character of atheroma, but there was a circumscribed thick-
ening which was due to a deposit of cells and  nuclei.   Similar
thickenings have recently been noticed  (Heubner), in the adven-
titia of  the smaller vessels of the brain ;  they occurred  very
abundantly in the brain, in a case reported by C. Allbutt,1 in
which it was doubtful whether these infiltrations were seated in
the walls of the vessels or in the perivascular spaces.
   The blood-vessels in the course of this process either undergo
a contraction of their calibre, which may lead  to thrombosis, or
if retrograde metamorphosis  of  the  cell-growth sets  in,  the
strength of the walls of the vessels becomes impaired, and small
aneurisms are formed, which, in the case of the cerebral arteries,
may, by their rupture, cause  grave symptoms, or even lead to
death.
   Amyloid degeneration of the blood-vessels may also be men-
tioned,  as a change which  takes place,  in  some way as yet un-
known, in consequence of  syphilis.  It is often first recognized
in the vascular coats, and, as a rule, begins in the smaller vessels.

                     THE NERVOUS  SYSTEM.
L. Gros et E. Lancereaux, Des affections nerveuses syphil. Paris, 1861.— Virchow,
    Archiv, B. XV. p. 290.  Geschw., II.  p. 444.-5. Wilks, 1. c. — E.  Wagner,
1 Transact. Path. Soc, Vol. XXIII., 1872, p. 16. 
AFFECTIONS OF THE NERVOUS  SYSTEM.         219
   1. c, B. IV. p. 161.—For Symptomatology, see numerous articles by Hugh-
   lings Jackson in the Med. Times and Gazette, Lancet, London Hosp. Rep. since
   1861.— Owen Bees, Guy's Hosp. Rep., Vol. XVIL,  1872, p.  249.—Broadbent,
   Lancet, Jan. and Febr., 1874.

   Since a special division of this work will be devoted to syphilis
of the nervous  system, we may here confine ourselves to a brief
mention of the numerous forms  under which the  nervous sys-
tem may be affected in syphilis.
   In the first place, as  already indicated, the affection of  the
various parts of the nervous system  may be of a purely passive
nature, as when protuberances form on  the inner surface of  the
bony case  which  encloses the brain or spinal marrow, causing
compression of these organs, or as when a nerve  is subjected to
pressure during its  passage through a  bony canal which is
affected by the disease.  According  to the degree of injury done
to the nerve tissue, will the result be either simply a disturbance
of function, which disappears completely  with the removal of
the cause, or the nervous substance may sustain severe and per-
manent  derangements  of its nutrition,  which will  be all  the
greater in case it is itself implicated in the syphilitic changes.
It is in a perfectly analogous way that those syphilitic affections
act, which proceed, not from a  bony envelope, but from mem-
branous sheaths of the  central  nervous  system,  or from  the
surrounding connective tissue of the peripheral nerves, or, from
adjacent organs.
   A  second category  of  affections  which  are peculiar to  the
central  nervous  system — particularly the  brain — are  depend-
ent upon disturbances of nutrition  in  the  nerve  substance,
caused by syphilitic disease of the nutrient vessels.  (See above,
p. 218.) A diminution of the calibre  of  the internal  carotid,
the middle  cerebral,  the basilar, and other arteries,  in conse-
quence  of syphilitic disease, may give rise to grave lesions of the
brain.
   Finally, the connective substance of the central organ may
become the seat of diffuse or  circumscribed   syphilitic disease
(gummata),  in  consequence of  which,  the ganglion  cells and
nerve-fibres undergo secondary  lesions.   It is not yet  decided
whether the proliferation of cells which takes place has its start- 
220
BAUMLER.—SYPHILIS.
ing-point  on the neuroglia or in the  connective  tissue which
surrounds the small blood-vessels.
   Quite recentlyx changes have been discovered in the ganglia
of the sympathetic, which are  analogous to the changes in other
organs : hypertrophy of the interstitial connective tissue induces
atrophy of the nerve-fibres and ganglion cells,  with  marked pig-
mentation and colloid degeneration.
   The symptoms which are directly or indirectly caused by the
action  of syphilis upon the nervous system are of the most vari-
ous description.  Among  them may be mentioned : irritative
manifestations, epileptic  attacks, unilateral convulsions (which
are said,  by Hughlings Jackson, to be pathognomonic of syph-
ilis), fixed pains and paralysis ; furthermore, symptoms of slowly
increasing pressure within the cranium,  with sudden  and total
cessation  of the  function of  important portions of the  brain
(apoplectic attacks)—aphasia, and psychical disturbances—may
present the most varied pictures of disease, and it is often only
by the concomitant symptoms, the history of the case, or some-
times by the result of antisyphilitic treatment, that a diagnosis
is reached.  It is especially common to  meet with paralysis of
the muscles of the eye as a consequence of syphilis,  and those
muscles are particularly liable to be affected which  are  supplied
by the oculo-motorius; so that  when they are found paralyzed
it is always well to think of syphilis.
   Diabetes or polyuria may also, though more rarely, be due to
nerve trouble,  originating in syphilis, as is made probable by the
history of a case recently reported by Mosler.3
   Syphilitic affections of the nervous system occur mostly dur-
ing the  tertiary period  of the disease ;  but this rule is  not
without exceptions, since grave nervous symptoms may occur at
quite an early period—in the  stage of eruption, even ; Fournier
mentions the occurrence of facial paralysis as early as this.   It
is more frequent, however, to meet  with purely functional dis-
orders  at this time, such as the insomnia that is so common, vari-
ous forms of headache, neuralgic symptoms,  and disturbances
of sensation—especially analgesia, which occurs very frequently
              1 Petroic, Virchow's Archiv, B. 57, 1873, p. 121.
              2 Virchow's Archiv, B. 58, 1873, p. 51. 
AFFECTIONS  OF THE EYE.
221
among women, and has recently been very fully described by
Fournier.

                ORGANS OF THE  SPECIAL  SENSES.
The Eye:  C. Schweigger, Handb.  d. spec. Augenheilk., 2 Aufl.  Berlin, 1873.—L.
    Mauthner in Zeissl, 1. c, p.  261 s.—v. Graefe, Deutsche Klinik,  1858,  No. 21.
    —J. Hutchinson, A Clin. Memoir on certain Diseases of the Eye and Ear, etc.
    London, 1863.—Liebreich, Atlas der Ophthalmoskopie.  Berlin, 1863.—Pulche-
    ria Jakowlewa, Ueber Keratit. interst. diff.  In.-Diss.  Zurich, 1873.—Organ of
    Hearing: J. Gruber, Wien. med. Presse, 1870, NTos. 1, 3, 6, 10. Ref. im Archiv
    f. Derm. u. Syph., B. III. p. 82.
    It has already been stated that the sense of smell may be
destroyed, through ulcerative and necrotic processes in the nasal
cavities.   Syphilitic processes proceeding from the base of the
skull  or from  the  cerebral  membranes may interfere  with  the
functions of the olfactory  nerve by compression  or by extension
of the morbid process to the nerve itself.
    The affections of the  eye are  more  common and of more
importance.
    The eyelids  participate in the various cutaneous affections of
syphilis, and may even be the seat of the primary lesion  under
certain circumstances.  Magawly '  has several times met with a
thickening of the palpebral cartilages,—a lesion which is prob-
ably due to syphilis.
    In  several cases—in one of hereditary  syphilis—there were
seen upon the  conjunctiva bitlbi, well-defined  tumefactions, of
a somewhat  coppery color, which extended  slightly over the
edge of the  cornea, and in one case (France2) were accompanied
by  a tubercular eruption  on the face.  Smee, who was the first
to report cases of this kind, states that the affection can be cured
by  anti-syphilitic  treatment,  and  France confirms  this  state-
ment.  Similar tumefactions have been recently described by von
Wecker,3 Estlander,4 and Hirschberg, * and by them are regarded
as gummy tumors.
  1 St.  Petsb. med.  Zeitschr, B. XII., 1867, p. 219.
  2 Guy's Hosp. Rep., III. Ser., Vol. VII., 1861 (plate).
  3 Traite theor. et prat, des mal. des Yeux,  T. I., Ed. II.  Paris, 1867, p. 177.
  4 Monatsblatter f. Augenheilk., B. VIIL, 1870, p. 259.
  6 Cit. by Mauthner. 
222
BAUMLER.—SYPHILIS.
   Of  much more practical value is  an affection of the cornea,
which, as Hutchinson has shown, is almost exclusively found in
cases of hereditary syphilis,  and is  known  as interstitial or
parenchymatous Jceratitis.  This disease develops itself in pa-
tients with hereditary syphilis, usually at the time of the second
dentition, and also in girls, at  the time of puberty.  It manifests
itself gradually, with photophobia and subconjunctival injection,
which  may be either slight or  very intense, and a diffuse opacity
advances from the edges towards the centre, by means of which
the cornea finally becomes of a uniform milk-white color ; within
the diffuse  opacity there may be spots of a still whiter appear-
ance.  Ulceration  never  occurs  in the course  of this process.
Gradually the  cornea begins  to clear up, proceeding from the
circumference  towards  the centre again ; though from five to
seven  months,  or  perhaps a  year, may elapse,  from the com-
mencement  of  the  affection,  before  the cornea becomes quite
transparent again ;  or cloudy or striped opacities, whose appear-
ance is very characteristic, or possibly an altered  curvature of
the cornea  may permanently remain.  Now  and then  fluctua-
tions occur in the course of the affection, and sometimes relapses.
   When the duration of the process is prolonged, it is associ-
ated with iritis, in the  form either of  an iritis  serosa or of an
adhesive iritis, with implication of the ciliary body and choroid.
   It is extremly rare to meet  with this affection of the cornea in
acquired syphilis (Jakowlewa).   Both eyes are usually affected
—not,  however, at the  same time, but in succession.   The pres-
ence either  of this  disease of the cornea or of evidences of its
previous existence,  is sufficient to arouse at least a suspicion of
hereditary syphilis, and for this reason the affection  is of great
importance in a diagnostic point of view.
   Iritis  belongs  to the more  frequent complications  of  the
secondary period, and  usually makes its appearance while the
exanthem is still present.  It occurs either in the usual adhesive
form, with intense subconjunctival injection, great photophobia,
sharp  supraorbital  pain, contraction  or distortion of the pupil
and punctate deposits—chiefly upon the inferior half  of the pos-
terior surface of the cornea ; or else in  the form of a yellowish-
red papule,  from the size of a  pin's head to that of a  pea, which 
AFFECTIONS OF THE  EYE.
223
is usually situated at  the margin of the pupil, and consists, as
shown by Graefe and  Colberg,1 of a circumscribed proliferation
of cells—in short, represents a small syphiloma.  In conjunction
with this, the usual symptoms of  iritis, and often hypopion, are
present.  This form, wliich  is more usually  confined to one eye
than  the former variety, generally occurs at a somewhat later
stage of syphilis,  and is found in conjunction with very well-
marked  papular or ulcerated forms of the cutaneous eruption.
When iritis  occurs in the  later stages  of syphilis—several or
even  many years  after  the infection—it  is  not generally the
first attack of the affection, but a recurrent one, to which the
synechise left from the  previous  attack,  which  was,  perhaps.
attended by insignificant symptoms, render the iris peculiarly
liable.  An affection of  the ciliary body and  the choroid may
accompany the  iritis,  or, in consequence  of  synechia or total
occlusion of the pupil, secondary  changes  may occur, at a later
period, in the deeper portions of the eye.
   Iritis is  of  rare occurrence  in hereditary syphilis ;  but, as
Lawrence,  Hutchinson,  and others have shown,  it  may occur,
coincidently  with  an exanthem,  in  either  of the  two forms
described above.
   The choroid  may be affected, independently of iritis, and the
inflammation may be either  acute or chronic ; nevertheless, there
is no anatomical form which may be  said to occur exclusively
in syphilis—that  is, there  is  nothing which may  be termed
pathognomonic  of  the syphilitic  choroiditis.   Von Graefe has
described, under the term  choroiditis  disseminata, a form of
inflammation which frequently occurs in syphilis,  and is marked
by the occurrence of numerous, very small, white, roundish de-
posits of exudation, with red borders, which are scattered over
the choroid, but are chiefly accumulated about the posterior pole
of the bulb, though they occur also in the neighborhood of the
equator,  with the retinal  vessels coursing over them,  unchanged.
These punctate deposits  may either entirely  disappear, or atro-
phic conditions  may develop in the choroidal pigment, leaving
small spots, devoid of pigment  and surrounded by a black bor-
1 Archiv f. Ophth., B. VIIL p. 288. 
224
BAUMLER. —SYPHILIS.
der, which remain permanently.  The subconjunctival injection,
which  was alluded  to above, is often present only in  slight
degree.  Opacities in the vitreous humor occur here as  in every
choroiditis.   The derangements of vision,  to  which these pro-
cesses  give rise, will vary in accordance with their seat, extent,
and the duration of the changes.
   These different choroidal affections, like the iritis, belong to
the secondary period of syphilis.
   A growth of  cells, which was supposed to be gummous in its
character, was described by von Hippel * as having been  found
in the choroidal and sclerotic coats, as well as in the ciliary
body, and, encroaching upon the retina, in a bulb  which had
become atrophied in consequence of irido-choroiditis.
   The retina is also, sometimes, independently attacked in sec-
ondary syphilis;  the  patient  complains of a gradual  diminu-
tion of the power of vision, moderate photophobia, and various
other  subjective symptoms, and, upon examination with  the
ophthalmoscope, the fundus looks as though it were veiled, this
appearance  being due to  an infiltration of  the  retina.  The
boundary of the papilla is indistinct, and the papilla  itself is
more or less reddened ;  the  veins are  often congested, and some-
times,  also,  there  are hemorrhages.  This  affection  usually
attacks both  eyes at the same time,  and is quite chronic in  its
course; but  if appropriate treatment is  employed at an early
stage, the vision may be perfectly restored.
   Von Graefeq has described an affection of the retina, which is
probably due to syphilis, under the name of " central recurring
retinitis."   In  this  affection slight exudations  occur at  the
macula lutea, which rapidly disappear again, and this appear-
ance and disappearance may be repeated several times.
   A form of retinitis pigmentosa has recently been described
which  is  attributed to hereditary syphilis (Swanzy, Galezowski,
and other authors).3  This affection, according to Hutchinson,4 is
  1 Archiv f. Opth., B. XII., 1867, p. 55.
  2 Archiv f. Ophth., B. XII., p. 211.
  3 Compare Jahresber. iiber d.  Fortsch. im Gebiete der Ophthalm. von A. Nagel, B.
II., 1873, pp. 295, 299.
  4 R. Swanzy, Dublin Quarterly Journal, Vol. LI., 1861, p. 294. 
                  AFFECTIONS OF THE EAP                22o

characterized by its  rapid development,  the early occurrence  of
amaurosis, want of symmetry—both eyes not being affected—the
roundish form and irregular arrangement of the pigment spots,
which are  generally situated in the  intervals between the larger
vessels, and by the implication of the choroid.
   The retina may also be affected,  secondarily, in affections  of
the optic nerve,  which are due to syphilitic changes taking place
in the osseous or membranous envelopes, or in the substance of
the brain.   Atrophy of the optic nerve and retina then takes
place, giving rise  to a progressive diminution  of  central vision,
with  defects at  various points  in the field of vision.  It should
also  be stated  here that  in some  cases  the  ophthalmoscopic
appearances of engorged papilla may exist for a long time with-
out any considerable impairment of vision (Hughlings Jackson).
   The optic  nerve  has been found several times affected in a
specific way in consequence of gummy growths in the neighbor-
hood, encroaching upon its  sheath,  or involving the substance of
the nerve  (Dixon1).   Horner2 describes  a case of neuritis with
enormous  thickening, in a man, aged forty-three years, who was
suffering  from  various other syphilitic  symptoms,  and within
three  weeks  became  totally blind, and  died with  paralytic
symptoms. The ophthalmoscope showed  the  papillae to be  of
a  cloudy white appearance, the  veins distended  and tortuous,
together with a slight amount of extravasation at the border  of
the optic nerve.   At the autopsy, in addition to the  changes in
the nerve, numerous encephalitic deposits were found, and the
liver  contained  a  quantity of  partially degenerated syphilitic
tubercles.
                     ORGAN OF HEARING.

   In the account of the syphilitic  affections of the pharynx it
was observed that it  was not uncommon for them to cause a
temporary or  permanent occlusion  of the orifices of the Eusta-
chian tubes.  This is the starting-point  for catarrh  of the tym-
panum, and a frequent cause of  deafness and tinnitus aurium,
       1 Med. Times and Gaz., 23. X., 1858.
       2 Jahresber. v. A. Nagel, B. II. p. 315.
VOL. III.—15 
226
BAUMLER.—SYPHILIS.
which are apt to occur in the course of syphilis.  Such a catarrh
of the middle ear may have the same issues as those  due to
other causes, and lead to perforation of the membrana tympani,
purulent infiltration of the cells of  the mastoid process, etc.
These conditions are especially apt to occur in consequence of
hereditary syphilis ; but Hutchinson has observed some cases of
deafness in which the history did not point  to the occurrence of
catarrah of the  middle ear,  and, upon examination, the mem-
brane and Eustachian tubes were found  in a normal condition.
In cases of this character,  the disturbance,  to which deafness
is due, must be more deeply seated, either in  the labyrinth or in
the auditory nerve.  More accurate investigation with regard to
this  subject is needed ; but Rayer J has observed a case of  deaf-
ness on the right side which was due to a tumor of  the size of a
pigeon's egg, upon the upper side of  the petrous portion of the
temporal bone,  wliich  pressed upon the auditory nerve,  and
which was probably syphilitic in character.
   Deafness  may be caused by syphilitic  affections of  the ex-
ternal auditory meatus,  in which moist  papules  sometimes
develop; or syphilitic enlargements proceeding from the  peri-
chondrium of the cartilage of the ear may cause a greater or less
obstruction of  the  canal.    Hyperostoses,  in  consequence of
syphilis, have also been observed,  both  in the osseous meatus
and in the bony portions of the Eustachian tube.


                    THE URINARY ORGANS.

Bayer, Traite  des malad. des reins.  Paris, 1840, t. II.— Virchow, Archiv, B. XV. p.
   'SU.—Barde, De syphil. renuui affectionibus. Diss, inaug. Berlin, 1863.—A. Beer,
   Die Eingeweidesyphilis. Tubingen, 1867, p. 27 s., p. 71, p. 161  s.—Gujol, Essai
   sur l'albuminurie syph. These  de Paris, 1867.—IF. Moxon, Guy's Hosp. Rep.,
   Scr. III., Vol. 13, 1868, p. 329.

   Until within  the last ten years  nothing was known of true
syphilitic processes in the kidney.  Their occurrence had been
suspected,  and  it had also  been ascertained that albuminuria
was not a rare complication  in  the later stages of syphilis ; but
1 Mentioned by Gros and Lancereaux, 1. c, p. 381. 
             AFFECTIONS OF THE URINARY ORGANS.         227

the only pathological  change which was known to occur,  and
which was sufficient to account for the phenomenon, was amyloid
degeneration.   But we have since  learned that the kidneys are
liable to the diffuse infiltration as well as to the development of
gummy tumors.   The  gummata which  were  seen in the  few
cases described by Tiingel, Cornil, and  Lancereaux were  only
about  as  large as peas.  Beer  met  with tumors  of  the same
kind, but still smaller  in size, and to him we are indebted for
our  knowledge of the diffuse interstitial  proliferation of
cells, which is usually connected  with amyloid changes of the
vessels and fatty degeneration of the parenchyma of the kidney.
This interstitial growth of  cells  leads to  cicatricial contractions,
and it  is often in these that the  miliary syphilitic tubercles are
found.
    These changes,  however, are  not in themselves characteristic
of syphilis ;  in case we have to do with  gummy tumors,  it is
necessary to have recourse to concomitant symptoms in order
to exclude tubercle, and if with  diffuse infiltration, we must
eliminate.' other conditions, such  as variola and typhus,  wliich
might  produce similar effects, before we  are justified  in  pro-
nouncing  the  changes  syphilitic.   Moreover,  the discovery  of
unquestionably syphilitic affections in other organs—the liver,
testicle, or bones—will assist in determining the diagnosis.
    Albuminuria,   either with  or  without dropsical swellings,
occurs  not infrequently in connection with affections  of bones
and joints.   I  had a case of this  kind  under observation for
several years, and during that period,  at various times,  the urine
was perfectly free from albumen.
   A. H., a laborer's wife, aged twenty-eight  years, who gave no history of heredi-
tary or acquired syphilis, in May of 1867, came under my care at the German Hos-
pital in London.  She was pale and cachectic in appearance, with a large serpigi-
nous ulcer upon the ear and temple, which had partially healed, swellings of the  knee,
elbow, and right shoulder joints, and oedema of both inferior extremities. In conse-
quence of this condition of the legs she had for two  years been deprived of  their
use.  The urine was found upon examination to  be heavily loaded with albumen.
Under the use of the iodide of potassium the condition of  the patient improved
with extraordinary  rapidity; not  only did  the swellings of the joints and the
dropsy vanish, but the appearance of the patient became that of perfect health, and
the menses, which had been absent for some months, reappeared.  In January, 1868, 
228
BAUMLER.—SYPHILIS.
although she was pregnant, there was but a trace of albumen in the urine.  The
child,  which was born on the 30th of May, was perfectly healthy and normally
developed, although the mother still had a small spot of ulceration upon the head,
and suffered from an enlargement of the joints  from time to time.  On the 27th of
July and on the 9th of August, and again on the 26th of October, the urine was free
from albumen, and the woman appeared healthy.  I lost sight of her from this date
until July, 1869, when a marked enlargement on the right tibia, and swelling of the
right elbow-joint led her to seek relief at the Hospital.  The  ulcer on the scalp
was found  to be entirely healed, but the urine was again very rich in albumen.
Under the influence of the iodide of potassium the amount of  albumen considerably
diminished; but whether this influence was permanent or  not, could not be ascer-
tained, since, on account of the distance she was obliged to come, her attendance at
the Hospital was very irregular.  In the early part of the year 1871 she lay in  the
London Hospital, suffering from severe pain in the bones of the legs.  When I last
saw her, on the 21st of March, 1871, her appearance was very good, but the urine,
which was light-colored, contained a large amount of albumen.

    Prescott Hewett' relates the case  of a man, with a depression
of the skull, who suffered also from  albuminuria, but was cured
by  the  iodide of  iron, and Beer2  reports  a similar result follow-
ing the use of the iodide of potassium.   Mr. Bradley 3 reports a
case of hereditary syphilis  in a child, four months old, who had
a papulo-squamous syphilitic  eruption  and  universal  dropsy,
together with albumen and a quantity of cylindrical epithelium
in the  urine ; in this  case a cure was effected, both of the erup-
tion and of the renal disease, in the course of about three weeks,
by  the use of hydrarg. c. creta.   Bradley expressly states that
in this case there  was no  possibility of  there having been any
infection from scarlatina.   In addition to this, the  same observer
states that out of  twenty  cases of hereditary syphilis in which
he examined the urine, in two of them he found albumen.
    No  affection which can be attributed to syphilis has as yet
been  observed  in the pelvis of the kidney, the ureters, or the
bladder.   Ulcerations in the urethra are associated with certain
processes which take place upon the  genitals,  and they  per-
tain much oftener to chancre than to  syphilis.
1 Presid. Address, Trans. Clin. Soc, Vol. VI., 1873.
2 L. c, p. 56.
3 Brit. Med. Jour., 1871, Vol. I. p. 117. 
AFFECTIONS OF THE TESTICLES.
229
                      THE GENITAL ORGANS.

Testicles:  Astruc, 1. c, p. 192.-5^'. Bell, Treatise on gonorrhoea virul.  and lues
    vener.  Edinburgh, 1793, Vol. I. p. 285 ; Vol. II., p. 103.—Astley Cooper, Dis.
    of the Testis.  London, 1835.—Bicord, Clin,  iconogr.—J. Hamilton,  Essay on
    Syph. Sarcocele.  Dublin, 1849.— Vidal (de Cassis), Du sarcoc. syph.,  Mem. de
    la Soc. de Chirurg., 1851 et 56.— Virchow, Archiv, B. XV.  p. 263;  Geschw.,
    B. II. p. 431.—De Meric, Fungus of the Testicle in Syph.  Lancet, 1859, March
    19.— J. F. West, Dublin Quart. Journ., 1859, Nov., p. 1323.— Lewin, Stud,  iiber
    d. Hoden, Deutsche Klinik, 1861, No.  31.—S. Wilks,  Trans.  Path. Soc, Vol.
    VIIL, 1858,  p. 240; Vol.  X., 1860,  p. 210;  Vol. XTL, 1861, p. 216.  Guy's
    Hosp. Rep.,  1.  c, p. 55.—^. Canton, Trans.  Path. Soc, Vol.  XIII., 1862, p.
    161.—S. Wilks,  Ibid., Vol. XVI., 1865,  p. 189. (Enlargement of both Testicles
    in a  five months' old Child suffering from Congenital  Syphilis).—Huber,
    Deutsches Archiv f.  klin. Med., B. VI., 1869, p. 104. (Anat. Unters. v. Zen-
    ker.)—Ovaries: Bichet, Traite d'anat.  chirurg.  Paris, 1857, p. 573.  (Lancereaux,
    1. c, p. 229.)—Lecorche, Gaz. m6d. de Paris, p. 743. (Lancereaux, ibid.)—Mam-
    mary Glands:  Yvaren, 1. c, p.  435.— Virchow, Geschw., B.  II. p. 436.—
    Hennig, Archiv f.  Gynaekol., B. II., 1871, p. 350.—Lancereaux, 1. c, p. 156.

    The Testicles.—Owing to the confusion which existed until
the latter   part  of  the  last  century,  concerning  the relation
between syphilis  and urethral blennorrhcea,  all swellings of the
testicle  of  venereal  origin were formerly classed together.  As-
truc, indeed, divided them into two classes, placing in one those
forms of inflammation of  the testicle which were acute and were
associated  with gonorrhoea, and in the other those which were of
a more subacute  character and were not associated with  gonor-
rhoea ;  but Bell  first made the  distinction perfectly  clear and
positive.
    In  the  blennorrhaic  affection  it is  the epididymis that  is
affected, the trouble being due to an extension of the inflamma-
tion along the spermatic  duct and into the tubules of the epidi-
dymis, accompanied by an exudation into the tunica vaginalis ;
while the testis  remains intact.  When, however, the affection is
of a syphilitic nature (sarcocele syphil.), the testis becomes the
seat of  the disease, which may make its appearance either as a
simple  indurated interstitial  growth,   or  in  the form of tuber-
cular caseous deposits (gummy  tumors).   As in  other  organs 
230
BAUMLER.—SYPHILIS.
 which are covered by  serous  membranes,  the  tunica vaginalis
 becomes involved in  the process  (vaginalitis), giving rise to
 adhesions or complete occlusion of the sac.
   The cell-growth  upon which  these  affections  depend  com-
 mences in the  fibrous capsule and in  the septa  of  the testis,
 beginning usually at the periphery,  and advancing into the rete
 testis.   Dense, bluish-white bands of  fibrous connective tis-
 sue  gradually develop, and between them  the  seminal tubules
 become atrophied.  According to the location and extent of the
 process, either a uniform contraction of the testicle will be left,
 or irregular  constrictions, with various alterations  in  the  form,
 may remain.
   In  the other variety, yellowish-white, dry tubercles, varying
 from the size of a millet seed to that of a cherry, are found in
 the midst of  fibrous tissue—either infiltrated through it, or the
 tissues form a sort of capsule about them.   In  the later stages
 this  yellowish-white substance, as  in the  similar tubercles in
 other organs, consists of an amorphous or fine felt-like mass, con-
 taining minute fat granules or the more or less recognizable  rem-
 nants  of disintegrated cells.  Towards the periphery of  the
 tubercle large fat  globules occur, and still  further outward we
 meet with fibrous  or  still vascular connective tissue, which con-
 tains numerous cells embedded in it.  Virchow  (whose descrip-
 tion  we  follow mainly)  found in  one case also crystals of
 cholestearin within the cheesy tubercle.
   There is no positive evidence  as yet that gummy tubercles
 may soften, gradually penetrate the tunica vaginalis, and  then,
 like subcutaneous gummata, break externally.  It is well known
 that perforations followed  by ulceration  do take place,  but the
 mode  in which they occur may differ from the above.  As in a
 case described by Huber, the ulcerative process may begin upon
 the skin, having been excited there  in consequence of pressure
 or friction of the  parts;  the ulceration extending into the tes-
ticle, the latter  becomes  prolapsed,  and a  granulating fungus
growth is formed.
   Syphilitic sarcocele occurs  at a late  stage of acquired syph-
ilis ;  it is very rarely seen  as a symptom of inherited disease.  It
is apt  to be associated with gummous affections of the bones, 
AFFECTIONS OF THE TESTICLE.
231
 and tubercular or ulcerative diseases of the skin.  In none of the
 cases of this affection reported by Zeissl did it make its appear-
 ance in less than ten  months after  the first syphilitic symp-
 toms, and, as  a rule, many years had intervened.   Frequently
 it is impossible to determine just when the trouble in the tes-
 ticle begins, since  the  progress of the  affection is slow, com-
 mencing with  very slight symptoms, and the patient only be-
 comes aware of it after  a considerable swelling has  taken place.
 It  occasions very little pain,  the  tumor is but slightly sensi-
 tive on pressure,  and, in this respect, it differs very essentially
 from the blennorrhagic  epididymitis, which is generally exceed-
 ingly painful.  The swelling and hardness of a syphilitic tes-
 ticle may be  very marked, but if the appropriate treatment
 is promptly resorted to, they  recede pretty  rapidly.   But in-
 asmuch as  the condition has usually existed for a  considerable
 time before medical aid is  sought, the result of treatment is not
 always so rapid, and in case the stage of cicatricial contraction
 has already been reached,  the effect  of  remedies is often only
 partial.  When left to itself, the course of the affection is very
 protracted ; a  pretty marked swelling remains stationary for a
 long time, or gradually gives place to contraction and deformity.
    Usually but one testicle is affected, and if the second becomes
 involved,  it is  not until the disease has  been present for some
 time in the  other; sometimes,  however, both are attacked
 together at the same time.   When both glands are thus affected,
 the functional  derangements are of  a  serious nature, since com-
 plete aspermia and permanent impotence may be  the result;
 while if but  one  testicle is  involved, the procreative function
 remains intact. According to Lewin, in cases of partial  fibrous
 orchitis, there  is sometimes an absence of spermatozoids in the
 testicles.
   Blennorrhagic  epididymitis can scarcely be confounded with
 syphilitic  sarcocele ; at least so long as it is in the  acute  stage.
 Doubt may more readily arise when a blennorrhagic affection has
left behind it an induration  ; but when this is the case, the head
of the epididymis is the j)art  implicated, while the syphilitic
induration affects  the  testis.   Affections of the testicle of  a
tuberculous nature, also, as a rule, originate in the  epididymis, 
232
BAUMLER.—SYPHILIS.
 the process, according to Virchow,1  starting from the walls of
 the vas deferens.  These  are further distinguished from syphil-
 itic affections,  by the gradual softening, suppuration, and forma-
 tion of fistulas.   Gummata  of  the testicle have  often  a  great
 resemblance anatomically to tuberculous deposits, but the  latter
 are more friable  and can be more readily separated from  the
 neighboring tissues, and moreover, in tuberculosis of the testicle
 miliary, gray, and  yellow tubercles  are met with.  Cancerous
 or sarcomatous growths  in  the tissues  of the  testicle are dis-
 tinguished  from  processes of  syphilitic  origin by their  rapid
 growth, the irregular alterations in form which they occasion, by
 their painfulness,  and by the fact that cancer never attacks both
 testicles.  Cancerous disease gradually causes ulceration, giving
 rise, then, to the condition known as fungus testis malignus.
    With the exception of a case of gummous growth in the vas
 deferens,  described  by Verneuil,2  syphilitic  affections of the
 other portions  of the internal male genital apparatus have  never
 been observed.  With regard to the external genitals, we should
 mention a partial induration of the corpora cavernosa, a condition
 which has been described by Zeissl.3  It is probably due to a
 process of the  same  nature as the diffuse syphilitic orchitis, and
 leads to changes  in the form of  the  organ which are particu-
 larly noticeable when it is in  a state of erection.
   But few changes have been  noticed in  the female genitals
 which  can with certainty  be referred to syphilis,  excepting the
 primary and  secondary affections  of the vulva  and  neck of
 the uterus.   Inasmuch as fibrous  degeneration  of the ovaries,
 especially in advanced life, is so commonly met with, cicatricial
 changes in these organs can only be regarded as  the result of
 syphilis when there  are other circumstances present which point
 to the disease—as, for instance, in  youthful persons, who bear
 decided evidences of  syphilis  elsewhere.  Such changes  have
been described  by  Richet, and a case of gummous ovaritis, wliich
is  perfectly analogous to  the  similar affection  of the testicle,
is figured by Lancereaux.

                  1 Geschwiilste, B. II. p. 682 s.
                  2 Cit. by Lancereaux, 1. c, p. 228.
                  3 L. c, p. 248. 
        AFFECTIONS OF THE FEMALE SEXUAL ORGANS.     233

   A few instances of imperfect sexual development which have
been noted (Hutchinson, Lancereaux) * render it extremely prob-
able that ovaritis, resulting in atrophy of the organ, may occur
in early youth in consequence of congenital syphilis.
   Gummy tumors  have been found in the Fallopian tubes by
Bouchard and Lepine,2 but whether they occur also in the uterus
or not, has never been ascertained.   Gummata, having all the
characteristics of the gummy tumors in the submucous connec-
tive tissue, are  not infrequently  met with upon the external
genitals.   Sometimes, when they ulcerate, they  become very
similar in  appearance  to soft chancres or phagedenic primary
syphilitic sores ;  but confusion will usually be avoided through
the presence of other symptoms of tertiary syphilis in the skin
or bones, or the scars of such as have previously existed.
    The functional disturbances of the sexual  system, which are
met with in syphilis in women,  are partly dependent upon the
anaemia caused  by the disease ; but they  may also be, in part,
due to certain  unrecognized changes in  the  structure of  the
mucous membrane, or substance of the uterus, or to disease of
the ovaries.   Irregularities in the menstrual function, of all
grades—from  complete amenorrhcea to profuse metrorrhagia—
together with fluor albus,  may occur in consequence of these
various conditions ; but  frequently syphilis runs its course with
no disturbance of  menstruation.  The  capacity for conception
may be impaired on account of certain conditions  arising in the
course of  the disease, but  in the majority of cases it remains
unchanged. Pregnancy, however,  is frequently not continued to
its normal term ; abortion and premature delivery are among
the most common effects of syphilis.   But their causes are not
always to be sought in the maternal organism ; the abortion may
be due to  a diseased foetus, which owes its disease to a syphi-
litic father. (See above, p. 53.)
    Gummy tumors have been demonstrated  in  the  mammary
glands beyond a doubt.   Verneuil has described a  tumor of
this kind in the breast  of a man, and Hennig  found them in the
1 L. c, p. 330.
8 Gaz. med. de Paris, 1866, p. 756 (Lancereaux). 
234
BAUMLER.—SYPHILIS.
female breast.  In addition to these, there are numerous reports
of cases in wliich tumors of  the  mammary gland  have been
absorbed in consequence of anti-syphilitic  treatment.   (Yvaren,
Maisonneuve,  Richet,  Lancereaux.)   The last-named  observer
alludes also to a diffuse swelling of this gland wliich he  observed
in connection with  Ambrosoli, and  which  disappeared under
treatment with iodine.  Moreover, Hennig1 states that changes
in the mammary glands sometimes take place in children with
hereditary syphilis.
1 Tagbl. d. Naturforscherversamml. zu Leipzig, 1872, p. 201. 
HEREDITARY SYPHILIS.
   When syphilis is  transmitted  from  parent  to offspring,
whether from  a syphilitic father,  or from a  syphilitic mother
during  gestation, the disease manifests itself in various ways.
The foetus may  either become diseased at an early stage of its
development, in consequence of  which it dies and abortion takes
place ; or it may be born alive  prematurely; or be still-born at
full term ; or, finally, the pregnancy may go on normally to full
term, and the child at birth appear perfectly healthy, but some
time afterwards  give evidences  of  its  constitutional taint.   In
many cases—especially in  such as belong under the first three
categories—the placenta is found diseased, and we proceed next
to speak of the syphilitic affections of the placenta.

                   Syphilis of the  Placenta.

S.  Wilks (Observation made by Wilkinson King), Guy's Hosp., Rep. 1. c.—Virchow,
    Geschw., B. II. p. 477.—Kronik Slavjansky, Prag. Vierteljahrschr., B. 109, 1871,
    p. 130.—Ercolani, Delle malattie clella Placenta.  Bologna, 1871.— C. Hennig,
    Jahrb. f. Kinderheilk., B. I.,  p. 424.  Stud,  iiber d. Bau d. menschl. Plac.
    und ihr Erkranken.  Leipzig, 1872, p. 33.—E. Frankel, Die Placentar-Syphilis.
    Archiv f. Gynaekol., B. V., 1873, p. 1 s.

   Although a few of  the  changes found upon the  placentse of
syphilitic children had already before been ascribed to syphilis,
Virchow was the first who investigated this question minutely ;
and he first pointed out the  necessity of keeping the foetal and
maternal membranes separate and distinct, in looking for any
alterations which might be due to syphilis.   Virchow thought
it  an open question whether the  foetal  portion was primarily
affected  or  not;  but in one case he found, on the maternal por-
tion of  the placenta, a hard, wedge-shaped gummous tubercle. 
236
BAUMLER. —SYPHILIS.
He described also another form of  disease which he met with in
the decidna of a syphilitic mother, and that consisted of a thick-
ening and polypoid growth of the free—not the placental—por-
tion of this membrane ; but this, as is proved by a case reported
by Strassmann, is not necessarily due to syphilis. E. Frankel, by
taking the osteochondritis described by Wegner  (see page 170)
as  the criterion  of hereditary syphilis, recently demonstrated
that the foetal portion of the placenta is often  affected by a
growth of  cells which fills out  the villi, and frequently leads
to atrophy of their vessels through compression.   This  process,
which Frankel  terms "deforming granulation-cell hypertrophy
of the placental villi," may also encroach upon the neighboring
portions of the maternal placenta.
   A placenta which has undergone this change is larger, heavier, and more dense
than normal, and is either uniformly or at certain portions of a pale color, and the tis-
sue which remains sound is congested with  blood or  beset with extravasations.
The amnion and chorion are also more or less  clouded and thickened, and in many
cases numerous miliary deposits have been found along the vessels, upon the fcetal
side of the placenta; these owe their origin to a growth of the connective tissue of
the chorion.

   Frankel thinks that this form of the affection is the most fre-
quent, and that it  is due to syphilitic infection from the side of
the father.  In this form it is possible for  the mother also to
have been  infected in the act of coitus.  There are only seven
cases known of primary affection of the  maternal portions of the
placenta (endometritis placent. gummosa).  In  cases  of  this
kind we must  either  presuppose  that  syphilis existed in  the
mother at  the  time of  conception, or  that  her  infection was
coincident with that of the ovum, or occurred very shortly after-
ward.  In  cases  belonging to either of the two  latter classes,
changes may be found both upon the maternal and fcetal por-
tions of the placenta.   Gummous disease of the placenta makes
its  appearance under the form of yellowish-white  tubercles,
which must not be confounded with the decolorized blood coa-
gula which  sometimes  occur in  otherwise normal  placentae.
In  Virchow's  case, the  periphery of  the tubercles  was more
dense and whiter than elsewhere, and in some places was stud-
ded with caseous spots, while  the  centre was more reddish and 
AFFECTIONS OF THE FC3TUS.
237
softened.  The tubercles consisted of connective tissue with large
cells,  and at certain points  there  were large accumulations of
younger cells.  Hennig was the first who called attention to  the
intimate relation of the cell growth to the vessels.   The oblitera-
tion or compression of numerous vessels  of the villi interferes
with the mutual interchange  of gases between  the maternal and
foetal blood, causing fatty degeneration of the villi, and, if  the
process is extensive, the death of the foetus (Frankel).   But the
foetus may also become syphilitic when no changes are  discern-
ible in the placenta.

                    Syphilis of  the Foetus.

  The degree of syphilitic disease in the foetus varies with  the
intensity of  the syphilis which  existed in one or  both of  the
parents at the time of conception.   But the circumstances bear-
ing upon this question are of such a complicated nature that no
definite rules have yet been established.  Only this much can be
positively affirmed, namely,  that the product of conception gen-
erally dies at  an early period when one or both  parents have
suffered from recent syphilis at the  time of conception ;  and  the
more  recent the general syphilis in the parents at the time of
conception, the greater will  the liability be to abortion.  Hence,
while the first  pregnancies under these circumstances are gener-
ally interrupted prematurely, the later ones—especially when a
mercurial course has been resorted to—become longer and longer
in their duration, and finally, after a series of  abortions or pre-
mature births,  children may  be carried  to full term, and be born
in a state of real or apparent health.
    When the foetus dies in utero it is usually born  in a state of
maceration, the epidermis being  wanting over large surfaces of
the body or elevated in bullae, and the  amniotic fluids are often
cloudy, of a greenish or brownish  color, and have an offensive
odor.  If the foetus has been carried almost or quite to its full
term, we find,  either on the  surface of  the body or in the inter-
nal organs only, and invariably in the epiphyses of the long
bones,  the  changes which were detailed  above.    Von Baren-
sprung supposed that if the syphilis of the foetus was inherited 
238
BAUMLER.—SYPHILIS.
from the father, lesions would be found  in the liver and supra-
renal capsules, but if from the mother, in the lungs ; but further
evidence does  not  confirm the existence of any  such  extraor-
dinary relation as this.
   Children that are born alive are usually small, undeveloped,
and have an aged  appearance ; the skin is either already cov-
ered with a rash, or in a few days papules  or pemphigus bullae
make their appearance.   Tubercles resembling boils (see p. 166),
develop in the subcutaneous  connective  tissue, and may break
upon the outer surface.   The  children soon become affected with
marasmus, and  perish in a short time from diarrhoea,  or from
suppurations  connected with the  epiphyseal affection.

   The eruption, which is almost universally known as pemphigus neonatorum
syph. (but which Zeissl, on account of the  slight resemblance of  its bullae to the
transparent ones of true pemphigus, prefers to call varicella  syph. confluens), may
also be  found upon  infants at  their birth. It  consists of flabby bullae, from the
size of a pea to that of a hazel-nut, several of which may become confluent, and which
contain a thin, greenish pus. A favorite seat of this eruption  is on the palms of the
hands and soles of the feet; in the latter situation, especially,  the epidermis is apt to
be rubbed off, laying bare the intensely red papillae beneath;  but there is no loss of
substance.  The entire body, but particularly the face, is often found covered with
the bullae, which, on  drying, form crusts, which spread at their edges.
   A very similar eruption (pemphigus cachecticus) is sometimes met with in chil-
dren who are not syphilitic, but are suffering from marasmus; and this has induced
some authorities to deny—though incorrectly—the existence of a syphilitic pemphi-
gus.  Zeissl urges, as  a mark of distinction between the two forms, the rapidity with
which the bullae of the non-syphilitic  affection become dry.  Lancereaux rests the
diagnosis of syphilitic pemphigus upon the fact that it appears within a few days
after birth, and is located especially on the palms  of the hands and the soles of
the feet;  while, if the eruption is of the  non-specific variety,  the bullae are dis-
tributed more generally over the body.  But if the case is at  all doubtful, the ante-
cedents of the child must be carefully inquired into before a diagnosis can be
reached.
   Some  of the children born  with  hereditary syphilis are  at
birth well nourished and strong,  and for some  weeks go on in
their normal development.  But  gradually the infant  becomes
delicate;  frequently, the first symptom which  attracts notice
is a  nasal catarrh, and coincident with this,  or  soon  after, a
cutaneous eruption appears.   This  eruption may be macular,
or, as is more usual, papular in character, and may be limited to 
            HEREDITARY AFFECTIONS IN CHILDREN.        239

 a  few bright red papules  upon  the buttocks, which rapidly
 assume the characteristics  of mucous patches.  Sometimes the
 entire body, but especially the face,  is covered with large, flat
 papules, which have the perfect copper color, and here and there
 are coalescent.  At  the angles of  the mouth and eyes, in the
 neck,  behind the ears, and in the inguinal folds they take the
 form  of moist papules and increase rapidly in size.
   The discharge from  the  nasal passages, which  become more
 and more obstructed, acquires a  more purulent character,  and
 causes excoriation of the nostrils  and upper lip.  In the mouth,
 evidences of  stomatitis—swelling  of  the gums—appear,  and
 mucous patches occur in the throat.  If  the symptoms are very
 intense the children fail rapidly and soon die.  Where the mani-
 festations are of a milder nature, the eruption becomes gradually
 less pronounced in color, and a few condylomata only remain at
 their   most usual seats—the anus, genitals, and  angles of the
 mouth.  But the nutrition  of the child  remains impaired;  the
 skin assumes a pale, earthy color, and the physiognoni}" acquires
 a peculiar character, which,  as the child develops, becomes more
 and more pronounced.   Among the most striking of its  features
 are a  depression or flattening of the nasal ridge  and a certain
 degree of hydrocephalus, with marked prominence  of the frontal
 protuberances.   The changes in the brain which lead  to hydro-
 cephalus, as well as some other processes (the encephalitis, for
 example, which was anatomically demonstrated by Virchow'),
 do not always run their course without giving rise to symptoms.
 The children are often very restless, crying a great deal, especi-
 all}r at night, are backward in their intellectual development, and
 when  grown often present striking idiosyncrasies of character.
   Iritis is met with in children with inherited disease, although
 not with the same frequency as among  patients with acquired
 syphilis.   It is of more frequent  occurrence among  girls than
 among boys; it attacks sometimes but one,  sometimes both
 eyes,  and is most common  in the fifth month of  infant  life
 (Hutchinson).   Deafness, due to changes in the middle or inter-
nal ear, may also be present  at this time.
1 Archiv, B. 44, 1866, p. 473. 
240
BAUMLER.—SYPHILIS.
   Rheumatoid symptoms occur now and then, even in infants,
and usually depend upon the epiphyseal affections already spo-
ken of.  I have seen painful symptoms develop in the vicinity of
different joints, in a child of eight months.  No objective  symp-
toms could be found in any of the bones and joints,  but the child
kept the affected limbs motionless, and gave evidence of intense
suffering when passive motion was made.
   The period at which the first outbreak of symptoms occurs,
in those children with  hereditary syphilis who are born  appa-
rently healthy, is very  uncertain ; the latest period being  stated
by different authors at from one week  to several months.  It
most  frequently occurs from the  fifth to the eighth week after
birth. Von Rosen' found that out of sixty-eight cases occurring
in the Lying-in Hospital, in Copenhagen, only nine showed the
symptoms  of the disease later  than three months after  birth.
More  extensive  statistics show that  nearly one-half of the chil-
dren are attacked within the first month of life ; one-third in the
second ; about one-eighth in the third, and only one-eleventh at
a later period.  The  symptoms very  seldom begin in the first
week, and not frequently in the  second.
   If  the symptoms appear at an early period, the children usu-
ally die  ; but if long delayed they  are sometimes very light in
character,  and even when they  are well marked may disappear
spontaneously.  Many children with  inherited syphilis have only
a few moist papules  about the  anus or genitals, which may
relapse many times during the first year of life,  though the chil-
dren  still  preserve a healthy appearance and  may be fat and
strong.
   Children with  hereditary syphilis who have passed through
the acute  stage, with  or without treatment, may develop nor-
mally or remain pale and weak,  and  they may bear traces  of the
disease for life.  Moreover,  they may ever after remain free from
all symptoms of  a specific nature.   It is very common, how-
ever, to  have a new train of symptoms developed at the time of
the second dentition, or—and this is especially true of girls—at
the time of puberty.  Among these  may be mentioned keratitis
1 L c, pp. 223 and 226. 
            HEREDITARY AFFECTIONS IN CHILDREN.          241

interstitialis (see  page  222),  eruptions resembling rupia,  ser-
piginous  ulcerations  of the  skin,  or,  lastly, affections  of  the
osseous system, wliich, unlike those of the tertiary period, are
frequently symmetrical in their development.  At this time, too,
it is common to meet with ulcerative processes  in  the throat or
upon the hard palate,  with necrosis of the bone.   Changes in
the liver or kidneys, wliich have  been hitherto in progress, may
now first manifest themselves in appreciable symptoms (ascites,
hydrops).   In addition to  all these manifestations, the children
show disturbances of the nervous system at this period, which
may be attributed to  syphilis—such as epilepsy, chorea, and par-
alysis (Hughlings Jackson).1  The paralyses of the cranial nerves,
which are so common in adults with acquired syphilis, are so ex-
tremely rare  in cases of  inherited disease that Hutchinson  has
never seen a single case.  But H. Jackson reports one case of facial
paralysis with paraplegia in a child with hereditary  syphilis.

   Von Graefe (Arch. f. Ophth., B. I. p. 433) observed a case of paralysis of the ocu-
lomotorius in a child two years of age,who showed traces of former iritis, and had
a papular  eruption. At the  post-mortem examination there were found circum-
scribed thickenings of the sheath of the left oculomotorius, and softened deposits in
both hemispheres.  There was, however, a reasonable doubt as to the hereditary
character of the syphilis in this instance, which was strengthened by the presence of
a copious papular eruption  in the second year of life.

    The group of symptoms just described is sometimes found at
puberty in  children who are  perfectly well developed, and
whose appearance, as well as their history, gives no  ground for a
suspicion of the existence of hereditary syphilis.   It was such
cases as these—which are certainly very rare—that  gave rise to
the supposition of "a tardy development of hereditary syphilis''
(s.  hereditaria tarda), while, according  to some authors, the de-
velopment of the disease may be still further  delayed in women,
and be determined by the  state of pregnancy or the change of
life.  But cases of the latter class must be regarded  as of such
an  extremely doubtful  nature as to be here discarded.   As for
the rest of  the cases  of supposed tardy development, the symp-
   1 Cases of Diseases of the  Nervous System in Patients the Subjects of Inherited
Syph. Transact, of the St. Andrew's Med. Graduates1 Association, Vol. I.  London, 1868.
          VOL. III.—16 
242
BAUMLER.—SYPHILIS.
toms really belong to the tertiary period (some of them possess-
ing such peculiar characteristics as the interstitial keratitis), the
secondary stage having been simply overlooked because very
light; or since it occurred at a very early period  of life, and was
perhaps attended by no very noticeable manifestations upon the
skin, those who had care of the child may have lost  all recollec-
tion of it.  In several  of the cases which have been adduced as
examples of delayed development of an inherited syphilis,1 men-
tion was made expressly of  secondary symptoms having occurred
at an early period, and in  others the presence of deformities of
the skull or of the incisor  teeth gave positive evidence that the
syphilis had manifested itself during the first  few months of
infancy.  To suppose,  in  explanation  of  these  cases, that the
child may have passed through the acute stage of syphilis in
utero, have been  born  in apparent health, and then afterwards
have been attacked by tertiary symptoms, is assuming too
much, since these children are usually still-born.
   This brings us to the  oft-repeated question,  as to whether
modified syphilis of the parents may not give rise to other con-
stitutional peculiarities in the offspring than those imparted by
a syphilis inherited directly.   It has been supposed that such
was the connection between  syphilis  and  lupus  vulgaris—a
disease which undoubtedly has many points of resemblance to
some syphilitic exanthemata.  But all who have made a special
study of this question agree  that there is not the most remote
relation between common lupus and syphilis.   Scrofula has also
been represented as a syphilitic inheritance, and the tertiary
symptoms of hereditary syphilis have even been denominated as
"syphilitic scrofula."  But a careful comparison shows clearly
the great difference between  true scrofulous  symptoms, and the
tertiary manifestations of  inherited syphilis, and Hutchinson,3
who has given special attention to this subject, asserts with great
positiveness that hereditary syphilis neither  predisposes to con-
sumption nor to the ordinary forms of scrofulous and  tuber-
culous disease.
1 Compare v. Rosen, 1. c, p. 230.
2 Med. Times and Gaz., 1867, Vol II. p. 658. 
HEREDITARY AFFECTIONS IN CHILDREN.        243
   But  hereditary syphilis, manifesting itself as it does at the
most important period of the development of the individual, is
followed, not only by the direct manifestations which are known
as tertiary symptoms, but by another train of morbid conditions
which must be regarded as the remains of former disturbances
of nutrition or of development, which took  place at the early
period while the  syphilitic poison was still operating upon the
foetal or infantile organism.  Under this head belong a portion of
the above-mentioned  nervous  symptoms—eccentricities  of char-
acter, idiocy, a tendency to epilepsy or to mental derangements. 
RETROSPECT.
   Now that we have described  both acquired and inherited
syphilis, in all their different phases, as  well  as the manifesta-
tions of the  disease, as they occur in the various organs of the
body,  it may be  well  to review, connectedly,  the events which
mark the development of syphilis,  and which have hitherto been
only incidentally  touched upon and in a disjointed manner.
   The first  event in the infection—as we comprehend it—is the
production of a  local deposit, in which  the virus gradually
increases,  and  from which,  as a  focus, an  infection,  slowly
advancing by way of the lymphatic vessels, principally, but also
through the blood, involves, by degrees, all the fluids of the
body.
   In the syphilis d'emblee—the occurrence of which is still a matter of much doubt
—the first affected lymphatic  gland is to be looked upon as equivalent to the
primary affection; if  a foetus  is infected from the  mother, then it is the whole
maternal organism, or, sometimes, the diseased maternal portion of the placenta,
which is to be so regarded; where the mother is infected from a syphilitic foetus,
procreated by a syphilitic father (choc en retour), the  primary affection exists in the
foetal portion of the placenta or in the entire foetus.

   This view of the local nature of the primary affection is not
the one most generally  adopted;  in fact, the  appearance of the
primary lesion has long been regarded as a local expression of
the general blood infection, which was supposed to take place
immediately, through  the inoculation.  According to von Baren-
sprung, who advocated  this view more particularly, the  indura-
tion is  "not  the precursor of lues, but a proof of its actual
presence." 1   This  supposition is based  mainly  upon  the non-
inoculability of the secretion of the induration upon the bearer
1 Mittheil. aus d. Abth. und Klin, fur syph. Kranke.  Berlin, 1855, p. 16. 
RETROSPECT.
245
of it, and upon the existence of a period of incubation.  Von
Barensprung  believed,  moreover, that  a correspondence  was
shown to exist between the substance constituting the induration
and  the products of the later stages of syphilis, in the action of
iodine upon them,  and thence  inferred that  the induration was
a manifestation of the  constitutional syphilis.   Virchow has
exposed the fallacy of this reasoning, and, as we have already
seen, the proposition of Ricord, that the induration affords an
immunity against  the syphilitic poison—which was asserted so
positively in  his  time—has  since  been  essentially  modified.
Bidenkap succeeded, in a small number  of cases, in inoculating
the secretion of primary sores  upon the bearers, and  produced
the  same effects as  though they had  been healthy subjects.
That these inoculations did not occasion  merely local outbreaks,
in an organism already imbued with syphilis, is evinced in the
fact that the papules which resulted, developed one after another
in exactly the order in which the inoculations had  been made.
At the points where the inoculations were made  several days
later, the papules  also  made  their appearance later ; in fact,
they developed exactly as if the subjects of the experiments had
not been syphilitic at all.   (See page 97.)  These cases, it is true,
when compared with the  large number of inoculations  which
were made  by Ricord and his followers, only represent  rare
exceptions, but the query arises as to how many of the inocula-
tions which were made from primary syphilitic  lesions,  before
the incubation of syphilis was generally recognized, were kept
under observation long enough to really ascertain the effects of
the inoculations, since the specific action of the inoculated virus
does not generally show itself until from three  to  four  weeks
have elapsed.
   Moreover, a number of therapeutic facts favor the theory that
the primary lesion is at first a purely local  affection.   In nu-
merous well-authenticated  instances (Hiiter, Humphry, von Sig-
mund, Vogt—see below) excision or cauterization of the primary
lesion was successful  in preventing  the  occurrence of constitu-
tional symptoms, which could not  have been  the case were the
syphilitic papule a manifestation of the general infection of the
organism.   It  is true that Hunter, Delpech, and others long ago 
246
BAUMLER, —SYPHILIS.
made similar  experiments,  which usually failed;  for  in these
cases the edges of the wound became indurated and showed all
the characteristics of the primary lesion.  This does not appear
so remarkable, however, when we consider that von Biesiadecki
has shown us,  by means of the microscope, that the cellular infil-
tration,  which is the  expression of  the specific local irritation,
extends along  the blood-vessels to a considerable distance  from
the primary lesion (see page 110).  What  takes  place here is
exactly  like what is seen in the extirpation of cancer.   It is not
necessary even that the cellular infiltration should  be  sufficient
to amount to  a  papule.  In the first twenty-four hours, the
virus may so affect the tissues in the neighborhood of the point
of infiltration  that, in  spite  of the partial destruction by cau-
terization, an  induration may  develop in the remaining  scar.
Berkeley Hill* narrates a case in which he cauterized  a wound
upon the frsenum with fuming nitric acid, within  twelve hours
after the coition;  but  notwithstanding  this, the cicatrix became
indurated and the patient had constitutional syphilis.   Experi-
ences of this kind only prove that the extent of the local action
of the virus and its first effects cannot  be  accurately  appreci-
ated.
   The  next effects of the virus, which is constantly increasing
at the point of infection, are manifested upon the neighboring
lymphatic vessels or  glands;  and, either through the infection
of successive groups of lymphatic glands, or through the absorp-
tion of  the virus into  the blood from  the primary lesion and
from the affected glands, or  in both ways, the entire mass of the
blood becomes gradually  saturated with the poison,  so that if
the blood is then inoculated upon others syphilis will result.
Exactly at what time this result becomes possible is not known,
and Kobner2  observes that, for the purpose of deciding this
question, it would be desirable '' to inoculate the blood of per-
sons, who show no other indication of syphilis  than a  very
recently developed  papule,  upon healthy subjects who submit
themselves voluntarily to the  experiment."   That the entire
mass of the blood becomes a vehicle of the virus,  after the
'L.c, p. 56.
2 L. c, p. 67. 
RETROSPECT.
247
 appearance of general symptoms, is evidenced independently of
 the direct proof furnished by inoculations, by the symmetry
 of the local symptoms and the universality with which  the most
 different organs are involved.
    The inoculability of the secretion of  certain of the local sec-
 ondary symptoms shows that a still further increase of the poi-
 son takes place in them, and so long as this continues, a fresh
 supply of syphilitic  poison  is being  constantly  added to the
 blood.  On the other hand, it  is highly probable that an elimina-
 tion  of the virus  is  continually in  progress.  With  the con-
 stantly changing relation between production and elimination  of
 the virus we  may have fluctuations in the patient's condition,
 as is often seen in the  occurrence of fresh  eruptions during the
 first weeks or months  of the secondary period ; especially when
 the course of the disease is interfered with by the action of the
 remedies employed.  If there  are  only a few local deposits, the
 elimination of the virus may be so much in excess of its produc-
 tion that  the  organism is gradually freed from it.  This takes
 place in a great majority of cases ;  at the expiration of  eighteen
 months or two years the infection is entirely exhausted.
    The  cessation of symptoms  may, however, be due  to other
 causes.  The tissues gradually attain a certain immunity against
 the virus  which circulates through them ; there are  no longer
 any outwardly apparent effects of  the poison, nor is there any
 possibility of  a new  infection  having  occurred from without.
 But there may still be enough of the virus in the blood to trans-
 mit the disease to others, if inoculated, or to induce symptoms
 again in  the  patient's organism  when,  for  some  reason  yet
 obscure, he again becomes susceptible  to  the influence of the
 poison—as in the event of a temporary  debility induced by
 unfavorable external influences.
   The syphilis is now  said to have become latent,  and this con-
 dition has from early times attracted the attention of physicians,
and has called forth many attempts at its explanation.  Virchow
 thinks the dyscrasia of syphilis is only temporary, but that  it
may from  time to time  be renewed  through the  repeated occur-
rence of a general infection of the blood from certain depots in
the body where the virus has been deposited.  Various  internal 
248
BAUMLER.—SYPHILIS.
organs—especially  the lymphatic glands—may serve  as such
depots,  in which the virus remains latent  until certain  out-
ward influences determine a renewed increase of the poison at
these places, and symptoms  of  a  general  infection are then
repeated.  Astruc  opposed this  view—for the  same idea was
maintained  by some of  the older physicians1—on the ground
that no foreign substance could remain  unchanged in  any por-
tion of the body, as it would either be expelled or else employed
for nutritive purposes.   Astruc therefore held that there was  a
permanent dyscrasia, and that the blood, when once contami-
nated, infected the new  nutrient material as rapidly as it was
received from the chyle, and thus the virus was constantly being
increased.   As long as  this  continual  new  production  of  the
virus did not exceed certain limits, the disease remained latent;
but  if  through outward influences disturbances  arise  in  the
organism, the disease again manifests itself.
   Much may be said in favor of both of these views.   Against
the objection of Astruc may be urged the fact that cheesy depos-
its often remain for years in the body, and  then suddenly give
rise to a new infection. On the other hand, the latency of syphi-
lis may be explained, on  the supposition of a permanent dyscra-
sia, as follows : After the first general infection, which causes a
powerful reaction in all the tissues, since the poison is yet some-
thing entirely  foreign to them, an immunity from, or  a sort of
inurement to, the accustomed irritation ensues, so that, while the
virus is  still present in the fluids of the body—though constantly
diminishing in  amount—the local and general processes of nutri-
tion proceed in an apparently normal manner, so long as no out-
ward disturbances  interfere.  The more  thorough  the  original
infection was, the more complete  will be the general and local
immunity from the syphilitic virus.  On the other hand, if, at
first,  only a small  amount of the poison entered the general
circulation (either because the infection was light, or because, by
means of an early mercurial course, the  action of the virus  was
temporarily restrained), the immunity of the tissues will be less
   1 Astruc, 1. c., p. 101 : "----vel in glandularum quarumdam recessibus seponi ubi
sint in tuto, sed unde data occasione possint quasi ex insidiis erumpere et vi atque im-
pressione sanguinem ceterosque humores, imo vero partes solidas pessundare." 
RETROSPECT.
249
complete.  Then if, in some local deposit, as, for instance, in a
remaining  isolated  papule of the skin,  the virus  has had an
opportunity to increase to any extent, or if, after the complete
extinction  of the first infection (which was perhaps  only very
light)  a fresh  inoculation  has taken  place,  a  new  and more
intense infection of the blood may ensue,  which manifests itself
in a recurrence of the cutaneous eruption, of the disease of  the
throat, etc. Latency, therefore, is an indication that the virus
does not exist in the fluids of the body  in sufficient concentra-
tion to excite  the  irritability of the tissues;  an increase of  the
poison or changes in the tissues which augment their irritability
may make the disease again manifest.   An insufficient mercurial
course will very frequently render syphilis latent for a time,
postpone the appearance of the secondary symptoms, and give
rise to delayed and scattered outbreaks.
    Those  cases in which, after  years of apparent health,  the
syphilitic virus again shows its effects, either upon its possessor
or  upon the offspring,  are extremely difficult  of  explanation.
When all local manifestations, from which new supplies of  the
virus could be conveyed to the blood, have for years been absent,
it must be supposed that the fluids of the body have become
entirely free from  the poison, and in these cases no other theory
seems  tenable than  the one advanced by Virchow, which sup-
poses the existence of concealed, perhaps circumscribed, deposits,
in some of  the internal organs.
   As  to the  symptoms of the tertiary period of syphilis,  we
have already stated  (p. 38) that we do not regard these changes
as due to  the direct influence of the syphilitic poison upon  the
tissues, and we will here only repeat that their peculiarity does
not consist so much in the proliferation of cells as in the peculiar
changes which  the  cells  undergo in  the  course  which they
pursue,—changes which depend upon  the modified  constitution
imparted to the tissues by the antecedent syphilis.   This view
does not conflict with the  fact that, in  foetal syphilis,—and,
therefore, at an apparently very early stage  of the disease,—
changes are found which belong to the tertiary period ;  for since
the tissues of  the foetus  are  actually formed  while under the
influence of the virus, the processes to which this influence gives 
250
BAUMLER.—SYPHILIS.
rise, may, to some extent, take the course which characterizes
the affections of the tertiary period.
   According  to this view, a pronounced tertiary stage would
imply a previous severe secondary period, and,  in many  cases,
this is found to be true.  But, on the other hand,  cases occur in
which the  secondary symptoms have been light, and have even
passed by unnoticed, and, notwithstanding, the tertiary symp-
toms have been severe.  With regard to this apparent contradic-
tion, it is to be remembered that the effect of a feeble operation
of the syphilitic  poison, continued for  a  long time,  may be
equivalent  to  one which is more intense, but of short duration.
Moreover, in the production of the characteristic condition  of the
tissues, other elements besides  the syphilitic virus—such as the
character of the  constitution, outward influences, and medical
treatment during the time that the syphilitic  intoxication is
active in the blood—are of great influence.  We see sometimes,
even in the  acute period of syphilis, outbreaks which approach
those of the tertiary stage of the disease (impetigo,  ecthyma, and
rupia eruptions, destructive ulcerations in the throat, bone-affec-
tions).  In hereditary syphilis this galloping form  of the disease
is exceedingly common.
   Among  the unfavorable  external influences  which,  in con-
junction with syphilis, predispose patients to the development of
tertiary symptoms, it has been customary for more than three
centuries to give  the  first  place to  mercury;  indeed,  some
observers have gone so far as to designate tertiary symptoms as
mercurial symptoms.   That an injudicious use of  mercury may
have an injurious effect upon the constitution, and in combina-
tion with syphilis may favor the outbreak of tertiary symptoms
is very probable, but that mercury alone  can produce them is a
supposition  utterly untenable.   Virchow, Kussmaul and  Over-
beck have confuted this hypothesis very completely.
   It will be appropriate to consider at this place the influence
which certain physiological and pathological  conditions of the
organism may have upon syphilis.   The state of pregnancy ex-
ercises an unfavorable influence upon the course of syphilis, for, 
RETROSPECT.
251
on the one hand, the constitutional symptoms of the disease are
more pronounced, while on the other, the local manifestations
—especially such as are situated upon the genitals—are apt to
be  of a particularly  bad character; mucous  patches,  especi-
ally, under the influence of  the venous congestion which exists
commonly in pregnancy, often become enormously developed.
After pregnancy has ceased, all the symptoms often disappear
with surprising rapidity.  As regards pathological conditions, it
must first be observed that it is not as yet known what relations
of mutual exclusion exist between syphilis  and other diseases.
Frequent observation has shown that various acute diseases have
a marked effect upon the development of  commencing syphilis,
and especially upon the appearance of certain symptoms. Bas-
sereau and Lancereaux * observed that, when acute febrile affec-
tions occurred in the course of syphilis, the disease was delayed,
—perhaps the appearance of the  exanthem was deferred.  Sev-
eral times also a disappearance  of syphilitic  exanthems was
observed during the course of cholera  (Lancereaux).   The occur-
rence of erysipelas  has  a striking influence on syphilitic erup-
tions.  In a case which was observed by Bidenkap (see page 98,
Case III.) syphilitic papules, produced by artificial  inoculation,
became level with the surface during an attack of wandering ery-
sipelas, and after the intercurrent affection had disappeared they
became elevated as  before.  C. Mauriac2 has  recently supple-
mented a number of  observations concerning this  influence of
eiysipelas, which he collected from older writings3 with a case in
which moist  papules of  the  lips and  of the mucous membrane
of the mouth and isthmus faucium disappeared during an attack
of erysipelas.   This effect is the result of the more active tissue
changes in the indolent syphilitic cellular  infiltrations  of  the
skin or mucous  membrane,  these changes being due to  the in-
creased fluxion excited by the erysipelas ; and in consequence of
this  the  cells imbedded in the tissues either degenerate more

  1 L. c.,p. 447.
  2 Gaz. des Hop., 1873, No. 39, s.  Arch. f. Derm. u. Syph.,  B. V., 1873, p. 596.—
Id., Etude clin. sur l'infl. de l'erysipele dans la Syph.  Paris, 1873.  (Gaz. hebdom.,
1874, No. 7, p. 108.)
  8 Ibid. 
252
BAUMLER. —SYPHILIS.
 quickly and are absorbed, or they are once more set in motion.
 This supposition  is sustained  by an observation of Cazenave1
 who saw a papulous  eruption disappear with rapidity in the
 neighborhood of  two  spots where  phlegmonous inflammation
 was developing.
    Chronic diseases and certain constitutional conditions, among
 which may be mentioned chronic alcoholism and gout, frequently
 render the course of syphilis severe.   Scurvy, which in hospitals
 is sometimes met with among syphilitic patients, is  due more to
 their unfavorable  hygienic  surroundings  and often, too, to the
 effect  of  remedies  employed,  particularly mercury,  than  to
 syphilis.
    It is an interesting and important question, but one  that has
 been as yet but little  studied,  as  to what influence latent or
 manifest syphilis may have upon other morbid processes.  Its
 unfavorable influence  upon pre-existing  phthisis is notorious.
 The effect can best be studied upon external affections—injuries,
 skin diseases—because these are so accessible to investigation.
 In the literature of the subject we find isolated statements that
fractures did  not heal in syphilitic subjects until antisyphilitic
 treatment was resorted to  (Swediaur); such a  case has  been
 lately  described  by Barnes,2 of Liverpool.   In some cases syph-
 ilitic ulcers have developed  from granulating wounds or  from
 scars.

   I observed an instance of this kind in a young person who had received a blow
 upon the shin, causing  a wound which healed under  a simple dressing.  In a few
 days it broke out afresh at its edges, and spread peripherally, forming several
 ulcers of a decidedly serpiginous character, which together embraced two-thirds
 of a circle.  The patient at the same time began to suffer from severe pains,  which
 were worse at night,  and his hair began to fall out.  It is probable that the infec-
 tion of this patient took place nine or ten months previously, for eight months be-
 fore the time of the injury there had been some suppuration around the nail of the
 forefinger of  the left  hand, and a well-marked indolent enlargement of  the cubital
 and axillary glands of that side.

    Such occurrences as these must, however, be rare ; otherwise
 they would  be frequently seen in a disease so common as syph-
1 L. c, p. 271.
a Lancet, 1873, Vol. II., No. 18. 
RETROSPECT.                      253
ilis.   Zeissl1 admits that specific symptoms may be produced in
syphilitic subjects by means of pressure or a blow, but denies
that the  process of healing of wounds, unless they  occur in
places already affected with syphilitic infiltration, differs in any-
way from that  seen in normal tissues.   Thomann2 also denies
that syphilis has any influence upon the process of  healing, but
J. Merkel3 has recently reported some cases of gunshot injuries,
in which  syphilitic  ulcers developed themselves in  the wounds,
the patients being affected with recent syphilis.
   Von Bamberger4 and StohrB have described instances where
the pustules of  variola have turned  into syphilitic ulcers.   But
in this connection  the  fact must be borne in  mind,  that  a
syphilitic eruption of papules and pustules may be ushered in
with active febrile symptoms, and present great resemblance to
variola.
1 Wiener med. Wochensch., 1865, p. 324.
2 Ibid., 1865, No. 21.
3 Aerztl. Intell.-Blatt., 1870, No. 49.
4 Oesterr. Zeitschr. f. pract. Heilk., 1858, No. 4.
6 Deutsches Archiv f. klin. Med., B. IV., 1868, p. 487. 
DIAGNOSIS.
   The diagnosis of syphilis is sometimes a matter of much diffi-
culty, owing to the great diversity of symptoms  which may be
presented at different stages of  the disease.  Some stages of the
affection, and some of the individual phenomena are, however,
so characteristic that the diagnosis can either be made as soon as
they are discovered, or rendered so probable that it is only neces-
sary to seek some confirmatory proof to establish it.  In this list
of typical symptoms belong well-marked primary indurations
on the genitals, some  forms of papular eruptions, condylomata,
symmetrical  exudative ulcerations of the tonsils, gummy iritis,
papules on  the palms of  the hands, serpiginous ulcers of the
skin, and tertiary ulcerations in the throat.   In addition to these
almost  characteristic  symptoms, which  belong  exclusively to
syphilis, there are also many others which occur as well in the
course of  other diseases, and which, when considered by them-
selves, do not warrant a diagnosis of syphilis.  It is  often the
case that the patient brings symptoms  of  this kind alone, or
indeed but one such symptom, to the notice of the physician.  It
then becomes necessary to make a diagnosis from such symp-
toms as are to be found on a close scrutiny, assisted by a careful
examination  of the history of the case, and to assign a proper
significance to the symptoms present.  It is not enough to recog-
nize a given symptom  as of syphilitic origin ; if possible its rela-
tion to the whole course of the disease must  also be ascertained,
and, as  a  general thing, it is only when the history and other
points of the case lead us to suspect syphihs that a symptom of
this kind  can be  accepted as specific.  Symptoms of this  kind
often  require, before we can recognize them  as  syphilitic, the
presence of coexisting or the traces of pre-existing symptoms, or
a critical examination  into  the patient's previous health, or even
delay until the result of the treatment employed can be seen. 
DIAGNOSIS.
255
   The history of many cases is entirely unsatisfactory.   Even
among patients whose condition calls for no particular precau-
tion or reticence, the facts of their past medical history, which
they are able or willing to give, are often quite insufficient.   All
such narratives must be subjected to most careful scrutiny, and if
this is true in regard to the histories given of themselves by men,
it is doubly so in the case of persons of  the other sex.  Particu-
lar inquiries should be made in regard  to such symptoms as are
usually met with at an early stage of syphilis, such as cutaneous
eruptions, falling off of the hair, sore throat, pains of the bones,
and iritis ;  as to the primary sore, it may be spoken of by men,
but scarcely ever by women.  The diagnosis of primary syphilis
can then only be made when the initial  lesion has become notice-
able and has been the seat of an induration of a more or less dis-
tinct  character.  If,  after a well-ascertained period of incubation,
there is found only an erosion seated on a parchment-like indu-
ration, which can only be felt by making pressure with the fingers
at  its edges, and if confrontation shows  the source whence the
sore was contracted to be a syphilitic one, it is safe to make  a
diagnosis of syphilis ;  and this is rendered more certain if in due
time  indolent buboes  appear.  It  is  often very difficult,  and
sometimes  impossible, to arrive  at  a diagnosis when there are
multir)le lesions  on the genitals, and when nothing  certain as to
their duration can be established, or when an ulcer or a vesicle
has formed within a  few days  after exposure to contagion.
Such lesions cannot be readily confounded with those of herpes
progenitalis, since in this affection a group  of small vesicles,
seated on a reddened  base, is usually  met with.  In these cases
the diagnosis of syphilis cannot be made with certainty until the
occurrence  of indolent buboes, or of an induration at the base of
the ulceration, or perhaps not until the  outbreak of secondary
symptoms.   In such cases the physician must express himself
with  much  caution, and will seldom be able during  the first five
weeks to give a positive diagnosis.  He must  never forget that
the primary sore may  at an early stage present the appearance
of a simple, harmless-looking erosion, especially in women.
    Attention  has  already been  drawn  (page 117) to various
conditions under which confusion might arise; but to distinguish 
256
BAUMLER.—SYPHILIS.
the inflammatory thickening of a chancre from  the ulcerating
initial lesion of syphilis, is not so difficult as to make a diagnosis
between  a primary papule, either dry  or  moist, and a papule
belonging to the secondary stage.  In  a case of this kind the
existence of indolent buboes would, to  a certain extent, render
the question more easy of solution ; but special attention must be
paid to  the period which has elapsed  since infection probably
took place.  Even when this cannot be  definitely ascertained in
uncomplicated  cases, the symptoms which are met with gene-
rally furnish data sufficient  to lead to a  correct opinion as to
the chronology of  the disease.  If,  in  a  sore which made its
appearance some days after infection, there is found,  after some
time, an  induration accompanied by indolent enlargement of the
glands, it is safe to suppose that from  four to  five weeks have
elapsed since infection took place.  The  same supposition is jus-
tifiable if a dry papule, followed by a similar enlargement of the
lymphatic glands, is met with.
   The commencement of the secondary stage is the period of
the disease at which the fewest difficulties in diagnosis are  met
with.   Obscurity may arise at this time from  the occurrence of
unusually  active febrile symptoms,  or of irregular forms of
cutaneous eruptions.  The most important  points relative to the
differential diagnosis have, however, already been given  (pp.  127,
128, and  135).
   The longer the time that has elapsed  since the eruptive stage,
the more difficult is the diagnosis, since we have then to deal
with symptoms wdiich are of  a more isolated character.  Among
these, then, are some which are characteristic of syphilis  and
which have been given  above ; there are others, however, which
ought to arouse a suspicion of this disease, and lead to  a search
for other manifestations of it. Among these are, paralyses of
cerebral nerves, persistent neuralgias, headache, and pains in the
bones, which are more intense at night, loss of hair, abortion,
especially when it is  of repeated  occurrence, remittent febrile
attacks, symptoms of a rheumatoid character, and finally, such
as occur with equal frequency without the  existence of  syphilis,
as anaemia, loss of  flesh, general weakness, and nervous distur-
bances of the most varied character. 
DIAGNOSIS.
257
   The diagnosis is often attended with special difficulty during
the tertiary period, when the symptoms are isolated ones, and
are due not to lesions of accessible parts of  the body,  but  of
internal organs.  In such cases the chance discovery of an exos-
tosis, of a characteristic scar, or the like, often serves to put the
observer upon the  proper track.  If we learn from a patient that
he has recently,  or some time previously, suffered from syphilis,
we should bear  in mind that therein may lie the possible cause
of any ordinary affection which he may present.  In all cases in
which there is any suspicion of syphilis, a careful examination
must be made of  all those parts of  the  body upon which the
earlier manifestations of the disease are apt to be localized.
   Above  all, the inguinal,  the epitrochlear,  and the cervical
lymphatic glands,  the skin, the  mucous membrane of the mouth
and fauces, the eyes,  and such portions of  the bones as are
covered only by skin, must be examined.   It  is not often, when
an obscure affection is really syphilitic in its nature, that such
an examination will not reveal some other symptom of the
disease.
   In doubtful  cases the effects of an antisyphilitic treatment
with the iodide of potassium, or even with mercury if the sus-
picion is very decided,  must be tried.
   In the diagnosis of  visceral syphilis and  of syphilitic ma-
rasmus, the remains of  former affections, especially those of the
bones, the fauces,  and  the skin, are frequently the only data for
the formation of a  diagnosis.
   The  diagnosis of hereditary syphilis is not usually attended
with any difficulty in early childhood ; the affection of the nasal
mucous membrane, the papular or pustular rash, and the puny
and aged expression of the child, form a group of symptoms that
can scarcely be misinterpreted.  It must not be forgotten, how-
ever, that children with hereditary syphilis  may be well de-
veloped at birth and present the appearance of perfect health,
affording no further evidences of syphilis than a  few condylo-
mata about the anus.
   Of much greater practical importance is the question which
sometimes arises subsequently, whether the  subject of  certain
affections  had, during earlier life, symptoms of hereditary syph-
          VOL. III.—17 
258
BAUMLER. —SYPHILIS.
ilis.   In this respect the signs wliich have been brought prom-
inently forward by Hutchinson are of the utmost importance.
The most typical  of these are the following : prominence of the
frontal protuberances, flatness of the tip of the nose, interstitial
keratitis or cloudiness of the cornea, fine white linear cicatrices
radiating from  the angles of the mouth or nostrils, and particu-
larly that condition of  the permanent incisor teeth which is well
shown in the wood-cut from Hutchinson's article in Reynolds's
System of Medicine, which is here given.
   The presence of all, or even of only the chief,  of these features
                        gives to children with hereditary syph-
                        ilis, and even to adults, who may more-
                        over have lost the deformed incisors,
                        such  a characteristic physiognomy,
                        that, if well-marked,  it  can be recog-
                        nized  at  a  glance.    If there is  any
suspicion of  syphilis in the younger children  of a family,  the
elder  ones should always be examined, since in  them the evi-
dences of inherited syphilis are  often to be found in a still more
marked degree.
 
PROGNOSIS.
    From what has already been said it can be seen that syphilis
 under all circumstances must be looked upon as a dangerous
 disease, since it is active throughout the entire organism for a
 long time, and often leaves  permanent injuries of some organs.
 Indirectly, therefore, syphilis may often be the cause of death.
 It  is seldom the direct cause, except among children with the
 disease in its hereditary form, a large majority of whom die at a
 very early  age.1  When we  reflect that quite  as many deaths
 occur from the same cause during the foetal condition, we may
 form some idea  of the  baneful  influence of syphilis  upon the
 mortality of a population.   All  trustworthy data necessary to
 the estimation  of the entire  number of deaths from syphilis are
 as  yet wanting, for even deaths which  are directly due to  this
 disease are not  always put under this  head in the lists of mor-
 tality.  How many cases of deaths among young children, which
 are really from syphihs, are  recorded under the terms atrophy
 or marasmus !   Among adults death as an immediate result of
 syphilis is very rare, and when it  occurs it is usually due to loss
 of blood in consequence of ulceration, or to exhaustion following
 an unusually severe course of the acute stage.  If all the cases
 in which syphilis, by causing  affections of the brain, of  the heart
 and blood-vessels,  of the fiver,  or of the kidneys, becomes a
 remote  cause of death, were  attributed to their true source, the
 list of deaths from this disease would in many localities be much
 augmented.   Thus far all estimates of the proportion of deaths
 among those affected with syphilis are  equally untrustworthy.
 No just idea of this mortality  can  be obtained from the statistics
 of the venereal wards of hospitals,  for fatal forms of syphilis are

  'In London during the twelve years 1854-65 there were 3,370 deaths from syphilis,
2,587 of these being children under one year. (Brit. Med. Journ., 1868, Vol. II. p. 116.) 
260
BAUMLER.—SYPHILIS.
there found in but small number, but  should be sought for in
the wards for internal or surgical affections and in the alms-
houses.
   In regard to the prognosis in individual  cases, it has already
been stated above that there are mild and severe cases of syphilis
to be distinguished.   In these latter, in which the first eruption
is frequently pustular, and in which the primary sore itself may
take on a gangrenous character, the life of the patient is often in
immediate danger.  Within certain limits  it is possible to esti-
mate the severity of the future constitutional involvement from
the character of the primary sore.  If phagedena, or rapidly  de-
structive suppuration in the primary lesion be not due to contam-
ination with hospital gangrene or to inappropriate treatment,  the
conclusion which  must be formed as to the constitution of  the
patient  must lead to grave  forebodings as to the effects of  the
later stages of the disease.  In the opinion of many physicians,
the presence of a very  extensive primary  lesion, with marked
induration, indicates that  the  subsequent  course of the disease
will be severe.  In so far as we are warranted in making the sup-
position that  an  intense and  extensive induration is due to a
more profound contamination of the tissues, and that there is
thus furnished a more prolific source of the syphilitic virus  for
infecting the rest of the organism, to just  that extent may  the
opinion given  in  the last  sentence be held.    But numerous
exceptions  to this rule  are  met with, in which,  for example, a
well-marked  eruption follows an insignificant primary lesion,
and it is always venturing a good deal to attempt  to foretell any-
thing beyond the acute stage.
   It cannot yet be decided whether the severity of the course
of the disease is influenced by the locality at which inoculation
takes place.   Some cases of infection on the fingers, of which I
have knowledge or which were under my observation, have given
me the impression that such  cases are apt  to follow an excep-
tionally severe course.  Cazenave also narrates several cases of
this  kind which were characterized  by severe symptoms; and
he attributes this to the unusual way in which infection took
place in the autopsy of a syphilitic subject, or the delivery of a
syphilitic woman while there was a wound on  the finger.   In 
PROGNOSIS.
261
some of these cases, the severity of the disease may be due to the
fact that the attack  was not at first recognized and treated as
syphilis, as has happened  in many cases of vaccinal syphilis.
The character of the rashes which appear during the eruptive
period forms a trustworthy ground for the formation of a prog-
nosis.  Not only is a roseola in itself  a lighter affection than a
papular, or especially than a pustular eruption, but it has less
influence upon  the later course of the disease than the  more
enduring exanthem,  since the latter, during its existence, is con-
stantly contaminating the blood by a fresh proliferation of syph-
ilitic virus in the various  local deposits.   If this is true, it does
not accord with the  assertions  of many authors, that there is a
greater  predisposition  to  tertiary affections,  especially in the
bones  and internal organs, among such as have had but slight
cutaneous manifestations.   This view,  however, is  not yet sup-
ported by a sufficient number of observations, and it must also
be borne in mind,  first, that there is  no  necessary relation of
cause and effect in these cases,  since  the antecedent syphilitic
affections are not the only elements wliich influence  the appear-
ance of tertiary  symptoms ; and, second, that the constitution of
the patient and  external influences also play an important part.
   Roseola must be regarded as the mildest form of eruption;
papular forms are more grave in character, and a pustular rash,
especially one that consists of tubercles, is of still more unfavor-
able omen.  In  all cases of syphilitic  local affections the more
nearly the results of the process approach the character of gum-
my tumors, that is to say, the greater their tendency to soften-
ing or  to cheesy degeneration, rather than to resolution, the
graver, as a rule, is the prognosis. This distinction  in the danger
attending deposits of these respective  characters, is due to the
fact that those of the secondary period consist of a simple infil-
tration of cells,  which is persistent, but still capable of removal
by absorption,  while those deposits which are tertiary in their
character undergo rapid changes which  lead to destruction of
tissue.   This distinction  is dependent, too,  on the importance of
the affected organ.   A simple proliferation of  cells, which after
some time is either absorbed or converted into connective tissue,
has a very different significance according as it affects the skin, or 
262
BAUMLER. —SYPHILIS.
a bone, or the iris, or the adventitia of an important blood-vessel
of the brain.
   Although the prognosis as to the results of cases of this sort
must always be grave,  we must remember,  on the other hand,
that many serious affections, more especially  some of those of the
nervous system, even such as epilepsy, various paralyses, apha-
sia, and the like, when  not of too long duration, are more favor-
able in their  course when due to syphilis, since  an anti-syphi-
litic treatment sometimes removes morbid conditions, which are
apparently hopeless.  Care must be taken, however, not to give
a too favorable  prognosis, especially in cases of syphilitic  affec-
tions of the  nervous system, for anatomical  changes which can-
not be removed are often at the bottom of  the symptoms, or a
temporary cure is followed by a recurrence of the affection.
   The prognosis in a  given case is  greatly influenced by the
patient's general condition at the time.  If  this bears  a certain
relation to the  local symptoms, the prognosis  is more favorable
than when great weakness, anaemia, and wasting are met with in
conjunction  with apparently unimportant local manifestations.
This statement  is especially true with regard  to  the secondary
period.   In  the tertiary period  a  cachexy of high grade may
exist with limited affections of the skin or bones,  and in a short
time, under  the influence of an anti-syphilitic treatment,  the
local sj^mptoms may vanish, with marked improvement in the
general condition, and  the  patient may ultimately regain his
flesh and present a healthy appearance.  But if this result is to
be attained, there must be no serious visceral changes, especially
of the liver and kidneys, and, above all, no intestinal ulcerations.
While  albuminuria may be relieved  and even cured  in  some
instances,  dysenteric symptoms,  when due to the lesions of
syphilis, almost invariably lead to speedy death.  Well-marked
marasmus in syphilitic  persons, particularly in those  who are
advanced in  years, is of grave omen,  even if the  administration
of the iodide of potassium, or other remedies,  suffices to remove
some of the local symptoms.  Such patients  frequently die from
some intercurrent inflammatory affection, such as pneumonia, or,
more commonly,  erysipelas, which starts from some  point of
ulceration on the skin or nasal mucous membrane. 
PROGNOSIS.
263
   As  in all diseases, the constitution of the patient has an im-
portant influence upon the course of syphilis, and, consequently,
upon the prognosis.  It is in differences in  this respect that we
must seek for explanations of the varieties which are seen both in
the primary lesions and also in the later manifestations.  Car-
michael assumed the existence of several varieties of  the syphili-
tic virus to account for these  differences, but Cazenave taught
that the constitution  of the patient  was  the most important
factor  in determining  the character of syphilides.  Scrofulous
individuals, and those who are prone to suppuration, are  apt,
when affected by constitutional syphilis, to suffer from pustular
cutaneous  eruptions and suppurative affections of  the mucous
membranes.
  The  age  of the  patient has  a  great influence upon the prog-
nosis.  The great  danger to infant life from hereditary syphilis
has been already pointed out, and this danger is not much less
when children acquire the disease from their nurses, or in other
ways, at a  very early age.  With  children,  the danger is due to
the  intensity with which the disease develops  and runs its
course ; in  the aged, to the slowness with which waste is repaired
in the senile organism.  Old  people,  therefore,  are  placed in
peril by syphilis,  and, at  all events, the disease in them runs a
more chronic course, even if the symptoms are not very severe.
   Sex influences the type of the disease more than its intensity.
Among women it is more apt to lead to anaemia of a high grade,
and  to functional diseases of the nervous  system, than among
men, and for this reason the symptoms of the early part of the
secondary stage, in the former sex, often lead to the supposition
that the patient is  suffering from chlorosis, phthisis,  or some dis-
ease of the  spinal cord.  Moreover, in women, menstruation,
pregnancy, and the change of life affect the  course and prognosis
of syphilis.
   The habits of the patient may also modify the course of the
disease to a great extent.   Those who  devote their nights to dis-
sipation, more especially if they are addicted to the excessive use
of alcoholic drinks, or are already suffering from chronic alcohol-
ism, are  very unfavorable subjects for syphilis, and they often,
when once  attacked  by it, are never entirely freed from some of 
264
BAUMLER. —SYPHILIS.
its manifestations, and their lives are often manifestly shortened
by it.
   Finally, the prognosis is to a great degree influenced by the
treatment which is  pursued, or which has  been already em-
ployed.  It  cannot be denied that a mercurial treatment, which
quickly causes salivation and other evidences of  mercurialism,
while it has but  little influence on the syphilis, may cause great
injury to the constitution of the patient, and, in  conjunction
with  unfavorable  hygienic  circumstances, lead to  a  scorbutic
condition.
   On the other hand, it is possible, by a judicious  administra-
tion of mercury, not only to cause a  disappearance of certain
symptoms, but to render the disease less severe in its course, and
indeed almost to cure it.  The favorable effect of  the  iodide of
potassium upon cases presenting the  gravest symptoms, may
cause the reversal of an unfavorable prognosis ; but it is not well,
under such  circumstances, to be too hopeful as to  the future.
The  action  which an anti-syphiUtic  treatment has upon the
symptoms of the disease is often the  measure of the severity of
the affection and  of  the activity of metamorphosis, and thus
furnishes important data for the formation of a prognosis.
   The question  of the possibility of the cure of syphilis, which
is  of such great prognostic  importance,  is  one which has in-
terested physicians from time immemorial, and one which has
often been  answered  in the negative.   We now know with cer-
tainty that  a patient may entirely recover  from  syphilis,  and
that, too, in a comparatively short time; for the  occurrence of
cases of second infection, some years after first contracting the
disease, has  been  abundantly  proved.  We know  also that a
spontaneous cure of syphilis may take place at any stage.  This
is established as  to the primary stage of, among others, the cases
of intentional inoculation  which were observed  by von Rin-
ecker and by the anonymous surgeon of the Palatinate (see p.
103), and numerous cases in which  an expectant treatment was
employed by Hutchinson, Diday, and  others, prove  the truth of
the assertion as to the secondary stage.  Tertiary manifestations
are only capable of  cure  in  proportion  as the loss  of  tissue
which they involve does not affect tissues, organs, or localities of 
PROGNOSIS.
265
great physiological importance.   It is to be regretted that we
possess no criterion of the actual cure  of syphilis ;  when we see,
after the  acute stage, a period of many  years of undisturbed
health, and the procreation of healthy  offspring,  it is  highly
probable  that  there has  been a complete and permanent cure,
but there  is no absolute certainty as to the future. 
TREATMENT.
                        Prophylaxis.

   In dealing with a disease which is propagated by a fixed con-
tagion, the hope might be entertained  that it would be possible,
by a strict prophylaxis, not only to cause a diminution of it, but
finally to effect its disappearance.   This was recognized as early
as the first epidemic outbreak of syphilis, as may be seen by the
strict rules for the isolation and confinement of  the syphilitic
which  were promulgated at the end  of the  fifteenth  century.
But  as to syphilis, which  spreads  principally by  sexual inter-
course, there are  difficulties in the enforcement of prophylactic
precautions which have as yet never been fully surmounted.  If
it is difficult in a  small, enclosed territory to limit to the infected
individual a disease which for months is directly contagious, and
for years communicable to his offspring, it is  well-nigh impossi-
ble to effect it in localities which are in  frequent and close com-
munication with  others  in which all  prophylactic precautions
are  neglected.    With the intimate relations existing  at the
present day between all parts of the world, syphilis is constantly
transported from  one place to another.
   Prostitution is the source  whence the syphilitic virus is ever
freshly drawn, and the first effort towards effecting any prophy-
laxis of syphilis should include some sort of supervision of pros-
titution, since the experience of thousands  of years  has shown
it to  be an unavoidable evil, the suppression of which is impossi-
ble.
   That an official supervision of this kind has the most favora-
ble influence in diminishing syphilis,  has been proved by the
results which have been attained whenever a strict control has
been substituted for  the freedom  or  insufficient  sanitary rules
which had  previously existed.  This has been seen in Belgium 
                         PROPHYLAXIS.                      267

and in England, where quite recently a supervision  and exami-
nation of  the notorious prostitutes  of the  garrison towns  has
been  practised, and where the  condition  of  the  troops has been
much improved.1
   A full consideration of this question, which is of such extra-
ordinary importance for the public health, would be  out of place
here.   We must limit ourselves to the statement of  some of the
principal points, which, however, as fundamental principles, are
pretty generally recognized.  It is the duty  of the State, in  the
interest of the health of its citizens, not  only to limit prostitu-
tion, but to exercise a supervision over it, for it  has been found
everywhere that the  secret, unwatched prostitutes are far more
active in the spread of syphilis than those who are subjected to
regular inspection.  For the attainment  of  this end, it has  the
right, in the interest of all, to limit the personal liberty of such
persons as may be considered dangerous to the common welfare,
and to use force, if necessary, to obtain an examination as to  the
condition  of  their  health.   Regular,  frequent, and thorough
examinations are necessary ;  and they are in most cases of great
benefit  to  those subjected to them,  since they  afford them an
opportunity of being cured by timely treatment.   Although it is
desirable  and necessary  to furnish all  inducements to  these
unfortunates to enter the hospitals voluntarily, still  it has been
found that but few  avail  themselves of  this privilege, and how
little influence the free treatment of all syphilitic patients at  the
cost of the state has in diminishing  the  prevalence of the dis-
ease, may be distinctly seen  from what has  taken place in Fin-
land.3
   Up to the present time,  it has been everywhere  found that
just that class of prostitutes who are the most apt to spread
syphilis will not subject themselves to treatment,  except under
compulsion.   The action of the State, or of a community, may
  1 A Parliamentary Commission reported in the year 1871, that in those districts in
which the  '' Contagious Diseases  Act" had been enforced,  the number of soldiers
affected with venereal disorders in one thousand had diminished from one hundred and
twenty to fifty-four, during the period from 1865 to 1870.
  • Compare the  interesting paper of  0. Hjelt, Die Verbreitung der vener. Krank-
heiten in Finnland. Berlin, 1874. 
268
BAUMLER.—SYPHILIS.
go  still  further in this direction.  Prostitutes,  when brought
under the discipline of the establishments maintained for their
treatment when diseased, can be subjected to influences which
may induce, at least some of them, to give up their old calling
and adopt some respectable means of earning a livelihood, as is
shown by the favorable results that have been attained under the
laws which have been in force in England during the last few
years.
   At all events, all prostitutes found to be syphilitic should be
kept in a hospital until they are cured.  An ambulatory treat-
ment precludes the attainment of one important  object,  that of
rendering them powerless  for evil  while their disease is in its
most  dangerous  stage.  How  long  such patients  should be
detained, is  a very important question, and one that  is difficult
to answer;  for, while  all such cases need careful consideration,
those which are  not  to be under supervision after their  dis-
charge demand still more careful scrutiny.
   It has been often urged  that entire classes of men, who noto-
riously  contribute  largely  to the spread of  syphilis,  as for
instance  soldiers  and sailors, should be  subject to periodical
examinations,  and that,sailors  especially  should be inspected
before leaving a port, and again before entering another,  and
that if  found  infected  they should  be placed in quarantine.
The workmen in some of the glass-works in the neighborhood of
Lyons have  of  their own accord demanded such examinations,
to do away with the possibility of  infection from  the tubes used
by  them for blowing glass,  which are passed from mouth to
mouth.
   Finally, it can scarcely be doubted that the authority of the
state warrants the punishment of a person who has knowingly
infected  another with  such a disease  as syphilis.  The laws of
various German countries formerly contained definite statutes on
this point, but they are not  included in the Imperial Criminal
Code of the 15th of May, 1871; however, the decree in regard to
punishment  for injuries to the person, whether caused by negli-
gence or  by design, might be applied.  It is possible that in some
countries there may still be definite police regulations in  respect
to this matter. 
PROPHYLAXIS.
269
    With the unbounded  intercourse  between different countries
 which has been developed  in recent times, thorough  efficiency
 cannot  be  attained by means of  prophylactic regulations that
 are enforced only by individual states.  It  is the duty of  all
 civilized  states  to adopt a  common course of  action  against
 these diseases,  and there is  a need of universal  prophylactic
 regulations that is being more and more widely recognized.
    In framing prophylactic rules, it must be borne in mind that
 syphilis, during a portion of  its course,  is capable of  being com-
 municated from its local manifestations, and during  a much
 longer period can be transmitted to the offspring of those affected
 with it.
    During the secondary  stage,  therefore,  the use of such drink-
 ing utensils, plates, towels, etc., as are used by  others, should
 be avoided by infected persons.  Especial watchfulness should
 be exercised to prevent  the  contamination of surgical instru-
 ments, which may through negligence become vehicles  of conta-
 gion.   By far the most important example of infection of this
 character is vaccination,  and  from the facts detailed above (see
 p.  61 et seq.) the following rules may be drawn :

    If possible, only  children whose parents are known to the physician should be
 used as sources of vaccine matter.  If there exists the slightest suspicion that either
 of the  parents is affected with  syphilis, although  the child may be apparently in
 perfect health, no vaccination  should be performed from it.   Since hereditary
 syphilis in a large majority of cases  manifests its existence before the expiration of
 the third month of infant life, it is advisable to vaccinate from children above that
 age, and if possible  from such as have attained the age of six months.   It is safer
 also in doubtful cases not to vaccinate from the first children of any given parents,
 although it is quite possible that those born subsequently may be syphilitic, while
 the earlier ones are healthy,  since the parents may have contracted syphilis after the
 birth of some of their offspring. A  child from whom it is proposed to vaccinate
 others must be examined by the physician with special reference to the discovery of
 any possible  symptoms of syphilis.    It must be  entirely stripped, and the  anal
 region in particular should be subjected to close scrutiny.  Special care should be
 taken to ascertain if coryza or a light grade of hydrocephalus is present, and if
 either of these symptoms is discovered it should prompt careful inquiry.   Great care
 should  be  exercised  to avoid the inoculation of blood, or of serum  which has
exuded from the vaccine pustule some time after  it has been opened.  Adults should
never serve as vaccinifers.  Finally, in case a number of children or adults are to be
vaccinated at one sitting, those of them who may be suspected of being syphilitic 
270
BAUMLER. —SYPHILIS.
should be separated from the others, and the conveyance of their blood to the vac-
ciniferous child, or to the healthy persons who come after them in turn, should be
most carefully guarded against.

    The choice of wet-nurses for healthy children places quite as
heavy a  responsibility upon the physician as does vaccination.
It is  not only necessary to make a thorough examination  of a
wet-nurse, devoting special attention  to those parts of the per-
son where traces of syphilis are apt  to be found, such  as the
genitals, the mouth and throat, the lymphatic glands, and the
bones; but, if possible, it is well to inspect also any children that
she has  previously nursed.   Any  symptoms that arouse the
least suspicion of syphilis  should suffice for the rejection of the
nurse.  It is no less  necessary to prevent  children with here-
ditary syphilis, or those upon whom a suspicion of latent syphi-
lis rests,  from being given  to healthy  wet-nurses.  In  countries
in  which the  custom of  employing wet-nurses  prevails, the
greatest care must be exercised in these  matters, and strict laws,
inflicting  a severe  penalty for careless  inoculation of syphilis
upon healthy persons, should be enacted and rigidly enforced.
A syphilitic child may be nursed by its mother, if she has herself
previously had symptoms of syphilis; but, if she has never had
such  symptoms,  it is safer  to forbid her  to suckle her child,
although the risk of  her contracting  the disease from it  is but
slight.
   The physician must on no account  delay to inform those hav-
ing the charge of syphilitic children  of the danger of infection
through kisses or the  use of its eating  and drinking utensils, etc.
   The question  of the propriety of  matrimony, in the case  of
persons who have recently  or at some  previous time had syph-
ilis, is of great importance  from a prophylactic  point of view.
Improbable as it sounds, it is not of rare occurrence, in countries
in which marriage is not surrounded by  many obstacles, for men
with  active syphilis  to marry, even in  spite of medical advice,
and speedily to infect their wives.   Although as long  as the
slightest trace of syphilis  can be discovered,  there can be no
doubt that a decided negative should be given by the  physician
to all such inquiries,  it is extremely difficult to state how long a 
                          TREATMENT.                      271

time must elapse, after the disappearance of all symptoms, to do
away with all danger of infection.  In such  cases it is  impossi-
ble to give a positive answer.  When a man has enjoyed one, or
still better, several years of undisturbed good health  after the
disappearance of all symptoms of syphilis, he may be allowed to
marry; but,  although  under these  circumstances  there is no
direct danger of his infecting  his wife, there is no certainty, but
only a  strong probability, that his  offspring will  be  healthy.
The difficulty above referred to, that there is no absolutely certain
sign of the complete cure of syphilis, is  nowhere more  manifest
than in the consideration of this question.  We must here  con-
tent ourselves with having pointed out  the  principles by which
the  physician must  be governed.  An  accurate  knowledge of
syphilis, and especially of the facts relating to its transmission,
combined with tact and knowledge of the world, will put him in
a position to give a decision for the best interest of  his patients,
and the community at large, in those  difficult and involved ques-
tions which are so  often  met with in  practice.   For a more
thorough consideration of the points wliich arise in  this connec-
tion, we refer to the brochure of Langlebert,  which  has  recently
appeared.1
   From what has been said  above  in  regard to the  different
means of  contagion, the  rules  which   an   individual  should
observe in order to preserve himself from infection may be infer-
red.  It is not our object to go more  deeply into this matter, to
enumerate  the  rules  proposed by physicians  as   early as the
fifteenth and sixteenth centuries, or to give the numerous lotions
and the like which have been recommended  as preventives,  and
it  is only on account of  its historical interest that we will state
that it was seriously proposed to  introduce syphilization  as a
prophylactic, from its analogy to the inoculation of  the virus of
variola (Auzias Turenne).

                         TREATMENT.
Aphrodisiacus : Full accounts of the treatment with  mercury are given by the vari-
   ous writers of this collection, e.g., by J. Widmann, G.  Torella, Cataneus, de
1 La Syphilis dans ses rapports avec le mariage.  Paris, 1873. 
272
BAUMLER.—SYPHILIS.
     Vigo, and others; while L. Schmaus, U. von Hutten, and N. Poll have discussed
     more particularly the merits of guaiacum.  Delicado's brochures, already quoted
     on page 9, also treat especially of guaiacum.—Mercurial Treatment: J. Hutch-
     inson,  On the Use of Mercury in Syphilis.  Paper read at the  Hunterian
     Society of London, Jan. 8, 1874, Med. Times and Gaz., 1874, Vol. I. p. 79.—
     v. Sigmund, Die Einreibungscur mit grauer Salbe  bei Syphilisformen.  Wien,
     1859.— B. Brandts,  Grundsatze bei Behandl. d. Syph.   Berlin, 1870.— J. E.
     Giintz, Die Einreibungscur b. Syph.  in Verbindung mit Schwefelwassem.  Leip-
     zig,  1872.—Internal Use of Corrosive Sublimate: v.  Sigmund,  Wien.  med.
     Wochensch., 1873, Nos. 15, 18, 19, 31, 35.—Hypodermic Injections of Corrosive
     Sublimate: G. Lewin, Annal. d. Charitekrankenhauses in Berlin, B. XIV., 1868.
     — Uhlemann, Wien. Med. Presse, 1869, No. 13.—Grunfeld, Ibid., Nos. 17,  20,
     24, 28.—v. Sigmund, Wien.  med. Wochenschr., 1869.—Hypodermic Injections
     of Calomel:  Bagazzoni and Appiani, Giorn. ital. delle malatt.  ven.,  etc., Aug.,
     1870, quoted in Arch.  f. Derm. u. Syph., B. III. p.  98.—Ibid.,p. 478.—Iodine:
     Wallace, Lancet, 1836.—& A. Lane, Lancet, 1873, July 26.

    In the treatment of syphilis  the first question which arises is,
 whether the virus can be destroyed at the point of infection, and
 its  absorption  into  the  organism  prevented.   Since we  have
 already stated,  that the primary affection is not the first local
 expression of a general blood-poisoning, but  the action of the
 virus which is  for  a time limited  to the point of infection, the
 answer  to this question  has a special significance.
    A great difficulty, and  one which, at all events, is the  cause
 of  such frequent failures in the attempt to cut syphilis  short in
 the primary  stage,  lies  in the  fact  that  the infection in  many
 cases does  not  manifest itself  at the  point  at which the virus
 entered until after  a  period of  incubation of some weeks.   It is
 therefore not to be wondered at that the observations which have
 been reported in regard to this question are conflicting.

   Hunter,' who looked  upon the primary lesion as a purely local affection, and
therefore  cauterized or excised it, did not omit to call attention to the fact that the
result was uncertain, since there was no positive evidence of the extent to which the
tissues were diseased.  Cazenave,2 who holds the  opposite view as to the nature of
the primary lesion, expresses himself distinctly as discountenancing  attempts of this
character.
L. c, p. 331.
   2L. c, p. 177:  "Le symptome  primitif, quel qu'il soit, est toujours l'expression
locale, plus ou moms tardive, d'un etat general."  P. 182: « a mes yeux elle pent avoir
des consequences funestee.'" 
TREATMENT.
273
   However, such attempts are constantly being made,  and favorable results are
obtained from an abortive treatment of this kind, not  only in cases in which the
local manifestations  are seen almost immediately after infection (v. Sigmund),1  but
also in  those in which the primary lesion had developed in the usual way, and in
which, from the presence of the induration, there could be no doubt as to the syph-
Uitic nature of the  affection.  Humphry,* of  Cambridge, Hiiter,3 v. Lan^enbeck,
and also P. Vogt,4 have published a number of cases in which the results were fav-
orable.  On the other hand, Bumstead has abandoned this treatment, and Berkeley
Hill reports a case in which he cauterized a wound on  the frenulum with fuming
nitric acid about twelve hours after coitus, but still the  cicatrix became indurated,
and was followed in due time by constitutional syphilis.  Upon this he grounds his
conviction of the uselessness of such  abortive methods.   V. Lindwurm6 and others
have tried the same methods repeatedly, but without success.

    Still, however,  the positive  results  that have been attained
give encouragement for fresh  attempts in such cases as are pecu-
liarly suitable for  this mode  of treatment, in those, for instance,
in which  the primary lesion  is on the edge  of the prepuce or on
one or the other of the labia minora, or in which there is a papule
with  sharply defined limits,  and even  the  presence of a slight
amount of lymphatic enlargement in the groin does not neces-
sarily contraindicate the  excision of  the papule.  The radical
removal of the deposit  at the  point of infection  must not  be
allowed, however, to excite too much hope.
    If, soon after infection,  the initial lesion takes the form of  an
ulcer, it should  be cauterized during the first two or three days
with  fuming nitric  acid,  or,  according to  v. Sigmund, with a
solution of sulphate of copper (two  drachms to the fluid ounce),
or with concentrated carbolic acid.    An ulcer of this character is
frequently only a chancroid ;  but if the virus of syphilis has been
inoculated at the same time, there is nevertheless some prospect
of destroying it by converting the chancre into a simple ulcer  by
cauterization.
    If the primary lesion is too  far developed, or if its location
forbids abortive treatment, it  is sufficient, when dealing with sim-
 1 Wiener med. Wochenschrift, 1867, Nos. 43, 44, and 64.
 2 Med. Times and Gazette, 1864, Vol. II., p. 181.
 3 Berliner klin. Wochenschr., 1867, No. 27, p. 287.
 •Ibidem, 1871, No. 38, p. 455.
 6L. c, p. 154.
VOL. TTT  18 
274                 BAUMLER.—SYPHILIS.

pie erosions, or with superficially ulcerated indurations, to keep
them clean by frequent washings,  or by means of  sitz-baths in
the case of females, and to  dress them with moistened charpie,
changed several times  daily for the purpose of promoting cica-
trization, which may occur while the induration is still percepti-
ble or even advancing.   If there is much suppuration, it is advis-
able to use  an astringent  solution of the acetate of lead or
sulphate of copper.  In  treating large  ulcerating indurations,  it
is well to  use lotions containing mercury, such as the  "black
wash," of  the strength  of  eight grains of calomel to the fluid
ounce  of lime-water, or perhaps still  weaker, as five, or even
threel  grains to the fluid ounce.  If corrosive sublimate be used,
it must be in extremely dilute solution, for even  in the propor-
tion of a grain to the fluid ounce, it will not be borne for any
length  of  time by  the  uninjured  mucous membranes.   Salves
cannot be used   to advantage in  the  treatment of  syphilitic
primary lesions.   .
   Phagedena is best  treated after the method  of Hutchinson
and Zeissl, by permanent baths in connection with irrigations, for
which  a solution  of the permanganate of potash may be used.
In a few days the  dead  tissues  become  separated and the  sore
begins to granulate.  The cauterizations with fuming nitric acid,
which  were formerly employed, are seldom followed  by a limi-
tation  of the process, and frequently the destructive action  pro-
ceeds with all the greater  rapidity, so that, partly by the mor-
bid  process, and  partly by the cauterization, the  whole organ
may be destroyed.  The administration of opium, which has
been so much praised, can  only allay the general discomfort  of
the patient, who is usually sleepless and much reduced; but  in
this respect it is of great service, and should not be omitted.
    The treatment  of primary lesions, having the form of chan-
crous  ulcers, when cauterization with  fuming nitric acid is not
feasible, consists  principally in keeping them clean and dressing
them with  a moderately astringent solution, a weak sulphate  of
copper solution being particularly serviceable.  Recently iodo-
form 2  has  been much praised as a remedy, which, if dusted upon
1 Equivalent to the Black 3Iercurial Lotion of the British Pharmacopoeia.
2 H. S. Purdon, Dublin Journal of Med. Science, 1873, p. 51. 
TREATMENT.
275
 chancres, will deprive them of  their  specific  character, and con-
 vert  them in a few days into  granulating surfaces.   As  it also
 possesses slight  anaesthetic properties, it may be used hkewise
 in the treatment  of painful phagedaenic ulcers.
     Complications of the primary lesion, such as phymosis, para-
 phymosis, and suppurating buboes, must be treated according to
 surgical principles.   When there  are ulcerating indurations in
 the sulcus glandis, and phymosis occurs, division of the prepuce
 is often indicated in order that the surface  of the ulcers may be
 kept clean and remedies applied directly to them.
     Ought the primary lesion to be  treated by the internal  use of
 anti-syphilitic medicines ?   This question presupposes an answer
 to the other, Are there remedies wliich act as direct antagonists
 to the virus of  syphilis ?   In accordance with the experience of
. the last three centuries in  the treatment of syphilis, the answer
 to  this  question  must  be,  that  mercury  appears to  be such a
 remedy.

    Mercury was in use as early as the end of the fifteenth century, and  apparently
 Widmann (1497) was the first to employ it.   It was then used by Italian phy-
 sicians, for example by Petrus  Pinctor (1500).  The favorable results of its action
 upon many cutaneous  affections, which were known to the Arabian physicians, pro-
 bably led  to its first  use, originally in  the form of salves and fumigations, in  the
 treatment of syphilis.
    The esteem in which this drug has been held by physicians  of different
 times,  has  been very  varied; while at one  time it has been praised  to the skies,
 at another it has been  reviled as the  most deadly poison, and been almost accused
 of being the source of  the symptoms of syphilis. The strife between  the mercuri-
 alists and the anti-mercurialists has been, especially at times, a very active one;
 and even our own times have seen some revival of the old conflict;  and  while a
 recent French author l  would put mercury in  the museum of therapeutic relics, J.
 Hermann 2 demands that government shall by law forbid its  use.  For a detailed
 account of the vicissitudes which the use of mercury in the treatment of  syphilis
 has undergone, we refer the reader to Kussmaul's work, and to the historical studies
 of Proksch, which have recently appeared, and I will only state that the opposition
 to the use of this drug, which  has sprung up from time to time, had its origin,
 especially in earlier times, in its abuse.  Originally employed  by the  quacks, into

   1 A. Despres, Traite theorique et pratique de la Syphilis ou infection purulente syphil.
 Paris, 1873.
   2 J.  Hermann, Ueber die Wirkungen des Quecksilbers auf den menschl.  Organ-
 ismus.  Teschen, 1873. 
276                   BAUMLER.—SYPHILIS.
whose hands, as shown by passages in the various authors collected by Luisinus, as
well as by statements in old chronicles, the treatment of this disease has always been
willingly entrusted by the public, the remedy was soon adopted by physicians, and
it is doubtful whether the empirical treatment of  the former or the modes sanc-
tioned by the faculty, which were employed  by the latter, did the greater amount
of injury to the patient.  When we read the descriptions of these modes of treat-
ment, even that of the inunction cure introduced in the present century by Louv-
rier-Rust, we are reminded of the torture chambers of the Middle Ages, and can
understand the truth of the statement of D.  Abercroinby, that many thought death
itself less terrible than the tortures of a treatment by salivation.   Salivation, up to
the secretion of several pounds of saliva daily, was, and remained, the object of all
mercurial treatment, in spite of the protestations of Astruc and others, who did not
entirely condemn the use of mercury.  It is only in modern times that physicians
have abandoned this fatal error; and v. Sigmund rendered a great service in show-
ing that salivation, so far from being necessary for the favorable effect of mercury
on syphilis,  was really injurious.
    Freed from this and other abuses, mercury, in spite of the vio-
lent denunciations of some modern anti-mercurialists, has  again
risen considerably in the estimation of the  physician of  recent
decades ; for no unprejudiced observer  can deny that its action
upon  syphilis  is  quite  evident.  This  is  nowhere better shown
than in its action upon the cutaneous manifestations of  syphilis.
It  is indeed  true that exanthemata, of light  grade especially,
may undergo  spontaneous cure;  but  when cases treated with
mercury are contrasted with such as have  been treated upon the
expectant plan, there is no comparison between the course of the
symptoms in the two instances*  Under mercurial treatment the
manifestations vanish completely in the course of a few weeks,
while under the  expectant  treatment they may last for months
with unabated intensity,  That mercury produces these results,
not alone by changes in  the general nutrition, but that  it has
also a direct local  action  upon the diseased parts, has been
proved by the results which followed the  hypodermic injections
of corrosive sublimate made by Ch. Hunter, Hebra, Kobner, and
others.   In Kobner's1 case, a confluent papular syphilide about
the shoulder rapidly became paler in color after the hypodermic
injection of corrosive sublimate into its centre,  while an equally
large  patch  of the eruption  situated  in the  lumbar   region
1 Archiv f. Derm. u. Syph., B. I. p. 628. 
TREATMENT.
277
remained unaltered.  Monti1 noticed that flat condylomata in
children rapidly disappeared when such injections were made
into them.  An analogous,  but slower,  action is  seen when a
plaster containing mercury is applied to  syphilitic  affections of
the skin, or when a mercurial salve, such as the  oleate of mer-
cury, is frequently rubbed into the skin.  If mercury is given
internally, or  rubbed into the  unbroken skin, its  action upon
local affections is less rapid, but no less evident.
   This action is also manifested when a general mercurial treat-
ment is commenced while the primary induration is  still present.
If it is of  small  size the papule will be speedily absorbed; if an
extensive and well-marked induration is  present, the  action of
the remedy is  manifested more  slowly.  This action  is shown not
only upon the primary, but also upon  the constitutional affec-
tion,  by the postponement of its  outbreak, as has been estab-
lished by  numerous observations.   Indeed,  according to the
testimony of Ricord,2 and more recently of Hutchinson, it is pos-
sible, by a well-timed mercurial treatment, to prevent constitu-
tional infection,  that is, to limit the manifestations of syphilis to
the primary lesion, and to cure the disease in its  primary stage.
These authorities express themselves in perfect accord as to this
point.  This declaration,  coming from Hutchinson, has all the
more significance, since he denied, some years ago, in his article in
Reynolds's System of Medicine, that the  outbreak  of secondary
symptoms could  be  prevented by mercurial treatment,  and
stated that, if they did not  occur,  their  absence could not be
attributed to the treatment, although it might cause them to be
of a  less severe character.  Hutchinson has in the meanwhile
become convinced of the contrary, especially by the  observation
of cases of vaccinal syphilis ; and when such a prudent and care-
ful observer as  he is finds reason to modify his former view,
especially in a matter of such importance, it behooves his com-
peers to  study  the  question  with great earnestness.   In the
above quoted interesting discourse before the Hunterian Society,
  1 Jahrbuch f. Kinderheilkunde, 1869, 4 H.
  2 Transact, of the Surg. Section of the Brit. Med. Association, 1872.  Brit. Med.
Journal, 1872, Vol. II. p. 187. 
278
BAUMLER. —SYPHILIS.
he expressly calls mercury an antidote to the syphilitic virus,
which is destroyed by it, prevented from  proliferating  itself in
the blood, and restrained in its effects on  the tissues, in case it
has already got so far in its action.
   Since we recognize syphilis only by its  effects on the tissues,
the influence of mercury upon it is  to  be known  only by the
alterations which take place after its administration .in the mani-
festations of the virus of syphilis;  the intimate  nature of its
action  is still veiled in  obscurity.  The action of  mercury on
syphilis was formerly thus defined :  the local affections due to
syphilis disappeared more rapidly under its- use, but the syphihs
itself was only rendered latent, and the poison circulating with
the blood was left undisturbed.  But  if it is really possible, by a
timely  and systematic  administration of mercury, to prevent the
occurrence of constitutional syphilis, this view is no longer  ten-
able.  The action  of mercury upon the syphilitic virus, is  not,
however, a simple chemical  neutralization, for, were that the
case, the largest possible quantity of the drug that  could be
absorbed in the shortest possible time would act the most  cer-
tainly ; whereas, we find that the opposite is the case, and  that
when, from large doses of mercury, salivation occurs, new locali-
zations of the disease take place.   The more nearly we approach
to an utter avoidance of the physiological  effects of mercury on
the system, provided  it exercises  a  sufficient influence on the
manifestations of  syphilis,  the surer we are  of obtaining bene-
ficial results.  Among the phases in the  history of the treatment
of syphilis,  when mercurial treatment was thrust into the back-
ground, there are deserving of mention the introduction of guai-
acum,  and  other drugs  of  vegetable origin, which were used in
compounding the various infusions made from woods, the purely
expectant mode of treatment,  the  so-called "simple treatment,"
introduced at the time of the Portuguese war in the early part of
this century, and finally the administration of iodine, the intro-
duction of which  among the means used in the treatment of
syphilis was principally due to Wallace.
   Guaiac wood, which was first employed in Spain, in 1508, soon came into repute
from  the special virtues claimed for it in  the treatises of Delicado, Schmaus, and
U. v. Hutten.   Among the Spaniards it was customary to make a  trip to the West 
TREATMENT.
279
Indies  for the sake  of  taking  the decoctions prepared by the natives themselves.
E. Bassereau states that the custom continued in force during the whole of the six-
teenth  century.   In Europe, in the meanwhile, confidence in guaiac had somewhat
diminished,  and other vegetable  substances, as the "China root"  (root of Smilax
China), sarsaparilla root, and sassafras wood took its place or were used with it,
without, however, being able to rival its reputation.   Gradually these remedies were
again thrust into the background by mercury, but have not even yet wholly lost
their repute, for  quite recently various voices have been raised in favor of the use
of  sarsaparilla,  more especially in the  treatment  of tertiary syphilis.   Exact
researches in regard to the virtues of this drug would be of great value.  The mode
of action of  this  remedy consists in causing a more active tissue-metamorphosis  by
inducing sweating, purging, and  increased diuresis, and it  must not  be forgotten
that the loss of force to the organism which may be brought about by an immoder-
ate excitation of these  excretions, in conjunction with a very limited diet, may
cause a disappearance of the symptoms of  syphilis in the same way  as, but  with less
rapidity than, by an  attack of  cholera, for  instance.  But  that this result, in the
acute period of syphilis, is  attended by any permanent advantage, appears to me, in
spite of the warm praise which v. Barensprung  gives this method  of  treatment, to
lack proof.
    Upon a  similar theory, namely, a stimulation of metamorphosis of tissue, was
based  the so-called "simple treatment" of the English physicians in the beginning
of  this century.   Some  of  these physicians,  and more particularly J. Thomson and
Thomas Rose, were induced by the observation of Ferguson, who  saw this disease
pursue a mild course among the  Portuguese without the use of mercury,  to adopt
this mode of treatment.   Their system consisted chiefly in strict prohibition of the
use of  mercury, rest in bed, very restricted diet, and the administration of antisyph-
ilitic remedies, more especially of laxatives.  Since, up to this time, all affections of
the genitals, of venereal origin, had been treated with mercury, it was very striking
to see  that, without the use of this remedy,  a large majority of their patients did
not give any evidence of constitutional syphilis, and particularly that those severe
symptoms which had previously been common, and for which the injudicious use of
mercury had been partly to blame, were not met with.  This method speedily found
advocates in other countries of Europe, and in North America.  These observations
of the  English physicians found a readier  acceptance in France, owing to the prev-
alence  of the doctrines of  the "physiological school" l of Broussais, in accordance
with which the specific  character of syphilis was denied, and the disease  simply
classed among inflammatory affections.   In Germany, Fricke and Kluge advocated
the simple treatment. It was not long, however, before a reaction set  in.  In Eng-
land especially,  a too hasty judgment  had  been pronounced, and  large experience
induced even Tliomson and Rose, the two principal  promoters of this  mode of
treatment, to return to the employment of mercurials.2
1 Compare Auspitz, 1. c., p. 58.
8 Berkeley Hill, 1. c, p. 274. 
280
BAUMLER. —SYPHILIS.
   The experience of Wallace, of Dublin, with the iodide of potassium led to the
belief that in this drug would be found a substitute for mercury, which so often
worked mischief, and it was accordingly administered in all forms and stages of
syphilis.  The conviction was soon reached, however, that there were certain syphi-
litic symptoms which yielded to this remedy with marvellous rapidity, whilst others
remained entirely unaffected by it.   Physicians of the ripest experience are unani-
mous in the opinion that the preparations of iodine manifest their greatest influence
on the symptoms of the tertiary period; on gummy affections  in the most varied
localities;  on tubercular cutaneous eruptions and serpiginous ulcers, in diseases of
the bones and  periosteum, and  in symptoms of disorder of the nervous system;
while, on the contrary, affections of  the skin belonging to the secondary stage,
especially macular and papular exanthemata, are not at all affected  by them.  I
have in numerous cases most thoroughly convinced myself of the truth of this, and
quite recently Zeissl1 has  published  accounts of some cases in which,  after the
administration of iodide of potassium  for a period of several weeks, no change was
noticed in papular eruptions.   Zeissl, on the other  hand, calls attention to the fact
that  iodine, in  doses of two minims of the compound tincture,2 properly diluted,
twice daily, brings about a more rapid disappearance of affections of the mucous
membranes  than mercury does.  Moreover, according to him, iodine in this stage
exerts a weakening action  on  syphilis, so that after its administration a few mer-
curial inunctions suffice to bring about a permanent disappearance of the cutaneous
rash.  Upon primary affections the influence of iodine is scarcely perceptible.
   The efficacy of iodine in tertiary syphilis is one of the most valuable weapons of
the anti-mercurialists, for  they conclude that, since the  administration of iodine
causes the excretion of mercury, if it be present in the organism, its favorable action
in tertiary syphilis depends upon the liberation and excretion of the mercury which
previous treatment had introduced into the body.

    After this digression we now return  to the  discussion of  the
question  stated  above,  as to the  use of anti-syphilitic remedies
in the treatment of the primary lesion.
    Since, according to  our view of the nature of  the  primary
lesion, it is desirable to render its existence  as short as  possible
by restraining it in its development, and since  we possess in mer-
cury a remedy which has an indisputable influence in this  direc-
tion, we are  of the opinion that as soon as it is established that a
local lesion is  syphilitic,  the use of  mercury should  be com-
menced.   In a majority  of cases, indeed, it is not  likely to be
administered until the glands of the neighborhood show the  first
1 Wiener med. Wochenschrift, 1873, No. 46.
2  "Tinct. of iodine," British Ph. 
TREATMENT.
281
symptoms of indolent enlargement.   If induration is developed
in a suspicious erosion, particularly in one on the female genitals,
or in an ulcer which began as a chancroid, and if the lymphatic
glands of the part show a slowly increasing enlargement, the
administration of mercury must not be delayed.  Usually three,
four, or even more weeks, reckoning from the date of infection,
will have elapsed ;  for this treatment should not be entered upon
until the suspicion that we are dealing with syphilis has grown
almost to a certainty.   In some cases we have to wait for the out-
break of constitutional symptoms.
   So soon as the employment of mercurial treatment has  been
decided to be necessary, it must be carried out  systematically,
whether we  are  dealing  only with a primary lesion or whether
secondary symptoms have already appeared.
   The patient must be informed of the importance of regularity
in the treatment,  and especially must he  be made acquainted
with the fact that,  even in the mildest case, the treatment must
be prolonged over several months.
   If the syphilis is destroyed in the primary lesion, a treatment
of three or  four months' duration  may suffice ; if this is not
attained, and secondary  symptoms appear, then the  treatment
will have to be prolonged to six or eight months,  for it  should
not be interrupted until all traces of the  symptoms  have van-
ished.  Otherwise  there  is danger that the virus may be prolif-
erated anew in some remaining local deposit, and again infect
the fluids.  This danger  from  a too  early cessation or interrup-
tion  of  the  treatment  cannot be too strongly stated, and care
must therefore be taken at the start to so  arrange the administra-
tion of our remedies that it may not be  interfered with by any
unfavorable complication, especially salivation.
   If due care is exercised in this respect, there need be no dread
that a mercurial course begun in the primary stage will render
the organism either so  intolerant of the remedy or so incapable
of experiencing its  good effects that we shall be deprived of our
best weapon when  secondary symptoms appear.  The  treatment
must be adapted to each  individual case, and  no definite asser-
tion can be made, either as to the dose that is  to be given or as
to the length of time over wliich the treatment is to  be continued. 
282
BAUMLER.—SYPHILIS.
One principle must be kept in view, namely, that  the treatment
must not only be continued until all manifestations have disap-
peared, but also for some time afterward, and the patient must,
after the last symptom has gone, still keep himself for  several
months under constant medical supervision.
   The influence of the  remedy on the manifestations  of the
disease, and the tolerance of the patient's system, furnish the
measure of the dose ;  and nothing beyond  the slightest grade of
mercurial  stomatitis should  be  allowed to arise.   A mild  mer-
curial course of this kind will indeed have to be continued  for a
long  time, but it can be done with  safety.   The employment of
larger doses causes a more rapid  disappearance of the manifesta-
tions, producing an apparent cure in three or four weeks, but it
does not prevent relapses.  I have seen this often enough,  even
in private patients,  who take good care of  themselves ; and how
often new outbreaks occur in hospital practice cannot be accu-
rately determined, since many patients do not return for treat-
ment except when the manifestations prove annoying to them.
In spite of this, the number of those who return again and again
with fresh manifestations  is not small.

   Fournier,  who  thinks that a long continuance of treatment  is imperatively
necessary, advises that it should be discontinued from time to time, in  order to
allow the system,  which has become accustomed to  the remedy, to regain its
susceptibility.  He continues the treatment for three months, then suspends it for
one month, and then resumes once more the administration of mercury, even when
no new symptoms have appeared in the interval.  After a further treatment of from
six to eight weeks, he pauses again for three months, and so on, so that, including
the intervals, the patient generally remains about two years under treatment, during
about ten months of which mercury is given, while the pauses in its administration
occupy the remaining fourteen months.

   I am unable to decide from experience whether this intermit-
tent  treatment possesses all  the  advantages which he claims for
it; but this much I can say,  that sometimes in obstinate cases,
especially in such as are not brought under treatment until  they
have  reached  an  advanced period,  mercury,  which even  in
increased doses seemed to have  lost its power of affecting the
manifestations of the disease, displays quite a different action
after the patient  has been  compelled by his business  to travel for 
TREATMENT.
283
a week or two by land or sea, and to give  up all treatment
during the time, resuming it subsequently.  In similar cases the
same result is sometimes attained by substituting another prepa-
ration of mercury.  This leads to a much more important point
—that of the hygienic management of the patient  during a
mercurial treatment.  Formerly patients who were undergoing
a mercurial course were kept in highly heated  and unventilated
rooms, as few changes of the bed and body linen as possible were
allowed  them,  although perspiration was  excited and main-
tained, and  their  diet was very much restricted.  Fortunately
these  things  belong to the past.  V. Sigmund was the first to
call attention to the great importance of proper hygienic condi-
tions  during a course  of  mercurial treatment.  One  question
which  arises at the outset is  this:  May a syphilitic patient
attend to business during the treatment; can he leave the house,
or must he be confined to his bed, or, at least,  to his room ?  In
urging the necessity of a treatment of long duration, we really
answer this  question, and it is scarcely necessary to state  that
unless some  special symptom, such  as fever, rheumatoid symp-
toms,  iritis, or laryngitis, calls for a rapid induction of  the mer-
curial influence, the patient may be allowed to go about in good
weather.   During  the eruptive stage, unless the  symptoms are
of light  grade  indeed,  and in the colder  portions of the year,
under all circumstances the patients had better  be confined to
the house, in some cases even  to their beds,  for a few weeks.
For the  rest, throughout the entire duration  of the  treatment,
patients  should,  as far as  possible, maintain both bodily  and
mental quiet.  During the entire time of treatment they should
go to bed at an  early hour, should favor gentle perspiration
during sleep, should wear flannel next the skin, and avoid great
and sudden ehanges of temperature.  It is of  great importance
that the air which they breathe should be fresh and pure.
   If  a patient is  to be confined to his room, it is well  that two
rooms should be at his disposal,  and if the weather is favorable,
he should, if possible, take regular exercise out of doors.   The
diet should be simple but nutritious.  Beer and wine should be
allowed in moderation  at his meals, but  all spirituous liquors
and any excess in alcoholic beverages should be most scrupu- 
284
BAUMLER.—SYPHILIS.
lously avoided.  Milk should be freely used when patients show
a want of appetite for other nourishment, as is frequently  the
case among women,  who  often  become quite anaemic  when
suffering with  syphilis.  I have often had opportunities of con-
vincing myself of the favorable influence of a  plentiful  use of
milk upon the course of this disease.
   While mercury is being given  internally, great  care must be
exercised in the choice of food, since catarrh of the stomach or in-
testines may readily be caused by any indiscretion.  Articles con-
taining acids,  such as fruit, salad, etc., must be avoided, and if
calomel is being taken, highly salted dishes must not be allowed.
   During the administration of any mercurial preparations, the
utmost care must be devoted to the condition of the mouth, to
avoid, if  possible,  the occurrence of salivation.  Morning and
evening,  after  every meal, and once or twice during the night,
the mouth should be rinsed out with water at a suitable temper-
ature, and  twice a day  the teeth should be carefully cleansed
with a brush.  To  the  water used for  cleansing the mouth, a
small amount of some aromatic tincture, as tincture of myrrh, of
Cologne water, or of some astringent preparation, may be added.
Among the astringents  most suitable for this  purpose may be
enumerated tincture of  galls, tincture of rhatany,  alum,  or the
acetate of  alumina, as  advised by Brandis.   It must not  be
forgotten that the long-continued use of the last two prepara-
tions results in injury to the teeth, and on this  account Brandis
advises that, after using a mouth-wash containing the acetate of
alumina, the patient should brush out the mouth with chalk and
camphor.  Chlorate of potassa (twenty grains to the fluid ounce)
may be used as a mouth-wash, and  its internal  use, in doses of
five grains  several  times a day, in water, may be practised from
the beginning of the  treatment, to ward off the occurrence of
mercurial stomatitis.
   As a  prophylactic measure against stomatitis,  and particu-
larly  when there are affections  of the  mucous membrane of
the mouth present, the patient must give up  smoking.  It is
quite common to see severe syphilitic affections  of the mouth in
those who are  great smokers, and these affections are very apt to
recur in such patients. 
TREATMENT.
285
    Warm baths are a necessary hygienic measure when mercury
 is used externally, but even when the medication is of an internal
 character, regular warm baths, by promoting the activity of the
 skin, have  a favorable  influence.   If  the patient is tolerably
 strong, Turkish  baths  may be substituted  for ordinary warm
 baths, for they not  only promote  the general metamorphosis of
 the  tissues  by the active fluxion which they cause, and by their
 more permanent  influence on the skin,  but they also hasten the
 disappearance of syphilitic eruptions.
   Vapor baths  or douches, such  as are commonly employed in
 Aix-la-Chapelle,  have also a very favorable influence, especially
 when  the inunction  treatment is  used, since they give rise to
 a  more active cutaneous circulation, and thus render the  skin
 better fitted for the absorption  of the mercury. If it is desirable
 to produce a still stronger influence upon the tissue changes, the
 patient may be allowed to perspire for some  hours after leaving
 the vapor bath.
   The principal methods in which mercury  is administered are
 the following:
   Its outward use  by inunctions with blue  ointment.  This is
 the  oldest  form of the mercurial treatment of  syphilis;  and
 although it  has at various times fallen into disrepute on account
 of the improper way in which  it was performed,  it has of late,
 thanks to the judicious  rules enunciated by v. Sigmund, again
 acquired  considerable favor.    For,  although this method  is
 annoying  to the  patient, and  also  uncleanly, it possesses the
 great advantage  that it does not directly affect the digestive
 organs, and yet is very efficacious.  It is possible that the digestive
 tract may be indirectly affected by this treatment, and according
 to Brandis a mercurial intestinal catarrh may arise, and compel
a temporary cessation of the inunctions.  With reference to the
way in which mercury is taken up into  the fluids, J. Neumann'
has shown that the  metal, in the form of little globules, enters
the follicles, where it is apparently slowly converted into corro-
sive sublimate and absorbed.
   In carrying out the inunction treatment, different parts of the
1 Lehrb. der Hautkrankh., 3 Aufl.  Wien, 1873, p. 455. 
286
BAUMLER.—SYPHILIS.
 skin must be chosen for the application of the frictions on differ-
 ent  days, so  that no one surface  may be covered with the
 ointment for too long a time.  If the skin is irritable, or if the
 frictions are made in localities where there is a heavy growth of
 hah*,  an eczema may be  readily caused, which  would compel a
 cessation of the treatment.  For this reason, hairy portions of
 the body are to be avoided in the performance of these inunc-
 tions.
   It is best to observe, in accordance with  the rule of v. Sig-
 mund, a certain order in  making the successive inunctions.   On
 the first day  they should be performed on the legs ;   on the
 second day on the thighs ;  on the third day on the abdomen and
 the sides of the chest; on the fourth day on the back, and on
 the fifth day on the arms ;  and at the expiration of this time, or
 after  ten days, if  the inunction is performed on but one  side
 of the body daily,  this regular course may be begun again.
   The  inunctions must  be done methodically, with moderate
 pressure of the palm  of the hand; and, if the patients  are
 too weak, they must be  performed  by an attendant.   The
 frictions should be made for ten minutes continuously at each
 place, and fifteen or thirty  grains of the mercurial ointment
 should be used on  one or both of the places chosen for the day.
   From the experience of the physicians of Aix-la-Chapelle, the
 nurses who perform these inunctions upon several  patients
 daily, run no  risk of suffering themselves from mercurialism,
 although they  use the naked  hand simply smeared with soap,
 before beginning the frictions.  The use of a tightly fitting glove
 of fine leather would prevent  the  disadvantage of wasting  the
 ointment.
   Before the daily inunction is made, the patient should take
a warm  bath;  or, if his circumstances do  not allow of this,
 at least  the seat of the  inunction of the day previous  can be
 washed with soap and water.
   If  the treatment by  inunction is  carried out with  a  due
 observance of all the precautionary rules which have been given,
it  can be kept up for months without the  appearance  of  any
 symptoms  of  mercurialism.   But different  patients are very
differently affected by it.   While many show an extraordinary 
TREATMENT.                      287
tolerance  of  mercurial  inunctions, others, after a short time,
manifest symptoms of slight stomatitis.   Apart from other cir-
cumstances, the character of the  skin is of great influence in
this respect.  I once had an opportunity of seeing this quite dis-
tinctly  exemplified  in  entirely  parallel cases in two young
persons, one  of  whom  was fat and had a white, tough skin,
while that of the other, who was not so well provided with fat.
was softer and more florid.   The treatment was exactly the same
in both cases, but its influence upon the existing induration was
much  more quickly seen in the  case  of  the  latter person,
manifestly because his  skin was  better qualified to absorb the
mercury which was rubbed upon it.
   The skin of many persons is very sensitive to the influence of
mercury, and it requires but a small quantity of the ointment to
occasion eczematous or extensive erythematous eruptions  (see
page 136).  It is not always necessary, under these conditions, to
put a  stop to  the inunctions, a temporary intermission being
sometimes  all that  is  needed; and  when  they  are again re-
sumed with due precaution, there are no more evidences of cuta-
neous irritation.
   If stomatitis occurs, the  inunctions must be  discontinued,
and, while continuing the use of the chlorate of potassa and the
mouth-wash, the  gums  should  be  brushed  with a stronger
astringent solution, or touched with nitrate of  silver, care being
taken to avoid the teeth, and to wash out the mouth afterwards
with salt water.
   This method of treatment is to be preferred above all others
in all cases of syphilis in which the state of the digestive tract
forbids the internal  administration of mercury, and also in all
cases in which it is desirable to obtain the action of mercury as
speedily as possible, as when destruction of important organs,
such as the eye, the brain, or the larynx, is threatened by the
disease.  It is contraindicated in the cases of those who have
very sensitive skins, with a  tendency to  eczema  or acne, who
have  a thick growth of hair upon their bodies, or who are
suffering from a copious eruption, with exudation into the hair-
follicles, or a tendency to the formation of pustules.
   Another mode in which mercury is administered through the 
288
BAUMLER. —SYPHILIS.
skin consists in fumigation  with various preparations of the
metal.  This method,  which  dates from the time when syphilis
was epidemic,  has quite  recently  found a warm  advocate  in
Henry Lee.   Cataneus (1504)x employed  the fumes of cinnabar
in the treatment of syphilis, and the same treatment was used by
various physicians of  subsequent  centuries,  among the  more
recent of whom may be named de Blegny  (1683)  and Pearson
(1786).   In  England,  Henry Lee  and  Langston  Parker  have
recently done much in the development of this method of treat-
ment.   According to Lee, calomel is the most suitable prepara-
tion of  mercury for this purpose; he sublimes it by means of a
simple apparatus, and the fumes which arise are  employed for a
partial or general fumigation  of the patient.
   The apparatus devised by Lee consists of an enclosed spirit-lamp, above which
is a plate having a central depression to hold the calomel, and  surrounded by a
broad, deep groove filled with water,  so that the fumes of the calomel are mingled
with steam.  To fumigate the whole person, the patient is stripped, and  placed
upon a stool over the lamp, and  enveloped  in a  flannel  mantle,  so as to be
thoroughly exposed to the vapors which rise.   Lee advises that during each bath
the patient should open the mantle about the neck two or three times, and thus
inhale some of the vapor.  After the bath the surface of the skin will be found to
be covered with a fine white powder of calomel, which is not to be removed.  It
is, therefore, best to administer the fumigation in the evening, so that the  patient
can at once go to bed, either with or without the flannel mantle, and thus favor  the
continuance of the sweating which is  already established.  Each sitting should be
of fifteen or twenty minutes' duration, and the amount of calomel used should not
be more than fifteen grains—on an average about eight.   It is well to so regulate
the amount of alcohol in  the lamp, that the flame will  go out of itself when  the
water and calomel have been exhausted.
    Lee recommends  this treatment for all  stages of syphilis, but
thinks that it is especially advantageous in  ulcerative affections
of the tertiary  stage, when the general condition does not  allow
of the  internal  administration  of mercury,  and the  character
of the skin forbids  inunctions.   In cases of early syphilis, Lee
continues  the  fumigations for  two  or three months; indeed,
until all  symptoms  have  disappeared.  He looks upon a very
slight affection of the gums as an evidence of sufficient mercurial
action,  and thinks that it should not be pushed further.
1 Aphrod., I. p. 168. 
TREATMENT.
289
   The only preparation that is suitable for external administra-
tion in solution in baths is corrosive sublimate.   This method of
administration is very uncertain in its effects ; for, especially in
the case of  adults, if there are no erosions or ulcerations, it is
very problematical if the  sublimate finds its way into the blood
by absorption.1  For small children, on the other hand, the care-
ful use of baths containing sublimate is often of great advantage,
especially when a pustular eruption is  present.   For an adult
two  and a half drachms of sublimate should be dissolved in each
bath, in which the patient should  pass an hour or an hour and a
half; for a child's bath, of a half hour s duration, from thirty to
sixty grains should be used, according to the age.   Zeissl adds
the sublimate to the bath in combination with sal ammoniac, pre-
paring the  solution with about two and a half drachms of corro-
sive sublimate, eighty grains of the muriate of ammonia, and
three fluid ounces of distilled water.
   For internal use, a great number  of mercurial preparations
have been tried, and more or less highly  prized.   Apart from the
undeniable  idiosyncrasies against certain preparations  of  mer-
cury which patients possess, the  rule  should be, to make use of
that one which can be continued for the greatest length of time
without causing derangement of  the  digestive organs.   This is
more apt to be the case with such preparations as are only ren-
dered  capable of absorption in the stomach and intestines, than
with such  as are given in a form capable of immediate absorp-
tion.  Among the former,  metallic mercury, as contained in blue
pill, in  the pills  of  Sedillot,  and in mercury  with  chalk,  is
deserving of the first mention.  Blue mass will generally be borne
in a dose of five grains daily, and is  therefore a very  suitable
preparation for such cases as require a long-continued course of
mercury. The same is true of mercury with chalk, which may be
given  in doses  of from three to five grains, either alone or com-
bined with a  small quantity of opium or Dover's powder.  This
preparation, in doses of from one-sixth  to one-third of a grain
several times  during the  day,  is  especially  serviceable  in  the
   1 Compare an instructive case in Cazenave, 1. c, p. 615, in which thirty-three baths,
a single bath finally containing- an ounce of sublimate, were administered with no mani-
fest effect.
          VOL. III.—19 
290
BAUMLER.—SYPHILIS.
treatment  of hereditary syphilis.   Sedillot's pills  consist of
mercurial ointment, soap, and  marshmallow  powder, and are
given in the same way as blue pill.  Lebert' and Zeissl2 have also
given mercurial ointment in the form of suppositories introduced
into the rectum, each suppository containing from three-quarters
of a grain to five grains of the ointment, with cacao butter.
   The  oxides of mercury,  of which the red was the first pre-
paration of mercury which was administered  internally, are no
longer used in this  way.
   Of the  two chlorides, the bichloride, or corrosive sublimate,
has,  since the time of van Swieten,  been highly prized in the
treatment  of syphilis.  This preparation is at all events the one
best fitted for absorption from the digestive tract without previ-
ously undergoing  change, for  all  other  preparations have to
become  converted into the  bichloride before they are capable of
absorption.   Quite  frequently, however, it gives  rise to distur-
bance of the stomach.   For this reason  corrosive sublimate
should not be given upon  an  empty stomach, but after meals,
and, as  it  is probable that it is converted into  an albuminate
before absorption, v. Barensprung has proposed  to administer it
in this form,  mixing it  with albumen.   This method has not
been widely adopted, since a portion of the bichloride is removed
from the mixture by the process of filtration to  which it has to
be subjected.
   Corrosive sublimate is best given in  pill form or in alcoholic
solution, the dose being from a twentieth to a tenth of a grain,
and the quantity given daily from a sixth to a quarter of a grain.
The pills can be made by using clay, or, as advised by Zeissl,
starch, for the excipient.  The  famous liquor of van Swieten,
which is still largely used in France, was made by dissolving a
grain  and  a half of corrosive sublimate in three fluid ounces of
corn whiskey, which can be replaced by any other strong spirit,
such as rum or brandy.   The dose of this solution is from one to
two fluid ott&fies.
   Two  doses of corrosive  sublimate daily are  sufficient, and
1 Berl. klin. Wochenschrift, 1870, No. 14.
2 L. c, p. 359.

°[  tl 0. 
                          TREATMENT.                    291
these may be of equal amount, or the larger dose may be given
after  the evening meal, or in a cup of some mucilaginous drink.
If small doses are employed,  and the digestive organs are in a
healthy condition, the use of  this remedy can be kept up for a
protracted period.  I saw in one case eleven grains administered
during two  months, without the occurrence of any unpleasant
symptoms.  If the remedy ceases to produce perceptible results,
the dose  should be  increased,  great care, however, being ob-
served.
   Julius  Miiller,1 founding his  idea upon the fact observed by
Lassaigne,2  that chloride  of sodium  in a solution of corrosive
sublimate  prevented the precipitation of  albumen by the subli-
mate, recommends  a mixture containing the double chloride of
mercury and sodium, with an excess  of chloride of sodium, as a
more suitable  preparation fo- internal use than the simple corro-
sive chloride.
   In recent years,  principally on account  of  the warm  recom-
mendation of  G. Lewin, the hypodermic use of this preparation
has been attempted by some observers, by Hebra indeed as early
as 1860. The distinguishing features of this method are the pro-
duction of a speedy action upon syphilitic  symptoms, which  is
frequently first manifested locally (see p. 276); the accuracy with
which the dose can  be measured; and, its cleanliness compared
with the treatment by inunction.  But the severe suffering which
it occasions is scarcely counterbalanced by the  short duration of
the treatment,  which is said to require on an  average only four
weeks; and moreover, this rapid disappearance of the  external
symptoms of syphilis is by no means equivalent to a cure of the
disease itself;  and  according  to  Zeissl there is more apt to be
an early recurrence  of the manifestations when this treatment is
employed  than  when others are chosen.   Some observers fre-
quently met with suppuration at the points at wliich the injec-
tions  had been  made;  but this complication,  except among
patients having  a predisposition to it, can usually be avoided
by observing due precaution.
'Berl. klin. Wochenschrift, 1871, No. 49.
2i?. Maly, in Zeissl, 1. c, p. 396. 
292
BAUMLER.—SYPHILIS.
   The  solution for hypodermic use should be made by dissolv-
ing a grain of corrosive sublimate in one hundred minims of gly-
cerine and water, mixed in equal proportion; and of this from
four to seven minims, containing respectively about the one
twenty-fifth and one-thirteenth of a grain of the mercurial salt,
should  be injected hypodermically once  daily.   The  solution
recommended by Miiller has also  been advised for hypodermic
use.  Prumers1 advises the  hypodermic  use of  " ethyl-subli-
mate " in the quantity  of one-thirteenth of a grain to each injec-
tion, and Staub,2 that of the chloro-albuminate of mercury and
soda.  The  most appropriate places for making these injections
are the  back and the  sides of the thorax.
   Calomel also has recently been  administered by hypodermic
injection.  When  suspended  in  glycerine  and water, it can be
readily  injected ; but it has to a greater degree even than corro-
sive sublimate the disadvantage of causing abscesses in the sub-
cutaneous connective tissue.  According   to v. Sigmund, who
thinks injections of calomel more efficacious than those  contain-
ing the  bichloride, the formation of abscesses can be avoided by
the employment of small quantities of the  mild chloride, as from
three-quarters of a grain to a grain and a half.
   Calomel is less appropriate for internal  use, since it  is  apt to
affect the digestive organs, and, when thus used, it is  therefore
usually given in combination with small doses of opium.  If,
however,  the occurrence of some symptom of serious import, as,
for instance, iritis, renders it desirable to induce a rapid mercu-
rial ization,  the  administration of  calomel in conjunction with
mercuiial inunctions  is the most ready way of attaining this end.
Under such circumstances it is given several times daily in doses
of two-fifths of a grain, with one-twelfth of a grain of opium,
until evidences of  slight salivation are produced.
   The  combinations  of iodine and  mercury are especially prized
in France.  Of these the milder or green iodide is a favorite with
Ricord  and his followers, and is frequently given by them  during
   1 Prumers, Quecksilbersethylchlorid.  In.-Diss.  Berlin, 1870.  See Archiv f. Derm.
u. Syph.,  B. III., 1871, p. 454.
   ■ Traitem. de la Syph. par les inject, hypoderm de sublime.  These de Paris.  (Lan-
cereaux, 1. c, p. 550.) 
TREATMENT.
293
the entire treatment, extending  over a period of many months.
It is, indeed, a very active preparation, but causes in some indi-
viduals very unpleasant symptoms of disturbance of the diges-
tive tract, such as colicky pains and purging, with blood-evacua-
tions, even when given in doses not exceeding three-quarters of a
grain twice a day in combination with opium.  The  addition of
opium  is necessary for the  avoidance  of such symptoms, even
when the dose of the mercurial is a small  one, but it should be
stated that Biett and Cazenavel assert,  from special investiga-
tions wliich they have made,  that this narcotic interferes with the
action of  the protiodide of  mercury, and on this account they
give the preference to lactucarium.   They order a pill mass  con-
sisting  of eight  grains  of  the  green iodide of mercury  and
twenty-four of  lactucarium, to be  divided  into twenty pills.
Each pill  contains therefore two-fifths of a grain of the mercurial
preparation, and this, when  given two or three times daily,  con-
stitutes an average dose.  If the remedy is well borne, and if no
action on the symptoms is  effected, or  if a cessation of such
action  occurs,  the dose may  be carefully increased to  three-
quarters of a grain, or even a grain.
   The use of the yellow iodide in  the treatment of hereditary
syphilis, and especially of infantile syphilis, has been warmly
advocated by R. Foerster,2 the suggestion of its use having, how-
ever, been previously made by others.  He gives a twelfth, or at
most a quarter  of a grain  twice daily, in combination with pow-
dered gum.  The mercury with chalk is  a preparation which is
better borne, and one which  less frequently gives rise to  intesti-
nal catarrh, which,  as Foerster admits, is an unpleasant com-
plication to which the administration of the iodide is apt to give
rise.
   The red, or  biniodide  of  mercury, has much more irritating
qualities than the protiodide.  It is therefore  scarcely ever given
by itself, but may be employed in  small amount, dissolved in
a solution of  the iodide of  potassium.   It is prescribed in the
following  formula, which is  modelled after that of  Gibert:  red
1 Cazenave, 1. c, p. 599.
2 Deutsches Archiv f. klin. Med., B. II., 1867, p. 214. 
294
BAUMLER.—SYPHILIS.
iodide of mercury, three-quarters of a grain ; iodide of potas-
sium, thirty-eight grains ; distilled water, eighty minims ; filter,
and add  a fluid ounce of  syrup,  and four fluid ounces of dis-
tilled water:—dose, a tablespoonful twice daily.   Berkeley Hill
gives at a single dose  from a quarter to a third of a grain  of
the mercury, with from three to  five grains of the potassium
iodide, in solution in water.   Corrosive  sublimate also may  be
given in a solution of the iodide of potassium.  In the mixture a
reaction takes place, by wliich a certain amount of the biniodide
of mercury is formed and held in solution by the excess of iodide
of potassium.
   The iodides of mercury, and more particularly the biniodide,
are especially recommended in the treatment of relapses of the
cutaneous manifestations, in  particular those of the squamous
form, and also for recurrent papules of the  palms of the hands,
etc.   In the treatment  of tubercular eruptions also, and, when
the  condition of the digestive tract will allow of it, in that  of
tertiary symptoms, the  combination of  the red  iodide of mer-
cury with the iodide of potassium often seems to have a very
favorable effect.  Under these circumstances, however, the  pre-
parations of iodine alone have a similar influence.
   Mercurial treatment is contraindicated  in but few cases  of
syphilis, and chiefly when the disease is met with in patients
who are already seriously affected by some other disease.  The
existence  of chronic pulmonary affections,  which is quite com-
monly regarded as one  of the principal contraindications of this
treatment, does not absolutely forbid the  use of mercury.  If
the syphilitic symptoms are sufficiently urgent, a careful trial of
the  treatment by inunction may always be made.   Cases  of
chronic  kidney disease,  with albuminuria, on the other hand,
provided  the  albuminuria is not due to syphilis, as may  be
pretty clearly ascertained from the  history, are not suitable for
mercurial treatment, since the patients are  often salivated after
the administration of but a small quantity of mercury.  In cases
of this  kind, even in an early stage of the disease, preference
should be given to the  preparations of iodine and to the various
decoctions of the woods which are  used in the treatment of syph-
ilis. 
TREATMENT.
295
   Many  physicians  are  reluctant  to  administer  mercury  to
anaemic patients, even in the height of the secondary stage.  But
in very many cases  this ansemic condition is directly due to the
syphilis ;  it increases  as the symptoms of syphilis become more
developed, and improves with great rapidity under the adminis-
tration  of mercury, while treatment with ferruginous prepara-
tions  produces no  effect.   Such is not the case when syphilis
attacks a person who is already chlorotic or anaemic.  In such
cases it is proper to administer iron  in some form until distinct
manifestations of syphilis  make  their appearance.  I have fre-
quently, and, as it  appeared to me, with good results, used qui-
nine,  and  in some cases  cod-liver oil,  together with mercurial
inunction, in the case  of delicate  persons or such as had  been
reduced by previous disease.
   The existence of pregnancy offers no contraindication to the
use of mercury, and  least  of  all during the early months, for
there  is then some hope that abortion may be prevented, and
that,  in case the father is healthy,  the  child may escape con-
tamination.   However, the  mercurial  treatment of  pregnant
women must be conducted with due precaution; von Sigmund
recommends it only up to the seventh month of pregnane}'.
   Of the preparations of iodine, the one that is most frequently
employed is the iodide of  potassium.  It manifests its greatest
activity when given to pa-
tients  with affections  of
the  bones,  rheumatic  Fahr
symptoms, pustular erup-  m 0
tions, and serpiginous ul-
cers, or with dry tubercu-  m;.=
lar affections of the skin.
Even  in  the course of a  ioo.4<
few  days it  shows  its
effects in these cases, and  lte-sc
if there are febrile symp-
toms   present,  provided  9,-°
they are due to the syph-
ilis and not to some inter-
current disease, its influence  upon them is  made evident  after
 
296
BAUMLER.—SYPHILIS.
two or three days, as may be seen by a glance  at the  curve
on the preceding page.

   The symptoms in this case consisted of an impetiginous eruption, nodes at vari-
ous points, more especially upon the frontal bone, severe headaches, with nocturnal
exacerbations, which for weeks had interfered with the patient's  rest, and had been
but little benefited by the hypodermic administration of morphia.  On the second
night after beginning the use of the iodide of potassium the patient slept better,
but he was not entirely free from pain until the night between the 24th and the 25th
of the month.  After eighty grains of the iodide had been administered, the fever,
which had  been present for a long time, completely  vanished.  The remaining
symptoms slowly but steadily disappeared.

   It is not necessary that  the symptoms  should be very late in
the order of time  to  be  benefited by the iodide  of  potassium.
Even in the eruptive stage  this remedy has a very striking influ-
ence  when  it is used in the treatment of  pustular eruptions,
rupia, and the  like, and of ulcerations in  the  mouth, with rapid
destruction of tissue.   Fortunately cases of this kind are not of
frequent occurrence, and for the most part the symptoms, for the
alleviation of which the iodide of potassium  can be  employed
with  advantage, occur at a very late period after  infection.   In
addition to the affections already enumerated, degenerating gum-
mata of the subcutaneous and submucous tissues, and  destruc-
tive  ulcerations of the throat and larynx especially call for its
administration.
   In  such  cases  the remedy is  usually  strikingly well borne,
and  only  exceptionally occasions nasal catarrh or conjunctivitis;
and  I have  never, under such circumstances, seen it  cause the
conditions to which  the name Iodism has  been given.   One
patient complained, while  taking moderate doses (thirty grains
a day), of intermittent symptoms of weakness, which, however,
ceased upon the  addition of the aromatic spirit of ammonia to
the solution.
   Several English physicians, and among them are Sir J.  Paget
and Hutchinson, advise that this remedy should always be given
with the carbonate of ammonia or the aromatic spirit  of ammo-
nia, for they assert that  it  is better borne  in this combination.
Patients usually have a good appetite, and increase rapidly in
weight while taking  the iodide, unless the good effects of the 
TREATMENT.
297
drug are interfered with by keeping  them upon too restricted  a
diet.  Those patients who are usually in a  more or less cachectic
state should have as good and rich  a  diet as the condition of
their digestive organs will permit.
   The  dose in which  this remedy is usually given to patients
who have not  yet  taken it,  is from  three to five grains three
times daily ; in old cases, and to patients who have already used
it for some time, or where symptoms  are present which make it
desirable to arrest an ulcerative process as  speedily as possible, a
larger dose,  from eight to fifteen grains several times a day, must
be given.  Some cases  are not affected by doses of this size, and
under such  circumstances larger quantities, even thirty or forty-
five grains several times a day, must  be given to  attain a  cure.1
Iodide of  potassium should always be taken in a large quantity
of fluid, about  half a tumblerful of water to each  dose, and pre-
ferably after meals, so  that its elimination may follow its absorp-
tion at a  longer interval than would be the case were it  taken
kito an empty stomach.  This  remedy may often be given in
surprisingly large doses for a long time without  causing  any ill
effects ; indeed there are some cases of  tertiary syphilis in which
this is almost  a necessity, for only by its constant use can the
tendency  to ulceration be kept within bounds.  I knew a woman
who took the  iodide in increasing doses, with but few interrup-
tions, for  a period of five years, and only while taking it did she
enjoy good health.  Whenever she stopped its use for any length
of time, the serpiginous ulcerations from which she suffered, and
which were almost healed, increased  in size, and new ones made
their appearance.   It must be admitted, as a matter of regret, in
regard to  the striking  results often  obtained by the use of the
iodide of  potassium, that they  are very frequently not lasting;
that when the remedy  is not  continued long enough after a com-
plete cessation  of all symptoms has been reached, a speedy recur-
rence of the manifestations is apt to  take place.   On account of
this peculiarity of  the  remedy, it is important that, whenever
possible, the smallest efficient dose should be given at the begin-
ning of the treatment, so that if its use is to  be  long continued,
1 Compare also Langston Parker, Brit. Med. Journal, 1869, Vol. I. p. 466. 
298
BAUMLER.—SYPHILIS.
it  can be  done without having  to  resort to  unusually large
quantities.
   In the treatment of cerebral affections attended with convul-
sive  attacks, such as epilepsy,  chorea, and the. like, Hughlings
Jackson* advises the use of the iodide of potassium in combi-
nation with the bromide.
   Sometimes the iodide  of  potassium will  not be tolerated
either alone or in combination ; and under such circumstances
the iodide of sodium, which does not occasion catarrh, or the
iodide of ammonium2 may be tried.
   It frequently occurs, in cases in which it is advisable to use
the iodide, that the presence of pronounced anaemia calls for the
use of ferruginous preparations; and this is especially the case
when the occurrence of albuminuria renders  the existence of
amyloid  degeneration probable.  In such cases it is better to
order the iodide of potassium in combination with the ammonio-
citrate of iron, rather than a preparation containing both iodine
and iron, such as the syrup of the iodide of  iron.  I have con-
vinced myself, as others have  done, that the action of iodine
obtained by  the use of the syrup is  not so manifest as that
resulting from the use of a solution of the iodide  of potassium
containing a far smaller amount of iodine.
   Instead of the iodine saRs, the  tincture of iodine, or what is
better, the compound tincture,3 may be given.
   Although the iodide is so efficacious in the tertiary stage of
syphilis, still, cases are met with in which a complete cure cannot
be obtained  even with increased  doses, or in which a  constant
recurrence of the symptoms takes place whenever  the treatment
is suspended.  In some cases of this character, a permanent cure
may be finally obtained by the use of a tentative course of mer-
curial inunctions or calomel fumigations.  Numerous cases have
also been reported in which this result was  obtained by treat-
ment with the decoctions of woods.
   There are several magisterial preparations used in this method

   1 Med. Times and Gazette, 1873, Vol. L, May 10.
   * As  to  the iodides of sodium and ammonium, compare Berkeley Hill, Brit. Med.
Journal, 1871, Vol. II. p. 725.
   3 Equivalent to the simple '' Tincture of Iodine " of the British Ph. 
TREATMENT.
299
of treatment, the one most often employed in Germany being the
one known  as Zittmann' s decoction, while in Italy preference is
given to that of Pollini.
   The  former contains a small quantity  of mercury, and the
German Pharmacopoeia substitutes for it two  decoctions of sar-
saparilla,  of different strengths, which contain  a considerable
amount of  senna  leaves, so as to be purgative in the doses
usually employed.  With remedies of  this character, as with
others, it  is best not to follow any routine, but to adapt their
administration to  the condition of  the patient.  Since the main
object of this treatment is to stimulate the secretions, the patient
had better pass the greater  part of the day in bed, so that the
secretion of  the  perspiration may be kept  up ; in order to main-
tain the action of the kidneys and intestines, the decoction must
be given in pretty large quantities.   In the morning the  patient
should  take from eight to sixteen fluid ounces of Zittmann's
stronger decoction, and in  the evening  thirty-two fluid ounces
of the milder preparation.  These decoctions should be warmed
before being administered, and their use  should  be continued
until  all  symptoms  have  disappeared,  which  may  not occur
until  after the expiration of four or five weeks.   If the patient
does not  bear this treatment well,  it must be modified or even
suspended.  The diet during this time must be  nutritious, but
there  is often some difficulty in selecting appropriate food, since
the use of  such large amounts of these decoctions frequently
causes a catarrh of the stomach.
   During the secondary stage of syphilis decoctions of this kind
may be administered as adjuvants to the treatment by inunction,
and in the treatment of the tertiary stage, if the disease is advanc-
ing rapidly, their  administration  in conjunction with the iodide
of potassium is often attended by the most happy effects.
   Of the numerous other remedies  to which anti-syphilitic vir-
tues  have been ascribed at various times, and  which include
gold,  silver,  and platinum, it is  only necessary to refer  to opium
and nitric acid.  In the treatment of patients who are very much
reduced, and who suffer severely from painful ulcerations, opium
in conjunction with the iodide of potassium  is  sometimes of
value, and nitric acid, which was formerly largely administered 
300
BAUMLER.—SYPHILIS.
by  English physicians1  in  all  stages of  syphilis,  has  been
recently advised in the treatment of amyloid degeneration of the
liver, spleen, and other organs.
   Various local manifestations of syphilis,  although they dis-
appear  under constitutional  treatment alone,  are much more
quickly removed when local applications are also made directly
to them.  There is the greatest inducement for local applications
in the treatment of papular affections of the mucous membranes,
which greatly annoy the patients by the pain to which they give
rise and by their secretion.  This is especially true with regard
to condylomata about  the  anus and genitals.   The  use  of
Plenck's  solution,  which was formerly in  high  favor, often
caused oedematous swelling, and  was attended by much pain,
especially when  only the deposit wliich is formed  in this combi-
nation was employed.  No less active and much  less  painful is
the use of an ointment containing calomel in the proportion of
one part of calomel to eight of lard, or the very effective applica-
tion of calomel in the form of  a powder dusted over the  surface
of the condylomata, previously moistened with chlorine water,
or with a solution of common  salt, as advised by  Zeissl.  Clean-
liness and the use of charpie  moistened  in a dilute solution of
carbolic acid or in black wash often greatly promotes the absorp-
tion of moist papules.  Hardy2 uses aromatic vinegar with good
results.   Sometimes, especially when the condylomata are situ-
ated about the anus and cause much pain, the  application of a
dilute solution of nitrate of silver (from half a grain to a grain
to the fluid ounce) several times daily, exerts a favorable influ-
ence, by temporarily covering  the painful papules with a pro-
tecting coat.
   The treatment of papular and ulcerative lesions in the mouth
and throat often require great  care.   The avoidance of  irritating
food,  frequent washing  of  the mouth,  and gargling with mild
astringent  solutions, suffice only in  cases  of mild  character.
  1  Compare a letter from J. Currie to Dr. Beddoes in Currie's Med. Reports on the
Effects of Water, etc., Vol. II. p. 46.  London, 1805.
  2  Cazenave, 1. c, p. 613. 
TREATMENT.
301
When these affections are  extensive and obstinate, the diseased
points should be repeatedly touched with the mitigated  stick of
nitrate of silver, or with a solution of carbolic acid in alcohol, or
with the tincture of iodine  of a strength appropriate to the cases.
When ulcerations are present, threatening the uvula, all nourish-
ment should be taken in fluid  form.   Small painful  erosions or
papules on the tongue should  be touched with  nitrate of silver,
or from time to time with the acid nitrate of mercury.
   Smoking frequently causes a continuance of papules on the
point of the tongue, or a  recurrence of them after they have
been  once removed,  and  must therefore  be  forbidden such
patients.
   Affections of the  nasal  mucous  membrane and of the other
tissues of the  nose may often be topically treated very advan-
tageously.   These  affections  are  especially annoying  to  the
patient  when  they are attended by  an ill-smelling discharge
(ozama).  A discharge  of this character may be kept up by the
presence of  necrosed portions of bone in the nasal cavities after
the syphilitic affection has run its course.   If these  can be dis-
covered and removed, the  suppuration will be remarkably dim-
inished  and shortened.  In all  such  cases it is necessary to keep
the cavities of  the nose thoroughly  cleaned  by the use of nasal
douches, containing some  antiseptic substance, such as carbolic
acid or  permanganate  of  potassa.   Zeissl  very  justly observes
that such patients are often very unnecessarily subjected to  an
antisyphilitic treatment, since this is manifestly uncalled for if
the morbid process is no longer active.   It is not always easy to
decide whether or not syphilis  is still active in these cases ; but
from the history of the case, the use of  the rhinoscope, and from
the presence or absence of recent manifestations in other parts,
data  sufficient  for  a diagnosis can  generally be obtained.   If
there is  reason  to suppose  that the process is still active, if  the
bones are affected, the iodide  of potassium should be adminis-
tered ; but in the  early stages  of syphilis, when it may be sup-
posed that  the necrosis is consequent upon ulceration  of  the
mucous membrane, and when papules are met with on other por-
tions of the mucous membrane, mercurial treatment will have an
influence on the local affections of the nose.  To aid this treat- 
302                  BAUMLER.—SYPHILIS.
 ment, calomel may be directed to be snuffed up the nose ; but it
 must not be forgotten that this  may readily cause slight saliva-
 tion—indeed Biett made use of the nasal mucous membrane for
 the application of calomel  in a general mercurial course.
   When  affections of  the  skin are entirely isolated, the attempt
 may  be made  to  remove  them  by local treatment alone.  The
 application of mercurial plaster, or frequent inunctions of white
 precipitate ointment,  or of the oleate of mercury,  or hypodermic
 injections of calomel or corrosive sublimate into the centre of the
 affected portion of skin sometimes suffice.   V. Sigmund recom-
 mends in the treatment of  the very obstinate papular affection of
 the palms of  the hands, the  application of corrosive sublimate
 with collodion, using the following formula: Corrosive sublimate,
 thirty grains ;  collodion, three fluid drachms ; castor-oil, twenty-
 three minims.

   The oleate of mercury, which was  first prepared and used by J. Marshall,1 is an
 elegant  preparation when compared  with other  mercurial salves,  and  has been
 applied by O. Martini,2 of Dresden, in the inunction treatment, in place of the ordi-
 nary mercurial ointment, but was found by him to be less efficacious than the latter.

   The treatment of  serpiginous ulcers  is  often  attended with
 difficulty.  If  the crusts which form are thin  and superficial,
 and have but little secretion  beneath them, it is best to allow
 them to remain, especially  when they are extensive.  If they are
 so situated as to be liable to be  removed  by friction or external
 injuries, it is well to cover them with some indifferent plaster, or,
 if they are of small extent,  with mercurial plaster.  Small, round
 ulcers,  especially  those in  the face, which are due to the pus-
 tules of impetigo, or those resembling varicella, are best treated,
when the crusts become loose, with black wash or with an oint-
ment  containing either red or white precipitate.   Zeissl states
that iodoform, which has been so extensively used  of late, is
very useful in  the  treatment of torpid ulcers, and Lancereaux,
  'Lancet, 1872, Vol. I., p. 711.  It was first brought forward by Messrs. Hopkins
& Williams, of London.  Compare  also Prof. Hilger, in the Proceedings of the Phys.
Med. Society at Erlangen, H. 6, 1S74, p. 108.
  2 Schmidt's Jahrb., B. 160, 1873, No. 10. 
TREATMENT.
303
that the same  remedy is  attended with good results  in  many
cases of serpiginous ulceration.
   Painful periosteal swellings do not, as a  rule, demand any
local treatment; but sometimes the tincture of iodine painted
upon them moderates the suffering. The oleate of mercury, with
the addition of morphia,  may also be thus employed.   This
combination is also  recommended  to  be rubbed into the skin
over swollen joints.   Ricord advises the use of flying blisters in
the treatment of painful nodes.  Syphilitic testicles should  be
enveloped  in mercurial plaster, or the  oleate  of mercury should
be rubbed into  the scrotum.
   In all cases of iritis a solution of atropia  should be dropped
into the eye,  in  conjunction with  general mercurial treatment.
If the inflammation is very severe,  blood should be  drawn from
the temples, and the mercurial treatment should be more ener-
getic, and pushed even to  the production of slight salivation (see
p. 292).  The  occurrence  of choroiditis or retinitis is also  an
indication for prompt and vigorous mercurial treatment.
   In addition to these,  many active local  affections, such  as
those of the larynx, the lachrymal passages, the eye,  the geni-
tals, or the rectum, may call for special local interference,  which
is often of surgical character, and  which  must  be  specially
adapted to the case in question.
   The treatment of hereditary syphilis, and especially of syphi-
lis occurring during childhood, must be guided by the same prin-
ciples that have already been given.  In these cases also mercu-
rial treatment plays the leading part;  but the particular method
of administration which is to be adopted will depend upon spe-
cial circumstances.  The treatment by inunction is very suitable
when its use is not forbidden by the presence of a pustular erup-
tion.  The amount of mercurial ointment  that  should be used
daily is about five grains.  The frictions should be made upon
various parts of the body in succession, and should be suspended
on the slightest symptom of commencing eczema.
   In the syphilis of very small children, as has been previously
stated, baths containing corrosive  sublimate may be used with 
304
BAUMLER.—SYPHILIS.
advantage, and Monti, v. Sigmund, and others advise the use of
the hypodermic method of administration.
   Most frequently, however, mercury is given internally, either
in the form  of mercury with chalk, or calomel,  or the green
iodide,  in  doses  varying from a sixth  to  a  quarter of a grain
twice or thrice daily, and, if purgation is caused, a  small amount
of opium, from  the one one-hundred and  thirtieth  to the one-
sixtieth of a  grain, must be added to each dose.  The internal
use of mercury may be supplemented by causing the child to
wear  upon its breast or back a flannel compress  smeared with
mercurial ointment.  If proper precautions are observed, and due
regard paid  to all complications which may arise, the internal
administration of mercury may be kept up for months with the
greatest advantage.
   The  attempt  has been made to administer mercury to chil-
dren through the milk either of the mother  or of goats; but
the quantity of  the  metal  which  passes  into  the  milk is so
minute  that no result can be looked for from this mode of treat-
ment.
   The  feeding  of infants  is a  matter of much importance.
Mothers who have had syphilis may be  allowed to suckle their
syphilitic children, if they are in other respects suited to perform
this office.  If a  child which is apparently healthy is born of a
woman who but a short time before has given evidences of syphi-
lis, she  should not be allowed to suckle it,  for it is  possible that
the child may not be contaminated, unless it becomes infected
from  some lesion which develops  upon the  mother's nipple.
Such  a  child should not, however, be given to a healthy wet
nurse, since it is  possible that syphilis may be simply latent in
it, and may break forth during the first three months of its life.
It is still less allowable to permit a child which  shows signs  of
syphilis to be suckled by a healthy wet nurse, even when she is
made acquainted with all the dangers and expresses her willing-
ness to  take  the risk.   The use  of apparatus to prevent the
child's mouth coming in contact with the nipple will most prob-
ably be  soon neglected on account of its inconvenience, and the
nurse consequently be infected.  If a syphilitic child has to be
artificially nourished, either  cow's milk, or condensed milk,  or 
TREATMENT.
305
some one or other of the various substitutes for mother's milk
should be used.
   In the treatment  of infantile  syphilis, the most scrupulous
cleanliness and the regular use of baths should be enforced ; and
all moist papules must be treated with some of the various appli-
cations suggested above.
   When tertiary affections of the skin or bones, or interstitial
keratitis are met with  in  older  children, mercurial  treatment
will often be found of use;  but its effects in  such cases are by
no means so striking as those produced by it in the earlier stages
of hereditary or  acquired syphilis.  In most  of these cases the
preparations of iodine, and  these more especially in combination
with iron, cod-liver oil, and a general tonic  treatment, country
air, milk, a sojourn at the seaside, salt-water baths, etc., will be
of service.
   In various  stages of  syphilis  the  proper specific treatment
of the disease may be  much aided by completely removing the
patient from his business and usual mode  of life, and  the same
course will often be found of advantage at  the conclusion of a
prolonged course of treatment.   For many patients  who  are
much debilitated, a  winter in a mild southern climate, or a resi-
dence of several weeks during the summer in the country, or at
the seaside, will  be found extremely  beneficial.   While symp-
toms of syphilis  are still  present, the effects of treatment will be
much promoted by  attention to these hygienic precautions.
   It was formerly believed that waters containing sulphur exer-
cised  an influence upon  syphilis  in various ways ;  in the first
place, sulphur baths were thought to cause a retrocession of the
manifestations, in addition to which, waters  containing sulphur
were supposed to  act favorably by removing  the excess of mer-
cury wliich had been introduced into the organism ;  and finally,
it was asserted that sulphur baths had the property of awakening
latent  syphilis,1 so  that  their use gave a -means of  testing  the
completeness of a supposed cure.

  1 Compare, on this point, A.  Beumont, Beitr. z. Path.  u. Ther. d. constit. Syph.
Erlangen, 1864, p. 11.  Id., Ueber die Behandlung der constit. Syph. und der Quecksil-
berkrankheit an den Schwefelquellen.   Berlin, 1874, p. 11 et seq.
          VOL. III.—20 
306                 BAUMLER.—SYPHILIS.

   Recently more and more doubt has been expressed in regard
to  the  last-mentioned quality  claimed  for  these  baths,  and
patients are not now so willingly sent to Aix-la-Chapelle, Baden,
or other sulphur baths, merely to obtain a diagnosis of the suc-
cess of the treatment which they have undergone.  In regard to
the other good effects of  sulphur  baths in  the  treatment of
syphilis, they are for the most part due to an increased activity
of tissue metamorphosis, and can be obtained as readily from the
use of warm vapor or hot-air baths.  If, in spite of this, certain
resorts at which there are sulphur springs, more especially Aix-
la-Chapelle, have obtained  a particular reputation for the treat-
ment of syphilis, this is due to the completeness and comfort of
the baths and other appurtenances, which aid in carrying out a
treatment with iodine or mercury.
   Some physicians are of  the opinion that the internal and ex-
ternal use of waters containing sulphur, during a course of mer-
curial treatment, may prevent too  active effects from the remedy
by rendering inactive the  excess of mercury which  is adminis-
tered.  Giintz,  therefore, advises that when mercurial treatment
has been previously employed, the patient  should, before com-
mencing another course of it, prepare himself by the use of sul-
phur baths, and by drinking either water from Aix-la-Chapelle
or Weilbach, or an artificially prepared sulphur water ;  and
should also keep up the same treatment during the use of inunc-
tions.  The results attained at Aix  seem to render  it probable
that  this  practice is of advantage ;  but it is very desirable  that
accurate observations should be made, so that this  question may
if possible be decided.
   There have  been  great  hopes that hydro-therapeutics would
produce good  results in the treatment of syphilis ; but these
hopes have not been wholly fulfilled.  Mild cases of syphilis will
end in recovery under this treatment, as they  will  under a
purely expectant one ; but the course of well-marked syphilitic
manifestations  is scarcely  shortened by it.  Although impossi-
bilities must not be expected from this mode of treatment, it
still deserves an important place in the  treatment of syphilis in
conjunction  with, or  at  the expiration of, a specific  course.
Hydropathic treatment, when suitable  to the strength  of the 
SYPHILIZATION.
307
patient,  by exciting the general  metamorphosis of tissue, and
the activity of the skin, increases the action of mercurial  oint-
ments.   The usual increase of appetite which attends  this plan
of treatment must be regarded as likely to produce a favorable
effect upon the patient's general condition.
   In  the cases of patients who have been much reduced  by
syphilis, or who have undergone a protracted and severe mercu-
rial course, hydropathic treatment, together with good food and
pure air, usually acts very favorably.

                        SYPHILIZATION.
Auzias Turenne,  De la Syphilisation, etc. Archives de MeYlec.,  1851.—Sperino,
   La syphilisation etudiee comme methode curative et comme moyen prophylac-
   tique, etc. Traduct. franc.  Paris, 1856.— W. Boeck, Die Syphilisation beiKin-
   dern.  Christiania, 1856.—The same, Recherches sur la Syphilis.  Christiania,
   1862—v. Sigmund, Wien. med. Wochenschr., 1859, Nos.  17 and 19.—v. Lind-
   wurm, Aerztl. Intell.-Blatt, 1860, No.  13.—A Hoist, Behrend's Syphilidolog.,
   N. R., B. III., 1861, p. 394.— W. Boeck, Med. Times and Gazette, 1865, Vol. I.,
   June 10.—Lane and Gascoyen, Med.-Chir. Transact., Vol.  50, 1867, p. 281.—A.
    Oewre, Archiv f. Derm. u. Syph., B. II., 1870, p. 1.
   This method of treating syphilis was based upon experiments
which were conducted by  Auzias Turenne in 1844,  and were by
him  laid before the  Paris Academy of Medicine in 1850.   He
inoculated the secretion of ulcers which he regarded as syphi-
litic, first  upon animals and  afterwards upon men,  and found
that after the operation  had  been many times repeated,  a  state
of immunity  was  finally caused, and inoculation was no longer
possible.   While Auzias Turenne concluded from  these  experi-
ments  that it would  be possible in this way  to  render  men
insusceptible  to syphilis without  having undergone the  disease
in its  constitutional form, others, and among them Sperino, of
Turin, applied this method to the  treatment of  constitutional
syphilis.   Auzias  Turenne gave  to  that state of the system  in
which inoculation was  no longer possible the name of syphiliza-
tion, and this term has since been adopted  to express the method
itself.  The use to which it was proposed by Auzias Turenne to
put syphilization may be called  prophylactic, while its employ-
ment  in  the treatment of  syphilis which  already exists may be
called  "curative." 
308
BAUMLER.—SYPHILIS.
   Prophylactic syphilization never found much favor, and the
investigations made upon Dr. Lindemann, as well as others given
above (page 45), furnish absolute proof  that the inoculation of
any amount of chancroidal virus will  not blunt or  protect the
organism against the action of the syphilitic poison.
   Curative syphilization is at present practised only in Norway.
The  method  followed  by W. Boeck, who is a warm advocate of
this  treatment, is as follows : Inoculations are made every third
day upon various parts of the body—the chest, the upper arm,
and  the thigh—with secretions obtained from chancres, or from
syphilitic ulcers which have been irritated by the application of
savine powder  or ointment.   The pus which is  used for subse-
quent inoculations is taken from the pustules already produced,
and only when the secretion  from this source is no longer capa-
ble of inoculation is recourse had to a fresh syphilitic sore, and
this  in turn is then kept up until these  inoculations also fail to
produce any result.   The tolerance which the skin and organism
manifest for  inoculations  of  this character is often merely local,
for while the operation fails if performed  near the last pustule, it
succeeds at a more remote locality, and it is also of temporary
duration, for  when some time has elapsed after immunity has
been attained, inoculation is  again  possible (Danielssen's case,
page 100).
   From the standpoint which we have already taken, we cannot
consistently call this proceeding " syphilization," for the inocu-
lations are not done with syphilitic but with chancroidal virus,
and  on  this  account  Faye has proposed the  name "curative
chancre-inoculation" for this mode of treatment.
   It cannot be  denied  that  cases of  constitutional  syphilis
recover under this treatment, but their progress is tedious, and
does not differ from that which is seen  under a purely expectant
treatment, or under what  Hjort, Cullerier, and  others  tried as
equivalent  to chancre-inoculations,  namely,  the production of
numerous small pustules on the skin by small blisters or the use
of tartar emetic ointment.  According to Boeck, however, syph-
ilization  only manifests its full effect  when it has not been pre-
ceded by mercurial treatment.
   A. Oewre, who took part in Boeck's observations for years, 
SYPHILIZATION.
309
thinks that the action of  syphilization is due to "derivation,"
and  regards the whole method  as  an expectant treatment of
syphilis.   Recurrent attacks and tertiary manifestations are not
prevented by this mode of treatment, and mothers treated by it
bring syphilitic offspring into the world, as well as do those who
have been treated in other ways.
   This method,  then, is not likely  to obtain the confidence of
physicians to any extent, and is as little likely to meet with the
approbation of patients, for it is not only tedious, and causes,
in comparison with  mercurial treatment, but a very slow retro-
cession of the symptoms ; but, moreover, it annoy  sthe patients
by the production of numerous ulcers, which are often pain-
ful and sometimes even phagedenic, and which leave indelible
traces of their existence.
   The employment  of  vaccination  in a similar way  {i.e., by
repeated inoculations) in the treatment of syphilis, has also been
recommended;* but, outside of Russia, where the first experi-
ments were made, it has not been extensively attempted.
1 Behrend's Syphilidologie, N. R., B. HI., 1861. 
 
INFECTION  BY  ANIMAL  POISONS.







         DISEASES OF ANIMALS.
BOLLINGER, 
 
DISEASES   OF   ANIMALS.
 Virchow, Infectionen durch contagiose Thiergifte (Zoonosen).  Handbuch der spec.
    Pathologie und Therapie.  Red. von Virchow, B. II., 1 Abth.  Erlangen, 1855.
    —Beder und Kordnyi, Zoonosen.  Handbuch der allg. und spec. Chirurgie von
    Pitha und Billroth, I. B., 2 Abth.   Erlangen, 1870.
 Greve, Erfahrungen und Beobachtungen iiber die Krankheiten  der  Hausthiere im
    Vergleich mit den Krankheiten der Menschen.   Oldenburg, 1818-1823.—Levin,
    J., Vergleichende Darstellung der von den Hausthieren auf Menschen ubertrag-
    baren  Krankheiten.  Gekronte Preisschrift.  Berlin, 183Q.—Heusinger,  Re-
    cherches de Pathologie compares, Vol. I. und II.  Cassel, 1847.—Veyssiere, Des
    maladies transmissibles  des animaux  a  l'homme.   Paris, 1853.—Forster,  A.
    Hand, der spec. path. Anatomie, 2 Aufl.   Leipzig,  1863.—Schmidt, Max, Zoo-
    logische Klinik.  Handbuch der vergleich. Pathologie und path. Anatomie der
    Saugethiere und Vogel, B. I., 2 Abth.  Berlin, 1872.—Compare also articles by
    Hering,  Bitter, Skrezcka,  Waldeyer, Leisering,  and Bollinger in  the  Jahres-
    berichte of Canstatt, Virchow, and Hirsch.
Laubender,  Seuchengeschichte der  landwirthschaftlichen Hausthiere.   Miinchen
    und Burghausen, 1811.—Kreutzer, J. M., Grundriss  der gesammten Veterinar-
    mcdicin.  Erlangen, 1853.—Bychner, J. J, Specielle Pathologie und Therapie
    der nutzbarsten Hausthiere.—Spinola, W. Th. J., Handbuch der spec. Patholo-
    gie und Therapie fur Thierarzte.  Berlin, 1858.—Hering, Pathologie und Thera-
    pie fur Thierarzte, 3 Aufl.  Stuttgart, 1858.— Boll, M. F, Lehrbuch der Patholo-
    gie und Therapie der Hausthiere, 2Bde., 3 Aufl.  Wien, 1867.—Bruckmuller, A.,
    Lehrbuch der path. Zootomie der Hausthiere.   Wien, 1869.—Haubner, G.  C,
    Handbuch der Veterinarjjolizei.  Dresden, 1869.—Derselbe, Landwirthschaftl.
    Thierheilkunde, 6 Aufl.  Berlin, 1873.—Gerlach, A. C, Handbuch der gerichtl.
    Thierheilkunde, 2 Aufl. Berlin, 1872.—Bouley et Beynal, Nouveau Dictionnaire
    pratique de  medecine, de  chirurgie et d'hygiene  veterinaires.   Tom.  I-IX.,
    Paris, 1856-71.—Hurtrel d'Arboval, L.  H J.   Dictionnaire de Medecine,  de
    Chirurgie et d'hygiene veterinaires.  Edition entierement refondue et augmen-
    ted par A. Zundel, T. I.   Paris,  1874.

    Although the actual number of diseases communicable from
animals  to man  is by no means large,  this class  of affections
may,  nevertheless, justly  be said to occupy  a  relatively impor-
tant   position in human pathology.   Apart  from  the  great
severity  that  characterizes   these  animal  diseases,  several  of
which are, so far as our present knowledge extends,  practically 
314      BOLLINGER.—INFECTION BY ANIMAL POISONS.

incurable, they present so many peculiar phenomena, especially
as regards their origin and mode of communication, that their
comparative study cannot be regarded as other than one of the
most important pathological problems now awaiting a solution.
It can be safely predicted that a persistent and methodical inves-
tigation of the  etiology of  the  entire class of animal diseases
will  contribute materially to our knowledge of human pathology.
   When we consider the list of  diseases capable of being trans-
mitted from animals to man, we cannot fail to be impressed with
the fact, that in this respect the relation between the two species
is much more intimate than is generally appreciated.  In addi-
tion  to the more important maladies to which our attention is
most frequently attracted {glanders, malignant pustule, hydro-
phobia),  it has  been  shown by numerous recent  observations,
that  another less formidable affection, foot and mouth disease,
not unfrequently gives rise  in man to a specific disorder.  The
discovery of  the communicability of cow-pox  to  man, for the
knowledge of  which we are  indebted  to Jenner, has proved one
of the greatest boons ever conferred upon mankind through the
medium of the medical profession.  Another class of parasitic
diseases {trichina, tape-worm) has likewise been shown to have
its exclusive origin in our domestic animals.  Numerous epizoa,
moreover, of  animal  and vegetable origin, are communicable
from animals to man, giving rise in the latter to specific morbid
symptoms.  Furthermore,  observations  made  in  experimental
pathology have rendered it extremely probable that the tuber-
culosis to which cattle are  subject may prove  to  be one of the
sources of the tuberculosis that prevails in the human subject.
Mention  should be made, finally, of those diseases produced by
the specific physiological virus of certain animals, reptiles, and
insects (snake-poison, the poisonous sting of  numerous insects),
as well as by  the implanting of septic poisons derived from ani-
mals.  Whether future scientific investigations will reveal still
other animal diseases  dangerous to man, must for the present
remain an open question.
   If, on the other hand, the inquiry be put, what diseases are
communicable from man  to animals, we cannot fail to be im-
pressed with the peculiar character  of the reply.  There are, 
GENERAL CONSIDERATIONS.
315
indeed, a few parasitic diseases to the contraction and develop-
ment of which the two species are  equally susceptible, and also
another class of  diseases which  have been transmitted experi-
mentally from man to  animals {tuberculosis,  syphilis,  small-
pox, septicemia).  Certain animal diseases also have been com-
municated  by retro-inoculation  from  man  to animals.   The
exceptionable nature of these few instances, however, will enable
us the  better to  appreciate  that to the lower animals is granted
in this  respect a much greater immunity from contagion than to
man.   It is important at the outset  to reject emphatically the
theory, however much may  have been advanced in its favor, that
certain epidemic diseases  {e.g.,  cholera,   typhoid fever) may
occur in animals,  especially our domestic animals.  On the con-
trary,  the results of all artificial attempts to implant these dis-
eases in animals, hitherto reported,  admit of an extremely varied
interpretation.   In view, then, of the  above  facts, we are justi-
fied in affirming that while man evinces a strong affinity for ani-
mal poisons,  the  susceptibility of  animals to contagion of human
origin  is but  slight.

   Note to the American  Edition.—It may be well to remark at this poiDt, with
the view of obviating  any misunderstanding on the part of the reader, that in the fol-
lowing articles upon animal diseases communicable to the human subject, the nomen-
clature recently proposed by v. Pettenkofer (Zeitschrift fur Biologie, IX. Band, p. 411,
1873) with reference to the materies morbi has been adhered to.  This classification is
here quoted in the words of the author: —
   u It would perhaps conduce to a better understanding of the subject if we should
strike out from our vocabulary the extensively employed and misused words contagium
and miasma, which no  longer retain their original  signification, and should select in
the place of these old, indefinite, and ambiguous  terms,  some new expressions better
adapted to our present ideas.  In accordance with the present status of our knowledge
and theories upon this subject, the so-called contagia and miasmata are now to be con-
sidered  as morbific agents which we  have long been accustomed to comprehend under
the general term of infecting virus.  Syphilis, as well as intermittent  fever, is con-
tracted through the medium of a specific infecting principle,  which makes its way into
the economy, the essential points of  distinction between  the two affections consisting
merely in the difference in their specific character,  their mode of origin, and the laws
which govern their communicability.  Some  of these morbid poisons, that of syphilis
for instance, are developed and propagated only within the organism of the living  and
infected  body ; some, such as the  malarial poisons, are  developed and generated not
within the infected individuals, but only in their immediate vicinity ; while still others
(possibly small-pox) grow and multiply in both ways. 
316       BOLLINGER.—INFECTION BY  ANIMAL POISONS.

   "Both these categories of infecting principles would be, perhaps, more perfectly
appreciated, if we were to adopt, instead of the terms contagium and miasma, some
other expressions which would serve to embody the  idea of  the multiplication of the
specific virus within or witfiout the organism of the patient, a distinction which might be
expressed  by the words, derived from the Greek, endogenous  (engendered within) and
exogenous  (engendered without).   The exogenous infecting agents would again be
divided into two sub-orders, or groups: first, those which are fixed in the locality where
they originate, and are not transferable from one place to another by means of the in-
ter-communication of human beings (as has hitherto been supposed to be the case with
respect to malarial poisons) ; second, those of which the materies morbi, though having
a local origin, are capable of being conveyed about in an active state by means of human
intercourse, or which, to use the language hitherto employed, are ''transportable."
According to  my own view and that of others,  cholera, yellow and typhoid fevers are
produced by the exogenous, transportable, infectious agents, whose vitality is mani-
fested in any locality to which they may be conveyed by man, but which are only cap-
able of reproducing themselves and spreading  the disease outside the infected  organ-
ism."


                             GLA1TOEBS.

                  (malleus  humidus.   MALIASMUS.)

Lafosse, Abhandlung von dem Sitze des Rotzes bei den Pferden.  Aus  dem Fran-
     zos. von  Schreber.  Frankfurt und Leipzig, 1754.—Viborg, Kurze Nachrichten
     iiber  Rotz, Wurm, etc.   Sammlung  von Abhandlungen  fur Thierarzte und
     Oekonomen.   Kopenhagen, 1797.— Wolstein, Bemerkungen iiber die Entstehung
     und Verbreitung des Rotzes.   Hamburg,  1807.— Dupuy, De l'affection tubercu-
     leuse vulgairement appellee morve, etc.  Paris,  1817.— Vines, Pract. Abhand-
     lung iiber die Rotzkrankheit und den Hautwurm des Pferdes.  Aus dem Engl.
     von Wagenfeld, 1833.— Leblanc, U., Des diverses especes de morve et de far-
     cin, considerees commes des formes variees d'une meme affection generale con-
     tagieuse.  Paris, 1839.—The same,  Recherches experimentales et comparatives
     sur les effets de rinoculation au cheval et a  Fane du pus et du mucus morveux
     et d'humeurs morbides d'autre nature. Paris, 1839.—Benault et Bouley, Intro-
     duction  dans les veines d'une jument d'une  Emulsion  de matiere purulente.
     Developpement de la morve, etc.  Recueil de med. veter.  Vol.  XVII. p. 227.
     Paris, 1840.—Loiset, Recherches anatomico-pathologiques  sur la  morve.   Rec.
     de  med.  veter., Vol. XIX. p. 703.—Dittrich, Rotz und Hautwurm  in anatom-
     pathol. Hinsicht,   Kreutzer's Central Zeitung fur die gesammte Veterinarmedi-
     cin, I. Jahrg., p.  40, 1851.—Leisering, Zur pathol. Anatomie des Rotzes.  Be-
     richt  iiber das Veterinarwesen im Konigreich Sachsen fur das  Jahr 1862, p.
     121 ;  the  same, ibidem, 1867, p. 13.— Virchow,  Die krankhaften Geschwiilste,
     Bd. II.,  1 Halfte, p. 543,  1863.—.Ba^e, Snive Sygdommens forekomst i Dan-
     mark. Kopenhagen,  1863.— Erdt, W. E. A., Die Rotzdyskrasie  und ihre ver- 
GLANDERS  IX HORSES.
317
    wandten Krankheiten.  Leipzig, 1863.—Boloff, Die Rotzknoten in den Lungen.
    Magazin fur die ges. Thierheilkunde, B. 30,  p. 357, 1864.—Gerlach, A. C, Die
    Rotzkrankheit.  Jahresbericht der k. Thierarzneischule zu Hannover, I., 1868,
    p. 75; ibidem, II., 1869, p. 80.— Waldenburg, L., Die Tuberkulose,  die Lungen-
    schwindsucht und Scrophulose, p. 186. Berlin, 1869.
Schilling, Rust's Magazin fur die gesammte Heilkunde, B. XL p. 480. Berlin, 1821.
    —Bayer, De la morve et du farcin chez 1'homme.  Paris,  1837.—Tardieu, De
    la morve et du farcin chron.   Paris, 1843.—Hauff, H, Die Rotzkrankeit beim
    Menschen.  Stuttgart, 1855.—Guerin,  Tardieu, Bouley, etc., Contagion de la
    morve du cheval si 1'homme.  Bull, de l'Acad. imperiale de med., T. XXVI.,
    No. 19 sv., 1861.—Buyer,  La question de  la  morve a l'academie.   L'Uhion
    medicale, 10 Sept., 1361.—Kuttncr, Beitrag zur Frage iiber den Rotz beim Men-
    schen.  Virchow's Archiv f. Path. Anat., B. 39, p,  548,  1867.  See  also the
    works of Virchow (Die Zoonosen, Handbuch  der spec.  Path, und Therapie, B.
    II. 1.  Erlangen, 1855), v. Kordnyi  (Zoonosen, Handbuch der allg. und spec.
    Chirurgie, B. I. 2.  Erlangen, 1870), die Jahresberichte von  B. Bitter, Hering,
    Leisering,  Skreczka, und  Bollinger,  in Canstatt's Jahresberichten und deren
    Fortsetzuug von  Virchow und Hirsch.


                       GLANDERS IN HORSES.

                        Historical  Notice.

    The first allusion to glanders is found in  the literature of the
fourth  century, reference having been  made to it  under  the name
of  fiahg and malleus  by Apsyrtus, a  veterinary  surgeon  in  the
army of Constantine  the Great.    Apsyrtus included, moreover,
under  this  name,  a  number of  very diverse dangerous maladies,
while his description  of farcy corresponds to  the elephantiasis of
the present time.  Yegetius, in the fifth century, made a similar
error in describing glanders.
    For  a long time  before the  communicability of glanders to
man was recognized,  the disease had  acquired a certain interest
as regards its bearings upon human pathology, from the circum-
stance  that  van Helmont (1682)  sought to refer to it the origin of
syphilis,  a  theory adopted at  a later  date  by  Ricord.  The
source  of this erroneous  idea has been traced by Virchow to the
report,  at one time accepted as true, that glanders first appeared,
together with  syphilis,  at  the siege of Naples,  toward the end
of  the fifteenth century.  More  recent observations' have since
  1 Semmer, Oesterr. Vierteljahrschrift f. wiss. Veterinarkunde, B. XXXII. p. 110, 1869. 
318      BOLLINGER.—INFECTION BY ANIMAL POISONS.

demonstrated that the virus of syphilis, when introduced into
horses, never produces glanders, and it is still more significant
that syphilis as such  is never known  to occur in domestic ani-
mals.
   The principal points  in the history of glanders to which the
discussion has  ever recurred are, in the first place, the question
of contagiousness, which has given rise, especially in France, to
long and obstinate disputes ; and second,  the mode of develop-
ment of the disease.
   The contagious  character of glanders was indeed recognized
at an early date by Soleysel (1664), Garsault (1741),  and both
writers named Lafosse (1754-1772)—the latter at least as regards
certain forms—while the inoculability and fatal character of the
malady were demonstrated by Abildgaard;' and finally the ques-
tion of contagiousness was established by Viborg (1797), from
accurately conducted experiments.  In the face of all these facts,
however, the non-contagiousness was again firmly maintained in
France at the end  of  the last  century, and this  theory,  mani-
festly tending to produce most detrimental results,  was taught
by Bourgelat and Chabert at the representative veterinary school
at Alfort.
   The experiments of Viborg were, it is true, confirmed at the
beginning of the present century by Gohier and Huzard,  yet it
was only by slow and gradual steps that  the non-contagionists
yielded  ground, admitting the contagiousness of the acute form
of the disease,  but denying the presence of this property in the
chronic  form which prevailed much more extensively.  On this
point of dispute the veterinary school  at Lyons never failed to
uphold  firmly the theory of contagion as opposed to the doc-
trines of Alfort, and it was a representative of the former school,
St.  Cyr, who at a later  date—about the middle of the present
century—rendered  signal service  in disseminating throughout
France correct  views  on this point.  Barthelemy, it  should be
said, had previously (1849) entered  a strong  protest  before the
Paris Veterinary Society in favor of  the  theory  of  contagion.
This delusion as to the non-communicability of glanders cost the
1 Der Pferde- und Vieharzt, 3 Ausgabe.  Kopenhagen und Leipzig, 1795. 
GLANDERS IN HORSES.
319
government very dear,  the yearly mortality from this disease
among the French army horses reaching an enormous figure.
   As  to  the nature of glanders, Dupuy (1817), regarded it as a
form of tuberculosis, and  on that ground was inclined to favor
the theory  of  non-contagion.   Other writers  (Dittrich [1851],
Baron, Philippe, Engel, Roll [I. Aufl.], and Falke) adopted the
views of Dupuy, or else considered  the disorders to be closely
allied to  (Spinola), or almost identical with (Villemin),  tubercu-
losis ;  while a third  class  (Erdt  and Ravitsch)  attempted to
establish a relation between glanders and scrofula.
   The attempt was also made to connect glanders with diph-
theria (Dittrich, Kreutzer, Roll), as well as with  pyaemia (Erco-
lani, Bassi, Bruckmuller),  but the  investigations of  Virchow
(1855 and 1863) placed the question  upon  a new basis, and the
theory advanced  by  him  soon met with  general  acceptance.
The pioneer researches of this pathologist  resulted in assign-
ing glanders to the  class  of  "granulation tumors,"  and his
views were soon confirmed by the brilliant researches of Leisering,
in consequence of which the disputed question as to the  nature
of glanders entered upon a  new epoch.
   Finally, as regards the pathogenesis of glanders, a  question
of the  utmost  importance, the  results   of the experimental
researches of Renault and  Bouley (1840) seemed  to support the
belief at that time generally prevalent, that the disease might
be developed de novo, as well as by inoculation ; and when these
investigators pretended that they  had produced glanders in
horses by the injection of simple pus, this served to render ques-
tionable the specific nature  of the affection, tending to make it
appear at most merely a form of  pyaemia  or septicaemia.  The
theory that glanders might be developed from a number of other
diseases,   such, for instance,  as "Druse"  (rhinitis), bronchial
catarrh, inflammation of the lungs and lymphatic vessels, etc.,
—a theory that met with almost universal acceptance—received
in this way additional  support.   Erdt claimed, furthermore, to
have produced glanders by inoculations with scrofulous material,
while Vines went so far as to claim similar results from the intro-
duction of certain irritating substances (vitriol) into the wind-
pipe, and even by injecting the blood of a  rabid dog  into the 
320      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

veins of a horse.   After the theory of the spontaneous develop-
ment of glanders—fortified,  as it appeared, by clinical  experi-
ence—had  been  constructed  upon  this basis, the attempt was
next made to demonstrate anatomically (Ravitsch) that the nod-
ules found in the lungs in glanders were embolic infarctions.
   This, then, was the status of the  theories which were current
respecting glanders till within a recent date, when a few writers
(especially Gerlach) began to vigorously oppose  the idea of the
autochthonous origin of the disease.   We shall see, as we pro-
ceed, that additional arguments may be adduced in support of
the views of  this latter class, which serve to render the theory of
development de novo extremely questionable, if not improbable.

                          Etiology.
   Glanders in horses is a specific infectious disease,  the  spon-
taneous origin of which has not been demonstrated.
   Glanders  and farcy  are perfectly identical  affections,  both
equally  contagious, and differing only in  their local  manifesta-
tions.   Farcy is nothing but  the cutaneous eruption incident to
glanders, and is  often  only a secondary manifestation, bearing
about the same relation to the other phenomena that the ery-
thema  and  specific  papules do  to syphilis.    The  distinction
between glanders and farcy, recognized by most authors, has its
origin in certain clinical  requirements, and is not founded upon
any scientific mode of classification.  We might, with as  much
propriety, designate the pulmonary phenomena of glanders as a
separate affection.
   The contagiousness of glanders is at present almost univer-
sally admitted to be one of the most clearly demonstrated facts
in the pathology of animal diseases,  and yet the successful pro-
duction of an infection is dependent, in a measure, upon indi-
vidual susceptibility, the extent of which must always be uncer-
tain ; this  factor is of less importance,  however, than is com-
monly supposed.
   Lamirault1 placed 138 healthy horses among glandered  animals, where all were
fed together, groomed with the same instruments, and, furthermore, worked in the
1 Hering, Canstatt's Jahresbericht f. d. J. 1849, p. 35. 
GLANDERS  IN HORSES.
32J
same harnesses.  Of this number, twenty-nine only (twenty-one per cent.) became
infected—twenty-eight with glanders, one with farcy.  Of twenty-three horses in
which direct attempts at inoculation were made, eight only, or thirty-five per cent.,
became infected.  In like manner, Bagge and Tschering1 having in five cases intro-
duced the infectious material beneath the skin, succeeded in producing in but one
case only any positive result.

   Observations  have thus far failed  to determine  the exact
mode in which the virus of glanders penetrates the system.  It is
believed  that  the virus having become attached to the mucous
membrane, or the unabraded skin, sets up  first at that  point a
local process,  and thence forces  its way subsequently into the
remainder of the economy.   It is  a well-anthenticated fact, that
contagion is often produced  by bringing in contact diseased and
healthy animals, and, furthermore, by placing sound animals in
stalls that have been previously occupied by those diseased.
   Reasoning  upon a priori  grounds, and from analogy with
similar morbid  poisons,  it  seems,  indeed, improbable that the
virus of glanders  can be introduced into the system through the
unabraded  cutaneous and  mucous  tissues,  and the  results  of
the  experimental  researches above alluded to serve only to in-
crease  these doubts.   There  are upon  record, however, still
further experiments, the results of which  render it possible that
the commonly received opinions upon this point are fallacious.
If it were  the fact  that the virus  of  glanders is, as a  rule,
communicated by direct  contact,  we should naturally expect  to
find, on  the one hand,  a  more  frequent  development of the
cutaneous eruption, while, on the other hand, the mucous mem-
brane in  the immediate vicinity  of the nostril would,  with a
certain  degree  of regularity,  form  the seat of tubercles and
ulcers.
   We  have been instructed, however, by clinical as well as  by
anatomical observations, that the cutaneous phenomena of glan-
ders seldom2 make their appearance as a primary symptom, and,
moreover, that the ulcers found in the mucous membrane of the
nasal cavity are located, as a rule, in the  upper portion of that

  1  Hering, Ibid. f. d., Jahr., 1859. p. 24.
  a There occurs upon the average one case of the specific cutaneous eruption in every
ten cases of glanders.
          VOL. III.—21 
^22      BOLLINGER.—INFECTION BY  ANIMAL POISONS.

cavity, extending thence downward toward the orifice.   And if
we assume  the existence of an  abrasion of the skin or  mucous
membrane to be essential to the introduction  of the infecting
principle into the economy, we are  again met by the fact that
the portion  of the nasal cavity the least protected, and for that
reason the most frequently exposed to injuries, is in reality the
part that in exceptional cases only forms the seat of ulcers.  It
will be found, moreover, that the  specific nodules and ulcers indi-
cate no preference for those points that are shown by experience
to be the most common seat  of  abrasions, cracks, and excoria-
tions.
   In denying, then,  the correctness of the  prevalent belief, that
the mucous tissues of the nose form the usual point of entrance
of the infecting principle of glanders,  we are almost of necessity
forced by these reflections to admit the possibility of the  absorp-
tion of the  virus together with  the inspired air, and in  many
instances, also  with the food.   Inasmuch as the lungs,  the
trachea,  the larynx, and the upper  portions of  the  nasal cavity
are known to form the usual seat of the primary lesions, we are
justified  in  concluding, that  in  a large proportion—possibly a
majority—of all cases  of glanders, a volatile infecting virus'
has found its way into  the economy, together with  the  inhaled
air, producing either a primary blood-poisoning with secondary
specific phenomena in  the parts above described,  or primary
nodules  and ulcers in the lungs, followed subsequently by the
symptoms of general poisoning. The mucous membrane of the
nose may, indeed,  be primarily  infected, when that part hap-
pens to be the seat of a wound or erosion.
   This volatile property of  the virus of  glanders, which has
thus far  been either imperfectly appreciated,  or not at all recog-
nized, was first demonstrated about the end of the last century,
through  the brilliant researches of Viborg, whose observations
were at a more recent date confirmed by Gerlach.
  1  It may as well be distinctly stated here, that by the term volatile infectious matter,
it is by no means intended to convey the idea of a gaseous substance.  The agent may,
however, be of a corpuscular character, and so light as to be capable of being caught
up by the ah and carried for a considerable distance. 
GLANDERS IN HORSES.
323
   Viborg (Viborg's Sammlung, II. p. 347) succeeded in producing glanders in a
number of horses by inoculating them with the condensed exhalations and sweat of
glandered horses.  Similar results were attained by Gerlach (Jahresbericht f. 1868,
p. 117).  The negative results of the experiments of Hertwig and Regnault (Gaz.
des Hopitaux, 1861), by whom the noses of healthy and glandered horses were kept
in contact by means of a leather band, are to be attributed to the inferior degree of
susceptibility of the animals upon which the experiments were tried; and they
argue just as little against the volatile nature of the virus, as, for example, do the
negative results obtained by J. White l against direct infection.  White inserted a
piece of linen, saturated with pus from a diseased  animal, within the nostril of a
horse, and allowed it to remain there for a considerable length of time without com-
municating the disease.

   The recognition of the volatile character of  the  virus of glan-
ders tends to strengthen materially the theory of its spontaneous
origin.   Upon this question some light  is thrown, first,  by those
cases in which  the contagion  proceeds  from animals exhibiting
neither  a  discharge from the  nasal  cavity nor cutaneous symp-
toms,  but suffering  rather from  the  specific  pulmonary  phe-
nomena, and second, by those instances in which  the latent, or
quiescent  form of  the disease  is developed in  healthy animals,
which having had the poison implanted  in their system, present,
externally, the picture of perfect health, and only after a consid-
erable interval, extending it  may be to months, begin  to mani-
fest the specific affections of the nose, skin,  and glands.  These
last cases  then are commonly reported and cited as affording sat-
isfactory evidence of the origin de novo of glanders.
   It not  unfrequently happens that a post-mortem examination
reveals the fact that  the ulcers of the nose and the affections of
the cutaneous surface are absent;  but  that,  on the other hand,
the larynx, bronchi, and lungs form the  seat of specific ulcers
and nodules.   This phenomenon can only be  explained upon the
hypothesis that contagion  took place through the  medium of
some volatile  poison, or else that the primary alterations in the
external parts of  the body had healed, while the secondary phe-
nomena only remained.
   Experimental evidence of the correctness of this view is like-
wise afforded  by the circumstance that  in the case also  of  other
1 Compendium of Veterinary Art 
324      BOLLINGER.—INFECTION BY ANIMAL  POISONS.

animals which evince an  affinity for the poison of glanders, the
nose forms the favorite seat for the specific local manifestations,
in  whatever way the poison may have  found its  way into the
body.
   On March 28th, 1873, I inoculated the ear of a rabbit with fresh  infected pus
taken from the nose of a horse.   The animal died in about three months.  The
autopsy showed the presence of specific uclers upon the ear, with  partial disorgani-
zation of the cartilage; inflammation of the corresponding lymphatic vessels;
specific nodules of the frontal bone and sinuses, and finally, tubercles and ulcers of
the  mucous membrane of the nasal cavity.  On November 21st, 1873, I inoculated
a goat with the puriform secretion formed upon an ulcer in the nose of a horse, the
virus being implanted  by injecting the substance, diluted with water, into the
abdominal cavity.  At the expiration of seven weeks, there were produced in the
animal specific ulcers of the nose, accompanied by a profuse purulent discharge
from that organ, lymphangitis of  the corresponding lymphatic vessels, and lympha-
denitis of the laryngeal glands, forming, in a word, the typical clinical picture of
acute glanders.  There were found also at the autopsy numerous specific nodules in
the peritoneum, spleen, lungs, and various muscles.

    It has also been determined that the virus of glanders, in the
form of a fixed infectious material,  may  be  found not only in
the specific products of disease (the secretion  from the nose, the
solid and fluid contents of the nodules  and ulcers), but  also in
the blood1  (Viborg,  Coleman, Hering,  Chauveau), and  in  the
secretions and excretions of the diseased body, for example, the
tears, saliva, sweat, urine,  and milk.
    The communication of the morbid poison by means of exter-
nal media, especially the harness, has been frequently observed.
Some cases are  also known in which the  disease was communi-
cated by the act of coitus,  by suckling, by hereditary transmis-
sion, and  finally, by the absorption of the poison together with
the food.  The nasal discharge, when taken into the stomach with
the food, appears, however, to be less capable of  producing in-
fection than are the exhalations from  the lungs (Gerlach).
    All varieties  of  glanders, both acute and  chronic, are in an
   1 It is also true, however, that attempts to inoculate  the disease by means of the
blood are in many instances unsuccessful (Hering, Gerlach).  I once injected beneath
the skin of a rabbit several grammes of fresh, warm blood, taken from a glandered
horse that had been just killed.  The rabbit remained perfectly unaffected. 
GLANDERS IN HORSES.
325
equal degree infectious, although the infectious properties of the
acute form are regarded by many as the stronger.   If a horse
affected with the chronic form of glanders be inoculated with pus
taken  from another  horse suffering with  the acute form, the
result is negative (St.  Cyr); this serves to demonstrate the unity
of the various forms of glanders, wliich in reality are only differ-
ent manifestations of the same morbid process.
   We come  now  to  consider the  question of  the spontaneous
development of glanders,  a point  that,  as  we have already
remarked,  has not yet been absolutely proved.   While the
authorities of all countries admit  the possibility of this mode
of development, it has been  denied by  Gerlach alone.   Some
writers go so far even as to regard glanders as a form of pyaemia,
and consequently look  upon  the nodules found in the lungs as
embolic infarctions.  The non-contagionists, whose theories are
now, fortunately, completely  exploded, held it to be an estab-
lished  fact that glanders might be produced by all imaginable
causes, for example, by excessive exertion, colds, impure air, dete-
riorated food, overwork, injuries, long-continued general debility,
the sudden checking of the action of the cutaneous sweat-glands,
catarrh, inflammation of the lungs, influenza, and the so-called
"Druse"  (rhinitis).  The  contagionists,  while they  admit the
spontaneous origin of  the disease as a phenomenon of rare occur-
rence, are by no means disposed to consider this as  the common
mode of its development.  The difficulty of obtaining sufficient
evidence as to the mode of infection, especially when we consider
the chronic course of the latent variety of the disease, renders it
obviously impossible to trace  in each individual  case the spon-
taneous origin of the disease, and it must therefore be admitted
that the entire  theory of  spontaneous  development is  based
merely  upon the results of a few experimental researches of very
questionable value.
   The most significant experiments bearing upon this point are as  follows:
Renault and Bouley 1 injected into the  veins of a horse, selected for the purpose  of
experiment, healthy pus obtained from an issue that bad been established in another
sound animal.  Upon the sixth subsequent day there were developed upon the nose
specific pustules that were soon followed by ulcers.  Death resulted at the expira-
              1 Recueil de med. vet., Vol.  XVII., p. 257, 1840. 
326       BOLLINGER.—INFECTION BY ANIMAL POISONS.
tion of eight days.  The autopsy showed numerous nodules  in the lungs, with
tubercles and ulcers on the lining membrane of the nose.  The retro-inoculation of
another horse, by means of the nasal discharge of this animal, was followed by a
positive result.  Laisne ' claimed to have implanted glanders by the introduction of
healthy pus into the nasal cavity.   Erdt,2 who regarded glanders as a form of scrof-
ula, inoculated horses with scrofulous matter taken from the human subject, and
asserted that he had in this manner produced glanders.  Vines (loc. cit.) went still
further, alleging that he had seen  glanders induced in mules and asses  by various
irritating substances, for instance, by the injection of vitriol into the trachea, and by
the introduction of the blood of a rabid dog.

   In estimating  the true value of experiments of this nature, it
is important to bear in mind that  they all date  from a period
when pathological  anatomy, as  a  science,  was  in a primitive
state ; furthermore, that only a  single  instance of retro-inocula-
tion is  reported ;  and finally, that in cases of pyaemia produced
by embolism, structural changes  are frequently seen,  especially
in the lungs, very similar to those occurring in genuine glanders.
It will thus be understood how Hering,3 having injected pus into
the circulation, in  the case of horses, saw produced a series of
morbid changes that bore a strong resemblance to the  lesions of
glanders.  Furthermore, observers of even limited experience are
familiar with the  fact that  in the internal organs of old horses,
and especially in the lungs, peculiar tubercles and circumscribed
inflamed spots often occur that can easily be  confounded with
the lesions of glanders.  All assertions like that,  for instance,
made by Erdt, that there have been developed in the lungs within
sixteen days after inoculation tumors of the size of an egg, and
in part affected with amyloid degeneration, can hardly be brought
into harmony with general pathological experience.
   On the other hand, there might  be  quoted a series of experi-
ments, likewise made upon horses, in  which  different forms of
purulent and ichorous matter were introduced into the organism,
producing,  it is true, purulent deposits in the lungs, septicaemia
and pyaemia, but in no instance glanders.

   1 La clinique veterinaire, T. IV., p. 463, 1864.
   5 Die Rotzdyskrasie, etc. Leipzig, 1863.—The experiments of Erdt were made in
the years 1834 and 1835.
   ;' Ueber die Entwickelung der Rotzkrankheit.  Repertorium fur Thierheilk., 1871,
p. 10. 
GLANDERS  IN HORSES.
327
   In this connection may be mentioned the experiments of Leuret,1 who injected
putrid ichorous matter directly into the veins, and also into the subcutaneous cellu-
lar tissue of horses.   In this manner  he obtained, it is true, the appearances pro-
duced by putrid infection ; but nowhere does he make any allusion to alterations at
all characteristic of glanders.  Billroth 2 refers to a similar experiment upon a horse,
that was not followed by any symptom of glanders.  Giinther3 and Spinola4 made
injections of pus in horses without producing glanders.  Gaingee5 reports a case
of thrombosis of the vessels of the  lungs, with abscesses of these organs, occur-
ring  in a horse after the injection of pus into the jugular vein. Similar negative
results were obtained by Lee.6 Finally Waldenburg,7 in conjunction with Kohne,
inoculated several horses with tubercular, phthisical, and purulent substances, with-
out causing in a single instance the development of glanders.
   The experimental proof, then, of the development of glanders
from purulent processes is indeed meagre, and the clinical obser-
vations which appear to lend  support  to this  idea of the genera-
tion of the disease are  offset  by several facts in the history of
glanders, which  make it evident that an  imperfect familiarity
with the mode of development of  the affection forms the basis
upon  which the theory of  spontaneous development has been
constructed.  These phenomena, to which  too little importance
has  been assigned,  are, first,  the  long period, of incubation of
chronic glanders ;  second, the fact—of more frequent occurrence
than is commonly supposed—that the  primary lesions are  fre-
quently located in the lungs, bronchi, and larynx.
   Apart from my own experimental researches  above related,
which  show most  clearly that, where  glanders is  inoculated (in
rabbits and goats for instance), the discharge from the nose and
other  nasal symptoms generally make  their appearance  as  the
final phenomena, there may be found also in the history of glan-
ders, as  it  occurs  in  the  human  subject  (Kiittner), numerous
instances in which the  nasal  lesions  were  developed only after
the  chronic  affection  had  already existed for  a considerable
period.
      1 Archives generates de Med., T. XL, p. 98,  1826.
      2 Allg.  chir. Pathologie und Therapie, 5 Aufl., p. 97, 1871.
      3 Rust's Magazin fur die ges. Heilkunde, Vol. XXX., 1841.
      ♦ Handbuch der spec. Path. u. Ther., B. II., p. 1690, 1858.
      5 Hering in Canstatt's Jahresbericht f. 1855,  p.  13.
      6 Hering in Canstatt's Jahresbericht f. d. Jahr.. 1854, p. 14.
      ' Die Tuberculose, die Lungenschwindsucht, etc., p. 540.  Berlin, 1869. 
328       BOLLINGER.—INFECTION  BY ANIMAL POISONS.
   It is a fact, more generally noticed, that glanders may be communicated by
horses which have not evinced  any symptoms of the malady; in which case the
trouble  was  called by the  old  writers (Viborg and others)  concealed  glanders.
Hering, Loloff, (loc. cit.) and Gerlach affirm that the lesion of the lungs may exist
for a considerable length of time without being accompanied by any trace of nasal
symptoms.  Jesscn ' succeeded in producing glanders, by transferring some of the
substance of a specific nodule from the lung of a horse in which this was the only
lesion found.  Similar views are  held by Goubaux,2 who alleges that in horses the
alterations peculiar to that disease may be confined to the lungs and spleen.  Bagge3
found, upon examining 107  horses of a  Danish regiment that were killed within a
period of three years, in consequence  of being glandered, or having suspicious
symptoms, that in the  case of 10 there were decided structural changes (ulcers of the
nasal cavity) ; in 13 the alterations were moderately pronounced ; in 53 there were
merely nodules in the lungs, and  a few ulcers of the air-passages (this number were
to all appearances healthy during life) ; and finally, in 33 animals no lesions what-
ever were found.

   In view of all this  evidence,  it may be  laid  down as a settled
fact that  our  notions respecting  glanders have hitherto been
formed too exclusively from the contemplation of the clinical
features of the disease, that is, from the affections of the skin
and nose appreciable during life, whereas equal significance, at
least, ought  to be attached  to  the lesions of the lungs that are
almost invariably coexistent, and,  furthermore, to the structural
changes in  the trachea and larynx, that are  not  unfrequently
encountered in carefully conducted autopsies.
   An equally important  cardinal  point,  it would appear, but at
the  same  time  one  to  which  comparatively  little  value  is
assigned, is the circumstance that the lesions of the lungs consti-
tute quite  as often the  primary symptoms, in  chronological
sequence, as do the changes  in  the nose  and skin.   In the light
of our present anatomical and pathological  experience, I am
compelled  to deny, then, the  correctness of the theory  enter-
tained by Virchow and others, that the mucous membrane of the
nose forms the point of entrance of the virus into the system in
as large a proportion of cases as do the genital organs in the case
of syphilis.   I should in like manner dissent from the opinion of
1 Thieriirztl. Mittheilungen, 1868, p. 14.
2 Hering in Canstatt's Jahresbericht f. d. Jahr 1859, p. 24.
3 Ibidem f. d. J. 1863, p. 25. 
GLANDERS IN  HORSES.
329
Virchow (loc. cit.,  p. 550)  that  the  lesions of the lungs form, as
a rule, the final phenomena of the disease.
    To illustrate more clearly my views upon this  point I will
quote as evidence  abstracts  from some post-mortem  examina-
tions :

   1. A horse was taken down with swelling of the right hind foot;  a  moderate
mucous discharge from the nose was observed ; at  times cough and fever.  As the
swelling increased in severity, the fever likewise became more intense, and emacia-
tion increased.   The animal was therefore destroyed as incurable.
   Autopsy, 30th October, 1871:  Subacute glanders of the larynx, air-passages, and
lungs.   Nasal cavity quite intact.  In the larynx extensive ulceration,  with partial
destruction of the vocal cords and the greater part of  the mucous membrane of the
larynx ; necrosis of the arytenoid cartilage.  On the upper part of the air-passage
numerous characteristic  ulcers.  Several tubercles and nodules in the lungs, varying
in size from  a hemp-seed to a walnut, the central portions of  which  were  partly
broken down.  Inflammation of the lymphatic glands and vessels of the right hind
foot.  Mucous membrane of the nose and adjacent cavities quite unaffected.
    2. A nine-year old horse, well nourished,  was led into the  clinique, with symp-
toms of great dyspnoea.  The animal presented a nasal discharge  from the nostril
of each side; moderately high fever;  respiration and pulse accelerated; temperature,
104° F.; had a weak, painful cough.  The opinion was formed that there existed
in the larnyx some obstacle to respiration (oedema of the glottis  or muscular  para-
lysis), and tracheotomy  was resorted to, which was followed by an amelioration of
the  symptoms.  The animal was killed upon the eighth day after coming under
treatment.
    Autopsy, March 27th, 1872:  Chronic and subacute glanders of the larynx, acute
glanders of the nose, air passages, and lungs.   Upon the right and lower side of the
septum nasi, an ulcer of recent formation was  found, in the vicinity of which, above
and below, were several similar though smaller  ulcers.  Well-marked swelling of
the  retro-pharyngeal and laryngeal glands, which organs were studded with specific
tubercles.  Excessive oedema of the glottis.  The entire inner surface of the larynx
transformed  into one large  specific ulcer that was  partially covered  with granu-
lations.  The arytenoid cartilage denuded for the most part  on both sides, and
necrosed.   Confluent miliary tubercles in anterior edge of left lung.
    3. Autopsy,  March 28th, 1873: Chronic glanders of the larynx and lungs; acute
glanders of the nose, with swelling of the laryngeal glands.  Upon the right side of the
septum nasi, small, recently formed  ulcers, with a few tubercles in the immediate
vicinity; similar appearances also upon the right  conchse.  Considerable enlarge-
ment of the laryngeal glands upon the right side.   In the larynx, at a  point corre-
sponding to the inner surface of the left arytenoid cartilage, a funnel-shaped ulcer,
about four-fifths of an  inch  in diameter, whose base was  formed by the exposed
necrosed cartilage.  At  a corresponding point on the right side was a stellated cica- 
330      BOLLINGER.—INFECTION BY ANIMAL POISONS.
trix, while a  segment of the cartilage was wanting.  In the lungs, tubercles and
nodules, varying in size from a hemp-seed to a walnut, composed in part of firm
cicatricial tissue, at points caseous and calcified.

         NATURE OF THE  MORBID POISON  OF GLANDERS.

   The question as to  the nature of the  infectious  principle in
glanders, as well as in other  infectious diseases, still remains to
be solved.
   The discovery  of  the presence of a parasitic growth  in the
nasal  discharge of glandered  horses  was  long since made (B.
Langenbeck).   This parasite, known as puccinia, proceeds from
the fodder, and may be detected in almost every nasal secretion.
More  recently,  still  lower parasitic  organisms—bacteria—have
been described by different authors as  found in both horses and
men when affected with glanders, and believed  to be intimately
connected with the materies morbi.   The researches of Christot
and Kiener, Hallier,3 Ziirn,3  Rindfleisch,4 and  others, all relate
to this  point, some of these writers describing the parasite as
existing in the blood, others finding it in the pus of the ulcers
and abscesses.
    I have  already stated in another work,5 that having examined
most carefully the fresh nodules found in glanders, and the fresh
blood of horses suffering from this disease, I have never been
able to verify the  assertions of these writers.   The virus of glan-
ders induces  a  catalytic  action,  as has already been  demon-
strated  by Franck,6 similar in this respect to the infecting prin-
ciple of syphilis and small-pox (Schonbein), resolving peroxide
of hydrogen into water and oxygen.
    The poison of glanders is fixed and volatile.  It adheres first
of all to the specific products of the disease, the solid and fluid
portions of the nodules  and  ulcers in  every stage of their devel-

   1 Comptes rendus, LXVIL, No. 21, p. 1054, 1868.
   2 Bayer. Aertzl. InteUigenzblatt, 1868, No. 25.
   3 Zoopathol. Untersuchungen, 1872, p. 36.
   'Lehrbuch der pathol. Gewebelehre, 2 Aufl., p. 204,  1871.
   6 Beitrage zur vergleich. Pathol., II., p. 143. 1872.
   6 Thierarztliche Mittheilungen der Mtinchener Thierarzneischule, Heft XIV., p. XL,
1867. 
GLANDERS IN HORSES.
331
opment, also to the blood, the secretions, and probably to all the
tissues of the diseased animal that are  permeated by the blood
or other fluids.  The volatile infecting principle differs essen-
tially in its mode of action from that of various other infectious
diseases, attaching  itself for the most  part  to the  exhalations
and sweat of the diseased animals.  According to the researches
of Chauveau,1 with regard to the  diffusibility of  the  virus  of
glanders,  the  materies morbi  is  contained  not in the  serum
but  exclusively in the organized bodies (pus and other corpuscu-
lar elements) suspended in the animal  fluids.  This hypothesis
does not conflict with the  volatile character  of the poison, and
will be found, moreover,  to harmonize with the known phe-
nomena of other morbid  poisons.  Upon the other hand, the
chemical property of  this virus is held (Virchow) to be the more
important, being regarded as acrid and irritating.
   The virus of glanders manifests a pretty strong tenacity for
life ; for although in a dried condition its activity is frequently
diminished (Viborg), it is often found to be effective after having
remained for many months in stalls.  If exposed in water to a
temperature of 133° F., it loses  its virulence  (Viborg, Hofacker,
Renault),  and the same effect is produced by  a number of chem-
ical  agents  (disinfectants),  such as chlorine,   carbolic acid, etc.
Its activity is  said to  be  destroyed by decomposition (Gerlach).
While it loses its virulent property when taken  into the diges-
tive  canal  of  man (Decroix), dogs, swine, and fowls (Renault),'
in the case of  horses its activity is impaired,  but not destroyed.
   Probably no special conditions are required for the spread  of
the poison by  intermediate vehicles, such as harnesses and other
objects  that are  saturated with  the virus.  It belongs to that
class of morbid poisons  which are only multiplied within the
infected body (entogenous).
   The diffusion  of  the virus within the organism itself is pro-
duced  partly through the agency of  the blood-vessels,  lym-
phatics, and serous  canaliculi; partly also through the  medium
of the inspired air—for instance, from  the nose to the larynx,
bronchi, and lungs, or vice versd.
                 1 Recueil de med. veter., 1861, p. 161.
                 2 Recueil de med. veter., 1851, p. 873. 
332       BOLLINGER.—INFECTION BY ANIMAL  POISONS.


              COMMUNICABILITY TO OTHER  ANIMALS.

    Glanders prevails  not only in horses,  but  frequently occurs
also in other animals belonging to the same general species (asses
and mules), and is also communicable to man and the entire class
of domestic animals, with the exception of cattle.
    Sheep are especially susceptible to the poison of glanders (Gerlach reports a case
which ended fatally in fifteen days), as are also goats (Ercolani observed a case of
spontaneous  infection in a stall in which infected horses were kept).  Wirth saw a
case of infection by inoculation  ending fatally in  twenty-one days; I myself wit-
nessed a well-marked case of glanders in a  goat developed  in  seven weeks after the
peritoneum had been inoculated.  As  regards dogs, which manifest on the whole
only a slight affinity  for this virus, there results after inoculation  a local infection
(Gerlach, Delarbeyrette,  Decroix);  Nordstrom observed spontaneous infection in
the case of a dog that had eaten infected meat.  In the  cat, glanders  may be pro-
duced  by inoculation (Christot and Kiener) ; also by the consumption of infected
meat (Gerlach); to which latter mode of infection prairie dogs, polar bears (Leiser-
ing), and lions (Leisering, da Silvestri) are susceptible;  rabbits may become diseased
either by being kept in an infected stall (Rivolta) or by inoculation' (Schilling,
Colon, O. Wyss, Bollinger).   Finally, guinea-pigs (Christot and Kiener) and mice
(Ercolani and Bassi)  are susceptible to  glanders.   Gerlach has produced in swine,
eight months after inoculation, a morbid growth similar to that which occurs in the
lungs of the horse ; but in no case were these local lesions  accompanied by general
constitutional symptoms.  Spinola, on the  other hand, has observed cases of glan-
ders occurring in swine.
   Glanders  may likewise be produced in horses by retro-inoculations, either from
animals in which the disease has been implanted in the manner above described, or
from the human subject.

          DISTRIBUTION AND  FREQUENCY OF  GLANDERS.

    Glanders appears to occur among horses in all localities where
these  animals are found, while its dissemination and frequency
in  the different  countries of Europe  depend  chiefly  upon  the
sanitary measures adopted by local authorities.  In cold climates
{e.g.,  Sweden)  it prevails   as extensively as  in  hot regions
(Algiers, Tunis,  Tangiers) ; in Java it is of common occurrence.

   Dupuy (compare Vines) erroneously  supposed  glanders  to  be  unknown  in  hot
climates.   In countries where there exist  properly qualified  medical boards,  and
efficient sanitary regulations capable of dealing with the infectious diseases of  ani-
            1 Gerlach inoculated rabbits with uniformly negative results. 
GLANDERS  IN HORSES.
333
mals, the animal mortality from glanders is comparatively small.   Hahn ' calculates
from statistics kept for a period of nine years, that 175 horses are annually destroyed
in Bavaria by glanders (equivalent to four per cent., estimating the entire number
of horses in that country at about 400,000).  Up to the  middle of the present cen-
tury glanders raged in the  French  army to such an extent that when the rate of
annual mortality amounted  to 75 in a thousand, 35 of  these deaths resulted from
this disease.  Not until the idea of curing the disease was abandoned, and its con-
tagiousness was gradually recognized, did the total mortality fall from 75 to 44.5 in
a thousand, and the number of those affected with glanders from 35 to 20.2 in a
thousand (Castelnau).2
   Glanders prevailed in France in the form  of an epizootic in 1776, 1807, and
1808 (Erdt, p.  61).  At Mezohogyes, in Hungary, in one  of the largest studs in
Europe, glanders raged in the form of an epizootic from the year 1808 to 1816, to
such an extent as  to cause the death  of nearly 20,000 horses.   In the year 1812
alone, as many as  12,000 were  killed in consequence of being  glandered. This
immense loss is to be attributed to the fact that the contagious nature of the disease
was not suspected
                      PATHOLOGICAL ANATOMY.
    Glanders is characterized anatomically  by the formation  of
neoplastic  growths which appear either in  the form of  circum-
scribed tubercles developed  in parts for which they have a pecu-
liar affinity, or else as diffused  infiltrations  in certain  organs.
The nodules of glanders and farcy were formerly regarded as the
result  of deposits or exudations from the  blood,  and Virchow
was the first (1854) to  demonstrate that these  lesions were  of
neoplastic  origin.  These  conclusions, which his later work upon
tumors established  upon a  broader basis, were fully confirmed
by the researches  of Leisering, Forster, and others.
    The neoplastic growths   of  glanders  are characterized  by a
great  tendency to disintegration, as  well  as to the formation of
ulcers  and abscesses, and are located in the mucous membrane
of the organs of respiration (nose, larynx, bronchi), in the lungs,
in the skin and subcutaneous cellular tissue, and less frequently
in the other internal  organs (liver,  spleen, kidneys).   A  char-
acteristic sign in the case  of horses is the symmetrical manner in
which  the   corresponding  lymphatic vessels  and  glands are
affected.
   1 Beitrage zur Statistik der Seuchen in Bayern.  Thierarztl.  Mittheilungen der
Munchener. Th. A. Schule, H. 17, p.  83.
   2 Moniteur des Sciences medicales,  1861. 
334      BOLLINGER. —INFECTION BY ANIMAL POISONS.
    The tubercular form of Glanders.—If the mode of  develop-
ment of the tubercles upon the mucous membrane  of the nasal
                                cavity is carefully studied at any
                                one place, there will be observed at
                                first miliary and submiliary ele-
                                vations projecting from  a more
                                strongly   injected  background,
                                and  rendered  visible by  their
                                turbid-white  or yellowish-white
                                opaque  central portion.  These
                                points  gradually  enlarge, vary-
                                ing in size from a pin-head to a
                                hemp-seed, and appear either iso-
                                lated or united in  larger groups.
                                Upon  careful observation  there
                                may often be seen a gray, trans-
                                parent  zone around  this  turbid
                                white  centre, and beyond this a
                                faintly marked red areola.  Up-
                                on  section  these tubercles appear
                                succulent,   of  a  grayish-white
                                color,  while  the  centre  seems
                                somewhat  turbid, and frequently
                                softened.   In consequence of pur-
                               ulent degeneration of the super-
                               jacent mucous membrane there
                                ensues  a  slight erosion, and a
small,  isolated ulcer is rapidly formed.  The small ulcers thus
developed  soon enlarge, presenting an eroded base  and slightly
everted edges.  The confluence of adjacent ulcers  results in the
rapid formation  of larger ones, upon the base  and edges of
which new tubercles arise,  and these in turn by their rapid dis-
integration  contribute  to the enlargements of the ulcers.   The
surface of  these  glistening ulcers is for the  most part  covered
with a yellow-white puriform secretion, frequently foul-looking,
and tinged with blood.   These ulcers, after they have existed for
some time, are apt to  attack the cartilage and  bone, producing
more or less destruction  of these tissues.   Alterations precisely
            Fig. l.
  Extensive ulcers of the mucous membrane of the
walls of the nasal cavity of a horse. The base of
the ulcer corroded, the edges everted, and stud
ded with tubercular growths. Toward the lower
edge small ulcers of more recent formation, with
tubercles in process of being transformed  into
ulcers. 
GLANDERS IN HORSES.
335
similar are often also noticed within the cavities in the vicinity of
the nose, and in the larynx and bronchi.
   Microscopically these specific miliary tubercles are in reality
composed of round cellular elements, not to be  distinguished in
most cases from pus-corpuscles,  and  approximating  in appear-
ance,  especially  in chronic glanders, to
the pale and somewhat larger granulation
cells.   Whether these cells are formed by
the growth of pre-existing elements, or by
migration of the  white blood-corpuscles
from the vessels, is in the present state of
our knowledge not to be determined.
   There results,  in consequence of  the
softening of the tissue,  and the granular
and purulent  degeneration  of  the newly
formed cell elements, a central  disintegra-
tion of  the  papules, while in other cases
an ulcerative process is established.  These
ulcers, in the  case of  chronic glanders,
may heal, being transformed into stellated
cicatrices;  in  most instances, however,
there are produced in the neighborhood a
continuous  succession of  new tubercles
and ulcers.
   The  specific tubercles of the lungs, in
the early stage of their formation, bear a
very  close resemblance, when viewed with  the naked eye,  to
miliary tubercles; they are, however, never  found in so large
numbers as in the  miliary tubercnlosis  of man.    They  are
composed, at  first,  of  a  cloudy-white or pale-yellow, puncti-
form, central portion, encircled by  a grayish, translucent zone,
which in turn  is surrounded by a red, inflamed, and hypersemic
areola.   Microscopically, these tubercles  consist of a  vascular,1
delicate stroma, filled  throughout  with  numerous round cells
        Fig. 2.
  Acute ulcers in the mucous
membrane of the bronchus of a
horse. The base of the ulcer greatly
excavated, and the edges consider-
ably everted.  At one point a tu-
bercle may be seen in process of
being converted into an ulcer.  The
other ulcers are partially confluent.
   1 Leisering demonstrated, by means of artificial injections, the existence of blood-
vessels in the nodules of the lungs found in glanders.  I myself saw in one nodule,
which  had become injected by natural means, large capillaries distended with blood,
very similar to the newly formed capillaries in the granulations of wounds. 
336      BOLLINGER.—INFECTION BY ANIMAL  POISONS.

crowded tog«ether in clusters,  and presenting  the appearance of
pus-corpuscles or ordinary granulation cells.   In acute glanders
they attain, at the  most, the size of a pea; in the subacute,  or
chronic course  of the disease, they become  larger,  varying  in
size from a walnut to an apple, and  then assume often in part a
fibroid structure.
   From the fact that these  nodules and tubercles have an  irri-
tating effect upon the surrounding tissue, marked inflammatory
changes are found, in the acute stage  of the  disease, involving
the parts in their immediate vicinity ; these changes take on the
form  of a circumscribed desquamative pneumonia, combined
with  vitreous, hyaline swelling of the  tissues, and considerable
distention  of  the blood-vessels.  At  a later  stage in the progress
of the disease, there is often formed a  capsule of connective tis-
sue around the  tumors,  which then show signs  of fatty or case-
ous degeneration, calcification, or gangrene.
                              Fig. 3.
  The indurated cicatrized portions of the mucous membrane of the septum nasi, the sequela of healed
ulcers. These parts present a white, glistening appearance, and are but meagerly supplied with blood-vessels,
while their surface is rendered uneven by the stellated cicatricial bands of connective tissue, all of which con-
verge toward a common centre.  Towards the left, and lower down, fresh ulcers of a more recent crop.

   In the  cutaneous variety of glanders, or farcy, the  specific
nodules are located in the cutis, or else in the subcutaneous cel-
lular tissue, and penetrate  frequently into  the muscles.  They
vary, moreover, in size, from a pea to a cherry,  those of  most re-
cent formation being usually overlooked.   They are not sharply
defined from the surrounding tissue.  Their  minute structure is
the same as that  of the nodules of the nose and lungs.   The 
GLANDERS IX HORSES.
337
process of  central disintegration  advances  rapidly,  the super-
ficial openings giving rise to the so-called farcy ulcers, wliich
have an eroded and generally  foul  appearance,  discharging a
creamy  secretion  of  a grayish-yellow color,  frequently tinged
with blood.   With these phenomena there is generally combined
an  inflammation of the lymphatic ves-
sels, wliich become distended by a yel-
low, purulent liquid, and are decidedly
thickened,  so as  often to resemble a
string of pearls (" farcy  buds").  The
corresponding  lymphatic  glands are
similarly affected,  becoming enlarged in
cluster form, at some points taking on
a form of hyperplastic swelling, and at
others being studded with miliary tuber-
cles.   In the  chronic variety the lym-
phatic glands become indurated, in the
same manner as is observed in the infil-
trated form.
    The infiltrated form  of  glanders,
inflammatory glanders {diffused glan-
ders. Roll).—This variety of  neoplastic
formation is found most frequently in
the  mucous  membrane  of  the  nose,
and neighboring cavities ; less often in
the  larynx and bronchi, and more  fre-
quently again in  the lungs,  skin, and
subcutaneous tissue.  In many respects
it resembles ordinary inflammatory pro-
cesses.   Tubercular growths  are,  as  a
rule, found in  the immediate vicinity.
Patches of the mucous membrane of the
nasal cavity,  varying in  size, become
livid, swollen, and infiltrated with a gel-
atiniform serous liquid, the result of a
diffused deposit of  round cellular ele-
ments in the cavities and interstices of the connective tissue.
   As in ordinary  diphtheritic infiltrations, there is produced, in
          VOL. III.—22
         Fig. 4.
  An elongated cicatricial band,with la-
teral projections, situated in the mucous
membrane of the septum nasi, found in
a horse affected with chronic glanders.
The cicatricial tissue firm, white, glis-
tening, poorly supplied with blood-ves-
sels, forming a long, strong band, with
here and there radiating projections,
which,  on the right,  enclose several
small ulcers in process of repair. On
the left, an isolated ulcer, likewise in
process of healing. 
338       BOLLINGER.—INFECTION  BY ANIMAL POISONS.

consequence of  the  excessive deposit of cellular elements, gan-
grene of the tissue, recognizable by the excoriation of the super-
ficial integument and the formation of ulcers.
   In  this  manner are formed extensive checkered ulcers, the
bases of which project above the level of the mucous membrane,
the  edges  being slightly raised.   These  formations  are often
designated  diphtheritic ulcers.  Frequently solitary points only
of the superficial surface are  involved in the ulcerative disinte-
gration  now beginning.   In  the  immediate  vicinity  are often
found very small tubercles or small  infiltrations varying in size
from a  hemp-seed  to  a bean;  in   other cases the  tubercular
growths may be altogether wanting.
   It is  significant, therefore,  that these checkered ulcers, which
attain frequently the size of the palm of the hand,  should  have
been formed, not by the confluence of  numerous isolated tubercles
and  ulcers, but in the manner above described.   The surfaces of
                              Fig. 5.
fin ^P0*?^0 no.d"1es °f the skin (" farev buds"), a and ft. nodules as seen in perpendicular section : the abscesses
filled with thickened pus are in both instances enveloped in a dense capsule of connective tissue: at a, on
the point of bursting, c, " farcy buds." with central puriform softening: capsule of connective tissue seen
from within,  d, farcy ulcer of the skin.


these ulcers present likewise an eroded appearance, generally of a
cloudy-white  or  grayish-white  color,  and  in many instances
having a pale red hue. 
GLANDERS IN HORSES.
339
    A more frequent result of these infiltrations is induration and
the formation of cicatricial tissue.   In that case the mucous mem-
brane of the nose at the points affected becomes more or less
firm, indurated,  and  of  dark-brown hue,  while on  the surface
may be seen,  according  to the  extent  of the loss  of the tissue,
either cicatrices of diverse shapes, for the most part stellated, or
a smooth, shining, epithelial covering.   Upon making a thin sec-
tion of such an indurated mucous  membrane, it is found  to  be
composed of connective  tissue, more or less  rich in cellular ele-
ments, with recently formed vessels,  but  devoid  of mucous
glands.   These specific cicatrices and callosities represent, there-
fore, ulcers that have  been actually healed  ; the former may also
be  produced  in  another manner,  from isolated  ulcers formed
from the disintegrated papules.

   These specific infiltrations occur exclusively in the  chronic variety of glanders,
and were first accurately described by Leisering, whose views on this point were
corroborated in the main by Virchow.  The latter differed from Leisering in this
respect only, that he admitted  the possibility of  genuine specific cicatrices being
formed from ulcers, whereas Leisering maintained  that the cicatrices produced by
the infiltrations were not to be regarded as evidences of healing specific  lesions, but
merely as a special form of  neoplastic growth concomitant to the disease. My own
experience as regards this point  confirms  the views of Virchow, in accordance with
which the specific ulcers, whether developed from tubercles or from infiltrations,
are actually capable of healing,  and the  cicatricial tissue represents, therefore, the
effects of a reparative action.

    Before proceeding  to the consideration of  the specific infiltra-
tions of the lungs, it may be well to refer to one of  the most con-
stant and by no means unimportant complications which is often
encountered among the  different nasal phenomena of the glan-
ders.  This lesion  is  connected with the veins, especially those
found in the erectile tissue of the  septum  nasi, and consists  in
an extensive formation of thrombi in these vessels, accompanied
usually with thrombosis of  the lymphatic vessels.   The  obvi-
ously erroneous theory based upon this phenomenon, that acute
glanders is nothing else than a phlebitis of the nose {rhinophlebi-
tis), has already been exploded by Virchow.  On the other hand,
it must be admitted that  this secondary thrombosis of the venous
plexus of  the nose has indeed a by no  means unimportant influ- 
340      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

ence—more particularly in connection with the thrombosis of the
lymphatic  vessels—in the development of the specific lesions
found in the nose.  The  great extent of the infiltrations, their
persistent character, and  the  extensive swelling and  inflamma-
tion of the entire mucous membrane,  are  attributable, in part,
surely, in such cases, to thrombosis of the vessels.
   Specific infiltration of the lungs is of frequent occurrence,
especially  in  the subacute and  chronic  form of the disease.
This lesion is found in the vicinity of the tubercles and nodules,
and is observable most frequently upon the anterior  and lower
edges  of the lungs.  On account of the decidedly inflammatory
and exudative character of this change, it may be termed also the
pneumonia of  glanders {pneumonia malleosa), and  its resem-
blance, moreover, to the tuberculous infiltrations has been also
insisted upon by other writers (Virchow).  The parts attacked
appear at the outset to contain no air;  they seem to be infiltrated
with a gelatiniform substance of  a dull-white or cloudy-yellow
color,  and of  a pretty firm consistence.   They may  attain  the
dimensions of  a pigeon's or goose's egg, and in many instances
that of a child's heart.  The  histological alterations correspond
to those of indurative pneumonia.  The process may terminate in
partial puriform softening, caseous degeneration, calcification, or
also in ichorous degeneration, and finally  in an indurated neo-
plastic formation  made  up of connective tissue, whereby  the
entire  part  acquires a dense, firm appearance (carnification),
enclosing often regular cavities.
   The specific infiltration of the slcin, subcutaneous cellular
tissue, and neighboring  muscles  corresponds in general to  the
analogous process in the mucous membrane of the lungs, though
in the former parts  the lymphatic  vessels play a more  important
role.   The ultimate result is induration of  the subcutaneous cel-
lular tissue, and often the formation of ulcers and abscesses.
   Erysipelatous  sioellings   often appear in acute  glanders,
especially upon the  extremities;  these may  be regarded as an
acute specific infiltration.
   Before adverting to the less significant changes in the remain-
ing organs we will consider some of the concomitants and compli-
cations of the disorder occurring in the parts already referred to. 
                      GLANDERS IN HORSES.                   341

   The mucous membrane uniformly presents  the appearance of
some  catarrhal or  inflammatory  affection,  the favorite seat  of
this specific eruption being the septum nasi and the concha?.

   So far as my personal observations extend, in one-third of all cases of glanders.
both sides of the nasal cavity are involved ; in  one-third of the number the right
side alone is affected, while in the same proportionate number the left side  only is
diseased.

   The nasal  passages  are often distended and filled with thick-
ened pus, which fills also the cavities extending from the  nose,
especially those of  the frontal and maxillary bones.   The  latter
often exhibit, moreover, specific infiltrations, and  less frequently
a tubercular eruption.   The fact that the mucous lining of  these
sinuses, as well as of the  nasal passages, takes the place of the
nourishing  periosteum of the bony  walls  of these  parts, will
serve  to explain  how the bones  may become  implicated in the
inflammatory process—a feature  that is often  observed, appear-
ing  in the beginning as a deposition of bony matter, later as an
indurated hyperostosis.
   In  acute as well as in chronic glanders there is found in the
mucous membrane  of the larynx and bronchi, much more fre-
quently than  is commonly supposed, specific  tubercles, infiltra-
tions,  and ulcers, accompanied often by extensive destruction of
the tissues,  the results of which are indicated by  the loss of sub-
stance seen  in the epiglottis, and in the destruction of the  vocal
cords and the cartilages.

   In fifty-two cases of  glanders, I observed twelve times, equal to twenty three
per cent.,  ulcers  of the  larynx and bronchi;  and that this
calculation is in  reality  an under-estimate of the frequency
of the occurrence of this symptom, is shown by subsequent
and more exact observations made by me (in Zurich), where
in  eleven  cases, four only were free from these lesions of the
bronchi and larynx.  To these specific lesions then, wdiich, as
I  am inclined to estimate, may be detected in from fifty to        pIQ# D-
sixty per cent, of all attacked, too little attention by far has    specific nodule from a
hitherto been directed, a remark which is also applicable to   Tho'se^f" ^rettffirm
the pulmonary phenomena of the  affection.  A few  cases   ™^^dj^t£H
have  been  already referred to in which these organs alone   or softening.
were  invaded by the specific symptoms, the nose remaining perfectly intact, or at
 
342       BOLLINGER.—INFECTION BY  ANIMAL POISONS.
least  becoming only secondarily affected.  In fifty-two  cases of glanders  and
farcy, the lungs were perfectly sound in four cases only, equal to 7.6 per cent.; of
these, two were cases of farcy, one of acute glanders and farcy, and one of farcy
with  secondary nasal symptoms.  In the same  fifty-two cases, the nose remained
entirely free from disease in five cases.

   There is frequently  found as a concomitant disorder,  in lungs
affected  with  glanders, bronchitis in its different varieties, or
simple broncho-pneumonia, especially in  the anterior and lower
portion  of  the lung,  induced  by the settling of the bronchial
secretions.   It is a questionable point to what  extent this form
of  circumscribed  pneumonia,  which  has  its  chief  origin  in
mechanical influences,  can be included under the head  of  glan-
                       ders,  if  indeed it can be referred at  all
                       to this  process.   It is not uncommon to
                       meet with cases of cheesy pneumonia of
                       the lobular variety, induced,  as  I am in-
                       clined  to think, by an acute  or subacute
                       specific infiltration.
          fig. 7.            The specific nodules also occur in  the
 specific noduie from the liver of  large internal  glands, such as the liver,
a horse. The nodule is almost com-
pletely calcified, and enveloped in a  spleen,  kidneys,  and  testicles,   though
capsule of connective tissue.        -*•            %/ >               jo
                       with far less frequency than  in the  mus-
cles.  They are found in moderate  numbers lying  either  be-
neath the peritoneum  or  in  the parenchyma, and they  vary in
size from a pin-head to a pea, rarely being larger ; they are of a
grayish-white color, with a yellowish-white softened centre, and
surrounded with a dark red areola.
   In the liver these tumors have an especial tendency to calcifi-
cation.   In acute glanders, moreover, the above-named paren-
chymatous organs usually manifest, to a greater or less extent,
the lesions of the so-called cloudy swelling, with granular degen-
eration of the epithelial and glandular cells.
   Finally, leucocytosis of the  blood is  a constant accompani-
ment of glanders in horses.  The increase  of the white corpuscles
is in many instances so marked as to give  the appearance of leu-
caemia, this increase being manifestly due in a great measure to
the irritation excited in the lymphatic glands by the presence of
the  specific poison.   The parasites  detected by some in  the
 
GLANDERS IN HORSES.
343
blood of glandered horses, I have not been able to find in the
blood of living animals ; on the  other  hand,  bacteria are fre-
quently seen  in the  blood of horses  a  few hours  after death,
independently of the disease  with which they may have  been
affected.
   Whether the abscesses that have been found in the various
parts of glandered horses (for instance, in the brain, upon the
neck, and in the parotid  gland) are in like manner attributable
to the specific  blood-poisoning, or whether these are possibly to
be referred to secondary embolisms, future researches can only
determine.
   Concerning the relation of glanders to analogous diseases,—
to tuberculosis, syphilis,  lepra, lupus, radesyge,  etc.—I concur
fully with the views of Virchow, remarking only that the vascu-
lar structure of the  nodules, and  the absence of  giant cells dis-
tinguish it  clearly from  miliary  tubercles,  genuine  forms of
which occur, though in extremely rare instances,  in the lungs of
horses;  they have, however, no connection whatever with glan-
ders.

    Symptomatology,  Course,  Duration, and Termination.

   The period of incubation lasts usually, when the virus is arti-
ficially implanted, from three to five days,  seldom longer.  On
the other hand, when the  contagium is spontaneously communi-
cated, it is said that  weeks and months may elapse before the
appearance of the first symptoms.   The notion of any such dif-
ference,  however—a difference that in the history of infectious
diseases would be  unique—must have  its  origin in imperfect
observation  and the  insidious approach of the early symptoms
that so often occurs.   According to my own views, the reasons
for which  I have already endeavored  to  state, the alleged long
periods  of incubation are  to be explained in the following way :
either a constitutional blood-poisoning, or a localization of the
disease in the internal organs continued after  the primary symp-
toms—those manifested upon the external skin or mucous mem-
brane of  the  nose, for instance—had healed;  or else—which
may be of more frequent occurrence—the virus  was implanted 
344       BOLLINGER. —INFECTION BY ANIMAL POISONS.

through the agency of a volatile infecting principle, which  ex-
cited local changes in the lungs, bronchi, larynx, and upper part
of the  nasal  cavity, and  yet  did not prevent  the  animal from
presenting, to all  external appearances,  the picture of perfect
health.

   According to  experiments made by Chauveau, horses in which the disease has
been  artificially implanted—either by injection of the poison into the veins, or by
feeding with infected substances—exhibit an increase in pulse and temperature, as
well as other symptoms of fever, although in this stage of the disease no alterations
can be detected after death, either in the luugs or nasal cavities.

   In chronic glanders, the duration of wliich may be prolonged
from a period of months to a year and longer, the disease cannot
be diagnosticated, if the symptoms  are confined exclusively to
the  invisible  internal organs ;  and the case is equally obscure
when the primary morbid  deposits have been overlooked.
   With the above exceptions, however, when nodules and ulcers
are present in the nasal cavity,  the onset of the disease is char-
acterized  by  the  appearance  of  a nasal  catarrh, which  is fre-
quently confined to one  side.   The  discharge,  at first  clear,
becomes gradually  turbid, viscid, and purulent,  drying on  the
edges of the nostril, and is expelled in solid masses.  Upon an
examination of the nasal cavity by the eye—which, if the local
lesions  are situated posteriorly, will be materially aided by  the
employment of a mirror—or, if the finger be introduced into  the
cavity,  the characteristic tubercles  and  ulcers will be found,
especially upon the sides of the septum nasi.  The submaxillary
glands upon the affected side will also be  found to be enlarged,
forming often  an irregular mass  the  size of a walnut.   These
have a hard feel, are not painful to the touch, and are, as a rule.
not  movable  with  the integument,  owing to  the fact  of their
being adherent to  the ramus  of  the jaw beneath.  When  the
nasal ulcers have attained a certain  size,  the discharge becomes
decidedly purulent, and often foul-looking, being  tinged with
blood.  It produces then excoriation  of  the parts over wdiich it
flows.   In the majority of cases little or no constitutional distur-
bance  is  excited.  Upon  longer duration and more  complete
development of the disease in the lungs,  the animals fall away, 
                    GLANDERS IN HORSES                  845

the appetite diminishes, emaciation ensues,  and with the signs of
increasing cachexia death ultimately takes place, febrile symp-
toms  having in  many instances  previously set in.  Cicatriza-
tion of single ulcers, calcification and resolution of the nodules
of the internal organs may take place, but these changes are not
of frequent occurrence.
   When in the course of chronic glanders there are developed
still other specific affections of  the  superficial integument or of
the cutaneous connective tissue, or  when farcy is superadded
to glanders, there are  formed upon different portions  of the
body, most frequently upon the extremities,  head  and neck,
abscesses and nodules,  of the size of a hazel-nut, which at the
outset are hard and painful.  While these abscesses are  more
or  less  rapidly breaking out, the farcy sores make their ap-
pearance, from which an exceedingly foul, sanguino-purulent
discharge is poured out.  These ulcers are for the  most  part
deeply excavated, and have turbid-gray or grayish-red glisten-
ing bases,  with  elevated, usually ragged-looking,  edges.  The
surrounding cellular tissue is generally indurated and swollen ;
the corresponding lymphatic vessels swell,  giving to the touch
the idea of  a cord ("farcy  pipes"). Finally, the neighboring
lymphatic  glands are  enlarged, hard,  and at first  somewhat
painful.
   In acute glanders,  whether in the  form that is developed
from the chronic,  or in that which appears at the outset as such,
there is to be seen, joined with  marked febrile appearances, an
excessive, hypersemic swelling of the mucous membrane of the
nose, upon wliich, in the course  of a few days, numerous tuber-
cles, ulcers, and infiltrations may be made out.  The nasal secre-
tion is of a yellow tinge, viscid,  and often sanguineous.  The
ulcers spread rapidly, even  in the direction of the air-passages,
and in the neighboring lymphatic glands and vessels the changes
peculiar  to  lymphangitis and  lymphadenitis may  be  found.
There are frequently seen u cords" in the  scalp, which  in  some
places  may be cedematous.   As the fever  and prostration in-
crease, the nodules and ulcers often appear in other portions of
the body, accompanied by cedematous swelling of the extremi-
ties, the lower portion of the abdomen, and the breast.  The 
346      BOLLINGER.—INFECTION BY ANIMAL POISONS.

animals grow thin, and, after an illness varying in length from
eight to twenty-one days, death ensues.
   When the mucous membrane of the larynx and  bronchi is
affected, the animals begin to cough and to manifest great sensi-
bility in the laryngeal region.
   In cases where the process of pneumonia is extensive, and in
bronchitis, a physical examination  of the chest will indicate the
nature of the internal lesions.   As a rule, however, glanders  of
the lungs is not diagnosticated.
   The  varieties of  the affection running a more subacute
course present numerous intermediate features between acute
and chronic glanders,  on which account an exact classification is
often impossible.  With regard  to the relation between acute
and chronic glanders,  it is proper to  observe in this connection,
that the latter variety is often found  to produce, by inocula-
tion, the former.
   Although the chronic form often has an acute termination,
the acute form is never transformed into the  chronic.

                         Diagnosis.

   The  diagnosis of glanders is, as may be inferred  from what
has already been stated, in many  cases extremely difficult,  or
even absolutely  impossible, and the latter is especially true  in
cases where the lungs  form the  seat of the trouble, or where the
specific  morbid processes are situated mostly in those  portions
of the respiratory  organs  which, from their  location, do not
admit of an examination.  In such cases it  is erroneously con-
cluded,  as we have already seen, that the disease has  been spon-
taneously developed, or that there  has been an extremely long-
period of incubation.  The trephining of the sinuses of the jaws,
as proposed by  Haubner, may often  render  a  correct diagnosis
possible.  In general, the inoculation of another horse,  or  of
some other animal having a susceptibility  to glanders (sheep,
goat, rabbit), forms one of the surest aids to diagnosis.
   The auto-inoculations attempted in several  instances (Haub-
ner, Harms),  gave  generally a negative result, or  else the local
effects of inoculation rapidly disappeared without treatment. 
GLANDERS IN  HORSES.
347
   As regards diagnosis, moreover, it not unfrequently happens
that the symptoms are confounded with those of other processes,
especially  of simple  catarrh of the mucous membrane of  the
nose and neighboring cavities, with the so-called "Druse"  (non-
malignant  catarrhal  rhinitis,  with swelling of the  lymphatic
glands), and, furthermore, with the  croupous and diphtheritic
affections of  the  nasal  cavity  accompanying croup  and  diph-
theria.  Upon the skin, simple erysipelas, lymphangitis, etc.,
may often be mistaken for farcy.

                          Prognosis.

   The prognosis  is  always  unfavorable.  Although  from a
purely anatomical  point of view the  possibility of these ulcers
being healed must be admitted, yet perfect recovery is indeed an
extremely  rare  occurrence, inasmuch as in the vicinity of  the
healed  portion  new eruptions,  as a  rule, break out.    The  nu-
merous reports  of the healing of glanders and farcy have their
origin, in a great  number of cases, in errors of diagnosis, or else
the recoveries were only apparent, the  temporary arrest of  the
discharge from  the nasal cavity being mistaken  as an indication
of recovery,  whereas  subsequently,  genuine glanders and  farcy
reappeared.
   The  nearest  approach to  a successful  result is seen in  the
reparative action occurring in the  primary tubercles  and ulcers
of the skin.

                          Treatment.

   The  external treatment consists in the application  of the dif-
ferent caustic agents; internally,  the  various  salts  of potash
(bromide and iodide  of  potassium,  chlorate of  potassa), iodide
of copper, calomel, arsenic, and arseniate of strychnine * may
be given.   In this connection,  reference should be made to  the
method of repeated  inoculations,  which,  as  in the  analogous
method of syphilization,  was said to afford immunity against  the
contagion of  glanders, and was tested experimentally, in Copen-
   1 In most European states the treatmeut of the disease, after a sure diagnosis has
been made, is forbid Jen by law, and the afT">ctfcd animals must be  forthwith destroyed. 
348      BOLLINGER.—INFECTION BY ANIMAL POISONS.

hagen, by Bagge and Tscherning.1   The result of this  "malleos-
ation" was, that repeated inoculations (as  many as  160)  with
the pus  of  glanders and farcy neither produced recovery from
the disease  nor prevented a fatal termination; but, while tend-
ing in no way to modify the usual symptoms, seemed rather to
accelerate death.  No absolute immunity from this disease is to
be obtained.

              GLANDERS IN THE HUMAN SUBJECT.

                      Historical Notice.

   For the  first researches, incomplete though they were, con-
cerning the  injurious effects of  the virus of glanders upon man,
we are indebted to a French military  surgeon, Lorin,2 and also
to Waldinger,3 Veith,4 and others.  Lorin observed, in the case of
a veterinary surgeon, an extensive inflammation of the fingers of
both hands, resulting from an  injury received during an opera-
tion upon a glandered horse.  Fourteen days after the extirpa-
tion of  the small tumors that had formed, complete recovery
ensued.  According to Waldinger,  when  the  infected  pus is
brought in contact with an abraded surface in man, an incurable
fatal disease of  the  glands is produced.  Veith, in like manner,
affirms that he has  observed  severe  inflammatory  processes
resulting from  inoculation with  infected  substances,  the sur-
rounding lymphatic glands becoming thereby  sympathetically
affected.
   To the regimental surgeon Schilling,  of Berlin (loc. cit.),
must be  accorded the honor  of having been the first  to give an
exhaustive description of  glanders as it affects  the human sub-
ject.  A well-marked typical case was described by this writer in
1821.  Rust and Weiss soon after described a second case, which
was rapidly followed by numerous similar communications (Seid-
ler, Wolff, Grossheim,  Eck,  Brunzlow, Lesser).   Meanwhile, in
   1 Hering, in Canstatt's Jahresbericht f. 1858, p. 30.
   2 Observation sur la Communication du Farcin des Chevaux aux Hommes. Journ.
de Med., Chirurg. etPharm., Fevrierl812.
   3 Ueber Krankheiten an  Pferden und ihre Heilung, 2 Aufl., p. 158. Wien,  1816.
   4 Handbuch der Veterinarkunde, 2 Aufl., § 685, 1822. 
GLANDERS IN THE HUMAN SUBJECT.
349
England, Travers (1827) and Elliotson (1833) published valuable
observations, and later there appeared the admirable monograph
of Rayer (1837), and in 1843 that of Tardieu.   Passing over a
large number of miscellaneous  articles that have appeared each
year since that date, the works of Virchow (1855 and 1863) have
above all contributed materially to our knowledge of glanders in
the human subject, in  connection with which may be mentioned
the monograph of Koranyi (1870).

                          Etiology.

   The  source  of glanders in the human subject can uniformly
be traced to diseased horses.   The question that has been dis-
cussed at different times and places,  as to whether  glanders can
arise spontaneously in  man (Trousseau and Teissier), appears to
me to  have been clearly solved when the fact was once estab-
lished that in the case of horses it is  a purety infectious disease.
The few alleged cases of spontaneous glanders in man are either
based upon diagnostic errors, or otherwise the mode of infection
was such as could  not be apprehended, as may be often enough
observed in the glanders of horses,  as well as in all infectious
diseases.
   There are very  many ways in which the virus of glanders
may be transferred from  horses to the human subject.  If the
mode of origin of the  disease  be carefully studied in a large
number of  cases,  the diverse forms of the malady will  be found
to range in this respect under two different categories, namely,
those cases occurring after known infection, and those appear-
ing without any evidence of infection (Kuttner).
   To the first group belong those cases of infection  in which the
specific virus has forced its way into the system after the recep-
tion of  some injury of the hands (especially minute  wounds,
excoriations, cracks, and hangnails), the patient being inoculated
either while grooming or feeding glandered horses, or else whilst
handling or examining  such animals, whether alive or  dead (for
example, during the operation  of venesection, skinning, slaugh-
tering, or making an autopsy).   Still another mode of infection
may be  observed; as, for instance, when the mucous  membrane of 
350       BOLLINGER.—INFECTION BY ANIMAL  POISONS.

the nose, mouth, or conjunctiva of the eyes forms the point  of
entrance;  this latter mode of  origin is most frequently produced
by the snorting'  of a  glandered horse, by win jh act small par-
ticles  of  mucus  and pus are driven against  the above-named
organs, where they  are  capable of producing infection.   Infec-
tion by means  of the bite of a glandered horse has  in some few
instances  been observed,  in  which cases  the  saliva manifestly
furnished  the vehicle for the poison.
   There can be no doubt but that the infection of glanders may
be produced by  eating  the  meat of glandered  horses,  which,
according  to my  experience,  owing  to  the imperfect sanitary
regulations for the inspection of meat, is not unfrequently used
as food.  The common  processes for preparing the meat for the
table would naturally tend, it is true, to  destroy its virulence ;
but meanwhile the risk of infection is incurred by the manipula-
tions involved in  preparing it.

   The fact has already been alluded to, that glanders  is not of unfrequent occur-
rence in lions confined in menageries and zoological gardens, when these animals
have been fed for a time upon  the meat  of glandered horses.  In  this connection
the bold experiments of Decroix '* should be mentioned, though, it is not easy to
credit them.  Decroix  consumed with  impunity the meat of horses that had been
killed  on account of  farcy or  glanders,  the meat having  been cooked in various
ways (boiled, roasted,  and stewed,).  He asserts, moreover, that upon seven or eight
occasions lie ate even the raw meat of glandered horses  without ill effects.

   Infection from contact with  diseased  horses, arising inde-
pendently of any previous abrasion or wound, has also been
observed  in a few instances  (Ungefug, Roll),  where the  poison
must have penetrated the skin  through  the cutaneous follicles.
A more indirect mode of  communication occurs in rare instances
through intermediate vehicles, for instance by  drinking from the
same pail that has been used by a glandered horse,  by wiping a
wound with an infected blanket, or by using the same handker-

  1 The snorting (Ausbrusfcen) is a mode of blowing through the nose peculiar to the
horse, by means of which the contents of the nasal cavity  are forcibly expelled, the pro-
cess being accompanied by a loud noise.  It can be best likened to the sneezing of man,
and is occasioned by any irritation affecting the mucous membrane of the nose.
  2 Decroix, Bulletin de la Soc. centr. de med voter , Annee 1870-71. 
               GLANDERS IN  THE HUMAN SUBJECT.           351

chief, that has been employed to cleanse the nose of a diseased
horse.
   Under the second class of modes of infection occurring with-
out known local inoculation, come all those cases whose origin is
attributable to a volatile infecting principle.   This mode of in-
fection may be inferred in all cases in which the general consti-
tutional disease precedes any localization of the symptoms.1   It
is also observed in the case of individuals who groom and have
the care of  glandered horses, who sleep in a stall with diseased
animals—without  in any manner  coming in direct contact with
them—or who become infected by sleeping on  straw upon which,
shortly before,  glandered horses have been standing.

   Errors in diagnosis are not unfrequent.  Many instances of alleged glanders
occurring in man (those of Zimmermann2 for instance,  which were throughout
graphically described), which  have been reported as arising from atmospheric con-
tagion, were, in reality, as has been  demonstrated by other writers (Kiittner and
others), not glanders at all, but cases of typhoid fever.

   The communication of glanders from man to man has been
known to  occur in extremely isolated instances only, for exam-
ple, where one has eatem from the same dish with a diseased ind'r
vidual, or when an entire  family,  consisting  of man, wife, and
four children, have been rapidly attacked one after another with
the malady.
  Susceptibility.—The  question  as to how great an  affinity is
manifested  by  the human subject for the virus of glanders, I
can answer  in a measure from my  own experience, viz., that this
affinity is on the whole  moderate, not to say  slight.   When we
consider the manifold opportunities for infection,  especially dur-
ing the handling,  examination, and autopsy of diseased  horses,
and  then compare with  that  number the proportionately small
number of cases of infection, the  correctness of this statement
will  be made manifest  without  further  argument.   As with
horses,  so also  with the human subject,  a peculiar individual
susceptibility appears essential to  insure the propagation of the
1 An absorption of the poison with the ingesia would be also possible in such cases.
^Virchow's Archiv f. pathol. Anat., B. 23, p. 209-415, 1862. 
352      BOLLINGER.—INFECTION BY ANIMAL POISONS.

virus, many individuals being in every way  frequently exposed
to infection without contracting the disease.
   If furthermore we inquire what class of persons become most
frequently the victims  of contagion, we shall find, as would be
expected from the description of the methods of communication
above given, that those  are most liable to contract  the disease
who, from the nature of their occupations, are brought into fre-
quent  contact with horses.   In about  ninety per cent, of the
cases occurring in  the  human  subject, the  affection will  come
under the head of genuine industrial diseases.
   The following table will give the best idea as to the frequency
of glanders in workmen of different occupations.
   In 106 cases of glanders collated by me, there were found to be:
     41  hostlers,
     11  Coachmen, drivers, or postilions.
     14  Land proprietors and horse-owners.
     10  Veterinary surgeons and students in veterinary medicine.
     12  Horse-butchers and flayers.
      5  Soldiers.
      4  Surgeons.
      3  Gardeners.
      2  Horse-dealers.
      1  each : Policemen, shepherds, blacksmiths, employes at veterinary school.

   No further comment upon this point is needed, if the fact be
regarded that the female sex constituted only five per cent, of the
cases of glanders, six only out of 120 cases being found to occur
in females.   The infected women were for the most  part maids
who were obliged to take care of diseased horses, or the wives of
hostlers  and  drivers, the communication of the virus  being
accomplished  through the agency of an intermediate object.
   In like manner children enjoy still greater  immunity  from
infection.   Out of the same 120 cases one diseased child only was
found, and that  proved to be the child of a coachman who had
been brought in contact  with glandered horses.

                       Symptomatology.

   Incubation—Classification.—When the infection of glanders
has once taken place, either by the transfer of the fixed mater ies 
GLANDERS IN  THE  HUMAN SUBJECT.
353
morbi to an abraded skin or mucous membrane, or by the agency
of the  volatile poison, drawn in probably by the act of inspira-
tion, there will be observed a prodromal stage lasting from three
to five  days, but which is said to be prolonged in many instances
to fourteen days, and even three weeks.

   The introduction of  the virus through  the unabraded  skin is at all events
limited to some quite exceptional cases, and  has been demonstrated to a certainty
in a very few instances only.  If we consider how easy a thing it is to overlook
small excoriations and desquamations of the epidermis, and if, too, we reflect that
the points of inoculation may rapidly heal, we shall have no difficulty in accounting
for many of the alleged cases of infection through the intact skin.

    In  the attempt  to classify glanders in  the human subject
according  to the diverse phenomena  manifested by the different
forms  of  the disease, the division  has  been made by some au-
thors, with respect  to its  localization, into glanders and  farcy,
while by others  the duration  has  been selected as the basis of
classification, and the disease  divided  into a  long  list  of sub-
divisions.  In this respect, however, Tardieu went to the greatest
extreme, recognizing no  less than six different forms of glanders
in man.
   This fanciful subdivision cannot  be  said to be  based upon
any pathognomonic lesions, and is, moreover, in a clinical  point
of view, of no practical utility, for if we examine the symptoms
of a large number of  cases, we shall hardly find any uncompli-
cated instances of either glanders  or farcy.  The simplest  and
most practical classification would appear to be that based  upon
the  course and  duration of the  malady,  and I  have,   there-
fore, deemed it best to recognize the acute, subacute, and chronic
varieties.
   The distinct line of division drawn by many authors between acute and  chronic
glanders  has no real existence, and for this reason we are justified in recognizing an
intermediate form, designated by the term subacute.  In  seventy-nine cases of glan-
ders in the human subject, which admitted of accurate classification according to
their  duration, thirty-eight were acute (lasting as long as four weeks), seven were
subacute  (lasting from four to  six weeks), and  thirty-four chronic (lasting longer
than six weeks).
  It is maintained by some writers that the infection induced by the fixed virua
assumes an acute form, whereas the volatile virus induces the chronic form, or vice 
354      BOLLINGER.—INFECTION BY ANIMAL POISONS.
versa.  These theories, the latter of which has been supported especially by Kiittner
(loc. cit.), do not appear to me to be supported by any sufficient proof.


                      ACUTE GLANDERS.

   In twenty-eight cases of acute glanders, of  which  number
one only  did  not terminate fatally, the  average duration, not
reckoning the period  of latency, amounted to 16.5 days.   In-
stances in which the duration was from seven to eight days are
rare.    For the most  part the  disease lasts from two to three
weeks, though frequently it is prolonged to four weeks.
   The  initiatory  symptoms  consist frequently  of malaise,
fatigue, and prostration,  accompanied by headache and chills,
and often joined with obscure pain in the extremities, especially
in the muscles  and joints.   While at the outset of the disease
no appreciable cause for these rheumatic pains can be made out,
distinct local symptoms soon appear on the skin or in the mus-
cles, in the form of circumscribed or diffused lesions.
   If a wound or  excoriation forms the point  of entrance of
the virus, there is then experienced at that  point, usually situ-
ated on the hands or  face,  a sensation of pain, followed by a
redness and inflammation of the part involved, and finally swell-
ing, and often inflammation of the surrounding  lymphatic ves-
sels.
   The  disease is seldom  ushered in with a chill, and all indica-
tions  of fever are frequently wanting.   As the pains become
more  severe, regular fever turns often supervene, or a continued
fever  appears.
   Meanwhile the ulcer  enlarges,  its edges  and  base acquire
an unhealthy aspect, the  pus discharged being  of  an offensive
character ; often  the whole ulcer assumes a corroded, chancroid
character, and  a dirty white hue.  If the wound is situated on
the finger, there is often observed a swelling of the arm, at times
of a  phlegmonous  and erysipelatous form, accompanied  fre-
quently by  a formation of pustules and ulcers.
   The constitutional symptoms are  then aggravated, the appe-
tite fails, and gastric disturbances follow  with constipation;
the patients manifest  very  great  prostration,  the pain in the 
GLANDERS IN THE HUMAN SUBJECT.
355
joints and muscles becomes more violent, and the febrile dis-
turbance constantly increases.
   Where the early history of the patient is imperfect, and when
the disease has been produced by a volatile infection,—in which
case, of course, outward signs of infection will be  absent,—the
disease presents, as a whole, a picture very similar to that of the
early stage of typhoid fever, or,  in other cases, when the pain is
excessive, to  that of acute  articular  rheumatism.  When the
fever is slight, the premonitory symptoms are often intermittent;
the patients  give up their business,  and complain at most of
weakness, fatigue, and general discomfort.
   In the further course of the disease, there appear frequently
on different parts of the skin red spots, which  change  into pus-
tules like those of  small-pox,  and  less often into pemphigus
blebs.  The pustules, about the size of a pea,  often arise in  large
numbers, bursting and discharging a thick, mucous, sanguineous
pus, emitting often  an offensive odor.   There may, on the other
hand, be developed large projecting  tumors and  abscesses, that
become  extremely painful  and hard, but then gradually change
to a doughy consistence,  fluctuate, and after they have  been
lanced, or have spontaneously opened, present the appearance
of extensive  ulcers with irregular edges, covered with a white
deposit.   These ulcers often penetrate  so deep as  to lay bare the
tendons and bones.
   All these  cutaneous affections—the erythema, ihe erysipela-
tous and phlegmonous processes, the abscesses, pustules, and
ulcers—are often spread so extensively over the surface of the
body that hardly any part  remains  free.  Frequently there
appear swellings of different joints, to which may be super-
added periarticular non-fluctuating tumefactions.
   Although the pustules and  abscesses  are  often developed
quite rapidly,—within from twenty-four to forty-eight hours,—
in other cases they only appear at the end of  two, three, or four
weeks, preceded in the meanwhile by a discharge from  the nose,
swelling of various portions of the skin, pains, and a feeling of
indisposition.
   The mucous membranes (and first  of all that of the nose)
manifest symptoms of inflammatory and ulcerative disease. 
356      BOLLINGER.—INFECTION BY ANIMAL POISONS.
   The localization of glanders in the mucous membrane of the nose  occurs much
less frequently in the human subject than in horses.  According to Hauff (loc. cit),
out of seventy cases there were thirty in which affections of this organ were found.

   When,  however, the nose is affected, there may be  seen  at
the  outset a  discharge of  thin,  viscid, light-colored  mucus.
Gradually  there appear swelling and redness of this  organ and
adjacent parts, accompanied by severe pain ; the upper  portion
is specially sensitive  to the touch, exhibiting a diffuse, erysipe-
latous swelling.  The nasal discharge, which  is often secreted
from one side only,  becomes later of a thicker consistence, and
more purulent, being often of a brownish-yellow color, sanguin-
eous, and  offensive.   Less frequently, distinct tubercles  may
be made out, situated most commonly upon the alo3.
   In many instances we may  distinguish, even during life, the
formation  of pustules and  ulcers in the mucous membrane  of
the nose, which, in the malignant type  of the disease,  terminate
in erosion of the perichondrium, and perforation of the septum
and  vomer.
   This secretion, from one  or both sides of the nose, at first  of
a sero-purulent character, makes its appearance usually in the
second  or  third week,  attended by a  diffused redness  of the
nose that spreads from this point over the forehead and face.
   Thus it may be  seen that in the human subject, just as  in
the horse,  the  nasal affection  fails often to appear  until the
later stage  of the illness, which affords  convincing evidence that
in both species these symptoms cannot be regarded  otherwise
than pathognomonic.
   Synchronously with the appearance of the cutaneous erup-
tion, or later,  catarrhal,  inflammatory,  and ulcerative processes
are developed  in other  mucous membranes.  These alterations,
which  are  more or  less  intimately connected with  the nasal
lesions, are seen, for instance, upon  the conjunctiva of the eye,
the mucous membrane of  the mouth, the gums, the fauces, and
the entire respiratory canal.  Ulcers appear in the mouth, the
gums show a  tendency to bleed,  the breath of the  patient
becomes offensive, the inflamed condition of the pharynx makes
swallowing difficult, while the altered  condition of the  larynx 
             GLANDERS  IN  THE HUMAN SUBJECT.           357

produces hoarseness, an  irritative cough and dyspnoea, and ren-
ders the act of speaking difficult.
   The  submaxillary and  sublingual glands, which  often take
on a suppurative inflammation, are swollen and painful, while
at  times  there may be formed  abscesses  that  open  exter-
nally.
   In some cases there may  be observed the symptoms of gastro-
intestinal catarrh.   In addition to the loss of  appetite, the
patient  complains of gastric disturbances, indigestion, and con-
stipation ; while, in the later stages, diarrhoea is not an  unfre-
quent symptom.  The tongue is dry,  thickly coated, and this
organ and the gums appear often to be covered with a black,
sooty deposit.  Thirst is excessive, especially when the patient
is suffering from diarrhoea.   In a few isolated instances enlarge-
ment of the  spleen has been  diagnosticated during life.
   In connection  with the  respiratory apparatus, there are
often seen in addition to the specific  changes above mentioned,
the symptoms of bronchial catarrh ; the patients cough severely,
and expectorate profusely,  the  sputa  bearing usually a strong
resemblance to the discharge from the nostrils.   Extensive rhon-
chi are  heard over the walls of  the  chest, while  the breath is
in many instances fetid.   At first, respiration is  but partially
impeded, but later absolute  dyspnoea ensues.
   The  pulse is fdr the most part very frequent and small in
volume, ranging from 110 to 120  beats  a minute; but in  some
cases it appears to be retarded.   The temperature  reaches 104°
F. and over, although at the outset symptoms of fever are  often
entirely absent.
   The  sympathetic affection of the  central nervous system is
indicated in the beginning by fainting turns, headache, tinkling
sounds  in the  ears,  insomnia, and great restlessness, to  which
disturbances may be soon superadded nocturnal delirium, and,
provided there  be  numerous muscular abscesses  or extensive
cutaneous ulcers, chills and fever.
   The  exacerbations of fever  are either irregular, or less fre-
quently they may be of regular intermittent character.
   In those cases, the course of which  is rapid and  the  symp-
toms of a malignant type, there is  considerable  fever,  which 
358      BOLLINGER.—INFECTION BY ANIMAL POISONS.

rages without remission, so that even  in the morning the tem-
perature may be as high as 106° Fahr.
   Albumen  has  been found in the urine in some  cases; also
shortly before death leucine and tyrosine.   In the case of preg-
nant women,  abortion has been in several instances observed.
   In the course of three or four weeks the patients relapse into
a condition of general prostration, accompanied by considerable
emaciation.  The  fever increases, the pulse  grows weaker, deli-
rium sets in, and  there is  developed a  condition of stupor; the
skin becomes  cool, respiration short and irregular, the pupils
dilated;  involuntary evacuations ensue, and death takes place
under symptoms of collapse.
   At other times  the dryness of the mucous membrane of the
mouth and pharynx increases ; the patients become  hoarse and
deaf ; the nasal secretion  has a foul appearance ; now and then
icterus also appears ; an increased difficulty in breathing and in
deglutition, an  increase  in the cutaneous patches  and  pustules,
a loss  of activity of the  sensory  organs, attacks of  muscular
cramp, and a loud snoring respiration culminate in a fatal termi-
nation.

                    CHRONIC GLANDERS.

   The local phenomena, when  the virus has evidently been im-
planted in an exposed portion of the body, are, in the initiatory
stage, the same as those of acute glanders, and the same remark
is  true with regard to  the constitutional symptoms where the
infection has been produced by the volatile form  of the poison.
These symptoms consist in attacks of fever, pain  in  the various
parts  of  the  body, restless sleep,  general indisposition, and  a
diminished appetite.
   Swellings  of certain parts of the body arise, their locality
depending upon the point of entrance of the virus into the sys-
tem—generally the face or extremities; there is seen, further-
more, inflammation of the lymphatic vessels, and  swelling of the
lymphatic glands.  These local  symptoms may abate, or  even
entirely disappear.  The disease assumes then a quiescent form
until some new local and constitutional features are developed. 
GLANDERS IN THE HUMAN SUBJECT.
359
   The separate organs  at this stage  show the following altera-
tions :—
   The external cutaneous ulcers manifest no disposition to heal,
but have a livid appearance, or here and there they may heal, at
least the majority of them, by the formation of cicatricial tissue.
New abscesses are constantly forming in the vicinity of  these
ulcers, and especially about the joints ; there also appear  sinu-
ous and fistulous ulcers that secrete  an  offensive, watery pus,
and show  no tendency to  throw out granulations.  There are,
moreover, frequently found upon the extremities nodular tumors,
which upon being opened discharge thick purulent masses, mixed
with blood and serum.    In other  cases pustules gradually
appear, as in acute glanders, on every part of the body ; also
fluctuating tumors in the muscular tissue ; erysipelas, especially
upon  the nose and face,  and painful  swellings  of the joints.
After the lapse of  a few months, large abscesses may develop
upon different regions of the body, complicated with inflamma-
tion of the lymphatic vessels and glands.
   The affections of the nose in chronic glanders do not  differ
essentially from those of the  acute form  of the disease.   They
run a  longer course, however, and very frequently—in one-half
at least of all cases—they are entirely absent.   They are usually
characterized at first by the presence of an offensive muco-puru-
lent discharge, but begin, sometimes, with a swelling of the nose,
appearing a long time (two to three months) after the contraction
of the disease ; in rare cases gangrene of the swollen root of the
nose may ensue.  The nostrils are covered with foul crustaceous
deposits.   In the case of the mucous membrane of the nose, the
disease takes on the  form of ulcerative processes, which  often
terminate in destruction of the septum and vomer.
   Chronic glanders is  characterized by other features, such as
inflammatory affections of the mucous  membrane of the mouth,
often joined with swelling  of  the tongue, salivation, the forma-
tion of ulcers upon the  gums and throat, and finally angina.
   The organs  of respiration are  but partially involved ; the
patients  suffer from a  slight cough and  hoarseness, the sputa
being often bloody.  The difficulty in breathing is either very
slight,  or it increases with the development of extensive lesions 
360      BOLLINGER.—INFECTION BY  ANIMAL  POISONS.

in the larjmx, and subsequent oedema  of  the  glottis, until it
amounts to actual dyspnoea, a symptom that is hkewise produced
by extensive affections of the lungs.
   In consequence of the long-continued  suppuration and pain,
the patients become greatly debilitated and emaciated, presenting
on the whole an appearance very similar to that seen in chronic
tuberculosis with hectic fever.
   The manifestations of the fever are  manifold ;  when a series of
abscesses follow in  rapid succession,  the fever is seldom absent;
at other times, feverish exacerbations only occur  in cases of a
relapse and the formation of new eruptions.   Colliquative diar-
rhoea, severe sweats, combined with, general cachexia and exhaus-
tion, generally precede the fatal termination.
   The chronic form of glanders is often transformed—as in the
horse—into the acute (Tardieu); numerous fresh abscesses sud-
denly appear,  the fever becomes very high,  the pulse small and
rapid, and death ensues, as in typhoid fever, with  symptoms of
decided coma.
   When the disease  terminates favorably, as not unfrequently
happens in the mild form of the malady, the symptoms above
described are  all much less pronounced.  Cicatrization of the
abscesses then takes  place, while  the cutaneous vesicles,  both
large and small, dry up.  If the nose has been affected, the swell-
ing of that organ diminishes, the discharge becomes less pro-
fuse and thicker, the general condition is ameliorated, the fever
becomes very  slight, the exacerbations cease, while the gastric
and respiratory symptoms disappear.
   The patients rally,  for the most part, pretty slowly, in many
instances  never  regaining  complete  health.  An  instance has
come under my own observation in which the patient (a veteri-
nary surgeon), after an illness  lasting eleven years, continues to
suffer constantly from  cough and obstructed respiration, result-
ing chiefly from a cicatricial contraction of the mucous mem-
brane of the nose and larynx, in consequence of which he pres-
ents the picture of decided cachexia.
   In other cases, after months of severe illness, a pretty rapid
improvement  follows,  and  under  favorable  surroundings  the
patients soon recover their health.   The average duration of sub- 
              GLANDERS IN THE HUMAN SUBJECT.           361

 acute  and chronic glanders, of which about  one-half the num-
 ber of cases terminate in recovery, was found to be (computing
 from about forty cases) four months, omitting in this estimate
 certain quite exceptional instances, in which  the illness lasted
 from one to four and a half, and  even eleven years, and omit-
 ting also those more  frequent  cases lasting from two to three
 months.

                   PATHOLOGICAL ANATOMY.

   The post-mortem appearances bear in  general a close resem-
 blance to those of pyaemia.
   Externally there are found in various parts, especially upon
 the fingers, and in general upon the extremities and the face, at
 some points, pustules  or blebs, at others, abscesses and ulcers.
   The cutaneous pustules, which  often present a strong resem-
 blance to those of small-pox, are found to contain, at one time,
 caseous-purulent contents, at another a sanguineous fluid.  Be-
 neath the larger  blebs, which here and there are seen to be col-
 lapsed, are  frequently found well-defined sloughs of a dull gray
 color.
   The numerous abscesses of the  cellular' and muscular  tissues
 are to be distinguished from ordinary abscesses chiefly by this
 circumstance, that their contents are often tinged with  blood,
 and have a more viscous consistence, while the connective tissue
 or the muscular substance at these points is softened.   Here and
 there are found subfascial abscesses, and the surrounding mus-
 cular layers are pale, discolored and readily torn.
   In more diffused localizations of glanders there are found the
 alterations peculiar to  erysipelatous and phlegmonous processes,
 either  a  simple swelling and oedema of certain parts, beneath
 which are situated small nodules, varying in size and  filled with
 reddish pus, or in the same diffused forms there may be seen
 purulent infiltrations of  the skin and the cellular tissue, especi-
 ally upon the forehead and  eyelids, and in the vicinity of the
joints.
   Upon the whole, there is manifested in glanders, as  seen in
the human subject,  a  relatively slight tendency to the develop- 
362      BOLLINGER.—INFECTION BY ANIMAL POISONS.

ment of tumors, as  has been  remarked  by Virchow (Gesch-
wulstlehre II. p. 552), although even the cutaneous pustules are
formed from tubercles in the substance of the cutis vera.
   The contiguous  parts become involved in the  diseased pro-
cess ; for instance, if  the disease is situated upon  the head, the
bones  of the  skull and  face, and more frequently the frontal
bone, are affected, becoming often necrosed ; while even upon the
inner surface of the skull, between the bone and the dura mater,
purulent collections may be formed {pachymeningitis externa).
In other cases tubercles may appear in the periosteum of the
skull,  in the  dura mater,  and even in  the plexus choroides.
Virchow is therefore  justified in speaking of an osteomyelitis
malleosa.
   In the nose, alterations are found in the human subject quite
similar to  those seen  in  the horse, although in  many instances
indeed no  discharge has been observed  during life.  The small
papules are of a yellowish color, and are seated upon the mucous
membrane, the appearance of which is changed by the catarrhal
and inflammatory processes.  At the same time ulcers are formed,
which, when the disease is prolonged, may attain a considerable
size, presenting, for the  most part, an  irregular outline.  The
cartilage becomes exposed and  necrosed, after  the malady has
lasted a certain length of time, and the same changes take place
in the adjacent bones,  so that we may find the septum, the vomer,
and  the palate bone  disorganized, precisely as in the case of
the horse.  The neighboring submaxillary glands are generally
enlarged and swollen.
   In the frontal sinuses, the pharynx and larynx, and in the
trachea, are likewise frequently found papules and ulcerations,
wliich lesions are found also—though in rare instances—even in
the bronchi.   The growths and ulcers  in the larynx may lead
to oedema of the glottis.1
   The lungs  may be either entirely free  from disease  or  they
may be the seat of tubercles, nodules, and specific inflammatory
processes.   Externally there are often seen subpleural ecchymo-
  1 According to Hauff (loc. cit.) the larynx was diseased in eleven out of thirty-five
cases ; that is, in 31 per cent. 
GLANDERS IN THE HUMAN SUBJECT.
363
ses ; at other times small tubercles are found upon the pleura ;
less frequently  the pulmonary abscesses  are  accompanied by
pleuritis upon one or both sides.
    When the lung is  the seat of localized processes, there are
found in the  substance of that organ numerous tubercles, vary-
ing in size from a millet-seed to a pea, of a firm texture, and of
a gray, yellowish, or reddish color ; or, at other times, nodules
are seen of the size of  a pea, of a gray, whitish appearance, and
of  a firm, lardaceous  consistence.   In other cases  an entirely
different appearance is presented, one or two infarctions  of the
size of  a bean being  developed in one lobe,  distinctly circum-
scribed, and of a dark-red color,  in  and around which lie  small
abscesses.
    In the more diffused forms of these specific affections of the
lungs, which, as in the analogous changes found in the  lungs
of glandered horses, may be properly termed the pneumonia of
glanders {pneumonia malleosa), the nodules are larger, forming
isolated hepatizations and abscesses.  The lobular nodules and
abscesses may be  either confined to one lobe, or they may be
scattered throughout  the entire lung.  It frequently happens
that large sections of the lungs are found to be in a condition of
gray hepatization  and  purulent infiltration,  while the  other
portions are in a state of collateral hypersemia.
    Of the remaining tissues  of  the  body,  the muscles form
unquestionably the most frequent  seat  of specific  changes.
According to  Kiittner (loc. cit., p. 572), the specific nodules are
mostly situated in the biceps, the flexors of the forearm, the rec-
tus, and the pectoralis, and Anally at the point  of insertion of
the deltoid.
    The cartilages and bones are often involved secondarily in
the destructive  action  of  the  adjacent specific  affections,  the
ulcers and abscesses.   In rarer instances, the bones and  perios-
teum are the primary seat of the specific growths  and inflamma-
tory processes.
   In the other internal organs numerous ecchymoses are often
found in acute glanders.   Furthermore, a stomatitis is sometimes
observed at the autopsy, due to an extension of the disease from
the cavities of the nose and  throat;  and upon the mucous mem- 
364      BOLLINGER.—INFECTION BY ANIMAL POISONS.

brane  of the pharynx, ecchymoses, redness,  swelling, erosions,
and foul ulcers are also found.  Ulcerations are often seen upon
the velum of the palate.   In some cases a  croupous  exudation
is found upon  the mucous  membrane of the mouth and throat.
The mucous lining of  the  stomach is often the seat of numerous
large ecchymoses,  while in exceptional cases specific papular-
shaped formations are found in the substance of this tissue (0.
Wyss *).
   The serous membranes are here and there affected with puru-
lent inflammation, especially the lining  membranes of the joints.
The joints of the knee, hip,  and hand are said to be particularly
liable to be implicated in this process.
   The spleen  is generally enlarged, filled  with blood, softened
and liquefied,  and of  a grayish-red,  or dark color.   Wedge-
shaped abscesses (possibly of  a pyeemic character?) are in some
instances observed.
   The liver is usually greatly enlarged, often showing  signs of
fatty degeneration.  In one case2 there was observed, in addi-
tion to the specific hepatitis of glanders, gangrenous and ulcer-
ative inflammation of the gall-ducts.
   In the nervous system there are found, in addition to the rare
instances of inflammation of the membranes of the brain, scat-
tered abscesses in the brain substance, and also a form of  dif-
fused myelitis  malleosa, attributable to infiltration.3
   Among the  less frequent concomitants of the disease may be
also mentioned specific4 tubercles  and abscesses of  the glans
penis,  testicles  {sarcocele  malleosa,  Virchow),  and  kidneys,
specific papules of the choroid coat  of the eye, and furthermore,
inflammation of the parotid gland.
   The lymphatic glands,  in cases of glanders  in man,  are
affected far less frequently, and also to  a much  smaller extent
than is the case with horses.
  1 For the knowledge of this fact, and an inspection of his excellent microscopic
preparations, I am indebted to the politeness of Prof. Wyss.
  2 Sommerbrodt, Virchow's Archiv, B. 31, p. 463, 1864.
  3 Coupland, Med. Times and Gaz., 1872, p. 373.
  4 Here and throughout the article in the sense of pceuliar to glanders. —Trans-
LATOB. 
GLANDERS IN THE HUMAN SUBJECT.
365
   It is  to be remarked in  conclusion, that  in cases of glan-
ders, as seen in the human subject, the entire process presents a
strong resemblance to certain forms of pycemia, and under cer-
tain circumstances may be confounded with that affection; and
furthermore, it should be carefully borne in mind that  metas-
tatic pyaemia  may be superadded,  as a final  symptom, to pre-
viously existing glanders; thus tending  to render the anatomical
diagnosis difficult.
   A microscopic examination of the  morbid  products of glan-
ders gives a result very similar to that found  in the horse.  In
addition to the tubercular eruption, there are diffused infiltra-
tions and  specific inflammations, all  of which manifest  a very(
great tendency to disintegration and the formation of  abscesses.
My own investigations and experience, with respect to the organs
affected with glanders in  the human subject, enable me not only
to accede to, but to put even in a more emphatic form  the state-
ment of  Virchow, that in the  human subject the tendency to
the formation  of tumors is by no means one of  the essential
features  of the malady.  Out of a large collection of prepar-
ations  I was  hardly able to find one well-developed  tubercle,
whereas  in  the horse such formations can be detected without
difficulty.
   In microscopic sections it will be seen (O. Wyss) that the
nodules of  the skin are formed  by a deposit of numerous round
cells, of  the character of  pus corpuscles, in the upper portion of
the corium, beneath the papillary layer.  In  a more advanced
stage the papillae are filled with pus cells, and become  gradu-
ally disorganized ;  thus arises beneath  the epidermis a small
abscess, wliich may extend into the deep tissues.   When large
pustules have  formed, their contents will be found to  consist of
pus corpuscles, while the surrounding tissue of the  cutis appears
to be infiltrated with cellular elements, or rendered cloudy by a
deposit of fat globules.
   Wyss found analogous changes in  the mucous  membrane of
the nose, only more  extensive in character.  There are also seen
in the  subcutaneous tissue, as  in the mucous  membrane, larger
caseous tubercles (from  two to four millimetres  in diameter),
composed of small granules and granular detritus. 
366      BOLLINGER.—INFECTION BY ANIMAL POISONS.

                         Diagnosis.
   The  diagnosis of glanders in the human  subject is often diffi-
cult, especially in the early stage of the disease and where  the
previous history of the patient  is  incomplete.  This  is  to be
attributed to the comparatively rare occurrence of the disease,
for, even at the  larger cliniques, years elapse without  a case
being observed.   The  autopsy  often gives the first clue  to  the
character of the disease, as Virchow ' illustrates in  the report of
a case, in this respect  instructive (observed at Wurzburg), in
which the post-mortem examination of a patient, who had been
under treatment  for over  six  months, on account  of ulcers of
the extremities, led to the discovery of a regular epizootic pre-
vailing among the tow-horses of the rivers Main and Saale.
   While in cases  of infection by the fixed contagium,  in  the
early stage at least, the symptoms may possibly be confounded
with  those  produced  by inoculations with morbid  matter or
cadaveric poisoning, in infection  by the volatile contagium  the
disease  at the  outset  is hardly  to  be recognized.  When  the
local  phenomena, however, once appear,—the  cutaneous  exan-
thema in the form of pustules, blebs, abscesses, erysipelatous and
phlegmonous processes—accompanied  by rheumatic pains, nasal
affections, and other constitutional symptoms, the diagnosis pre-
sents  no longer any difficulties.
   It  is  always of great importance  to ascertain  the occupation
of the patient, and in cases of  individuals who have much to do
with  horses,  suspicions as to the existence of glanders  can be
readily  confirmed or  dispelled  by elucidating the other circum-
stances  under which the illness  was contracted.
   If  the  pain in the muscles  and extremities is prominent and
severe, glanders  may always be confounded with rheumatism in
its various forms, or if a high  fever prevail, and the sensorium
become decidedly  involved, it may be mistaken for typhoid
fever; in both cases, however,  a careful observation and  exami-
nation will soon enable the physician to form a correct opinion.
   Finally,  glanders  may be  confounded with pyaemia, when
the fever  is accompanied  by chills, cutaneous  abscesses, and a
            1 Die krankhaften Geschwiilste, II., p. 553, 1864. 
             GLANDERS  IN THE HUMAN SUBJECT.          367

high fever.  But inasmuch as chills are an exceptional phenome-
non in glanders, there is small danger of a wrong diagnosis being
made in consequence of this symptom.  Practically, however, all
this is of no great significance, as has  been forcibly remarked by
Virchow  in enumerating  other sources of error (infection by
cadaveric poison and  other putrid substances).   It is  likewise
possible  to  confound glanders with malignant pustule, but the
cutaneous pustules and tubercles differ entirely from the carbun-
cles of the latter disorder.
   In cases  running a chronic course,  with moderate ulcerations
of the nose and larynx,  glanders may acquire a very  strong
resemblance to certain forms of syphilis, or,  if the larynx and
lungs form the principal  seat of the eruption, to tuberculosis.
   As in horses, so also in the human subject, and especially in
chronic cases, the inoculation of animals might be resorted to as
an aid to diagnosis, for wliich purpose goats and rabbits are pre-
eminently appropriate.
   Auto-inoculation was undertaken in one  case by Poland,1
who produced pustules with inflamed areolae by implanting the
purulent secretion of a locally diseased part in the skin of the
same individual.

                          Prognosis.

   Concerning the  curability of glanders in the human subject,
recent authors (Virchow and Koranyi) appear to agree that the
prognosis is exceedingly  unfavorable.  Although Virchow3 re-
ports some cases of cure,  Koranyi goes so far as to affirm that no
case of recovery from  either acute  or chronic  glanders  has ever
been authenticated ; while to farcy, making allowance for diag-
nostic errors, he accords a comparatively favorable diagnosis.
   Apart  from  the fact  that  glanders and farcy,  as we have
already endeavored to  show, are, both in the human  subject and
in the horse, perfectly identical  processes,  the distinction be-
tween  them being of a traditional  nature, and not based upon
any observed phenomena, it is also to be observed that the essen-
1 Med. Times and Gaz., 1869, p. 297.
2 Zoonosen, p. 418, 1854. 
368       BOLLINGER.—INFECTION BY ANIMAL POISONS.

tial features of both processes are perfectly  similar.  The most
that can be admitted is, that the so-called farcy in its initiatory
stages may be more easily affected by therapeutical agents, and
upon this account  may make a  more favorable show as regards
the comparative rate of mortality.
   According to the  results  of  my own  tabulated statistics, I
should be inclined to assign an absolutely unfavorable prognosis
to acute glanders only; the subacute and chronic forms permit-
ting a relatively favorable opinion as to the termination.

  In 38 cases of acute glanders, recovery ensued in 1 instance.
   "7     "    subacute   "       "        "      2 instances.
   " 34     "    chronic    "       "        "     17

   From this it will be seen that recovery took place in chronic
glanders in  50  per  cent.    In  this  connection,  it  should be
remarked that in the 34 cases designated  above as chronic glan-
ders, are included not only cases of farcy, but also the most pro-
nounced forms of glanders.'

   Out of a total of 120 cases of glanders (including the above 79, differently clas-
sified according to their duration), that I  have succeeded in finding, there were 28
recoveries, equivalent to 23 per cent.
   Hauff (loc. cit.), out of 70 cases collected by him, was  able to report but 8 re-
coveries, equivalent to 11.4 per cent.  According to Kiittner, cases of infection from
a fixed contagium have a decidedly more favorable chance of recovery than such as
are induced by the volatile poison.

   In  view of the  above figures, we are able to pronounce the
prognosis in  acute  glanders as unconditionally unfavorable, the
result being  almost invariably fatal, whereas, since in the sub-
acute and chronic  varieties of the malady, one-half of all cases
terminate in recovery, the prognosis is far more favorable.
   When the disease has  continued for some time the prospect
for recovery  becomes decidedly favorable, and  this point, in  a
   1 The favorable character of these figure* may possibly be explained in this way,
that in addition to the material found in strictly medical literature, I succeeded in col-
lecting from the veterinary medical journals a series of cases which will bear most
cribical examination, but which, coming under the head of milder and less interesting
cases, are seldom reported by surgeons. 
GLANDERS IN THE HUMAN SUBJECT.
369
therapeutic point  of view, cannot be overestimated in  impor-
tance.

                            Treatment.

   The inefficiency of  all  therapeutic agents in the treatment
of glanders in the human subject renders prophylactic measures
of great importance.
   The most  efficacious  of these  measures consists in  stamp-
ing out, as far as possible, both glanders and farcy in  horses,
a  procedure  to  wliich, from  considerations  of economy, the
attention  of state  governments has  for  a long time been care-
fully directed.
   Thus,  efficient  sanitary  regulations,  carried  out by  police
authorities, the destruction of glandered animals, as well as  of
animals suspected  of being thus  diseased, are the  principal re-
sources at our command.

   Experience has taught us that, in countries provided with a thoroughly drilled
corps of veterinary inspectors, the number of glandered  horses falls to the mini-
mum.   In the French army,1 so long as the contagiousness was denied, and attempts
at treatment undertaken, the loss in animals by this disease amounted to about four
per cent., but when more correct views were entertained, it sank to two per cent.
In Bavaria, where the total number of horses  is estimated at about  400,000, the
annual number of cases of glanders, takiug the average of nine years, is one hundred
and seventy-five,  equivalent to 0.04 per  cent. ; in Saxony, estimating the average of
ten years, 0.1 per cent. ; in Prussia, 0.07 per cent, of the entire number of horses.
Although absolute immunity from glanders is for the present scarcely within the
bounds of possibility, we may, nevertheless, with the aid  of properly qualified sani-
tary officials and  stringent regulations,  reduce very materially the  number of cases,
and at the same time render decidedly less the danger with which man is threatened.

    All persons, who  from  the nature  of their occcupations are
brought  frequently in  contact with  horses,  especially hostlers,
soldiers,  and  the like,  should  be  made thoroughly acquainted
with the contagious properties of glanders.  Instruction  should
be especially  given as to the precautions to be  taken whilst hav-
ing to do with glandered horses, or those suspected of being dis-
eased.   Careful  cleansing  and  disinfection  are to  be enjoined
           1 Compare previous statements.
VOL. III.—24 
370       BOLLINGER.—INFECTION BY ANIMAL  POISONS.

after post-mortem  examinations, as well as at the killing and
slaughtering of suspected horses.
   From my own experience, I can  add, in  confirmation of the
statement of Virchow, that by the most thorough cleansing, cau-
terization, and disinfection  of small wounds and excoriations
that have been inoculated with the poison of glanders, the dan-
ger of a transference of the disease  to man, who,  on the whole,
manifests but a slight affinity for the poison, is not very great.

   A systematic inspection will readily suffice to prevent the sale of the meat of
glandered horses, and the consequent risk of infection incurred by those compelled
to handle or prepare such meat.  Notwithstanding the experiments of Decroix, pre-
viously referred to, I deem it essential that there should be a strict supervision of
slaughter-houses, and particularly for the reason that attempts are often made to
conceal the existence of the disease.

   In the treatment of glanders in man, if an early diagnosis
can  be made, and the point of entrance of the virus can be dis-
covered, the energetic local destruction  of the virus is first of all
indicated, either by excision  or  cauterization with concentrated
nitric acid, carbolic acid, fresh chlorine water,  or other caustics.
Abscesses and tumors should be laid open as soon as possible by
free incisions,  and local antiseptic treatment (injections  of  per-
manganate of  potash, or carbolic acid in solution, and applica-
tions of carbolic oil, in  the proportion of  one part to ten) should
also be resorted to with the view of  stimulating the healing pro-
cess.

   The experiments of Gerlach demonstrated  that carbolic acid, as well as fresh
chlorine water, has a decidedly destructive effect upon the virus of glanders.

   In extensive phlegmonous and erysipelatous processes, appli-
cations of ice, leeches,  and the  internal use of laxative agents
have been at various times employed with success.
   In ulcerations  of the  nose,  injections of  creosote  water or
carbolic acid have been  often  successful; so likewise the  local
treatment with tincture of iodine or nitrate of silver.
   Of the numerous  agents administered at various times inter-
nally with favorable results—bichlorate of  iron, iodide  of  sul-
phur,  iodide of potash, Fowler's  solution, arsenic with nux 
              GLANDERS IN THE HUMAN SUBJECT.           371

vomica, mercury, iodide of potash, and carbolic acid—the last
two should be made the subject of further investigation.
   Of  the greatest importance is  the  general regime, which
should be of a tonic, stimulating character.  In  this connection
may be mentioned quinine in large doses, alcoholic  stimulants,
especially wine or strong beer, nutritious diet, which should con-
sist chiefly of broth and animal  food.
   The acids, which are frequently administered; furthermore,
the bitter agents, discutients, and purgatives afford little  or no
assistance.
   In  case  of decided  collapse, sinapisms  and  ethereal irri-
tants are indicated, and have frequently produced favorable
results. 
ANTHRAX.
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   Menschen.  Bayer, arztl. Intelligenzblatt, No.  25, 1869.—Stone, E., Malig-
   nant Vesicle.  Boston Med. and Surg. Journ., Feb.  11, 1869.—Neyding. J., Bei-
   trage  zur path. Anat. der Pustula maligna beim Menschen.  Vierteljahrschrift
   f. gerichtl. u. off. Med., p. 241, 1869.— Waldeyer, Virchow's Archiv f. path.
   Anat., B. LIL, p.  541, 1871.—Miinch, G., Mycosis intestinaHs und Milzbrand.
   Centralblatt f. d. med., Wiss., 1871, p. 802.— Wasservogel, Allg. Wien. med. Zeit-
   ung, Nos. 1 u. 2, 1871 ; ibid., No.  19 u. 21, 1871 ; ibid., No. 2, 1872.— Wagner,
   E., Ein Fall von todtlicher Pilzkrankheit—Mycosis intestinalis.  Leipzig, 1872 ;
   the same, Die Intestinalmykose  und  ihre Beziehung zum Milzbrand.   Archiv
   der Heilkunde, B. XV.,  p. 1, 1874.—Nicolai, Erfahrungen und Notizen iiber
   Milzbranderkrankungen beim Menschen und Thier.  Darmstadt und Leipzig,
   1872.—Leube  und Midler,  W., Drei Falle von  Mycosis intestinalis  und deren
   Zusammenhang mit Milzbrand.  Deutsches Archiv f.  klin. Medicin, B. XII.,
   p. 517, 1874.
                      ANTHRAX OF  ANIMALS.

                             History.

   Among all the contagious maladies affecting animals, anthrax
has  been the longest known,  since in the earliest records of all
historical knowledge (Exodus IX.) we possess  descriptions  of
devastating diseases of animals, which in all probability  relate  to
maladies of the same type as anthrax.   According  to the thor-
ough investigations  of Heusinger, the Greek and Roman veterin-
arians describe anthrax of the domestic animals under the titles
Oidwa, Sacer ignis,  Gutta robea, Gulta renalis,  Pustula.   The
ancient  Greek physicians also designated malignant pustule  as
anthrax, the Romans called it carbunculus,  while the Arabians
described anthrax, as affecting mankind, in a still  more  precise
and  detailed manner,  as At sitae, at Humrah, or Persian fire.
After the authors of the middle ages—from the fourteenth to the
eighteenth century—had concealed the various forms of anthrax
as different diseases  under  numerous  names, it first  became 
374      BOLLINGER.—INFECTION BY ANIMAL POISONS.

known, toward the end of the last century, that these manifold
diseases were, in reality, only different forms of the same disease.
The  most notable  services in this direction were  rendered by
Chabert* (1780), who, in his monograph, proved the similarity of
the maladies, which until then  had been considered as totally
distinct.   Even to-day—after nearly one  hundred years—the
classification and  nomenclature  adopted by Chabert is adhered
to in all essential  particulars,  not only in France  but  also  in
other countries.
   Although the contagiousness of anthrax was proved by the
numerous  observations  of  the  eighteenth  century (Audouin
de Chaignebrun, Fournier, Bertin, Brugnone, Montfils,  Glaser,
Thomassin, Enaux, Chaussier, etc.), Kausch, in the beginning of
this  century, maintained  its  non-contagiousness in cattle.   He
endeavors to locate the essence of anthrax—wliich in every other
respect, especially as to its pathological anatomy, he depicts in
an admirable manner—in a  paralysis  of  the  pneumogastrics,
granting, however,  the infection of men and animals by means
of blood, flesh, etc.
   Next in order, valuable contributions towards the elucidation
of this formidable scourge were  furnished  (more especially) by
Larrey (1811), Remer (1814), Laubender (1815), Greve (1818),  Gas-
pardin (1820), Glanstrom  (1824),  J. F. Hoffmann (1827-30),  Car-
ganico (1835),  C. G. Hildebrandt (1841), Delafond (1843),  who
made anthrax of sheep {maladie de sang) the particular subject
of his studies, located the especial seat of anthrax in the rennet
stomach and in the intestines, and described it as being by nature
an acute  enteritis associated among other things with blood
changes.  Thus Delafond denies the contagiousness of anthrax,
and  finds the chief  causes in an over-nourishment of the animal
and  in the chemical conditions of the soil.  On the  other hand,
Gerlach  (1845), in  his exhaustive work  on  the  sheep-plague
{Blutseuche  der Schafe), proved the identity of the latter with
anthrax, established its contagiousness experimentally,  and con-

   1 Ph. Chabert, Description et traitement du Charbon.   Paris, 1780.  It may be
inferred how great a general interest  in  anthrax existed even at that time, from the
fact that this work passed through not less than seven editions in the course of seven
years, and was moreover translated into Spanish and Italian. 
ANTHRAX OF ANIMALS.
375
eluded  that  the contagious principle was volatile and of great
tenacity.  The immediate cause or the essence of the plague  (he
believes) consists primarily in a  poisoning of the blood, which
(poison) in idiopathic cases is derived from the intestine, but in
cases due to inoculation makes its entry into the blood through
different channels.
   Heusinger in his classical work (1850) sets forth the  results of
his investigations—historical and geographical, as  well as patho-
logical—in declaring anthrax to  be  a malarial neurosis ;  the
malarial poison primarily attacking the ganglionic nervous sys-
tem.  As a first result the vessels of the spleen become paralyzed,
and  the spleen perishes—hence the name Milzbrand (inflam-
matory death of the spleen), which  should not  be discarded;
then  follow  similar vascular paralyses, local points  of stasis,
extravasations of blood and local points of death {Brand) in  the
different organs. In anthrax a contagious principle is developed,
which assists largely in the extension of the malady,  and exer-
cises the same power as the morbid influence first originating  the
disease.   The poison is conveyed  away from  the  areas of local
disease  by the lymph, and especially by the blood-vessels.  The
seemingly different forms of the malady, as found  upon animals
and men, are essentially identical.  Anthrax is primarily devel-
oped only in herbaceous animals, mammals, solipeds, ruminants,
swine.   All  animals  are,  however,  susceptible  of contagion.
These are Heusinger's views.
   In relation to the malarial nature of anthrax, Virchow (1855)
is in accord with Heusinger.   He dwells upon the  septic charac-
ter of the disease,  and is inclined to consider a specific ferment
the cause of anthrax.
   During the same year (1855) Pollender made known his dis-
coveries, which instituted a new epoch in  the  study of anthrax.
Pollender found—as early indeed as 1849—in the blood of cattle
suffering from  anthrax a countless mass of fine rod-like bodies,
which, in figure and  appearance, resembled vibriones,  and in
their  microchemical behavior were  seemingly of a  vegetable
nature.   Independently of Pollender, Brauell (1857) found  the
same little bodies in the blood of men, horses, and sheep which
had died of anthrax.  Brauell found that  these bodies,  which he 
376      BOLLINGER.—INFECTION BY ANIMAL  POISONS.

described as vibriones, were even present  during life in the blood
of the diseased animals ; he believed them to possess  diagnostic
value, while Pollender considered the question of their deriva-
tion, origin, and existence to be an open one.
   As soon as the investigations of Pollender and Brauell became
known, the general interest was turned  towards these  peculiar
structures in the blood, and a majority of the works which next
appeared discussed the  question of the  nature of the  rod-like
bodies and their relation to anthrax.  From a number of further
experiments, Brauell arrived at the conclusion that the little rods
appeared one, two, three, less  often from eight  to  ten, hours
before death—in very acute cases only a few minutes before final
dissolution, while they were wanting in the blood of convalescing
animals.  Therefore Brauell concluded that the rod-like bodies
furnished a sign of diagnostic and prognostic value ; but, on the
other hand, he denied that they constituted the  poison of an-
thrax or were  the carriers of that poison, since he could produce
anthrax by means of blood which did not contain them.
   Now, in turn, the most varied judgments were rendered con-
cerning the rod-like bodies.   They were considered  by various
authors  as particles of  fibrine, shreds of tissue, blood-crystals.
Delafond thought  them a kind of leptothrix.  He  declared him-
self, moreover (1860), to be entirely in accordance  with  Brauell,
and confirmed nearly everything laid down by the latter, sup-
porting himself by numerous  examinations of blood.
   On  the grounds of  his  experiments, Davaine (1863) pro-
nounced the rod-like bodies  to  be bacteria, later  bacteridia, in
order to distinguish them from the  bacteria of  putrefaction
which are capable of motion.   Since blood without these bacte-
ridia is not infectious, the latter constituted (for Davaine) the
poisonous principle, by means of which  anthrax is propagated.
The bacteridia are destroyed by decomposition, but when  dried
they may be preserved for many months.
   From this  time forward the divergence in the views enter-
tained   concerning  the  rod-like bodies  constantly  increased;
indeed,  the entire question was  thrown into a confusion which
it is difficult to depict.   Instead of abiding by the  results of the
investigations  of  Brauell  and Pollender—results  the value and 
ANTHRAX OF ANIMALS.
377
exactness of which are still recognized—all sorts of structures
(blood-crystals, the bacteria of decomposition, little rolls of blood
corpuscles) were  looked upon and described as the anthrax cor-
puscle {Stdbchen).  There can be no doubt that this confusion
was greatly due  to  the exceeding  smallness  of  the rod-like
bodies, the presence of other very similar structures in the blood,
and a lack of unanimity as to what really was, and what was not,
anthrax.
    The study of anthrax and of the rod-like bodies was brought
into especial prominence  in France as the question of the day,
and was materially furthered by Davaine, who  rendered  impor-
tant services in this direction.
    Davaine found in every case of anthrax that bacteridia were
present,  and that their appearance preceded the morbid symp-
toms.  With the disappearance of  bacteridia (by decomposition)
the contagiousness of anthrax blood ceases.  The number of the
little bodies in a single drop of blood was estimated by Davaine
at from eight to ten millions, and he claimed to have produced
anthrax  by the millionth dilution of such a drop.
    Among the numerous  opponents of Davaine may be men-
tioned especially Sanson,  Leplat, Jaillard, and Bouley, who sev-
erally contended that the rod-like bodies were merely the bearers
of the contagion, since they are often wanting,  and yet  in such
cases  the blood,  devoid of bacteria, possesses infectious prop-
erties.
    Now, bacteria,  which had  been neglected by botanists, be-
came in this aspect also the subject of zealous discussion.   After
the failure of Hallier1 s attempt  to  transform the whole doctrine
of the lower fungi, and to vindicate  for them a cardinal role in
the doctrine of contagious diseases, de Bary,  H. Hoffmann, and
F. Cohn, in a very comprehensive manner, enlarged the  founda-
tions of our knowledge of these important structures, wliich had
been laid by Ehrenberg and Nageli.1
    Henceforward bacteria, and  among them our anthrax-bacte-
ria, were classed  along  with  the scliizomyceles  {Spaltpilzen,
Nageli),  so named on account of their great friability.  Although
   1 See Bollinger, Zur Pathologie des Milzbrandes. Munchen, 1872, pp. 15-22, where
an attempt is made to give a review of the bacterial controversy. 
378      BOLLINGER.—INFECTION BY  ANIMAL POISONS.

bacteria, especially those possessed of motion, were classed by
certain zoologists (Schmarda) among animals (infusoria), or were
placed (Hackel) in a third organic kingdom, holding an interme-
diate position  between the animal and the vegetable kingdoms,
with such organisms as the zoophytes, still the near relation of
the schizomycetes to the lower plants,  as shown by the results of
more recent investigations, has been established, and their vege-
table nature is of late no longer doubted by zoological authori-
ties.
   While, in relation to anthrax of the human species,  we refer
to some later and more special historical remarks which we shall
make further on,  we have still to call to notice here the results
of our own investigations, which in all essential  particulars sub-
stantiated the hypothesis of Davaine—according to  which the
anthrax bacteria  actually represent the poison—and  assisted in
explaining their action upon the animal  organism.  Moreover,
the contradictory  statements of the  earlier  investigators have
now been set at rest by the microscopical and experimental
proof of the existence of bacterial germs.


                          Etiology.

   Anthrax is an acute  infectious malady, which breaks out
commonly in an epizootic or enzootic manner, and is not infre-
quently sporadic in herbivorous  animals  and  swine.   It is
transmissible to a great number of other  animals, as well  as to
mankind.

   Local peculiarities of soil play an  active part in the develop-
ment of enzootic anthrax.  While the inorganic  constituents of
the soil are by just so much of significance as they hasten or
retard the decomposition of the  organic material, the amount of
the latter exercises a very positive influence.  Anthrax is  chiefly
found on soils rich in decaying vegetable matter—on peat-moors,
in the vicinity of dried-up water-courses  and lakes,  on freshly
upturned  soils, and  especially where  intermittent  fever also
flourishes (anthrax-districts).
   An unusual amount  of decaying vegetable matter in the soil, 
ANTHRAX OF  ANIMALS.
379
 joined with an excess of moisture, appears to  furnish the most
 favorable conditions of life for the poison.
    But still  weighty objections  may be urged  against the com-
 monly adopted theory of the  malarial nature of anthrax.   The
 latter, for instance, does not by any means always hold a course
 parallel  to  other  malarial maladies—intermittent  fever.   In
 many anthrax districts intermittent  fever is wholly unknown;
 while on the other hand, in localities where the latter is preva-
 lent,  there is no anthrax.   Then,  again, in  large anthrax  dis-
 tricts, small  areas may be separated out which  possess a total
 immunity from  anthrax,  or where the cases observed may be
 especially numerous.   It may be assumed  for anthrax, as well
 as in the case of  certain other infectious diseases, that only such
 soil as  is impregnated with  the anthrax poison,  causes the  dis-
 ease ; and that it does so as soon as it is in a favorable condition
 for the preservation and development  of the virulent material;
 while,  on  the other hand,  on  the  same soil, if there  be  no
 anthrax-poison present, the disease never develops there.

    In support of this assumption, which has been recently insisted upon by Nicolai,1
 who endeavored to actually  prove it, the following observations may be adduced.
 Oemler2 (Mansfeld) reports that in one year, after he had most positively forbidden
 the interment of all cadavers, without exception, in his fields  and meadows,  his loss
 of sheep from anthrax sank from 21 to 2 per cent. Leonhardt3 reports from the  Nid-
 der- and Niddathal  in Oberhessen, where anthrax is enzootic, that  in Bonstadt,
 which  suffered severely from the disease, the  latter almost entirely disappeared
 among cattle, and  finally, was nearly forgotten, after the  sheep had been carried
 away.  It had been usual for numbers of these sheep to perish of anthrax during the
 summer, and their bodies had either not  been interred at all, or had been  only
 imperfectly buried in  the fields.  On the other hand, in  certain places lying in the
 immediate neighborhood, Assenheim and Florstadt, where there were still sheep-
 folds, anthrax raged with unabated severity, manifestly because there the sheep
 which died of anthrax were (as formerly in Bonstadt) either  imperfectly buried on
 the spot, or thrown aside among the grass and growing  grain.  The commission
 appointed by the Russian government to investigate the causes of the anthrax enzoo-

   1 Nicolai, Erfahrungen und Notizen iiber Milzbranderkrankungen bei Mensch und
 Thier., p. 25.  Darmstadt and Leipzig, 1872.
   2 Zeitschrift des landwirthsch, Centralvereins der Prov. Sachsen, 24 Jahrg., No. 6,
 1867.
   3 Zeitschrift fur die landw. Vereine des Grossh. Hessen, 1870, p. 68; also a commu-
nication by letter  to the author. 
380      BOLLINGER.^-INFECTION BY ANIMAL  POISONS.
tics occurring in Russia, reported as one of the most important points of origin of
the epizootics, that the horses which were used for towing boats on the Scheksna
frequently  died of anthrax, and that their bodies were improperly disposed of.
They were not ordinarily buried at all, but befouled the air and the water of the
stream, which latter, moreover, ran through a swampy region (Massmann).1

   Certain physical conditions of the soil, moreover, are of great
influence  in the  development  of  anthrax—such as the amount
of water it contains, and its temperature.   Thus a considerable
drying up of the soil seems to prevent  the escape of the miasm.
When this crust  of surface soil,  which has been rendered imper-
meable by great heat, is destroyed by a return of rainy weather,
the number of cases of anthrax  increases; while, on the  other
hand,  upon a soil  saturated with  water, the cases of anthrax
become more  frequent when, on the advent of warm weather,
large quantities of  water are evaporated (Nicolai).   As to ther-
mometrical local  conditions there can be no doubt—from a com-
parison of  the conclusions of Koranyi, Lengyel,  and  Nicolai
—that even  among men anthrax reaches by far its greatest inten-
sity in those months in which the temperature of the soil attains
its maximum : these months are,  according to the investigations
of Pfeiffer, August and September.
   That the soil and local conditions are among the chief factors
in the development of anthrax is, then, hardly to be doubted.
This question  alone needs an accurate solution, namely, whether
it is  necessary  that the soil shall be impregnated with  the
poison, or whether  it is able to generate the poison spontane-
ously.  The fact that anthrax was formerly a common malady
(for  example,  even  in  Switzerland),   and was of much  more
frequent occurrence than to-day, admits  of  various interpreta-
tions.  While, on the one  hand, a large share in the lessening
of anthrax  is ascribed to a more  thorough cultivation  and  a
steadily progressive  tilling  of the soil, the  transformation  of
dangerous meadow lands into arable  territory (Wald); on  the
other hand it may be urged that  the improvement is (not impro-
bably) due to  the more thorough and intelligent disposal of  the
bodies of animals which have perished of anthrax.
1 Deutsche Zeitschrift fiir Staatsarzneikunde. Heft I., 1869. 
\NTHRAX OF ANIMALS.
381
   Regarding the influence of stagnating water, here also there
exist some well-attested facts.
   Buhl1 reports that the "horse typhus" (a form of anthrax), which raged for a
long time in the Neuhof stud at Donauworth, ceased entirely after the stagnating
water had been  drawn off—following the advice of Pettenkof er.  Reinelt2 states
that in the Biharer district anthrax, which had been very common, nearly ceased to
appear after the river Theiss had been cleared.  According to V,rald (1. c, p. 5o) in
many of the districts lying around Potsdam, anthrax, which at one time had been
common there, gradually disappeared, after the swampy land had been dried up by
extensive improvements and drainage, and a suitable outlet had been furnished for
the stagnating water. In this way the over-saturation of the soil was relieved.

   It  is  wholly unproved  whether or not a manuring of  the
soil with certain  mineral  substances  (gypsum,   sulphates)—
which  favor  the decomposition of its organic  constituents—is
capable  of  originating anthrax in districts till  then  exempt.
Toward elucidating  this  point  it  would first  be  necessary  to
decide whether  artificial  manures—and especially  bone-dust,1
which is quite frequently employed as a fertilizer—may not r>er-
haps act  as vehicles of contagion.
   If now we seek to explain the bearing which the state of  the
soil has upon the existence of anthrax, and are inclined (follow-
ing a course somewhat different from that pursued by the major-
ity of former observers)  to attribute  to  the soil something like
the role of an intermediate bearer of the anthrax poison—which
it only preserves and  holds in a condition capable of life—still
other arguments may be adduced to support our view.
   It is a recognized fact that  anthrax is markedly stationary,
or occasionally  appears in an enzootic form in places where  the
bodies of  infected animals, or  indeed only  certain portions, as
the blood, are disposed of in  a faulty manner.  In this way I
account  for  the obstinate and enzootic appearance of anthrax
upon  certain Alpine pastures (so-called anthrax Alps), for  there
the bodies of animals perishing  of  anthrax are  often simply
   1 ZeitschriftfOr Biologie, B. I., 1865.
   2 Oesterr. Vierteljahrsschrift f. wiss. Veterinarkunde, B. XXXI., p. Ill, 1869.
   3 The preparation of raw bone meal—which is employed by preference as a fertil-
izer by farmers—does not destroy the anthrax poison, when the bones are  taken from
infected animals. 
                           /                )
                           /

382      B0T.1.INGER.—INFECTION BY ANIMAL POISONS.

thrown co one side among the cliffs and out-of-the-way places, on
account of the lack of hands necessary  for a careful burial.
The  truth of this assumption is made more probable by  the
above  detailed observations of  Oemler  and  Leonhardt,  and
finally it is substantiated by the anthrax  enzootic at  Werikon,
which I thoroughly investigated and reported.   Here for more
than four years continuously, in two  stables belonging to the
same owner,  anthrax decimated  the stock of cattle,  while  the
yards were spared,  although lying partly between the infected
stables;  thus showing  that under certain circumstances, even
where anthrax rages as an enzootic, the soil may remain without
any  share in the infection  although the  stables are  involved.
The  final  deductions  of Nicolai—a thorough and exjjerienced
observer, whose rich experience was derived from observations in
a very positively marked anthrax district;—ratify  the conclu-
sions which I adopted in connection with the anthrax enzootic at
Werikon,  namely, that contagion, and indeed mediate  conta-
gion, is one of the most important sources of anthrax.
   Hence, as  a matter of course, climate, geographical position,
altitude above the sea, weather, and other influences—such as
the nature of the fodder, the keep of the animals—although they
have severally been blamed as so many causes of anthrax, are
totally denied as such.  On the  other hand, the conditions of
earth and air, of place and time, are certainly of the greatest sig-
nificance as auxiliary causes, as for example the amount of dew,
the temperature of  the  air,  the varying amount of moisture in
the soil (ground-water), the temperature of the  soil, the move-
ments of the lower atmospheric strata.
   The chief source, then, of anthrax is contagion.  This, how-
ever, is seldom direct,  but is usually brought about  through the
instrumentality of  mediate agents;  the specific poison  of  an-
thrax is transmissible in a high degree.
   Consequently anthrax is not contagious like  small-pox.  It
approaches more  nearly to pyaemia and septicaemia, and even—
though only to a certain extent—to cholera and typhoid fever.
   If we inquire what material is  most  frequently the carrier of
the poison of anthrax, the diseased and dead animal, in all its
parts, deserves the first mention.  Most frequently the fluids of 
ANTHRAX OF ANIMALS.
383
diseased animals  are  to be blamed (blood  from blood-letting,
blood which in the slaughtering, cutting up,  and burying of ani-
mals adheres to everything it touches and  quickly dries  up);
then the hides, hair, bristles,  hoofs, horns,  bones,  flesh,  secre-
tions, excretions—especially the excrement—all of these are to
be feared as vehicles of contagion.
   Further, as carriers of the poison must be mentioned healthy
animals  and men,  who themselves  for  some  reason  do not
become sick (perhaps on account of lack of aptitude for the mal-
ady).   In  this class  belong flies, which are  particularly  danger-
ous  as carriers of the poison.

   Gerlach, 1. c, reports the transmission of anthrax by dogs as inoculators.  When
the shepherd  dogs are called away from their meal—devouring the bodies of animals
destroyed by  anthrax—and used for getting the flock together, the sheep which are
bitten perish  in two or three days of anthrax.  By some observers (Davaine and
Raimbert) all cases of anthrax wliich cannot be explained by direct contagion are
attributed to inoculation by flies.  That this hypothesis is untenable is shown at once
by the fact that the disease continues its devastations through the  winter when
there are no flies.
   Davaine obtained positive results by inoculation with the proboscis and feet of
flies,  contaminated with the blood of diseased animals, and thus founded his theory
experimentally.  According to Raimbert's investigations flies which sting by means
of a sting situated in the back part of the body are without danger, although such
stings often give rise to a bad sort of furuncle.   On the other hand, those flies (house-
flies, blue-bottle flies) which live upon flesh and blood, carry the poison on their
feet, wings, and in their dejections, and by depositing it on the uninjured skin pro-
duce  anthrax.  I communicated some similar results to the gathering of naturalists
at Wiesbaden (1873) :  the contents of the  stomach  and intestines of horse-flies,
wliich I collected from the body of a steer which had just died of anthrax, showed
the well-known bacteria, and inoculation upon two rabbits produced the disease.  In
the same manner I demonstrated experimentally the virulence of the milk and vagi-
nal mucus of diseased  animals, although, according to the experience  of other
observers (Cauvet), the milk of animals suffering from anthrax may frequently be
taken without injury.

   There must be mentioned further, as carriers of the contagion,
the harness of animals, implements used in  stables, straw,  hay,
all objects  which come into  contact with  sick or diseased beasts
(their blood,  mucus,  etc.),  and thus  become soiled.   Earth—
especially  when  loaded with vegetable  matter  in  decay—is
marked  by the special facility with which it  preserves the con- 
384      BOLLINGER.—INFECTION BY ANIMAL POISONS.

tagious material—perhaps also by a power of reproducing it—
and that through a period of years.
   The propagation of anthrax by means of food, particularly
coarse fodder, is especially  frequent.   The greatest blame is
bestowed upon such fodder as grows in places where the bodies
of animals which have died of anthrax  have been buried, and
many believe  that, in  these cases, the plants themselves act as
bearers of the poison.  There is as yet no proof  of the truth of
this assumption.  In my  opinion, in these cases, the earth adher-
ing to the plants seems to act as the vehicle of contagion,—earth
which was contaminated at the time of burial of the animals—
for the body  itself  very soon loses  its  specific  virulence after
it has been buried,  as I have been able  to prove  experimentally
{L c, p.  86).

   According to the investigations of Renault,  Colin, and myself, animals not dis-
posed to acquire anthrax (carnivorous, omnivorous, birds)  may  eat raw portions of
diseased animals without injury, while herbivorous  animals (sheep, horses, goats)
are more liable to infection in this manner, as are also rabbits.

   Moreover,  when the  fodder comes  into  contact with any
infected  matter—especially with blood which has been  dried in
the air—it is  capable  under certain circumstances of again pro-
ducing anthrax.  Likewise drinking-water may act  as  a source
of infection by trickling  through infected soil or  by direct con-
tamination with diseased  matter.   Stable drainage seems to be
less  dangerous,  since the poison is destroyed by  decomposition.
The customary medium of communication for anthrax poison is,
however, the  air,  whether the carriers of that poison  (anthrax
bacteria) come out of the soil or are derived from  living animals.
The  digestive tract holds the  second place.  Here  the  poison
enters the body  with the food.  Even  in  those experiments
which gave positive results where food was used, as well as in
the frequently recognized infection  after voluntary  feeding on
diseased meat, the possibility must always be borne in mind, that
either before  or during feeding (by smelling or  snuffing at the
infected  material) the light and movable poisonous matter might
have been drawn into the lungs, and  thus reached the blood and
animal fluids ; or indeed, during feeding on contaminated matter, 
ANTHRAX OF ANIMALS.
385
the poison may directly  inoculate pre-existing  injuries of the
mouth  or  throat.  Accurate experiments have  proved (Colin,
1. c.)  that  the gastric juice of carnivorous animals is capable of
destroying the poison.
   For the existence of  anthrax, however,  in  whatever  way
the infection occurs,  an individual susceptibility is necessary,
depending partly upon the species of  animal and partly upon
unknown  factors.  While herbivorous animals  (cattle, sheep,
goats, and horses)—as also grass-feeders in  the  wild state (roe,
stag)—are  noticeable  for their great  susceptibility, the latter is
less marked in omnivorous  animals  (swine, men), and is  least
pronounced in the carnivorous, among which the cat acquires the
disease more readily  than  the dog.
   Age and sex  are  without  influence ;  not  so the keep and
nourishment of the animals.   Just as in the  parasitic infectious
diseases of the vegetable  kingdom,  where the fungus attacks
perfectly healthy plants,  indeed, where the parasite  seems to
flourish so much  the better as  the  plant which nourishes it
thrives,' well-nourished animals  fall victims to anthrax by pre-
ference. Hence, animals which have been recently introduced,
brought from stables and districts free from the disease, are
more frequently seized by the malady than such as have long
remained in the infected  stables and districts.  Animals which
are turned out upon  the fields in the  anthrax districts  are more
apt  to  receive  the poison than  such as are kept in stables.
Other infectious diseases  {e.g., inoculated tuberculosis) do  not
afford immunity from anthrax.

              NATURE OF  THE ANTHRAX POISON.

   Although the  first discoverers of  the anthrax bacteria (Pol-
lender  and Brauell)  had  declared it possible, that the  latter
might bear  some  relation to  the genesis of the  disease,  yet
Brauell entirely abandoned this idea on the ground of his experi-
mental  researches.

  1  De Bary, Handbuch der Physiol.  Botanik von  Hoffmeister,  B. II., p. 222, 1866.
Formerly exactly the opposite idea prevailed, namely, that lack of health on the part of
a plant was most favorable for a development of the vegetable parasites.
          VOL. III.—25 
386      BOLLINGER.—INFECTION BY ANIMAL POISONS.

   Brauell* produced anthrax in two foals  by inoculation with
blood which did not contain any rod-like bodies, while the blood
of the inoculated animals showed them.   From this he drew the
deduction  that  these structures  were  neither the contagious
material nor the  necessary carriers of  the same.  Bouley2 failed
to produce anthrax  by inoculating with the blood of  infected
animals which contained no bacteria.  These experiments, which
were  also  verified by me  (1.  c, p.  49), constituted the  most
powerful argument which could be raised against  the theory of
Davaine, according to which the bacteria represent the  specific
anthrax virus.  It is  easy to conceive that bacteria in the blood
and  organs of  diseased animals may be easily overlooked on
account  of their smallness, especially if they are few  in num-
bers and scattered, that investigations of blood are frequently
not carried on with  sufficient thoroughness, and that bacteria,
when they exist only locally in  the body, may remain unnoticed.
This I have proved experimentally and by the microscope, show-
ing that in infectious blood of this kind, without bacteria, the
germs of the latter  are already present in the form of spheri-
cal bacteria3  (1.  c, p. 48 et seq.)  Indeed, I succeeded, by the
inoculation of diseased blood  containing bacteria, in producing
true anthrax  in which  the blood of  the diseased animals  con-
tained no  bacteria, although there were  bacterial  germs which,
after death, developed outside  of the body into  characteristic
cylindrical bacteria (1. c, p. 67).
   After Davaine's assertion,  that  blood without bacteria was
incapable  of  producing anthrax, had been thus  refuted, the
results of fresh experiments again pronounced strongly in favor
of Davaine's  theory.   Brauell4 had already  established  that
blood without bacteria,  derived from  the embryos of mares and
sheep  suffering  with anthrax, and inoculated upon foals and
  1  Virchow's Archiv, B. XXXVL, p. 463, 1866.
  3  Recueil de med. vet., Vol. XLVL, p. 41, 1869.
  3  It has of late been again brilliantly demonstrated by G. W. Milller (and Schuster)
that it is possible to produce true anthrax with filamentous bacteria, by the inoculation
of diseased blood  containing spherical bacteria (bacterial germs), but no filamentous
bacteria.
  i Virchow's Archiv, B. XIV., p. 459, 1858. 
ANTHRAX OF ANIMALS.
387
 sheep, did  not cause the disease.  Davaine1 arrived at the same
 results, making use of pregnant guinea-pigs.
    Thus while all efforts to isolate anthrax bacteria  by filtration
 with ordinary  apparatus (filter-paper, earthen cylinders) have
 thus far failed, yet  the placenta appears to  be a physiological
 filter, not allowing the bacteria to reach the fcetal circulation.
 On the other hand, the results of inoculation speak strongly in
 favor of the virulent  properties of the bacteria.   Fcetal blood
 without bacteria  does not produce anthrax,  while inoculation
 of the blood of the mother which  does contain bacteria gives
 positive results.
    From the almost  constant  appearance of characteristic bac-
 teria (or bacterial germs) in  the blood of the diseased animals,
 and in view of  the results of inoculation adduced above, and  the
 exquisite character of  anthrax  as a blood disease,  it appeared
 proper to consider these little  organisms as the anthrax  poison
 itself, provided we could explain the  clinical  and anatomico-
 pathological appearances from their peculiarities and behavior.
    When Davaine endeavored to explain the whole course of a
 disease,  the anatomical changes  of which  are so  important,
 chiefly  by  a cohesiveness of  the  blood-corpuscles  leading to
 obstruction of  the smaller vessels, it  was at once evident that
 this basis was not  sufficiently broad to explain  the  disease
 thoroughly, or  for the physiological elucidation of  the appear-
 ances during life.
    Should it now be asked, What is the action of the bacteria
 and similar structures upon the bodies in which they dwell ?—
 relying upon modern  investigations  a  comprehensive answer
 may be given.
    Pasteur, in his search into the requirements of life of the bac-
 teria, arrived at the result that their  existence was  dependent
 upon the presence of oxygen,  and on this account called them
 Aerobia.   By the action of schizomycetes (bacteria and  vibri-
 ones) a rapid oxidation takes  place in organic bodies, the pro-
ducts of which are  water, carbonic acid,  and the more  simple
organic compounds.  The oxygen, of wliich the fungi absorb a
1 Recueil de med. vet., 1868, p. 199. 
388      BOLLINGER.—INFECTION BY ANIMAL POISONS.

considerable quantity in  this process, they extract from the air
when the  latter has free access to  them, otherwise from the
organic substance  itself.  H. Hoffmann and F. Cohn have also
conclusively proved that the  life and growth of  bacteria  is
dependent upon oxygen,  which they greedily absorb.  Without
oxygen bacteria cannot five.  When it fails, they are arrested in
their growth, or die.
   The serious objection, that it is d priori inadmissible to bestow the physiological
peculiarities of the saprogenic bacteria without question upon those which are seem-
ingly pathological, appears to me to be answered by one of the earlier experiments
of Davaine.1  By sealing up anthrax blood in five glass tubes, to the entire exclusion
of air (and consequently of oxygen), the bacteria died in a few days, and inocula-
tion with such blood would not produce anthrax.

   By deductions  from  numerous  experimental,  clinical, and
anatomico-pathological results,  I believe that I have adduced the
proof (1. c.j p. 132) that the action of anthrax bacteria—(which are
present in  enormous numbers2  in the blood of the domestic ani-
mals suffering from apoplectiform  anthrax, which is very com-
mon)—is apparently this : the bacteria, by their rapid increase in
the blood,  by virtue of their powerful need for oxygen, and their
enormous  chemical affinity  for the same, absorb it with great
greed and  in large  quantities, thus  taking it away from  the red
blood-corpuscles.   All the symptoms of  the  sick animals while
alive—dyspnoea, cyanosis, clonic spasms,  dilated pupils, finally,
depressed  temperature and the appearance of  asphyxia—all  of
these symptoms, as in every case of carbonic-acid poisoning, are
explicable by  the  above detailed  mechanism  which  quickly
results in a lack of oxygen, and an  excess of carbonic acid in the
blood.  Likewise the  post-mortem examination reveals changes
similar  to  those which we are accustomed to  find  after  death
due to  lack of  oxygen and overloading of  the blood with car-
bonic acid—engorgement of the venous system, dark, tarry char-
acter of the blood, slight hemorrhages in different organs, cya-
notic coloring of the parenchymatous organs, hyperemia of the
  1  Journ. des Veter. du Midi, T. VIL, p. 444, 1864.
  8  Davaine estimates the number of bacteria in a  drop of anthrax blood at from
eight to ten millions. 
ANTHRAX OF ANIMALS.
389
lungs.   The overloading  of  the blood  with carbonic acid is,
moreover, greatly increased on account of the active oxygenation
which is going  on,  yielding a further quantity of  carbonic
acid as  the product of combustion.   In this manner I explain
those lightning-like and apoplectiform cases where the animals
suddenly sink  to the  earth and promptly expire.  These forms
of anthrax are  very common.   In their course and in their whole
pathology they find  their analogy in no spontaneously exist-
ing process of disease, but offer the greatest  similarity to poison-
ing by hydrocyanic acid.  Death by  this poison is, according
to Preyer, in  fact  a death by  suffocation,  on account  of the
withdrawal of  the  oxygen by the  acid; therefore I place the
lightning-like action of the bacteria in such cases in the same
rank  as  poisoning by hydrocyanic acid.   In discussing the ana-
tomico-pathological changes of  anthrax, we will return to this
question, and see to what extent the other cadaveric changes may
be explained by the action of the bacteria, which is, moreover,
partly mechanical.
   In those cases  of anthrax which  run a slower course, and in
those  rare forms where the blood  contains only the bacterial
germs, apparently other  chemical poisons are secondarily pro-
duced in the blood,  and furnish a cause for the fever and other
symptoms.
   The morphological peculiarities of anthrax bacteria may be
characterized as follows :
   According to Colin's ' recent systematic classification of bac-
teria,  anthrax bacteria belong to the group known as filamen-
tous bacteria (desmobacteria) and to the species  bacillus.  The
bacillus anthracis (Cohn) is closely related  to the bacillus sub-
tilis {Vibrio subtilis, Ehrenberg), to the butyric acid ferment
{ferment butyrique Pasteur).
   Bacilli, such as are almost constantly found  in the  blood of
animals suffering from anthrax,  possess  the  following morpho-
logical peculiarities.  They are straight,  less often bent or with
obtuse angles,   indented  cylindrical rods  of  pale appearance,
  1 Beitrage zur Biologie der Pflanzen, II., p. 173, 1872.  Cohn has not personally
studied the anthrax bacilli. He has arranged them according to the description given
by Davaine  and myself. 
390      BOLLINGER.—INFECTION BY ANIMAL POISONS.

never branched, motionless, generally 0.007-0.012 mm. long, and
of a breadth  which is hardly measurable.  Besides these well-
pronounced filamentous bacteria, smaller  transitory forms may
be found, although fewer in number, 0.002, 0.003, and 0.005 mm.
long, down to  the very smallest forms wliich cannot be measured,
and which, when viewed with  ordinary  glasses (Hartnack 7.3')
appear as fine points, while with higher powers they are seen to
be spherical bacteria, with all the optical and chemical peculiari-
ties of the filamentous bacteria.
   Larger bacteria, which exceed the measurement above given,
are very rarely found, and  those of 0.050 mm. length,  as de-
scribed  by Davaine,  have  been only once observed by me, and
perhaps then they were rather  to be considered as post-mortem
products.  With medium  and  low magnifying powers (Fig. 8),
the filamentous bacteria appear without joints and homogeneous.
 ^^^^^^^^^^^^^^p^p^_     With higher powers, and by
        ^^^^^^^^^         employing artificial means  (caus-
    Pr      Ulr '/  ^^      *n&  *nem t° swell by soaking in
  ^T  \   ~7   v    /   /V^H  water), it  is seen that the fila-
 W  /.   ^  I         ^   ^  mentous  bacteria are formed of
       '  \ \ ®t-   i ~    ~~'s ■  different  members,  and are  in
 ■  W >  '   u ■   /   \ • ■  fact  constituted by a juxtaposi-
 A   jfc.—   -^ JP, _y  M  tion  of round or short  cylindri-
  ^L^  ^^  ■  y • ^ *^H  cal cells (Fig. 9).
    ^^^\  '  ^ N. '^^k  I    The isolated spherical bacte-
        ^^^w^^^      I  ria mav also ^e found alone in the
                              blood of  anthrax.   They grow
   Fresh anthrax bacuii, from the biood of a cat continually by scission, and,  as
  which died of anthrax after inoculation.  (Case                       .
  xxn., i. c.) Hartnack 7,3, * 320.         little rows  ol   cells united to-
gether, constitute the rods (filamentous  bacteria)  which grow
symmetrically at all points  by scission.   The  little rods,  which
in the fresh  state seem homogeneous,  after  they have been
swollen by  water and then dried,  exhibit an  envelope  and  a
plasma.  Anthrax bacteria are distinguished from other bacteria
(bacteria of  decomposition,  as found in animal  or vegetable infu-
sions, bacteria of sour milk) particularly by the fact  that they
1 Objective No. 7, ocular No. 3. — Translator 
ANTHRAX OF ANIMALS.
391
have a certain symmetry of form and appearance, and are devoid
of motion.  Otherwise  their behavior  with  reagents is exactly
the  same  as that of the above-mentioned varieties, and  they are
noticeable  for  their great resistance to  concentrated  acids and
alkalies.

   The varied descriptions of bacteria, as given by authors, may be mostly explained
by the fact  that the  bacteria of decomposition and other post-mortem products
(blood-crystals) have frequently been mistaken for anthrax bacteria.  Whether the
latter are capable of  motion in the  blood of living animals  is  as  yet undecided.
I did not succeed in giving them motion by artificially warming the blood.
The development of anthrax bacteria is dependent  upon the
                                  Fig. 9.
  Anthrax bacteria from the blood of a steer which died of apoplectiform anthrax (Case XII., 1. c, 26, II.,
1872). The segments made plain by artificial swelling (with water).  Drawn from a fresh preparation, two
days after death, by E. Jager (of Brugg), student.  Hartnack 9, oc. 3,  x 550.
presence of oxygen.  By being dried they may be preserved, but 
392       BOLLINGER.—INFECTION BY  ANIMAL POISONS.

decomposition  rapidly destroys  them.   With  their  departure,
and the appearance of bacteria of decomposition, disappears also
the virulence of anthrax blood.  The disease is no  longer pro-
duced by inoculation of the fluid, which is either negative or
gives rise to putrid infection.  Anthrax bacteria are  deprived of
their  power of development by cooking, or  by the  action of a
temperature of 140°  Fahr.
   Davaine states that fresh anthrax blood, after remaining ten  minutes in a glass
tube in boiling water, continues  to be infectious.  According to investigations
recently instituted, anthrax blood  loses its virulence after  being cooked for five
minutes.  Rabbits inoculated with such blood remain well,  while the same blood
before being cooked produces fatal anthrax by inoculation.
   On the other hand, bacteria are  apparently not destroyed by
very low temperatures, as low as—1° Fahr. maintained for several
hours.   According to the investigations of  Cohn, they become
dormant at 32° Fahr., like other (saprogenic) bacteria, and  seem
ingly even at a somewhat higher temperature.   Under the  influ-
ence of cold they lose certain physiological peculiarities (growth,
action on foreign substances), not, however, the power of recover-
ing their development at a  higher temperature.  Moreover, bac-
teria are destroyed by solutions of  carbolic acid, chlorine water,
and similar disinfectants.
   Unfortunately  our knowledge  of the  behavior of  anthrax
bacteria  in the living body is very limited.   It is certain that
they may appear locally, or be unevenly distributed (which par-
tially  explains  their frequently alleged absence) ;  and  further,
it may be concluded  from the clinical and anatomico-pathologi-
cal bearing of  many forms of anthrax (horse-typhus), that they
may disappear from the body, as I have endeavored to explain
elsewhere (1. c, p. 131).
   From the intermittent  character of anthrax, which is frequently observed (see
my work, Case X., p. 32 and p. 94), and the  paroxysmal nature  of the symptoms,
it is certainly allowable to assume a corresponding appearance of bacteria in mass,
and a gradual disappearance  of  the same.   In this way  a coincidence of  the
bacteria with the attacks  would take place  analogously to the appearance of the
recurrens-spirochaite, recently discovered by  Obermeier.1  Moreover, it has  been
   1 Prof. Cohn (in Breslau), in a communication  by letter, is  inclined to accept this
theory. 
ANTHRAX OF ANIMALS.
393
proved by numerous injections of fungus into the blood of living animals, as well
as by the injection of blood containing bacteria into the veins of a dog (see 1. c,
Case XXXIX., Inoculation  13,  p. 86), that the living animal organism has the
power of ejecting blood parasites of this kind, or at least of causing them to
disappear.

    How anthrax bacteria or their germs  get into the body may
be  imagined without difficulty by recalling the  common charac-
ters of these organisms.  Whether they originate from the soil,
or, becoming  dried up,  as the  remains of a  case of anthrax,
adhere to  some  object, sooner or later  they get free  by some
mechanical influence,   or by  accidental contact  become mixed
with water.  Small and light, they are wafted by the breeze, and
either directly breathed in by the animal, or they fall upon the
fluid or solid food, and with  it enter the body.   Such bacterial
germs suspended in the  air  may be washed down by rain, con-
veyed to a distance and deposited in any  place whither chance
may carry them.1  The penetration of  anthrax  bacteria through
the loose and thin mucous membranes of the animal body is easy
to comprehend, in view of  their  minute size and of the fact that
even hard substances (egg-shells)  oppose no obstacle  to the pas-
sage  of analogous substances, as  well as finally  of this fact, that
bacteria of decomposition,  after  death, penetrate  immediately
from the  cavity of the intestine (and with great rapidity) into
the organs of the  body, and spread  themselves in  all direc-
tions.
    The  tenacity  of the  anthrax poison—bacteria—is exceed-
ingly great.  In the dried state the bacteria are able to preserve
their virulence during  months, and even many years.
   Davaine succeeded in producing anthrax by inoculation of dried anthrax-blood
twenty-two months old.  Einike2 relates the following case as very well illustrating
   1 It is noticeable that similar ideas prevailed in the olden time concerning the origin
and spread of anthrax: "Take you  handfuls of ashes of the furnace, and let Moses
sprinkle it toward  heaven in  the sight of Pharaoh, and it shall become  small dust in
all the land of Egypt, and shall be a boil breaking forth with  blains upon man, and
upon beast" (Exodus IX., 8-10).  The peculiar belief existing in North Sweden in the
last century, that a fabulous  animal dropping out of the air caused  anthrax, was so
deeply rooted that Linnmus and Solander received it into the zoological system s&furia
infernalis, and later it was retained in its position by Pallas.
  2 Mittheilungen aus der thierarztlichen Praxis im preuss. Staate, 1855. 
394       BOLLINGER.—INFECTION BY ANIMAL POISONS.
the virulence and tenacity of the poison.  The skin of an ox (from whose flesh two
persons got carbuncle), which died of anthrax in the fall of 1852, was soaked in the
following spring in the water of a pond, and then made up by a saddler into har-
ness.  The saddler got carbuncle. From  a  flock of sheep which were washed in
the pond four weeks later, twenty perished in a few days  of anthrax, and  both of
the horses (for whom the new harness was made), after they had worn it for four
days, died of the disease in forty-eight hours.

   Hence, anthrax may be characterized as follows :
   Anthrax is an acute infectious disease.   The infectious
material consists of a vegetable  parasite, which is produced in
the diseased animals (endogenous), and  perhaps also  finds the
conditions adapted to its  development  outside  of the  same,
namely,  in the soil (ectogenons);—it being understood that  the
soil  has been  previously impregnated with  these  organisms or
their germs.  Anthrax  is not contagious in  the ordinary sense
of the term, since an immediate contagion from animal  to animal
has hardly been proved.   It is, however, in a high  degree  trans-
missible (mediate contagion),  since  the anthrax poison may be
preserved for a long time, and transported by numerous mediate
objects.1  The  poison, which  although a  fixed one, is also dif-
fused through  the  air, most  often  enters  the body through the
lungs, but perhaps also it gets in with the food and drink.

                    Appearance  and Spread.

   We have shown above that the herbivorous animals are  par-
ticularly liable to acquire anthrax,  that the susceptibility  is less
in the omnivorous,  and least of all in the carnivorous.   Indisput-
ably the disease appears most often among the domestic animals,
—cattle, horses, sheep—the ass  and the goat being less often
attacked.  Swine also suffer,  although much less  often than is
commonly believed.   They are subject to a scourge wliich is fre-
quently, though falsely,  reckoned as anthrax, and is indeed  sim-
ilar  to it in many  of its features, and  equally dangerous—the
hog-plague (Rothlauf, Schioeineseuche, mat rouge).   Anthrax is
  1 While Davaine maintained the non-contagiousness of anthrax, yet he evidently
drew his conclusions from considerations similar to those here advanced, and only
erred in that as a counterpart he set up septicaemia as a contagion. 
ANTHRAX OF ANIMALS.
395
very  easily communicable  (by inoculation)  to  guinea-pigs, with
more difficulty  to dogs and poultry,  somewhat more easily te
cats.
   Among the wild animals ruminants are most often attacked,
especially the roe, the stag, the reindeer, the  buffalo,—and the
elephant is not spared.  Scientific investigations  must decide in
what relation certain pestilential diseases of  other animals stand
to  anthrax—diseases  which, affecting especially birds, mice,
fishes, etc., in anthrax districts,  are frequently  regarded as cases
of the latter.
   Forel and du Plcssis,1 a few years since, described a malady resembling anthrax,
among the small perch (perca fluviatilis) of Lake Geneva and  its tributaries, in which
bacteria were found in the blood. This infectious  disease, though evidently of
parasitic origin, and described as typhus, could not be communicated to other ani-
mals by inoculation.
   As to its geographical area, anthrax is found in all latitudes
and in all portions of the world, as  Heusinger has proved  by
thorough research.  In the farthest inhabited polar regions (Lap-
land, Siberia) it  rages as in the temperate zones (Hungary) and in
the tropics (West Indies).  As  to our special portion of the earth,
anthrax, more or less severe, appears in nearly all the districts of
Europe.  It is most widely spread in Russia and Siberia, and is
greatly dreaded in the latter as the Siberian boil-plague (Beulen-
seuche).
   In 1864 there died in Russia, of the Siberian boil-plague,  72,000 horses (Hcring's
Jahresbericht fiir 1865, p. 32). In Gouvernement Nowgorod alone, during four years
(1867-1870), according to Grimm (Virchow's Archiv, B. 54,  p. 262), there perished
of anthrax more than 56,000 horses, cows, and sheep, and 528 men besides.
   Anthrax is particularly  common in Hungary, in the  districts
of the lower Danube, and in certain parts of France  (Auvergne,
Beauce, Sologne, Eure and Loire).  In Germany one of the chief
anthrax districts is the Prussian province of Saxony.

                           Symptoms.                            ,
   Since Chabert, the different forms of anthrax have been com-
monly separated into two great  classes, the more nervous forms
1 Gaz. des Hopitaux, No. 122, p. 487, 1868. 
396      BOLLINGER.—INFECTION BY ANIMAL POISONS.

being designated  carbuncular fever (Milzbrandfieber), the more
anatomical, anthrax or carbuncle.   While the former are partic-
ularly acute, and often last only a few hours, and depend seem-
ingly more upon the action of the malarial and anthrax poisons
upon the nervous system, the carbuncular and slower forms are
more marked by anatomical and chemical changes.
   Among the carbuncular  fevers, in which, from its  short and
usually fatal course, the disease does not reach the stage of local
outbreaks, authors  class the  following:  the apoplectiform,  or
lightning-like anthrax {Erdsturz,  Hexenschuss,  Teufelsschuss,
apoplexia  carbunculosa), maniacal  anthrax  {Milzbrandwuth,
rabies carbunculosa), and finally, intermittent anthrax {inter-
mittens carbunculosa).  On  the other hand, to the carbuncular
and erysipelatous forms  of  anthrax, with local manifestations,
belong the horse-typhus {Pferdetyphus), (Roll and Bruckmuller),
tongue anthrax, rectal carbuncle, " Ruckenblut,'" the carbuncu-
lar disease of cattle, anthrax carbuncle and sloughing erysipelas
of sheep, and quinsy (mouth or gum anthrax),  anthrax quinsy,
the " Weisse Borste," and the sloughing erysipelas of swine.
   The faultiness of this classification is due to the fact that even in the so-called
carbuncular fever, in the most acute cases of the disease as  I  have proved, there
never fail to be localizations of the malady; such are, namely, the jelly-like hem-
orrhagic infiltrations in the different internal organs, especially the connective tissue
of the abdominal and thoracic cavities, and further, the intestinal carbuncle, which
in its origin as well as anatomically, is indistinguishable from the external cutaneous
carbuncle, as it is also from the local expressions of the disease in the neck, on the
tongue, in the rectum, and in other places.

   The different forms of anthrax, as affecting the domestic ani-
mals in  a general way,  may be  more accurately arranged  as
follows :
   1. Apoplectiform anthrax {anthrax acutissimus sivefoudro-
yante), which only lasts from a few minutes to several hours.
   2. Acute anthrax {anthrax acutus), lasting from a few hours
to a few days.
   3. Subacute forms of anthrax {anthrax subacutus).
   Here should be included all cases of anthrax of a longer dura-
tion, especially the so-called horse-typhus.
   Among the apoplectic and  acute forms are to be reckoned 
ANTHRAX OF ANIMALS.
397
apoplectic, maniacal, and intermittent anthrax—the carbuncular
fever—while the majority of the erysipelatous and carbuncular
cases would belong to the subacute forms.
   The period of incubation of anthrax among the domestic ani-
mals has been variously estimated by authors.   In  many cases
the disease is said to break out immediately after the reception
of the infectious material.   In medium-sized animals  (sheep,
goats), after inoculation, a period of  incubation of three  or four
days has been observed, during which the animals have appeared
entirely well.'  The same holds good, apparently, for cattle and
horses.  For the former, according to my experience, the incuba-
tion hardly  lasts longer than  four  or  five days.   Among the
smaller  animals (rabbits,  cats) the  incubation  is twenty-four,
thirty-six, or forty-eight hours—seldom three or four days.
   On account of the numerous forms assumed by anthrax, the
symptoms, during life, are much varied and difficult  to depict.
   In the apoplectiform cases,  which are very frequent,  and
chiefly affect cattle and sheep, the animals drop as  if they had
received a blow, go into convulsions, show a rise in the pulse, and
increased quickness in respiration, cyanosis, dyspnoea, and often
in a few minutes the fatal termination is reached.   In such cases
it appears that the animals, immediately beforehand, showed a
good desire for food, or were turned out to  work in the full pos-
session of all their functions.  They are  frequently  found dead
in their stalls in the morning, though having had  the best appe-
tite the evening before, and not having manifested the least mor-
bid symptom.
   Acute attacks of anthrax run  the following course in cattle
and  horses.  The animals,  while in  full health, suddenly  suf-
fer from a diminished appetite, or they  lose it  altogether.   In
milch cows there is a diminution or an  entire  stoppage of the
secretion of  milk.   Thirst  is increased; the  animals begin to
shake, and frequently  there is a pronounced chill;  the surface
is cold.  After a variable duration this coldness is succeeded by
a marked heated stage.  It is almost the rule to observe peculiar
convulsive movements and  clonic spasms of  the extremities.
  1 Gerlach (1. c.) estimates the duration of incubation  in sheep at from thirty to
forty-eight hours, reaching sometimes several—as many as six—days. 
398      BOLLINGER.—INFECTION BY ANIMAL POISONS.

During the remissions the animals appear weak and depressed,
or they may again seem in  perfect health, eating and chewing
the cud.   The activity of the heart is increased ; the number of
pulsations nearly doubles the normal frequence; the temperature
rises to 106° or 107° Fahr.   The excrement is frequently either
mingled with dark blood, or decidedly bloody and diarrhoeal.
   The symptoms above detailed generally appear  in a parox-
ysmal manner.  Between  the paroxysms irregular remissions
and intermissions may be observed, lasting a few hours—often
six, twelve, or twenty-four.
   In cases of the intermittent character the animals seem in the
intervals to be entirely well,  or have such inconsiderable symp-
toms of disease that the  latter readily escape notice.
   In fatal cases—and the mortality reaches  about 70 per cent.
among cattle  and horses—the breathing during a paroxysm
becomes  labored and gasping (dyspnoea),  such mucous mem-
branes as are visible  grow cyanotic,  the extremities cool,  the
convulsions  become violent,  opisthotonos and convulsive  con-
tractions of the muscles  of the eye are observed, so that only the
white of the eye remains visible, the animal grows very weak,
can no longer keep itself upon  the  feet, the temperature  falls
below the normal standard, the extremities become cold,  the
pupil is  dilated to its utmost, and death follows  in the form
of asphyxia,  generally  twenty-four,  thirty-six,  or  forty hours
after the appearance of  the first  symptoms of the malady.   On
the other hand in cases running a favorable course convalescence
sets in just as rapidly, and there is never  any  fear of secfuelse.
   Although in a majority of the cases among cattle,  cutaneous
carbuncles are absent, the latter are more frequent  in horses,
and especially in the  slower, less acute cases, extensive carbun-
cular infiltrations are  frequently found, which generally occupy
certain parts (by preference the head, neck, extremities, and the
under portions of the breast  and  belly), and often present them-
selves as conical swellings of a board-like  hardness.
   In other respects the  symptoms of the  acute forms of anthrax
are similar in horses  and cattle.  The animals  suddenly show
great weakness, they seem stunned, and  there are hemorrhages
into the  mucous  membranes within sight, especially the nose. 
ANTHRAX  OF ANIMALS.
399
Difficulty of breathing comes on with increase in the pulse, ele-
vated temperature, colic, together with convulsions, and a fatal
termination may be reached in a few hours, though frequently
not before several days have passed.  As in the anthrax of cattle,
so in horses  these  symptoms may show distinct paroxysms,
remissions, and (although less pronounced) intermissions.
   When cutaneous carbuncles occur, and in many regions they
are seen even on cattle, cool and painless furunculoid  swellings
appear  and quickly develop on  different portions of the body.
Pressure upon these spots shows them  to be emphysematous,
emitting a  crackling  sound {Gerdusch,  rauschender Brand).
Should the disease not prove promptly fatal, large  portions of
integument are  thrown off in slough, and enormous ulcers are
often left behind.
   In medium-sized and small animals  (goats  and rabbits) the
symptoms during life are far less clearly marked ; the dyspnoea,
however, the dilatation of the pupils, and indeed the convulsions,
may be observed.

                   PATHOLOGICAL ANATOMY.

   As to the  changes  found on post-mortem examination, there
is no essential difference between cattle and horses.
   After death from apoplectiform or acute anthrax  in cattle,
the blood is found to be dark, thick, tarry, and unclotted, just
as it is  after blood-letting  during life.   The entire venous sys-
tem is engorged.   The spleen is regularly enlarged up to two,
four,  or five times  its natural  size.   It is pulpy and  softened in
its parenchyma, and of a dark color.  In the intestine it is cus-
tomary to find a tar-like bloody substance ;  the intestinal walls
(especially the small intestine) are more or less infiltrated with a
sero-hemorrhagic exudation ; similar jelly-like infiltrations are
found in the omentum, the mesentery, in the mesenteric  glands,
and in  the fatty  tissue  around  the kidneys.  The abdominal
cavity often  contains  a  sero-hemorrhagic  effusion  (Hydrops
ascites).   Large and small  collections of blood are found in the
muscular structure of the heart, and  effusions of blood under
the endo- and epicardium, especially about the' auricles.  In 
400      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

female  animals the ovaries  and uterus are  often  the  seat  of
hemorrhagic effusions.  Actual intestinal carbuncles are seldom
seen in cattle.
   The anatomical  changes of anthrax in the horse differ espe-
cially from  those found in cattle, in that the jelly -like yellow
and sero-hemorrhagic infiltrations are encountered nearly every-
where in the body where there is loose connective tissue, chiefly
in the retro-pharyngeal and  laryngeal tissues, along the  course
of the great blood-vessels of  the neck, in the mediastinum, peri-
toneum, and about the kidneys.   The corresponding lymphatic
glands, especially the mesenteric, show sero-hemorrhagic infil-
trations, are considerably enlarged, and here and there in a state
of commencing gangrene.
   The intestinal lesions in the horse are for the most part not
so diffusely spread ; but still upon the mucous membrane, which
is in a catarrhal state, oedematous, and sprinkled with ecchy-
moses,  there are found well-pronounced carbuncles, which are
the seat of  more or less  superficial sloughing.  The intestinal
contents are likewise often bloody and thinly fluid.
   The  large glands, liver, and kidneys, as a rule, are swollen,
the parenchyma cloudy, succulent, full of blood (triibe Schwel-
lung).
   In the blood, besides the presence of  bacteria, the white cor-
puscles are found to be considerably increased in number.   The
red corpuscles, for the most part, are of lessened consistence, and
manifest a tendency to cohere together in little heaps.
   On microscopic examination of the carbuncles—in the intes-
tine  as well as elsewhere—and of  the  jelly-like hemorrhagic
effusions into the connective tissue, there are found in the capil-
laries, which are  considerably  dilated,  besides a  massing  of
white blood corpuscles (cellular  oedema),  numerous bacteria,
and a finely granular mass, consisting partly of metamorphosed
blood detritus, and partly of bacterial germs.
   In anthrax of smaller animals (goats, rabbits) the cadaveric
changes are much less positively pronounced.  The spleen is only
slightly enlarged, there is not much of the jelly-like bloody effu-
sion, the hemorrhages are  more scattered, and oedematous and
dropsical changes are often found.  The blood in goats is thinly 
ANTHRAX OF ANIMALS.                 401
fluid, and in other respects shows the same variations  from the
normal type as in larger animals.
   I could not remark any special tendency toward rapid decom-
position in the cadavers of cattle and goats, which had perished
of anthrax,  although it was somewhat evident in horses.   On
the other hand,  rigor mortis was almost constantly absent.  The
latter is explicable, as is the softening and the cohesiveness of
the blood corpuscles, and the failure of the blood to clot, by the
special property, which the bacteria possess, of rapidly softening
albuminous bodies.
   The increase of white blood  corpuscles is evidently a direct
result of the acute irritation  and  swelling of the lymphatic
glands  and of the  spleen, giving rise to a lively production of
lymph cells.  It is easy to understand that the bacteria and bac-
terial germs, which are found in great  numbers in these organs,
occasion an abnormal  irritation there,  as indeed was  proved,
even in man, by Buhl.
   The thickness of the blood  is  due to  its being deprived of
water  by the  dropsical, jelly-like, and oedematous  effusions^
The dark color is caused by carbonic-acid poisoning.
   The carbuncles, the oedematous infiltrations, the transudations,
the hemorrhages, are explicable partly by the already detailed
mechanical obstruction (embolism), partly by the chemical action
of the bacteria,  an assumption which (as has been thoroughly
discussed by me in another place, 1. c.) appears to be established
by various  experiments,  especially those  of L. Franck.1  The
local hyperemias, the cellular oedema, in part the hemorrhages,
are due on the one hand to the blood changes, but, on the other,
the acutely disturbed nourishment of the walls of the vessels is
to be borne in mind as a factor of not less importance.
   A few  words on  the  diagnosis, prognosis, and treatment are
all that is required  to conclude what we have to say concerning
anthrax of the domestic animals.

                         Prognosis.

   The prognosis of anthrax is very unfavorable.  As  already
  1 Jahresbericht der Centralthierarzneischule zu Munchen, pro 1869-70, p. 22.
          VOL. III.—26 
402       BOLLINGER.—INFECTION  BY ANIMAL POISONS.

stated, the percentage of mortality in cattle  and horses  reaches
about seventy.  In the most acute cases, the apoplectic form,
recovery  is  the  greatest  rarity,  and in  less acute  attacks
the mortality is placed by many authors as high as from 75 to
80 per cent.
                           Diagnosis.

   Outside of anthrax districts, the diagnosis during life, espe-
cially of  sporadic cases, is often made with difficulty, and  fre-
quently is absolutely impossible.   An examination of the blood
of the living animal—which I was frequently induced  to under-
take  to verify the diagnosis—gives, as  a rule, a negative result,
when the blood is taken from the animal during an intermission,
or a remission, and in such cases inoculations are also unsuccess-
ful.   The same holds good  for cases which have gone into con-
valescence.  An autopsy, as a rule, leads to a positive conclu-
sion,  and in doubtful cases, inoculation of rabbits, guinea-pigs,
goats, and sheep is a sure and befitting adjuvant to diagnosis.
   When in the blood of  a  living animal, or immediately after
death, the characteristic bacteria are encountered, the diagnosis
is assured beyond a doubt; but, on  the other hand, should the
latter not be found, it cannot be decided  that anthrax is  not
present, as is  evident from  the views which have  been already
advanced concerning the behavior of these organisms.

   The difficulty of a certain  diagnosis of anthrax lies chiefly in a lack of una-
nimity as to just what  is to be considered anthrax—a feature which added not a
little to the confusion which long existed in the anthrax question, as it did also
in the bacterial question.  Haubner appears to take the proper position when he
declares that anthrax itself is seldom mistaken, but that other maladies are often
incorrectly considered to be anthrax.   To this class of diseases belong,  according
to my experience, putrid infection, septicaemia, and other specific maladies,—as for
example, the so-called erysipelas of swine (Rothlauf),—which in a measure, and
indeed in different particulars, bear a strong resemblance to anthrax, but in reality
are very different.

                         Prophylaxis.

   Contrary to the prevalent opinion  that the  prophylaxis of
anthrax in districts where it is enzootic is difficult  to carry  out 
ANTHRAX IN MAN.                     403
effectively,  I have  no  doubt,  as may appear  from  what has
already been said, that  the effort is well worthy of trial.  If it is
established that only such soil as has been impregnated with
the anthrax poison constitutes a source of disease, and since we
know that  the malady apparently has its exclusive  existence
through infection, by transmission of the poison,—let this occur
as it may, through the  wind,  the water, food, insects,  or in any
manner,—and since we know that the poison is in  the highest
degree  transportable—means  and  ways  immediately suggest
themselves  by  which a successful contest  may  be maintained
against this fearful enemy.   Careful disinfection, thorough dis-
posal of the dead, of the excrement, and of all objects to which
portions of the  diseased animals may adhere, protection from
insects,  etc., are,  as numerous  and  well-attested  facts teach
us, the  most important elements  in  the struggle with this dis-
ease.
   In addition to the above, as a matter of  course, such general
regulations as have a bearing  upon the improvement of the con-
ditions  of the soil, and the establishment of more perfect drain-
age, are of the greatest  significance.  The prophylactic employ-
ment of antiseptic means (as carbolic acid) in the  drinking-water
has here and there been proved of service.
   The legal enactments relating to these subjects in most states are, in the main,
ample to cover the ground, and when they are  thoroughly carried  out, offer a cer-
tain guarantee against the transmission and extension of the malady.  Yet, accord-
ing to my experience, collected on the spot, in connection with many cases of
anthrax, the sanitary police regulations are generally carried out in an entirely unsat-
isfactory manner. In enzootic anthrax, at least, the frequency of the disease certainly
bears relation to the manner in which  the  above-mentioned preservative measures
are carried out (disinfection, disposal of cadavers, and of all things pertaining to
the diseased animals).  It is therefore entirely incomprehensible to  me—again sup-
ported by special  experience—how so well-versed an observer as Haubner (Hand-
buch  der Veterinarpolizei, Dresden, 1869, p. 291) can desire to limit the sanitary
police regulations down to instruction, and to leave the rest to  self-protection; and
this, too, on the ground that while anthrax is indeed an enzootic and infectious dis-
ease, it is  not  contagious.  Such  a plan ignores the transportability of anthrax
poison, and its tenacity in the soil (or its adhesiveness to all sorts of objects), and
even allows the skin of the cadaver to be removed—without other precautions than
simple disinfection—and to be put to further uses.  The experience in Hesse and
in Saxony, above adduced, corresponds  exactly to the conclusions which I arrived 
404      BOLLINGER.—INFECTION BY  ANIMAL POISONS.
at from my experience in this direction in many parts of Switzerland, all going
directly to show the necessity of exercising the strictest police control.

                          Treatment.

   Among the  remedies which have been used  for  anthrax,
blood-letting is the one most commonly resorted to, with—in the
beginning  of  the disease—laxatives.   The following measures
have also  been recommended: the internal use of acids, cold
showering, irritation of the skin, and, in  weak conditions,  ex-
citants.
   Aside  from all  these remedies, the  therapeutical  value of
which is thus far, to say the least, doubtful, advantage has  fre-
quently been derived of late from  carbolic acid as a prophylactic
as well  as after the disease has declared itself, and I can person-
ally certify to its value when appropriately employed.


                      ANTHRAX IN MAN.
              (Malignant pustule.  Carbunculus contagiosus.)

   Anthrax in man has been hitherto  almost entirely yielded to  .
the domain of surgery, and too little attention has been bestowed
upon it by the representatives of internal medicine.  So much
so, indeed, that one of the most recent,  thorough,  and popular
text-books of special pathology and  therapeutics simply refers
to text-books  on  surgery for information  on this subject,  on
account of its "especial surgical interest."
   Aside from the fact that anthrax, as a typical infectious dis-
ease, might claim, on the  ground of  utility alone, a prominent
place in the  teaching  of  the  internal diseases,  certain  truths
which have come to light of late years prove most plainly that
this pest has nearly the same claim upon the physician as upon
the surgeon.
   The  appearance  of anthrax in man  has been long known.
We are, however, especially indebted  to  French physicians and
veterinarians of the last century (Fournier, 1769 ; Montfils, 1776 ;
Thomassin, 1780;  Chabert, 1780)  for positive  descriptions and
for the  distinctive characteristics of the different forms.   Four- 
ANTHRAX  IN  MAN.
405
nier first distinguishes the spontaneous and the  communicated
carbuncle of man.   The existence of the latter he ascribes to the
eating of the flesh and the handling of wool of diseased animals
in manufactories.  While Kausch (1790-1811) denied the conta-
giousness of anthrax, he granted the frequent infection of men,
and intimated that  the malignant pustule (schwarze Blatter) of
man derived its exclusive source from inoculation of the anthrax
of animals.
    The primary existence of anthrax in man was again stoutly
defended,  and supported  by allusion  to numerous facts, by
Bayle (1800) and by Davy la Chevrie (1807).
    When compared with the development of medicine in gen-
eral, the progress toward a knowledge of anthrax in man was not
very considerable during the first half of the present century, as
the admirable work of Heusinger (1850) very clearly reveals. We
have already referred above to  the historical and geographical
investigations of  Heusinger, and have  only now to state that,
subsequently,  many authors,  especially Virchow,  Bourgeois,
Davaine, Guipon, Koranyi, Nicolai, and others have done good
service in relation to our knowledge of anthrax in man, while a
list of new observers  (Buhl, Waldeyer,  E. Wagner, Munch, W.
Miiller,  Leube, and others have called  attention to forms of
anthrax in man, which,  although of great importance, had  been
hitherto but little noticed.

                          Etiology.

   As in the case of other infectious diseases, we must decidedly
deny the spontaneous origin of anthrax  in man.   Since we have
endeavored to prove above that, even among the domestic ani-
mals, anthrax never appears spontaneously, and that the infec-
tious material — anthrax bacteria — reproduces  itself endogen-
ously in the bodies  of the diseased animals, the  much disputed
question of the spontaneous origin of anthrax in man, it would
seem, may be denied on the same grounds.  If,  on  the  other
hand, we put the question thus : Can man,  without direct inocu-
lation of the anthrax  poison, emanating from a diseased animal,
suffer primarily from  anthrax ?  our answer would be, that,  thus 
406      BOLLINGER.—INFECTION BY ANIMAL POISONS.

far, we are  possessed  of no facts which in any way prove this
method of genesis for anthrax in man, or even make it probable.
By the earlier investigators (Bourgeois, Guipon, and others) the
spontaneous origin of  anthrax was  denied, in opposition to
Bayle, Davy, and others, yet the same was newly affirmed  with
all  positiveness by experienced  observers (for example, Nicolai),
who for a long time practised continuously in anthrax districts.
But even Heusinger (1. c, p. 561-571), who  has collected the pre-
vious sentiments of  authors on  this subject, cannot conceal the
objections which militate against  spontaneous development;
and, likewise, Virchow (1. c, p. 402) doubts this method of gene-
sis of anthrax,  while Koranyi (1. c, p. 199)  considers the solution
of  the question as yet impossible.  I have already stated in
another place (1. c,  p. 117) that  even the cases of intestinal spo-
radic anthrax (Buhl, Waldeyer, E.  Wagner),  which have  been
published during recent years, could hardly furnish any support
for the spontaneous origin  of  the disease  in man.   I explained
these cases  by supposing the infectious material to  have entered
the organism through the intestinal canal, and especially empha-
sized the fact, that after establishing the tenacity of the  conta-
gious material of anthrax,  and the manifold means by which it
may be acquired, all remaining cases (those apparently spontane-
ous) are to be ascribed to indirect inoculation.   The more  recent
publications of Nicolai,  E. Wagner,  Leube, and  Miiller fully
ratify this view.  Since those authors  who collect  their experi-
ence from anthrax  districts are unable to  give us any infor-
mation of the so-called  spontaneous origin of anthrax, we are
justified in  giving it up unconditionally;  but  yet  we willingly
concede that the mediate communication of the poison—which is
diffusable and  transportable as  is hardly any other—might very
easily give rise to a belief in a spontaneous origin of the disease.

   This transportability of anthrax poison for long distances was also distinctly
recognized by Guipon (1. c). Facts in our possession show beyond a doubt that it
is imported into Europe from Siberia, and over  the  Atlantic Ocean from South
America as well, and that too not unfrequently.   More than a hundred years ago
(1769) Fournier reported upon the frequent and very common method of transmis-
sion of anthrax to men, in the manufacture of the wool of diseased animals, in the
tapestry works  of Montpellier.  The great tenacity of  the poison  was also known 
ANTHRAX IN  MAN.
407
to Fournier, as well as the fact that it retained its virulence through many years.
Likewise Montfils (1776) relates that anthrax is transmitted to man in part by
handling diseased animals, partly by the manufacture of their hides, hair, wool, etc.,
as well as by the bites of flies.

    As a residence in an anthrax district does not necessarily pro-
duce the disease  in man, neither is the neighborhood of diseased
animals  a sufficient cause for  its  occurrence.   If  we investigate
more  closely the  different ways in which man acquires anthrax,
we shall find that the following modes may be established :—
    1.  The Direct Inoculation of the Poison.—This applies espe-
cially to individuals who in the course  of  their occupation come
into  contact with  diseased animals or their remains, as for in-
stance, shepherds, husbandmen, laborers, tanners, butchers, veter-
inarians, and workers  in hides, in horsehair, in woollen  fabrics,
and in  paper-making.   Such manipulations as  are required in
blood-letting, slaughtering and skinning animals, and in burying
them  or  preparing them  for  food,  manifestly expose  to the
greatest danger.   In   such cases  the  inoculation is generally
external,  and the  point  of entrance of  the poison  is  situated
ordinarily on those parts of the body wliich are the seat of slight
injuries or are deprived of epidermis.
   One of the most common methods of infection is in the washing of wool, hair,
etc.,  derived from diseased animals.  Besides what has been  said by Fournier
(already given)  and the  cases of  Trousseau, cited by Virchow,  some more recent
observations are worthy of notice.  Kolb * reports several cases  of inoculation of
anthrax by means of rags which were used  in a paper factory in Styria.  Among
the thirty or thirty-five hands of a paper factory, Dokahl, during  the course of four
or five years, treated eleven cases of malignant pustule due to the above cause and
terminating fatally in from forty to forty-two hours.  Borstieber2 narrates that, in
Waag-Neustadt  and the neighborhood, where the chief business is in wool, tanning,
and the manufacture of coarse hats from wool, anthrax is very frequent in man, and
often terminates fatally.  Malignant  pustule may arise from simply carrying the
hides and skins  of diseased animals.  Broca3 noticed that the workers in leather
establishments often got anthrax carbuncle on the side of the neck.  He explains
this from the manner in which the laborers carry the hides, and advises  the use of
protective bands about the neck.
'Deutsche Vierteljahrschrift fiiroff. Gesundheitspflege, II., p. 316, 1870.
2 Wiener, med. Presse, Nos. 7 and 8, 1870.
5 Bull, de 1'Acad. de Med., XXXIIL, p. 367, 1868. 
408      BOLLINGER.—INFECTION BY ANIMAL POISONS.
   Moreover, it has been established by numerous observations, that anthrax poison
adhering  to the  uninjured skin is able to  penetrate into the body through the
cuticle—probably by first entering the hair follicle.

    2. Eating the flesh of diseased animals, as also  their milk,
or the butter made from it.  In this form of infection the poison
may enter the  body  either through some slight epithelial abra-
sion on the lip or in  the mouth, or directly through the stomach;
or, finally, the bacteria may penetrate into the lungs during the
eating of infected food.
    This method of acquiring the disease is relatively infrequent.
In  the great majority of  instances infected flesh is eaten by man
without injury ; indeed,  such meat, after being properly roasted
or boiled, is generally harmless.   Man in this respect resembles
the carnivorous animals (dogs),  whose gastric juice, as has been
experimentally proved, is capable of destroying the poison even
in raw flesh.   From various facts, however,  bearing  upon  this
point  (Schwab, Wasservogel, and  others), the  assumption  that
by cooking  the meat the  poison will always be destroyed, must
be  set down as incorrect.  I myself have never witnessed the
least disagreeable result in men who had eaten the flesh of  ani-
mals that had perished by the most acute and formidable forms
of  anthrax.   In many cases it is difficult to  decide whether the
eating of the flesh or direct contact  with  it is the  cause of the in-
fection,  since the latter almost always co-exists with the former.
   A few proofs may be  adduced in support of this latter supposition.  Meyer ]
observed that not one out of two hundred men who had eaten the flesh of a diseased
ox became sick, while five  persons who had handled the flesh were attacked with
anthrax, and three of them died.   Wasservogel2 reports a case where in one family
three children,  who had only eaten the  flesh of a diseased animal, but had not
assisted in preparing it,  remained well, while nearly all the other members of the
same family, who had prepared the same animal for eating, got malignant pustule,
and  one of them died.  That the milk and butter of sick  animals likewise
possess virulent properties is proved, according to  Heusinger (1.  c, pp. 29, 30, and
39), by numerous observations in America and Russia.  The malady so produced is
the "milk sickness'''' of the Americans. As to the noxiousness of milk, as established
by experiment, see my results already given.
1 Preuss. med. Vereinszeitung, 1841, p. 149.
"Allg. Wien. med. Zeitung, 1871, Nos. 1 and 2. 
ANTHRAX IN MAN.
409
   3. The  transmission of anthrax from the domestic animals
to man is often effected by insects  (flies) which have been  in
contact with diseased animals.   Certain more recent observers
(Davaine and Raimbert) have  sought to  establish this mode  of
infection (which has long been known) as the exclusive source of
the spread of anthrax ;  but they are not justified in this, as we
have shown above.  Evidently the proboscis of the fly (especially
the blue-bottle fly) plays a prominent part in the propagation of
the disease.
   Since the anthrax pustule, as we shall see later on, first calls attention to its
existence by a pricking pain like that of the bite of a fly, the patient is apt to draw
a faulty conclusion from this subjective fact, and to state that he has been bitten by
a fly,  while in reality the inoculation  has been due to direct contact, as several
reported observations (my own, among them) show.   To this category apparently
belongs the case narrated by Siederer, where the bite of a flea is said to have been
the point of entrance of the poison in a man who carried flesh of diseased animals
on his shoulders.

   4. A  further form  of  anthrax infection (although  a very
infrequent one)  is the  inoculation from  man to  man.  This
method of propagation was observed by Thomassin, Kessel (two
women infected by their husbands), Helbich, Nicolai, and Haus-
brand (see Heusinger's statements, 1.  c, pp. 25, 34, 41, and 45).
   Since the virulence of anthrax in man has been established by re-inoculation
upon different animals—dogs (Hoffmann),  rabbits (Greese and Gayet), guinea-pigs
(Davaine)—there is no possibility of doubt on the subject,1 and infection from man
to man cannot be denied.  The immediate transmission of the poison in this man-
ner, however, must be less frequent than the same between animals and men.
Mediate infection, on the other hand, may certainly occur very often, as is shown in
a case recently reported by Leube.

   5. As a final mode of transmission of anthrax to man, inter-
nal infection is still to be mentioned, where the poison—anthrax
bacteria—enters the body either in the inspired air or with the
nourishment.   Here  belong those cases  which  we have recently
learned to consider as intestinal anthrax  {mycosis  intestinalis),
where  infection has  taken  place by  eating diseased meat; and
further, such cases  of anthrax as follow upon a sickness which
Guipon and others. 
410      BOLLINGER.—INFECTION BY ANIMAL POISONS.

was  at first general—a blood poisoning with symptomatic  car-
buncle.

   It may  be assumed with all plausibility, following the analogy of cutaneous
carbuncle due to external infection, that in intestinal anthrax the digestive organs
furnish the point of entrance of the poison. The bacteria are probably taken in
with the food, and a portion of the fungus not destroyed by the gastric juice settles
upon different parts of the intestine and there produces its effects.

   We have now to mention the points of predilection where in
external anthrax the poison finds its entrance.  Anthrax  pus-
tules chiefly occupy uncovered portions of the body (84 per cent.
Virchow), namely, the  face, forearms, hands, fingers, neck, less
often the ear; while on covered parts of the body (arms, feet,
lower extremities) carbuncles do  not  occur  in more than  16 per
cent, of  the cases;  in women  and  children, however, many of
whom habitually have those parts more or less  uncovered,  they
are not a very uncommon seat of the pustules.
   In general the cutaneous carbuncles have their seat on parts
where direct inoculation of the poison is easily possible—by flies,
by contact with infected objects,  etc.   A sort of  auto-inoculation
is possible where any part  of the body is scratched with fingers
soiled with anthrax blood.
   As to anthrax bacteria, their  nature and special peculiarities,
we must refer to what has been already said of  them in  connec-
tion with anthrax of the domestic animals,  and may sum  up our
views of the etiology of anthrax  in man as follows :
   Anthrax in man is most frequently found where the disease
rages as an  enzootic among  the domestic animals,  and it is
peculiarly  apt to attack those  who have to do with  diseased
animals, living as well as dead, and those who work in  indus-
trial establishments where the  products of diseased animals
are  manufactured {especially   hides,  horsehair,  and  wool).
Anthrax in man is, therefore, truly a disease attaching to certain
occupations.   In many cases,  however, it is absolutely  impos-
sible to establish the source of the infection.
    Finally, as to predisposition to anthrax, man is not so  suscep-
tible to  the disease as are the animals.  In  my  own experience,
when considering the manifold dangers of infection to which 
ANTHRAX  IN  MAN.
411
man is exposed, I cannot believe that he has more than a moder-
ate predisposition to the disease, and doubt  the value of con-
trary assertions (for  example, by Koranyi) wliich set him down
as eminently predisposed to it.  In this respect man is certainly
more like the carnivorous and omnivorous animals  (which take
the disease with difficulty) than the herbivorous.
   The cause of certain individual peculiarities of predisposition
is difficult to  explain.   That men (59 per cent.) should suffer
from anthrax more frequently than women (41 per cent.)1—pro-
portions, however, which hold only for anthrax districts—is easy
to understand from what has already been said.  In anthrax dis-
tricts children participate in the number of the sick only to the
extent of 16 per cent.  The majority of the patients are between
ten and fifty years of age.
   A single attack of the disease does not overcome the predis-
position  to acquire it, as the malady may seize upon the same
individual  again.
   As to the effect of season as  an accessory cause of anthrax
in man, the same rule holds good as in the case of the domestic
animals ; that is, the summer months, July, August, September,
furnish the greatest contingent of cases in anthrax districts.

                   Symptoms and  Course.

   In man the first symptoms of anthrax,  which  occur after
infection, are varied, and depend seemingly upon  whether the
poison has entered through the integument or through the inter-
nal organs (digestive canal or breathing apparatus).
   While the  cases  of external  infection are much the more
common, and,  as a matter  of  course,  come more frequently
under the notice of the surgeon, and only in the later stages fur-
nish the fearful symptoms of blood-poisoning, still attention has
been directed by a number of recent observations toward the far
more dangerous internal infections.  At present we will first con-
sider anthrax  as it affects  the  skin  (external infection).   It
appears under two especial  forms:  the primary anthrax car-
buncle, and the much less common anthrax oedema.
           1 In making up this estimate children are not included. 
412      BOLLINGER.—INFECTION BY ANIMAL POISONS.

   After an incubation of variable duration, lasting occasionally
only a few hours, generally several  (rarely longer than from
twelve to fourteen) days, the patient notices on  the part which
has come in contact with the infected matter, a slight  burning
and itching, like that which is felt  after the bite  of an insect.'
Inspection of the region implicated reveals  a little red speck,
like the bite of a flea, with a central black point.   By gradually
swelling, the spot very quickly becomes changed into an itching
papule, capped with a small, clear, generally reddish or bluish
vesicle, which gradually enlarges.   This promptly bursts, and
discloses  a dark red base.   The actual anthrax pimple, which
naturally runs this course, is generally scratched off before it
has reached  the size of  a pea.  The excoriated spot  dries  up,
becomes brown and livid, and a local eschar forms.  By inflam-
matory swelling of the surrounding skin a red or violet raised
border is  formed, and around  this very frequently a bluish or
pale yellow ring,  upon which little vesicles, of  the size  of  a
hemp-seed, often appear, and surround the central eschar like  a
wreath.  These secondary vesicles contain a yellowish,  reddish,
and blackish fluid, but sometimes they are absent, as well as the
red raised border.  With an increase of the round, thick eschar,
which measures from  a  quarter to three-quarters  of an inch in
diameter, the raised border also extends. The dense (or doughy)
soft papule or pustule, situated around and  beneath the eschar,
varies from the size of a pea  to that a nut.
   The tissue in the immediate neighborhood becomes indurated
very quickly, and this oedematous swelling rapidly spreads over
a considerable area—the entire arm—half  the neck—occasioning
lively pain and a feeling of heaviness in the affected extremities.
The general  condition may still be normal;  the patients often
continue at  their business, or they complain especially of an
uncomfortable feeling  in the head, have  slight chills  and evi -
dences of mild fever.
   In  cases  which run an  unfavorable course,  or where no
treatment is resorted to, the oedema and infiltration of the cellu-
  1 According to the careful description of Wasservogel.  Wien. med. Zeitung, No. 2,
1872. 
ANTHRAX IN MAN.
413
lar tissue spread rapidly ; the skin of the affected parts is either
hard or doughy, or, in rare cases, also oedematous, more or less
reddened, sometimes  cool, sometimes hot.  In  many cases dis-
colored lines appear over the veins of the oedematous region,  or
red lines and stripes  mark out the course of the lymphatics;—
the corresponding lymphatic glands also swell.
   The general symptoms in the further course of the disease
are but  little constant.  The febrile movement,  slight in the
beginning,  is often followed apace by high fever, great weakness,
delirium, excitement,  confusion; it is also  frequently attended
by sweating, diarrhoea,  and severe pains in the  extremities and
joints.   In bad cases, a sudden fatal issue, preceded by extreme
collapse, is not uncommon.   But in this connection it is always
proper to remember that a secondary septicaemia may complicate
anthrax, especially when grangrene and sloughing attend the
local  cutaneous lesion.   E. Wagner thus  explains the difference
which in many cases  is observed between  the phenomena of con-
stitutional  carbuncular poisoning and the same as witnessed  in
intestinal anthrax. In the  more serious cases there may be ob-
served a considerable increase in the frequency  of  the  pulse,
cold sweats, a feeling of anxiety, difficulty of respiration—more
rarely clonic spasms,  trismus, opisthotonos.
   In cases which terminate favorably,  as they of ten  do after
energetic local treatment, even when the symptoms have reached
a very formidable height, the general symptoms disappear along
with the local infiltration.
   Therefore, in a general way, we may assume,  with Bourgeois,
that there are two periods in the development of malignant pus-
tule, of which the first is characterized exclusively by local symp-
toms, and lasts from forty-eight to sixty hours, while the second
period begins with the commencement of  the general symptoms.
The duration of the latter in fatal cases is at most from five  to
eight  days.  In favorable cases the  eschar  is thrown off either
by suppuration, or after the formation of a line  of demarcation,
without appreciable suppuration.

   It is to be observed as a very important fact, that, after infection has taken place,
anthrax retains its local character much longer in man than it does in animals. 
414      BOLLINGER.—INFECTION BY ANIMAL  POISONS,
According to the investigations of Renault,1 cauterization in animals  is without
result, even when it is made ten or twelve minutes after the inoculation.  Guipon
states (1. c.) that the disease lasts, in about half the cases, from one to ten days.  The
other half is divided in such a way that one-sixth lasts from eleven to twenty, one
sixth from twenty-one to thirty, and the remainder over  thirty-one days.  Cases
which last more than three or four months are exceedingly rare.  Just as rare are
those very acute cases after external  infection, which end  fatally in two or three
days after the outbreak of the pustule.

   The second variety of  external carbuncle is  the malignant
anthrax oedema  {Voedeme  malin,  Bourgeois), first noticed  by
that observer simply in the eyelids, but  later in other  parts of
the body as well.   This only differs at the start  from the com-
mon carbuncle—malignant pustule—in that the  vesicle  and  the
primary eschar are wanting.  There may be observed  a some-
what pale,  yellowish or greenish swelling, which, in the eyelids,
has often a half-translucent aspect.
   This form, which Virchow has described as the diffuse or ery-
sipelatous  anthrax carbuncle,  approaches  very nearly to  the
anthrax eruptions of the skin and subcutaneous cellular tissue,
which are  frequently  observed  among  the  domestic animals,
especially horses,  and are commonly described as carbunculous
swellings, or simply as  cutaneous carbuncles.  Guipon  believes
that this anthrax oedema occurs chiefly as a consequence of  in-
haling infected air,  and he therefore classes it etiologically with
symptomatic  and secondary cutaneous  carbuncles.  Scientific
researches must establish the soundness of this view before it can
be adopted.  In some cases erysipeloid anthrax oedema has been
observed after eating the flesh of infected animals,—without  the
appearance of any carbuncle.
   Here, perhaps, belong  also  those cases of carbuncle which
appear in different  situations several weeks after the manipula-
tion of infected material.
   Although in the  local circumscribed carbuncle the course of
the disease is often so mild that the patient is  not interrupted in
his ordinary avocation, yet, when general infection has occurred,
the eruption is frequently multiple in different parts of the body.
   On the other hand, in observing the picture of the  disease as
1 Union Medicale, 1857, p. 482. 
ANTHRAX IN MAN.
415
it occurs after internal  infection—that is, after actual feeding
upon diseased flesh—we find here  the uniting link, constituting
the point of contact with the cases of intestinal anthrax, such as
they have been described of  late years.
   The older observers had already noticed (Carganico)1  that,
after eating the flesh of infected  animals, a general malady was
often occasioned in man, which offered the greatest similarity to
a poisoning,  namely, to that caused by poisonous mushrooms.
   The first symptoms after eating diseased flesh often come  on
very quickly—as  early, indeed,  as at the end of eight hours.
The patient complains of feeling chilly, of debility, of headache;
or the disease is ushered in2  by a general feeling of malaise, loss
of appetite,  restless sleep, great debility and  depression, after
which—but  often not until eight or ten days have  elapsed—
anthrax carbuncles first appear,  by  preference on  the arm,
forearm, and head.   In fatal cases the accompanying oedema
(with  a superadded  gangrenous  process)  spreads itself very
rapidly over the whole  extremity, collapse  quickly comes  on,
with  difficulty of breathing, loss of consciousness,  and finally
death.   Frequently in from twenty-four to forty-eight hours
after eating  infected flesh there will be a decided chill, followed
by pain in the belly,  nausea, vomiting, and—after the malady
has lasted two or three days, with the supervention of collapse
and cyanosis—death, without   there  having   been  any local
formation  of carbuncle  on  the external surface of  the body
(Leube and M tiller).
   Heusinger has  collected similar  cases: Winkler (1. c, p. 41) describes a case
where a  woman, after eating some  liver taken from a  diseased animal, died in
twelve hours, without the formation of any carbuncles.  Lorinser (ib., p. 43) relates
that two persons, after eating diseased flesh, were seized with vomiting, and that one
of them died before any carbuncle had developed.

   While we now pass on to describe the symptomatic features
of intestinal anthrax in  man, we must premise  with the remark
that,  on the whole, our knowledge is  still  far  from complete
concerning this  form  of the disease, which is, perhaps,  more

           1  Rust's Magazine, XLIV., p. 387, 1835.
           2 Menschd, Preuss. med. Zeitung, 1862, No. 23, p. 180. 
416      BOLLINGER.—INFECTION BY ANIMAL POISONS.

common than  has been hitherto supposed—and this we  say
in spite of certain recent and very valuable observations which
lead to a different conclusion.
   The  earlier authors were well acquainted with  the fact that
after external infection anthrax may sometimes come to a local
outbreak even  in  the internal  organs, especially in the neck
(anthrax quinsy).
   On account of the relative rarity of  anthrax in man—since in
the largest hospitals it is frequently never observed during many
years—it is easy to conceive that these uncommon forms were
forgotten, and that it became the custom to connect the idea of
anthrax in man almost exclusively with cutaneous carbuncles.
   In this way it may be explained why intestinal anthrax of
man, which of  late has had  to be rediscovered (first by patho-
logical anatomists), was regarded by the first observers as an in-
testinal mycosis.  According to our present knowledge of the es-
sence of anthrax, it is not to be denied that the character of the
malady was in the main correctly indicated  by the term intesti-
nal mycosis;  and just this circumstance, which rendered possible
a full, free, and unprejudiced  analysis of  the  entire picture of
the disease as a whole, did perhaps more toward furthering  our
knowledge  of this interesting malady than would have been the
case had the anthrax nature of  the process been recognized from
the first.
   After von  Wahl and von Recklinghausen (1861 and 1864) had
already, at  an earlier date, published similar observations, atten-
tion was again called recently  to the  different and important
relations of these processes by Waldeyer, E.  Wagner, Leube, and
W. Miiller.  On account of the  few records of its clinical course,
it is entirely impossible at the present time to give an exhaustive
picture  of intestinal anthrax.
   The  symptoms often first appear as debility and depression,
with pains in the  limbs, a general sense of  malaise, pain in the
head, dizziness, ringing in the  ears, followed very soon by dis-
turbances in the intestinal canal.   The patients  complain of
loss of appetite and gastralgia;  there is moderate swelling of the
belly, and in  many cases a slight difficulty in swallowing.  With
an increase of the general symptoms vomiting commonly sets in, 
ANTHRAX  IN  MAN.
417
followed by a painless, moderate, or more or less intense, often
bloody diarrhoea, whereby, in very acute cases, the patients very
quickly fall into a cholera-like collapse.  As a rule, also, there
are present difficulty of breathing, cyanosis, great restlessness,
excitement or somnolence, loss of consciousness ;  or the patients
are fully conscious and only complain of great pain in the head,
or a moderate, sometimes colicky pain in the belly.  The breath-
ing is difficult and accelerated, the pulse small and frequent,
the temperature very slightly elevated,—in those cases where the
thermometer was used.  In several cases epileptiform convulsions
were observed, tetanic spasms of the upper extremities, opistho-
tonos, and great dilatation of the pupils.  In one case (E. Wag-
ner) the course was irregularly intermittent.  Localizations of the
disease are frequently found on the integument, in the shape
of little carbuncles, a diffuse phlegmon,  or gangrene.  On the
mucous membranes of the cavities of the mouth and nose bloody
suffusions  and hemorrhagic collections are seen.  There  is con-
tinued bleeding from the mouth, and the escaped blood shows  a
lack of power of coagulating.  In the  cases thus far observed,
with one exception (case of Leube), the  termination was always
fatal either within the first twenty-four hours, or after two, three,
five, or seven days—with symptoms of  cyanosis, asphyxia, and
the most extreme collapse.
   The entire picture of abdominal anthrax shows a certain con-
cordance with the acute forms of anthrax in cattle (carbuncular
fever) as we have above described it in detail.
   As characteristics, then, in the majority of cases we find the
suddenness of the invasion, the rapid course and the stormy out-
break of the phenomena, among which are to be especially noted
vomiting, diarrhoea, cyanosis, and rapidly following collapse.
   Localizations on the  integument and  visible  mucous mem-
branes may be present at the same time, as a matter of course,
and from the data of a  great number  of  autopsies of cases of
intestinal anthrax, which Munch observed (in Moscow), the con-
clusion may  be  drawn that pure cases of  abdominal  anthrax,
without  carbuncle of .the integument, constitute altogether, in
many places, from one-third to two-fifths of the cases of anthrax
in man.
          VOL. III.—27 
 418       BOLLINGER.—INFECTION BY ANIMAL  POISONS.

    The existence of internal anthrax carbuncles, in men who died  of external car-
 buncles, had already been established by a number of older observers (Heusinger, p.
 597).  Virchow describes, as constituting a peculiar form of anthrax, those cases where
 general symptoms precede the outbreak of the secondary (external) carbuncles, and
 in these cases the latter appear not alone upon the skin, but also in all possible situ-
 ations, even in the internal organs. The description which Virchow gives of the symp-
 toms of this dangerous form of  the disease, which generally runs an acute course,
 corresponds in the main to the picture of our intestinal anthrax.  After the first
 observations of von Wahl and von Recklinghausen, followed the important case of
 Buhl (1. c.) (in which I made the autopsy), which was marked by numerous peculiar
 hemorrhagic and superficially escharred infiltrations  of the  stomach and  intestine,
 as well as by the localized presence of the  pathognomonic bacteria in the blood of
 the vena  porta.  Although Buhl (1. c, p. 138), while enumerating analogous pro-
 cesses in his remarks, explicitly mentions  anthrax, he seems  (in view of Davaine's
 conclusions concerning bacteria,  which at that time were still hotly contested) not
 to have recognized the anthrax nature of his case, describing it as mycosis intestinalis.
 Waldeyer (I.e.) immediately thereafter reported two similar cases, which,  however,
 aroused in  him the  suspicion of  anthrax, especially as there were present in one
 case papular and pustular hemorrhagic foci  of  the integument.   Miinch (1.  c.)
 observed, in a great number of autopsies of anthrax cases, changes which were simi-
 lar in  quality to those noticed in the cases of Buhl and Waldeyer.
   After E. Wagner (1872) had accurately described  another case of mycosis intes-
 tinalis, there followed, quite recently, the publication of a great number of observa-
 tions by E. Wagner, Leube, and Midler, which positively decide the anthrax nature
 of these mycosis cases,  and thus ratify (in every way, experimentally  as  well) the
 opinion which I  decidedly pronounced regarding the identity of the same with
 anthrax—an opinion which I arrived as in my anthrax investigations in 1872.


                      PATHOLOGICAL ANATOMY.

    Although there have existed until very recently only a small
 number of  data of the pathological lesions  of  anthrax in  man,
 the observations of  the last few years have furnished us  with  a
 number of positive accounts of autopsies which now make it pos-
 sible to undertake a general description.
    The  bodies show—contrary to  a very  common impression—a
more  or less marked rigor mortis, and, moreover,  a pronounced
cyanosis.
    In the dermoidalforms of anthrax, due to external  infection,
bloody spots are often noticed in the skin.   In the parts involved
are found  the  characteristic papules  and pustules,  generally 
ANTHRAX IN MAN.
419
accompanied by extensive oedematous and phlegmonous  infil-
trations of the neighboring skin and  subcutaneous tissues.  It
is  customary to find, also,  small and large epidermal vesicles
filled with serum, and large cutaneous eschars.
   In cutting into the anthrax pustule the process is  seen to
penetrate quite  deeply  into  the subcutaneous cellular tissue.
From the  tough infiltration, which is hemorrhagic, and  often
sloughed in the centre, blackish-red hemorrhagic bands go off
into the underlying  adipose  tissue, and send into it numerous
branches.  The external superficies of the carbuncle appears of a
dirty blackish-red, greasy, and often more eroded than ulcerated.
The oedematous and phlegmonous swellings show the changes
of cloudy oedema, being often striped and flecked with blood.
    TJie  blood in  the heart and great vessels is of a dark cherry-
red, generally fluid, or with some loose clots.
   Most of the mitcous membranes are injected and reddened,
the  submucous  tissue, especially in the fauces and around the
larynx,  being thickened  and oedematous.  The tongue is  often
covered with a  thick, brown coat.  At different points on the
mucous membrane of the mouth it is usual to find dark, red,
bloody  ecchymoses  and (more  seldom) superficially escharred
pustules.
    The  lymphatic glands in the neck,—the submaxillary, laryn-
geal, and  retro-pharyngeal—when the above-mentioned changes
in the mouth and phaiynx  occur,  are infiltrated,  hypersemic,
filled with hemorrhagic foci, colored of a grayish or of  a  dark
blackish-red, and considerably enlarged. The surrounding cellu-
lar tissue is infiltrated with a cloudy serum and small  hemor-
rhages.
    The  lungs are, on the whole, but little changed.   Subpleural
ecchymoses are  found with vascular  engorgement and  a  dark
coloring of the parenchyma.  There is often a slight serous effu-
sion into the pleural  cavities, together with oedema of the medi-
astinal connective tissue, and swelling of the  mediastinal  lym-
phatic glands.
   The  heart, as a rule,  is not materially altered.
   In the abdominal cavity, in  intestinal anthrax, there is gen-
erally a moderate serous or sero-hemorrhagic effusion, and sub- 
420      BOLLINGER.—INFECTION BY ANIMAL POISONS.

peritoneal  suggillations  in moderate  amount;  the  retro-peri-
toneal and mesenteric connective tissue is infiltrated, jelly-like,
and of a yellowish and reddish color.
   The walls of the  stomach and intestine appear  on section
more  or less  oedematous, and colored of a cloudy red.  Besides
the changes  of  an acute catarrh, there is  encountered in the
digestive tract—especially in the small intestine—a thinly fluid
material, often  slightly  colored  with  blood.  On  the reddish
and swollen mucous membrane of the  stomach and intestine are
found isolated or numerous oedematous, hemorrhagic,  prominent
infiltrations,—most of them varying from the size  of  a lentil to
that of a coffee bean—which show a grayish or  greenish-yellow
discolored  surface, with a positively sloughing centre.  Besides
these  genuine stomach and intestinal carbuncles—which are also
encountered in the rectum,  and appear, upon section, to consist
of the tissue of the mucous membrane,  infiltrated in a hemor-
rhagic manner—there  are seen,  also, simple  hemorrhagic infarc-
tions  and foci in the different parts of the intestine.
   The mesenteric and retro-peritoneal glands  are enlarged, as
a rule (like the glands  of the  neck, which have been already
described),  to the size of a wTalnut. Thej^ form  dark, blackish-
red masses, held together by a  jelly-like connective tissue, infil-
trated with serum.
   The spleen is ordinarily only moderately enlarged, of soft con-
sistence,  full of blood, and of  dark color.   The  liver, also, is
engorged, and shows slight hemorrhages here and there.
   The kidneys—whose capsule of connective tissue  and fat is
often  swollen with oedema, and sprinkled with small hemorrhages
—are  also  engorged, and frequently show suggillations in the
mucous membranes of the pelves.  In other  respects the urinary
and genital organs are very little altered.
   The membranes of the brain often  exhibit circumscribed or
symmetrically extended bloody infiltrations.  Here and there, in
all parts of the  brain, are to be found small and  large hemor-
rhages, which for the most  part (E. Wagner)  are of embolic
origin.
   In glancing again over the above-depicted changes  we notice,
beside the  carbuncles and oedema of the skin, as  the most im- 
ANTHRAX IN MAN.
421
portant: peculiar pustular and carbuncular foci in the intes-
tinal tract, transudations into the serous  cavities, serous and
sero-hemorrhagic infiltrations of the peritoneal and mesenteric
connective tissue, of the walls of the stomach and intestine, and
of the mucous membranes as well; hemorrhagic infiltrations of
the mesenteric and other lymphatic glands ; hemorrhages  in
different parts of the body ; and frequently an enlargement of
the spleen.
   The presence of internal—without any external—carbuncles was mentioned by
several of the older authors (Bertin,  Costa), and recently has been confirmed by the
communications  (adduced above) of von Wahl, von Recklinghausen, Buhl, Wal-
deyer, E. Wagner, W. Midler, and Munch.  Likewise, the simultaneous appearance
of internal carbuncles, in connection with anthrax of the skin, was recognized long
ago (Fournier, Barez, Sanson, Raver, Meier, Houel, and others).  Blavot1  indeed
stated  that the changes in the intestinal canal were nearly constant, and described
them as black hemorrhagic infiltrations and pustular tumors, the summits of which
were ulcerated, and concealed a yellowish detritus, surrounded by an inflammatory
raised border.

    The  results of microscopic examination are of the greatest
importance, and may be considered as pathognomonic in anthrax
—at least where these results are positive.
    To begin with the histological changes of the cutaneous car-
buncles, Davaine, with Raimbert, was the first who demonstrated
bacteria in them.  Davaine2 found  the bacteria—after two  or
three days' development of the carbuncle—embedded chiefly in
the centre of  the pustule in the Malpighian layer, beneath the
cortical  layer  of the epidermis.   They were not distributed
evenly,  but formed little islands and groups, which were com-
posed of a compact felting together of bacteria.   At the periph-
ery of the pustule the bacteria were found  scattered among the
epithelial cells.   On the third day of development  the bacteria
constituted the exclusive  and essential element  of the tumor;
after  this  they gradually insinuate  themselves into the deeper
layers of the  skin, work their way into the vessels, and by means
of the blood spread themselves through the  entire organism. Vir-

  1 Considerations sur la pustule maligne.  These. Strassburg, 1863.
  2 Comptes rend., LX., p. 1296, 1865; Bulletin de l'Acad. de Med., XXXIII., p. 620,
1868. 
422      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

chow,1 in  a cutaneous carbuncle, as large as  a silver dollar,
wliich was extirpated on  the  twelfth day of its existence  by
Bardeleben found all the external parts of the pustule permeated
by bacteria.   They  were found everywhere in the  cellular ele-
ments, on the surface  and in the hair bulbs, in  the  cells of the
rete Malpighii, in the connective  tissue,  in the spindle-shaped
cells,  which were greatly  enlarged  and filled full of bacteria.
These  cells,  regular in  their  outlines,  and of  a dull,  shining
appearance, bore  a certain resemblance  to granular cells.  E.
Wagner (1. c, p. 23), in an anthrax pustule which was extirpated
by Thiersch on the second  or third day of its development, and
was of moderatesize, also found the central papillae very friable,
as much as two or three times enlarged in every direction, and so
thickly permeated  by bacteria that  no other constituent of the
tissue  was recognizable  microscopically.   Man}' papillae  were
filled with  bacteria only in their upper parts, or verj^ sparingly
elsewhere,  while  these organisms  were present in the capillaries
in great numbers.  Wagner, moreover, found a fibrino-purulent
effusion separating  the epithelial  from the papillary layer.  In
many papilla?  there was only a puriform infiltration.  The deeper
layers of the  corium were also infiltrated with blood and pus,
but no fungus could be recognized.
   In like manner bacteria were discovered in anthrax pustules
by Lancereaux, Fereol, and E.  Bergmann.
   As to the microscopical changes in anthrax blood, the charac-
teristic bacteria have also been found in it by a number of observ
ers, particularly by Davaine, Gayet, Stone, Buhl, Waldeyer, E.
Wagner, and W. Muller.   According to  their  conclusions and
certain particular  researches made  in  this  especial  direction
(Buhl's case),  the bacteria behave  just as they do in  anthrax of
the domestic  animals ;  and if the pathogenic  significance of
these  organisms could still in  any way be called into question,
yet after the careful investigations recently made into the intes-
tinal forms of anthrax (especially by the last-named observers),
doubt is hardly  admissible any longer.   So far as a judgment
can be formed from the small  number of cases thus far known,
1 Franz Bitter, Ueber den Milzbrand. Inauguraldiss.  Berlin, 1872, p. 29. 
ANTHRAX IN  MAN.                  423
anthrax in man  seems to be  distinguished from  that  of the
domestic animals essentially in these respects, that the bacteria
are much less often so regularly distributed through the blood of
man, and  that  they appear on the whole to be less  numerous
than in the blood of the domestic animals.  In connection with
the fact that in man the  poison  (the bacteria) remains  much
longer confined to the point  of  its  entrance,  this  difference
may,  perhaps, be  explained on  the  theory  that the human
organism  affords far less favorable  conditions for the increase
and reproduction of bacteria than does that of the herbivorous
animals.
   Besides the filamentous bacteria, spherical bacteria are con-
stantly  found  in the blood,  or the latter exist alone, and are
limited to  certain vascular areas, as was  shown  by Buhl,  E.
Wagner, and W. Muller.   The blood, moreover,  shows a more
or less pronounced leucocytosis, and the white corpuscles are
very often granular, due  perhaps to the presence of spherical
bacteria which have penetrated within  them.   The  red  blood
corpuscles hardly ever evince the well-known tendency to collect
into rolls.
   The  histological changes found in the internal carbuncles, as
well as those found in the serous and sero-hemorrhagic infiltra-
tions, are due to the presence of the fungus, to cellular oedema,
and to an infiltration of serum and blood.  Anthrax bacteria are
found (in intestinal anthrax) in the cellular tissue of the intes-
tine, in  the blood and chyle vessels, in  the follicles  of Lieber-
ktihn, in the mucous and  submucous tissues, and  in the  great-
est number in the swollen, hemorrhagic, infiltrated  mesenteric
glands.   At the same time, in these  "fungus-stiffened" parts, a
secondary cellular oedema is  often  found,  wliich  goes on to a
positive fibrino-purulent infiltration.   Furthermore, bacteria are
found in the spleen, at the  points  of hemorrhagic effusion in
the different  organs, especially the brain (E. Wagner), and also,
though  in  smaller  number, in the serous effusion in  the  serous
cavities.
   Finally, in the great parenchymatous glands—liver and spleen
—the microscope reveals the well-known changes of cloudy swell-
ing and parenchymatous inflammation. 
424      BOLLINGER.—INFECTION BY ANIMAL POISONS.

                          Diagnosis.

   In anthrax districts the diagnosis of anthrax in man is  not
difficult, especially when the point of entrance  of  the poison is_
situated upon the skin.  Likewise in manufactories and estab-
lishments where  animal products are  worked  up  (especially
hair,  wool,   bristles,  and  hides),  every  cutaneous carbuncle
awakens the suspicion  of  anthrax, and a diagnosis is readily
made from the history of the case.   The  latter receives  its chief
support from the social position and place of abode of  the  pa-
tient.
   On the other  hand,  in intestinal anthrax, which is much
more rare, it is difficult to make a diagnosis from  the symptoms
and appearances alone.  In consideration, however,  of the rapid
onset of the disease, its acute  course  and stormy manifestations
(diarrhoea, vomiting,  cyanosis,  convulsions,  collapse),  and  the
business of the patient, an accurate diagnosis  is  possible.   A
simultaneous appearance of carbuncular or oedematous affec-
tions of the skin naturally goes far to assist the diagnosis.
   Microscopic  examination of the blood will only furnish con-
clusive  evidence when the characteristic filamentous bacteria  are
found in it;  but in the  earlier stages of the  disease, and even
later on, they may be wanting.  They only have a positive value ;
while no conclusion can be  formed  from their absence as to  the
non-existence of anthrax.1
   On the other hand, microscopic examination of the cutane-
ous  carbuncle is imperatively necessary in every doubtful case.
Judging from the data of a large number of such examinations,
carried  out by competent observers, the presence of  anthrax bac-
teria in true anthrax carbuncle can with certainty  be depended
upon as pathognomonic.  Likewise in anthrax oedema, according
to Raimbert, bacteria may be found in the vesicular  prominences,

   1 I entirely agree with E. Wagner where he says that, in microscopic examinations
of the blood, only the fungous filaments—the characteristic Bacillus anthracis—can  be
considered as pathognomonic; yet Leube made a diagnosis in one case from the  pres-
ence of spherical bacteria in the white blood corpuscles.  In a drop of blood  from
a case of intestinal anthrax examined twenty-four hours before death, E. Wagner failed
to discover any bacteria. 
ANTHRAX IN  MAN.                    425
thus very much lightening the difficulty of diagnosis.   Should
no bacteria be found in  the excised malignant pustule, we are
justified in considering it as a spurious case, as a common car-
buncle.
    In many cases the inoculation of animals may be resorted to
as an aid to diagnosis.  The most appropriate animals  are rab-
bits, guinea-pigs, goats, or sheep; but  here also only a positive
result is conclusive—not so a negative one.
   Inoculations from anthrax  of man upon animals, with positive results, have
been already made by  Greese, Wendroth (upon  sheep), Davaine, (upon guinea-
pigs), Gayet (upon rabbits), and,  recently, by W. Mailer and Schuster  (upon rab-
bits, and from these again upon rabbits, guinea-pigs, and cats). On the other hand,
Hiibner (in dogs) and Neyding (rabbits) got negative results.

    In relation  to  the morbid processes, which may be mistaken
for anthrax carbuncle, the simple carbuncle1 of  the surgeons
must first be mentioned.   This is a circumscribed necrotic inflam-
mation of the skin, in which a number of furuncles occur so near
each other that the intervening skin sloughs.  As  distinguished
from this, the anthrax carbuncle  proceeds from a sharply defined
centre, extends widely, and  in its further course is attended by
general symptoms.
    In anthrax  carbuncle, moreover, there is an early superficial
eschar,   which  is  surrounded  by a raised vesieulated  border.
Furthermore,  its centre is  somewhat  depressed,  the slough is
more  dense, the swelling very little sensitive, and the  develop-
ment  quicker than in simple carbuncle.   The latter has no raised
vesieulated border; its centre is  prominent;  the  slough is less
tough, the tumor painful, the neighboring oedema redder, or of a
livid color, the entire process more indolent.
   Finally, the seat of the lesion is  of importance.   While
anthrax  carbuncle  preferably occupies  a  portion  of the  body
habitually uncovered, simple  carbuncle generally  chooses the
skin of  the back  and neck, and in its mature state  is  riddled
superficially by numerous purulent openings.
   1 That Koranyi should prefer to consider this non-contagious form of carbuncle as
anthrax (1. c, p. 180), and anthrax carbuncle  as carbuncle, appears to me to be unfor-
tunate, and only liable to produce confusion. 
426      BOLLINGER.—INFECTION BY ANIMAL POISONS.

   Anthrax carbuncle is distinguishable from the bites of insects
in that the latter have a small yellowish  spot on the summit of
the papule, which is  wanting in the former.  It is not difficult
to distinguish  an anthrax carbuncle from  a furuncle.   The
rapidly appearing raised red border is wanting in furuncle.
   Carbuncles  accompanying  glanders  are  usually multiple,
smaller, accompanied by intense general  symptoms.  In noma,
the sloughs are more  extensive, softer, discolored, and shreddy.
The  plague-boil (Pestkarbunkel) is generally found on covered
portions of the trunk and extremities, is especially painful, and.
for the most part, multiple.
   For  the diagnosis of malignant anthrax  oedema, we refer to
its description  already given, as well as to the published results
of Raimbert' s investigations,  who found bacteria in the serum of
the vesicles of the raised border.
   In discussing prognosis and treatment,  we  shall  have an
opportunity to  look  more closely into  the  value of a correct
diagnosis  of anthrax in  man; and, finally, for the establish-
ment of a diagnosis we must recognize  the  fact that a skilled
microscopic examination of the carbuncle and the detection of
bacteria are absolutely essential.


                         Prognosis.

   The indications for the prognosis of anthrax in man are, on
the one hand, the point of time at which treatment is resorted
to, on the other, the way in which the infection has taken place.
   In external infection, when medical aid is  sought early, and a
rapid and accurate diagnosis  is accompanied by energetic treat-
ment, the prognosis is in general favorable.   The fact that  the
physicians of anthrax districts  have favorable results to report,
is  due incontestably to the fact that  the disease there is reason-
ably well known, medical aid is not sought too late,  and further,
that these experienced observers  are  in  a position to make  a
diagnosis quickly and without  difficulty.   Lengyel and Koranyi
out of 142 cases of anthrax carbuncle, lost only 13, = 9 per cent.
Nicolai had still better results.  Out of 209  cases  he lost only 
ANTHRAX  IN MAN.
427
11, _ 5 per cent.  Weiss 2 cured malignant pustule in nine cases
by energetic local treatment.
    Were we in a position to give the statistics of sporadic cases
of  anthrax—occurring  outside  of anthrax  districts—the mor-
tality would necessarily have to be placed  much higher, at least
at from 30 to 40 per cent.

   Menschel4 observed in twenty-four cases of anthrax in man, produced partly by
eating diseased meat, and partly by external infection, that five died;  these, how-
ever, had summoned medical  assistance too late, or not at all.  Of nine cases  col-
lected by Budd,3 eight ended fatally. Among  my own observations I know of
two cases of4 external anthrax infection,  in which the  fatal termination was in one
attributable to the fact that medical aid was sought too late, in the other undoubt-
edly to an error in diagnoses.

    The prognosis in intestinal anthrax, after  internal infection,
is far worse.   Recovery in any case is very rare.
    Judging from the reported cases, it may be stated that with
correct diagnosis and energetic local treatment—especially when
the latter is instituted  before the appearance of general symp-
toms—the prognosis  is very favorable.   In very few  diseases,
therefore, is the responsibility of the physician so great as in
this.

                            Treatment.

    The prophylaxis of anthrax in man is naturally the same as
in the  case of the  domestic animals, and we refer  to what  has
been  already said on that subject.  We must remark here, that
those authors  who consider  the legal enactments which are in
force in most European states as being too stringent, evidently
have  an entirely faulty  conception of the essence of anthrax and
its methods  of  transmission.   These  enactments are, however,
for various reasons, enforced and carried out for the most part in
a very  inefficient  manner.   It is indeed inconceivable  for what
   1 Bayer, jirztl. Intelligenzblatt, No. 25, 1869.
   ! Preuss. Medicinalzeitung, 1802, p. 180.
   a British Med. Journ., Jan. 24, 1862.
   4 Zur Pathol, des Milzbrands. Munchen, 1872, 'p. 109.  Besides the case there com-
municated, I have recently observed a second similar case, where the fatal termination
could with great certainty be ascribed to false diagnosis and bad treatment. 
428      BOLLINGER.—INFECTION BY  ANIMAL  POISONS.

other reason, than that  above given,  these authors are willing,
in the case of animals that have been affected with the disease,
to countenance the use of their hides and bodies for various pur-
poses, and of their flesh for food.
   As I have already in  another place endeavored  to make clear
and  distinctly to prove, it is necessary  that there should be a
particularly stringent prohibition against eating the flesh of dis-
eased animals, not only  on account of the fear of direct infection
by eating, but also from  the serious  danger which attends the
slaughtering of animals and the preparation of their flesh for
eating.
   In anthrax districts,  moreover,  it would be advisable  to
spread abroad a general knowledge of the  danger of the disease
and  its methods of propagation ; this should be done in such a
clear and simple  manner that  all could understand  it,  and (as
Borstieber has proposed, 1. c.) suitable instruction should also be
given certain handicraftsmen (workers in wool,  in hat factories,
and in  tanneries) as to the means by which  anthrax is  spread,
and the value  of an early application of caustic (carbolic acid)
—which  latter should be kept constantly on  hand in manufac-
tories and workshops.
   I have repeatedly had an opportunity  of  convincing myself
that infection may easily be averted by taking  the  necessary
precautions when coming into contact  with  diseased animals,
and in the necessary handling of cadavers (for example at autop-
sies).
   The most essential point in the treatment of  anthrax in man,
where the infection has taken place externally, is a thorough
destruction of the local affection.
   After infection has occurred, or when there is any suspicion
of it, the point implicated should be thoroughly cauterized, most
appropriately  with concentrated carbolic acid, caustic potash,  or
fuming  nitric  acid.   Should an actual anthrax carbuncle be
already present, the  treatment to be recommended uncondition-
ally in most cases is extirpation with the knife, followed by cau-
terization.  Instead  of  excision, deep incisions (preferably cru-
cial) may be resorted to, followed by cauterization.   In crucial
incisions, the  flaps may be  trimmed.  Various agents may be 
ANTHRAX IN MAN.
429
used successfully as  cauterants.  Those most usually employed
are fuming nitric acid, caustic potash, and  of late }Tears carbolic
acid.  A number  of other  caustics (sulphuric  acid, nitrate  of
silver,  acid nitrate of  mercury, butter of antimony,  corrosive
sublimate, ammonia), as also the actual cautery, work with less
certainty.  Simple cauterization does not usually answer so well
as when extirpation or incision has preceded it.
   The energetic destruction of anthrax pustules is also often
successful even in the later  stages,  indeed  after important gen-
eral symptoms have appeared.  The cauterization may be then
often repeated with advantage—even two or three  times—until
the  raised border ceases to appear.  Generally a single thorough
cauterization  is  sufficient to effect  a cure.  After excision and
cauterization, the oedema in the neighborhood of the anthrax pus-
tule, as  a  rule, promptly disappears.   As a precautionary mea-
sure, however, a reapplication of the caustic is advisable.   Hopes
of a recovery may still be entertained, even after constitutional
symptoms have appeared, provided  these be not too severe.
   As the slough may in any case give rise to septic infection,
it is further  advisable to  put on  an antiseptic dressing (lint
soaked in chlorine  water, or, better  still, in carbolic acid), which
latter is  to be followed by warm poultices, preferably containing
a little carbolic  acid, wliich  hasten the formation of the line  of
demarcation,  and  the separation  of the  slough.  In this stage
local stimulation  is  indicated (spirit  of camphor,  tincture  of
myrrh, stimulating ointments).
   If general symptoms  have already appeared, large doses  of
quinine  render valuable service, especially when the cauteriza-
tion has  been made too late, or is insufficient.  By analogy with
the  undoubtedly good results of the use of carbolic acid  in
anthrax  of animals,  the latter is probably of  value internally
administered, and indeed simultaneously with  the  quinine (in
the course of a day fifteen grains of  carbolic acid, and  thirty  of
quinine),  as  it has  been  recently  employed with  success by
Leube in a case of anthrax.
   In other respects  the treatment should be tonic and sustain-
ing ; the diet  should  be strengthening and easy to digest (wine).
   When there is  considerable oedematous swelling of  special 
430      BOLLINGER.—INFECTION BY ANIMAL POISONS.

portions of the body,  and threatening gangrene, deep  incisions
are appropriate,  penetrating  into  the yellow, infiltrated  con-
nective  tissue, and these should be dressed with disinfectants
(carbolic acid).
   In intestinal forms  of anthrax, the internal treatment is the
same as that for  the general symptoms occurring  after external
infection.   Carbolic acid and  quinine are  also indicated here.
Cinchona, iron, wine,  are to be recommended as tonics, and an
appropriate diet as well.  When it is certainly known that flesh
from diseased animals has been eaten, a powerful  emetic may
be of value. 
HTDEOPHOBIA.
                            LYSSA.   RABIES.

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    441.—Boudin, Etudes sur la Rage  dans divers etats  de l'Europe.  Gaz. med.
    de Paris, p. 713, 1861.—Eulenberg, H, Ueber die Wuthkrankheit  beim  Men-
    schen.  Preuss.  med.  Zeitung, 1863,  Nos. 39-43.—Fuchs,  M. V., Der Dermo-
    Pneumo-Tetanus, eine Auffassung der von  wuthkranken Thieren ausgehenden
    Hydrophobic,  I. u. II., 1867.—Guisan, E., De la Rage, considerations  sur sa
    nature et son traitement.  Dissert, inaug., Bern, 1868.—Base,  E., Ueber das Ver-
    haltniss des Tetanus zur Hydrophobic  Pitha und  Billroth,  Handbuch  der
    allg. und spec. Chirurgie, B. 1, 2 Abth., p. 79.  Erlangen, 1870.—Eichborn, F,
    Ueber die Hydrophobic.   Inaug.-Dissert.  Erlangen,  1871.—Marx, K. F. H,
    Ueber das Vorkommen und  die  Beurtheilung  der Hundswuth in  alter Zeit.
    Aus  dem 17 Bande  der  Abhandl. der kgl. Gesellsch.  d. Wiss. zu Gottingen.
    Separatabdruck. Gottingen, 1872.—Schaller,  v.  J.,  Die Wuthkrankheit, ihre
    Natur, ihre Heilbarkeit, und ihre Behandlung.  Inaug.-Diss.   Freiburg, 1872.
Compare Monographs of Virchow (Handb. der spec. Path. u.  Therapie, B. II., p. 342,
    1855), Von Beder (Pitha und Billroth, Handbuch der Chirurgie, B. I., 2, p. 116, 
HYDROPHOBIA IN ANIMALS.
433
   1870), as also the treatises on the special pathology of domestic animals, by
   Boll, Haubner, Hering, Spinola; also Bruckmuller, Pathol. Zootomic  Wien,
   1869.—Schmidt, Maximilian, Zoologische Klinik, B. I., 2 Abth.  Die Krank-
   heiten der Raubthiere, p. 322-376.  Berlin, 1872.


                     HISTORICAL NOTICE.

   The antiquity of hydrophobia is not precisely known.  Ac-
cording to  the* results of comparatively  recent  investigations
(Marx), the earliest descriptions of this appalling malady have
 uite a mythical character.
   The first unmistakable account of hydrophobia  is found in
Aristotle (f 322 before Christ): "Dogs suffer from rabies.  This
induces a state of madness, and all animals which are then bitten
by them are likewise attacked by rabies.  This malady is fatal
to dogs, and also to other animals that have been bitten by a
mad dog,  with the exception of  man."   The genuineness of  the
last  passage, however, which fails to recognize hydrophobia as
occurring in man, has been frequently questioned.
   About  the  same time we find hydrophobia alluded to by
Xenophon,  Epicharmus,  and Democritus  (the laughing philo-
sopher).   By the latter the malady was described as an inflam-
mation of the nerves, and  classed with the severe spasmodic
diseases allied to tetanus.  On the  other  hand, it is extremely
doubtful whether Hippocrates was acquainted with hydrophobia.
   To numerous later authors, poets and historians, hydrophobia
was a well-known disease, mention having been made of it by
Andreas of Carystos, Gaius, Themison, Eudemus ; also by Virgil,
Horace, Ovid, Plutarch (130 before Christ), Pausanias, and Pliny
the Second.  Most admirable accounts of  the malady are  con-
tained in  the writings of Cornelius Celsus  : "If the wound pro-
duced by the bite be not promptly and  energetically  treated,
hydrophobia ensues—a most deplorable malady, one in which no
hopes of recovery can be entertained.   The virus should be with-
drawn by means of a dry cupping-glass, while the wound, if its
situation permit, should be treated with the actual cautery.  If
this  be impossible, then other caustic agents should be applied,
and the part should be bled."  A detailed  account of hydropho-
          VOL. III.—28 
434      BOLLINGER.—INFECTION BY ANIMAL POISONS.

bia is also given by Dioscorides, who pronounces  the affection
frightful, there being no possibility of saving the  life of those
attacked.  He insists upon the importance of  prophylactic mea-
sures (caustic applications, the  actual cautery, scarification, and
amputation), and describes the varying period of  the stage of
incubation.
   Galen (131-201 after Christ) declares hydrophobia to be the
worst of all diseases, and recounts with great accuracy numerous
phenomena attending it.  As a protection against  infection, he
recommends excision of the wound.
   Cselius  Aurelianus—probably  a contemporary  of  Galen-
celebrated for his truthful and life-like representations  of dis-
eases, treated all  the  important questions relating to  hydro-
phobia  with  wearisome accuracy: the modes of origin,—spon-
taneous  as well as those depending upon communication ; the
organs  serving  as absorbents of the poison; the localization of
the disease ; the parts principally attacked ; the character of the
disease ; the differential diagnosis ; the points whereby it may be
distinguished from inflammation of the brain and mania ; the
time of  outbreak ;  the course ; and, finally, the treatment.
   With Galen and C.  Aurelianus, independent  observations
concerning hydrophobia ceased  for a considerable length of time.
With few exceptions (Rhazes, 922 ;  Avicenna,  1036), the authors
of many succeeding centuries contributed little or nothing to the
previous knowledge of  the disease.
   The  disease was  also known  to the ancient inhabitants of
India, to the Egyptians, and the Israelites.
   The  fallacious theories  and  hypotheses regarding hydropho-
bia which have obtained credence with the  public,  and medical
men,  and which to a  very great extent prevail to this day,—
these preconceived notions, originating  a  thousand years ago,
are justly designated by the terms here applied to  them.  This
may be  shown by the fact that  in our own day, about the same
characteristic features  are ascribed to hydrophobia that were
accorded to the disease by the writers  of two thousand years
since ; it being asserted now, as formerly, that dogs  affected with
rabies present, as prominent symptoms, reddened eyes, a droop-
ing tail, foaming mouth, a projecting tongue, etc. 
HYDROPHOBIA  in  animals.
435
   After the lapse of so many centuries, during which no advance
was  made in our knowledge of hydrophobia,  notwithstanding
the large amount of literature on this subject, there were at last
reported, towards the end of the last century, a series  of better
investigations by different observers (Chabert, J. Hunter),  while
recently a more exact knowledge of  hydrophobia  has  been
acquired—chiefly through the researches of  the  Englishmen
Meynell and  Youatt, as well as by the extensive experiments of
Hertwig.
   Numerous other observers also, by means of experimental, as
well as of clinical and historical studies, have served to increase
our knowledge  of hydrophobia.   Among these names may  be
mentioned Magendie, Breschet,  Rust, Greve, Krugelstein, Blaine,
Faber,  Schrader,  Pillwax,  Bruckmuller, Bouley,  Marx, and
others ; furthermore, Virchow  and Reder, as well as different
veterinary pathologists.

                 HYDROPHOBIA IN ANIMALS.

   Hydrophobia, which prevails  chiefly among animals of  the
canine species (dog, wolf, fox, hyena,  jackal)—of ten as an epi-
zootic—is an acute infectious disease, coming on in  the form of
afunctional disturbance of the central nervous system, with an
absence of all gross anatomical changes, and distinguished from
other similar  diseases by its  long and extremely variable period
of incubation.   The specific mater ies morbi, the intimate nature
of which is unknown, belongs to the endogenous class of specific
poisons,  is propagated only in  infected animal organisms, is
fixed, non-transportable (nicht verschleppbar), and never vola-
tile.   As in the case of genuine inoculable diseases, hydrophobia
originates only  through infection,  it being  essential  that  the
virus should come in contact with an abraded portion of the skin
or mucous membrane, in which respect it bears the closest resem-
blance to syphilis.   The communication of the poison is effected
almost invariably by means of the bite of a rabid or infected
animal,  whereby the poison is implanted directly in the animal.
The existence of a spontaneous, or so-called  miasmatic develop-
ment of hydrophobia, which is extensively credited, is entirely 
436      BOLLINGER.—INFECTION BY ANIMAL POISONS.

unproved.  The disease is transferable from animals of  the
canine species to man and all domestic animals.

                          Etiology.

   Although for  a long time authorities have agreed that the
disease in by far the greatest number of cases arises from inocu-
lation by means of the bite of a rabid animal, it has  at the same
time been admitted by many, that  a spontaneous or primary
origin of the disease  might  also be  possible to animals of the
canine species (dog, wolf, fox, jackal, badger).
   If inquiry be made respecting the cause of the alleged spon-
taneous cases of  hydrophobia, the reply will  be by  no means
satisfactory.  It was believed that  a peculiar miasma formed a
direct, active, causative factor, and to this were referred espe-
cially the epizootic outbursts of hydrophobia.  In respect to the
etiology of the disease in dogs, certain influences are frequently
cited as predisposing and accidental causes ; such, for instance,
as intense  heat or cold, want of  drinking water, domestication,
training,  physical  deterioration  induced by  their artificially
acquired modes of life, wliich are quite contrary to  their nature
as beasts  of  prey.  Furthermore, the stimulated but ungratified
sexual desire has been selected as the exciting cause, and in this
connection the  disproportion existing in the number of male and
female dogs' was thought to be especially significant.  Finally,
certain breeds—especially those of a vicious disposition, over-
fed dogs, and curs were said  to evince an especial affinity for the
spontaneous form of the disease.
   It is not necessary to enter  into a  detailed enumeration and
description of all  the influences  that have  hitherto  been  sup-
posed to serve as causes for hydrophobia, and  we will therefore
content  ourselves with the consideration of the more  important
questions relating to the matter.
   When hydrophobia prevails as  an epizootic—a phenomenon
that is often  quoted in support of its spontaneous origin—there
can almost always be detected,  upon careful examination, one or
   1 In Central Europe the females form only from ten to fifteen per cent,  of the
entire number of doga. 
HYDROPHOBIA IN  ANIMALS.                437
more central points which serve as distinct depots or centres of
infection.  We know, moreover, that the spread of the epizootic
is arrested by the larger rivers.

   Schrader relates that during the prevalence of hydrophobia in Hamburg and
vicinity (1852-1853), no cases were observed upon the islands of the Elbe, although
upon both sides of the  river instances of  the disease were of frequent occurrence.
Similar facts have been collected by Virchow (loc. cit., p. 358), all of which, coin-
ciding fully with the results attained by a study of the geographical distribution of
hydrophobia, afford powerful arguments against its spontaneous development.
   Furthermore the mere epizootic and enzootic appearance of hydrophobia indi-
cates in itself nothing more than the existence of a primary genetic  cause; whereas
we know, on the other hand, that the infectious diseases themselves appear  almost
invariably in the epidemic and endemic form.

    As to the hypothesis that changed nervous influences, such as
extreme  domestication and training, serve as causative factors in
the primary development  of hydrophobia, it is simply neces-
sary to  state that  the  disease prevails  also in those localities
where  dogs roam  at large, for instance in the  East, where they
pass their life in freedom  from  all  control.   I willingly admit
that the  above-named abnormal conditions of life, and the unna-
tural mode of  living may tend to predispose dogs to mental and
nervous  disturbances, and  may also play a certain part in pre-
disposing these  animals to traumatic rabies;  but  these condi-
tions never suffice to produce a development de novo of  the dis-
ease.
   Attempts to produce hydrophobia artificially by starving dogs, have been ineffec-
tually made by Radi and Bourgelat.1  The same negative results were obtained by
Menecier,2 who did not see a single instance of hydrophobia among 160  dogs that
had been poorly fed and kept.   Pillwax observed, during one of the severer epizoo-
tics in Vienna, that the greater number of affected dogs belonged to  owners  in
good circumstances in  life, enjoying, therefore, for the  most part, good care and
food.

    The extremely disproportionate occurrence of hydrophobia in
male animals has likewise  been attributed to one of the causes
above alluded  to, namely,  to unsatisfied  passion, —to the sexual
excitement, which,  in the greater number of male dogs,  is being
constantly stimulated but never gratified.  According to the evi-

       1 Chabert, p. 73.              '' Gazette des hopitaux, No. 25, 1869. 
438      BOLLINGER.—INFECTION BY ANIMAL POISONS.

dence of statistics, however, the total  number of mad  dogs  is
divided between the two sexes in a ratio nearly equivalent to the
numerical  relation  of the two  sexes to each other;  and, on the
other hand, castrated  dogs are just as liable to contract  the dis-
ease as other dogs.

   Of 267 cases of hydrophobia, observed by Schrader in Hamburg in 1852-3,
256 occurred  in male dogs, ten in females, and one in a castrated dog.   Of fifty-
four pronounced cases of hydrophobia occurring in Denmark from 1855 to 1857,
there were found, according to Tscherning, four male and three female dogs that had
been castrated, equivalent to a percentage of thirteen.  Furthermore, the fact of the
occurrence of hydrophobia in wild animals (wolf, fox)—among which the numerical
relation of the males to the females is a natural one, no obstacle being interposed to
the gratification of the sexual  appetite—affords proof  of the fallacy of the above
hypothesis, as does also the circumstance that hydrophobia  does not prevail in all
places and continuously, but appears at certain times only, and is then confined to a
certain territorial district.   Greve (loc. cit., Bd. I., p.  152)  attempted to produce
experimentally in this manner  hydrophobia, but without success.   In the case of
wild beasts, that are kept in close confinement in menageries and zoological gardens,
to whom the gratification of the sexual appetite is for a long period of years denied,
hydrophobia is never seen to arise.1  Some individuals have been so thoroughly
convinced of the significance of the suppressed sexual passion as a causative ele-
ment in the production of hydrophobia, that they have advocated the castration of
all dogs not intended for breeding purposes.

    The theory so frequently advanced,  that  even the bite of an
angry dog is  sufficient to produce hydrophobia,  will be found
upon a priori  grounds to be extremely improbable, since,  were
this the  case, almost  every dog-bite would have  a lyssogenous
effect, inasmuch as dogs are, as a rule, apt to bite only when irri-
tated and enraged.
    The relation thought to exist between the excited sexual pas-
sion and hydrophobia is analogous to  that  of  numerous other
alleged  causes of the  malady, such for instance  as  tape-worm.
It is  indeed true that we seldom fail to find tape-worms in the
intestines of rabid dogs ;  but  these parasites are generally ob-
served in the majority of all dogs.   Symptoms similar to those
of  hydrophobia  may indeed,  under   certain conditions,  be
induced  by parasites of this nature, just  as by  various other
1 Schmidt, Zoolog. Klinik, I., p. 362. 
HYDROPHOBIA IN  ANIMALS.                439
causes, but the infectious  hydrophobia  can never be so pro-
duced.
   Finally, to prove the spontaneous origin of hydrophobia, the
occurrence  of the disease in  wolves, foxes,  and cats has  been
cited ; this having been induced in the latter by depriving them
of their young, or  by subjecting them to  painful burns.  In
cases, however,  where hydrophobia has prevailed, in the form of
an epizootic, such as has  raged for years  among foxes through-
out  entire provinces or districts (for  instance in Carinthia from
1866 to 1872), no other etiological condition could be  discovered
than the continual infection from fox to fox (Oertl).  The attempt
to elucidate the cause of such diseases by tracing  a  connection
between  them and external influences, other than those above
mentioned,  or by referring them to a miasma, is futile, for the
following reason, namely,  that it frequently happens that during
the prevalence of  such epizootics no cases of  hydrophobia occur
among dogs.  The original source  of these epizootics of hydro-
phobia is the bite of rabid dogs, and, on the other hand, hydro-
phobia may be communicated  to the dog  by wild animals of
kindred species.
   Dogs living in the mountains of Switzerland (herdsmen's or mountain dogs) are
said to frequently contract the  disease from rabid foxes.  At those times when
rabies rages among dogs, rabid foxes are usually found, with whom  the epizootic,
it is true, may  have  originated (v. Tschudil);  Kochlin (loc. cit., p. 14) reports a
case of the communication of hydrophobia  from a fox to a dog.  Oertl (loc. cit.)
relates that during an epizootic of hydrophobia among the foxes of Carinthia, rag-
ing from 1866 to 1872, numerous animals, especially dogs  and other domestic ani-
mals, were bitten, as were also two men.
   A further  proof  of  the alleged spontaneous origin of hydro-
phobia was claimed to have been found in the circumstance that
neither wound nor cicatrix could be detected  upon the smoothly
shaved bodies of  dogs that had died from this  disease.   But,
inasmuch as the smallest  erosions,  such as heal without leaving
any  scar, are sufficient to admit the virus into the system, it must
be admitted that this argument will not bear a close scrutiny.
   Many cases of alleged spontaneous development are obviously
to be explained  by this circumstance, that the bite of an infected
      1 Das Thierleben der Alpenwelt, 5 Aufl.  Leipzig, 1860, pp. 357 and 525. 
440       BOLLINGER.—INFECTION  BY ANIMAL POISONS.

—though  apparently  healthy—dog,  when inflicted  during  the
period of incubation, has even then the power of communicating
the disease.
   Thamhayn (loc. cit., p. 341) has collated nineteen cases, occurring in the human
subject, in which dogs, to all appearances healthy, but which subsequently became
rabid,  produced by their  bite hydrophobia, the result being fatal in eighteen of
these cases.  Fessler' relates the following case, observed at Bamberg: A dog,
whose  penis was cut off during the act of coitus, died in the course of a few days
from grangrene of the wound, without having manifested any symptoms of hydro-
phobia. His master, who had been bitten by him, was seized in the course of a few
weeks  with hydrophobia, and died.
   The communication of rabies  in any other manner  than by
a bite, is indeed extremely rare.   Infection by coitus, which, it
is pretended, takes place in the  human  subject, has not been
shown to occur in  the case of animals, although there  must be
sufficient opportunity for this mode of infection;  rabid bulls
unite with cows, for instance, without infecting the latter.
   An instance  of congenital hydrophobia is related by Calli-
nac:2 A cow, which, forty-eight days before  being  attacked by
the disease, had  been bitten by a rabid  dog, gave birth, while
suffering from  hydrophobia, to  a calf.   The  calf was  likewise
seized with  hydrophobia, although  another cow had been  sub-
stituted for it to suck from.
   No instance of the transference of the poison of hydrophobia
by intermediate vehicles is as  yet known to  have occurred, it
being either not at all,  or at  all events  only to a very slight
degree, transportable.  If minute  particles of  the virus suffice to
propagate infection, it may be inferred, judging from analogy
with  other infectious diseases (for instance, malignant pustule),
that  possibly certain parasites  (fleas and  lice), which are nour-
ished by the blood of the dog, and which hardly any dog is free
from, may transfer the poison  by means of their blood-drawing
apparatus, and thus produce inoculation.3
    The  communication  of  hydrophobia  from one animal to
   1 Wochenschrift fiir Thierheilkunde, 1872, p. 358.
   2 Matton, Donat., Considerations sur la Rage.  Strassburg, 1862.
   3 The fact of the communication of small-pox by flies can hardly be questioned ;  a
case of vaccination by the medium of a flea, was a short while ago reported in England.
(Lancet, June 22, 1872.) 
HYDROPHOBIA  IN ANIMALS.                 441
another, by the consumption of the meat or  milk  of rabid ani-
mals, is extremely rare.   As a rule, food of this kind is taken
into the stomach without ill effect.
    In conclusion, the views  above expressed as to  the mode of
origin  of hydrophobia may be summarized as follows :  Hydro-
phobia, like all other infectious  diseases, never arises spontane-
ously,   but  requires,  as  an indispensable  antecedent causative
factor, an infection, by the introduction into tlie organism of the
specific mater ies morbi.   All  the etiological  conditions, such  as
the season   of  the year, temperature,  want  of  freedom,  sup-
pressed  sexual  appetite, age, sex, and  race  are  to be regarded
neither as  direct nor predisposing causes.   Very  many  of the
best observers,  recent as well as  old,  such  as Blaine, Youatt,
Magendie,  Dupuytren,  Breschet, furthermore  Schrader, Adam,
St. Cyr, Peuch, Boudin, Virchow, and  others reject the theory
of  spontaneous development,—a  theory which has been adopted
in a great measure as a matter of convenience, until additional
and more exact investigations shall have been made.
    Predisposition.—This is, on the whole, moderate.  By artifi-
cial attempts at inoculation, from two-fifths to two-thirds of the
animals inoculated or bitten were infected.
   Hertwig experimented upon 30 dogs, some of which he inoculated with  saliva
taken from rabid dogs, while others were allowed to be bitten by such animals.  In
eleven instances—equivalent to 37 per cent.—he obtained positive results, whereas
19 of  the inoculated and bitten animals remained unaffected.1  Renault caused 99
   1 The important experiments of Hertioig may be summarized as follows :—Sixteen
inoculations with saliva (taken  from  a rabid  dog either during life or soon [fifteen
hours] after death) produced positive results in six cases.
   Six inoculations with saliva obtained from the cold cadaver, from twenty-four to
forty-eight hours after death, resulted negatively in each case.
   Seven inoculations with portions of the substance of the salivary glands produced,
in one instance, a positive result.
   Fifteen inoculations, by means of the bite of mad dogs and by natural inoculations,
produced, in five instances, positive results.
   Six inoculations with portions of the nerve tissue of rabid dogs were all negative.
   Twenty-three experiments made with food smeared with the saliva and blood of
rabid dogs were all negative.
   Five attempts at inoculation by means of  intermediate vehicles (placing the subject
in a stall where a mad dog had been previonsly confined) were negative.
   Hertwig, in tabulating the results of his attempts at inoculation, affirms that, from 
442       BOLLINGER.—INFECTION BY ANIMAL POISONS.
different animals (dogs, horses, and sheep) to be bitten by rabid dogs.  Of these,
67—equivalent to 67 per cent.—became rabid, while  the  remainder continued
healthy, although they remained under observation for at least one hundred days.
In Wurtemberg, from 1864 to 1867, out  of 943 animals, which were wounded by
dogs  that were rabid, or suspected of being rabid, or particularly given to biting,
28, or 3 per cent., were seized with rabies.  It is obvious that the favorable result
in this instance is attributable principally to the fact that merely savage dogs were
included in the estimate.  According to Youatt, two-thirds of  those dogs which
are bitten by rabid dogs contract the disease.   Of 137 dogs that were bitten by
mad dogs in the years 1823 to 1827, and subsequently kept under observation at the
veterinary school at Berlin, six died from hydrophobia, while the rest remained
healthy (Hertwig, loc. cit., p. 145).

   From causes  that cannot be explained, inoculation is  often
unsuccessful, even when  performed  under the most favorable
circumstances.    Many dogs resist all infection;  nine different
attempts, in the  course of three years, to inoculate the famous
poodle of Hertwig, were ineffectual,  while other dogs in  whom
the same poison was implanted were infected.   In the veterinary
school at Lyons, a dog which had been bitten, experimentally,
four different times, remained unaffected.  Other dogs resist two,
three, and even four attempts  at  inoculation,  and are  finally
infected  at  a  subsequent  trial.   According to  the experiments
of Menecier, a rich feeding of the dogs that have  been infected
favors the outbreak of  the  disease, while, on the other hand, it is
retarded by poor nourishment.
   That  hydrophobia  occurs most frequently  among dogs be-
tween the ages of one and six years (Pillwax) is manifestly due
to the fact that the majority of dogs are under six years of age.
   Before proceeding to review  our  limited  knowledge of the
fifty-nine experiments, he obtained fourteen positive results.  This number, however,
should not be taken, as it  often has been, as a basis for a general estimate of the dis-
position to contract the disease, for there were included in this calculation inoculations
with blood,  with saliva obtained a long time (twenty-four to forty-eight hours) after
death, with the substance of the salivary gland, and with portions  of the nerve sub-
stance, all of which, in thirty attempts, produced only three positive results.
   Moreover, the  low  percentage of positive results yielded by Hertwig** experiment*
are to be attributed in part to the fact that they were repeated upon dogs manifesting
no affinity whatever for the virus ; his own poodle, for instance, having  been selected
no less than nine times. 
HYDROPHOBIA IN ANIMALS.
443
nature and mode of action of the virus  of  hydrophobia, a few
words must be devoted  to those who deny altogether its exist-
ence, regarding it either as a phase of another disease (tetanus,
anthrax,  typhus), or else explaining it—at  least in the  case  of
man—as  being a  simple psychosis in consequence of anxiety
resulting from a bite.
    The denial of the existence of hydrophobia as a specific dis-
ease, a theory that has recently been adopted  by Maschka * and
Lorinser,2 does  not possess the  merit even of novelty,  for the
existence of hydrophobia, as a disease sui generis, as well as the
existence of a specific virus, was denied in France by Bosquillon3
as early as the latter part of tv last century. According  to their
views, the symptoms are to be ascribed to fright, or to the local
injury.  In like manner Girard  and J. Simon (1819)  described
hydrophobia  as  an imaginary disease.  R. White4  regarded hy-
drophobia as  nothing more than an ordinary inflammation of the
oesophagus, the stomach,  and the  muscles of respiration, and
went so far as to deny utterly, not only the specific character, but
also the infecting property of  hydrophobia.   In order to prove
the latter, he inoculated  several cats, rabbits, and other animals,
and finally himself, from two  rabid dogs—all without results.
It is hardly necessary to add that these negative results, as com-
pared with the numerous positive effects following inoculation,
and with simple  clinical experience, are entitled to no weight,
and are valuable, at most, only as illustrations of foolhardiness
indulged  in with impunity.  Another writer also, Franque (loc.
cit.), having at first opposed the idea of  the primary  existence
of hydrophobia, and of  a  specific contagion,  after being made
acquainted  with  the experiments of Hertwig,  renounced his
views, and admitted the hydrophobia  of foxes to  be a specific
disease.a
   1 Prager Vierteljahrsschrift f. wiss. Heilk., 1871, III., p. 1.
   2 Wien. med. Wochenschrift, 1865, Nos. 19-21.
   3 Memoire sur la cause d'hydrophobie, vulgairement connue sous le nom de rage.
Paris, 1802.
   4 Froriep's Notizen fiir Natur und Heilkunde, 1826, Nos. 264, 266, und 268.
   6 Geschichte der Seuchen, die  in dem Herzogthum Nassau seit dem Ende  etc.
geherrscht haben. Frankfurt a. M., 1834, p. 239. 
444      BOLLINGER.—INFECTION BY ANIMAL POISONS.

   All these attempts to dispute the existence of hydrophobia
are not easily comprehended by such persons as have had occa-
sion to witness the disease, with all its horrors, in cases of ani-
mals and men.  As these hypotheses have not been adopted to
any great extent, either by professional men  or the public, they
may,  on the whole,  be pronounced tolerably  harmless ; neverthe-
less they might,  under certain  circumstances, be conducive to
very great injury.
   As Virchow has already forcibly stated,  the  doctrine of the
spontaneous development of hydrophobia contributed most of all
to involve in doubt the specific character of the disease.  On the
other hand, it is well to consider that the diagnosis of hydropho-
bia, especially in  the case of animals, is extremely difficult and
doubtful; that numerous  cases  are  designated  by that term
which are not entitled to it.  Finally, as regards the human sub-
ject,  as will be seen later, there can be no question as to the
existence  of hydrophobia,  which,  like certain affections of the
mind,  may present  diagnostic difficulties, but its existence as a
specific disease should not on that account be denied.
   That  the  rabies of dogs has  no connection with tetanus,
anthrax,  and similar affections,  it is hardly necessary to dis-
cuss.   Tetanic symptoms, such as are now and then observed in
cases  of hydrophobia in the human subject, are never known to
occur in the case of dogs.

NATURE AND MODE OF ACTION OF THE VIRUS OF HYDROPHOBIA.

   The specific infecting principle of hydrophobia is absolutely
unknown.  Neither chemical  nor microscopic  analyses of  the
saliva of  mad  dogs  have as yet  given any clue to its detection.
The virus is reproduced only within the diseased economy, never
outside the same, and belongs therefore to the endogenous mor-
bific agents.    It is  distinguished from  the  other  chemical and
morbid poisons principally by this circumstance, that it remains
within the organism for weeks,  and even months, without pro-
ducing any morbid  symptoms whatever.  In its action upon cer-
tain  organs  of the  central nervous system,  upon  the centre of
the mechanism involved in  deglutition, upon the  centre of the 
HYDROPHOBIA IN  ANIMALS.
445
respiratory system, and the  nerve centre influencing spasmodic
contractions,  its action is analogous to certain nerve poisons of
a vegetable or chemical nature.
   The virus of hydrophobia is contained  in the saliva and
foam of the affected animal,  also  in the blood and  salivary
glands, and possibly also in still other solid and fluid portions
of the body ;  it is always fixed, never volatile.
   It is probably capable of infection even during the stage of
incubation, and also continues active for some time after death
—hardly longer, however, than twenty-four hours.
   By natural or artificial inoculation, the virus, either by pen-
etrating a denuded portion of the skin or external mucous mem-
brane, or  an actual  wound,  may be transferred to numerous
other species of  animals and to man, and reproduce (under cer-
tain  conditions  depending  upon individual  predisposition)  a
fatal hydrophobia.
   The manner  in which the wound is inflicted, as well as the
psychical condition (fear) of the person or animal bitten, exer-
cises, as a rule, no influence in the production of the disease.
   Inoculations performed  with saliva taken from a rabid dog after death are
often without effect.  When brought in contact with the unabraded mucous mem-
brane of the digestive canal—in connection with the food—the virus is innocuous.
In twenty-two experiments of this kind, made by Hertwig, the results  were invari-
ably negative.  Out of eleven inoculations with the blood of rabid  dogs, taken
partly from living animals, partly from those that had just died, Hertwig obtained
positive results in only two instances.   Six inoculations with nerve tissue yielded
invariably negative results.
   Whether the bite  of a mad dog shall be followed by infec-
tion,  or not, depends, apart from the individual predisposition,
upon accidental conditions, especially upon  the  circumstance
whether the bitten part is protected by hair or other  covering,
whether the saliva is  wiped off before the teeth come in contact
with the skin, etc.
   We have no accurate knowledge as to whether the virus of
hydrophobia possesses a variable intensity,  or virulence, depend-
ing upon the individual from which it  is obtained.   It  is very
generally asserted that the so-called  sullen hydrophobia  has
a less infectious property than the violent species of the malady. 
446       BOLLINGER.—-INFECTION BY  ANIMAL  POISONS.

Nevertheless, it sometimes happens that an  inoculation derived
from a dog affected with the rabid  form may produce the  sullen
form, and vice versa.
   There can be  no doubt  that the  virus may be  reproduced
within the body of a person or animal infected, so to speak,  sec-
ond in order.  According to  the  experiments of  Rey (1842), it
retains its  infecting power down to the fifth generation.   From
rabid herbivorous animals, as well as  from  man,  the disease
may be communicated back to dogs.
   The experiments  of Hertwig, tending to show that the virus
is inactive when brought in contact with the unabraded mucous
membrane  of  the digestive canal, are  confirmed  by the  fact,
demonstrated  by  numerous  experiments, that  the  milk  anl
flesh of rabid animals {dogs, sheep, cattle) may,  as a rule,  be
consumed by man and animals without any ill effect.  Gohier
alone states that he has seen hydrophobia produced in a dog by
eating the flesh of a rabid dog ; he has also seen it  occur  in the
same animal from eating the flesh of a rabid sheep.

   Hertwig carried out his important experiments  with infected food in  a  great
variety of ways: at one time he simply  introduced the saliva and mucus of  a  rabid
dog into the mouths and throats of healthy  animals; at another he injected  water
mixed with virulent saliva into the throat and stomach; he fed dogs with  small
pills  composed of meal, mixed with infected saliva and mucus, and also spread
meat and bread with the saliva of mad dogs (both living and dead), adding  a cer-
tain amount of warm  blood also taken from rabid dogs—all with negative  results.
Again, he placed healthy animals in stalls where mad dogs had just previously been
kept, so that the animals to be experimented upon were brought into frequent con-
tact with the same straw, halters, chains, food, and wash-basins, that had been used
by the diseased animals, but in no instance was hydrophobia produced; and the
same may be said of  placing animals  in the stall with dogs which had recently
died of this disease.   According  to the statement  of this writer, healthy  animals
never manifest any aversion towards bread and meat that has been smeared with the
mucus and saliva of rabid dogs.
   Breschet obtained negative results in his attempts to produce hydrophobia by
inoculating with small portions of the muscles, tendons, and the  tissues of various
organs taken from mad dogs; the same result followed inoculations made with
blood, in which respect his experience was similar to that of Lessona and Renault.
   In several instances in which guinea-pigs affected with hydrophobia were  suck-
ling  their young, it was observed by Greve (loc. cit., II., p. 38),  that some of the
young ones were infected by the bite of the mother; but in  no case did they con- 
HYDROPHOBIA IN ANIMALS.
447
tract the disease through taking for some length of time the milk of their rabid
mothers.
   We thus see that the theory previously advanced in this
article finds full confirmation in the results of these experiments,
and  leads to the conclusion  that the poison is only in very rare
cases communicated in other ways than by the bite of a  rabid
animal; such cases, for example, are  those in which infection
takes place by means of coitus or through intermediate vehicles,
or by the consumption of meat or milk.   In accordance with the
opinions already expressed,  I should be inclined to admit that
the transfer of the poison by the agency of parasitic  media is
quite within the range of possibility.
   Respecting the action of  the specific poison within the ani-
mal economy, no adequate explanation has thus far been offered.
In general, its action may be explained in two different ways:
Either the virus remains awhile latent  at the point of inocula-
tion, and only after a certain interval—at the expiration of the
period of incubation—enters and circulates  with the blood and'
other fluids of  the  body;  or else the poison, by undergoing
incessant reproduction, is constantly supplied in fresh quanti-
ties  to the blood.  The aggregate amount of the poison  intro-
duced into the economy by the latter method is too slight, how-
ever,  to  give rise  to any decided symptoms ; or,  possibly,  the
virus is  by some physiological neutralizing process  rendered
innocuous  and destroyed.   In accordance with  this view of the
matter, we should  be unable to attribute  the long  period of
latency of the disease to  the localization of the poison at the
seat  of inoculation.   The  latter hypothesis  is supported, how-
ever, by the fact that dogs, wliich have been antecedently bitten
by other rabid animals, are  capable of communicating the dis-
ease  by their  bites even during the period  of incubation; this
view is also confirmed by the circumstance that an unquestion-
ably beneficial effect is produced by the prompt  local destruc-
tion  of the tissues  forming the atrium of  the poison.    This
theory renders, moreover, quite intelligible, the  favorable re-
sults (verified  by several writers) which are obtained by the de-
struction—even after the lapse of some little time—of  the local
deposit, in which the process of incubation is taking place. 
448       BOLLINGER.—INFECTION  BY ANIMAL POISONS.

   In  what  manner, or by what  course the poison  penetrates
the body from the seat of the wound, is absolutely unknown.
   The action of the poison has been compared  by Virchow to
that of a ferment,  fresh  particles of which are constantly being
conveyed into the blood from the seat of the inoculation, pro-
ducing through the medium of the circulation the specific effect
upon the nervous  system.  The resemblance to alcoholic  intoxi-
cation, and  to certain forms of mental  affections is unmistak-
able, the poison in each  case producing its effects upon the cen-
tres of the medulla oblongata and  cerebral hemispheres.

HYDROPHOBIA IN OTHER ANIMALS—GEOGRAPHICAL DISTRIBUTION.

   Hydrophobia occurs in the fox, wolf, jackal, hyena, badger,
and marten, as well as in  the dog ; also in horses, cattle, sheep,
swine, goats, does, antelopes, guinea-pigs, and rabbits.
   Although formerly the possibility of the communication of hydrophobia to her-
bivorous animals was generally doubted, it is now known, from the results of numer-
ous experiments by inoculation, that the rabies of herbivorous animals also possesses
infectious properties.
   After similar experiments had already been made by various investigators,
Bourrel  (1847) inoculated a sheep successfully by means of matter taken from a
rabid steer.  Lessona (1852) inoculated two horses and a sheep from a rabid ox.
Pillwax (1868) inoculated a dog with the blood  of a rabid horse, taken  from the
body shortly after death.
   In like manner are recorded positive inoculations from a man to a rabbit (Earle),
and to a guinea-pig (referred  to by Youatt). Inoculations with negative results
were  made by Adam (1858), who inoculated two rabbits with warm foam taken
from a dog that had just previously died of hydrophobia; furthermore  by Greve
(loc.  cit.,  I. 128), who introduced the virus into the native amphibia,—serpents,
lizards,  frogs, toads, and salamanders.

   With regard to the geographical distribution of the disease,
it may be stated, in a word, in accordance with the views already
expressed,  that no land or climate is free from  hydrophobia.
The malady prevails just  the same in countries where dogs  live
in perfect freedom—for instance  in the  East, in Algiers, China,
Cochin-China,  and  the arctic regions—as  in  every part  of
Europe, where dogs, being domesticated, are deprived more  or
less of their freedom.  In Europe hydrophobia is said to  prevail 
HYDROPHOBIA IN ANIMALS.
449
most extensively  in Germany,  France,  Holland,  the north  of
Italy, and in England (Fleming).
   On the other hand, as must appear  evident, the greatest dis-
cretion should  be exercised in crediting any report of the occur-
rence  of hydrophobia  in uncivilized  and imperfectly  known
lands.
   Virchow has stated,  with a certain degree  of  reserve, it is
true, that among  the countries reported to be  least frequently
visited are  Kamtschatka,  Greenland,  portions of Sweden and
Denmark, the southern coast of the  Mediterranean,  the whole
of Africa,  and the southern  portions  of  Asia  and America.
Boudin  (1861)  appears  to  confirm the view that hydrophobia,
although of such  frequent occurrence in Europe, is much more
rare in the tropics and the polar region.
   As opposed  to these views, I will  append a  few more recent
observations:
   In February, 1860, hydrophobia broke out as an epizootic in Upernavik, the
northernmost settlement of Greenland (72° north latitude).  The thermometer stood
then for some time at 25° F. below zero, and the favorable condition of the sledge
roads contributed greatly to the spread of the disorder, which proved fatal to all
dogs attacked.' In like manner, in 1863, hydrophobia prevailed in epizootic form
in the northern portion  of Greenland, completely destroying all the dogs in certain
districts (Hamann).8
   In Missouri and  Ohio (United  States) hydrophobia  prevailed so extensively in
the year 1860, that the cattle-owners solicited reimbursement from the government
on account of their great loss in cattle.

   In  Constantinople,3  hydrophobia rages  in  some years—e.g.,
1839—very widely ;  as a rule, however, according  to  one writer
(Fauvel), it is rare, while according to another (Zoeros) it is not
so unfrequent.   It prevailed in Athens in epizootic form during
the summer of 1866.  The occurrence  of hydrophobia in  Crete
and  in Asia Minor  has been recounted  by Caelius Aurelianus.
Notwithstanding a former report, it is now known for a certainty
that hydrophobia occurs not unfrequently in Algiers (Guyon).
Contrary to  the assertions of Alpin and Larrey, who  denied its

          1 Hering, Jahresbericht iiber Thierheilkunde, 1880, p. 55.
          2 Leisering, Jahresbericht uber Thierheilkunde, 1866, p. 448.
          3 Froriep's Xotizen, 1839, No. 188.
          VOL. III.—29 
450      BOLLINGER.—INFECTION BY ANIMAL POISONS.

existence in Egypt, the occurrence of this malady there has been
verified by Pruner.1
   Hydrophobia is found, moreover, in the East Indies, in Java,
British Guiana, the West Indies, etc.
   Although the study of the geographical distribution of hydro-
phobia leads us to deny in toto the theory of its spontaneous
origin, on the other hand we see that in many regions it remains
unknown for a series of years, at length to burst out suddenly
in epizootic form.  That which is true of Greenland, where, when
the sledge roads  are  in  good  condition, hydrophobia  spreads
most  easily and rapidly,  holds  good generally for other coun-
tries.   The frequency  and rapidity  of  communication between
individual  countries is an important factor in determining  the
area of the geographical  distribution of hydrophobia, and  the
parts  of Europe above alluded to are the most frequently visited,
because  their intercourse is the most  extensive, while  at  the
same  time they are the most thickly inhabited and contain  the
largest number of dogs.
   We possess  numerous observations  by  Franque, Kochlin,
Oertl, and  others,2 concerning epizootics of hydrophobia among
foxes.  The malady prevailed toward the end of  the last cen-
tury in the vicinity of Frankfort, in 1803-1804 in the Pays-de-
Vaud, in 1806 in Wurtemberg (on the Lake of Constance), in
1819-1820 in  Spessart,  in 1823-1824 in the Taunus, in  1819-1828
in the eastern part of  Switzerland, in the cantons of Zurich  and
Glarus, and from 1866  to 1872 in Carinthia.
   By the prevalence of such maladies among those wild beasts
of prey (fox and wolf), which are distinguished by their  propen-
sity to bite, their numbers become very materially diminished ;
in fact, they become almost decimated.
   In  respect to the  seasons,  no very decided  preference is
evinced by hydrophobia for any particular period of the year.
It may rage at any time, but appears to be slightly more preva-
lent during the spring and summer months.
  1 Compare the statements of VircJww (loc. cit., pp. 356 and 357).
  2 Compare the extensive statistics of Schmidt concerning hydrophobia of wild ani-
mals in his Zoological Clinique, B. I., p. 322. Berlin, 1872. 
HYDROPHOBIA IN ANIMALS.
451
    It is difficult either to prove or to deny the statement that
in former  times  hydrophobia occurred less frequently than at
present.  According to the official mortuary statistics of London,
no instance of  the disease appears to have occurred between the
years 1603 and 1728 ; subsequently to the latter date cases have
been reported almost regularly.
    In Hamburg hydrophobia raged  as an epizootic from 1851 to
1856,  about six  hundred well-authenticated cases having been
observed,  although during the previous twenty-three  years  no
instance of the disease had occurred.   In  Saxony, between the
years 1853 and 1867,  eight hundred  and  seven cases, genuiue or
suspected, were reported—a yearly average of about sixty ' cases.
In  Bavaria,  out  of a total number  of  about 275,000 dogs, there
averaged yearly during five years (1863-1867) eight hundred cases
of  hydrophobia, genuine and suspected, giving a  proportion of
1:350/

                      Symptomatology.

   After a bite the wound generally heals  very rapidly, inflam-
mation ensuing in exceptional cases  only.   During the period of
incubation, no  specific changes are to be observed  as the  result
of the hydrophobic infection, either  at the seat of the wound  or
in any other portion of the bitten or  infected animal.
   The period of incubation lasts in  the  majority of  cases from
three  to five weeks.   Instances, in which this stage is of shorter
(from six to eight days)  or longer duration, are comparatively
rare.   According to Haubner  the disease  breaks  out within two
months in eighty-three per cent, of all cases, within three months
in sixteen per cent., while in the remaining one per cent,  it ap-
pears at the expiration of four months  and later.  The longest
period of latency [in the dog—Tr.] is said to be eight months.
   In the other domestic animals the  period of  incubation  varies
from two to  five, seven, or ten weeks, and  in exceptional cases
may be extended to nine or fifteen months.
1 The original text reads " one hundred and sixty."—Translator.
2 The number of merely suspected dogs has undoubtedly been very considerable. 
452      BOLLINGER.—INFECTION BY ANIMAL POISONS.

   Hydrophobia appears in dogs in two different forms, wliich,
in view of the experimental results,  are to be regarded as two
forms or varieties  of  the  same malady.   We recognize, there-
fore :
   First. The violent form of hydrophobia or rabies.
   Second. The sullen form.
   There can  scarcely be found any other  disease respecting
whose characteristics so many fallacious notions and reports uni-
versally prevail among medical men as well as among the general
public, notwithstanding the fact that we have long been in pos-
session of admirable accounts  of the malady by Meynell, Youatt,
and Hertwig.  Before entering upon a description of the forms
above mentioned, we  may as  well state at the outset that it is
no easy task to trace an  accurate description  of  a disease which
presents so  many varieties, depending upon the race, age, sex,
temperament,  and physical condition, so  that, as is stated by
Hertwig, two cases rarely correspond exactly.

        THE VIOLENT FORM  OF HYDROPHOBIA IN DOGS.

   In the course of this variety of the affection three stages may
be distinguished, viz. :
   First. A prodromic or melancholic stage.
   Second. An irritative or maniacal stage.
   Third. The paralytic stage.
   1. The prodromic or melancholic stage. Duration, from half
a day to two or three  days.
   At the outset of the disease the animals manifest a changed
behavior, becoming  irascible, sullen,  fidgety,  and constantly
changing position.  In their conduct to those  around them, they
evince  a variable  disposition, being  either more confiding and
friendly than  usual,  or extremely  irritable,  morose, and easily
enraged.  The condition of hypersesthesia is indicated by the
fact that upon the slightest  provocation  they crouch, and are
easily frightened.  There is frequently observed a moderate red-
ness of the eyes, and they will often lick their cicatrized wounds,
thereby inflaming them afresh.
   The animals manifest even at this stage a disordered appetite, 
HYDROPHOBIA IN ANIMALS.
453
and this feature, according to the most experienced observers,
forms one of the most constant morbid symptoms.  They reject
all food, touching only a few favorite bits, or at other times the
particles taken are dropped from the mouth.  On the other hand,
they will swallow all sorts of indigestible substances, such as are
never devoured by healthy dogs—hair,  straw, dung, rags, earth,
bits of leather, and the like.  They will  eagerly lick cold objects,
such as stones, iron, the noses of other  dogs, and  hkewise their
own urine.
   The  sexual instinct appears at times to be stimulated; the
dogs will eagerly smell of and lick the genitals of other dogs.
Meanwhile they manifest constant uneasiness, spring at the door,
appear  shy, and seem to be the subject of what is termed  spec-
tral illusions ;  they obey only with reluctance.   Their  move-
ments  already begin to show signs of uncertainty, and there  is
observed a weakness  and  tremulousness of the hind part of the
body.
   In this initiatory stage the outward appearance of the ani-
mals is not much changed.  In consequence of wrinkles and folds
being formed on the forehead and over  the eyes, there is  often
exhibited a morose, ferocious look ; the conjunctiva is generally
strongly injected; the eye is frequently kept shut for several
seconds ; the pupil  is moderately dilated.   An  increased dis-
charge is poured out from the mucous membrane  of the nose ;
a tendency to  choke  is not unfrequently noticed  ; also a diffi-
culty in swallowing and a disposition to vomit.  The seat of the
bite, which is often sensitive, is frequently licked, scratched, and
gnawed.
   It often happens that the early symptoms are  insignificant,
nor are they uniformly present, and  for this reason the greatest
danger incurred by man is at this stage.
   As  some of the symptoms above described are  frequently of
very short  duration, and  are, moreover, met with in other dis-
eases, they are  therefore  often of but  slight diagnostic import-
ance.   At times the outburst of the disease is very sudden, in
which  case the early symptoms, supposed to be of a precursory
nature,  prove generally to have been active  indications  of its
presence. 
454      BOLLINGER.—INFECTION BY  ANIMAL POISONS.

   2. The violent  or  maniacal stage;  the period  of actual
rabies.   Duration, not longer than three, or,  rarety,  four days.
   The  characteristic symptoms appear only  spasmodically,
while in the  intervals between the attacks they are present only
to a slight degree.   Among the  most important of these symp-
toms may be enumerated a change  in the entire demeanor, con-
tinued absence of all desire to take food, a very striking propen-
sity to  bite,  a  peculiar change in the tone of the bark, and the
violent  efforts made to break away and stray about.
   At the onset of  an attack  there is noticed  an  increasing
uneasiness, a frequent changing of position ;  house-dogs will  fly
at the door, while dogs that are fastened will  struggle  to break
their chains,  or, if  shut up, will  try to tear in pieces the sides of
their kennel.   In the latter case they will seize hold of the posts,
bite into the  woodwork of the sides, and roll about in the straw,
which meanwhile they shake between the teeth.
   When at large, the dogs wander about with no definite object,
and often travel over a considerable extent of country within a
short time (formerly termed  running [laufende]  rabies).   Fre-
quently the animals will  return  home, and  are then  suspicious
and sly, or they will slink away, appearing  very friendly,  how-
ever, to persons with whom they are acquainted.

   As has been correctly observed by Hertwig, the desertion of his home by a  pre-
viously faithful dog indicates the existence of a high degree of mental disturbance.
The propensity to stray off, especially after having been excited or corrected,  is then
often ascribed to fear, obstinacy, disobedience, or unsatisfied sexual desire, and the
animal is  all the more dangerous in this  state if he quietly and peaceably return
home.

   During the paroxysms there is observed  a decided propen-
sity to bite, manifested to a less degree, however, in good-natured
dogs than in ugly and ferocious  animals.  Many dogs snap and
bite at whatever comes in their way ;  some eagerly attack  other
dogs, cats, birds, or larger animals,  and more seldom men, who
mostly  escape with  superficial  wounds; they also  frequently
injure and tear their own bodies.
   If a  hard  object, a cane, for instance, be presented to a chained
dog, he will  seize it spasmodically with the teeth, in  a peculiar 
HYDROPHOBIA IN ANIMALS.
455
manner, and cling to it pertinaciously, often with such force that
the teeth break and the lips bleed.
   These rabid paroxysms, characterized by a strong  disposition
to bite, vary in their duration, often lasting several hours.   The
attacks ma}T be excited by external means, for instance, by teas-
ing, or they may come on without  provocation, at  the  sight  of
other dogs or of cats.  Frequently the animals give evidence of
unusual strength, e.g., by breaking loose from their chains, and
by leaping over obstacles.   During a  paroxysm the animals are
found, as  in the case of  mania, in a state of  complete delirium ;
they evidently become the subject of hallucinations, snap at the
air as if trying to catch flies, afterwards  relapsing often into a
sort of stupor.   The expression of the countenance  is then  fixed
and staring; frequently there is noticed a convulsive twitching of
the face, while in the later stages there are occasional convulsions.
   Sometimes the animals  manifest a decided insensibility  to
external impressions, remaining perfectly quiet under blows and
abuse, at which a sound dog would cry out lustily.  They will
even  bite  at a red-hot iron rod, and snap at the fire that is con-
suming their bed.   In consequence of  this impaired  sensibility,
the rabid dog has  been known to bite off both testicles  together
with the  prepuce, or the end of the tail, or they will gnaw  away
their  feet even to the bone.
   There is often observed a very decided perversion of instinct;
rabid mothers, for instance,  have been seen to bite their pups, or
even to tear them with their teeth.
   In the intervals  the mental  aberration  either  disappears
entirely or becomes very greatly modified, and the animals then
generally  recognize their masters.
   A  closely related pathognomonic sign, that frequently makes
its appearance in the first stage, is a peculiar alteration in the
tone of the voice.   When an attempt is made to bark, a peculiar
sound, between a bark and a howl, is uttered  in a rough, hoarse
tone.   This short, sharp sound is often prolonged into a howl.
In emitting this characteristic noise, such as is heard in no other
disease of  dogs, the animals raise the muzzle somewhat in the
air, just as healthy dogs do at the sound of music.  The tone of
the voice is seldom natural. 
456      BOLLINGER.—INFECTION BY  AXIMAL  POISONS.

   The food is, as a rule, rejected;  occasionally the diseased ani-
mals will nibble a little  of  their favorite feed, but invariably
only in small quantities.  Instead of food, however, they will
almost without exception devour large quantities of indigestible
and offensive  substances,  such as hay, straw, hair, earth, and
dung.
   No special dread of water is manifested.  In exceptional and
extremely rare instances only do the animals suffer from spasms
of the  throat accompanying  an  attempt to drink  (Adam).
Moreover, rabid  dogs will lick their own  urine, splash  about in
water that is  set before them, and drink freely thereof.   They
tolerate the sight  of water without any signs of  excitement, a
fact that was demonstrated  by Meynell, and  subsequently  by
Blaine, Greve, Hertwig,  and others.   Equally unfounded is the
notion that there is  any aversion to light, air, or to the glare of
the sun.  In rare instances only is observed a slight sensibility
to a bright light.
   There is a very  limited excretion of  urine and faeces,—the
faecal discharge  especially is reduced to a very small quantity,
attributable to the circumstance that little or  no nourishment is
taken, for which reason  an intestinal obstruction is hardly to be
suspected.   This condition may  result, however, when the large
intestine becomes distended like a sausage by masses of earth and
sand; one very marked  instance  of which I have myself seen.
   The  emaciation of the animals, that  rapidly supervenes, is
attributable in part to  the phenomena last mentioned, and in
part to the excessive waste resulting from their continuous state
of excitement.  The entire appearance soon becomes unnatural,
the eyes being sunken, the hair lifeless and rough, and the bodies
thin.  The  mucous membrane of the mouth is but slightly moist-
ened,  and is often  parched,  and of a dirty livid  color; a dis-
charge of saliva and foam from the mouth is scarcely ever seen.
Saliva is emitted only when there is inability to swallow.
   The  respiration,  though  at  times hurried, is usually but
slightly affected.   On account of the great difficulty of control-
ling the animal, the pulse has been observed only in rare cases,
when it was found to be slightly accelerated, and often irregu-
lar. 
HYDROPHOBIA IN ANIMALS.
457
   Among the ancient and unauthenticated traditio»s concerning the course of
hydrophobia, may be mentioned the notion that there is always a discharge of saliva
from the mouths of rabid dogs, and that the muzzle is covered with foam;  fur-
ther, that the tail is held closely to the hind legs, and  that they always run in a
straight line.  All these symptoms are purely imaginary.  As has been remarked
above, the saliva is discharged only when there is inability to swallow.  So long as
there is sufficient strength, the tail is carried and wagged as usual; but with increas-
ing weakness it droops; the course in  running, as with healthy dogs, is sometimes
straight forward, sometimes in diverse directions or in circles.  Equally erroneous is
the belief that a healthy dog can recognize one that is mad by a peculiar odor, and
for this reason will avoid food that has been smeared with the secretions and excre-
tions of the latter.

    3. The paralytic stage.
    This is developed directly  from the previous stage, the par-
oxysms becoming weaker and  less distinctly separated from the
remissions.
    Within a very short space of time  the  animals  become  com-
pletely changed in appearance by the sudden emaciation, wliich
is all the  more striking, when one considers the short duration
of  the disease.  The hair  becomes  thoroughly roughened, the
flanks fall in, the eyes  appear  dim, glistening and sunken ; the
lead-colored  tongue projects from the mouth,  which is generally
open and dry.  The countenance is staring and devoid of expres-
sion,  the tail droops,  and the whole appearance is appalling and
repulsive.
    The general weakness  constantly increases, especially in the
hind  parts;  the  gait  becomes uncertain  and  staggering; the
animals  are hardly  able to stand, but tumble  about like one
intoxicated.  Often they lie curled up, as if attempting to sleep,
raising  themselves on their fore-legs only when  irritated ; they
still attempt to  bite, or at least  to  snap,  and are now only in a
slight degree dangerous to  those  immediately about them.   The
voice becomes constantly hoarser, the breathing  labored, the
pupils dilated, the expression  stupid and drowsy.  The pulse is
small and  thread-like.  At times  partial or complete convulsions
set in.  Death ensues in most cases on the fifth or sixth day,
very  rarely later,—on  the seventh  or eighth day,—and life is
never prolonged beyond the tenth day.
    The result is invariably fatal.   The cases of alleged recovery 
458      BOLLINGER.—INFECTION BY ANIMAL POISONS.

reported from time to time are not supported  by trustworthy
evidence.

                THE SULLEN RABIES OF DOGS.

   The  sullen or melancholic form of rabies, which constitutes
about fifteen or  twenty per cent, of the total number of cases,
is  to be regarded, as has been intimated above, as a peculiar
manifestation  of the  disease.  While formerly the sullen  was
commonly supposed to  be the first, and the  rabid form,  on the
other  hand, the  second stage of the disease,  it would  appear
more rational to consider that  in  the  former the melancholic
stage passes at once into the paralytic stage, according to which
view the second  or maniacal stage is to be regarded as omitted,
or at the most barely noticeable.   The disease runs therefore a
shorter  course.  The  symptoms of irritation of the  brain are
observable  only  in a  slight degree; the animals are  less lively
and active,  appearing silent, quiet, and depressed.  Excitement,
incessant motion, the propensity to stray away  and to bite are
less frequently noticeable.
   Similar changes are manifested in the general disposition of
the animals.  There is but  a  slight inclination to  gnaw  and
bite, and no great tendency to slip away.  There is no aversion
whatever evinced for fluids ; the sexual passion is often aroused.
Paresis of the lower  jaw soon supervenes,  in consequence of
which the mouth remains partially or completely open, and it
is  only  when greatly irritated that the power  of  shutting the
jaws and biting is retained ; a  similar  difficulty, though not
always  present,  is experienced during an attempt to  take food.
There is great difficulty in swallowing, and  almost everything
that is taken into the mouth, however carefully, falls out again.
In this  form of the disease genuine frothing appears, resulting
from the flow of  mucus and saliva from the open mouth.
   In addition, we may observe  a variety of phenomena analo-
gous to  those of  the violent form : the peculiarly changed voice,
but seldom heard,  the  mental  disturbance,  the change in  the
appetite, the absence  of faBcal  discharges, the rapid emaciation,
the paralysis of  the hind parts,  and the uniformly fatal termina- 
HYDROPHOBIA IN ANIMALS.
459
 tion, which  results more  quickly than in the violent  variety,
 namely, within two or three days.
    To review the general features presented by these two forms
 of  the disease,  we would  note, as the most  important symp-
 toms in violent hydrophobia, the changed behavior, the peculiar
 uneasiness, the tendency to slip away, the propensity  to bite,
 the perverted appetite, the  absence of all desire to take food, the
 intermittent mental disturbance, the rabid paroxysms, the pecu-
 liarly changed voice—the howling bark—the altered appearance,
 the absence  of any dread  of water,  the rapid emaciation, and
 the uniformly fatal termination  after a brief illness.
    In the sullen form of hydrophobia the general  features of
 the first stage  are similar to those just described ; paralysis of
 the lower jaw very soon appears, with the hoarse tone of voice,
 the disturbance of the mental faculties and appetite,  and emaci-
 ation ;  while the  rapidly fatal  termination is  also preceded by
 symptoms similar to those of the violent form.


    HYDROPHOBIA IN OTHER DOMESTIC  AND WILD ANIMALS.

    However  interesting we might find a complete comparative
 description of hydrophobia, as  it occurs in the different species
 and varieties of  the zoological  kingdom, we must content our-
 selves with an explanatory survey1 of  the chief symptoms to be
 noticed in the principal domestic and wild animals.
    1. The horse, when attacked  by hydrophobia, is at the outset
 greatly excited, and appears to be the subject of illusions. There
 speedily ensue  indications of excessive fright, a tendency to bite,
 gnashing of  the  teeth,  frequent neighing,  great sexual  excite-
 ment, and loss  of appetite.   When the specific paroxysms set in
—and these are generally very severe—the animals begin to strike
and kick, and  manifest a strong propensity to bite.   They will
bite at the objects surrounding them, or that may be held before
them,  often wounding themselves and tearing  portions  of the
flesh  and integument of the  fore-legs  and flanks, or they will
seize  upon other  animals.  It  is also observed that diseased
1 Drawn partly from Boll, 
460      BOLLINGER.—INFECTION BY  ANIMAL POISONS.

horses will rub the nose and mouth, making peculiar motions
with both these organs.  Respiration is generally greatly accel-
erated, and there soon follows a  general  aggravation of the
symptoms—weakness, paralysis of the hind parts,—death gener-
ally resulting in from four to six days.
   2.  In  cattle the symptoms are in part similar  to  those  of the
horse.  When seized with hydrophobia, they bellow often and
loud, in a hollow-sounding voice, show signs  of mental  derange-
ment, stamp, and often butt so violently as  to break off their
horns.  They seldom manifest a disposition  to  bite.   Finally,
paralysis ensues,  and death takes place after a period varying
from four to seven days.
   3 and 4. In  the sheep  and goat the morbid  symptoms are
similar to those of cattle.  The animals make unnatural  leaps,
butt eagerly,  and soon become  emaciated.   At last  paralysis
and death are observed in from five to eight days.
   5.  Swine generally manifest fright at first; they are inclined
to hide away, and become greatly excited by noises, wild, and
exceedingly dangerous.  During the  paroxysms  the disposition
to bite is very  great,  and they tear first one ear and  then the
other.  Meanwhile respiration is greatly accelerated. The visible
mucous membranes assume a leaden hue, as does also the super-
ficial integument; a viscid foam is  discharged from the mouth;
the eyes  glisten.  Death follows in from two to four days.
   6.  On account  of the timidity of rabid cats, their symptoms
are not easily observed.  They manifest a great uneasiness, run
about in  an excited manner, and evince a strong propensity to
bite.  Death takes place in from two to four days.
   7.  The domestic fowl, when attacked with hydrophobia, is
said to manifest  great uneasiness, and to spring about wildly;
a hoarse voice is noticeable,  also a certain tendency to  bite, and
finally paralysis.
   8.  Of the to/Id animals' in which hydrophobia occurs, men-
tion should be made, first of all, of the wolf and fox ; then of the
badger, marten, jackal, and hyena.  In the wolf and fox, symp-
  1 Compare the work (with catalogue of literature) of M. Schmidt, Zoologische Klinik,
I., 2, p. 322.  Berlin, 1872. 
HYDROPHOBIA IN ANIMALS.
461
toms are manifested quite similar to those  observed in the dog.
They wander about incessantly, lose their fear of and aversion to
man, manifest a strong propensity to bite, and attack with great
boldness men, and the larger animals, especially dogs.  In many
instances they will make their way into villages and cities,  and
even into houses.  Meanwhile all desire  for food disappears;
they have no dread of  water.   At last  the animals become
extremely emaciated  and die.   In many districts,  where  the
malady rages in epizootic form, the foxes are actually decimated.
The badger, jackal, and hyena behave  similarly to  the fox and
wolf, though but few observations are to be found respecting the
last two animals.  Rabid martens  are distinguished for their
strong propensity to bite men, dogs,  and other animals.
   As in the case of rabies in the dog, there are, accordingly, to
be observed in these  different animals,  as characteristic symp-
toms of hydropltobia, an altered  demeanor, a peculiar restless-
ness, a changed voice, a loss of appetite, an absence of faecal dis-
charges, and finally a kind of paralytic weakness of the hind
extremities, and death with convulsions.  A constant disposition
to bite is observable in those animals whose  natural disposition
is to bite.   Rabid animals make  use, moreover,  of  their special
organs of attack and defence :  horses kick, cattle and sheep butt.
The disposition to swallow unnatural substances is observed only
in the case of  carnivorous animals.   In none  of  the animals
above mentioned is the dread of water found to be a  symptom of
rabies.  They will lap water eagerly,  or at least manifest no aver-
sion to it so long as they are  not  prevented by the affections of
the organs involved in the act of swallowing, which often super-
vene.
                  PATHOLOGICAL ANATOMY.

   As is the case in some  other serious  affections of  the nervous
system (epilepsy, chorea), the  results of the  post-mortem exam-
inations of rabid animals  are of  a decidedly negative? character,
and in part  extremely  variable,  affording  in  this respect a
marked contrast to the severe symptoms evinced during life.
   Although  post-mortem  examinations, taken alone, furnish
only in rare instances the data for forming an exact diagnosis, 
462      BOLLINGER.—INFECTION BY ANIMAL  POISONS.

they are nevertheless of great value, and when considered incon-
nection with the clinical features  of  the case,  will generally
enable us to arive at a correct conclusion.
   The morbid appearances are variable, an absence of specific
changes being the only constant phenomenon encountered by the
pathological anatomist as a slight reward for his labor.  Apart
from the unnatural  ingesta found in the stomach  and intestines,
the appearances met  with in the carcases after  death  bear the
strongest resemblance to those seen in the case of certain forms
of poisoning,  for instance, in poisoning by strychnine, prussic
acid, etc.  As the result of my personal observations and experi-
ence, I should describe, in brief, the pathological changes found
in rabid dogs as follows :
   Upon outward inspection, the animals are generally  found to
be extremely emaciated ; rigor mortis is noticeable in the usual
degree ; the hair  is rough ; the tissues  about the nostrils and
mouth are covered  with  dried mucus  and  dirt;  the pupils are
dilated; and the  visible  external mucous membranes (the con-
junctiva and mucous membrane of the lips  and prepuce) are
covered with purulent mucus, and are of a dirty, livid color.
   If the alae of the nose be pressed together, there is discharged
from the nostrils a foul-colored muco-purulent fluid. Upon the
fore-legs are found, here and there, excoriated spots denuded of
hair, and also superficial wounds.  The cutaneous veins are dis-
tended with dark, thick blood.
   Upon the removal of the calvaria, which contains  an  unusual
quantity of  blood, the membranes  are found to be injected to
a variable  extent,  while the longitudinal sinus is filled with
dark-colored, thick  blood ;  slight hemorrhages are rarely noticed
here.
   The brain itself  is generally more or less oedematous, glisten-
ing brightly, and containing a variable quantity of blood.  If the
oedema be  excessive,  the convolutions are  obliterated.  The
medulla oblongata and the spinal cord are often hypersemic and
oedematous, but more frequently exhibit no appreciable altera-
tions.
   The mucous lining of the mouth  usually shows signs  of catar-
rhal  swelling, and is covered with  a viscid, gray, dirty mucus, 
HYDROPHOBIA IN ANIMALS.
463
except upon the surface of  the  tongue, which is for the most
part dry and of a dirty brown color.  There may often be seen
within the  mouth fragments  of  foreign substances,  such,  for
instance, as bits of straw, and at various points, especially upon
the inner surface of the lips and the tip and edges of the tongue,
numerous  erosions and  solutions of continuity.  Vesicles and
tubercles upon the under surface or at the base of the tongue are
utterly wanting.
   The throat frequently contains foreign substances, in the form
of small collections of compressed hair or  bits of straw.  The
mucous membrane, like  that of the interior of the mouth and
nose, is of a dark, dirty, brownish-red color,  injected with  blood,
and usually covered with  a  dull-gray  or grayish-white,  muco-
purulent  liquid.   The  tonsils are either slightly  swollen, or
normal.  The glands at the root of the tongue  are, as a rule,
likewise normal in appearance, but at times are moderately swol-
len and prominent. The submucous retro-pharyngeal and  laryn-
geal connective tissue is generally filled with blood, while  the
lymphatic glands in this region are rendered dark by injected
blood, hemorrhagic infiltrations being frequently noticeable.
   The  salivary glands are generally of  a  light grayish-red
color, but are in other respects normal.
   The oesophagus often contains a small collection of foreign
substances.  At  the entrance  of  the canal  the  mucous  mem-
brane is frequently of a livid color and covered with a dull gray,
viscous, mucous liquid.
   The mucous membrane of the larynx, especially at the  upper
opening,  is slightly reddened, injected, and lined with a grayish
slimy deposit.  In the trachea  there is  frequently found  a thin
mucous or purulent collection, often very abundant here, as also
in the bronchi, wliich, moreover, contain here and  there a few
foreign substances.
   The lungs seem on the whole normal, but are of a cyanotic
color.  There  is  poured out  from the cut surface of the  paren-
chyma, which contains air, and is both hyperasmic  and oedema-
tous, a considerable  quantity of  dark,  tar-like blood.  In some
cases there  are found  lobular  collections, which project  some-
what above the cut surface, and discharge a  sanguinolent, dark, 
464      BOLLINGER. —INFECTION  BY ANIMAL POISONS.

purulent fluid, and which have been proved microscopically to
be the products of circumscribed pneumonia, induced by the
presence of foreign bodies (small vegetable particles  and  pave-
ment epithelium).
   The large blood-vessels of the  cavity of the thorax contain a
black, thick blood, in part loosely coagulated.
   The pericardium  and  heart are generally  normal:  a few
ecchymosed spots are seen here and there upon  the inner surface
of  the pericardium.  There is contained within  the cavities
dark-colored blood, in semi-liquid form, or loosely coagulated,
mingled in rare cases with fibrinous coagula.
   The liver is either of normal size or  slightly enlarged, its tis-
sue more or less hypersemic and cyanotic.  The blood that flows
from a cut  surface is likewise thickened and tar-like.  The pa-
renchyma is, moreover, succulent and glistening, and still shows
upon the cut surface its natural markings, though at times  these
may  be obscured.   Under the microscope  the  cells of  the liver
ayjpear cloudy, owing to the presence of fine granular matter.
   The spleen is usually of normal size and consistence, and in
rare instances only is slightly enlarged.'
   The kidneys  are usually of a livid and dark-grayish  blue
color, the capsules being readily separable from them.  Upon sec-
tion, the tissues  are found to be rich in blood and friable, their
natural outlines  being well preserved.  The inner zone of the
cortical substance, as in the majority of the kidneys of dogs, is
usually marked by turbid yellow stripes, while the microscope
reveals  the presence  of  fatty degeneration.   The convoluted
uriniferous  tubules show microscopically a slight opacity of the
epithelial  lining, combined also  in some cases with  molecular
disintegration.
   The bladder is generally empty, or it may contain some tur-
bid-yellow urine, which is often albuminous.
  '  The spleen vesicles described by J. H. Locher (Dissert, inaug. exhibens magnum
lienis in Hydrophobia momentum.  Gott., 1822), which he likened to the exanthema of
small-pox, are manifestly nothing more than lymphadenomata—grayish-white nodules
of the size of a pea—which very often occur in dogs.  So, likewise, the hemorrhagic
tumors of the spleen, described by Prim, are simply accidental phenomena, which are
also  observed in perfectly healthy dogs. 
HYDROPHOBIA IN ANIMALS.
465
   The genitals are normal; though  in  the case of males  there
is frequently found  a catarrhal  inflammation of  the mucous
layer of the prepuce.
   The  stomach displays  upon the outer  surface an  increased
injection of the subserous venous trunks ;  the  organ is usually
firmly contracted, and contains no remains of food ; but almost
invariably  there  are seen foreign bodies  and  indigestible sub-
stances, most frequently hair and straw, in variable  quantity,
in sausage-shaped bundles ; in many instances there are found
large balls and  rolls  composed of  hair,  grass,  straw, bits of
leather, cloth, wood, and stones, mingled often with soft masses
of dirt.   The mucous lining of the organ is often of a brownish-
red color, the apparent result of rapid imbibition ; it is covered
with a viscid and  usually  gall-colored  liquid,  and may exhibit
the  deep redness of vascular injection ;  it may also be the seat
of hemorrhagic erosions.
   The  intestinal canal contains  either  a  small quantity of
pasty, gall-colored matter,  which  frequently emits an offensive
odor (even  in the small intestine), or foreign bodies, such as hair,
wood, small stones, straw, earth, etc.
   The large  intestine is generally completely empty,  but is at
times  distended  with  foreign  bodies, in which case it forms a
firm sausage-shaped  mass, composed often, in  larger dogs, of
dark-grey and half-dried earth, mixed with small stones, weigh-
ing in all several pounds.

   The lesions frequently found in the brain and medulla oblongata—the hyper-
semia and oedema—are in all probability to be regarded as functional alterations, as
are also the hyperaeniic and hemorrhagic appearances observable in  the mucous
membranes of the throat and other organs of deglutition.  The form of pneumonia
produced by the presence of foreign bodies, which, possibly, is of frequent occur-
rence, though  often overlooked, is to be referred, as  in the case of mental disorders,
to a disturbance of the mechanism of deglutition.  One typical instance of this
affection I have myself observed and reported at length.1  In the case of rabid cat-
tle, Franck2 observed that  the medicines administered very readily  found their
way into the lungs.  This " foreign-body pneumonia " is also noticed in other affec-
tions of the central nervous system of dogs, in chronic hydrocephalus, for instance,
1 Virchow's Archiv fiir path. Anat., Bd. 55, p. 285, 1872.
* Wochenschrift fiir Thierheilk. und Viehzucht, 1870, p. 340.
 VOL. III. —30 
466       BOLLINGER.—INFECTION  BY  ANIMAL POISONS.

on which account its significance, especially with regard to a differential diagnosis,
is at most only a relative one.
   As to the attempt recently made by Rudnewl to refer the appearances found in
rabid  dogs to a parenchymatous  inflammation of the kidneys, and to the uraemia
produced thereby, I have already in another place (loc. cit.) demonstrated that the
fatty infiltration and degeneration of the epithelium of the uriniferous tubules, as
Rudnew designates it, is a physiological phenomenon, since the same lesion is met
with in the majority of perfectly  healthy  dogs, as  has been proved by numerous
earlier writers, who were in the habit of observing the kidneys of dogs (Frerichs,
Vulpian, and recently Parrot),  and also by chemical analysis.  Moreover, even if
recent changes of this character (cloudy swelling, granular disintegration)  occur
here and there in the kidneys (and the prevalence of these phenomena is confirmed
by recent investigations), they  are manifestly, as in the  case of  hypersemia and
oedema of the brain, the results of the disease, induced either by prolonged hunger,
or possibly by a lesion of the nerve centres  situated in the medulla oblongata, and
controlling the vessels  of  the  kidneys.  In an examination of the urine of a rabid
dog, obtained after death, I was  able to  determine the presence of a moderate
amount of albumen; under the microscope  there were also found  the elements of
semen in considerable quantity.
   Many observers describe changes  similar to those of typhus, and to those found
in anthrax, as occurring in rabid dogs;  and also regard hydrophobia as  a specific
form of typhus  fever.   According to my experience, however, no  disease prevails
among dogs which can be designated by the term typhus, and the predisposition of
these animals to malignant pustule is likewise extremely small.
   On the other hand, it remains to be determined whether the absolute deprivation
of all nourishment may not in  a measure tend to promote the rapid course of the
disease,  and possibly  contribute also  to  the  production of certain symptoms,
as phenomena similar to those seen  in rabies have been often observed in starved
dogs.

    To sum up,  then, the anatomical lesions described above, we
find  as the  most important:  a dark, thick, and tar-like condi-
tion  of the  blood;  oedema of the brain;  more   or less  pro-
nounced  catarrhal  alterations of the mucous membranes, espe-
cially of the respiratory and digestive canals, conjoined often
with  hyper aemia  and  ecchymoses;  hyperemia  and cyanotic
discoloration of the  parenchymatous organs ; an absence of the
usual contents of the stomach and intestine, and  the presence
therein  of  indigestible foreign  substances;  and,  finally, the
striking emaciation of the entire animal.
    In wild animals which have died  of hydrophobia, just as in

              1 Centralblatt fiir die med. Wissenschaft, 1871, p. 321. 
HYDROPHOBIA IN ANIMALS.
467
 cats, similar lesions are found upon post-mortem examination to
 those observed in dogs (Kochlin, Oertl, Bruckmuller).  In her-
 bivorous animals there is a complete absence of all characteristic
 changes.  In cattle the morbid appearances are often similar to
 those of the cattle plague (Adam).


                          Diagnosis.

    The diagnosis  of hydrophobia in dogs is so difficult, and,  on
 the other  hand, of such  decidedly practical  interest,  that  we
 shall be justified in entering into a somewhat detailed considera-
 tion of this point.
    In forming the diagnosis,  we should have  constantly before
 us  a picture of the disease as a whole,  and never base an opinion
 upon individual symptoms, such as the propensity to bite, which
 may be slight,  or even entirely absent.
    In general terms,  it  may be  stated  that  in  very many
 instances an accurate  diagnosis cannot be made solely from the
 symptoms  observable during life ; nor, on  the  other hand, from
 the post-mortem   appearances alone.  With few exceptions,
 however, the diagnosis may be correctly established by a study
 of the clinical and anatomical appearances taken together.
    Characteristic symptoms of  the  violent form of rabies  are:
 the very great excitement, the marked  uneasiness, the propensity
 to break away, the great disposition to bite, the peculiar bark or
 howl, the paroxysmal  occurrence of the attacks, the rapid ema-
 ciation,  the perverted appetite, the acute course, and the  uni-
 formly fatal termination  of  the  affection.   The sullen form
 of rabies, in which the violent  stage is hardly recognizable,  its
 course  being  extremely rapid,  is characterized by  the greater
 degree  of  tranquillity, the marked depression of the animals,
 the slight disposition to run away, the slight propensity to bite,
and the partial inability to do so, in consequence  of the paresis
and paralysis which rapidly  attack the lower jaw.   The next
most  characteristic symptoms, common to both forms of rabies,
are the peculiarly changed voice, the perversion of the appetite,
 the absence of all dread of water, the inevitably fatal termination 
468       BOLLINGER.—INFECTION BY ANIMAL POISONS.

after a very brief illness, and the uniformly infectious character
of the malady.
   In respect to  the  clinical diagnosis,  great difficulties  and
frequent  errors  arise, from the circumstance that  several other
diseases of dogs are accompanied by analogous symptoms.
   Symptoms resembling those  of rabies are observed  in para-
sitic enteritis, caused  by tape-worms ;' in gastro-enteritis, pro-
duced by poison  (arsenic, corrosive  sublimate, benzoic acid),
or by the presence of foreign bodies in the intestine (bones  and
pieces of  coin that have been swallowed); in intestinal  obstruc-
tions  (invagination),  caused  by the  collection of indigestible
substances in the intestine (fragments of bone);  in the case of
foreign bodies in the ear (heads of wheat, for instance, with the
beard attached); in the case of parasites in  the  nasal cavity
(pentastoma),  in the  kidneys  (large  palisade-worm),   or skin
(mange); in uraemia, induced by long-continued unnatural ali-
mentation (starving,2 feeding with substances containing no salt).
In poisoning by means of metallic preparations (the salts of cop-
per  and zinc), there are likewise produced  appearances  similar
to those  of  rabies:—constrictions  of the  pharynx, vomiting,
and  acute gastro-enteritis.
   Symptoms similar to those of hydrophobia may furthermore
be occasioned by severe pain  (toothache), by  severe  mental
disturbance (deprivation  of  their young, extreme stimulation
and  non-gratification  of the sexual appetite); also by various
functional and anatomical changes of the central nervous  sys-
tem.
   In this  connection  should be mentioned numerous  cases of
meningitis, encephalitis,  hydrocephalus, blood-poisoning (pyae-
mia, septicaemia); furthermore, the whole class of mental diseases
in dogs, which have hitherto been completely overlooked, their
  1 Tasnia Echinococcus, for instance, which is often found in large numbers.
  2 In the case of herbivorous animals (stags, for instance), symptoms similar to those
of hydrophobia may be produced by want of food. The animals then foam at the
mouth, attack each other like dogs, tear out their own hair and flesh, and bite every-
thing that they can seize hold of.  This assemblage of symptoms was formerly mis-
taken for rabies, until eventually the true cause was ascertained, the disease being sud-
denly arrested by the administration of food.  (Hering's Jahresbericht, 1856, p. 49.) 
HYDROPHOBIA IN ANIMALS.
469
 existence  not having  even  been  suspected by most  observers.
 The  dog,'  wliich as an intellectual  and  sensual being stands so
 high in  the scale,  and whose domesticated  in-door life, as  the
 companion of man, is  in certain respects directly contrary to his
 nature  as a  wild animal,  possesses a highly excitable  nervous
 system,  and  is  extremely liable to  contract nervous diseases.
 This fact is shown by the frequent occurrence  of the disorders
 falling under that head (for  instance, epilepsy, chorea,  epilepti-
 form spasms, and spasms of reflex  origin), and equally certain is
 the prevalence  among  dogs  of pure  psychoses,  such as mania
 and melancholia, unaccompanied by  any material  post-mortem
 changes  that can be detected;  and these very forms of  illness—
 having  in part  also a reflex  origin  through the causes  above
 mentioned—are   frequently confounded with hydrophobia,  and
 quoted in support of the theory of  the spontaneous origin of the
 disease, although they are in no respect  infectious.
    The fact that phenomena  analogous  to those of hydrophobia
 may be developed, as  we have  already seen, spontaneously, or
 in a reflex manner, has certainly tended  in  no small  degree to
 encourage the denial of the existence of  this specific malady.
   It was  known even to the ancients, that hydrophobia was confounded with
 other diseases, and in various authors the statement is found that a great  number of
 dogs considered to be mad  are not  really so.   This serves to  explain the reports
 that are always being circulated, of alleged  cures  produced by this and that spe-
 cific.  Greve (loc. cit., I., p. 158), a good observer, admitted that out of twenty dogs
 supposed to be rabid, scarcely two or three are really so, and this admission appears
 to be not without foundation.  According to Faber (loc. cit., p. 46), of 892 dogs
 which were brought into the veterinary institute at Vienna, suspected of being rabid,
 from 1826 to 1830, only 31  proved to be actually rabid and succumbed to the dis-
 ease, while 61 were pronounced vicious and given to biting, and on that account were
 destroyed.  Of 207 dogs pronounced (by medical men) rabid,  or suspected of being
 rabid, in Wiirtemberg, in the years 1865 and 1866,108—equivalent to 50 per cent.—
 proved to be rabid.  The difference between a professional and unprofessional diag-
 nosis seems pretty accurately expressed by these  figures.  As late even as the last
century no fewer than seven varieties of hydrophobia were accepted by some writers
   1 "The world moves by a dog's wit," is a proverb in the Zend-avesta, and while
these words have a current value only amongst certain uncultivated people, or in cer-
tain lands, yet they forcibly express the high degree of mental development and capacity
of the dog, with which few animals can compare. 
470      BOLLINGER.—INFECTION BY ANIMAL POISONS.
(Hernauld), or which two passed as incurable and five as curable.  The latter form
manifestly had their origin in diagnostic errors.

   It has been proposed to determine the diagnosis by inocula-
tion.  This process would be of very little practical utility, how-
ever, on account of the long period of incubation, and would be
valuable, moreover, only in the case of positive results.
   On the other hand, it not unfrequently happens that cases of
hydrophobia, especially when appearing sporadically, or in the
quiescent form, are not  recognized.  Cases of this character are
frequently confounded with the distemper, an extremely preva-
lent disease among dogs.
   What significance in a diagnostic point of view do the post-
mortem appearances possess %
   The difficulty of drawing definite conclusions from post-mor-
tem appearances that have, on the whole, a negative character,
renders it necessary, in order to arrive at an accurate anatomical
diagnosis, to appeal to the symptoms  observable during life.  If
these symptoms have not been noticed, as very often happens,
or, in general, if there has been no previous clinical  observation
of the  animal by a competent person, then, in accordance with
the advice of Bruckmuller, in which  I fully concur, it  will  be
best to pronounce every dog free from the disease, provided his
stomach  contain  normal ingesta, and his small intestine con-
tain chyme.  On the other hand, if the mucous membrane of the
throat, larynx, and upper  portion of the pharynx  be hyperse-
mic ; if the stomach contain indigestible foreign substances, and
if  the  mucous membrane of the organ be spotted with hemor-
rhagic  erosions,  then  the  suspicion of  hydrophobia  will  be
strengthened.
   A sure method of attaining greater accuracy in our diagnosis
consists in following up the clinical  observation of the cases
as thoroughly as possible, in order to familiarize ourselves with
the natural course of the disease, and in making a careful exam-
ination of the cadaver.
   The following  may be adduced, then, as the principal data
in determining the  diagnosis of  hydrophobia:  the previous
history of the animal;  the symptoms manifested during life; 
HYDROPHOBIA IN ANIMALS.
471
the acute and uniformly fatal course and termination ; and the
post-mortem appearances.
   Although  it must be  admitted  that a dog already diseased
may also become  rabid, a diagnosis  of  hydrophobia will, never-
theless, under all circumstances, be extremely questionable, pro-
vided some other cause of  death can  be  discovered (hydroce-
phalus, meningitis, pysemia, apoplexy,  etc.).
   With  regard to the frequent  suspicions and charges—generally perfectly
unfounded—to which veterinary surgeons are subject, when they express fears as
to the existence of a case of hydrophobia, it may be remarked that, in view of the
very weighty  responsibility devolving upon medical men, a great many wrong
diagnoses would  be of insignificant importance, when compared with the serious
results that might follow the failure to recognize a single case of genuine hydro-
phobia.  That the physician, as  guardian of the sanitary interests entrusted to his
care, is entitled in this respect to be leniently judged, will be sufficiently evident
when we consider that obstinate and unreasonable dog-owners understand very
well how to procure the lax enforcement of police  regulations designed to prevent
the spread of hydrophobia ; and that, furthermore,  the exceedingly responsible duty
of the veterinary surgeon is, as a  rule, not a little onerous.

                            Prognosis.

    Hydrophobia  in dogs, as in all other animals, is  inevitably
fatal.  There are no trustworthy  instances  of recovery upon
record,  the alleged  successful results generally having  their ori-
gin in diagnostic  errors, by wliich hydrophobia was confounded
with similar  affections.  The only favorable chance is that  de-
rived from an energetic  local treatment  of the bitten part.

                            Treatment.

    Inasmuch as  the prophylactic  measures  to  be  employed
against hydrophobia will  be  taken up in detail when we proceed
to the consideration of  the disease in the human  subject, I will
onl}r observe now, in passing, that the majority of the therapeu-
tic agents embraced in the materia medica  have been  tried thus
far to no purpose, being administered, in most  cases, prophylacti-
cally after  the  infliction  of  the bite.   Besides  cantharides and
cock-chafers,  which for  a  long while enjoyed  great repute, there 
472      BOLLINGER.—INFECTION BY ANIMAL POISONS.

have been tried, ineffectually, arsenic, prussic acid, tartar emetic,
alternating with the sulphates of copper and zinc,- not to men-
tion carbolic acid and chloral.   The latter was administered in
one case subcutaneously to  a rabid dog by Horand and Peuch1,
without effect.
   In cases where hydrophobia has broken out, every therapeu-
tic application is attended with great  difficulty and danger, and
the only rational procedure left, therefore, consists in  destroy-
ing  the  wound prophylactically by  cauterization or  excision,
thereby inducing purulent  inflammation.  Meanwhile, however,
it should be borne in mind  that upon the hairy body of the dog
small wounds and  incisions are easily overlooked, and that the
injuries inflicted by a rabid  dog are often numerous.
                    HYDROPHOBIA IN MAN.

                       Rabies—Lyssa.

   "Dogs are subject to hydrophobia, which makes them rabid ;
all animals bitten  by them likewise become rabid, with the ex-
ception of man."   If  these words of Aristotle are not interpo-
lated,—which is at  all events a disputed point,—then, hydro-
phobia, as  it occurs  in  the  human subject,  was unknown to
Aristotle, and remained so down  to the time of Celsus (about 200
B.C.).  In the writings of the latter is found for the first time
the word  hydrophobia,2 which is employed, however,  to indicate
a symptom of the disease, and  for many reasons should have
been abandoned.   Celsus recommended as a prophylactic meas-
ure the application of a cupping-glass to the wound inflicted by
a mad  dog, and also cauterization by means of a hot iron.
   At a later date  we find mention made of hydrophobia, as it
occurs in man, by Plutarch, Pliny, Dioscorides, Cselius Aureli-
anus (a.d. 300), and  others.   The last writer raised the question

  1 Du Chloral, etudes cliniques et experimentales.  Paris, 1872.
  2 The expression hydrophobia has manifestly given rise to very great confusion, and
the dread of water, erroneously ascribed to rabid animals, is without doubt due to the
fact that a symptom of rabies pecuhar  to  man was transferred, without reason, to
animals. 
HYDROPHOBIA IN  MAN.
473
whether  hydrophobia was an affection of the body  or of the
mind.  With few exceptions  (Aetius, Paul of iEgina, Avicenna,
and Actuarius), authors during many subsequent centuries only
reproduced the writings of the ancients respecting this disease ;
but at length in the fifteenth  and sixteenth centuries more trust-
worthy observations were made and reported.
   In consequence of the totally incorrect ideas which prevailed
in ancient times with regard to this most dreadful of all diseases,
the fate  of  human  beings who were  seized with hydrophobia
was  indeed appalling.    The nearest  relatives fled  from the
unfortunate patients, abandoning them to their fate, as though
they were caged wild animals.   Every  one feared to be bitten,
and fancied that, by merely coming in contact with the body,
or treading  upon the saliva,  of  a  diseased person, the  malady
might be contracted.  And even in our day there are districts
in Europe (the Military Frontier of  Austria) in which the dread
of hydrophobia—which, indeed, to  the horror of the population
and the despair of the surgeons, rages  terribly—is  so great, that
human beings who are  suffering from it, or who are  suspected
of being so affected, are shot by their neighbors, whilst those
who have been bitten by rabid animals  not unfrequently commit
suicide.

                          Etiology.

   Hydrophobia in the human subject appears in the form of an
acute infectious disease, uniformly fatal, produced only by the
implantation of a specific virus, the inoculation being  brought
about almost  without exception by the bite of a rabid animal,
most frequently that of  the dog.   An essential factor in the pro-
duction of infection is a superficial wound of the skin, or of the
external  mucous  membrane.  Of the  spontaneous development
of hydrophobia in man there  is just as little proof  as in  the case
of animals.  The disease may be transferred artificially back to
animals ; on the other hand,  infection  from man to man may be
said practically never to occur.   The period of incubation, as in
the case of animals, is extremely variable.
   By far the most frequent source of hydrophobia in man is 
474       BOLLINGER.—INFECTION BY ANIMAL POISONS.

the bite of  a rabid dog (90 per  cent.),  while the other cases are
communicated by  cats  (4 per cent.), wolves (4 per cent.), and
foxes (2 per cent.).
   Of 796 human beings who  died of hydrophobia in France, Wiirtemberg, and
Milan, 716 had been bitten by dogs} 30 by cats, 31 by wolves, 19 by foxes, and one
by a cow.  This proportion will, as a matter of course, vary according to local con-
ditions ;  thus, in less cultivated lands (Russia, Galicia, the Military Frontier) rabid
wolves prove a frequent cause of hydrophobia, whereas in the East Indies it is often
produced by rabid jackals.

   The situations of the bites upon the human  body, the points
of entrance of the specific virus, are divided as follows : '—Of 495
human beings attacked with hydrophobia, 263, equivalent  to 53
per cent., had been bitten  upon the upper extremities ;  110,  or 22
per cent., upon the head and face ; 108, or 22 per cent., upon the
feet, and 14, or 3 per cent., upon  the  body or scrotum.   As we
shall see hereafter,  the wounds upon  the face are the most dan-
gerous  ; those upon the upper and lower extremities the least so.
If a number of wounds be inflicted at the same time, the danger
of infection is thereby increased.  Large wounds are in general
less dangerous than small ones,—a fact insisted upon by Diosco-
rides as much as eighteen centuries ago—because in case of the
former the virus is more easily washed out by the flow of blood.
   That this is not always the case, is proved by an observation made by Essroger,
who reports that in December, 1863, 22 human beings were bitten by rabid wolves in
Galicia;  of these, eight, who had been severely wounded, died of rabies, and only
one who  had been slightly bitten.  Moreover, it  is to be remarked in this connec-
tion, that the  prophylactic treatment of  large wounds presents greater  difficulties
than that of small ones.

   It is not necessary, however,  for the production of  infection,
that an actual wound should be inflicted by  the bite, for a sim-
ple scaling off of the epidermis  is  quite sufficient to permit the
absorption  of the virus.
   A variety of  well-authenticated observations tend to  make it
extremely probable that dogs may, by  their bite, produce hydro-
phobia in the human subject, even during the period of incuba-

      1 According to the statements and statistics of Tardieu and Thamhayn.
      2  Oesterr. Zeitschrift fiir prakt. Heilkunde, 1864, Nos. 3 and 8. 
HYDROPHOBIA IN MAN
475
tion of the disease, as was shown at length when considering the
etiology of  rabies  in  the dog.   Infection may therefore be  pro-
duced by dogs that are apparently healthy, and for this  reason,
in practice  it is advisable  to pronounce every wound made by a
stray dog suspicious,  and to treat it accordingly.
   Although dogs may  produce  infection  by  their bite even
during the  period of  incubation, the danger of such an occur-
rence is, nevertheless, comparatively  small, inasmuch  as during
that stage there is no  disposition to bite.  The theory, frequently
advanced, that  even the bite of  a non-rabid  but enraged animal
may  induce hydrophobia, may possibly  be explained in  this
way, that the animals in question happened  to be in the stage of
incubation of rabies.    In  a similar way, dogs affected with  the
sullen form of rabies are  less dangerous,  because they are less
inclined to bite, and, moreover,  their ability  to bite is very much
impaired.   The bite of rabid wolves is the most dangerous ; then
follow those of  dogs,  foxes, cats, badgers, martens, and swine;
and, finally, as the least dangerous, the bite of rabid herbivorous
animals.
   In some cases the contagion of hydrophobia is transmitted by
an apparently healthy dog in  the act of licking, when an open
wound is licked.  That the unabraded epidermis can  in such
cases permit the absorption of  the virus, as  has  been pretended
by many writers, is as yet  hardly demonstrated, and is extremely
improbable.
   Communication of the specific poison by means of accidental
wounds inflicted at the post-mortem examination of rabid dogs,
has as yet in only one instance been satisfactorily proved.
   On February 25th, 1857, a student of the veterinary school at Copenhagen, who
had a small wound on the finger,  made the autopsy of a dog, which had died the
previous night of hydrophobia.  In April he began to experience pain in the  arm.
On April 7th he complained of a feeling of malaise and fatigue, lay down, and was
carried to the hospital, where, on the succeeding day, he died of hydrophobia.1
Oppolzer2 relates a case in which it was  doubtful whether the individual in ques-
tion was infected at the autopsy of a rabid dog, or by a bite.  Autopsies of rabid
dogs  are said  to have  been frequently conducted without ill effect, at Alfort, by
students having wounds, and although I am able to corroborate this evidence by
               1 Tidskrift for Veterinairer, B. VII., p. 276, 1859.
               *  Wiener allg. med. Zeitung, 1863, p. 83, No. 11. 
476      BOLLINGER.—INFECTION  BY ANIMAL POISONS.
my own personal experience, a certain amount of caution  should, nevertheless,
be insisted upon when the autopsy of a rabid animal is being made.

    What proportion of the entire number of human beings that
are bitten by rabid animals are infected f
   The percentage of individuals who, having received a suspi-
cious bite, become ill and die of hydrophobia,  depends really
upon the accuracy of the diagnosis of rabies as occurring in the
dog, and whether we  take into consideration only the bites of
animals decidedly rabid, or whether we include the bites of ani-
mals suspected of being mad ; and  finally, whether a prophy-
lactic treatment (cauterization) of the wound has been resorted
to, and if  so, within what length of time.  If, bearing  the above
conditions in mind, an accurate computation be made, it will be
found that of the human beings bitten by rabid dogs, about 47
per cent,  die  of hydrophobia.   Out of 855 human beings  thus
bitten, 299 (or nearly one-half) cases ended  fatally.1  But  if we
include also the bites of dogs suspected of being rabid, then the
proportion becomes decidedly more favorable, 8 per cent,  only
of those bitten becoming ill and  dying.   Out of  1,362 human
beings that had been bitten by rabid dogs, and dogs suspected of
being rabid, there occurred 105 fatal cases.   If the wound is pro-
perly cauterized, the  number of  human beings attacked  with
hydrophobia amounts to 33 per cent, of the whole number bitten;
where, on the other hand, cauterization is not resorted  to, it
amounts to 83 per cent.
   The above explanation will enable us to reconcile the conflict-
ing statements of different writers.  Thus,  Oppolzer admitted
that, upon the average,  one-half of those bitten were taken ill
and died of hydrophobia, while Renault affirmed that the pro-
portion was  only  33  per cent., and Hunter declared it to  be 5
per cent.
   How great  an influence is exerted upon the final result by
individual predisposition, or  by those  factors which are  acci-
dentally brought  into play at the  time of the bite (clothing,
deposit of the saliva upon  the garments, the extent ox' the hem-
orrhage), it is  difficult to determine.
1 According to statements and statistics of Tardieu, Thamhayn, and Bouley. 
HYDROPHOBIA IN MAN.
477'
    When several individuals are wounded by the same  rabid
 dog,  and one of them is attacked with hydrophobia, while the
 others remain unaffected, it does not necessarily follow that this
 is  the result of individual predisposition ; the immunity from
 infection may possibly be produced by one of  the accidental fac-
 tors above mentioned.   This view is entirely  in accord with the
 following experience, drawn, however, it must be admitted, from
 a moderate number of cases.  Of those bitten in the  face—this
 being an unprotected portion of the body—fatal  hydrophobia
 results in 90  per cent. ; in  those bitten upon the hands, the pro-
 portion of those who sicken and die is 63 per cent. ; in the case
 of  numerous wounds  upon the body, 63 per  cent. ; in wounds
 upon  the lower  extremities,  28 per  cent. ;  upon  the  upper
 extremities, 20 per cent.
    It appears to me, therefore, unreasonable  to deny altogether
 the influence of predisposition in the human subject (Oppolzer),
 on  the ground that  there is no gradation of the power of resist-
 ance  to the  poison, as  shown by the fact that neither milder
 nor severer forms of the disease occur, all cases running a simi-
 larly fatal course.  This argument can hardly be maintained in
 the face of our  knowledge of hydrophobia in  the dog, and the
 results of experimental researches that  are upon record (especi-
 ally those of  Hertwig), for in  the case of dogs, also, there is no
 gradation of  the resistance to the poison; no different grades in
 the disease have been known to occur, but all cases  terminate
 fatally ; and  yet it has been proved beyond a doubt that there
 exists in  dogs a very considerable resistance to, or affinity for,
 hydrophobia.
   With  respect to  the  sex, males compose 60 per cent, of the
 entire number of those attacked with hydrophobia,  while  fe-
males form 40 per cent.1  Age  exerts no appreciable  influence
 upon the deaths  from  this disease, the  youngest and  oldest
 succumbing  alike.    In  195 fatal  cases of  hydrophobia,  the
ages of the patients were  divided, according  to Thomhayn, as
follows :
  1 Of 2,021 individuals dying from hydrophobia, 1,218 were men, and 803 were
women. 
478       BOLLINGER.—INFECTION BY ANIMAL  POISONS.

                  12 between  3 and  5 years.
                  27    '       5 and 10   "
                  62    "    10 and 20   "
                  49    "    20 and 40   "
                  36    "    40 and 60   "
                   9    "    60 and over.

   As to  the influence exerted by the different seasons  with
respect to the prevalence  of the malady in the  human  subject,
this  differs in no respect from  that manifested in the dog,  and
the  reader is therefore referred to what has  already been  said
upon the subject.   If hydrophobia in the human subject  also
prevails more extensively in the warm months, as appears to be
the case, this may be attributable to the fact  that the dogs are
better able to rove about and come together at that time than in
the cold season.
   The consumption of the meat  and  milk  of rabid  animals
(the  dog,  fox, ruminating  animals,  and swine), according to
numerous observations, produces no  injurious effects whatever
upon man, a fact wliich harmonizes fully with  the results of the
numerous food experiments previously referred to, which Hert-
wig conducted upon dogs with uniformly negative results.
   That the meat of animals dying from hydrophobia is not in itself  injurious, but
produces at most only a psychical effect upon those consuming it, is proved by the
following experiment of Decroix.1 He consumed a piece of roasted meat, taken from
a dog which had died of hydrophobia, and afterwards he also ate a small piece (of
the size of a nut) of the raw meat—six hours after the death of the animal.   After
having read, however, of  the experiments  undertaken by Gohier, in which a dog
had become infected by devouring the meat  of another rabid dog, while two
other  dogs had contracted the disease  by devouring the meat of a rabid  sheep,
Decroix exper'?nced a sensation  of enlargement of the upper portion of the  phar-
ynx, difficulty in swallowing, weakness of the voice, disturbed sleep,  and  other
symptoms, which, however, rapidly disappeared.

   There are contained in the  works  of  the older writers a few
cases of  communication of hydrophobia from one human being
to another, the trustworthiness of which, however,  is more than
questionable.  Such infections are said to have been  produced,
1 Recueil de med. veter., 1864, p. 171. 
HYDROPHOBIA IN  MAN.
479
for instance, by sexual congress.   Equally doubtful is it whether
any reliable cases are known in which human beings  suffering
from hydrophobia have communicated the disease by their bite,
although, in view of the successful attempts at retro-inoculation
from men to animals, the possibility of that mode  of  infection
cannot be denied.  Attempts * of  this sort have been made with
positive results by Busnout, Berndt, Loftier, Magendie, and
Breschet, while numerous  similar experiments  have  resulted
negatively (those of Pillwax, for instance).
    There remain finally to  be considered certain views concern-
ing the nature and mode of  origin of  hydrophobia, as occurring
in man, which differ essentially from those already referred to.
    The hypothesis  that  the disease, when  developed  in the
human subject, is simply an affection of the nerves,  which may
be induced  by anxiety and excitement, brought on by apprehen-
sions of the formidable malady,  and that accordingly there is no
specific virus of hydrophobia, is disproved  by the fact that chil-
dren  under five  years of age, and even under two years, whose
imaginations surely cannot be affected by dread of hydrophobia,
are likewise attacked by this disease.
   Of  three hundred and nineteen persons who died  of hydrophobia in France,
from 1850 to 1862, more than thirty, or nine per cent., were under five years of age.
To the experiments of Decroix, above related, designed to illustrate the effect of
eating the meat of rabid animals, should be appended a similar incident.2 A num-
ber of persons who had partaken of the meat of a cow that had  died of hydropho-
bia, were taken ill after being informed that the animal in question had been rabid.
Their illness was confined, however,  to vomiting, nausea, etc.

   As for the old and periodically  renewed theory,3 which regards.
the existence of hydrophobia in man as simply a myth,  the most
that can be said in  its defence is, that  appearances analogous
to those of hydrophobia may also, under certain conditions, be
developed spontaneously, as purely mental affections, or as con-
comitant symptoms of hysteria,   hypochondria,  etc.  In  very
many cases  of this character it is difficult, and almost  impossible,

   1 Faber, loc. cit., p. 284.
  2 Journal de Med. veter., 1854, T.  X., p. 379.
  3 Lorinser, loc. cit. ; Maschka, Prager vierteljahrschrift fiir wiss. Heilkunde, B. III.,
p. 1, 1871. 
480      BOLLINGER.—INFECTION BY ANIMAL POISONS.

however, to exclude for a certainty the idea of an antecedent bite
from a mad animal.
   It  has been affirmed by many more recent psychologists (L.
Meyer,1 Christian,2 Westphal, and  Skrzcecka),3 that hydropho-
bia occurs as a  symptom  in various  diseases.   To this class
belongs a peculiar variety of violent hydrophobia,  a genuine dis-
order of the intellectual functions,  a kind of hypochondriacal
delirium,  which  often occurs in persons so predisposed, and
is  occasioned by fear  of  becoming  mad—lyssophobia.   Under
certain  circumstances,  upon the accession of congestion  of  the
brain, this may  become fatal, and  confers upon the disease a
very strong resemblance to acute delirium.  Cases of this kind
are often erroneously  designated as spontaneous  hydrophobia.
although  they have  no  connection with  the genuine  lyssa
humana.   The question of the spontaneous origin of hydropho-
bia in man we will not include  in  the list  of our subjects for
discussion, having already denied emphatically, with regard to
dogs,  the idea of this mode of origin.
   According  to another view, hydrophobia in man represents a
simple neurosis,  a traumatic tetanus proceeding from the bite.
Rose (loc. cit., p. 79) has adduced proof, supported  by personal
observations, that there exists no resemblance between a severe
case of  rabies and acute tetanus ; he describes in detail the diag-
nostic points of difference.   "In traumatic tetanus a continuous
spasm is present,  to which there is finally added an increased
reflex excitability ; consciousness remains clear until the  death
struggle ; the organs involved in the act of swallowing are gener-
ally unaffected ; the tetanic spasm begins in the masseter mus-
cles and in those of the cervical region ; the disease is fatal only
when it breaks out within a few weeks after the injury.  In
rabies, on the other hand, clonic  convulsions  occur;  reflex con-
vulsions are  noticeable from the outset; loss of  consciousness
often ensues at an early stage; the masseter muscles and those of
the neck are  not affected  by the spasms; the disease makes its
appearance after a period of incubation lasting often for months ;
         1 Virchow's Archiv, B. IX., p. 98.
         8 Gazette des Hopitaux, 1869, No. 50.
         3 Archiv f. Psychiatrie u. Nervenkrankh., B. II., p. 520, 1870. 
HYDROPHOBIA IN MAN.
481
its course is uniformly acute ;  its termination fatal; its promi-
nent feature consists of  an affection of the organs involved  in
the process of deglutition/,  Rose further describes a rare form
of  tetanus, which in a more advanced stage presents a perfect
picture  of  hydrophobia, the tetanus  of  the head,  or  tetanus
hydrophobics.  This affection is a peculiar form of tetanus,  in
which the wound is invariably situated in the immediate vicinity
of  the cerebral nerves, and is  frequently accompanied  by con-
vulsions of the muscles supplied by those nerves, especially the
muscles of deglutition.   These cases,  according  to  Rose, have
manifestly given rise to the notion of the identity of tetanus and
hydrophobia.

                          PATHOLOGY.

       Frequency of Hydrophobia in the Human Subject.

    The  frequency  of  hydrophobia in  man depends  upon the
extent of its prevalence among animals.
    The number of human lives sacrificed yearly to this disease
may be appreciated from  the following figures :
    In Prussia there occur annually, taking  an average of fifteen
years (1820-1834), seventy-one  deaths from rabies ;—in Austria,
average  of  eighteen years (1830-1847),  fifty-eight deaths annu-
ally ;  in France, average  of   twelve  years  (1850-1862),  from
twenty-four to twenty-five  cases annually ; in Bavaria,  average
of four years (1864-1867),  hydrophobia causes from seventeen to
eighteen deaths annually.
    Although the annual number  of cases of  hydrophobia in
France is estimated by Boudin at two for every million of inhab-
itants, in Bavaria the annual number amounts to  four in every
million.
   The question whether the rabies of dogs, like other animal diseases, may have
been disseminated more extensively by the increased communication of men with
each other, is worthy of  a more thorough investigation, but cannot be accurately
answered from the data now at hand.  It is my own belief that the increased facili-
ties  for  intercourse tend to facilitate the propagation  of the disease, as I have
already endeavored to show when  treating of canine rabies.  This circumstance is
perhaps  compensated for, however, by the improved sanitary police regulations for
          VOL. III.—31 
482      BOLLINGER.—INFECTION BY ANIMAL POISONS.
checking the disease, and the energetic administration of these measures.  It is
important in this connection, however, to consider in our estimate the variation in
the number of dogs in a given locality, and similar factors.

                          Incubation.

   The  period of  incubation  of hydrophobia in  man  varies
extremely  in length.  The duration of this period varies,  in six
per cent, of all cases, between three and eighteen days ; in  60 per
cent, between eighteen and sixty-four days, while  in 34 per cent.
this stage exceeds sixty days.1
   While this period is seldom less than fourteen  days, it  is fre-
quently protracted to from three to six months, and in extremely
rare cases  to two years  and more.   It is extremely improbable
that this stage is ever extended to  five and one-half, to seven
(Schuh), or to from ten to twelve years (Chabert),  and the latter
statement  especially should obviously  be regarded  as purely
mythical.
   In the  young the period  of incubation is, on the whole,
shorter  than  in the old.  In one hundred and sixty-six cases2 of
hydrophobia  in the human subject, the period  of  incubation
lasted, on  the average, in individuals between the ages of three
and twenty years, forty-four days ;  in those between the ages of
twenty  and seventy-two years, seventy-five days.
   During  the stage of incubation the persons bitten feel for the
most part  quite well, giving no evidence by any symptom that
the germ  of  so appalling a disease lies dormant within  them.
According  to Fuchs (loc.  cit.), the  wounds, being generally in-
significant, heal kindly with or without treatment.  Many observ-
ers have affirmed  that  these  wounds  are characterized  by  a
striking absence of inflammatory reaction,  on which account
they are often kept open only with great difficulty.   Even after
the application of strong caustics, the wounds produced by the
bites of rabid animals are said to manifest  a strong tendency to
skin over  without granulating.  The subsequent inflammatory
1 According to the statistics of Hamilton and Thamhayn.
3 Bouley, Comptes rendus de l'acad., LXX., No. 14, 1870. 
HYDROPHOBIA IN MAN.
483
reaction is generally slight, while the pain thereby proauced is
likewise for the most part moderate.
   Touching the scar is said  to produce pecuhar sensations—
a shuddering, feeling of anxiety, and sighing.

                       Symptomatology.

   1. Premonitory Stage, Prodromic Stage, Melancholic Stage.
   After the expiration of the period of incubation in hydropho-
bia,  a variety of precursory symptoms  supervene, which, how-
ever, are often only in a slight  degree characteristic, inasmuch as
they may in like manner accompany other diseases.
   The wound  at  the outset  of  the disease is generally cica-
trized ; the scar usually presents a  normal appearance, and only
in exceptional cases appears inflamed  and swollen, and of a
reddish or bluish hue.  Tearing pains often proceed from  the
wounded parts, and they are frequently attributed by the patients
to the  effects of a  cold, and  to rheumatism thereby  induced.
Peculiar sensations are frequently experienced at the seat of  the
bite  or in the adjacent parts ;—either a sensation of prickling,
or a  boring, pricking, or burning feeling, always  proceeding from
the wound.
   It is often asserted that  there are accidental causes which
hasten  the outbreak  of  the  disease, such as  an outburst of
passion, taking  cold,  or  excesses of various  kinds.   Mean-
while, the  majority of patients have no  adequate conception of
the real origin of their malady ; not even when their attention is
directed, by questions put to them, to the possibility of an infec-
tion  with  hydrophobia ; they then affirm in decided  terms that
the scar is of no  significance whatever, and that it causes them
no pain.
   In other cases the patients  evince various symptoms of con-
stitutional disturbance, complaining  of a want  of appetite and
of headache ; very soon they relapse  into a state of depression
and gloomy agitation; they are ill-natured, apprehensive, excita-
ble, and are seized with a  mental disquietude, by which they
are driven incessantly about without any definite aim.  This agi-
tation often increases  to an indescribable  feeling of  anxiety, 
484      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

especially when they know that they have been  bitten.   In the
latter case, they endeavor to  contend against this idea, and try
to convince themselves and others that  the  bite cannot  be the
cause  of  their  trouble; and in  many  instances they  do  not
hesitate to deny with great obstinacy that they have ever been
bitten.
   Almost all  patients, however,  appreciate  even in this stage
the formidable character of the disease, and speak frequently,
with a remarkably quick and sharp articulation,  of the impend-
ing unfavorable result.   They suffer now  from insomnia,  or
else their  sleep  is extremely restless, and disturbed by  fearful
dreams.
   A not uncommon, and pretty significant symptom is the aver-
sion to fluids, and the great sensitiveness to every breath of air
and reflection of light.  In this stage, moreover, there is  notice-
able at times a trouble in the throat, a  difficulty in  speaking,
spasmodic contractions upon the attempt to drink, slight diffi-
culty in swallowing, and,  together with the  dread of fluids, an
intense thirst.  As indicative of the obstructed respiration, there
may be heard a frequent sighing and sobbing ; if the patient is
lying in bed, there is often noticeable an unnatural contraction
and tossing about of the limbs.   Headache is complained of,
sensations of convulsive action in  different parts, distress at the
epigastrium,  heaviness of the limbs,  and general prostration.
The interior of the throat will often be found upon examination
to be reddened.
   If  the mental anxiety is great,  the pupils  are, in some cases,
dilated, while the face and conjunctivae are injected.  The pulse
is usually slightly accelerated and hard, being more  frequently
small than full.
   The appearances  on the part of the  digestive apparatus are
extremely variable,  and rather of an  accidental character.   In
addition to the want of appetite  and excessive thirst, there are
sometimes  observed vomiting  and  frequently constipation.
There is no loss of consciousness ; nor are the intellectual facul-
ties in any way impaired.
   It  should be remarked that these appearances are more or
less inconstant, and when the precursory  symptoms are absent,— 
HYDROPHOBIA IN MAN,
485
when the disease breaks out of a sudden in all its severity—then
the inability to drink is the first symptom.
   To recapitulate the initiatory symptoms above described, it is
noticeable that the local neuralgia  generally has the peculiarity
of shooting out from the bitten part towards the trunk, less fre-
quently extending outward from the sensorium, or appearing in
some locality other  than the part injured.  There are to be
found, moreover, as precursory signs, in the majority of cases,
uneasiness,  anxiety, a changed disposition, gloomy forebodings,
and a  sensation of creeping and pain in the  scar.  As less
characteristic symptoms, may be mentioned  a feeling of prostra-
tion,  insomnia, want of appetite,  headache, and  rarely a slight
fever.
   The duration  of  the prodromic stage is generally not  more
than twenty-four hours; very rarely, it is  extended  to two or
three days,  or even longer.

         II.  Stage of Excitement—Hydrophobic Stage.

    It occasionally happens in the human subject, and often in
the case of dogs,  that the disease  begins without being ushered
in by  any  precursory signs.   The patients are then  suddenly
seized with  convulsions  of a paroxysmal character, which are
brought on by the attempt to drink water, by a sudden fright,
or by any agitation.
   The above described symptoms of  oppression in  the throat
and difficulty in swallowing will, as a rule, be found to have pre-
ceded the severer phenomena; at  other times  the patients first
complain of an oppression in breathing, before a pretty severe
suffocative attack occurs, induced by spasmodic contractions of
the respiratory muscles, combined usually with alarming  spas-
modic constrictions  of the pharynx, and at this time surgical
assistance is often for the first time summoned.  Both forms of
convulsions are pathognomonic, and there results therefrom the
dread of water, the patient experiencing thirst and desiring to
drink, but being prevented from doing so by the spasmodic con-
striction of the throat.
   From this time on, all further attempts to drink are avoided, 
486      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

the patient preferring to endure  the most intense thirst.  The
mere  sight of a drinking vessel containing water is intolerable ;
the patient will turn away his face, shriek out loud, beckon anx-
iously with the hands to have the water removed, for voice and
breath fail him.  The mere thought of  fluids, of drinking, or of
swallowing, or the  offer of anything to  drink,  is sufficient  to
bring on the convulsions, and the same  effect  is produced by
other sources of irritation, such as a simple breath of air, the
attempt to touch him, every hurried approach towards him, the
sight of shining objects.
   During these attacks the expression  of the face indicates
great anxiety and  alarm ; the muscles  of  the neck and breast,
and frequently the  entire muscular system, contract spasmodi-
cally ;  a convulsive trembling of the limbs is  noticed, and  in
rare cases opisthotonos ensues.
   Meanwhile the patient suffers from great distress in the pre-
cordial  region,  and  dyspnoea;  he has  a disturbed look,  is
greatly excited, and is disposed to be  extremely  talkative,
but is  not delirious.  As the malady progresses, these convul-
sive attacks are repeated, and  are conjoined with an exalted
state of the sense of  smell,  taste,  and touch,  and with a feeling
of anxiety and a fear of being  alone.
   This excessive hyperoesthesia is manifestly the cause of the
aerophobia, in consequence of which even a current of air, a
bright light, the sight of any shining object, the slightest  touch,
and even conversation in the vicinity of the  patient may throw
him into a most violent agitation, and  bring on severe convul-
sions.
   In consequence of the dyspnoea, a sighing and groaning res-
piration is often to be heard, or  there are emitted before and
after,  as  well  as  during, the  paroxysms,  shrill,  inarticulate
sounds.  The latter are either  the expression of  utmost despair,
or they may  be occasioned by violent expirations;  they fre-
quently give rise to the idea that the patient utters a  sound
like a bark, after the manner of dogs.
   The local sensations of pain, experienced in the wound dur-
ing the prodromic stage, still continue, often even in an increased
degree, but are now scarcely heeded.  As the disease progresses, 
HYDROPHOBIA IN MAN.
487
the convulsive attacks increase constantly in severity, while the
intervals, which afford rest at least for a brief space of time,
become shorter and shorter.
   The feeling of suffocation, and the hallucinations which often
supervene, produce in the patient the most intense anxiety ; and
at times we may see this excitability and restlessness aggravated
to such a pitch that the paroxysms appear like maniacal attacks
accompanied by delirium.  These  attacks come on usually at
the height of the disease, and the fury of the patient is then
for the most part vented upon those about him.  The surgeons
and attendants are charged with having been the cause  of his
misfortune, and,  when  they approach  him, are struck and
insulted.   Such attacks do not  usually last long, and  subse-
quently the patient will often evince great regret at his  beha-
vior, making earnest  apology, and warning from  time  to time
those about him not to allow him to bite them.  At times, dur-
ing the phrensical fits, snapping motions are made  with the jaw,
of an  involuntary and spasmodic character, and  bearing some
resemblance to the motions of biting.
   The general  muscular  contractions  appear  with variable
degrees of intensity, from the slightest  convulsions to  those of
the most severe and  clonic form, while frequently tetanic con-
vulsions are observed.
   Although,  during  these convulsions, mental  illusions and
hallucinations often occur, in the intervals,  consciousness and
the mental faculties are for the most part retained.  In addition
to the symptoms  above mentioned, it may be noticed that, dur-
ing these tranquil  intervals, the patient responds correctly to
questions put to him, recognizing those  around him, and, with
a presentiment of impending death, begs them to pray for him,
and not to leave him alone.
   The saliva, which is now secreted in increased  quantity, can
no  longer be swallowed, and salivation is therefore  induced,
the saliva being ejected by the patient in all directions.
   It often happens  that all the  symptoms  become quickly
aggravated, and death takes place of  a sudden, preceded by a
striking  amelioration in  the  condition  of the patient, and at
times even after  the  ability to drink  has been restored.  The 
488      BOLLINGER.—INFECTION BY ANIMAL POISONS.

fatal result may, on the other hand, occur in the midst of a par-
oxysm, through apoplexy or asphyxia.
   Those cases  are very exceptional, in which there can  cnly be
detected the symptoms of a simple affection of the throat, con-
joined with a state of extreme excitement.

             Analysis of the Different Symptoms.

   It is evident that the most important of all the morbid symp-
toms  evinced by man in cases  of  hydrophobia are, first, the
peculiar spasms of the muscles of deglutition and respiration,
which make their appearance especially when water is offered
—hydrophobia—or are  induced  by a draught  of air, or by the
opening or closing of a door—aerophobia.
   The duration of the hydrophobic paroxysms is variable ; the
spasms are  generally short, and rarely continue  longer than
from one-half to three-quarters of an hour.  They come on for
the most part suddenly.  There are observed during the attack,
in addition to the symptoms  already alluded  to, muscular
twitchings, a flow of saliva from the mouth, and a restless toss-
ing about.  The quiet intervals are likewise of variable length,
at some times being very brief, and hardly observable, at others,
prolonged to several hours.
   The intensity of the paroxysms is  materially influenced by
the sex, age  and individuality of the patient, and by the mode
of treatment.
   In the case of females, and also of children, the attacks run
a milder course.  The patients can be quieted in a remarkably
short  space  of time,  especially  in the  beginning, if  a calm,
friendly tone be used, while the exaltation is increased more and
more if the conduct of those about them be agitated, or if force
be resorted to.
   In rare instances, the paroxysms are completely absent, as
in the sullen form of rabies in  dogs.   In their place  is then
observed dyspnoea, and deep sighing upon the  attempt to  swal-
low ;  or, at  other times, the patient complains merely of great
anxiety and obstructed respiration, and it is only shortly before
death that a few paroxysms  set in. 
HYDROPHOBIA IN MAN.
489
   The  accidental causes of the paroxysms  are :  the attempt
to drink,  the sight of fluids,  the hearing of noises—such, for
instance, as  are  produced by  pouring out fluids—or the mere
idea of these things.  There is experienced in consequence a feel-
ing  of  extreme  anxiety;  and the paroxysms which rapidly
ensue, combined with a feeling of suffocation, almost produce
strangulation.
   In exceptional  cases,  the patient  is able  to  swallow fluids
during  the entire  course of the  disease,  although  the  act  is
accompanied by pain.  It often happens  that  he succeeds in
drinking,  after those who were  around  him have retired, or when
the attempt to drink is made with closed eyes, and with the aid
of a straw.   Warm drinks, such as milk, soups, and also wine,
are often  more easily taken than water.  In the  greater number
of cases, however, there exists  an absolute impossibility to swal-
low  anything;  and whenever the attempt  is  made, the attacks
of suffocation,  and the spasms  of  the respiratory muscles, as
well as of the muscles of the face, the neck, and the rest of the
body, return, together with great mental disturbance.
   In like manner there is an inability  to take solid food, or else
this is consumed with the greatest difficult}1'.   Attempts  to eat
generally give rise to convulsions.  There are exceptional cases,
however, in which food can be swallowed without difficulty.
   The spasms appearing during the paroxysms partake  of the
character of reflex spasms.  Their proximate causes are attempts
to swallow, speaking, coming  in  contact with another person,
the sight  or idea of fluids,  a bright light, the sight of shining
objects  or  of some  strange  person, a loud noise,  and  strong
odors.
   The spasms  of the individual muscles, as well as of the mus-
cular system in general, partake usually of a clonic character.
There are  rarely observed  tetanic convulsions, and a decided
tetanus or trismus has never been known to occur.
   In the  intervals between the attacks, the intellectual faculties
and  consciousness remain, as a rule, unimpaired.   Those about
the patient are recognized, and  questions put to  him are cor-
rectly  answered.   On  the  other hand, the  tone of the voice
is at this time very much suppressed ;  the patient  is extremely 
490      BOLLINGER.—INFECTION BY ANIMAL POISONS.

apprehensive,  or disturbed  and talkative, suffering constantly
from insomnia, except when narcotics are successful in produc-
ing sleep of shorter or longer duration.
   It is not uncommon to meet with  cases, in which there is an
impairment of the intellectual faculties, together with delirium
and hallucinations affecting the different organs of sense.   Many
patients  fancy that they see  objects,  animals,  and men that
are not present; others believe that  they are reduced to their
present wretched condition by the instrumentality of those about
them, or they imagine that they are being abused, and energeti-
cally defend  themselves against attacks and insults,  which  in
reality are but the products of their own fancy.
   In this way it may happen  that a patient will  fancy that he
is being blown at  by several  persons, some of whom are not
present; another will complain bitterly  that a  fire  has been
lighted, and that the stove is  smoking, although there is no fire
whatever in the stove ;  a third will continually direct a window
to be closed, which is not open.
   The patient's range of  ideas is often extremely limited, and if
left  to  himself he will  occupy himself continuously with the
same things,  bringing frequently forward the same ideas within
a short space  of time,  and always in the same manner.   His
speech is labored, short, and pathetic.
   The  maniacal attacks, which are often observed, are in many
instances attributable in part  to  the treatment of  the patient
(to attempts to fasten  him with chains, for instance),  at other
times they are merely the expression and result of horrible anx-
iety, and great distress  occasioned by the feeling of suffocation.
In like  manner, the attempts to bite, which  are  now and then
made, are merely actions of despair.
   The  expression  of the face is  quite variable; the reddened
countenance often  exhibits  the reflections of the  utmost mental
and physical  misery, of most horrible agony.   The eyes  are
wild, rolling,  staring, and  livid ;  or the  entire  complexion is
pallid and cyanotic, and  the expression stupid.   The  globes of
the  eyes  are  generally  injected,  the pupils dilated, and  the
retina in the highest degree sensible to impressions of light.
   The pulse,  which at the outset is usually full, moderately 
HYDROPHOBIA IN MAN.
491
strong,  and rarely accelerated, becomes gradually weaker and
quicker, especially after the paroxysms (120-180 beats to the
minute); it is frequently irregular, becoming variable in its rate,
and  this variation- takes place, moreover,  with great rapidity.
As death approaches, the pulse becomes constantly more rapid
and smaller, until at length it is thread-like, and finally can no
longer be felt.
   The temperature of the body is usually but slightly elevated,
the  thermometer  indicating 100.4° Fahr.   It seldom  rises to
105° or 106° Fahr., and is, moreover, quite difficult to  determine,
on account of the great restlessness of the patient, and can rarely
be made out with accuracy.
   The  skin is generally moist, and even covered with perspira-
tion,  but during  the paroxysms  the extremities are cool and
livid.
   Respiration is, as a  rule,  normal during the  intervals, but
during the paroxysms it is gasping, irregular, and usually quite
rapid, being often accompanied by  decided dyspnoea.   These
convulsive respirations,  which  during the  paroxysm  play so
important a part, are similar to those produced by the  sudden
application of a cold-water bath, and  are regularly accompanied
by spasms  in the muscles of the throat.  These forms of  convul-
sions may either come  on together, or those affecting the respi-
ratory apparatus may precede those of the throat.
   A viscid, thick discharge from the mouth may  always be
observed a short time before death.  On  the other hand,  when
the disease is fully developed, a  profuse discharge of  saliva is
almost constant.   The salivary, as well as the lachrymal glands,
evince an increased activity, and the copious secretion of saliva,
wliich, in consequence of the  disturbance in the  mechanism of
the throat, cannot be  swallowed, is incessantly ejected,  the
quieter patients expectorating into vessels provided for  the pur-
pose, or upon an indicated  spot, while by the more excited ones
it is  discharged  upon all  sides.  The ejected saliva is frothy,
slimy, and ropy.  It  seldom  happens that  froth is observed
around  the outside of the mouth.
   The  thirst is  always very much  increased, and the patient
complains  of burning pains in the throat.  The appetite remains 
492      BOLLINGER.—INFECTION BY ANIMAL POISONS.

frequently unaffected ;  but, owing to the extreme  solicitude of
the patient, it is commonly suppressed.   The tongue is usually
moist and clean; frequently it is  slightly coated, more seldom
dry and thickly coated.  Less constant symptoms are : convul-
sive  eructations, nausea, vomiting of a foamy, mucous,  dark-
colored substance resembling coffee-grounds.   Constipation is
generally  observed, and a dejection is only obtained after ene-
mata or laxatives have been administered.
   The quantity of urine secreted, in consequence  of  the small
amount of fluids taken into the stomach, is very scanty.  The
urine never contains albumen, has a dark-colored, cloudy appear-
ance, and frequently contains  a pretty large amount of sugar,
evidently the result of lesions in the medulla oblongata.
   We see, therefore, that the second stage of hydrophobia is
chiefly characterized by the spasmodic character and violence
of the symptoms.  Especially prominent  are the severe spasms
affecting  the  organs  of respiration  and deglutition, induced
by different  irritative  causes,  especially  the attempt to swal-
low, the  sight of fluids,  and  the hydrophobia thereby created.
With these symptoms are usually associated general clonic con-
vulsions,  and  less frequently tetanic  convulsions,—all of reflex
origin.   Finally, an anxious  expression  is depicted  upon the
face, and there is distress in the precordial region, together with
a  copious discharge from the mouth; the sensorium,  however,
commonly remains unaffected  in the intervals, while the parox-
ysms often approach in intensity to maniacal fits.
   The duration of this stage is generally from one and  a half
to three days, seldom as short as one day, or  as long as four
days.

      III. Stage of Paralysis—Stadium  Paralyticum.

   The last stage of hydrophobia, as it occurs in the human sub-
ject, is often of such  short  duration as to suggest a  doubt
whether it really forms  a distinct  period  in the progress  of the
malady.
   The fatal termination may ensue very shortly after the acces-
sion of the severe hydrophobic paroxysms, in which case the 
                   HYDROPHOBIA IN MAN.                 493

death agony lasts at most from one-quarter to one-half of an
hour ; less frequently death may take place suddenly, and dur-
ing one of the convulsions.
   It usually happens that death  is preceded by a stage of
general paralysis, the  most important features of  which are an
abatement of all the more distressing symptoms, a freer respira-
tion, a diminution in the reflex excitability, less impediment to
deglutition, a rapidly increasing debility and prostration.
   The  transition from the preceding stage is often quite grad-
ual ; the convulsions become feebler and cease entirely—possibly
from lack  of vital energy—or they may burst forth  afresh in
full strength, to terminate in a complete collapse.
   In this period of complete tranquillity, during which twitch-
ings of the muscles are often seen throughout the entire body,
the pupils are usually contracted, or they may be of unequal
size, the eye is fixed, and strabismus frequently appears.  Pria-
pism, accompanied by frequent seminal emissions, is more rarely
observed.
   The  saliva is no  longer ejected, but runs  from  the  open
mouth.    The voice becomes  harsh and weak,  the  breathing
accelerated and rattling, the pulse very small, irregular and very
rapid.   The skin is covered with a clammy sweat.
   The  subjective condition of the patients can hardly be  said
to be improved, notwithstanding the remission of the severe
symptoms and the apparent  amelioration, the majority being
oppressed with forebodings of  impending death.  Consciousness
is not generally impaired until a short time before death.
   Many patients are again enabled  to drink large quantities of
water without difficulty, and this was considered  of old to  be a
certain sign of death.   Death itself may take place amid convul-
sions or  from asphyxia.   It may also approach quietly,  seldom
with symptoms of coma or suffocation.
   This last stage of hydrophobia is the shortest, and lasts, as a
rule, only from two to eighteen hours.

                 Duration  and  Termination.

   Rabies  in  men lasts, in the greater  number of cases, from 
494      BOLLINGER.—INFECTION BY  ANIMAL POISONS.

two  to four days  (in 82  per cent.);  in rare  instances, from
twelve  to  twenty-four  or  forty-eight  hours;  while in  still
more exceptional cases it may  be protracted  to six days and
over.

   Of the total  number of those dying from hydrophobia, 9 per cent, die upon the
first day, 36 per cent, upon the second day, and 14 per cent, upon the third day ; in
other words, then, 59 per cent, die upon the three first days.  The shortest dmit of
the disease is from twelve to sixteen hours.  Instances in which death occurred two
hours after the outburst of the disease must be classed, to say the least, among the
greatest rarities.

   The uniform termination  of  hydrophobia is death.   As will
appear later, when we come to the consideration of the progno-
sis, the cases reported to have terminated favorably will readily
admit of a different  explanation, the alleged cures being in all
probability based upon  diagnostic  errors.  Alleged  recoveries,
therefore, whether occurring spontaneously or brought about by
means of artificial assistance, are, in the present state of  our
knowledge, to be designated as very questionable.
   In concluding our description of the clinical characteristics of
hydrophobia in man, it should  be distinctly stated  that  the
complicated  phenomena of the malady are not to be attributed
exclusively to the action of the specific virus.  However certain
it  may be that  the  mental disturbance and  the anxiety of  the
patients  at the  appearance  of  certain symptoms  exert a great
influence upon the severity of the phenomena,—admitting even
the existence of a genuine lyssophobia,—yet it will not do to
go in  this  respect  too far, and we  are therefore bound to char-
acterize as erroneous  the  idea  that hydrophobic children, who
are  unacquainted with  the effects and result of  the malady,
may go through the disease without being attacked by convul-
sions or mania.  It must be confessed, however, that  in  the
case of children, and also of  men who have no  suspicion of
the nature of their disease, the course of the malady is generally,
though not  invariably,  milder.   The  influence exerted upon
the  symptoms by prolonged thirst and hunger, can hardly be
determined with accuracy.  Reasoning from  analogy with other
experiences, with respect to the phenomena induced in  man and 
HYDROPHOBIA IN MAN.
495
animals  by long-continued thirst, it may be safely affirmed that
this factor plays a by no means unimportant role.

                   PATHOLOGICAL  ANATOMY.

    The morbid changes found in the human subject in the case
of  hydrophobia, as in some other neuroses (epilepsy, tetanus,
chorea),  are of an unsatisfactory character.
    The results of post-mortem examinations are, upon the whole,
generally negative, the  alterations being even less pronounced
than in  the case of animals ;—a phenomenon which presents a
strong contrast to the formidable symptoms observable  during
life.  The anatomical picture bears the strongest resemblance to
that obtained in cases of death from asphyxia or thirst.
    The cadaver of those who have died of hydrophobia is usu-
ally found  to be decidedly emaciated ; the rigor mortis may be
moderate or well-marked; cyanosis of the skin,  and extensive
post-mortem discolorations, are also  present, and mortification
speedily ensues.
    It often happens that the fatal wound, or the cicatrix left by
it, is hardly to be detected.  The nerves in the immediate vicin-
ity of the cicatrix  are generally quite unaltered in appearance,
though in some cases  they look  slightly reddened ; and in still
rarer instances,  in several of  the smaller  nerve-filaments in the
neighborhood, there is considerable induration,1 which may ex-
tend for a short distance beyond the seat of the wound.
    There is  found in some cases  an emphysematous swelling of
the subcutaneous cellular tissue of the lower part of the neck,
the result probably of the interstitial emphysema  of  the lungs
produced by excessive  dyspnoea.   This swelling may extend
along the upper portion of the breast, and into the mediastinum.
   The brain and its membranes are, as a rule, hyperaemic, and
often moderately oedematous.  The sinuses  and the peripheral

   1 Eichbom (loc. cit., p. 36) discovered, in a case that came under  his observation at
the Augsburg Hospital, several small branches in the vicinity of the cicatrix percepti-
bly thickened (to 1 or 1| millim.  in diameter).  These filaments diminished abruptly in
diameter as they approached the main nerve, and at a short distance off were not to  be
distinguished from the nerve-branches running parallel to them. 
 496      BOLLINGER.—INFECTION BY ANIMAL POISONS.

 veins  are generally distended  with dark-colored blood,  only
 slightly coagulated.   The pia mater appears injected, while the
 venous plexuses and the membranes of the spinal cord are like-
 wise filled with blood.   In rare cases there are found serous effu-
 sions in the opaque subarachnoid tissue and the  lateral ventri-
 cles,  and also an increased adherence  of  the membranes of the
 brain to the convolutions.   The  brain itself appears  often en-
 larged,  its  convolutions flattened; its specific  gravity is in-
 creased, while on the other hand,  that  of the medulla oblongata
 and spinal cord is diminished (Bastian ').  The consistence of the
 brain substance is  usually  normal,  and is seldom diminished.
 The gray substance is often  strikingly rich in blood, the small
 blood-vessels and capillaries being distended, and in spots vari-
 cose.
    The membranes  of the spinal cord are more or  less congested
 and oedematous.  The spinal cord itself, like the brain,  is rich in
 blood, as is also the medulla oblongata.
    In the  nerves  of the brain,  as a rule, no abnormity can be
 detected.  In certain cases  there is found  an injection of par-
 ticular  nerves or ganglia, for instance of the recurrent nerves,
 or of  one pneumogastric, or of some one of  the cervical ganglia
 of the sympathetic.  The latter are then said to be of a less firm
 consistence and enlarged.

   An actual inflammation of the sheath of the pneumogastric, and also of the cervi-
 cal nerves at their origin-, is also occasionally found.  It is hardly necessary to add,
however, that individual observations of this sort possess no especial value until
they have been confirmed by more complete investigations.

   In the digestive organs the following changes are found : The
mucous  membrane of the pharynx and epiglottis is usually of a
deep red color, and injected, though,  on the other hand, it is
often  quite normal.  The soft palate is frequently reddened and
swollen.  Virchow2  found in one case hyperplasia and recent
swelling of  the tonsils and follicular glands of the tongue, and
  1  The Lancet, II., No. 3, 1866.
  2 Die krankhaften Geschwulste, II., p. 611, with engraving of hydrophobia angina,
Fig. 188.  Berlin, 1864-1865. 
                      HYDROPHOBIA IN MAN.                  497

he expresses the belief that this may possibly correspond in'part
to the peculiar vesicles whose occurrence has been reported.  In
the case alluded to there were found  flat, roundish swellings at
the root of the tongue, in the middle of each one of which was
seen  the dilated opening of a pocket  (crypt, follicle).  The folli-
cular enlargement, according to Virchow, is a phenomenon J quite
commonly observed  in  hydrophobia; it involves also the pha-
ryngeal follicles and the lymphatic glands in the  neighborhood
of  the  jaw.  Similar swellings were found by Virchow upon the
inner side of the epiglottis, and these, corresponding possibly to
the more chronic course of  the malady, were  pretty firm,  and
were characterized by the abundance  of lymph  corpuscles found
in the gland  substance.
   The vesicles described by Marochetti2  (observed first in 1813, in the Ukraine),
and which  are scarcely worthy of  mention, were found,  as was pretended by this
writer, in men and mammalia which had been bitten by rabid animals.   They
were said to be situated beneath the tongue, on both sides of ihefratnum lingua;, and
consisted of from four to eight bluish-white papules and vesicles of the size of a
hemp-seed, which increased in size,  became purulent, and contained the virulent
poison.  Whether these phenomena were accidental concomitants, or whether  their
description was an intentional fraud, is hard to determine.

    In the mucous membrane of the stomach  and intestine  there
is generally found a decided injection of the blood-vessels,  while
upon the former are frequently seen hemorrhagic  erosions.    The
cavity of the stomach is in most cases empty, or it may contain
a dark, opaque substance, frequently resembling coffee-grounds.
The intestinal canal  is usually well distended by  gas ; in excep-
tional cases the mesenteric glands are  somewhat swollen.
   The spleen and liver are,  as a rule, in a normal condition;
their  consistence is variable, as is also the quantity of blood con-
tained in them.   Fatty degeneration of the latter organ  is often
observed.
   The heart is  normal, being  filled  with  thick  or slightly

   1 At the  autopsy of a case of hydrophobia in the human subject made by me in
Munich, the follicular glands, tonsils, and remaining parts of the throat were found to
be perfectly normal.
  2 Observations sur l'Hydrophobie.   St. Petersburg, 1821; and Theoretisch-praktische
Abhandlung iiber die Wasserscheu.  Wien, 1843.
           Vol.. III.—32 
498      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

coagulated blood.   The blood in the other parts of the body is
usually thick,  tarry, black,  and  but slightly coagulated.  The
coloring matter shows a tendency to stain the tissues.
   The lungs are charged with blood, contain air,  are frequently
oedematous and studded with points of atelectasis and hemor-
rhagic infarctions,  while numerous sanguineous  suffusions are
observable beneath the pleura.  In  the bronchi bloody froth is
not unfrequently found.  The trachea and larynx are hypersemic
and reddened.  The bronchial glands are frequently gorged with
blood, and enlarged.  Upon the  pleura is often seen a  soap-like
deposit, as in the case of cholera.
   The kidneys are for the most  part hypenemic, the cortical
substance being swollen,  slightly opaque and cyanotic.
   Klebs1 found,  in a recent  case, at the post-mortem  examina-
tion, an intense redness of the ulnar and axillary glands of the
upper extremities, as well as of the jugular and inguinal glands,
the tonsils, and likewise the lingual glands.  Peyer's  glands
presented,  as a result of  the very  great swelling and redness of
the outer follicles,  a peculiar wall-shaped appearance.   Upon
microscopic examination,  there were found  in all the swollen
portions of the lymphatic system, and particularly in  the sub-
maxillary gland, a deposit of  finely granular,  strongly refractive
corpuscles of a faint brownish color, closely packed together in
clusters ; at some points in the form of a long row, and at others
branching  out so as to form large star-shaped figures, following
in general the course of  the blood-vessels.  These corpuscles,
according to Klebs, may possibly prove to  be the vehicles for the
transfer of the specific infecting material, but this is an hypoth-
esis which further investigations alone can render valid.

                          Diagnosis.

   The diagnosis of hydrophobia in the human subject is not, as
a general thing, difficult.  Whoever has once viewed the striking
clinical  phenomena will be able, by the aid of the previous his-
tory of the patient, readily to make a diagnosis.
  1 Sitzungsbericht des Vereines deutscher Aerzte in Prag.  Aerztliches Corresp.-Blatt
fiir Bohmen, 1871, 11. 
HYDROPHOBIA IN MAN.                 499
   With respect to the diagnosis, the most important symptoms
to be mentioned are :  the decided phenomena, attributable to the
lesions of  the central nervous system  (medulla oblongata), the
severe spasms of the muscles of respiration and deglutition, the
increased  reflex  excitability, and the spasmodic character of
the morbid symptoms.
   If the previous history of the patient is  altogether wanting,
or is imperfect,  the affair may, in the initiatory stage, be con-
founded with other affections.  Either hydrophobia may be mis-
taken for some  other  nervous affection, whose general course is
analogous to it, or the latter may, under certain circumstances,
be regarded as,  and treated for, hydrophobia.
   The latter case may now and then occur after the infliction of
simple wounds by dogs.  Several cases  have already been related
in which patients, in  their fear  and anxiety, evinced symptoms
really similar to those of hydrophobia, without having been at
all infected by specific virus, and  fell into a peculiar, mentally
diseased state termed lyssophobia  {liydrophobia imaginaria).
With appropriate treatment these cases invariably terminate
favorably, and  are then apt  to be regarded  as  instances of
recovery from hydrophobia.
   From a large number of  cases upon record, there may be cited here an  instance
observed by  Stadthagen.   A boy was followed  about by the street rabble, who
charged him with having hydrophobia, and he was so thoroughly frightened that
in a few days he  began to  manifest symptoms similar to those of hydrophobia.
Having been sent home to his parents in the country, he speedily became well. He
returned to the  city, however, when the same wanton charge against him was re-
newed, and the result was that he relapsed into his former apparently hydrophobic
state.
   There is frequently observed, moreover, in certain forms of
hysteria and epilepsy, a peculiar  affection of  the organs of
deglutition, in which  symptoms are manifested strikingly analo-
gous to those observed in genuine  rabies (Marsars de Cazelles, L.
Meyer).
   The resemblance between rabies in men, and  several varieties
of tetanus, was  claimed to lend  support, apart  from the diag-
nostic significance of  their phenomena,  to the  theory that ralnes
is but a form  of tetanus.   The fallacy of this theory has already 
500      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

been exposed by Virchow (loc. cit., p. 379), who portrayed accu-
rately the distinctive points between lyssa and tetanus.  In our
account of the etiology of hydrophobia in the human subject,
the observations of Rose were cited, which serve to confirm the
deductions  of  Virchow.  It is  indeed admitted by Rose, that
there exists a hydrophobic tetanus, in which the wound is always
situated in the immediate vicinity of the cerebral  nerves, and in
the course of which spasms occur in the muscles of the jaw and
throat,  thus affording a certain resemblance to genuine lyssa.
The chief difference between tetanus traumaticus and lyssa con-
sists in this, that the  former breaks out in from three to ten
days after  the reception  of  the injury,  whereas lyssa is de-
veloped in  the greater number of cases in from four to seven
weeks after the bite.
   A symptomatic hydrophobia may be developed  as a form of
the  dysphagia wliich accompanies different affections  of  the
throat and brain, and is easily distinguished from genuine hydro-
phobia.
   Finally,  there occur cases of  so-called  spontaneous  hydro-
phobia,  which  obviously should be included under the head of
psychical affections, the term  having its origin in  diagnostic
errors.  To  this  class  are  to  be referred the violent forms of
hydrophobia,  which,  according to Dubois,1  are  nothing more
than species of monomania resembling hydrophobia (monomanie
hydrophobiaque), or peculiar forms of hypochondriacal delirium.
This affection occurs in the case of individuals having  a  predis-
position to  imaginary  diseases,  is generally induced by fear of
hydrophobia, and is therefore a lyssophobia.   At the  outset, it
bears a strong  resemblance to acute delirium, and, if congestion
of the brain supervenes, may prove fatal.
   In all these cases in which hydrophobia2 occurs as a symp-
tom of  other  diseases, an essential point of distinction between
them and genuine lyssa is based upon the circumstance that in
the former, although there indeed exists an  impediment to the

   1 De l'hypochondrie et de l'hysterie. Paris, 1833, p. 232.
   2 Apart from the confusion  created in our ideas respecting the  symptomatology of
hydrophobia in  the  dog, the existence of  the opinions above described  furnishes an
additional reason for abandoning completely the term " hydrophobia." 
HYDROPHOBIA IN MAN.
501
act of swallowing, there is, nevertheless, in the greater number of
cases an absence of all reflex excitability; furthermore, in actual
lyssa the paroxysms come on spontaneously, whether the patient
be awake or asleep,  and are induced by spasms of  the muscles
involved in respiration, as well as those of deglutition.
   On the other hand, if we are ignorant of  the previous history
of  the  patient, genuine  cases  of hydrophobia in man  may be
easily mistaken for acute mania, inasmuch as in the insane #here
is frequently developed  a dread of water, and  even salivation,
characterized by a reckless ejection of the saliva.

   Westphal observed a well authenticated case of rabies which bore the strongest
resemblance to acute delirium.  In like manner two cases are described by Maschka,
in which  during life symptoms were manifested similar  to those  of hydrophobia.
The autopsy revealed the  existence of  softening of the spinal cord, and also an
effusion of blood between the membranes of the brain, with acute hydrocephalus.
In cases of rabies, therefore, occurring  in man, as well as in dogs, errors of diag-
nosis may be corrected by a post-mortem examination.

                          Prognosis.

   The prognosis of hydrophobia in the human  subject  is abso-
lutely unfavorable.
    The malady always terminates fatally.   The cases of alleged
recovery, which are  constantly recurring in the literature of the
disease, when subjected  to an  accurate  critical  analysis,  are
invariably found to  admit of  some other explanation.  Either
proof is wanting that the animals in question, by whom the bite
was inflicted,  were really rabid,  or else the  pretended  instances
of  recovery from the disease were in reality cases of mental
disorder simulating  rabies.  Although I by no means wish to
deny the  possibility of  recovery from hydrophobia, I  cannot
but  regard it as a significant fact  that  not a  single case of
recovery has been reported by any of  the recent able observers.
Although, then, the  prognosis  of rabies in  man is involved in
so little doubt, and is indeed of a nature  to inspire no  hope,
something more favorable may,  nevertheless,  be said, upon  the
other hand, respecting  the  danger to  be apprehended from a
wound  inflicted by the bite of a rabid animal. 
502      BOLLINGER.—INFECTION BY ANIMAL POISONS.

   I have already taken occasion to point out the rabid animals
which are to  be considered the most  dangerous, and  also the
parts of the human body which form the seat of  the most dan-
gerous wounds.
   According  to the statistics collated by Bouley, wounds of
the face are the most serious, for 90 per cent,  of these are fol-
lowed by hydrophobia terminating fatally ; in  wounds inflicted
upon the hands  the mortality amounts to 63  per  cent.,  and a
similar rate is observed where there are several wounds inflicted
upon the body; in wounds upon the lower extremities only 28
per cent,  are  fatal;  and finally  upon the upper  extremities 20
per cent.
   How  great importance  as  regards  the prognosis is  to  be
attached to a prompt cauterization and prophylactic treatment
of the wound may be appreciated from  the following facts :
   Of 195  persons  who   died  from  hydrophobia in France
between the years 1850 and 1862, the cautery  was not employed
in 111; 45 were cauterized late,  and 39 insufficiently (Tardieu).
Of 200 human beings  bitten by rabid animals, 134 were cauter-
ized; of these 92 (69 per  cent.) remained healthy,  while  42 (31
per cent.) died of lyssa.  On the other hand, in the  66 wounds
that were not cauterized the rate of mortality amounted to 84
per  cent. (Bouley).    While therefore  in those cases in  which
cauterization  is resorted to, scarcely 33 per cent, of the human
beings bitten  by rabid animals fall victims to the disease, in
cases where this operation is not practised, exactly 83 per cent.
of those bitten encounter certain death.

   Of 143 persons bitten  by rabid dogs in France from 1858 to  1862, 63 (44 per
cent.) escaped without infection, and among these were 35 who had been cauterized
within the first hour subsequent to the infliction of the bite.  In the department of
Hautes-Alpes 16 persons and one ass were bitten in the year  1862 by the same
rabid dog.  The human beings were cauterized and remained unaffected.  The ass
was subjected to no treatment and became rabid.

                        Prophylaxis.

   In view of the unfavorable prognosis in hydrophobia, and the
complete  inefficacy  of all  therapeutic  agents when the disease 
HYDROPHOBIA IN MAN.
503
is once established, it naturally follows  that  in all rational
efforts to control the malady prophylactic measures must always
form our chief weapons of offense.
   Of chief importance in this  connection are the general pro-
phylactic measures to be enforced by the State against hydro-
phobia in animals,  and we will therefore endeavor  to indicate
what sanitary regulations are best adapted to confine the spread
of this malady within the narrowest possible limits.
   The first important point to  be insisted upon is the reduction
of the number of dogs.  The comparative danger to be appre-
hended  from  hydrophobia  diminishes  as the total  number  of
dogs becomes  reduced,  and  the  most effective method  of reduc-
ing  the number of dogs consists in  laying the highest possible
tax  ur>on them.   This tax should be the same for all dogs,  with-
out  regard  to sex,  and any remission  of the same should  be
strictly limited to such dogs as  are absolutely necessary for the
performance of certain  kinds of  work.
   The aggregate number of dogs is very large.  In Central Europe there is found
on the average one dog for every sixteen human beings.  The total number of dogs
in all Europe amounts to about twelve millions. Delafond estimated the number of
dogs  in France in 1846 at between three  and four millions.  In Bavaria, according
to recent computations there  are found 300,000 dogs to 4ia0-  millions of human
beings.  The disproportion between the sexes is shown by the fact that while the
male  constitute 85 per cent, of the total number of dogs, there are found on  the
average but 15 per cent,  females.   It may  be stated, furthermore, in favor of  the
taxation of dogs, of  wliich about 80 per  cent  are kept as a matter of  luxury, that
these  animals,  from the fact that they  form the vehicles for the communication
of various parasites, and  also  serve as nests for the propagation of these parasites,
exercise a deleterious influence upon the breeding of cattle.

   The State should also provide for a general registration of  all
dogs.   Every  dog should be provided with some distinguishing
mark;  the unrestrained roaming about of dogs  should be pre-
vented ; all stray dogs should be  pursued by  the  police and
destroyed.1
   When  cases  of  hydrophobia occur, directions  should  be
issued to cause all dogs to be muzzled for a considerable length

   1 Principien  einer rationellen Hundeordnung.  Amtl. Bericht iiber den II. interna-
fcionalen Congress der Thierarzte zu Wien, 1865. 
504       BOLLINGER.—INFECTION BY ANIMAL POISONS.

of time;  they should  either be led  by means of a cord, or else
kept penned up.   The failure  to notify the authorities of the
existence of a case of  hydrophobia should be made a punishable
offense.   The  regulations  just  mentioned  ought always  to  be
made applicable to as large a district as possible.
   Rabid dogs should  be destroyed,  and  likewise dogs which
have been bitten by them,  although  no human  being may have
been bitten.  If human beings have  been bitten  by rabid or sus-
pected  dogs, these should be destroyed, as soon as the existence
of rabies  in them has been determined.
   Dogs  suspected of being rabid, and also  the dogs bitten by
them, should be carefully confined at  the owner's expense, and,
in consideration of the long period of incubation, they should be
kept secured for at least six months.  The  ordinary term of con-
finement  from six weeks to three months is manifestly too short.
   The obligatory muzzling of dogs at times when hydrophobia prevails as an epi-
zootic has always in all localities been attended by favorable results.  On the other
hand, it is pretended by some, especially those who favor the theory of the spon-
taneous origin of hydrophobia, that the wearing of muzzles favors the development
of the disease, an assertion which is  unsupported by proof, and which is also com-
pletely refuted by what is known respecting the mode of origin of  rabies and by
various observations.  In Berlin, dogs were required for  a period of nine years to
wear muzzles, during which  time no instance of hydrophobia occurred.  It is, more-
over, fallaciously urged by  the opponents of  the muzzle, that in localities where
dogs roam about in large numbers perfectly unrestrained, and subject to no inspec-
tion, hydrophobia is an unknown evil.  In the description of the geographical dis-
tribution of hydrophobia, I  have already demonstrated how unfounded this notion
is, and have taken pains to show that in such  localities (Constantinople, Egypt)
hydrophopia does occur. It may be mentioned as a matter of curiosity, that the
artificial blunting of the front teeth of all dogs has been recommended by some, as
a prophylactic measure against the malady, and it has been even suggested that
small flattened metallic caps be fastened by a screw to the corner-teeth,  for the pur-
pose of rendering the bite innocuous.

   The excessive prevalence of hydrophobia in many years  is
mainly attributable  to the  absence of any  sanitary organiza-
tion  charged  with the supervision of veterinary matters;  to
the want of statutory  or police regulations, or to their inefficient
administration, simple  points regarding which  medical  authori-
ties  are of one opinion.   By appropriate and energetic sanitary 
HYDROPHOBIA  IN MAN.
505
measures the hydrophobia of dogs, like the greater  number
of infectious  animal diseases, may be  easily confined within
a small area, even if the malady be not suppressed at the very
outset.   The hypothesis of  the  spontaneous development of
hydrophobia forms a powerful obstacle to the enforcement of all
sanitary measures of this sort, and furnishes here, as in other
epizootics, a convenient loop-hole, which leads to endless mis-
chief.
   The only efficient means of eradicating the disease, in the
case of wild animals (foxes, wolves), is  to  destroy them indis-
criminately in the infected  localities ; this step is also impor-
tant for the reason  that the prevalence of the malady amongst
these animals forms a continuous source of  danger  to  human
beings and dogs.
   All attempts as yet made to subject dogs to preventive treat-
ment by means of internal remedies have proved ineffectual.
   Finally, the circulation among dog-owners of popular infor-
mation concerning the  nature and most important symptoms of
hydrophobia, as it  occurs in dogs,  is extremely desirable,  and
at the same time an opportunity will be thus afforded of correct-
ing  the numerous erroneous ideas which are prevalent with
regard to this disease as it exists in man and animals.
   Proceeding now to the consideration  of the special prophy-
lactic measures  to be adopted in cases  of hydrophobia in the
human  subject, we shall be met at the outset by the interroga-
tion, AVhat agents should be administered before the outbreak
of the disease for  the purpose of  affording the greatest  protec-
tion to those who have been bitten by rabid dogs %
   The  prompt  and thorough destruction of  the virus  at its
point of entrance into the  economy, is the answer to this inquiry.
For  this  purpose various methods, which produce  with more
or less  certainty the desired result,  have for centuries been re-
sorted to.   The  object of  all these prophylactic measures is
to destroy the wound,  and with  it the  adjacent tissue, or to
alter the character of the same, so that the virus may be made
innocuous.  In this connection should be mentioned cauterization
with the red-hot  iron, with chemical agents (nitrate of silver, solu-
tion  of  chloride of antimony, sulphuric and nitric acids, caustic 
506      BOLLINGER.—INFECTION BY ANIMAL POISONS.

potash), by  igniting gunpowder in the wound, or by  washing
out the same with  corrosive  fluids,  and this  treatment is fre-
quently combined with the administration of internal prophylac-
tic agents.
   As an efficient and thorough procedure the method proposed
and carefully tested by Brefeld is  worthy of recommendation:
After the wound has first been syringed out with warm  water, it
is to be gently and thoroughly bathed and cleansed by means of
soap-suds and a sponge, or with a solution of potash (or what is
still better, a solution of carbolic acid).  The wound is next to
be cauterized by means of  caustic  potash, and for several suc-
ceeding weeks (from four to six) a suppuration of the cauterized
wound  is to be kept up ;  a simple ointment like resin cerate
being used as a dressing, or  compresses saturated with a two-
grain solution of potassa.  Whenever cicatrization proceeds too
rapidly,  the cauterization by means of a  strong  solution of
potassa, is to be repeated.   At the  same time some simple mix-
ture should be prescribed internally to allay the anxiety of the
patient.
   In order to effect a  prompt and direct extraction of the
poison,  the  application  of suction to  the wound is advisable,
either by the mouth of the sufferer, if the position of the wound
permit, or by some other person, this constituting decidedly one
of the most efficient measures, and one  that can  always be
applied upon the spot.   By the greater number of writers this
simple procedure has been condemned on account of its alleged
danger.  Apart from the circumstance  that the danger  incurred
by the bitten person is at  all events not  very much increased
by  sucking  the wound, even if   it has not  been  cauterized,
it has been  demonstrated also by  the  numerous  and carefully
conducted experiments of  Hertwig, that  the specific  virus  is
completely innocuous  to dogs when brought  in  contact with
the unabraded mucous lining of the mouth and digestive canal.
We can therefore  conclude with a tolerable degree of certainty,
that  the mucous membrane of the human mouth is in like man-
ner unaffected by the virus.  The application of a dry cupping-
glass, if the  seat of the wound permit its use  might prove, in
small wounds, equally efficacious. 
HYDROPHOBIA IN MAN.
50?
   This method of sucking the wound was long since described by Celsus, and was
practised among the ancients  by a distinct class of  persons termed "Mlli."  The
same process, wrongfully regarded by many as the most frightful of all prophylactic
measures, is at the present day resorted to in many portions  of France, in Italy,
Scotland, and the wilds of North America, where no instance of infection by this
means has ever been observed.'  Li Lyons, during the first twenty years of the pres-
ent century, certain women (Hundssaugerinnen) made it their business to apply suc-
tion  to the wounds made by rabid dogs.   Their  compensation was fixed  at ten
francs for the first operation, and five for each succeeding one.  Of thirty-eight per-
sons  bitten  by rabid dogs, and subsequently subjected to this operation, not one was
attacked with lyssa.  Finally, individual cases are known  in which the saliva of
hydrophobic men, or an object  smeared with such  saliva, has come in contact with
the mucous membrane of the  mouth of human  beings without causing any ill
effects, so  that  the experimental experience of Hertwig with respect to dogs may
be said to be equally valid in the  case of human  beings.  The observations con-
flicting with the  views above expressed, wliich seem to favor the theory that infec-
tion may take place by the act of kissing, are of ancient date and untrustworthy.

   The application of  the actual cautery, and burning the
wound by means  of gunpowder, are to be  less strongly recom-
mended ; the former mode  of  cauterization is indicated at  most
only in cases of  small excoriations, or  in simple open wounds.
The chemical and corrosive caustic agents penetrate with greater
certainty every nook and corner of the wound.
   While simple  scarifications are useless, having merely the
effect of  producing, by  means of  the knife, additional inocula-
tions, the excision of the wound or cicatrix with subsequent cau-
terization is very efficacious.   This method is continuously indi-
cated during the entire  period of incubation, and  for several
subsequent  days  or weeks, and may possibly be  of  advantage
even during the premonitory stage of hydrophobia.
   Amputation of the wounded  part, of a  finger for instance,
where no additional injury  has been inflicted, has been likewise
resorted to.    In cases of numerous wounds upon  different parts
of the body  or of an extremity, the  general corrosive sublimate
bath, as  recommended by  Fuchs,  may be of advantage.  As to
the efficacy of a permanent  hot-water bath applied to the injured
parts, as  recommended by Eulenberg, with the object of decom-
posing the virus by the application of heat,  or at  least of dilut-
1 Compare statements of Faber, loc. cit., p. 268. 
508      BOLLINGER.—INFECTION  BY ANIMAL  POISONS.

ing and extracting it, there  are no observations on record  with
regard to this point.  Where the above cannot be carried into
effect, the application of sponges and compresses saturated with
hot water  is  said  to  produce a  similar result.   On the other
hand, hot Russian steam baths have been suggested as a preven-
tive  measure  (Buisson).  Bathing the  wound  with cold water,
vinegar, or brandy,  is  said  to operate unfavorably, warm salt
water being better.
   Although, in accordance with authentic observations—those,
for instance, made by Blaine and Hertwig upon themselves,—a
careful,  free cauterization  affords  great protection against the
outbreak of the  malady,  no  sure and absolute  immunity  is
obtained by any local, prophylactic treatment of this sort, not
even when applied within a short time after  the infliction of the
bite, and with all necessary thoroughness.   On this account the
custom has always prevailed  of exhibiting also internal  remedies
as preventive agents.
   In addition to a long list of secret remedies, which assuredly
do more harm than good, there is hardly a medicament in the
whole pharmacopoeia which  has  not  been  tested in cases of
hydrophobia, either as a prophylactic  or a therapeutic agent.
The  most  commonly  employed drugs  were  always cantharides,
the Meloe  majalis, belladonna in large doses (even to the affec-
tion of the eyesight),  mercury (in the form of calomel or mercu-
rial ointment, pushed to the salivating point), calomel combined
with venesection ;  furthermore,  prussic acid,  tartar emetic, sul-
phates  of  copper and zinc, strychnine, chlorine,  and a  variety
of vegetable remedies.  Arsenic, formerly employed  extensively
in India, was  recommended at a  later  date  by Arendt,2 and
quite recently b}^ Guisan and v. Schaller.3   It  has been resorted
to in Lyons (1846) ineffectually.
   1 Faber, p. 399.
   2 Memoire sur un nouveau traitement de l'hydrophobie.  Compt. rend., T. LV., p.
570, 1862.
   3 Guisan (De la  Rage, etc., Bern,  1868), and v. Schalier (Die Wuthkrankheit, ihre
Natur, etc., Freiburg, 1873) adopted the following treatment in a large number of cases.
After the bite of a rabid dog there was administered internally, as a prophylactic agent,
thrice daily, for a period of six or seven weeks, from one-twentieth to one-tenth of a
grain (children, one-fortieth) of the arsenite of potash (or  soda). The wound was 
HYDROPHOBIA IN MAN.                 509
   Thirdly, the psychical treatment of the patient after a sus-
picious bite is of great importance.   On the part of the medical
attendant, and those about the patient, the greatest care should
be taken "to preserve a calm demeanor, to avoid all allusion to
the  previous injury, and to  appear  cheerful" (Romberg).  The
physician should impress upon the mind of the patient a con-
viction of the efficacy of his  treatment (Virchow).   Attention
should furthermore be paid to physical and mental rest, to regu-
lar habits of  life, to the abstinence from  all kinds of excesses,
and the avoidance of every excitement.

                   Therapeutical Treatment.

   The majority of therapeutical, agents  which have  been em-
ployed prophylactically, have been likewise resorted to when the
malady was fully developed; all, however, without effect; and
our allusion to these remedies, which merely possess a historical
interest, will be therefore as brief as possible.
   Among the remedies  taken from  the vegetable  kingdom
should be specially  mentioned box, rue, sage, the Anagallis
arvensis,  belladonna, opium, morphine,   to  which have  more
recently been added atropine, curare, and quinine, the  last three
of which have also been employed subcutaneously.
   Of animal substances, those already alluded to, cantharides
and  the Meloe majalis, have been frequently resorted to.  The
mercurials formerly played an  important part, and are still
employed, even  at  the present  day, as a general  thing, exter-
nally, in the form of mercurial ointment.
   Neither the warm bath, prescribed in the most ancient times,
nor river-bathing (Celsus, von Helmont), is at the present day
resorted to.   Buisson,  however,  suggested in their  place the
dressed daily with Fowler's solution.  Upon the full development of rabies the treat-
ment was symptomatic, arsenite of potash or soda being administered in doses of from
one-twentieth to one-tenth of a grain from three to six times daily.  If the toxicological
effects of these drugs was produced, the dose was diminished.  Inasmuch as the cases
observed and reported by Guisan and v. Schaller admit of a varied interpretation, so far
as concerns the efficacy of the arsenic treatment, it is to be hoped that further experi-
ments will be instituted with this agent. 
510      BOLLINGER.—INFECTION BY  ANIMAL POISONS.

employment of steam baths, in order  to produce active diapho-
resis.
    Venesection—to the fainting  point—serves, at times, to miti-
gate somewhat the force of the convulsions ;  and when combined
with the mercurial treatment,  is  followed by temporary  relief.
Copious venesections, however,  undoubtedly  hasten  the ap-
proach of general paralysis and the fatal result.
   Here should be mentioned, too, the amputation of the wounded
extremity, which has repeatedly been performed to no purpose.
    Transfusion with warm water (Magendie,  Gaspard, Mayer)
has proved equally ineffectual.   Magendie injected two pints of
water into the veins, and  quickly produced  thereby a decidedly
quieting effect, a reduction of the pulse from  150 to 86,  and a
return of the ability to drink.   The patient died upon the ninth
day.  In a similar manner, Gaspard saw the dread of  water dis-
appear  after the injection of  water, but death  quickly ensued
at the expiration of fifty-four hours.   The transfusion of blood
might possibty be worthy  of a trial.
   The  exhibition of the mercurial preparations—internally in
the form of calomel, externally by means  of the mercurial oint-
ment—to the  extent of ptyalism, notwithstanding its extensive
employment, has newer been of any  efficacy ; on the contrary,
it has rather tended to aggravate the  misery of the patients, in-
ducing  a more copious  flow of saliva, while  the manipulations
involved in the inunctions, acting as a strong excitant, tend to
induce a constant recurrence of the convulsive paroxysms.
   The administration of belladonna has likewise proved unsuc-
cessful.   The application of the actual cautery to the  skin  upon
both sides of the spinal column affords no alleviation, though the
patient  may experience  hardly any pain from this severe oper-
ation.   The same  negative results follow the cauterization and
excision of the wounds after the disease has once broken out.
The  amputation of the parts  bitten (an arm or finger),  has had
indeed the effect of allaying the pains, but is a source of  great
excitement to  the patient,  without causing any mitigation in the
severity of the paroxysms.
   The  subcutaneous injection  of daturine, curare, atropine,
quinine, and furthermore, the internal use  of  arsenic, prussic 
HYDROPHOBIA IN MAN.
511
acid, and carbolic acid, are  all in like manner attended by no
appreciable results.   The inhalation of pure oxygen is  said to
cause  the  disappearance of the  convulsions,  and also  of the
delirium, without arresting the fatal  termination ; the  method
of faradization is also said to produce a transitory amelioration,
but no permanent benefit.
   The narcotics are unquestionably of the greatest value in the
symptomatic treatment of hydrophobia in the human  subject.
   While belladonna, even in large doses, has no especial effect
in diminishing the reflex excitability, large doses of chloroform,
opium, and morphia (opium to the  extent of forty-six grains
in twelve hours ; morphia in half-grain doses) furnish the most
efficient  means of  alleviating  the sufferings  of the patients.
These agents  frequently afford, even  though for  a short time,
quiet  sleep and a subjective relief, though the convulsive  par-
oxysms are none the less severe.
   Among all the narcotic  agents, chloroform stands at the head
in the treatment of hydrophobia.   With the production of com-
plete chloroform narcosis, the paroxysms cease, returning, how-
ever,  with  the disappearance of the narcosis.   The  great diffi-
culty, however, in the use of chloroform lies in the fact that the
patients  struggle so against the inhalation of this  agent, that its
administration is often impossible.  Wagner, who, as the result
of his own experience, strongly recommends chloroform, availed
himself,  at  the same time, of  the state of narcosis to adminis-
ter, by the aid of the oesophageal  tube, an abundant supply of
nutritious food.  He succeeded in keeping a patient in the  con-
dition of chloroform narcosis for sixteen consecutive  hours.
   During the narcosis the attempt may also be made to intro-
duce liquid nourishment per rectum.
   Repeated clysters of chloral have thus far proved ineffectual;
but it is to be  hoped that further experiments will be made with
this drug, in the  form, perhaps, of clysters, combined with  sub-
cutaneous injections, with the object of producing euthanasia.
   To  summarize, in conclusion, what has  already been stated
(appending a  few words respecting the psychical treatment of
the sufferers),  our knowledge of the therapeutics of hydrophobia
may be expressed as follows : 
512      BOLLINGER.—INFECTION BY ANIMAL POISONS.

   The entire treatment must be symptomatic and palliative, and
all the remedies hitherto employed, with  the  exception  of the
inhalation of chloroform and the administration of the prepara-
tions  of opium, have  proved of no especial benefit.  In  these
attempts to mitigate as much as possible  the  severe symptoms
and to produce euthanasia, the chief indications are :
   The removal of every cause of excitement;  the separation of
the patient from everything calculated to disturb or render him
anxious ; the maintenance of the utmost quiet; the employment
of a friendly tone of address {in place of coercive measures);
and  the endeavor to  calm the sufferer by kind treatment.  In
order to  maintain the strength,  nutritious enemata, the intro-
duction of the oesophageal tube during the narcosis produced by
chloral or chloroform, and the administration of food by its aid,
are indicated.   To this may be added the subcutaneous injection
of curare and morphia. 
THE FOOT-AND-MOUTH  DISEASE.
                          APHTHAE  EPIZOOTICS.

Sagar, Libellus de aphthis pecorinis.  Vienna?, 1765.—Hoffmann, De insitione febris
    bullosa; epizootic*.  Bona?, 1817.—Brosche, Die  Maul- und Klauenseuche der
    Rinder, Schafe, Ziegen und Schweine.   Dresden, 1820.—Erdt, Ueber die Klau-
    enseuche im  Jahre 1838.  Mag. fiir Thierheilkunde, IX. p. 420, u. X. p. 34.—
    Andrea;,  Ueber die gutartige Maul- und Klauenseuche.  Magdeburg, 1839.—
    Schneider, J., Erfahrungen iiber die Maul- und Klauenseuche.  Freiburg, 1840.
    —Hildebrandt,  Magazin  fiir Thierheilkunde, VI., p.  140, 1840.—Herberger,
    Ueber die Kuhmilch in der Klauenseuche.  Pharmaceut. Centralblatt fiir 1840,
    No. 9,  p. 138.—Lafosse, Maladie  muqueuse-aptheuse, 1843.—Perty, Recueil de
    Mgd. veter pratique.  Paris, 1843.—Heusinger, Recherches de Pathologie com-
    parer   Cassel, 1847; II. p. CCCCLXXIX.—Donne, Rapport sur des observa-
    tions concernant  le lait  des  vaches affectges de  la  maladie  vulgairement
    appellCe la cocotte.  Paris, 1867.
Hertwig, Medic. Vereinszeitung, 1834.  No. 48, p. 226.—Levin, J., Vergleichende
    Darstellung der von den Hausthieren auf Menschen iibertragbaren Krankheiten.
    Berlin,  1839, p. 156-169.—Nozeran, Journal de la Soc. de Med. prat, de Mont-
    pellier, 1842, p. 81.—Jacob, Journal  de Med. veter. de  Lyon, 1846, p. 70.—
    Neuere Erfahrungen iiber die Maul- und Klauenseuche.  Landw. Zeitschrift fur
    Kurhessen, VII., 1861, p. 141.—Hering,  Repertorium der  Thierheilkunde,  B.
    XXIH, 1862, p. 238.—Hislop, Two Cases of Murrain (Aphtha Epizootica) in
    Man.  Edin. Medical Journal, 1863, p.  704.—Dumur, Sur langue observee chez
    1'homme.  Journal de Med.  veter. de Lyon,  1868, p. 220.—McBride, J. A.,
    Report  on a Case of Contagion of the Foot-and-Mouth Exanthem in the Human
    Subject.  British Medical Journal, 1869, p. 536.—Fangel, Albrethsen und Holm
    (Denmark),  Uebertragung der Maul- und Klauenseuche auf Menschen.  Vir-
    chow und Hirsch, Jahresbericht  f. 1870, I. p. 482.—Dammann,  Sind Fleisch
    und Milch Maul-und  klauenseuchekranker Thiere schadlich?  Der Landwirth
    von Korn und Peters, VI. p.  374, 1870.— Amyot, F. E., Foot-and-Mouth Dis-
    ease in  the Human Subject.   Med. Times and Gazette, 1871, p. 355.—Briscoe,
    W. F., A Case of Foot-and-Mouth Disease in the Human Subject.   British
    Med.  Journal, Oct. 26, 1872.—Bircher, H, Beobachtungen iiber die Maul- und
    Klauenseuche.  Correspondenzblatt fiir schweizer Aerzte, 1872, p.  123.—Com-
    pare  also the treatises  of Bruckmiiller, Haubner,  Hering,  Kreutzer, Boll, and
    Spinola.
            VOL.  III.—33 
 514      BOLLINGER.—INFECTION BY ANIMAL POISONS.


          THE FOOT-AND-MOUTH DISEASE IN ANIMALS.

    The foot-and-mouth disease, which has been known for cen-
 turies, is an acute infectious disorder,  communicated invariably
 from one animal to another by contagion.  It prevails chiefly
 among  cattle, sheep,  swine, and  goats, less frequently among
 horses, and still less often among fowls, and dogs.   The affection
 is  characterized by a  moderate   constitutional  disturbance,
 with fever,  by the formation of vesicles and ulcers upon the
 mucous membrane of the mouth {stomatitis aphthosa),  upon the
 coronary border  and  in the cleft of the hoofs, combined fre-
 quently with a pustular exanthema upon the udder.

   The so-called miasmatic mode of development of this malady, though almost
 universally conceded, has in this disease, as well as in the animal diseases already
 treated of, not  yet been proved. All observations tend to show that the foot-and-
 mouth disease is propagated only by contagion.

    The  materies morbi, the precise nature of  which is as yet
 unknown, is fixed, and probably volatile also.  It is contained
 principally  in the "products of the specific local  affection, the
 contents of the vesicles,  the secretion of the  ulcers,  the saliva,
 and the  blood, and in  all the  secretions and excretions of the
 diseased animal, especially the fseces, urine,  and milk.  The
 specific  virus  is  capable of reproducing itself  only  within the
 diseased organism, and comes therefore  under  the head of the
 endogenous morbid poisons, evincing a pretty strong tenacity
 to life.   In  infected stables its activity is preserved for many
months.   The infecting principle is,  moreover, transportable, its
transference being effected through the agency of human beings
(articles of clothing), animals, manure, tools, and other objects of
every description.  Inoculation may be produced either directly
by immediate  contact,  or indirectly by means of the fodder, the
inhalation of infected air, or by walking over ground  previously
trodden by  diseased animals.  Young  animals (sucking calves)
are frequently infected through the milk.
   No wound  is necessary to enable the virus to penetrate the
economy.  It  may  fasten upon the unabraded epithelial lining 
FOOT-AND-MOUTH DISEASE IN ANIMALS.         515
of the mouth, or it may find its way into the organism through
the inhaled air or the food.  Once having obtained a foothold
in a stable, the malady generally extends from one animal to
another, those in the immediate proximity of the diseased animal
being invariably first attacked.

   Bender1 discovered small parasites, spores, and also great numbers of micro-
cocci in the matter deposited upon the ulcers and aphthae, while in the milk no trace
of any organism was detected when this fluid had not been rendered impure by the
presence of scurf or lymph. In one case observed by me, there were found in the
fibrino-purulent deposit upon the ulcers in the mouth, numerous micrococci and
cylindrical bacteria, and  also numerous spheroidal bacteria, collected in groups
between the layers of the partially detached epithelium.

   A very great affinity for the foot-and-mouth disease is evinced
by the above-mentioned animals,  especially cattle, sheep, and
swine ; the predisposition is less marked in goats, and least of all
in the horse and other animals (dogs, fowls).  In animals which
have once acquired  the  disease, the susceptibility ceases for a
considerable period, or at least becomes very slight.   Repeated
attacks  of the  malady in the same animal are upon  the whole
rare.
   The period-  of incubation lasts usually  from  three  to six
days, less frequently from two to eight days.

                          Symptoms.

   The disease  is ushered in  with moderate febrile symptoms,
the animals appearing dull and  stupefied.  Soon a catarrhal
inflammation  of the mucous  membrane of the mouth sets  in.
Feeding is thereby rendered difficult, and  the salivary  secretion
is increased to such an extent  that the animals constantly drivel.
Upon the mucous membrane  of the mouth, especially upon the
inner surface of the  upper lip, and the  edge of the upper jaw,
where no teeth are  found,  also  upon  the tip and edges of the
tongue,  and less frequently  upon the  other  portions  of the
mucous  lining  of the mouth, there are found whitish-yellow,
'Zeitschrift fiir Parasitenkunde, B. I.  Jena, 1869 and 1870. 
516      BOLLINGER.—INFECTION BY ANIMAL  POISONS.

slightly turbid vesicles, at first transparent, but filled later with
a purif orm fluid.  These vesicles  burst in a day or two, leaving
behind,  after the dead epithelium has been cast off, erosions  and
shallow ulcers.  The  latter  frequently become confluent, form-
ing in this way still larger ulcers.   These sore spots heal in from
three to six days, the  process rarely occupying a longer period,
after which the  animals begin to feed once  more with accus-
tomed appetite and without difficulty.
   The development of the morbid process within  the  mouth is
at the same time accompanied by indications of increased sen-
sitiveness, redness, and  pain in the cleft and  along the upper
border of the hoofs; standing is  rendered difficult, the animals
move reluctantly and  cautiously,  are inclined to lie down a good
deal, while their gait is constrained and labored.  In the course
of one or two days there will be found, as in the mucous mem-
brane of the mouth, vesicles both large and small, filled with a
yellowish, opaque fluid, which soon burst, discharge their con-
tents and dry up, leaving  in their places  crusts.  Beneath these
crusts the epidermis  is  gradually  re-formed,  the sensation  of
pain disappears,  and at the expiration of  about fourteen days—
reckoning from  the beginning—the  healing process  is accom-
plished, provided no complications supervene.
   Upon the  teats, and generally  in  the vicinity of  the  ori-
fices of  the lacteal ducts, vesicles, pustules, and crusts often
appear upon the reddened integument.  The immediate neigh-
borhood of the orifices of the lacteal ducts, and in many cases
also the greater part of the superficial  surface of the teats, is
frequently transformed, by  the process of milking and the  con-
tinuous  tearing  away of the crusts, into one purulent  and cor-
rupt surface.
   In exceptional cases there is noticed a vesicular  eruption
upon the  muzzle,  the mucous membrane of the nose, the  con-
junctiva of the eye, and also upon the mucous membrane of the
vagina.
   During  the course of the malady, as above described, the
temperature is moderately elevated, reaching 102° or  even  104°
Fahr., while the pulse is  slightly accelerated.   In consequence
of the fever and  the disinclination to feed, the animals lose flesh, 
              FOOT-AND-MOUTH  DISEASE IN ANIMALS.          517

the flow of  milk is diminished, while its quality is at the same
time materially altered.
    If the case 'is severe,  and its  progress  unfavorable,  there
ensues  an inflammation of the soft tissues of the hoofs, with the
formation of abscesses, with  separation of the horny wall and
frequently also an arthritis of the contiguous joints.   As the ani-
mal lies down  constantly, this tends to  the formation of metas-
tatic  abscesses.  It  is  not an  unfrequent thing  for an abortion
to occur during the course of the disease.  As one of the sequelae
of the disease,  especially in  animals not  readily controlled, there
occurs  an inflammation of the feet,  resulting  from  the  great
weight  of the  body,  and  accompanied  by  detachment of  the
outer wall of the hoof.   In  consequence  of this the animals often
become so much reduced that it  is necessary to destroy them.
Inflammation  of the udder is another  common after-effect  of
the disease.
    The total quantity of milk given by cows suffering from  foot-and-mouth dis-
ease is seldom diminished by more  than  one-half, provided the animals are well
kept.   The alteration in the milk secreted  consists really in this, that  it coagulates
prematurely, and presents frequently a yellow, colostrum-like  appearance.  In  the
severer varieties of the disease, there is formed a mixture of whey and slimy coagula,
and the  milk, when boiled,  curdles in stringy masses.   In  other cases  the milk
acquires an acid taste, and after standing for about twelve hours it  deposits a thick,
yellowish sediment, having a  nauseating, rancid flavor.  At the same time the milk
sours quickly, and  evinces a  strong disposition to  curdle.  If the casein be arti-
ficially coagulated  (by means of rennet) there is then formed a slimy, pasty mass
(Bircher).  Lavena found that milk of this sort contained more water and salts than
usual, but that it  was free from mucus  and pus corpuscles.  Raikem states, that
upon microscopic examination he saw pus corpuscles upon the bottom of the vessel;
according to the statements of this writer, and also of Lombard, the milk gave an
acid reaction.  Donne and Turpin found the milk in this affection to be less homo-
geneous, and of rather a semifluid character ; it did not coagulate upon the addi-
tion of acetic acid, but was made stringy by ammonia, and contained colostrum-
like cells as  well as  mucous  corpuscles.  Herberger found in the milk of cows
affected with foot-and-mouth disease, during the first stage, an increased quantity
of alkalies, while the fat globules had  a less distinct contour and were more run
together than usual; the  milk coagulated but imperfectly upon  the addition of
rennet.  In the  second stage it contained only a few fat globules, was  slimy, viscid,
and of a foul odor  and taste, and coagulated likewise imperfectly upon the addition
of rennet. In both stages the  milk contained but little casein and sugar, but, on the
other hand, a large amount of salts, among which was some carbonate of ammonia. 
518       BOLLINGER.—INFECTION BY ANIMAL  POISONS.
   It is possible that the milk, as one of the secretions of tbe diseased body, con-
tains within it the specific poison; aside from this, however, it is almost invariably
mixed with the specific discharge from the wounds upon the affected teats.

   The course of the disease is, as a rule, a mild one.   Complica-
tions with other infectious  diseases, especially anthrax,  which
is frequently  believed  to  supervene  in the severer forms  of the
malady, have not  as  yet been satisfactorily  proved, and are
besides altogether improbable.
   The duration of  the whole process is from  twelve to fourteen
days, seldom less.
   The disease  terminates,  in the greater number of cases,  in
recovery.   It  is  only young animals,  less frequently  grazing
animals,  under  unfavorable  conditions, and finally,  those who
have already  some other illness (tuberculosis, myocarditis), which
now  and then succumb,  or  have  to be destroyed.  Yet many
attacks of the disease  are remarkable for their malignant char-
acter.

   In sheep  and goats the disease runs a similar course, attacking especially the
feet,  the vesicular eruption being, however, less pronounced.  In swine, likewise,
the feet form the principal seat  of the eruption.  In horses the disease appears but
rarely, and then in the form of a moderate aphthous stomatitis. In beasts of chase
(does, stags, and wild boars) the course of the disease is similar to that in tame
animals.  Fowls  are often attacked, but carnivorous animals, on the other hand
(dogs and cats), are seldom affected.

   Foot-and-mouth  disease   spreads by  following the  lines  of
communication,  and is carried along the different highways, par-
ticularly by driven cattle, moving with increased rapidity along
the track of railroads.  The  following statements will convey an
idea of the frequency and extensive prevalence of the malady.
In the year 1871, according to the official reports, 700,000 animals
were attacked by foot-and-mouth  disease in  England, and the
same number in France.  In the year 1869, the greater  portion
of Europe was visited by  this malady ; and, according to authen-
tic estimates, were not the spread  of the disease in  a measure
restricted by police regulations in most countries  of Europe,  at
least one-quarter part  of  all  susceptible animals would be annu-
ally attacked. 
FOOT-AND-MOUTH DISEASE IN ANIMALS.
519
                   PATHOLOGICAL ANATOMY.

   When a post-mortem  examination is made of those animals
which have been destroyed on account of severe and threatening
symptoms, the following changes are observed:
   Upon the inner surface of the lips ;  upon the gums and the
toothless edge of the upper jaw, there are found, to a greater or
less  extent, ulcers with depressed, whitish edges, with a finely
granular,  rose-red  or pale yellowish-red base,  thinly covered
with a grayish-white secretion.   Other spots in  the vicinity are
covered with a scaly epithelial layer in process of desquamation ;
or, it may be, one portion of this layer is already thrown off, the
eroded points being still  loosely covered by the corresponding
subjacent epithelial layer.  It is in rare cases  only that vesicles
of varied size are found  upon the muzzle.  The ulcers and
erosions, in which a healing process has been established, exhibit
much less prominent  edges, and a smooth,  pale, or pale-yellow-
ish base.  Precisely similar changes are found within the mouth,
upon the tip and edges of the  tongue, and upon its surface as
far as the median line,  which often  forms the seat of superficial
ulcers as large as a  silver half-dollar.
   The lower half of the teats is often covered with pretty thick,
brownish, yellow crusts, which frequently cover the greater por-
tion  of the udder, or else appear in the form of papules, varying
in size from a pin's head to a pea, and  adhering firmly and
closely to the surface.   The tissues immediately  around the ori-
fice of the  teat are  generally transformed into a small superficial
ulcer.  It often happens that single teats are covered throughout
their entire extent by  the above-described brownish-yellow,  or
dark-brown crusts.
   Upon the hoofs, and chiefly in the cleft, both in front and
behind, are likewise seated  superficial ulcers, which are accom-
panied by induration and swelling of the adjacent subcutaneous
tissue and fleshy portions of the hoofs.
   In the paunch  are frequently  found,  especially upon  the
rugffi, numerous erosions,  with desquamation of  the epithelium,
—changes which are precisely analogous to those found  in the 
520      BOLLINGER.—INFECTION BY ANIMAL POISONS.

mucous membrane of the mouth;  vesicular formations  are also
frequently observed.
   The  liver  is  generally  gorged  with  blood,  and  slightly
enlarged, being in the condition of what is termed cloudy swell-
ing with parenchymatous inflammation.   In one case, the course
of wliich had been veiy severe, I detected acute disintegration of
the hepatic  cells, so pronounced as to induce a general icterus.
The morbid  changes in the kidneys are quite similar to those in
the liver.  The spleen is normal.
   In the respiratory apparatus is found a moderate  injection
of the mucous membrane of the trachea and bronchi.  The lung-
tissue is hyperaemic.
   The heart presents no alterations.
   In sucking calves, which become ill and die in consequence of
having consumed  the milk, there  are found the  changes pecu-
liar to gastro-enteritis, and also regular aphthae and erosions in
the stomach and intestinal canal.

            Diagnosis, Prognosis, and Treatment.

   The diagnosis of foot-and-mouth disease presents hardly any
difficulties.
   The prognosis  is, as a general thing,  favorable; the almost
invariable termination  is in recovery ; and only in exceptional
cases, in which the animals are affected with some chronic disor-
der, does death ensue.  To calves, the consumption of  the milk
of the diseased cow is dangerous in the  highest degree ;  it fre-
quently happens that from fifty to  seventy-five per cent, of these
animals die, chiefly in consequence of gastro-enteritis.
   The best treatment for animals suffering from this malady is
shown by experience  to be a purely symptomatic one.  They
should be kept quiet in the  stall,  care should  be taken to pro-
vide them with a  supply of pure air, a moderate temperature,
plenty of  soft straw, frequent opportunities to  drink, and suffi-
cient soft  aliment,—milk, meal  and water, boiled grain,  mash,
bran,  etc.   The  feet and hoofs  should  be bathed with  warm
water.
   Any additional treatment, particularly if it involve any active 
FOOT-AND-MOUTH DISEASE IN MAN.
521
medication, is quite  superfluous,  and  in the majority of cases
positively injurious.  Compulsory inoculations should be resorted
to in order to stamp out the disorder, a procedure which is gene-
rally attended by favorable results.
      FOOT-AND-MOUTH DISEASE IN THE  HUMAN SUBJECT.

                            Etiology.

   The fact, formerly disputed by many, that there occurs in
the human subject a morbid process identical with the foot-and-
mouth  disease of animals, is now established beyond  question
by numerous observations.
   The affection is generally communicated to man in one of two
ways :—either by the consumption of unboiled milk,  obtained
from a diseased cow, the  most  frequent mode, or  else by the
direct inoculation of a wound, especially  upon the hand  and
fingers,  produced either  by  milking cows having  a vesicular
eruption  upon the  udders, or by coming  in contact  with the
saliva of infected animals.

   Sagar (loc. cit.) was the first  (1764) to observe, in Moravia, that human beings,
who had  drunk the milk of cows suffering from foot-and-mouth  disease, experi-
enced a difficulty in  swallowing, a sensation of increased heat in  the  mouth and
throat, and subsequently were affected with aphthae in the mouth.  At a later date
(1820) Brosche  (loc. cit.) reported an instance in  which two young girls, who had a
good deal to do with diseased cows, exhibited an exanthema similar to that upon
the cows, consisting of an eruption of  vesicles, filled with a transparent fluid, upon
the swollen fingers and toes.  A further observation ] was made in 1827 in Bohemia,
where, at a time when  foot-and-mouth  disease was prevailing very  extensively
among the  cattle, young people were attacked with an inflammatory rheumatic
fever, accompanied by an aphthous eruption in the mouth, or an exanthema resem-
bling that of small-pox, and also  by abscesses and ulcers upon the lower extremities.

   The first  to demonstrate experimentally  the  communicability
of the disease was Hertwig, whose positive results were confirmed
by Jacob.
   During an epizootic of foot-and-mouth  disease, Hertwig and
two other medical men drank, each, daily, for four days, a quart

             1 Medic. Jahrbucher des Oesterr. Staats, B. II. p. 86. 
522      BOLLINGER.—INFECTION BY ANIMAL POISONS.

of fresh milk taken from diseased cows.   Before  two days had
elapsed, H. began  to experience slight fever, twitchings in  the
limbs, headache, a sensation of dryness and heat in the mouth,
and an itching in the hands and fingers.  These  symptoms, by
no means severe, continued for about five days.   Then the entire
mucous membrane of the  mouth began to swell considerably^
especially that of the tongue, upon which organ, particularly the
edges of  it, and  also upon  the inner surface of the cheeks and
lips,  there appeared small vesicles, never larger than a lentil, of a
yellowish-white  color,  and  filled with turbid  whitish contents,
which were readily discharged when the vesicles were pricked,
but were  soon  reproduced.  Upon  the following days, these
vesicles became still larger, and burst; the epithelium was then
detached, leaving behind  dark-red  erosions  which  gradually
healed.   There was conjoined with the above symptoms a smart-
ing pain in the mouth upon the  attempt to masticate, speak, or
swallow,  and also an intense thirst.  The vesicles upon  the lips
dried up, leaving in their places  thin brown scurfs, wliich, upon
the tenth day  after the  appearance  of the former,  fell  off.
Simultaneously  with the  development of  the eruption  in  the
mouth, numerous  vesicles were  formed  upon  the hands and
fingers, which at first were of  the size of a millet-seed, firm, and
of a  yellowish-white color,  but in their further progress approx-
imated in look  to those in the  mouth, healing, however, more
slowly.   Both the other physicians, who had  also drunk the
milk, exhibited,  in addition  to  moderate febrile  symptoms,
vesicles in the  mouth and upon the  lips, the course of wliich
was similar to that  observed in the case of  Hertwig ; upon their
hands, however, no vesicles were formed.   At the termination
of this process all three were restored to the best of health.
   The great danger incurred from the consumption of unboiled
milk, taken  from  cows  suffering from foot-and-mouth disease,
may be appreciated from the fact that young animals, especially
sucklings, are destroyed thereby in great numbers, death ensu-
ing as the result of gastro-enteritis.  According to the statements
of trustworthy observers, in many epizootics of this malady as
many as seventy-five per cent,  of the sucking calves of infected
animals  perish.   To what  extent this result is attributable to 
               FOOT-AND-MOUTH DISEASE  IN MAN.           523

chemical  alterations in the milk, or to the  effects of the specific
virus, is difficult to determine.  It is certain, however, that such
young animals are infected by the consumption of unboiled milk.
Experience has shown that this milk is none the less dangerous
to human beings, even when added  to normal milk  in the pro-
portion of one  to ten, or when taken  with coffee.  By boiling,
the virus  is destroyed, and the milk rendered innocuous.
   In  the case  of  adults, the consumption of a  considerable
quantity  of milk is necessary for the production of infection.
   As to the notion that the milk of diseased cows is not generally used, I can
state from my own experience, that, during the prevalence of foot-and-mouth disease,
the proprietors of large dairies indeed cease consuming milk in their own families,
not, however, because they consider it injurious, but  that they may be enabled to
furnish to their customers in the city as nearly as  possible the quantity contracted
for.

   Communication of foot-and-mouth disease, by means of the
meat of diseased animals, is not known to have  occurred, and  is
also improbable, inasmuch as that kind of meat is almost invaria-
bly cooked before being eaten. The case is  different, however,
with butter and cheese made from the milk of diseased cows.
Several instances of infection, by the consumption of butter and
cheese of  this sort, are  reported by J. Schneider,1 who saw entire
families made ill by their use.  In view of our knowledge of the
nature and tenacity of the specific poison, such modes of infec-
tion are to be regarded a priori as possible, and should receive,
therefore, further study.
   The  second mode of infection,  direct infection, is produced,
in the majority of cases, by milking diseased cows,  and permit-
ting slight wounds, excoriations, and hangnails to come in con-
tact with  the  contents of  the vesicles upon the udders, or with
the morbid secretion from the wounds and  erosions  on  those
parts.   The infection may also result from taking  care of  dis-
eased animals,  if slight  wounds  upon  the hands  and  fingers
come in contact with their saliva and mucus.
   In many cases the infection may be the result both of con-
suming the milk and of milking the animals.
1 Heusinger, Pathol, comparee, II. p. DVIII. 
524       BOLLINGER,—INFECTION BY  ANIMAL POISONS.

    As regards  the  transference of  this malady indirectly  by%
communicating media, I have succeeded in finding in the litera-
ture of the subject only six cases reported by Hildebrandt.'
   1. A boy contracted a very severe aphthous eruption in the mouth, after having,
several days previously, bitten a pail that had been contaminated with the saliva of
a diseased cow.   2. A man inoculated  himself  by holding between his teeth  a
knife smeared with saliva.  3.  In like manner a young  girl became affected with
aphtha? in the mouth, after having held in her mouth a stick of wood that had
been previously used in cleansing the  mouth of a diseased cow.
   Fuchs 2 reported an instance of the inoculation of three boys, from having been
soiled with the dung of diseased animals. In this instance vesicles were developed
upon the toes.
    Respecting  the  predisposition of  man  to  this  malady,  no
accurate  estimate can be made.  The entire disease is compara-
tively unknown to the medical world,  and in the great majority
of  cases,  on account of the insignificance of the symptoms, does
not come under medical treatment.3   Human beings appear to
possess  no susceptibility whatever for the volatile  form of the
poison, and in general evince but a moderate predisposition, as
may be inferred from  the comparative  infrequency of the malady
in  man,  compared  with its very extensive prevalence  among
domestic animals.
   Dammann (Proskau), loc. cit., was unable to detect any ill effects either in him-
self, in  pigs, or in lambs, from the prolonged consumption of the milk of diseased
cows.  Reynal likewise drank the milk of such animals with impunity.
   The milk was also  employed in certain instances in the treatment of invalids,
without causing any bad results.
    It should be stated emphatically, notwithstanding the popu-
lar  notions  on this subject to the contrary, that the disease oc-
curs, at  all  events, much more  frequently than medical men are
inclined  to  admit.4   It  has been  proved by repeated observa-
   1 Ibidem, II., p. CCCCXCVI.
   2 Thierarztl. Mittheilungen, 1870, No.  VII.
   3 From the reasons  above-mentioned there is  found, in the journals and reports
relating to veterinary medicine, a much more frequent allusion to this subject than in
the ordinary medical journals.
   4 McBride affirms that in England, from 1839  to 1869,  there were observed, in all,
twenty-one cases of the infection of human beings with foot-and-mouth disease, a num-
ber which represents surely but a small fraction of  the cases of infection that actually
occurred. 
FOOT-AND-MOUTH DISEASE IN MAN.
525
tions,1 that  at  times,  when foot-and-mouth  disease prevails
among animals, a kindred affection, and especially an aphthous
eruption of the mouth, is noticed as occurring among children;
the local manifestations as well  as the  general  symptoms corre-
sponding very nearly to each other in both cases.
   Valleix described an epidemic of stomatitis occurring among children, in which
ulcerations were also exhibited upon the joints of the fingers.  Quite a number of
men were attacked with aphthae in the vicinity of Aix-la-Chapelle between the years
1838 and 1842, during which period foot-and-mouth disease was prevailing at that
place {Perty, loc. cit.).

    The attempt has been  made (Heusinger, Hering)  to account
for the prevalence of these diseases at the same time, among both
men  and  animals,  by assuming the  existence  of a common
miasma, an hypothesis which, in view of the definition already
given of the specific  infecting  principle, is manifestly unten-
able.  If we compare  many of the forms of aphthse (stomatitis
nlcerosa) described  in  the text-books  on diseases of children,
such as  frequently occur in  epidemic form, with the following
description  of  infectious aphthae, induced by foot-and-mouth
disease,  there will  certainly be found to exist  a marked corre-
spondence between the two.
    The majority of the victims of this  disease are children, and
individuals employed in milking or taking care of the diseased
animals.   Adults   are,  upon the  whole,  less exposed to the
disease, from the fact  that they are not so accustomed as chil-
dren  to drink unboiled milk.

                       Symptomatology.

   The period of incubation  of  foot-and-mouth disease in the
human subject  lasts, according to the clinical and  experimental
(Hertwig) facts upon record, from three to five days.
   Whether infection has been produced  by the consumption of
milk, or by the direct  inoculation of an abraded portion of the
skin,  there will be observed in both cases mild febrile symptoms,
  1 Kreutzer, p. 822;  Hering, Pathol, und Therapie, 3 Aufl., p. 367; Correspondenz-
blatt fiir schweizer Aerzte, 1872, p. 306, etc. 
 526      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

 slight headache, and  a sensation  of  dryness and heat in the
 mouth.  In rare cases the disease begins with one or more chills.
   After this slight indisposition,  combined  usually with an
 impaired appetite,  has lasted for several days,—the patient hav-
 ing,  meanwhile,  continued to drink the  infected milk,—vesicles
 appear upon the lips and tongue, and  less frequently also  upon
 the  hard  palate and  in  the throat, conjoined with  somewhat
 severer febrile syunptoms.  The vesicles may attain the size of a
 pea,  their  color being of a  yellowish-white, and  their contents
 whitish and turbid.  In the course of a day or two these vesicles
 burst, and the desquamated epithelium becomes detached,  leav-
 ing behind superficial,  dark-red ulcers and erosions.   Meanwhile
 the  patient complains of pain in  the mouth, which interferes
 with mastication,  speaking, and  swallowing.   The  lips  seem
 swollen,  there is a  copious flow of mucus and saliva, and the
 mucous lining of the mouth presents a  catarrhal redness. If the
 throat be affected  by  the process,  a difficulty in swallowing is
 then created.  In certain cases the  tongue and inner surface of
 the  lips become so  sore after the discharge of the vesicles, and
 the separation of the epithelium, that no solid food can be taken
 for many days (stomatitis ulcerosa).
   To the  disorders above  enumerated,  coming  on  after the
 consumption of  milk,  there are  almost invariably superadded
 disturbances of the digestive function,  the symptoms of gastro-
 intestinal  catarrh with fever, and  frequently  the  eruption of
 a vesicular exanthema upon the fingers and  hands.  Children
 especially,  who have consumed a large  quantity of contaminated
 milk, will complain of pain  in the lower part  of the abdomen,
 and  suffer  from loss of appetite, and  diarrhoea of more or less
 severity.
   A variable number of small vesicles very often make  their
 appearance upon the hands, about the nails, and upon the proxi-
 mal  ends of the fingers, being developed usually at the same time
 with the affection within the mouth.  The vesicles are at first
 only the size of a millet-seed, and contain a  transparent fluid;
but  they increase in size rapidly, while their  contents become
purulent, and of a  turbid-white color,  so that  they present the
appearance of ordinary pustules  of medium size.   The vesicles 
FOOT-AND-MOUTH DISEASE IN  MAN.
527
 are, for the most part, separate and distinct, but  some become
 confluent, especially  those  about  the nails and  the  posterior
 aspect of the phalanges.  The process of healing occupies usu-
 ally from two to three weeks, and  generally terminates without
 injury to the nail.  In exceptional cases only there is developed
 a severe  paronychia,  accompanied by mortification and loss of
 the nail.
    If  the specific virus is transferred by the operation of milk-
 ing, there will then be observed, at the expiration of the period
 of incubation, a vesicular eruption upon the hands, the  course of
 which  is  precisely similar to the local process produced by the
 drinking  of the milk.   The  patients complain  at the same time
 of headache, a sensation of heat and smarting within the mouth,
 and dysphagia ; while, in  addition to the eruption on the hands,
 red patches may  appear here  and there on the arms and breast,
 and, in rare instances, a vesicular  eruption on  the  face.   This
 latter  eruption may show itself as well after a  direct  infection
 through the hands,  as after  drinking the milk, and presents fre-
 quently a resemblance to small-pox.
    In one case an eruption covering the entire body was  observed
 after the  consumption of milk  (Bircher).   In another instance
 an eruption of bright  red spots appeared on the lower extremi-
 ties and the upper  portion of the body, and these subsequently
 became covered with thin, whitish scales (Hislop).
   All  these cutaneous eruptions—the vesicles  on the  external
 surface of the lips, on the face and hands, associated occasion-
 ally with  a very similar eruption on  the feet,l between the toes  -
 gradually dry up, and are converted into thin brownish scales,
 which, in  the course of nine or ten days,  fall off, though fre-
 quently a longer time,  two or three weeks, is required before the
healing process is completed.
   There  has  been observed in extremely rare instances a vesi-
cular exanthema on the breasts of women, analogous to the affec-
tion of the udder in the cow.
   Nozeran  (loc. cit.) observed an eruption of wart-like nodules on the  breast of a
  1A vesicular and papular eruption on the feet is rare, there being in all but three or
four authentic instances on record. 
 528      BOLLINGER.—INFECTION BY ANIMAL POISONS.
 woman,  accompanied by decided indications of inflammation, all  of wliich
 appeared after she had allowed her milk to be drawn by a sick lamb (the exact
 nature of whose malady was not determined).  The tumors were  so large as to
 require removal.  Holm (loc. cit.) saw small vesicles developed  on the  nipple of a
 woman, shortly after her confinement.  Scales were formed  upon the  seat of the
 vesicle, and in a few days recovery ensued.  The patient suffered at the same time
 from angina tonsillaris. This woman had been drinking, daily, milk obtained from
 cows affected with foot-and-mouth disease, and  had  also  been  attended by a
 young girl  who had herself milked these very cows.

   There have been observed, in still rarer cases, in addition to the
 vesicles upon  the inner surface of the lips, and the*slight inflam-
 mation of the velum of the palate and the tonsils, a development
 of scales upon the mucous membrane of the  nose, combined with
 symptoms of a  peculiar catarrh.  The stomatitis is sometimes
 accompanied by a severe glossitis.   Briscoe  describes a case in
 wliich  the tongue became  so swollen that it projected from the
 mouth to the  extent of an inch and one quarter.  Articulation
 became impossible, swallowing was rendered difficult, and respi-
 ration  obstructed.  Extensive ulcerations  were formed at the
 same time on the mucous membrane of the mouth, though upon
 the external surface of the skin there was no appearance of any
 eruption.  There was intense fever at the outset, and the patient
 was able  to take nothing but  liquid nourishment.  The disease
 lasted four weeks.
    The mildest forms  of this affection  appear  to consist of  an
 angina, accompanied by a catarrhal stomatitis.
    The appearance  of  pustules  and vesicles, not  only  on the
 hands,  but also on the wrists, and furthermore,  the development
 of  a phlebitis proceeding from an ulcer upon the finger (Fangel),
 are worthy of mention as forming the less frequent concomitants
 of the disorder.
   An inoculation succeeded by pretty severe symptoms came under the observation
 of Gaupp ' (Schorndorf).  A man,  twenty-six years of age, who had the care of a
 cow suffering from foot-and-mouth disease, was seized with fever, vomiting of yel-
low matter,  great prostration, pain in the forehead, racking pain  in the  joints, and
 a feeling of oppression about the chest,  and was obliged to take to his bed.  Upon
the sixth day a vesicular eruption appeared on the chin, extending upward so as
In Hering's Repertorium der Thierheilkunde, 1872, p. 10. 
FOOT-AND-MOUTH DISEASE IN MAN.
529
 to involve about one-half of the cheeks, and also on the dorsal surface of the hands
 and forearms.   The vesicles were at first the size of a lentil, and were surrounded
 by a red areola ; they gradually enlarged to the size of a pea, and became filled with
 a transparent lymph, which subsequently became more and more turbid.  The
 eruption was accompanied by severe burning pains; the mucous membrane of the
 mouth became of a bright red color;  from the salivary glands there was poured out
 a copious, viscid mucus, while  the sublingual and  maxillary glands were enlarged.
 The temperature of the body was  elevated ; the pulse moderately accelerated, and
 there was complaint of constipation, insomnia, and loss of appetite. The eruption
 wliich came out on the face and upper extremities, but which was absent from the
 rest of the body, resembled the  exanthema of variola.

    The course of the disease is, on the whole, mild.  Young chil-
 dren only,  who frequently  lose all appetite, and in whom  the
 disturbances of the digestive  function (diarrhoea) assume a  grave
 character, become  exceedingly  debilitated,  and  now and then
 succumb to the disease.
    The duration of the entire process is  variable.  Recovery
 often takes  place in from  five to eight days, especially when the
 infection has  resulted from  an inoculation of the hands ; as  a
 rule,  however, the affection  is prolonged,  as  in the  case  of
 animals,  to from  ten to fourteen days, or  even to three or four
 weeks.   The prolonged  duration is attributable  to the fact that
 the ulcers on the hand, or within the mouth, assume a malignant
 character, and heal but slowly.
    The malady terminates  in the  great  majority  of  cases  in
 recovery, a  fatal issue resulting but rarely, and  then usually  in
 the case of a weakly, sucking infant.

   Precy1 observed in the case of sucking babies emaciation, and in several instances
 death under symptoms of uncontrollable diarrhoea.  Ziirn2 reports the following
 case as having fallen under his observation: A herdsman, who had been handling
 with wounded  hands several cattle suffering from foot-and-mouth disease, was
 attacked with fever, and subsequently with an aphthous eruption affecting the
 mouth and various  portions of the body, and eventually died manifesting  symptoms
 which could only be attributed to septicaemia.  Ibid. p. 345:  A child, which had
 been drinking unboiled milk, obtained from a cow suffering from foot-and-mouth
 disease, became affected with so many aphthae and ulcers in the mucous lining of
the  digestive organs—as was observed by Ziirn at the autopsy—that death ensued.
   1 Repertorium der Thierheilkunde, 1873, p. 109.
   2 Die Schmarotzer auf und in dem Kurper  unserer Haussaugethiere, II., p. 344.
Weimar, 1874.
           VOL.  III.—34 
530      BOLLINGER.—INFECTION BY ANIMAL POISONS.
A fatal illness in a child produced by drinking milk was furthermore observed' in
the district of Aix-la-Chapelle
   As  regards the frequency and distribution of the  disease in
the human subject,  the reader is  referred to what  has  been
already stated.
                  Diagnosis and Prognosis.

   The diagnosis of the infectious aphthous  disease is, with the
aid of the previous history of the  patient, by no means difficult
to make.  Whenever,  during  the prevalence  of foot-and-mouth
disease, large numbers of children, and especially those who have
drunk the milk of diseased cows,  are taken  ill with  the symp-
toms of an  aphthous stomatitis, conjoined with  disorder of the
digestive  functions, such  cases  are always to be regarded with
suspicion.  In like manner, every vesicular eruption appearing at
such times on the hands  and fingers of human  beings who are
in the habit of coming in  contact with diseased animals, should
excite  the suspicion  that  an infection has occurred.  The vesi-
cular exanthema  on the face may often  be confounded with
variola, or varicella,  and the aphthous stomatitis with ulcerative
stomatitis.
   In  doubtful  cases, the diagnosis might be verified by the
inoculation of smaller animals (goat, sheep).
   The prognosis  is, upon the whole, favorable.   The epizootic
aphthae of our domestic animals, when communicated to human
beings, is not  a  dangerous affection, no more than in the case of
animals.   Serious  disturbances are produced only in very young
children, and  here assuredly an important role is played by the
chemical alterations in the milk.  It is possible that fatal results
are produced  in children by the diseased changes in the milk
more frequently than is commonly  supposed to be the case.  As
yet, however,  only isolated cases of this character are known.

          Prophylactic and Therapeutic Treatment.

   Although  the  predisposition of  man  to this affection is
pretty slight,  and  the course of the malady benign, it does not,
       1 Referred to by Fuchs, Thierarztl., Mittheilungen,, 1870, No. VII. 
FOOT-AND-MOUTH DISEASE IN MAN.
531
nevertheless,  seem  unreasonable  to demand that  the milk
obtained  from cows suffering  from  foot-and-mouth  disease
should be subjected in some way to the control of  the local sani-
tary officials, a measure which, up  to the present time, has  no-
where, so far as I know, been attempted.  It will be a  matter
for further consideration whether  the state prophylactic mea-
sures ought to  be extended so as  to forbid the sale of the milk so
long as  the animals show signs  of fever, or while the milk  ex-
hibits  any abnormal  character, or whether they should be lim-
ited to a simple official notice to the effect that  the  malady is
prevailing in such and such localities and stables, combined with
a warning  to milk  consumers.  Under no circumstances ought
the milk of diseased  animals  to  be consumed except after boil-
ing.  As we do not propose to enter into any discussion of  the
state measures  for preventing the  spread of the disease in ani-
mals,  we  may be  permitted to  append a  few  observations
respecting  the  therapeutic treatment of  epizootic  aphthae in  the
human subject.
   As  in the case of foot-and-mouth disease in animals, so in the
human subject, in order to promote the favorable progress of the
entire process, it is above all important  to abstain from all active
therapeutic measures, and also to avoid all powerful applica-
tions to the affected parts.   The treatment should be sympto-
matic and principally dietetic.
   If the infection has been  produced by the  milk of diseased
animals,  care should first of  all  be taken to secure a supply of
uncontaminated milk.  If  the stomatitis is extensive, the  fre-
quent application of a weak alkaline wash (borax in solution) to
the cavity of the  mouth  may be recommended, with the view
of neutralizing  the excessive acidity.  Cauterization of the pain-
ful erosions and  ulcers,  by  means  of  solid  nitrate  of  silver,
serves  to alleviate the pain, furnishes  a protecting covering
for the eroded  surfaces,  and facilitates  cicatrization.  Cooling
drinks may usually be administered, but should be witlield in
cases of severe diarrhoea.
   The affections  of  the  superficial integument  (hands and
fingers) should  be treated in accordance with the general rules of
surgery. 
INFECTION BY  THE  BITE OR STING  OF POISONOUS  ANIMALS.
                           STINGS  OF  INSECTS.

Steffen, Infection durch Insectenstich.   Deutsches Archiv fiir klin.  Medicin,  II.
    p. 192, 1866.—Bique, Ueber die Folgen von Fliegenstichen.  Rec. de mem. de
    m6d. milit., 3 Ser.  14, p. 472, 1865.—Faure, Piqures de mouches.   Gaz. des
    Hopitaux, No. 66, 1868.
Nivison, Fatal Result of a Bee Sting.  New York Journ., May, 1857.—Ewens, Death
    from Bee Sting.  Med. Times and Gaz., 1860, p. 389.—Finkh, Tod nach einem
    Wespenstich.  Wurtemb.  Corresp.-Blatt, XXXI, 35, 1861.—Michel,  Schneller
    Tod in Folge eines  Wespenstichs.  Wurtemb.  Corresp.-Blatt, XXXII, 1, 1862.
    — CDonnell,  W., Poisoning by a Bee Sting.  New York Med.  Rec, II. No. 43,
    1867.—Hawelka, Infection durch einen Wespenstich. Wien. med. Presse, No. 32,
    1869.—Thompson, D., Death from Bee Stings.   Brit. Med. Journ., April 24, p.
    374, 1869.—Terry, G., Wasp Stings.  Brit. Med. Jtfurn., Sept. 2, 1871.—Drury,
    C, Wasp Stings. Brit. Med. Journ., Sept.  23, p. 351, 1871.—Bienenstich, Cor-
    resp.-Blatt, fiir schweizer Aerzte, p. 583, 1872.
Cavaroz, Ueber  den  Biss des Scorpion  von Durango.  Rec. de mem. de med., etc.,
    milit.,  3 Ser., XIII, p.  327,  1865.—Heinzel,  Ueber Scorpionenstich.  Woch-
    enbl. der Gesellsch.  der wiener Aerzte,  1866,  p. 323.—Dalange,  Des  piqures
    par les scorpions d'Afrique.  Rec. de Mem. de m6d.  milit.,  1866, p. 136.—
    Guyon, Sur un phenomene produit par la piqure du Scorpion.  Compt. rend.
    Vol. LXIY. p. 1001, 1867.—London, Ein Fall von Verletzung  durch Scorpion-
    stich.  Wien. med.  Presse, No. 6, 1869.—Jousset, Essai sur levenin du scor-
    pion.  Compt. rend., LXXL,  No. 10,  p. 407, 1870.—Posada-Arango, A., Note
    sur les scorpions de la Colombie.  Arch, de mecl. navale, XVI., 213,  and Gaz.
    des Hopit., No.  121, 1871.
Wood,  H. C, Effect of  the Bite of  the  Scolopendra heros (Centipede).  Amer.
    Journ. of Med.  Sciences, 1866, p. 575.—Sebastiany,  Piqure de la  Scolopendre
    mordante.  Gaz. des Hopit., No. 91, 1870.
Frantzius, v. A., Vergiftete Wunden bei Thieren und Menschen durch den Biss der
    in Costa-Rica vorkommenden Minirspinne.  Virchow's Archiv f.  path. Anat.,
    Bd. 47, p. 235, 1869.— Wright, The Katipo, or  Poison Spider of New Zealand.
    Med. Times and  Gaz., Nov. 12, p. 570, 1870.—TJcke, Vergiftungen durch Spin-
    nenbisse  in der  Kirgisensteppe im Sommer 1869.  Petersb. med.  Zeitschrift,
    1870, 1 Heft,  p. 54. 
STINGS OF INSECTS.
533
Heimel, Ueber Tarantelbiss.  Wochenbl. der Gesellschaft der wiener Aerzte, 1866,
    p. 255.
Compare further, Billroth, Th., Von den vergifteten Wunden, Handbuch der allg.
    u. spec. Chirurgie, v. Pitha u. Billroth, B. I, II Abth., HI Abschn., p. 86 ; also,
    Die Jahresberichte iiber die Leistungen, etc., in der gesammten Medicin, von
    Virchow und Hirscli: A. Hirsch, Acute  Infectionskrankheiten, B. H v. 1866-
    1872.

    There exist  numerous insects which have the power of pro-
ducing  in man, by their sting, inflammation and poisoning of
greater or less severity.  Passing over the cutaneous parasites,
wliich are treated of in another portion of this work, and also
a variety  of  flies,  gnats,  and mosquitoes,  we come  to certain
hymenoptera (bees,  wasps, hornets),  arachnida (scorpions, spi-
ders), and  some  forms of  the myriapoda  (scolopendra),  which
especially demand our attention.
    1. Infection by the sting of insects, and especially by that of
certain  flies, is  an affair of frequent occurrence, yet it is impos-
sible to state with certainty whether the sting forms in itself the
injurious agent, or whether the insect serves merely as the vehi-
cle for  the implantation of some  other virus {e.g., cadaveric
poison,   or  the  poison  of malignant pustule).   Such cases of
infection by insect stings are often  characterized by very  severe
symptoms, and frequently terminate fatally.   There  is  com-
monly found at the seat of the sting a very painful tumefaction,
with deep-seated inflammation  and  an  infiltration of  the sur-
rounding  tissue.    As a result of  the constitutional infection,
there will  also  be observed an intense fever, great  restlessness,
and inflammations of the  internal organs.    Steffen describes  a
case of  this sort occurring  in a boy,  ten years old, which ter-
minated fatally.
    2. Infection  by the sting of bees, wasps, and hornets.
    The  so-called hymenoptera constitute the order of the poison-
ous stinging  insects (hymenoptera aculeata), and are  character-
ized essentially  by being provided with a denticulated sting, into
which the  excretory duct of  the  poison-bladder  opens.  The
poison-bladder  receives the secretion of two pyriform  glands.
The contents of  this  bladder are ejaculated  into  the  small
wounds  made  by the sting, giving rise to  a pretty severe and 
534      BOLLINGER.—INFECTION BY ANIMAL POISONS.

painful inflammation.   The skin at these points becomes indu-
rated and reddened to  a varied extent.  The pain, redness, and
swelling disappear, as a rule, in the course  of  a few hours, but
in many instances continue for one  or two  days.   Suppuration
rarely ensues.
   Wounds of this character have, in rare instances, been known
to be followed by symptoms of blood-poisoning, and now and
then by a fatal result.   Such dangerous stings are mostly inflict-
ed in certain special parts  of the body, as for  instance near the
eyes, ears, and lips, and occur in feeble women or in old persons.
The constitutional symptoms are usually  nausea, faintness, great
weakness, vomiting, precordial distress,  difficulty in breathing,
also  coldness of  the extremities, and frequently petechia? on the
body, or the general eruption of a pale-reddish exanthema, either
resembling that of measles, or in the form of  wheals, with intense
itching.  Less frequently an excessive thirst is  experienced, and
a hoarseness increasing to an absolute aphonia.   In place of the
slight redness and swelling in the vicinity of  the sting, there
appear  at  times  an extensive  tumefaction  and lividity, which
may involve a large portion of the affected limb, or even the
entire body.   These phenomena last for several hours, disap-
pearing in  favorable cases speedily, or within  a few days.  In
many instances death ensues within a quarter of an hour, or even
a few moments.  It is  probable that  in such  cases the virus
has been ejected from the sting directly into  a blood-vessel.
   A fatal  result may likewise ensue when  human beings, par-
ticularly children, are  attacked by an  entire  swarm of these
insects, or when  the seat of  the sting is in the  throat.   The lat-
ter accident happens when fruits or liquids are taken into the
mouth,  in which  some  insect of this order  happens to be con-
cealed, the puncture being inflicted  in the mucous membrane by
the insect on its way down.  In consequence of the acute swell-
ing and the oedema of the glottis, suffocation may be produced
within a very short time.
   3.  Infection by the sting of scorpions.
   Scorpions—belonging to the order  of arachnida—are  com-
posed  of a short cephalo-thorax,  which articulates along  its
entire breadth with the abdomen.  The latter is divided into two 
STINGS  OF INSECTS.
535
parts, a cylindrical  anterior portion, composed of  seven joints,
and a compressed,  caudiform, posterior  portion,  terminating in
an incurved sting, provided with two poison glands.
    Scorpions inhabit hot countries, and  are met with in Europe
as far north as the southern slope of the Alps.   They live  under
stones and  the bark of  trees, in  the sand,  or beneath plants,
making  their way also into houses.  The most important  spe-
cies are : The European scorpion  (sc.  europaeus) of Italy,  the
Tyrol, and  southern France; the  scorpio occitanus of  northern
Africa,  southern Spain,  and southern France ; and the scorpio
afer, the largest and most dangerous of  all, inhabiting  Asia and
Africa.   Scorpions are also  found frequently in Texas,  Syria,
New Granada (Colombia), and in Algiers.

   Jousset describes the contents of the poison-bladder as a colorless, clear liquid,
of an  acid reaction, whose specific gravity is somewhat higher than  that of
water.  Microscopically, the poison appears  perfectly transparent.   Epithelial  culls
and a finely granular mass are found in  it, but these  elements are not constant.
Within the poison-bladder of  a medium-sized scorpion  (sc. occitanus) there are
found about two milligrammes  of poison, a quantity sufficient to destroy rapidly a
medium-sized dog.  According  to the experiments of Jousset on frogs, the poison
attacks at once the red blood-corpuscles, causing them to adhere  to one another,
and thus forming masses which plug the capillaries, and thereby obstruct the circu-
lation.
   Heinzel performed experiments upon frogs and birds; both die within a few
seconds after the sting of a scorpion, death taking place—as when curare has been
administered—without convulsions, from paralysis of the peripheral nerves, respira-
tion being accelerated.  Guyon,  in his experiments with scorpion poison upon dogs
and guinea-pigs, noticed violent erections of the penis, a symptom which was also
observed by Delange in Algiers in the human subject.  Guyot,1 in the course of his
experiments, saw a guinea-pig destroyed in fifteen minutes, and a large  dog in fifty
minut

    The action of the poison is influenced by the size  and strength
of the wounded animal, the  quantity of the  poison introduced,
the  number  of  stings, and  the susceptibility of the  wounded
individual.   The symptoms are said to be more severe in summer
than in winter.   Children incur greater danger than  adults.
    The European scorpion gives rise by its  sting to an acute,
local,  and painful  inflammation, wliich generally disappears in
1 Jour, de med. vet. de Lyon, T. VIIL p. 191, 1852. 
536      BOLLINGER.—INFECTION BY ANIMAL POISONS.

the course of a few hours.  The large scorpions of hot countries
(Syria), on the other hand, are much more formidable.   Their
sting is quite virulent, acting more energetically in  many cases
than the poison of a  serpent.  In the fatal cases, such as occur
frequently in Algiers, especially in children and  debilitated per-
sons, there are  observed, as the most important symptoms, livid-
ity of the face, cyanosis of the  lips, weakened pulsation  of the
heart, a  small  and retarded pulse, erections  of the  penis, great
restlessness, severe vomiting, involuntary faecal evacuations, and
finally, at the expiration of several hours, death, with symptoms
of oedema of the lungs.  At other times, after the manifestation
of very violent symptoms of  constitutional infection—with con-
vulsions, unconsciousness, and excited action of  the heart—the
patient  is restored to health  upon  the third  or fourth day.
Posada-Arango (New  Granada) points out  a  symptom which he
regards as pathognomonic, and quite independent  of the wound,
viz.: a sensation of numbness and heaviness in the tongue, com-
ing on immediately after the injury, a form of paresis of the lin-
gual and hypoglossal  nerves, rendering it difficult to move  that
organ, and interfering with speech.  At the same time the  senses
of taste and touch appear to be impaired.
   4. Infection by the Bile of Spiders.
   Spiders, belonging also to the class of arachnida, are  armed
with hook-shaped mandibles, moving horizontally, at the apex
of which  the excretory duct  of  the poison-gland empties.  The
virus pouring  into the wound  (produced by the blow of the
claw), causes in the smaller animals instantaneous death.
   The bite  of  the bird spider  of South America {mygale avi-
cularia), which has a  body of from two to two and a half  inches
in length, is said to produce in man a prolonged inflammation,
with suppuration and  callous cicatrization (Schmarda).
   The bite of the scorpion  spider of Costa Rica, of the  genus
Mygale,  proves dangerous to man in  rare cases only.  It  never
bites except when irritated or disturbed,  wounding generally in
the feet or in the  scrotum.  The bite produces no general infec-
tion, there being merely a superficial and rapidly spreading der-
matitis, with serous exudation.  The  bitten persons experience
severe smarting pains;  vesicles  are formed at the  seat of the 
BITES OF INSECTS.
537
wound, which are filled  with a sero-mucous fluid.  After the
epidermis becomes detached, there remains an ulcerated surface,
wliich, like erysipelas,  spreads rapidly upon the periphery (v.
Frantzius), and forms the seat of a copious secretion.
   In the steppes of the Kirgheez there is found a spider {Latro-
dectus lugubris) which measures about  half an inch in length,
and which is extremely dangerous, especially to large  animals.
One-fifth of all those bitten  are destroyed, although of human
beings thus wounded only four per cent. die.   There is experi-
enced, after the wound, a smarting pain at the seat of the punc-
ture, gradually extending over the limbs and entire body, while
there is an absence of all  redness and swelling.   This is rapidly
followed by cold sweats,  restlessness, dizziness,  mental  anxiety,
depression,  vomiting,  cyanosis,  convulsions,   and a  typhoid
condition.  These  symptoms  do not abate before the third or
fourth day, while a  fatal result may occur  after two  or three
days (Ucke).
   The katipo spider of  New Zealand, by its  bite, produces a
white vesicle at the seat of the wound, which is surrounded by a
red areola, and is attended by severe pain. The  pulse is scarcely
perceptible, and greatly retarded.  Great dyspnoea is observed,
with lividity of the face,  and cold extremities.   If appropriate
treatment is employed, the symptoms gradually disappear, and
recovery ensues in the course of a few days (Wright).
   In the South of France and in Spain, especially in the vicin-
ity of  Tarragona,  there is found a spider that  is greatly feared
on  account of its bite  (the aranea tredecim guttata, theridium
malmignata), measuring nearly half an inch  in  length, and fur-
nished  with   largely developed  poison-glands.   The  virus  is
thought to exercise a specific action upon the  nervous  and
muscular systems.  The effects of the poisoning disappear within
a short time,  although, in many instances, especially in the heat
of the summer, a feeling of uneasiness remains (Schmarda).
   The tarantula {lycosa  tarantula) is met with in Italy, and is
greatly feared;  it  measures  as much as  an inch and a half in
length, and lives in  holes, which it digs in the ground.   The
phenomena following the bite  are  similar to those  of other
insects already described.  The notion that persons bitten by the 
538      BOLLINGER, — IXFECTION BY  ANIMAL POISONS.

tarantula fall into a state of delirium, accompanied by an exces
sive avidity for dancing (tarantismus), originates in a wide-spread
vulgar superstition, and is entirely unsupported by facts.  Hein-
zel, who experimented upon himself with a tarantula obtained
from  Syria, experienced, after  receiving a bite in the hand,  a
slight sensation of tension  in the arm.  An  eruption of wheals
with a red areola appeared, but aside from  this there were no
local manifestations, nor any nervous anxiety.
   5.  Infection by the bite of scolopendra (centipedes).
   The scolopendr ina—of the order of  Myriapoda—are insects
composed of several joints, and  have an elongated, cylindrical
body, each of whose numerous  segments is provided with a pair
of feet.   The anterior pair of feet, attached near the  head, are
employed in the prehension of food.  These form a sort of '' foot-
jaw,'' the anterior free portion of wliich contains more joints, and
is provided with  poison-glands and a terminal claw capable of
inflicting a wound.  These mandibles enable centipedes  to trans-
fix other animals and destroy them by the  poison  that is dis-
charged into the wound.  The  scolopendra morsitans  is found
in large  numbers  in  southern  Europe;  it lives  beneath damp
stones and old walls.
   The symptoms occurring after the bite are as follow : At  first
an itching is  experienced, which is soon followed by an intense
pain, which extends to the entire limb.  At the seat of the punc-
ture  a red spot appears, which  gradually enlarges and  becomes,
finally, perfectly black in the centre, as in the case of malignant
pustule.   Lymphangitis and lymphadenitis of the adjacent lym-
phatic glands frequently supervene.  The  constitutional symp-
toms consist of  great mental anxiety, pain in the limbs, irregu-
larity of the pulse, dizziness, headache, and  vomiting.   In  rare
instances death results, with convulsions, even  within five or six
hours, as has  been often observed  in Texas, for instance, after
the bite of the scolopendra heros (Wood).

                          Treatment.

   The treatment of all the stings and bites above described is
about the same.  The  best applications are cold compresses, ice, 
                          SNAKE-BITES.                       539

lead-water, and ammonia.  In wounds inflicted by the hymenop-
tera, it is well to ascertain whether the sting has been left in the
wound, and this, if found, should be extracted with a fine for-
ceps.  In the case of spider bites,  the withdrawal of the virus by
a cupping-glass, and the application of the actual cautery to the
wound, can also be resorted to.
   The local  application of ammonia, combined often with the
internal administration of water of ammonia, has been proved by
experience in all these poisonings to  be attended by favorable
results, and its employment seems reasonable,  inasmuch as when
applied externally it has the effect of neutralizing the acrid virus.
A favorite internal remedy is water of ammonia combined with
brandy or  hot tea, with the view  of producing,  at the  same
time, diaphoresis.
   Dalange recommends,  in the  case of a scorpion sting, the
application of a firm ligature above the  seat of  the wound, also
three or four incisions, from a quarter to half an inch in length,
over the wound, and, finally, the  employment of suction by the
mouth.  In New Granada a popular remedy is  employed with
success to relieve the peculiar paresis of the tongue in the case
of scorpion stings;  this consists in holding in the mouth the slice
of a very sour lemon.
   In the case of centipede bites Sebastiany advises the internal
administration  of fifteen  grains of carbolic acid, combined with
thirty of chloral, and external astringent  applications.


                          SNAKE-BITES.

Fontana, Traite sur les venins de la Vipere.  Florence, 1781.—Canton, Viper Bite in
    the Thumb.   Lancet, II, Aug. 6, 1857.—Heinzel, Zur  Pathologie und Thera-
    pie cler Vergiftung  durch Vipeinbiss.  Wochenbl. der Ges. der Wien.  Aerzte,
    1866, p. 169.  Ibidem, 1867, Nos. 16 and 17.—Encognere, Des accidents causes
    par la piqure du serpent  de la Martinique.    Montpellier, 1865.—Boullet,
    L. J., Etude sur la morsure de vipere.  Paris, 1867.— Viaud-Grand-Marais,
    De la letalite de la morsure des viperes. Gazette  des Hopitaux, Nos. 62 and 65,
    1868.  Ibidem, 1869, Nos. 48, 49, and 54.— Cheron et  Goujon, Sur Taction du
    venin de la vipere.   Compt. rend., LXVTL, No.  19, 1S68.—Mandic. Zur Casu-
   istik des Vipernbisses.  Wien. med. Presse. Nos. ?.">—27,  1871.—Fischer, Ein Biss
   der Kreuzotter (Yiperus Berus).  Zeitschrift fiir Wundarzte und Geburtshelfer, 
540      BOLLINGER.—INFECTION BY  ANIMAL  POISONS.

    1872, p.  95.—FreJJrt, Cas de mort par la  morsure d'une vipere.   Gaz. des
    Hopit., 1872, No. 106.—Vipernbiss, Corresp.-Blatt fiir schweiz. Aerzte, 1872, p.
    808.—Putz, Zur Behandlung des Schlangenbisses durch subcutane Injection von
    liq. amnion, caust.  Berlin, klin. Wochenschr., 1873, No. 28.
Imlach, Mortality in Consequence of Snake-Bites in the Province of Scind. Transact.
    of the Med. and Phys. Soc. of Bombay, 1855 and  1856;  also in Arch, gen., Dec.
    1857, p. 735.—Mitchell,  S. W., Researches upon the Venom of the Rattlesnake.
    Washington, 1861. The Venom of Serpents.  Med. Times and Gaz., 1869, Feb. 6.
    Observations on Poisoning with Rattlesnake Venom.  Amer. Journal of Med.
    Sciences,  April, 1870, p.  317.—Halford, G. B., Experiments on the Poison of the
    Cobra-de-Capello. Brit.  Med. Jour., 1867, pp. 53 and 563. On the Treatment of
    Snake-Bites.  Dobell's Reports on  the Progress of Practical and Scientific Med-
    icine, Vol. II., p.  447, 1871.—Jones,  J.,  Experiments with  the Poison  of the
    American Copperhead.   New York  Med. Record, p.  289, 1868.—Shortt, J.,
    Experiments with the Poison of the Cobra-de-Capello.   Lancet, p. 556, p. 615,
    1868.—Fayrer, J., On the Action  of the Cobra Poison.  Edin.  Med.  Jour.,
    1868, p. 522, 1869 and 1870.  The Thanatophidia of India; being a Descrip-
    tion of the Venomous Snakes of the Indian Peninsula, with an Account of the
    Influence of their Poison on Life, etc.  London, folio, 1872—Ogle, W., Loss of
    Speech from the Bite  of Venomous  Snakes.  St. George's Hos. Rep.,  Ill, p.
    167, 1868.—Berge, Trois cas de morsure  par  serpents a sonnettes.   Rec. de
    mem. de  med. milit., 1869, p. 168.
Compare A. Hirsch, Acute Infectious Diseases, in the Jahresbericht iiber die Fort-
    schritte und Leistungen in der gesammten Medicin von Virchow u. Hirsch,
    1866-1872,  Bd. II.

    Snakes—belonging to the class  of reptiles—are armed  with
solid incurved teeth, which are intended merely to enable them
to fasten upon then: prey ;  and some varieties  are also  provided,
in addition,  with hollow or grooved fangs, which form the excre-
tory  duct  of a poison-gland,  and  conduct  into  the wound  the
poison expressed by  the  action  of the temporal  muscle.   The
poison-fangs, which are furnished with a central tubular cavity,
are situated in the small  upper jaws,  one on each  side.   The
teeth, which are  at first movable,  after their  complete develop-
ment, become firmly attached to the  upper jaw, which is mova-
ble.  When the animal is at rest, the  fangs occupy a horizontal
position, being concealed in a fold  of  the  gum, but  when  the
mouth is  opened, they become  erected by the action  of the so-
called quadrate bone,  by which motion the upper opening of  the
tubular cavity is connected with the orifice of the duct of  the
poison-gland.  Each poison-gland corresponds  to a parotid gland, 
SNAKE-BITES.
541
and  is  composed of a similar  structure.   The excretory duct is
slightly tortuous, and, just  before  its  point of  union with the
fang, is provided  with a  powerful  constrictor muscle.   As the
act of biting is  produced by the  forcible closure of  the jaws, in
like  manner, by the action of the temporal  muscle,  the  poison-
gland is compressed,  and the  poison ejaculated, and with  such
force that, in the case of rattlesnakes, for instance, the poison
may be ejected  to a distance of  several feet.
    Respecting the habits of snakes,  it may be remarked that the
majority  of  them  inhabit tropical  countries, and live for the
most part in the woods, beneath  the foliage, and in holes in the
ground.   Some varieties are in  the  habit  of  climbing trees and
bushes, while others live in the water or in the sea.


       Systematic Classification of the  Venomous Snakes.
    I.  Sub-order : Vipers ( Viperina).  The upper jaw is very short, and contains no
other  teeth behind the hollow, ungrooved poison-fangs.
    1.  Family:  Burrowing vipers (Crotalidm).  A deep pit on each side of the head
between the nostril and the eye.  The tail is prehensile, and is furnished with horny
appendages.  America and Asia.
    Battlesnake (Crotalus).  Tail furnished with a rattle. Rattlesnake (Cr. durissus)t
south-eastern part of North America, Mexico,  and as far south  as Surinam.  Casca-
vella  (Cr. horridus,  banded rattlesnake), South America.
    Silent rattlesnake (Lachesis).
    Triangular-headed snake (Trigotocephalus).
    2.  Family :  Viperida. No pit between the eyes and nostril.  Tail non-prehen-
sile and destitute of horny appendages.   Eastern hemisphere.
    Viper (Vipera).  Hind portion of the head very broad, and its outlines sharply
defined.  Common adder (adder, Kreuzotter, Feuer-, Kupfer-, Hollennatter,  vipera,
or  PAias Berus).  Covered on the summit of the head with regular plates.   Color
quite varied.  A sure distinguishing sign is a dark-colored, zigzag stripe  on  the
back, slightly raised above the ground color.   It inhabits damp and wooded locali-
ties in mountainous  countries, living in the  clefts of rocks and in shrubbery.   It is
met with pretty often in Central Europe.   The shield-viper (Vipera aspis,  Vipera
Bedi).  Summit  of the head covered with scales only;  in other respects very  similar
to the common  adder.   The back without a zigzag band, but  covered with large,
distinct, dark spots.  Found principally in the south-western countries of Europe.
Sand-viper ( Vipera ammodytes) in Italy.
   II.  Sub-order.  Venomous serpents (Colubrina venenosa).  The upper jaw  is fur-
nished with grooved fangs,  behind which are a few  solid teeth, though in some
varieties there are no other teeth. 
 542      BOLLINGER.—INFECTION BY ANIMAL POISONS.
   1.  Family: The genuine venomous serpents (Elapidm).  Body almost cylindrical;
 tail short and pointed ; nostrils on the side.
   Flaps (Prunkotter).  Many varieties in America, Asia, and Africa.
   Bock-serpent (Bungarus).   East Indies.
   Shield-viper (Naja).  This has the power of  moving the front ribs, and thereby
 distending the region of the neck, in the form of a disk.  Spectacled-snake (cobra-
 de-capdlo, or hooded-snake).
   2.  Family: Sea-serpents  (Hydrophidai).   Body and tail  compressed laterally.
 Nostrils on the upper part of the head.  In the Indian and Pacific Oceans.

                          A. Viper Bites.
    In Central Europe (Germany, France, and Switzerland) there
 are found  two  species of  snakes which are moderately danger-
 ous,  viz. : the shield,  viper  {Schildotter,  Vipera Redi, Vipera
 aspis),  about  three feet long, of a reddish-yellow color, and
 covered with black spots, and also  the common viper {Kreuz-
 otter,  Vipera Berus,  Vipera  Pelias),  with the characteristic
 zigzag band on the  back.
   In  the Alps there is often found a black species of the common viper—Vipera
 ■prester—an irregular variety of the common female viper, which mates with the male
 of this species and commonly produces the common viper, to which, likewise,  it
 corresponds in respect to its venomous properties and mode of life.

    Next after Fontana, whose work was classical even down  to
 a recent date, we are  indebted  to  Heinzel, Boullet,  and Viaud-
 Grand-Marais for valuable observations respecting viper bites.
   Both varieties  of  vipers, Vip.  Redi,  and  Vip.  Berus, are
 equally venomous ; they bite,  as a rule,  only when irritated,  or
 in self-defence.   The virulence of the poison is the greatest  in
 the spring (after hibernation),  in the hot season,  when the poison
appears to be the most concentrated, and finally, when the poison
glands  are completely filled.  According  to  Fontana, the total
quantity of the  poison in both glands amounts to at most ten
 centigrammes.   The poison is  of a clear, yellowish color.
   The wounds produced by the bite, as is the  case with venom-
ous serpents  generally, are of a penetrating character, and two
in number, thus, •   *   ; whereas the wounds inflicted by a non-
venomous  snake are of  a zigzag shape, $X  .  In consequence  of
the curved  outline  of  the poisonous  fangs,  the wound  likewise 
SNAKE-BITES.
543
presents a curved shape, and upon those portions of the body
which the snakes are unable to grasp with  their jaws it pene-
trates but a short  distance (about one millimetre) into the tis-
sues ;  in other parts—upon the fingers and toes—the  wound
equals  in depth the entire  length of the fang which has been
forced into it.   The head of the viper may inflict a wound even
after it has been separated from the body (Viaud-Grand-Marais).
It rarely happens  that several  bites are inflicted by the  same
reptile.
   Of forty-five cases terminating fatally, twenty-six were ascertained to be males,
and twenty-one females.   One-half of the fatal cases occurred in children under the
age of fifteen.

   The seat of  the wound is, as a rule, upon the leg, and  usu-
ally in the vicinity of the ankle-joint, less frequently, by far, on
the  head,  face (in  children),  breast, or other  portion  of the
trunk.
   Small animals (frogs, toads,  rabbits) die  almost invariably
after the viper bite ; dogs and sheep less frequently, while in
larger animals (horses,  cattle) the wound is  never  fatal.   The
hog, pole-cat, and hedgehog are said to be insusceptible to the
virus.

                       Symptomatology.

   Immediately after the infliction of the bite, the wounded per-
son  experiences  a pain, more or  less severe, at the seat of the
injury.  A few drops of blood ooze from the two small wounds,
around which  a livid  redness very soon appears, attended by
extensive tumefaction.   The inflammatory  swelling  generally
supervenes within an hour after the infliction of the wound, and
frequently attains a considerable size, involving a large extent
of tissue, but recedes usually in from four to eight days.  Mean-
while, pain is  experienced in the seat of the wound and its im-
mediate vicinity, while  the  injured part feels to the  patient
benumbed, its  temperature falling to 86° or 88° Fahr.   Within a
few hours or a day after the injury, livid spots make their ap-
pearance, which are quite characteristic ; those spread from the
wTounded part  in all directions.   Phlyctsense  and gangrene are 
544      BOLLINGER.—INFECTION BY ANIMAL POISONS.

produced at the seat of the wound, due in part to  the therapeu-
tic measures resorted to (ligatures, ammonia).
   The secondary constitutional symptoms, which often super-
vene within a few  moments, and generally in one-half, one, or
two  hours, are faintness, loss of  consciousness,  chilly  sensa-
tions, cold clammy sweats, small, irregular pulse, gasping for
breath, sunken eyes,  fades  Hippocratica,  general prostration,
intense thirst, vomiting, prsecordial distress,  occasional diarrhoea,
icterus, more or less severe, and complete  suppression of the uri-
nary secretion. In severe cases the patient is seized with cramps,
convulsions, delirium, and involuntary evacuations of urine and
faeces, both of which are often mixed with blood.
   The symptoms of paralysis affecting the  motor nerves, begin-
ning at the periphery and extending towards the centre, afford  a
significant indication  that the system has been infected.  In this
case,  as happens after the administration of  curare, the paralysis
first affects the extremities of the motor nerves, then the  nerve
trunks of  the voluntary muscles, afterwards the  nerve-centres,
and finally the sensory nerves.
   In the fatal cases,  wliich are attributable to the blood-poison-
ing produced by the direct introduction of the virus into the cir-
culation, the shortest duration of the illness is from one to two
hours, though it usually lasts from a number of hours to several
days.  Death results  with symptoms of nervous prostration and
asphyxia.
   If the disease  terminates favorably, a gradual amelioration of
the local and  general  symptoms takes place, profuse perspira-
tion being often observed at the crisis.
   A fatal result  ensues in 25 per cent,  of the cases within the
first twenty-four hours, in 50 per cent, between the second and
sixth days, in 25 per cent, between  the seventh and twenty-first
days, and in a few cases only after the lapse  of several months,
in consequence of general cachexia.
   As sequelos, there are frequently  observed an oedema and
weakness of  the  injured part, which continue for a considerable
length of time; furthermore,  paralysis  and nervous disturbances.
   The  prognosis of the viper bite is, as  a rule, by no means
unfavorable.  The danger to be apprehended from  a bite depends 
SNAKE-BITES.
545
upon the quantity of the poison, in wliich connection are to be
considered  the  size of the reptile and of the individual  bitten,
the time that has elapsed since the  last bite  previously inflicted
by it, the number of the wounds made, and the extent to which
the animal  has  been irritated; also upon the depth of the bite,
and the locality of the wound,—wounds of the blood-vessels being
the most formidable, while  bites in  fatty, non-vascular portions
of the body are less to be feared; finally, upon the constitution
of the patient and upon the  treatment.

  Although  the mortality from viper bites in the Department Loiret amounted,
according to Boullet, to only one per cent, (two fatal cases out  of 200 persons bit-
ten), it is  stated by Viaud-Grand-Marais that in the Vendee, and the Department
Noire-Inferieure 14 per cent, died (of 316 persons bitten 44 died). Whether this dif-
ference is to be ascribed solely to the treatment, or to other local conditions, it is
difficult to say.  Of 50 cases of viper bite collated by Fontana, two only terminated
fatally. Upon the average, therefore, the rate of mortality would amount to 8.5 per
cent, (of 566 persons bitten, 48 died).

   The diagnosis presents no difficulties, provided that  we are
informed of the previous history of the case.  If the physician is
in doubt as to whether  the  bite was inflicted by  a venomous or
non-venomous reptile, this point can be determined by the shape
of the wounds, as above described.  The wound made by the bite
of a  non-venomous  snake is  of a zigzag shape,  while  that of
venomous  snakes presents the  appearance of two round aper-
tures.

                          Treatment.

   The most important indications presented in the treatment of
a case of poisoning by a viper bite are (Heinzel):
   1. Prevention of  the  absorption of the poison by such mea-
sures as the application of the cupping-glass,  or compression
at the seat of the injury with the finger or tourniquet;—the liga-
ture applied above the wound must be broad, and should not be
drawn too  tight.
   2.  The withdrawal of the poison  as soon as possible, by wash-
ing or squeezing the  wound, by means of suction by the mouth,
application of a cupping-glass  after moderately deep  incisions
          Vol. III.—35 
546      BOLLINGER.—INFECTION BY ANIMAL  POISONS.

have  been made across the  seat of the bite,  or by  amputa-
tion of the injured limb, in case the wound is situated upon  a
finger or toe.
   3.  Local destruction or neutralization of the poison by the
application of the red-hot  iron, of caustics  (nitrate of silver,
caustic potash), or of ammonia.
   4.  The disinfection of the blood by the internal administra-
tion of ammonia, iodine, bromine, or chlorine.  As to the action
of ammonia, there  is a great diversity of opinion.  Bromide of
potash has recently come into repute as being  efficacious.
   In case of collapse, wine should be given.  Mild stimulants
(good mulled wine, tea with brandy)  always do good service,
when administered from the outset.   Enveloping the  parts in
cold wet cloths has been likewise recommended.
   The subcutaneous injection  of  water of  ammonia, diluted
with  an  equal quantity of  water,  while the  same  agent  is
given internally in drinking-water,  has been  recently  proposed
by  Halford, and has  been resorted  to in several instances  with
success (Putz et at.).  There  is this objection, however,  to the
subcutaneous  administration of ammonia,  that  it is apt to
produce  a slight  sloughing  at  the seat of  the puncture, on
which account milder solutions may be preferable.  In accord-
ance  with the  experience   of physicians in India, Halford1 s
method of treatment for snake-bite is of no effect.

  Fontana' was likewise  in his time familiar with this mode of  treatment, and
made an experimental trial of it upon animals. His experiments upon sheep and
hares resulted unfavorably, but in the case of human beings his success was aston-
ishing.

  In  countries infested with  vipers, it is to be recommended  as
a prophylactic measure, that those persons who are exposed  to
the danger of being bitten (wood-choppers, huntsmen, herdsmen,
children), should protect their feet by wearing  high boots, and
thus avoid all risk of being wounded.  Vipers  are unable to raise
themselves higher than the tops of the boots, nor  can they pene-
trate  leather.
1 Fontana, Opusculi scientifici di Felice Fontana, p. 125.  Florence, 1782. 
SNAKE-BITES.
547
                        B. Snake-Bites.
   The pathology of  snake poisoning has been greatly enriched
during the past  few  years by a series of careful observations,
among wliich those of Halford, Shortt, Mitchell, and above all
those of Fayrer, are deserving of mention.   Referring the reader
to the monograph of Fayrer (1872) upon the venomous snakes of
India, we will content ourselves with a brief allusion to some of
the more important points of our subject.
   The most dangerous varieties of venomous snakes met with
in India are the spectacled snake {cobra,  cobra-de-capello, naja
tripudians), the rock-snake {bungarus cozruleus), bungarus fas-
ciatus, ophiophagus  claps (hamadryas) ;  of the vipers found in
India, daboia Russellii and echis carinala; furthermore, of  the
water-snakes, hydrophis  and  others.  In America, the rattle-
snake  (crotalus)  and  the  copperhead  (trigonocephalus)   are
regarded as the most  formidable of the venomous snakes.
   The poison of the cobra-de-capello, the  most dangerous of  the
venomous snakes of India, is  composed (according to the report
of Armstrong and Brunton,  of London,  to whom it was sub-
mitted by Fayrer for  analysis) of a brownish fluid of  the consis-
tence of syrup,  containing from forty-three to forty-five per cent.
of carbon, and from thirteen to fourteen per cent, of nitrogen.  It
invariably coagulates upon the addition of nitric acid or alcohol,
and also upon the application of heat.  It was found impossible
to produce from  it in any way a ciystallizable substance.  The
presence of a substance containing albumen can be demonstrated
by various reactions.   It was proved by  experiments, that the
poison, wliich had been sent to" them, and also the preparations
that had  been  formed from it, preserved unaltered and unim-
paired their peculiar venomous properties.
   According to  Shortt (Madras),  the cobra poison is composed
of an oily, clear,  bright yellow-colored fluid, similar to albumen,
having a specific  gravity of 1.046.   Its reaction is acid,; it con-
tains  albuminoid  matter, but no  mucus.   When placed upon
the tongue, it produces a burning  sensation, causing the forma-
tion of vesicles, and a feeling of numbness in  the part to wliich
it is applied.  It contains twenty per cent, of solid substances. 
 548      BOLLINGER.—INFECTION  BY ANIMAL POISONS.

    When the virus was mixed with a solution of potash, it was
 always rendered inactive, although the application of this agent
 externally and internally, after the  reception of a  bite, proved
 futile.
    A microscopical examination  showed the presence  of cells,
 suspended in an albuminoid fluid.

   Halford suggested the theory that organized germinal matter was thrown into
 the poisoned organism together with the virus, which rapidly developed and mul-
 tiplied, the process going on at the expense of the oxygen.  He maintained, there-
 fore, that death would be produced in the case of snake-bite by a want  of oxygen,
 just as in the case of death from suffocation.  Fayrer was unable  to confirm this
 theory. According to the latter, the alterations in the character of the blood after
 snake-bites consist principally in this, that after the bite of vipers (daboia) the
 blood remains fluid, while it quickly coagulates after the bite of the cobra-de-
 capello.  The blood of an animal killed by a snake poison has the effect of poison-
 ing other animals when injected into  them ; but the flesh of such animals can be
 consumed without any ill effect.  The  cells described by Halford, as being found in
 the blood of animals destroyed by snake poison, were demonstrated by Richardson,
 after repeated microscopical examinations, to be simply colorless blood-corpuscles.

    According to the observations of Fayrer, no animal possesses
 an immunity against the action of snake  poison, except  the ven-
 omous snakes  themselves.  Venomous snakes belonging to the
 same variety  are unable  to  poison one another, although, in ex-
 ceptional  cases,  those  of  different  varieties  may poison each
 other.  The non-venomous serpents are as  susceptible to snake
 poison as other animals.  Warm-blooded animals are the most
 quickly  affected by the  action of  the  poison,  and  especially
 birds.  The degree  of  rapidity with wliich death ensues bears
 generally a definite relation to the size of the  animal upon which
 the bite is inflicted; so that small  animals—with certain excep-
 tions—succumb more quickly than larger  ones.   The result of
 the  bite  is influenced materially by the species of the snake  in-
 flicting the wound, and its size and strength,  or, in other words,
 upon the quantity and  quality of the virus  introduced by the
bite.
   The poison of the copperhead (trigonocephalus contortrix) is
far less virulent in its action than that of the rattlesnake.  Each
 variety of snake poison, when taken into  the stomach,  is  abso- 
SNAKE-BITES.
549
 lutely  innocuous (Mitchell), whereas it is quickly absorbed by
 the small bronchi and alveoli of the lungs, and develops its full
 strength.   Mitchell observed, upon applying the snake poison to
 the mesentery of rabbits, that red blood-corpuscles immediately
 appeared on the outer walls of the capillaries, accumulating in
 such masses as  to compress  the vessels,  and impede  or  com-
 pletely obstruct the circulation.  Within five or ten minutes the
 entire field of vision becomes covered with extravasated blood,
 the origin of wliich can only be referred to some alteration in the
 walls of the vessels.
    Respecting  the frequency of snake-bites, Fayrer makes the
 following statement:

   In India, of a population of 121,000,000, 11,416 deaths from the bites of snakes
 were reported to have occurred in the year 1869.  The actual number of  annual
 deaths from this cause, however, is estimated by Fayrer to be 20,000, consequently
 the annual rate of mortality from this cause, for every 10,000 inhabitants, is 1.6.
 Most of these cases are produced by the spectacled snake (cobra-de-capello) and the
 rock-snake  (bungarus ca>ruleus), although a few deaths are caused by other varieties.
 The bite of a vigorous specimen of the above-mentioned families must inevitably
 result  in death, if  the poison be not in  some  way arrested by the clothing, or
 speedily withdrawn (by excision or cauterization).


                        Symptomatology.

    The local and  general symptoms resulting from the poisoning
 by a snake-bite are in all essential points similar to those follow-
 ing  the bite of an adder.  The  most important  constitutional
 symptoms  are : a feeling of numbness,  extreme restlessness,
 involuntary discharge of urine and faeces, dilated  or  contracted
 pupil, slow and irregular respiration, cramps,  twitching of the
 muscles,  suspension of reflex excitability, and anaesthesia of the
 skin, while consciousness  and the mental faculties are retained
 until the last  moment, paralysis and death supervening with
 or  without  cramps and convulsions.  Death  may ensue  even
 within twenty minutes after the infliction  of  the bite, or may
 occur almost instantaneously if the  poison is injected into a
large vein.  According to  Jones, the temperature at the begin-
ning  is but slightly  raised, and is  afterwards  lowered.  The 
550      BOLLINGER.—INFECTION BY ANIMAL  POISONS.

heart's  action is accelerated, but  weak.  Passive hemorrhages
frequently occur, particularly in the digestive canal, combined
with  general jaundice.  Aphasia  is not unfrequently  noticed
also among the first symptoms, and this  sometimes continues
after the disappearance of the other phenomena, originating pos-
sibly, as has been suggested by Ogle, in some central lesion.
   At the autopsy no muscular  rigidity  is  found; the  right
auriculo-ventricular  cavity contains tarry, loosely  coagulated
blood, while the left cavity is  empty.   The vessels of the  brain
and its membranes are distended with dark-colored blood.   The
liver  appears gorged  with blood,  swollen,  and  dark-colored.
The lungs in like manner appear hyperaemic.

                          Treatment.

   The most efficacious procedure  that  can be resorted  to after
the bite of a venomous snake  is—to quote the advice of Fayrer
—the following :  The application of a ligature as tightly as pos-
sible around the bitten limb, above the  seat of the wound, scari-
fication and suction by means of the mouth or cupping-glass, and
subsequently the application of the actual cautery, or cauteri-
zation with caustic potash or a mineral  acid.   If the limb  swell
after the application of the ligature, this must then be loosened,
to be drawn tight again, however, whenever symptoms of general
infection show  themselves.  If a finger or  toe  form the seat of
the bite,  it is then best to amputate the limb at the joint  next
above the wound.  If the bite has been inflicted at  a point which
does not admit of the application of a ligature, the indication
then is  to promptly excise the injured tissue, together with the
surrounding parts.
   The patient should rest  perfectly quiet.  As  soon as indica-
tions  of  poisoning  are perceived, preparations of ammonia
(liquor ammoniae) are to be administered, or, what is still better,
he should be made to drink copiously and  frequently of spirit-
uous liquors diluted with hot water, taking care, however, not to
produce intoxication.   Should symptoms of collapse supervene,
sinapisms,  galvanization  of the heart and diaphragm,   or cold
douches may be resorted to. 
SNAKE-BITES.
551
   In cases of poisoning by venomous snakes, especially the cobra, all the reputed
antidotes to snake poison (ammonia, arsenic, liquor potassae, carbolic acid) are inef-
fectual.   Although from  one to two drops of carbolic acid inserted within the
mouth of the cobra suffices to destroy it within a few moments, it produces no neu-
tralizing effect whatever upon the poison or the poisoned wound.

   The method recommended by Halford is the following :—He
injects  thirty drops  of water of ammonia (= gr.  0.95 ammonia)
into a superficial vein, which is immediately followed  by a brisk
activity of the circulatory and nervous systems; this procedure
is repeated as soon as the stimulating influence of  the remedy is
suspended.  As to the efficacy of this method, a contrariety  of
opinions prevails.  While some affirm that they have applied it
with favorable  results,   we  are assured  by  trustworthy and
experienced observers (Fayrer, Richards), that it  is  of no avail.
In the case of  rabbits  that had been bitten by  a rattlesnake,
Stern tried a solution of  the gall of a rattlesnake (one part to ten
of alcohol) diluted with water, and with the best result.
   Anderson administered  successfully in one  instance bromide
of potassium combined with copious alcoholic stimulants. 
 
DISEASES FROM MIGRATORY PARASITES.
HELLER 
 
INTRODUCTION.
    Under the head of  "Invasions-Krankheiten" '  I propose to
 describe such affections as  " depend upon the penetration of
 animal  parasites  into  the tissues."   My reason for  so naming
 them consists in the necessity of having at our command a short,
 expressive term, instead of an involved expression.
    According  to this  plan,  only  a  small  number  of  parasites
 come up  for consideration.   Of the Cestoda, the Echinococcus
 and the Cysticercus cellulosw,  and  of the  Nematoda, the  Tri-
 chinae are  here to be described.

    The Strongylus gigas has perhaps never yet been observed in man, or at all events
 only in extremely rare cases.   The Filaria medinensis is chiefly of  surgical  interest.
 The Cysticercus acanthotrias has been found only by Weinland,2 and  by him only
 once in fifteen cases ; 'it occurred in a maiden lady, aged fifty, and was situated in
 the muscles and under the skin, one specimen lying  loose on the  inner surface of
 the dura mater.  The Cysticercus tenuicollis has not yet, to a certainty, been observed
 in man.   The newly  discovered hsematozoon—Filaria  sanguinis  hominis—which
 Lewis3 believes is connected with chyluria, has not yet been sufficiently studied.
 May it not prove to be a young, freshly migrated specimen of Distomum haemato-
 bium ?
   Meschede's4  report of a case of epileptic mental disturbance " occasioned by the
 eggs of another kind of tape-worm (Bothriocephalus latus) in the brain," is of no
 value  without more accurate information as to whether or not this was the sole
 cause of the disease.  A larval state of the Bothriocephalus latus is thus far entirely
 unknown.
   1 "Diseases due to an invasion [of parasites]."  The difficulty, if not impossibility, of
 translating this into an equally short  and  significant English expression has led me to
 employ the title placed at the head of this chapter—Diseases from Migratory Parasites.
 —Translator.
   -1 Verhandlungen der K. L. C. D. Akad.. XXVIII. Band, 1861, S. A., p. 5.
   3 On a Ha3matozoon, inhabiting Human Blood, etc., by T. R. Lewis, M.D. Calcutta,
1872.  (Deutsches Archiv f. klin. Med., XL. p.  540, 1873.)
   4 Tageblatt der Xaturforscherversammlung in Leipzig, 1872, and Allgem.  Zeitschrift
f. Psychiatrie,  XXX. p. 109, 1873. 
556     HELLER.—DISEASES from  migratory parasites.

   The question, whether the  Cysticercus  of the Taenia  mediocanellata (saginata)
may occur in man, is not yet decided.  As the experiment on man is not admissible,
I fed an ape (Macacus cynomolgus of  the East India islands), which was at my com-
mand,  three times with three and a half, six, and four fresh joints respectively, each
one  containing a considerable number of eggs  of the Taenia mediocanellata (sagi-
nata).  After the unfortunate premature death of the  animal, seven weeks after
the first, and  two weeks after the last feeding, no trace was found of these para-
sites, with which I had become familiar  in  Prof. Zenker's experiments on goats.1
With the exception  of one encapsulated  strongylus found in the lung, the animal
was entirely free from parasites.   According to a verbal report by Prof. Volckers,
Colberg declared a  cysticercus extracted by the former from a man's eye to be in
fact  a Taenia mediocanellata, since the rostellum, the crown of hooks, and all indica-
tions of the earlier existence of such,  were entirely absent.
   The Pentastomum denticulatum,  the undeveloped  state of the Pentastomum
taenioides, which is found in  the frontal sinuses of the  dog and wolf, and is fre-
quently seen  encapsulated  and  generally calcified  in  the  liver,  small intestine,
stomach,  lung, spleen, and kidneys (found alive in the liver by Wagner and in the
lung by Zenker), when occurring singly causes  no  disturbance, but  according to
Leuckart's researches amongst animals, when in great numbers gives rise to enormous
destruction of tissue.


                         ECHINOCOCCUS.

                                Chapter I.

Van Beneden, Zoologie medic, II., p. 275.—Davaine, Traitg des Entozoaires.  Paris,
    1860, p.  350.—Gbze, Versuch einer  Naturgeschichte  d.  Eingeweidewiirmer.
    Blankenburg, 1782, pp. 258, 284.—Kuchenmeister, Die in und an d. Korper  des
    lebend.   Menschen vorkommenden Parasiten.  Leipzig,  1855,  I., p. 141.—
    Leuckart, D. menschlichen Parasiten, I., p. 342. Leipzig, 1863.—Naunyn, Archiv
    f. Anat., Physiolog., etc.,  1862, p. 612.—Pallas, Neue nordische Beitrage, I., p.
    83, 1781.— v Siebold, Zeitschr. f. wissenschaftl.  Zoologie, IV., p. 409, 1852.—
     Virchow, Verhandlungen  d.  med.-phys. Gesellschaft zu Wurzburg, IV., p. 84,
    1855.—G. Wagener, Entwickelung der  Cestoden.  Breslau, 1854.—Chemische
    Untersuchungen des Echinococcus veroffentlichten : Bodeker, Zeitschr. f. ration.
    Med. Neue Folge, 7, p.  137, 1855.—Heintz, Jen.  Annal. f. Phys. u. Med., I., p.
    80, and Poggendorf's Annalen, 80, p. 114,1850.—Lucke, Virchow's Archiv, 9, p.
    189,  1860.—Naunyn, Archiv f. Anat, Phys., etc., 1863, p. 417.—Sommerbrodt,
    Virchow's Archiv, 36, p.  272,  1866.— Wilde, Deutsches Archiv f. klin. med.,
    VIIL, p. 116, 1870.
1 Sitzungsber. d. phys.-med. Soc. zu Erlangen, 1865-67, I., p. 15; IV., p. 71, 1872. 
ECHINOCOCCUS.
557
                           HISTORY.

    Ever since the time of  Hippocrates we find descriptions  of
many tumors which are  undoubtedly to be considered as refer-
ring  to the echinococcus.  The echinococcus was,  however,  first
recognized as a separate living  creature by Pallas in  1766.   In
1782  Pastor  Goze discovered that the Scolices were tape-worm
heads.
    Kuchenmeister, v. Siebold, and van Beneden, and, still later,
Leuckart, have experimentally  proved the relationship  of the
echinococcus to the taenia echinococcus of the dog (1852).  Vir-
chow showed the connection of the echinococcus  multilocularis
—previously described as colloid cancer—with the echinococcus.
   In Hippocrates (Aphorism., Sect. VII., No. 55) we find the following: "Quibus
hepar aqua plenum in omentum erupit, his venter aqua repletur et moriuntur."

                         Clapter II
                      NATURAL  HISTORY.

    The echinococcus, or ensheathed worm, is  the larval  condi-
tion of  the taenia echinococcus,  a small tape-worm, about four
millimetres in length, whose usual haunt is the upper part of the
small intestine of dogs.  The whole tape-worm consists of a head
and three joints, or  segments,  the last of  which is usually
mature, and  the time for its separation close at hand;  this last
joint  exceeds in size the whole remaining  portion  of the  worm.
The very prominent rostellum of the head supports a crown con-
taining from  thirty to fifty rather blunt hooks, arranged in two
rows.
   The  larva—the echinococcus—consists  usually of a rounded
sac, of exceedingly variable size (from that of a pin-head to that
of a child's head), which is enclosed in a connective-tissue capsule,
formed from  the surrounding tissues, and is thus separated from
them.   This  capsule is usually very firm, and is frail only in the
brain.  The wall of  the echinococcus sac is itself either delicate,
and of a dull, white color,  or very substantial and translucent,
of about  the consistence of boiled white of  egg, and divided 
558
HELLER.—DISEASES  FROM  MIGRATORY  PARASITES.
into distinct  lamellae.   It consists  of  a substance  resembling
                 chitine.1   If a  section of  the  sac be  made, the
                 cut  edges will immediately  coil  around upon
              j  themselves.
              I     The sac is filled with a clear, often  yellowish,
                 somewhat opalescent, neutral, or weakly alkaline
                 fluid, having a specific gravity of from 1.007  to
                 1.015, which contains no albumen, or only a trace
                 of it,2 but is rich in chloride of sodium.   Besides
                 this, succinic acid,3 either free or in the form  of
                 succinate  of lime4  or of soda,5 inosite,  grape-
                 sugar, leucine,  and several less important ingre-
                 dients are found in small quantities ; and in the
                 liver—echinococcus,  crystals of haematoidine."
       fj-j         In rare cases the contents of the echinococcus
                 vesicle are of a bloody color.
   In four cases of echinococcus, Professor JacobsenT  found
0.55-0.61-0.71 and 0.84 per cent, of chloride of sodium.  In
two of these, from the liver, there was a considerable amount
of leucine; in two others, from unspecified portions of the abdo-
men, none whatever;  0.07 per cent, of succinic acid in the two
liver—echinococci, which was wanting in the two  others; the
    Figs. 1. 2.
Tasnia Echinococcus.
 Fig. i. sNatural size   „.rape sugar was absent in the latter, while the former yielded
 Fig. 2. Magnified (.alter did
   Cobboid).        0.096 and 0.006 per cent, of it.  Albumen was found in none,
although on evaporation one yielded the allied  substance, caseine, in small quan-
tity.

   The  inner surface of the echinococcus  cyst is lined  with  a
granular germinative or  parenchymatous  layer,  which is  fur-
   1 Liicke, 1. c.
   8 Naunyn, Heintz, 1. c.—Rosenstein and Sanger, Berl. klinische Wochen-chrift, 1873,
No. 20.
   3 V. Recklinghausen, Virchow's Archiv, 14, p. 481.
   4 Heintz, Bbdeker, 1. c.
   6 Naunyn, Bodeker, 1. c.
   6 Davaine, 1. c, p. 373.— Habran, These de Paris, 1869.  Jahresber., 1869, I., p. 5.
   ' These  analyses, thus kindly furnished me, will be more fully reported elsewhere.
   8 With the exception of Fig. 2,  all the  wood-cuts illustrating echinococcus have
been engraved with great care by Mr. Flegel from drawings which I made from nature. 
ECHINOCOCCUS.
559
nished  with small, rapidly vibrating  cilia, on its inner surface.1
This  germinative  layer  becomes thickened in  spots  into  little
                              Fig. 3.
          Incised Echinococcus Membrane from the Kidney. From the Kiel Collection.
 mounds, in each of which a vacuole-like cavity is formed ;  upon
 the  inner surface of  these cavities—brood-capsules—the  tape-
 worm heads—scolices—
 originate  as  conical-
 shaped   projections,
 which   comm unicate
 with the  cavity of the
 echinococcus cyst; the
 double row of hooks and
 the suckers are  formed
 on the  free  extremity
 wliich projects into the
 main cavity.  The brood
 capsules,  as  also the
 cone-shaped heads, are
 endowed with the capa-
 bility of lively contrac-
 tions.  The base of this
head  afterwards  con-
tracts itself posteriorly to a thin pedicle, which finally separates
entirely from  the wall of the brood capsule, so that the heads
                Fig. 4.
Transverse Section of Echinococcus Membrane.  (Magnified.)
1 Naunyn, 1. c, 1862, p. 615. 
560
HELLER.—DISEASES FROM MIGRATORY PARASITES.
          Fig. 5.
Brood Capsule, with Scolices, partly free,
 and partly still adherent. (Magnified.)
move about freely within the vesicle.  In this manner several (as
many as nine,  or even more) scolices originate in every brood
capsule.  So long as the pedicle has not yet become detached, the
heads may turn themselves as it were inside out, and appear on
                         the outside of the brood capsule.  The
                         free heads in the capsule are generally
                         spherical, because they retract the an-
                         terior portion, together with the  cir-
                         clet of hooks and the suckers, into the
                         dilated  hinder part.   At death they
                         are usually everted, and then  present
                         their conical form. Scattered through-
                         out the  parenchyma  of the heads are
                         more or  less  numerous  calcareous
                         bodies,  with concentric laminae.
                            This process of proliferation usu-
                         ally occurs after the echinococcus sac
has attained a considerable  size;  in many cases, however,  the
increase in size  does not result in the evolution of scolices; the
cyst frequently attains an immense size without proliferation.
   In man the development of  brood capsules  and scolices  but
rarely takes place directly from the primary echinococcus vesicle.
Much more frequently one or more generations of daughter vesi-
cles are produced, from which the development of brood-capsules
and  scolices may continue in the manner above described.  In
that case,  more or less  numerous daughter vesicles are found in
the mother sac, a single  one,  or  even all  of  which may have
grandchild  vesicles encased  within them.  These secondary or
daughter vesicles grow out  either from the brood-capsules or
from  the scolices, or directly from  the germinal layer.   They
develop either  from the  inner side, within the mother  sac—
endogenously—or upon the  outer si&e—exogenously.  The lat-
ter mode  is the more common in the lower animals, and the
former in  man.   The daughter vesicles may be  few in number,
or they may amount  to  several  thousands ; the size is  varia-
ble ; under  different circumstances they are found varying from
scarcely the size of a pin-head  to  that of a hen's egg ; they are
very seldom any larger. 
ECIIIXOCOCCUS.
561
   The echinococcus is endowed only to a slight degree with the
power of independent motion.1
   The route by which the echinococcus embryo migrates  from
the gut into the organism is not yet positively determined.   The
                      Figs. 6-8.
        Echinococcus Scolices attached to the Brood Capsule.
Protruded.            Retracted.            Partially protruded.
f
     Figs. 9 and 10.
    Free Echinococcus Scolices.
Retracted.
    Fig. 11.
Echinococcus Hooklets.
preponderating frequency of its appearance in the liver forces us
to the conclusion that its regular path is either through the bile-
ducts or  by  way of  the portal  vein; Schroder  van  der Kolka
pointed out the former by his injections, as did Friedreich3 in
   ' Kuchenmcister, 1. c, p. 155.— Wagener, 1. c.
   ♦ Cited by Virchow. Wurzburger Verhandlungen, VI., p. 93, 1856 (Ruyssenaers, de
nephritidis et lithogenesis quibusdam momentis.   Dissert, inaug. Traj. ad Rhen., 1844,
P 49).
   3 Friedreich. Virchow's Archiv, 33, p. 32.
           Vol. III.—36 
 562    HELLER.—DISEASES  FROM MIGRATORY PARASITES.

 multilocular echinococci.   Its presence in  other  organs  would
 render probable  the supposition that  it had been carried by the
 portal vein.   Leuckart,'  in  his feeding experiments, was unable
 to settle this question.

   Kuchenmeister (1.  c.) distinguishes two varieties  of  echinococcus, according as
 the scolices develop directly from the mother sac, or several generations of daugh-
 ter vesicles are  previously interposed; he calls the  former echinococcus scolicipa-
 riens, and the latter echinococcus altricipariens ; the former have from twenty-eight
 to thirty-six hooklets  in their crowns, the latter  from forty-six to fifty-two.  The
 hooks of these latter are much smaller.  Kiichenmeister  believes that the taenia of
 the echinococcus altricipariens is present in the small intestine of man, as in that of
 the carnivorous domestic mammals,  the dog and the cat.
   This view is rejected by the majority of helminthologists, and, on the contrary,
 the two forms of echinococcus are held to be identical.
   Whether, as  Kuchenmeister supposes, the taenia echinococcus really does appear
 in the intestine of man, and there give rise to self-infection, still remains undecided.
 The most minute inspection of the small intestine in  fresh  cases of  echinococcus,
 especially in such cases as those in which scolices had probably been swallowed
 during life, is extremely desirable.
   No  one has yet succeeded in producing the taenia echinococcus in dogs by
 feeding them with the echinococcus  originating in man.
   The so-called  hydatid purring is a peculiar symptom, and of
 considerable diagnostic value.
   If  we  grasp an  echinococcus tumor  with  one hand, at  the
 same  time exercising  slight compression on it, on short  quick
 percussion a feeling of vibratory motion will be experienced.
   This sensation  may be illustrated  by  lightly touching a base cord of a piano
with one finger, and then gently striking the corresponding key, or by resting three
fingers loosely on the spiral spring of a sofa, and then tapping with the middle
 one.
   According to Briancon,2 the discoverer of this symptom, it  is
most distinct when the  mother sac contains numerous daughter
vesicles with but  little fluid between ;  with  the decrease  in num-
ber of the daughter vesicles, and the increase of fluid, the hyda-
tid purring loses its distinctness; cysts  without  daughter vesi-
cles do not give rise to this phenomenon.
   As a rule, the echinococcus grows  very slowly, and  seems to
   1 Leuckart, 1.  a, I., p. 372.
  2 Briancon, Essai sur le diagnostic et le traitement de3 acephalocystes.  These de
Paris, 1828, I., p. 18. 
ECIIIX0COCCUS.
563
retain life very long.   The  products of proliferation often pre-
sent a good  and  healthy appearance after  decades;  more fre-
quentty, however, in the course of a year changes occur which
cause  their death or that of the animal.
    The membrane, then, in the beginning seems cloudy, although
still distended ; subsequently the  fluid contents gradually van-
ish, and  the vesicle may  completely collapse.  It  then  lies
folded in the cavity formed  by the  connective-tissue cyst.  A
deposit of fat and of lime salts  soon takes place
in  and  upon  it,  sometimes in great  abundance,
yet the membrane  itself  withstands complete
destruction  for a long time.   The daughter sacs
succumb to a similar alteration, but their walls
perish much  earlier than  those of the  primary     0}:;,.
sac.   The scolices die  early, lose their hooks,     '       ;.
and either go to ruin entirely, or,  being impreg-    ijf|f   Jv£k
nated with lime, form  a sediment in what little   .       !,..  \
fluid  may still  remain.    After a still  further   ?0k§   Wit?
retrogression  in the shrivelled and hardened  cyst   "%-&i'
contents, which art1 also in a condition  of fatty    figs. 12-14.
degeneration  and calcareous  infiltration, either DeadCalcl<
          -                 „,,       ,,        12. Retracted.
single hooklets, or crowns ot hooks, or whole seo-  is. wen preserved.
   0           '                                    14. Broken.
lices are found  calcified, besides crystals of  cho-
lesterine, often  in great quantities, and hsematoidine in  liver
echinococci.   Usually,  while the echinococcus is undergoing
these  changes, the  connective-tissue  capsule also shrivels ;  its
walls  thicken and are meantime  impregnated  with  lime salts.
The whole echinococcus  may  finally  be  converted  into a single
lime concretion of greater or lesser  size.

   The  term " Hydatids," which is still often employed, should be entirely dropped,
so far as regards the echinococci, since it is lacking in accuracy of description, and
frequently serves only as a mantle for ignorance.
   " Acephalocysts"  is the name given since the time of  Laennec to such echino-
coccus tumors as contain no scolices. There was  formerly a disposition not to
recognize them as echinococci; they are, however, to be considered as imperfectly
developed echinococci, incapable of proliferation, owing perhaps to their having
been blighted in their earlier stages of development by  some external influences.
Frequently in the same echinococcus,  daughter vesicles of corresponding size are 
564    HELLER.—DISEASES FROM MIGRATORY  PARASITES.
found, some with, and others without, echinococcus scolices.  Thus, in the case of
a cow, whose lungs and liver were thickly set with innumerable echinoccocus sacs,
I was able to find scolices in but very few. These were chiefly to be distinguished
from the others by a greater thickness of the walls.

   The echinococcus  multilocularis1  is  a  peculiar  develop-
mental form of the echinococcus.   This  growth bears a certain
resemblance to colloid cancer, and was  classed as such  by the
earlier observers ;  Virchow2 first recognized its  true nature.  Up
to the present time it has (with the exception of one case of its
occurrence in the suprarenal capsule) been observed  only in the
liver.  (Vide infra).
   The  echinococcus  multilocularis  forms  a firm  tumor,  of
greater or  lesser  magnitude, almost  as hard  as stone, which
takes the place of a corresponding portion of the liver substance.
It sometimes  increases  to remarkable  dimensions ;  in Griesin-
ger's case it occupied the whole anterior part of the abdomen;
in a case reported by Huber  it was of  the size of a child's head.
When the multilocular  echinococcus arrives at the surface of
the liver, its  (the liver's) capsule becomes immensely thickened
and firmly united to the neighboring structures, and is traversed,
particularly in the vicinity of the tumor, by fine yellowish stripes.
On section, the mass  is found to consist of very dense fibrous tis-
sue,  and ramifying  through it  are numerous large and small
cavities  branching and communicating with each other ; some of
these cavities are loosely, and others firmly,  filled with a sticky,
gelatinous substance, in which are found here and there rounded
and angular smaller cavities.  Microscopically examined,  these
smaller  cavities show essentially the  characteristic structure  of
echinococcus membranes, with, of  course, some variations; they
but seldom prove to be vesicles ; well-preserved scolices are very
   1 Griesinger, Archiv d. Heilkunde, I, p. 547, 1860.
   2 Virchow, Verhandlungen der phys.-med.  Gesellschaft zu Wiirzburg, VI., p. 84,
1856, and Virchow's Archiv, XL, p. 80.—Huber, Deutsches Archiv. f. klin. Med., I.  p.
539, 1865;  IV., p. 613;  V., p. 139, and Virch. Arch., 54, p. 269, 1872.  Jahresbericht
des naturhistor. Vereins zu Augsburg,  1861.—Kappeler, Archiv d. Heilkunde, 1869,
p. 400.  (Two cases).— Heschl (?), Oester. Zeitschr. f. prakt. Heilkunde, VII.,  5, 1861.
—Prougeansky, Dissert.   Zurich, 1873 (Five cases.)  The remaining literature may be
found in Klebs, Handbuch der pathol. Anatomie, II. Lieferung, p 517. 
ECHIXOCOCCUS.
565
rarely found ;  in many cases they are entirely overlooked, or are
discovered only by isolated hooklets.  Crystals of hsematoidine
are frequently seen.   The fibrous tissue is more or less icterous.
The multilocular echinococcus shows a strong tendency to ulcer-
ative destruction; we often find toward the centre of  the  mass
(seldom more toward the periphery) one or more abscesses, with
irregularly cut walls,  and  crumbling,  markedly  icterous,  and
sometimes dark-green contents.
                                Fig. 15.

Echinococcus multilocularis. The section shows several cavities (a) of irregular, bay-like outlines, markedly
                          icterous at their borders.
              (From a preparation in the pathological collection at Erlangen.)
    According to Virchow and Klebs, the development of echino-
coccus multilocularis takes  place in the lymph-vessels ;  accord-
ing to Friedreich,1 in the blood-vessels and gall-ducts.

   Virchow discovered on the surface of the liver, as well as on all parts of Qlis-
son's capsule in the liver, and also along the  bile-ducts, as they emerge from the
hepatic substance, thick, nodular, gelatinous cords, which he could only explain as
lymph-vessels filled with echinococci.
1 Friedreich, Virch. Archiv, 33, p. 16, 1862. 
566     HELLER.—DISEASES FROM  MIGRATORY PARASITES.

   In a hitherto unpublished case of Prof. Zenker's, a multilocular echinococcus
nodule, somewhat larger than a pigeon's egg, encircled the ductus choledochus ;
the section made through the tumor presented the appearance shown in Fig. 15.
   In one of Prof.  Jurgensen's unpublished cases, a large cavity was found in the
centre, filled with a fluid which presented the characteristic chemical reactions of
echinococcus fluid.
   In four cases, the multilocular echinococcus has been found in other situations
than those already mentioned; in two cases in the lung,1 in the  subperitoneal tissue
of the uterus,2 and in the intestinal wall.3  Huber questions  the genuineness of one
of the lung cases
   Besides being met with in  man,  the echinococcus is found
in its  larval state in the  ape,  cow,  sheep, goat, camel, drome-
dary, chamois, antelope, deer, giraffe, horse, ass, zebra, and hog;
also in  the  squirrel, kangaroo, and other  feline  animals.4  Von
Siebold found one in a  turkey ; but  with  this  exception, it
has not been noticed in birds.   In the future it will probably
be discovered in other ruminants.
   The echinococcus of  the ape,  horse, camel, and dromedary,
like that of  man, develops secondary or daughter vesicles endo-
genously.

   The  geographical  distribution of  the  echinococcus  corre-
sponds with that  of  the dog,  as this animal seems to  be the
especial  "host"  of  the tsenia  echinococcus;  it has probably
extended over the whole earth ; on this point,  however, we have
not yet sufficient information.
   In Europe it  has been observed everywhere; in America, it
seems,  but seldom; of its  presence in Africa,  our  sole informa-
tion thus far is derived from Bilharz, who  reports it in Egypt.
Even Australia is not free 5 from it.  The echinococcus is almost
incredibly frequent  in Iceland, where  the dog  plays such an
important role in the life  of the  inhabitants.  In  Iceland every
   1 Fereol, L'Union med., 1867, No. 114.— Scheuthauer, Oesterr. med. Jahrbucher, 14,
p. 17.
   2 Scheuthauer, 1. c.
   3 Heschl, 1. c., and Bottcher, Virch. Archiv, p. 15, 1858.
   4 Cobbold, 1. c, p. 261.—Davaine, 1. c , p. 617.
   6 Cutis, Melbourne Med. Rec, 1862 (Schmidt's Jahrbucher, 146, p. 183, 1862).
—Bichardson, Edinburgh Med. Journal, 1867, p. £25. 
ECHINOCOCCUS.
567
peasant owns, on an average, six dogs, which share his dwelling
with him.   According  to  Thorstensen, every seventh person in
Iceland harbors the  echinococcus, and in  some  districts even
every third person.
    With the exception  of a single case in Dorpat, the multilocu-
lar echinococcus has been found only in Southern Germany and
in Switzerland.
   According to a verbal report of Prof. Bartels, there was a case of multilocular
echinococcus  under  treatment  in the hospital here last year.
   The author saw  two livers in  the museums in London and Edinburgh, which,
as far as was possible without an examination, he considered as cases of mul-
tilocular echinococcus, and to wliich he called the attention of Drs. Cobbold and
Turner.


                           Chapter III

                        PATHOLOGY.
                              Section I.

          GENERAL PATHOLOGY OF THE ECHINOCOCCUS.

    The echinococcus occurs  in both sexes, and at all ages, yet
very seldom in infancy,  and most frequently in middle age.
   Cruveilhier's ' case in a child twelve days old may well be considered as some-
thing else, especially as no sac was found in the liver cyst, which  had  fibrous,
cartilaginous,  and bony Avails, and which  communicated with the  ascending
colon; if it really was a case  of echinococcus, the embryo must have migrated in
the earliest period of fcetal life.

   The  echinococcus  appears in  all the  organs of  the human
body,  but  most frequently  in  the liver ;  in fact, oftener  there
than in all  the other organs together.  It occurs not infrequently
in the lung, spleen, kidney,  and omentum ; seldom in the brain,
vertebral canal, eye,  heart,  testicle, vesiculas seminales, ovary,
uterus, breasts,  pancreas, and processus vermiformis ; somewhat
more frequently again in the subcutaneous  tissue of the  trunk
and in the bones.  Usually only one echinococcus is  found in
1 Cruveilhier, Traite d'anat. pathol., XXXVII., pi. 4, Text, p. 6. 
568     Heller.—diseases  from migratory  parasites.

the individual,  but sometimes  several  (as  many as twelve)  are
present, either in the same organ or in different ones.

   Davaine (1. c, p. 376) has collected a large series  of cases;  of 383  cases, 166
occurred in the liver alone; yet Davaine observes that he selects only such cases  of
liver echinococcus as possess a peculiar interest, while  he gives the fullest possible
collection of those found in other organs.  Some of the cases are doubtful,  so that
several, especially of those in the brain and spinal marrow,  may be believed to have
been cysticerci.
   In the kidneys there were 30, 16  of which were in the calices; 2  were in the
testicles  and  scrotum ;  (?) 1  each  in the suprarenal  capsule, vesiculae  seminales,
uterus, placenta; (?) 4 (?) in  the  ovary, 6 in the hip,  = 16; in all, in and  on the
abdomen, 238  cases.  Lungs 40,  heart  10, brain 20, (?)  spinal cord 10, bones 17;
2 each  in the pulmonary artery and vein, pituitary gland, face, mouth, thyroid
gland, upper  part of arm ; 3 were found in the eyeball, 5 on the neck, 9 (?) in the
orbital cavity, 7 in the mamma, 12 in the anterior thoracic and abdominal wall.
   Amongst 4,760 dissections made in the course of ten  years at-the Berlin Patho-
logical Institute, the echinococcus ' was found 33 times:
                          19 times  in 3,042 males.
                          14 times  in 1,718  females.
   Of these, 27 occurred in the liver alone, or in the liver and other organs together;
one  opened externally,  and  four through the  diaphragm ;  the  echinococcus was
found four times in the spleen, three  times in the lungs, twice each in the  pleura,
omentum, and kidney, once each in  the ligamentr.m latum and the heart, and five
times in the intestinal walls.
   Not one of these individuals was under ten or above seventy years of age.  The
majority were between twenty and forty years old.
   In addition to the situations already named, the echinococcus  has been observed
in the pancreas,2 in the  psoas muscle,3 and free in the abdomen; 4  in  the latter case,
it lay alongside  a liver  echinococcus, and may, therefore, have previously  escaped
from the liver; it has been noticed,  too, in the processus  vermiformis,5 once with
a liver echinococcus, and once, as observed  by Birch-Hirschfeld,6 lying free and
alone  in the dilated cavity  of  the  processus vermiformis, the  communication of
wliich with the  caecum was obliterated for the distance of one-fourth  of  an inch.
The atrophied mucous membrane presented  mosaic-like impressions, caused by the
pressure of the countless vesicles, which varied in  size from that of a pin's head to
that of a pea.
1 Booker, Dissert, inaug.  Berlin, 1868.
2 Seidel, Jena. Zeitschr. f. Med., etc., 1864, p. 289, fourth case.
3 Caillcux, Gaz. des Hop., 1802, No. 92 (Jahresbericht, 1868, II., p. 394).
4 Emmert, Wurtemb. Correspondenzblatt, 1871, 4 (Jahresbericht, 1871, II., p. 166).
6 Scholler, Preuss. militararztl. Ztg.,  1862, 2.
6 Birch-Hirschfeld, Archiv d. Heilkunde, 1870, p. 191. 
ECHINOCOCCUS.
569
    Thus  far  no phenomena have  been recognized which may be
attributed to the migration of  the embryos through the tissues ;
but since the number of penetrating embryos  must be exceed-
ingly limited, they are scarcely to be expected.
   Leuckart, too, as it seems, in his experiments with the echinococcus on hogs,
was unable to discover any disturbances.
   The migration of numerous cysticercus embryos produces marked symptoms in
animals (Zenker,1 Leuckart,2 Mosler).3

    The influence of the echinococcus on the tissues and organs
in  which it  develops is varied;  the latter may remain a  long
time without any considerable alteration, accommodating them-
selves to its slow growth;  while, in other instances, they  soon
undergo atrophy.  Those parts which are not in the immediate
vicinity of the echinococcus  generally present no changes, whilst
those lying nearest to it suffer a more  or less  decided  compres-
sion from the slow but constantly increasing growth of  the para-
site ; should even a large part  of -an organ be  destroyed in this
manner,  compensatory  hypertrophy of  the remaining portion
may take place.
   The right hepatic lobe of  a girl, on whom Prof. Bartels had operated success-
fully four years previously, after an echinococcus had probably penetrated into the
pleural cavity,  was found extremely  diminished in  size, and its surface united
to a moderate extent with the diaphragm and the base of the lung by coarse
cicatricial bands, through which were scattered small chalky concretions; by means
of these bands, moreover, the continuity  of  the diaphragm was destroyed, and
behind them was a fistulous opening in the thoracic wall—the result of the opera-
tion—surrounded by firm, callous tissue.  The left lobe of the liver was very much
enlarged, and occupied almost the whole space that the right normally did.

    Neighboring  organs are  often  displaced by the advancing
growth of the parasite ; the  various results of  such dislocations
are the same as when produced by other tumors.  The circula-
tion may be impeded,  or even stopped, by compression  of the
hollow  structures;   hindrances  to  the  passage  of  blood  and
lymph, prevention  of the discharge of bile or urine, obstacles to
1 Zenker, Sitzungsberichte d. phys-medic. Societiit, 1865-67, I., p. 15.
2 Leuckart, I., pp. 296, 407, and 747.
8 Mosler, Helmintholog. Versuche, 1864. 
570    HELLER.—DISEASES FROM MIGRATORY PARASITES.

the evacuation of the intestine,  even difficulties in labor, may
occur as results.   It is proportionately harmless in  the  cellular
tissue and the muscles.  Absorption of bone may take place from
the pressure of echinococci.
   Chronic inflammatory action usually takes place in the neigh-
borhood of  the echinococcus, and tends to thicken the cyst-wall.
The presence  of  the  parasite not unfrequently, however, occa-
sions acute inflammatory symptoms  in the organ concerned,
particularly if an injury from external  causes  be superadded;
the result of this  may be the formation of an abscess, with conse-
quent pyaemia; the multilocular form seems particularly prone
to ulcerative destruction.
   Frequently such complete  destruction of the adjacent parts
takes place, owing to the mere pressure of the advancing growth,
that an opening occurs either externally or into one of the neigh-
boring cavities.   This may also happen as the result of injuries,
such as kicks, blows,  or falls.
   The contents of the echinococcus may be discharged into  the
air-passages, the  intestinal canal, the  uterus  or  the vagina,  the
biliary ducts or the ureters, the pleural or the peritoneal cavity,
or the circulatory apparatus.  The  consequences naturally dif-
fer widely.  Among the most favorable is rupture through  the
skin, and, next  to that, discharge into the intestinal canal,
ureter,  gall-duct, or  vagina.   A  spontaneous  cure frequently
occurs in  such cases.  A  discharge through the air-passages is
less promising, although this not infrequently results in a cure.
An opening into the serous cavities of the abdomen and chest is,
as a rule, followed by  fatal inflammation, especially when accom-
panied by some sudden mechanical violence.
   A perforation into the  venous system,  or into the right heart,
results either  immediately, or very  soon, in death from embol-
ism of the  pulmonary artery;  rupture  into the left  heart, or
into the  arterial  vascular system, is followed by embolism and
its sequelae.

   The  development  and growth  of the  echinococcus  are very
slow ; consequently it causes early death  only when situated in
a vital organ.  As a rule, the duration is  several years; occa- 
ECHINOCOCCUS.
571
sionally  several  decades.  In  one  case,  six  months  after  the
appearance of the hrst  symptoms, an  echinococcus  found  in a
girl's axilla had only attained the size  of  a  small nut.1  In  one
of  the two cases of  echinococcus found on the  inner surface of
the dura  mater,2 the  disease,  from the  beginning of  the  first
symptoms until death, lasted seven and a half  months ; in this
case, the larger of the two parasites found had  not  grown to so
great  a  size as the one in the axilla, yet here it must probably
have made its presence  known much  earlier than in the loose
tissue of the axillary region.

   According to a collection of twenty-four cases, of which Barrier3 obtained suf-
ficient data in regard to the duration, from the first symptoms on, it was less  than
two years in three cases, four years in eight, six years in four, and eight years in
five; in the  remaining four cases,  it was fifteen years in one, eighteen years in
another, more than twenty years in the third, and more than thirty years in the last.
Ill still  another case,4 the  echinococcus remained in the liver fifty-five years.

    Very  frequently the presence of  the echinococcus has  no
effect whatever,  the  "bearer" dying of  quite a different disease.
In  many other cases, of  course, it causes early death.

    The symptoms indicating the presence  of the  echinococcus
are naturally manifold.   In  itself, it causes  no severe illness ; it
becomes dangerous  only under  certain accompanying circum-
stances,  especially  those referable to its  size.  Generally,  on
account  of  its  gradual  increase, it is  tolerably late  before it
occasions  any perceptible disturbance.  On post-mortem exam-
ination,  well  preserved and also  dead  echinococci  of very con-
siderable size are often  found, without the slightest  sjunptoms
having been manifested  during life, which  could be  attributed
to their  presence.   Only when it has reached  a certain size, as
compared  with the surrounding parts, does it become noticeable,
especially  so when, by its pressure on blood-vessels, urinary pas-
1  Velpeau, Gaz. des hop.. 1857, p. 396 (cited by Davaine, p. 544).
2 Bartels, Deutsches Archiv f. klin. Med., V., p. 108.
3 Barrier, These de Paris, 1840 (cited by Davaine, p. 383).
4 Edinb. Med. Journ., 1835, p. 286. 
572    HELLER.—DISEASES FROM  MIGRATORY PARASITES.

sages,  the  biliary ducts,  or the intestinal canal, it impedes or
prevents the normal evacuations.
   When, however, the echinococcus has its seat in a vital organ,
one  which cannot be  displaced, or its  functions delegated to
another,  we often see dangerous symptoms  setting in  from the
very beginning,  or an early death takes place, even before the
parasite has attained any considerable size.
   Sometimes, in the absence of an}^ very important damage to
an organ,  a kind of  cachexia seems to come on ; the patient
wastes away, loses strength, and dies with fever, diarrhoea, and
colliquative sweats.
   In itself the echinococcus is not painful, only creating by its
size an uncomfortable and troublesome sensation of fulness and
weight.  But, should inflammatory action be set up in the neigh-
borhood, or should it result in abscess,  severe pain, fever, and
chills may  ensue.

                         Diagnosis.

   The diagnosis of an echinococcus is at first very difficult  or
impossible ; only on further growth do symptoms manifest them-
selves  which  sometimes render a diagnosis possible.  Only the
sight of echinococcus membranes or shreds of membranes, of sco-
lices or echinococcus hooks, gives a positive diagnosis, and these
may be spontaneously discharged externally, or be  obtained by
operative means.  A diagnosis may,  however, be formed with ap-
proximative certainty by the coincidence of different conditions.
Should a tumor develop slowly and  gradually  to a  considerable
size,  without pain and fever, without symptoms of nutritive dis-
turbances, or cachexia ; should the tumor be of a regular rounded
form, elastic,  and show fluctuation,  the development of echino-
coccus must be  kept in  view.  If,  on percussion,  the hydatid
purring  should  be distinct,  the diagnosis is rendered almost
positive ; the absence of this  symptom does not by m\y means
prove the non-existence of the parasite.  Absence of  pain and
fever excludes abscess;   absence of  pulsation,  aneurism; the
presence of this latter symptom is no evidence of the absence of
echinococcus, as the pulsation may be transmitted from a  large
adjacent arterial trunk. 
ECHINOCOCCUS.
573
   The diagnosis may be well  supported,  or  positively estab-
lished, by an exploratory puncture.
   The  echinococcus  fluid is  free  from albumen,  and  presents
the  above-mentioned  chemical  constituents ;  a large quantity
of chloride of  sodium  is  its  special characteristic.  Dropsical
ovaries and large hydronephroses may occasion some confusion ;
other fluctuating tumors of the abdomen are too infrequent,  and
scarcely  ever attain a sufficient magnitude.  The former have
frequently been confounded with it, and the  mistake only  dis-
covered by means of an operation.1  The absence of albumen in
the echinococcus fluid is sufficient to distinguish it from the con-
tents of ovarian cysts, wliich are rich in albumen.  A previous
exploratory aspiration with a fine trocar should therefore never
be omitted.2
    Its differentiation from large hydronephroses is perhaps more
difficult.  The latter, besides the urinary salts,  seem  to contain
chiefly albumen in  considerable quantity.   The urine  salts are
of no assistance in diagnosis, as  they are  also present in  the
kidney echinococcus.3

   The chemical examination of the fluid of  ovarian cysts,  as also of the contents
of hydronephroses, still leaves a large field open for investigation.  In one case of
hydronephrosis,4 besides an abundance of urine salts and 7.5 parts in a thousand of
other  urinary substances, there was a considerable quantity of  albumen, together
with an abundant sediment of oxalate of lime in the form of octahedral crystals.
   Unfortunately we still lack  anything like a large number of analyses of echino-
coccus fluid from different organs, by means of which we might point out with cer-
tainty the anatomical location of the parasite.  It  cannot yet be positively stated
whether or not its chemical constitution differs according to the organs in which it
is situated. Thus, in the two above-reported analyses by Jacobsen (p. 558) suc-
cinic acid  and  grape-sugar  were not discovered,  whilst they were present in the
liver echinococci; "Wilde found both substances in a case of echinococcus of the
spleen; Naunyn (1. c), succinic acid in the liver and lung echinococci of the sheep.
   1 Spiegelberg, Archiv f. Gynaekologie, I., p. 146.—Smith, British Med. Journ., 1868
(Jahresber., 1868, II., p. 594).—Scherenberg, Virch. Arch., 46, p. 392, 1869.— Pean,
L'Union Med., 1867, Nos. 141 and 142.—Compt. rend., 65, No. 24.
   2 See Waldeyer, Archiv f. Gynaekol., I., p. 252, 1870.
   3 Davaine, 1. c, p. 374.  (Barker, on Cystic Entozoa in the Human Kidney. London,
1856.  p. 9).
   4 Heller, Deutsches Archiv f. klin. Med., V., p. 267, 1869. 
574    HELLER.—DISEASES FROM MIGRATORY PARASITES.
   The chemical examination of the fluid obtained by repeated punctures is not of
value in forming a diagnosis;  the albumen which it then contains is probably due
to transudation from the blood or other fluids.

   The microscopic discovery of scolices, rows of hooks, or single
hooklets, in the sediment,  establishes the diagnosis ; but their
absence does not disprove the existence of echinococcus.
   The occurrence of severely itching urticaria is said to indicate that the echino-
coccus fluid has escaped into the abdominal cavity.1

                          Prognosis.

   Infection with the echinococcus is not of itself a dangerous
disease, and only becomes so under certain circumstances.  The
prognosis varjes exceedingly, according to the situation and size
of the parasite ; in our  consideration of it in individual organs
we shall revert to this point.
   Very large  echinococci, or those  still  increasing in size,  are
always to be regarded with anxiety;  the prognosis is less  favor-
able when local or general disturbances supervene, either in con-
sequence of other diseases, especially chronic forms, accompanied
by exudation,  or as the direct result of the parasite.
   Pregnancy  does not tend to make the  prognosis any more
unfavorable; on the  contrary, an  entire  subsidence of a liver
echinococcus has been observed under its influence.2  In another
case,  however,  a sudden increase took place during pregnancy,
and the echinococcus was  afterwards removed by an operation.3

                          Treatment.

   Medicinal treatment  of echinococcus does not promise much.
Only remedies which are soluble  and easily absorbed by  the
blood, and which can, therefore,  be carried  to the parasite, and
permeate its capsule  by  endosmosis, need be considered; they
must also be administered  in  sufficient quantity to  be poison-
1 Jonassen, Ugerkrift for Laeger, 3 R , XITL, No. 25.
2 Seidel, Jen. Zeitschrift f. Med., etc., 1864. p. 289.
3 Hofmokl, Wiener med. Presse, 1868, No. 40. 
                        ECHINOCOCCUS.                      575

ous to the parasite, without exercising any injurious effects upon
the patient's system.
   Of the many remedies recommended, we shall mention only
the salts of mercury1  and the iodide  of potassium, the results
from which in some cases have been much lauded, but in others
found wanting.

   Heckford2 saw an echinococcus of the left lobe of the liver in a woman, twenty-
two years of age,  disappear in five weeks under the use of twenty-seven grains of
iodide of potassium daily.
   In the case of a boy, Reeb3 saw the  symptoms of an echinococcus tumor of the
brain disappear twice under the influence of large doses of iodide of potassium
(from two to fifteen grains daily), blindness alone remaining; on  a third occasion
this treatment accomplished nothing.

   Hjaltelin4 has  lately recommended,  incases of growing liver
echinococcus of recent formation,  the  tincture  of  kameela, in
doses of from  thirty to forty drops three times a day, in a table-
spoonful of water ; this  treatment to be continued  from four to,
six weeks.  Hjaltelin claims that in this manner he caused the
disappearance of the echinococcus in twenty-two persons.
   Electricity  is recommended from different  quarters, and its
results lauded.5  H. Fagge6 thrusts two gilded  steel needles into
the tumor, two inches apart, and connects both with the positive
pole ;  he places the negative pole of a constant current from ten
elements between the needles,  and allows the current to pass for
twenty-five minutes.  Forster does the same.  Only  a few drops,
if any, of the fluid escape by the side of the needles.
   The most favorable results in cases of echinococcus have been
attained by surgical means, where the parasite was  accessible to
surgical treatment.  Those  lying  in external  parts are simply
opened  by a  single incision,  and  emptied, and the treatment
carried out according to the rules of surgery.   For the cure of
echinococcus of internal organs  there is a variety of methods in
1 Davaine, 1. c.
2 Heckford, British Med. Jour., 1868.
3 Cit. Jahresbericht, 1871, IT., p. 70.
4 Edinb. Med. Jour., XIII., p. 137, 1867.
5 Davaine, 1. c, p. 565.
6 H. Fagge, Lancet, 1868, p. 75. 
576     HELLER.—DISEASES FROM  MIGRATORY  PARASITES.

use, with innumerable variations and modifications of detail,
which are all more or less worthy  of recommendation, and  all of
which have produced good  results.1   Their object is, substan-
tially, the prevention of the escape of the fluid into the serous
cavities, by obtaining a previous adhesion of the two surfaces.
   A single puncture2 with a fine trocar, and the withdrawal of
a portion of the fluid,  seems  to be sufficient in many  cases.
After the puncture, the patient is ordered to lie upon his back
for two days ; the wound is  closed with collodion; exudation
into the sac, death of the animal, and resorption follow.  Should
suppuration of the sac occur, the  formation of a larger aperture
would be rendered necessary, together with frequent injections
of a solution of carbolic acid.

   Of forty-six cases  treated in the English hospitals by puncture alone, complete
recovery followed in thirty-six; in ten suppuration took place, and incision be-
came necessary, followed by death in two cases.  The puncture should be made as
soon as the  echinococcus has  attained a sufficient size to determine positively the
nature of the cyst, provided it is still increasing in size.  Only a portion of the fluid
should be allowed to escape, that the  entrance of air may be prevented.

   Simon3 practises and recommends double puncture, with sub-
sequent incision.   The  tumor is  punctured with a fine trocar,
and  the canula allowed to remain ; in twenty-four hours  peri-
toneal union will  have taken place.   Eight days  afterwards a
second  trocar is thrust in  at  some distance from the former,
and  the canula again allowed to  remain.   After about twenty-
four hours the two  punctured wounds  may be  united by an
incision.  After the sac has been  emptied, it is washed clean by
tepid injections;  should  the secretion have  a bad odor, disin-
fecting  solutions of iodine, carbolic acid, hyposulphite of  soda,
and  the like, should be employed.  Fiedler4 recommends that
the trocar should be thrust  in obliquely, in  order to prevent
the sac  from gliding away from the canula;  and for the  same
reason he considers it advisable to allow only a portion of  the

          1  Davaine, op. cit., 565 et seq.,  gives a very full account.
          2  Murchison, Lancet, 1868, p. 75.—Anstie, Lancet, 1870.
          3  Simon, Deutsche Klinik, 1866, pp. 388 and 404.
          4  Fiedler, Deutsches Archiv f. klin. Med., VI., p. 607, 1869. 
ECHINOCOCCUS.
577
fluid to escape.'   Fiedler anesthetizes the skin between the two
punctures,  before it  is  cut, with spray,  according to  Richard-
son's method.
    According to Recamier's method,2 the echinococcus tumor is
opened by  cauterization ; by  its  gradual operation a  union  of
the serous membranes is effected before the  opening takes place ;
this method is exceedingly painful and tedious
   In a case reported by Bouchut, Gaz. de Paris, 1865, the time occupied in the
application of the cautery, previous to the opening, was twenty-one days.

    Trousseau aims at union by thrusting in  numerous needles,
yet this very frequently fails.
   Fiedler used four long Carlsbad needles, and Mireur (These de Paris, 1868), from
forty to sixty, without obtaining adhesion.
   With the immense amount of material afforded by Iceland, it is to  be regretted
that Finsen and Hjaltelin, the two Icelandic physicians who have had charge of the
greatest number of cases, should be engaged in fruitless disputes, as to whether cau-
terization or puncture and incision should be given the preference, instead  of
attempting the solution of more important  questions.   The  particulars of the
numerous publications on  this subject may  be found in Virchow, Hirsch, and
Gurlt's Jahresberichten.

    Simon's  method, with Fiedler's modification, or Finsen's pro-
posed improvement, would seem to be the most worthy of com-
mendation.  The puncture should be performed  with  a curved
trocar, in order  that  the second may be  made from within out-
wards with  the same instrument.  At all events, the  danger  of
tearing away the sac  from the adhesions  around  the  first punc-
ture is  thus avoided, and a  better prospect of  a good  result
obtained.
   Subsequent injections are necessary for  the promotion of healing and the pre-
vention of suppuration. Gall is used by many, and it deserves further trials.

    Far more difficult  than the choice of the method, is the deci-
sion whether,  and at  what time,  an operative procedure of  any
sort should be  undertaken.    In echinococci  which   show no

   1 Wilde, Deutsches Archiv f. klin. Med., VIIL, p. 116, 1870.
   2 Martinet, Clinique  Med.  de  THotel-Dieu,  1827.—(Davaine, p. 586.)—De mar-
quay's Modification : Paul, L'Union Med., 1866, 122 and 125.
           VOL. III.— 37 
578    HELLER.—DISEASES  FROM MIGRATORY  PARASITES.

tendency to increase, and which create no excessive disturbances,
one would scarcely resort to an operation.
   In echinococci of internal organs, which are still increasing in
size, we should not defer it until threatening  symptoms appear,
however unwilling we may be to undertake an operation, which
is not without its dangers,  when the derangements are  still very
slight.  The presence of  a  growing echinococcus is like the
sword of Damocles,  continually threatening  immediate danger.
Hence it is, that the prospect of a favorable termination dimin-
ishes with the growth of the tumor, since, on  the one hand, the
cyst wall usually becomes more and more inflexible as it grows,
and heals less readily, and  on the other hand, the accompanying
changes in other organs may become so far advanced, that, even
after the successful removal of the parasite, they may cause the
patient's death

                Etiology and Prophylaxis.

   As the echinococcus is  the  larval  state of the taenia echino-
coccus, the dog,  as the bearer of this tape-worm, claims the first
consideration, in connection with its etiology and prophylaxis;
and the other animals in which the echinococcus is found, and
which may, therefore, be  the  source of infection for the dog,
will receive secondary consideration.
   When we consider the important part played by the dog as
the constant companion of  man, and the too intimate intercourse
frequently existing between man and dog, especially in the lower
classes and  among  persons of but little culture, the wide distri-
bution of the echinococcus  will not seem strange.  Children  es-
pecially are exposed far more to the danger, since an invasion by
the encapsuled worms may occur much more readily in children
than in adults.  Even the  finest lapdog is not safe, and may fre-
quently harbor the ta3nia echinococcus,  and transfer the eggs  to
its mistress's mouth by a kiss.  Every one who has owned dogs
is aware of their habit of  frequently applying  the  nose  to the
vicinity of the tail;  this may be a matter of toilet with them,
or it may be done in the search for epizoa.  The greatest possible
limitation of intercourse with dogs is therefore the first step in a
rational prophylaxis. 
ECHINOCOCCUS.
579
   The tsenia echinococcus occurs also in wolves,1 and perhaps in other carnivora ;
but here they are of no consequence.

   The matter of preventing dogs from acquiring the  tsenia echi-
nococcus  is, therefore, of special importance.    Of the animals
besides  man in wliich the echinococcus is  found,  only the cow,
the  sheep, the  hog, the  goat, and perhaps the horse and  the
deer,  need be  considered.    This,  then, must  be attended  to :
"water-blisters" of  all kinds wliich are  found in  these animals
must  not  only, as  is the  usual  custom, be  cut  out and thrown
away, but should be burnt or destroyed in some such manner as
will prevent the dog from swallowing them.  The dangers incur-
red by neglect  of these matters  should be  made known  to  the
community.

   Although the taenia echinococcus has not yet been observed in the intestines of
man, we must not lose sight of the possibility of such an occurrence, and of self-in-
fection  from such a source.  Therefore the most  careful excision of all " water-blis-
ters,"  especially of the livers of  slaughtered animals, is to be practised, so that the
remaining flesh may not become infected with scolices either on  tearing or carving
it. It is best to consider as suspicious every cyst containing a watery fluid, as a fine
discrimination cannot be expected on the part of the public.
   After all that has been already stated, it is scarcely necessary to mention  that
man is  neither exposed to the echinococcus by the use of raw smoked meat, as Hjal-
telin 2 believes, nor by hereditary transmission.  A clear comprehension of the etiol-
ogy can alone give us the foundation for  a prophylaxis.   Thus Richardson 3 traces
the frequent appearance of the echinococcus in Victoria  (Australia), especially
among the shepherds, to the  use of  mutton as food.  The sheep, without doubt,
acquire echinococcus from the shepherd dogs.


                              Section n.

              ECHINOCOCCUS  OF INDIVIDUAL  ORGANS.

                      1. Echinococcus of the Brain.

   The occurrence of the echinococcus within the  skull is infre-
quent, and it only exceptionally attains a  notable size in  that

                  1 Cobbold, Entozoa.  London, 1864, p. 261.
                  a Hjaltelin,  Jahresbericht, 1870, I., p. 231.
                  8 Richardson, 1. c. 
580    HELLER.—DISEASES FROM MIGRATORY  PARASITES.

situation, as it usually causes the death of the patient too early
for this to occur.   The echinococcus is found  in the brain, in all
its parts,  and between the membranes ; it is seen in a free state
at the base and in the ventricles.   The brain substance is sup-
planted by the growing parasite, and there is  sometimes a condi-
tion of softening of the neighboring tissue, which again may be
hardened and sclerosed.   The membranes are, at times, thinned,
and in other cases thickened and oedematous, and the ventricles
distended. Not infrequently the roof of  the  skull  is absorbed
and perforated by the growing parasite, which then makes its
appearance externally.   It may  also extend  into the nose and
orbit, and may induce exophthalmos.
   On the whole, the symptoms  which indicate  an  intracranial
echinococcus differ but little from those of other tumors of slow
growth.   The principal and  most frequent are headache, dizzi-
ness, vomiting, syncope,  and spasms, at times of an epileptiform
character; disturbances of the motor and sensory functions, as
also of the mind,  are observed.  Continuous violent  headache is
sometimes the only symptom. A persistent trigeminal neuralgia'
was, in one case, the only symptom of an echinococcus sac, nine
centimetres  long,  situated  in the right  cerebral hemisphere.
Westphal2 makes special mention of an intermittence of  the
symptoms, with now  and then an intensified recurrence.
   The compression  which the  echinococcus, by its  size and
extent, exercises on  both hemispheres, or often onty on single
nerves, causes a multiplicity and  peculiar grouping of the symp-
toms, which  differ strikingly from those which were  formerly
considered as characteristic  either of acute or of chronic brain
disease.   The symptoms  usually increase suddenly in  severity,
and  cause death  in  a short time.  A  spontaneous discharge
externally, with subsequent cure, but seldom  takes place.3
   The diagnosis of echinococcus of the brain is extremely diffi-
cult, and is rendered possible only by the further presence of the
parasite  in some  more accessible  locality, or when it breaks
1 Visconti, Annali univers. dimed., 1869, p. 84.
8 Westphal, Berlin klin. Wochenschrift, 1872, No. 18.
3 Moidinie, Gaz. des Hop., 1836, X., p. 303 (Davaine, 1. c , p. U8).-~Westp7ial, 1. c. 
ECHINOCOCCUS.
581
through the skull and  reveals itself externally as a fluctuating
tumor.  The slow growth and the absence  of  fever make  the
diagnosis probable; an exploratory puncture may render it posi-
tive.
    The prognosis, if not absolutely bad, is at least very unfavor-
able.
    Naturally, the treatment  is  purely that of combating  the
symptoms.  On suspicion of the presence of an echinococcus, a
course of  the  iodide  of  potassium  should  not be  omitted.
Should the situation of the  echinococcus  be determined, especi-
ally by its breaking through the roof of the cranium, an explora-
tory puncture, with subsequent  gradual withdrawal of the con-
tents, should be attempted.  For this purpose Sibson's1 method
is the  best.  He  punctures with a hypodermic syringe,  with-
draws  some fluid by pulling back the piston, then replaces  the
syringe by a small tube,  and allows the echinococcus fluid to
drain away through this ; should it be necessary, especially if
the diagnosis be verified  by the examination of the fluid thus
obtained, an incision may  subsequently be made.
   Davaine (p. 651) enumerates thirty cases of echinococcus within the cranial
cavity, in eight of wliich the parasite was situated outside the membranes of the
brain.   Several of these cases—especially No. 22—may be considered doubtful.

                 2. Echinococcus of the Spinal Cord.
    The echinococcus is less  frequently found in the spinal cord
than in the brain.
   The parasite may here develop in three different modes ;  it
is extremely infrequent for it to have its primary seat within  the
sac of the dura  mater ; it occurs somewhat oftener  outside of it,
yet originally in the vertebral canal;  it  usually forces its way
from without into the vertebral canal by widening the interverte-
bral foramina, or it makes a path by absorption of  the vertebra.
The echinococcus has not  yet been  observed in the  substance of
the spinal cord.   Those developed primarily within  the vertebral
canal, but outside the sac  of the  dura mater,  escape  into  the
adjoining parts by the same routes,  only reversed.
1 Sibson, Lancet, 1868, p. 75. 
582    HELLER.—DISEASES FROM MIGRATORY PARASITES.
   Altogether only twelve cases of echinococcus of the vertebral canal have been
recognized; of  these, six were originally situated without  and  six within the
canal;  of the latter, two  lay within the sac of the dura mater.1 In one case which
I saw dissected in 1870, in Guy's Hospital, London, the echinococcus had crowded
out of the vertebral canal anteriorly, to the right and left, into the pleural cavities,
and also posteriorly by numerous ramifications into the muscles of the back.

   An echinococcus lying within the sac of  the  dura mater flat-
tens the  spinal  cord ; the  underlying  portion  of the  cord is
markedly softened,  and the blood-vessels seem much distended.
The effects of those  lying without the dura mater are similar, but
probably the changes do  not make their appearance  until  some-
what later.
   The symptoms of an echinococcus  in the  spinal canal  are
scarcely distinguishable  from  those which  appear  during  the
development of  other neoplasms.   Disturbances of innervation
are noticed from the  beginning  in the parts supplied by  the
nerves which emerge below the  parasite, particularly pains  in
these parts;  then  pains in  the vertebrae  appear,  which  are
increased  by pressure;  following  these come  numbness and
formication, merging into complete anaesthesia, and difficulties
of locomotion which may amount to complete paralysis ;  some-
times there are  cramps  and muscular  twitchings,  paralysis of
the bladder,  rectum, and  abdominal muscles, and  dorsal  decu-
bitus, with complete extension of the limbs.
   If  the echinococcus is situated in the lowest portion of  the
vertebral canal, all symptoms may be absent.
   The duration of the  disease,  from the beginning of  the first
symptoms until death,  varies from  one month to  five years.
Recovery has not yet been observed.
   For the diagnosis, prognosis,  and treatment, the same holds
good as was said with reference to echinococci of the brain.

             3. Echinococcus of the Respiratory  Organs.
   The echinococci which are found in the respiratory apparatus
either  develop originally in the  thoracic cavity or  they force
their way into it from the vicinity,  usually  from the  abdomen.

   1 Bartels, Deutsches Archiv f. klin. Med., V., p. 108, 1868.—Davaine, 1. c, p. 669. 
ECHINOCOCCUS.
583
The former, in the large  majority of cases, are situated in the
lung tissue itself, and  chiefly in the lower lobes.   They seldom
occur in the  pleural cavity, in  the subpleural cellular tissue, or
in the  mediastinum.  As  a rule, only one sac is found ;  the cyst
wall is usually frail and thin, and does not undergo retrograde
metamorphosis.  After attaining a considerable size, the echino-
coccus frequently occupies one whole side of the thoracic cavity,
compressing the lung against its hilus or its apex.   The heart is
displaced to  the opposite  side, toward the right or the left axilla,
or  the epigastrium, according  to  the situation of the parasite.
The diaphragm is pressed downwards, and the adjacent abdom-
inal viscera  are consequently forced  down.   The intercostal
spaces of the affected side are more or less bulged.
    After a still further growth, the echinococcus may pierce the
chest  wall,  or the depressed  diaphragm and  abdominal wall,
and an  evacuation  occur externally.   Far  more  frequently,
however, the bronchial tubes  are penetrated,  and the echino-
coccus and its contents—fluid and  daughter sacs—in course of
time expectorated ; the cyst-wall shrivels and cicatrizes, and the
younger and frailer the cyst is, the more rapidly does this occur;
older ones, with thickened and unyielding walls, heal only after
a long-continued illness, or cause death from exhaustion.
    An opening into the intestinal canal, with discharge of the
contents at stool, is an extremely rare occurrence.
    The penetration of the echinococcus externally, and its dis-
charge, is a very fortunate result.   The majority of such cases
terminate in  recovery.
    Its  penetration  into the pleural or pericardial sac (which, of
course, happens but seldom), is, however, very dangerous ;  usu-
ally occasioning fatal pleurisy or pericarditis.
    Of  the echinococci originating outside of the thorax, we shall
consider only those of the abdomen, which  usually find their
way into the chest by perforation of the diaphragm.  In general,
the preceding statements apply to them ; they may open into the
lungs and air-passages,  or into the pleura or  pericardium, with
the same results.   These  far oftener occasion effusions into the
two last-named cavities,  than  do those which are developed in
the lungs, since in the latter  the pleural surfaces  are usually 
584    HELLER.—DISEASES FROM MIGRATORY PARASITES.

united.   Very serious results may happen,  however, even with-
out penetration of the diaphragm, as the heart and lungs  may
be very much crowded out of their normal position (they may be
compressed even up to the fourth or  third rib).  Generally there
are echinococci of the liver, but seldom of the spleen or kidneys
(vide infra).
   While the echinococcus is still small, it occasions no distur-
bance.  It has usually already attained a considerable size before
the person affected applies for medical assistance.  Pains in the
back and sides often  occur, sometimes of great severity.  The
most constant symptom, however, is shortness of breath, which
may at times  amount to  suffocation.  Dry  cough then occurs.
There is but seldom any expectoration, unless a discharge of the
echinococcus takes place into the bronchial  tubes ; in this case,
the expectoration suddenly becomes  profuse ; it is clear or only
slightly dulled in color, thin, and  inodorous, or, by long stand-
ing, offensive.  Should there be secondary vesicles within the
echinococcus, part of them will be discharged entire, and  part
collapsed and in  shreds ;  fragments  of membranes are  found in
the sputum, and the scolices and hooks  form a sediment at the
bottom.  At times, there  is a slight  admixture of blood.  At a
later period, the expectoration becomes thicker, and more puru-
lent, and afterwards more  scanty, until finally,  with the collapse
of the empty  cyst, it  ceases entirely.   The  complete  drainage
may require from a few days to several months, according to the
size of the sac.
   In addition to  these symptoms connected with the respira-
tory apparatus, disturbances of neighboring organs take place.
A large echinococcus must cause an  impediment in the pulmo-
nary circulation, and, as the result of this, a stasis in the venous
system.  Deviations in the direction of the  spinal column may
easily be produced by a  very slow  growth of the parasite, es-
pecially in young persons.
   The disease brought on by the presence  of  the echinococcus
in the respiratory organs usually runs  a slow course ; the aver-
age duration is from two to four years ; yet, besides this, there
is always a period of incubation to be taken into account, since,
as has  been stated, the parasite may have attained a considera- 
ECHINOCOCCUS.
585
ble size before  any disturbances are noticed;  at times, the first
symptoms of disease are so severe that death occurs within a few
weeks.

                         Diagnosis.

   The diagnosis of echinococcus of the lungs is rather difficult.
It may happen that an opening  may form externally,  or the
tumor may be in such a position as to be palpable, and fluctua-
tion be discovered; but usually the nature of the disease has
been mistaken, and it has been considered  as consumption or as
pleuritic effusion.
   The physical signs are, as a matter of  course,  very variable,
according to its location and size, yet, as a rule, scarcely differ-
ing from  those of other changes producing dyspnoea.  As the
parasite  usually develops in the lower lobe, it may  easily be
mistaken for a pleuritic effusion.
   Absence of  respiratory  sounds, of bronchophony, and  of
noticeable fever, together with the constant increase of size, are
the chief points in the differential diagnosis.  Should  all possi-
ble causes of hydrothorax be absent, and  the dyspnoea be very
intense, with marked  deformity of the thorax, the presence of
the echinococcus  would seem to be indicated.  An exploratory
puncture, which is without  danger in the diseases previously
mentioned, makes the diagnosis absolutely positive, in part by
the discovery of the  chemical constituents of the fluid, and in
part by the  appearance of scolices, hooks, or shreds  of mem-
brane, which, obstructing the trocar, are often drawn out with it.

                         Prognosis.

   As the above remarks would imply, the prognosis is exceed-
ingly variable.   It is very favorable in those cases in which the
opening and discharge (whether direct  or  indirect) occur exter-
nally.  Should this not happen, the prognosis will be less hope-
ful, though not absolutely unfavorable ; the growth may come
to a  standstill, and  shrivelling and disappearance occur.  In
case of an increase of size, danger of death from sheer suffocation
becomes imminent, since  a more or less great,  usually a very 
586    HELLER.—DISEASES FROM MIGRATORY PARASITES.

considerable, portion of lung tissue is rendered useless for res-
piration.  Sometimes pneumonic infiltration in the vicinity or
gangrene of the lung may destroy life.

                         Treatment.

   What we have stated with reference  to the treatment of the
disease in general applies to both the medicinal and other treat-
ment in this  class.  Patients  in whom the  echinococcus has
opened  into the air-passages or the intestinal canal require very
attentive care, in  order to ward off all  possible complications.
In  case of  markedly ichorous and offensive  expectoration,
inhalations of oil of turpentine or of atomized disinfectant fluids
are to be resorted to.   Good nourishment is of importance, to
maintain the strength until complete recovery takes place.
   In gradually increasing echinococci which do not open, and
the prognosis concerning which is  unfavorable from the begin-
ning, we should not allow ourselves  to be idle, but—especially
where there is increasing dyspnoea—should resort to operative
procedures, according to the rules laid, down for thoracentesis.

            4. Echinococcus of the  Circulatory Apparatus.

   Echinococcus  of the heart is very rare,  and never attains  a
striking size.  Sometimes no disturbances whatever indicate its
existence until it proclaims its presence by the  alarming symp-
toms consequent on a rupture into the cardiac cavity; immediate
or speedy death  is the usual result  of  this unfortunate event.
When situated in the right ventricle, shortness of breath and
paroxysms of suffocation, lancinating pains in the region of the
heart, palpitation, and exhaustion, with  systolic murmurs at the
apex, are not infrequently the only symptoms.
   Should  the echinococcus open into the cavities of the heart,
the result—if into the right heart—would be an  embolus com-
posed of secondary membranes  or shreds of membranes in the
pulmonary artery, and immediate death  ; or, lung infarctions or
gangrene might occur ; if rupture into the left heart takes place,
we have peripheral emboli, with their results.   Penetration of  a 
ECHINOCOCCUS.
587
cardiac echinococcus  into the pleural or  pericardial  sac excites.
fatal pleurisy or pericarditis.
   In Oesterlen's ' case of a butchers servant girl, twenty-three years old, gangrene
of the lower extremity, extending up to the knee, appeared suddenly;  death occurred
from pyaemia, after  amputation through the upper part of the thigh.  An echino-
coccus of the size of a pigeon's egg had perforated the left auricular wall into the
auricle ; echinococcus membranes were discovered in adherent thrombi of the com-
mon iliac artery, and an entire sac, with secondary vesicles, was found in the arteria
profunda femoris.

    The  diagnosis of  echinococcus  of the heart may  be abso-
lutely impossible,  or only become practicable on the recognition
of an echinococcus tumor in another part of the body.
    An  echinococcus  of  some  other  part  occasionally breaks
into  neighboring vessels, and  may result  in thrombosis  and
phlebitis,  or, if  it open into a large venous trunk, in embolism of
the pulmonary  artery.

                    5.  Echinococcus of the Spleen.
    The statements already made  in the general discussion,  and
what will  be given in  respect to the liver, are applicable to some
extent  to echinococcus  of  the spleen, which is not of very com-
mon occurrence.   The phenomena,  apart from the  situation in
the left hypochondrium, are very similar.1
    With reference to treatment, the question of extirpation of
the spleen will  suggest itself, especially as it  has been done in
one case2 with a fortunate result.
   The case was that of a woman, twenty years of  age, who had had this tumor
(considered to be ovarian) in the abdomen for two years.

                    6.  Echinococcus of the Kidney.
    The development of an echinococcus in one kidney is not very
rare ; its size may be very considerable before it gives rise to  any

   1 Oesterlen, Virchow's Archiv, 42, p. 404, 1868.
   8 Wilde, Deutsches Archiv f. klin. Med., VIIL, p. 116, 1870.
   3Pean, L'Union  mod., 1867, Nos. 141  and 142.—Compt. rend., LXV., No. 24
(Jahresbericht, 1867,  II., p. 460). 
588    HELLER.—DISEASES FROM MIGRATORY PARASITES.

annoyance. It first causes atrophy of that portion of the kidney
in which it is situated, with subsequent rupture into the abdom-
inal cavity,  or into  the thorax  or bronchial  tubes,  into the
intestine,  or perhaps externally.
   Among the most frequent is  its rupture into the pelvis of the
kidney;  the  discharge of the content sthen takes  place through
the urinary passages ; pure fluid contents will  scarcely occasion
any noticeable derangement; if,  however,  there be secondary
vesicles in it, or  should the membrane of the sac be discharged,
the escape cannot take place without  considerable trouble.   Its
passage through the ureter sometimes causes impaction  and
stoppages  of urine, with their consequences,  ischuria, renal colic,
hiccough,  nausea, and vomiting.  The pelvis of the kidney and
the ureter become dilated by these repeated distentions.   The
passage of the  membranes and vesicles through the urethra
causes retention of  urine  and excruciating cystic tenesmus,
which latter disappears when the bladder has been emptied.
   A rupture in other  directions  is less  favorable.  Should an
opening  into  the intestine occur, complete cure may be the
result, but there is no  little danger of suppuration of the cyst;
penetration into  the chest is usually followed by opening into
the bronchi,  as union  of the  pleural  surfaces will have  pre-
viously taken place ; here, too, recovery is possible, but long-
continued  suppuration may cause death from exhaustion.  Per-
foration into the abdominal cavity generally terminates in fatal
peritonitis.

                         Diagnosis.

   The diagnosis of echinococcus of the kidney is exceedingly
difficult; it becomes  positive  only after the passage of vesicles
or shreds of membrane.  As the  echinococcus is usually unila-
teral, derangements of the urinary secretion  are not necessarily
present.  The difficulty of distinguishing it from  other tumors
of the abdomen  has  already been mentioned.   A puncture can
establish the diagnosis  only when scolices or hooks are  dis-
covered in the sediment, or daughter vesicles or fragments of
membrane  in the fluid. 
ECHINOCOCCUS.
58£
                             Prognosis.

   The prognosis is  not altogether unfavorable; kidney echino-
cocci often heal spontaneously by an emptying of the sac.

                             Treatment.

   The treatment of  kidney echinococcus is almost aimless ; the
internal  use  of  oil of  turpentine is recommended, especially in
case the  sac should open into the urinary passages.
   Surgical treatment has recently been proposed  by  Simon,1
and offers some prospect of good results.

                7.  Echinococcus of the Suprarenal Capsule.

   The  echinococcus occurs exceedingly  seldom in  the supra-
renal capsule.  Davaine cites  only one case.   A  very interesting
case  of multilocular echinococcus  of  this organ is reported by
Huber.2
   A master carpenter, sixty-three years of age, who had had a severe attack of
pain in the right hypochondrium six years previously, was taken ill with loss of
appetite, excruciating  pains in the right hypochondrium, and extraordinary muscu-
lar weakness;  sufficient sleep, and frequent somnolence, with extreme  thirst and
vomiting after drinking largely, were the  symptoms which he presented.  Gradual
exhaustion  caused his  death in about three months.
   Post-mortem examination showed that the right  suprarenal capsule had been
transformed into a tumor of about the size of a walnut;  this had a fibrous capsule
and a central ulcerous cavity.  The tumor itself consisted of firm, callous  connective
tissue, with  large and small alveolar  spaces ; the former provided with a greasy
coatino- consisting  of detritus, crystals  of  the fatty acids, and myeline.  In the
smooth-walled smaller ones  were gelatinous echinococcus vesicles without scolices
and hooks ;  these were folded together, but could easily be drawn out; in several
there was a beautifully developed water-vascular system.


                     8. Echinococcus of the Liver.

   The echinococcus, as already stated, occurs much more fre-
quently in the liver than in all the other organs together; at one

          1 Simon, Chirurgie der Nieren, 1871.
          3 Huber, Deutsches Archiv f. klin. Med., IV., p.  613; V., p. 139. 
590    HELLER.—DISEASES FROM MIGRATORY PARASITES.

time only one specimen,  at another several, may be found either
in the liver alone or  at  the  same time in that and other organs.
As many as twelve or more cysts have been found in a single
liver.  It frequently attains  a very striking size, sometimes that
of a  man's head,  or  even greater.  It occurs in all parts of the
liver, but by preference develops near the capsule.   Its increase
produces a very striking change in the shape of the organ.
   In consequence of the slow growth of the parasite, the results
induced  by its presence  are at first very  insignificant.   Only
when situated at the hilus, does it occasion early disturbances by
compression of the bile-ducts or portal vein.  In the beginning,
the growing parasite  crowds the liver tissue in its neighborhood,
condenses it, and causes its atrophy.   The connective-tissue cap-
sule around it is  formed to  some extent from the neighboring
parts, and also in  part perhaps from a new growth of connective
tissue.   On further growth,  large portions  of the  parenchyma
undergo  the same processes, while the remainder of the organ
continues normal, or, in certain cases, shows compensatory hy-
pertrophy.1   At times inflammation  and suppuration occur in
the immediate neighborhood, either brought on by mechanical
violence  or without being referable to any such influence.
   The echinococcus not infrequently comes in contact with the
bile-ducts.  The walls of one or more ducts are destroyed by the
pressure  of the parasite, and  a  communication  established
between  them ; the echinococcus then seems to be destroyed by
the contact of bile,  or  daughter  vesicles get into  the biliary
passages, and  from thence escape into the intestine.  At first,
as a  matter of course, only  small vesicles  can pass, since they
crowd through under the  pressure from behind of the echino-
coccus fluid, and  in  some degree also, of the secreted bile ; in
this  manner they widen the  ducts, and  make them capable of
admitting  larger  vesicles.    Thus  a complete  emptying  and
gradual cure may finally take place.
   In this way must we explain Barth's 2 case, in which the post-mortem examina-
tion showed no signs of an earlier  perforation, and in which only two shrivelled
'Vide supra, page 569, and Frerichs, Klinik derLeberkrankheiten, II., p. 223.
2 Archiv d. Heilkunde, XIII., Heft 4 and 5.  (See also Davaine, p. 463.) 
ECHINOCOCCUS.
591
vesicles, of the size of cherry-stones, were discovered at the posterior border of the
gall-bladder, whfch was itself displaced upwards; three years previously a liver-
echinococcus had healed spontaneously after discharging into the intestine.
   According to the opinion of certain authors, the echinococcus may develop in
the biliary ducts;  the cavity in wliich it is situated may therefore be lined with
mucous membrane. This would seem to afford a simple explanation of the frequent
communication with the gall-ducts, as also of the cases in which echinococcus vesi-
cles have been found in the gall-bladder, without a liver echinococcus having been
discharged into it.  A case of echinococcus of the processus vermiformis,1 shows
that it may really develop in a cavity lined with mucous membrane.

   An opening of the echinococcus into the blood-vessels of the
liver occurs less  frequently.  Now  and then a coexisting com-
munication with  the bile-ducts is observed-  Usually, however,
thrombosis of the  affected vessel takes place  before  the occur-
rence of perforation.
   The influence  of a liver echinococcus on the  adjoining  parts is
observed only after it has  reached a considerable size.  Echino-
cocci on the upper surface of the  liver are  among the  most
frequent;  they develop towards the thorax, push the diaphragm
upwards—occasionally  as  far  as the second rib—compress the
lung very markedly, and displace the heart upwards and to the
left.  Should  the echinococcus develop towards the lower sur-
face, it would then crowd  the stomach or the large and small
intestines downwards, and in this way cause various disturbances
of digestion, sometimes  obstinate constipation.  Should  it com-
press the ductus  choledochus or the  ductus  hepaticus, it would
occasion jaundice ;  and should the compression affect the  ascend-
ing  vena cava, disturbances of circulation in  its territory, and
their results, would ensue.
   The great majority of liver echinococci cause no severe dis-
turbances, but shrivel  and  decay before attaining a  noticeable
size.  The causes which lead to the death of the parasite  are not
always manifest.  In certain cases it is inflammatory action, with
exudation in  the neighborhood of  the parasite,  or the access
of bile  into the  cyst,  which  checks  its further  enlargement.
External mechanical injuries, such as a kick, a blow, or a  fall,
often exert  a  very unfavorable influence  on  the  parasite.  In
1 Vide supra, p. 568. 
592    HELLER.—DISEASES FROM MIGRATORY  PARASITES.

many  cases, indeed, these causes bring on  unpleasant conse-
quences,  such as  severe  inflammatory action  or  the sudden
rupture of the sac, with discharge of its contents into the neigh-
boring cavities, with almost always an immediately fatal result.
The echinococcus is generally noticed  only  after  such occur-
rences, and from that time forward shows such  a rapid growth
that the patient dates the origin of the tumor from the injury.
   Spontaneous  perforation  of  the echinococcus externally
through  the abdominal walls is to be  considered  as the most
favorable termination ; but, unfortunately, such a result, in pro-
portion to the number of cases, occurs but very seldom.  Most
frequently the echinococcus empties into the intestinal canal;
the contents,  fluid and vesicles, are often  discharged by  the
intestines in enormous quantity ; sometimes ulceration  of  the
parasite,  with severe pains, seems to precede this penetration.1
The communicating opening is frequently so contracted that  the
discharge can take place only very gradually; almost  all such
cases run a favorable course, and end in recovery. Most echino-
cocci which penetrate into the bile-ducts run a similar course,
with the  same result.
   Rupture into the serous cavities—peritoneal, pleural, or peri-
cardial—is far less  favorable.   When this occurs suddenly,  the
succeeding inflammation is, as a rule, speedily fatal; but, in rare
instances, a tedious recovery follows an opening into the abdom-
inal cavity.   Such a sudden penetration  is always accompanied
by severe pains.
   A gradual extension towards the base of the lung runs its
course with the  symptoms of a chronic or  a subacute pneu-
monia ; either only a slight infiltration occurs in  the vicinity, or
a more or less extensive cavity forms,  which is in immediate con-
nection with the echinococcus sac.   Should  a large bronchus
open into this cavity, or should one be laid open  by  the advanc-
ing destruction of the intermediate tissues, an abundant expec-
toration of purulent matter, mixed with vesicles and the remains
of vesicles, would follow.   On the other hand, a direct opening
of the echinococcus into the air-passages  is followed more or less
1 Tiingel, Klinische Mittheilungen, etc.  Hamburg, 1864, p. 87. 
ECHINOCOCCUS.
593
speedily by expectoration of a large quantity of watery  fluid,
with vesicles and shreds  of vesicles, which does  not assume a
purulent aspect until a later period.  A great number of these
cases result in recovery,  following gradual diminution of the
expectoration ; while others end fatally from hectic fever.
   Rupture into the vena cava usually destroys life at once,  by
embolism of the pulmonary artery.
   Of one hundred and sixty-six cases of liver echinococcus,1 four are recorded as
having penetrated into the thorax, nine as having opened into the pleural cavity,
twenty-one into the base of the lung or into the bronchi, eight (?) into the bile-
ducts, eight into the peritoneum, twenty-two into the intestinal canal, and ninety-
four in other directions.

    riie symptoms produced by the presence of the echinococcus
in the liver are about as various as the fate of  the parasite  itself.
At post-mortem  examinations,  liver echinococci  are  very fre-
quently found, without any derangements whatever having be-
trayed their presence during life.
   Of seventeen liver echinococci which were found in the Berlin Pathological
Institute, thirteen had given rise to no symptoms during life.2

   Only on  further  growth do those symptoms usually appear,
which are  to some extent  of a general, and in part only of a local
nature.  As  a rule, no pain is  present so long as there is no
inflammatory action ; but in the case of cysts of large  size there
is an unpleasant and continuous feeling of compression, fulness,
or tension.
   Jaundice is observed but seldom, and only under certain cir-
cumstances, either when the tumor compresses a large trunk  of
the hepatic duct or the ductus choledochus, or when the cyst is
in connection with  the bile-ducts, and  echinococcus vesicles  or
membranes  passing  through produce a temporary stoppage,  or
finally,  when the presence of the parasite occasions inflamma-
tion and abscess of  the liver.
   Dropsical  symptoms  are likewise rather  rare, and are pro-
duced only by the pressure of the tumor upon the portal vein or
       1 Davaine, p. 376.
       2 Rother, Dissert, inaug.  Berlin, 1867.
VOL. III.—38 
594    HELLER.—DISEASES FROM  MIGRATORY PARASITES.

inferior vena cava,  or as the result of general hydremia in the
later stages of the disease.
   Digestive derangements are very rare consequences of  echi-
nococci of the  liver.
   Displacement of the thoracic viscera by an upward growth of
the echinococcus,  produces a  short, dry  cough, shortness of
breath, which  often amounts to dyspnoea, and palpitation of the
heart, as the result of its dislocation.
   The direction in which  the liver increases in size is of special
objective importance;  according  to  the direction in which the
parasite  enlarges,  the  limits of the liver are  found displaced
upwards as far as the second rib, or downwards to  the pelvis.
The abdomen may be enormously  enlarged,  the right half of the
thorax seems  very much distended, immovable, and the  inter-
costal  spaces  widened, and sometimes bulging.   In cases of
development forwards and downwards, the tumor becomes tan-
gible, and its  limits may  be determined.   Sometimes an  echi-
nococcus may  be overlooked by reason of a dilated gall-bladder.

                         Diagnosis.

   What was stated in the general division  applies here to the
diagnosis, prognosis, and treatment.
   But the echinococcus  multilocularis presents a few peculiar-
ities.  As a rule, the first symptom, in addition to gastric irrita-
tion, is  icterus, which,   only  slight  in  the  beginning,  soon
increases in intensity,  until it  reaches the  highest degree.  In
some cases, however, jaundice is absent; there is usually, at the
same time, a feeling of fulness and uneasiness in the abdomen,
and sometimes attacks of diarrhoea  come  on at  intervals; the
stools appear colorless, but among them may be some of a very
dark color.  Examination  of the liver generally shows a well-pro-
nounced enlargement, which at times increases to enormous dis-
tension of the abdomen;   the surface of the liver is generally
smooth and  hard;  knotty tumors  are but seldom felt.   The
spleen is invariably enlarged.  The urine appears dark, at times
almost black, and is free from albumen.   Pain and fever to any
considerable extent are but seldom noticeable.  Gradual emacia- 
CYSTICERCUS CELLULOSE.
595
tion and loss of strength finally terminate in death ;  that event
being sometimes accelerated by hemorrhages from  the different
mucous membranes.
   The multilocular  echinococcus  is distinguished from  carci-
nomatous neoplasms by the splenic enlargement and the usually
smooth surface of the liver; from fatty and amyloid liver, by the
high degree of jaundice, as also by the general course of the dis-
ease ; other affections of the liver will scarcely be confounded
with it;  its difference from a common echinococcus has already
been stated.

                   Prognosis and Treatment.

    The prognosis,  like the treatment, is perfectly hopeless.
             CYSTICEECUS  CELLULOSE.

                           Chapter  I

Of the immense number of works which  have been written upon this subject, we
   shall only make mention of the following, in addition to those which we shall
   have occasion to refer to subsequently:  Stich, Annalen des Charite-Kranken-
   hauses, V., p. 154, 1854.— Leuckart, Die menschl. Parasiten, I., p. 228, and Die
   Blascnwiirmer und ihre Entwickelung.  Giessen, 1856.—Kuchenmeister, Die in
   und an dem Korper des lebenden Menschen vorkommenden Parasiten.  Leip-
   zig, 1855, I., p. 69.— Davaine, Tmit& des Entozoaires, p. 622.


                            HISTORY.

   The cysticercus  cellulosae has been observed in swine from
the earliest  times ; Goze'  first recognized its  animal  nature in
1784.  Werner 2 found it in man in 1786.
   The proof that the cysticercus cellulosae is the larval condi-
tion  of  the tasnia  solium  was  furnished  by  Kuchenmeister,
Haubner, and van Beneden.

   1 Goze, Neueste Entdeckung, dass die  Finnen im Schweinefleisch keine Driisen-
krankheit, sondern wahre Blasenwiirmer, sind.  Halle, 1784.
   3 Werner Verm, intest. brev. expositionis contin., II. Lips., 1786, p. 7. 
596     HELLER.—DISEASES  FROM MIGRATORY  PARASITES.
   Among the Greek writers, Aristophanes was the first to mention the measly con-
dition of the hog; Aristotle gave a tolerably accurate description of it.
   The animal nature of the measle was really known to Hartmann, O. Fabricius,
and Malpighi, before the time of  Goze; but  as their accounts were  so inaccurate,
and remained so long almost entirely unnoticed, Goze may rightly be  called the
discoverer.


                           Chapter II.
                Fig. 16.
Flattened border  of a fresh cysticercus cyst of the brain.
             (Highly magnified.)
                        NATURAL HISTORY.

    The  cysticercus cellulosae  is the larval condition of  a para-
sitic tape-worm, the taenia solium,1 found only in the small intes-
tine of man.  It is a thin-walled cyst, varying in size from  that
of a pea to that of a bean, seldom larger ; with clear, limpid con-
tents.    Like every  other foreign  body  penetrating into  the
organism,  it is almost always enclosed in a  connective-tissue
capsule, which is supplied by the adjoining parts ;  if  this be
carefully opened, the parasite will escape as a rounded, pellucid
cyst.
    At one point of this bag, a more or less  distinct  depression is
                                           observed,  and  within,
                                           in connection  with it,
                                           a firm,  yellowish or
                                           whitish body,  visible
                                           through   the   cyst
                                           walls.  On opening the
                                           cyst,  this body is
                                           found to be a club-, or
                                           pear-shaped   sac,  in
                                           which the inverted
                                           tape-worm head is en-
                                           cased, its position very
                                           much resembling  that
                                           of an inverted finger
                                           of a glove.   This bears
                                           a very striking resem-
blance to the head of the taenia solium ; it is furnished with  four
        Fig. 17.
  Cysticercus of the brain
(natural size); a black spot
Bhows the situation of the
pigmented crown of hooka
       Fig. 18.
  The same,  with the coil
magnified, the body markedly
twisted.
1 See Vol. VII. of this Cyclopsedia. 
CYSTICERCUS CELLULOSE.
597
              Fio. 19.
Head of a cysticercus of the brain.
(Highly magnified.)
suckers and a double coronet, always consisting of sixteen hook-
lets, whose points  form a  single circle.  The hooklets  of  the
outer circle are shorter than those of the inner one, and are pro-
vided with much shorter, lever-like  processes.  The hooks seem
to  be  inserted in  pouches, which,  like the  suckers, are some-
times entirely without pig-
ment, or may contain a lit-
tle, or, in still other cases,
a great  quantity of it.  A
neck  is  attached  to  the
head, and to it a short tape-
worm  body, which, being
longer than the enveloping
sac, are usually coiled and
transversely wrinkled.
    The surface of the cyst
always seems  slightly un-
even;  compressed  from
above, it seems  to  be  sur-
rounded   by  a  regular,
finely undulating, delicate
border.   This appearance
is very characteristic,  and
is  an  important point in
the recognition  of  cystic
formations  in which the
taenia-head  is no  longer
present.  (See Fig. 16, also
the border in Fig. 23.)
    The cysticercus is cap-
able  of  tolerably  active
motion;  if a fresh living
measle be  put  into tepid
water, it begins to contract
actively,  at times  backwardly, and in this manner to assume all
possible  peculiarities  of  shape ; sometimes these motions ap-
pear like waves passing over the cyst wall.
    In but few cases, and these in the brain, are cysticerci found
               Fig. 20.
  Large hooklets of the inner, and smaller ones of the outer
circle, in various positions, from Fig. 19, still more highly
magnified. 
598    HELLER.—DISEASES FROM MIGRATORY PARASITES.
"free," that is, without their connective-tissue  capsule;  these
usually occur in the ventricles, or beneath the dura mater and
the arachnoid, especially at the base; and sometimes, it seems,
in the meshes of  the arachnoid.   In the ventricles they float
around free,  so that on opening  the  latter  they are liable  to
escape ; in other localities they often cling fast to a certain point.
(Fig. 22.)
   One peculiar form of such free cysticerci is observed as a very
infrequent occurrence.  On removal of the brain, extremely frail,
veil-like formations,  folded and notched in many ways, and hav-
ing in some places sacciform protuberances, or sessile, frequently
pediculated vesicles  arranged in a racemose form, present them-
selves upon the base of the brain ; these are usually found sur-
                                     rounding single nerves or
                                     arteries; here and there,
                                     by  means of  processes
                                     which  have the  appear-
                                     ance of being fimbriated,
                                     they cling between  the
                                     fibre-bundles of the arach-
                                     noid,  but  without  any
                fig. 21.                firm organic union.  They
   Four forms, due to contraction, of a living cysticercus.    ,.           -,       . ^-,
                                     lie m some degree  with-
out, but in greatest part within, the subarachnoid space; follow-
ing the arachnoid, they penetrate the third and the  lateral ven-
tricles, and  there, too, form racemose masses;  they also force
their way between the convolutions of the brain, and there spread
out.    The arachnoid  meshes are here and  there clouded and
thickened.   The length of one of these sac-like formations may,
in single cases, be fixed at at least twenty-five centimetres; the
cysts  contain a  clear, serous fluid.   When examined micro-
scopically, they present the slightly undulatory  surfaces of
cysticercus cysts, a head seeming but  seldom to be developed in
them.  The pathological museum  of Erlangen contains two such
specimens of " cysticercus racemosus, sen botryoides;" in one
of these Prof. Zenker succeeded in  finding the characteristic
head  of the  cysticercus cellulosae.   In the second  it was  not
present, but the nature of the formation could not be doubted.
 
CYSTICERCUS CELLULOSE.
599
Virchow1 has seen three such cases of clustering cysticercus, and
is inclined to the belief in the identity of these formations with
the cysticercus, yet he was unable to obtain  any positive proof
of it.

   Virchow very correctly classes his cases with three similar ones observed  by
Dupuytren, Forget, and Calmeil.3 Two of Kiob's3 cases are perhaps also to be con-
sidered as low grades of this malformation.
   One of  the Erlangen cases occurred in a  man about  fifty years of age, who,
having previously been in perfect health, was, thirteen years before, attacked sud-
denly with epileptic convulsions, which recurred from time to time; he was also
very  much changed in disposition, becoming sensitive and irritable.  About the
same time (as his wife subsequently informed me, and her testimony was corrobo-
rated by the attending physicians) he passed a tape-worm. The foregoing points
form the substantial history of this case.

   The way in which the embryos reach the tissues is not yet
determined;  they  either pierce  their way forward into the tis-
sues, after  penetrating  the stomach  or  intestinal walls, or they
fall  upon a blood-vessel, perhaps directly, or it may be by the
round-about way of the lymph  current, and are thus carried  to
the different parts of the body (see Fig. 22).   Very probably the
portal vein is a more  frequent route.  The fact that  the young
measles often occur first in the liver, and afterwards  leave it,  to
be found in other parts,4 would  support  this view.   Leuckart*
succeeded,  also, in his experimental feedings,  in finding embryos
in the blood of the portal vein.
   The little six-hooked embryo  having  established itself in a
suitable place,  the irritation  occasioned by it causes a slight cell-
infiltration of  the  tissue, the hooks are lost,  and  a clearing
begins within.  This occurs  conjointly with a rapidly advancing
growth of the peripheral  portions of  the embryo, and it is soon
transformed into a bag filled with a limpid  fluid.  A vascular
network, with  large  and small  meshes  of delicate,  transparent
   1 Virchow Archiv, 18, p. 528.  Compare, also, von Siebold, Band- und Blasenwiir-
mer, 1864, p. G8.
   * Davaine, 1. c., pp. 64G and 655.
   3 Wiener med. Wochenschrift, 1867, Nos. 8 and 9.
   * Zenker, Verhandl. der phys.-med. Soc. zu Erlangen. 1865-67, p. 16.
   6 Parasiten, I., p. 199. 
 600    HELLER.—DISEASES FROM MIGRATORY PARASITES.

 vessels, is soon formed in the wall of the sac. At one point of the
 wall a slight depression is seen, and a flask-shaped, hollow body,
 the so-called head-cone,  is developed within the  cyst.  At the
 bottom of  this, at  its blind extremity, the development of the
 coronet of hooks, and of the suckers  now takes place.   At the
 same time the outer layer of the head-cone is separated from the
 head originating in its  interior, and  forms for it a  cloak-like
 covering, which is  very much extended by the further growth
 and increasing length of the neck and body.
   The formation of the measle, according  to this plan, cannot, as was formerly
 thought, be the cause of a dropsical condition of the wandering tape-worm head, for
 the cyst is formed first, and in it, according to Goze's comparison, the tape-worm
 head is placed, as is the light in a lantern.

    In but few cases does the tape-worm head escape externally
 while in its  measly  condition;  this generally  occurs when  it
 reaches  the stomach  and is prepared  for further development
 into a tape-worm.
    The development of the cysticercus is accomplished in about
 two and a half months.   The duration of its life, according to
 Stich's  observations of cysticerci of the skin, amounts to  from
 three to six years.   They  then  die,  and undergo retrograde meta-
 morphoses.   In the  beginning they seem somewhat withered,
 their contents duller, and the  vesicle less  translucent; at times
 the inner surface of the capsule grows slightly purulent; subse-
 quently they shrivel  and become fatty,  the fluid is absorbed,
 and lime salts are deposited both in its residue and in the callous,
 shrunken capsule; finally,  small,  hard  lime  concretions are
found in its place.   By solution of the lime salts with muriatic
acid,  it is usually tolerably easy to discover the circlet of hooks
 or single  hooks scattered through the detritus.

   In one of his numerous cases of cysticercus in the eye, von Grafe 3 was able to
follow the different phases of development.  In from three to four weeks after the
beginning of ophthalmoscopic changes, he saw cysticercus vesicles about three mil-
limetres in  diameter appear; the head and neck he saw a few weeks later, with a
diameter of from four to five millimetres.  Von Grafe found the growth very vigor-
ous during the first six weeks ; the  vesicles attained a diameter of six mm.; from
1 Archiv f. Ophthalmologic, XII., Abth. 2, p. 188. 
                     CYSTICERCUS CELLULOSE.                 601
 that time on it was slower; in the oldest, which were still living—after two years-
 he found a diameter of eleven mm.

    Besides in man and  swine, the cysticercus  cellulosae has been
 observed in the ape, the bear, the dog,  the rat, and the deer;  it
 often occurs in great numbers throughout the  whole body.
    Whether the cysticerci of  the animals mentioned are really to be considered as
 cysticerc. cellulos.,  is not beyond doubt.

    The geographical distribution of the cysticercus corresponds
 with  that of the taenia solium.  As man  incurs the risk of the
 latter  by the use of  measly pork, it is found wherever pork is
 used as food ; the people of nations which abstain from the use
 of pork are free from the taenia solium, as also from the cysticer-
 cus cellulosae.

                           Chapter III.

                      GENERAL  PATHOLOGY.
    The cysticercus cellulosae occurs  in persons of all ages and in
 both sexes,  but most frequently in middle age and in the lower
 classes of society.
    It  is  found  in most of the  organs, most  frequently in the
 intermuscular  connective  tissue of the trunk and extremities,
 then in  the subcutaneous  tissues, in  the brain and its  mem-
 branes, in the  eye, under  the conjunctiva, in the heart,  more
 rarely  in  the  lungs, the liver, the mesentery, and the lymphatic
 glands, and very seldom in the kidneys,  the  parotid,  the pan-
 creas, the spleen, and the bones.
    Commonly only single specimens are found ;  but  they are
 frequently very numerous, and at times innumerable.
   I found one cysticercus in the mesentery of a child six months of age.
   Delore and Bonhomme' found about three thousand cysticerci in one individ-
 ual, of which one each was found  in the heart, pancreas, and medulla oblongata,
 four in the cerebellum, several in the parotid, sixteen in the lungs, twenty-two in
 the meninges, eighty-four in the brain, 900 in the muscles, 2,000 in the subcutaneous
 cellular  tissue and elsewhere in the connective tissue.  The mesentery was filled;
the liver, spleen, and kidneys were free.
1 Archives gener., 1865, I., p. 355. 
602    HELLER.—DISEASES FROM MIGRATORY PARASITES.

    The  changes  occasioned by the presence of the  cysticercus
cellulosae vary according to  the organs affected ; for example,
while the symptoms of  its presence in  the subcutaneous tissue
are very insignificant, or altogether wanting, in the brain and its
membranes,  and in  the  eye,  the  most  intense  disturbances
appear; yet  even in these localities, with the exception of the
last-mentioned,  they may be  scarcely noticeable  or  entirely
absent.
    The symptoms which the migration of the embryos from the
intestinal canal into the body induces, have not  yet been recog-
nized in man ;  the migration of a single  one, is of itself an insig-
nificant  event, which can only cause a  disturbance by penetrat-
ing an important organ.   On the other hand, in  case of  an inva-
sion  in  force, very  important  morbid phenomena  must be pro-
duced by  the mere act of migration from the intestinal canal, but
such are  not  yet recognized  in their causative connection with
the cysticerci.  With  reference to this point, we are therefore
referred to the results of  experiments  on  animals, and  find, of
course, in such animals as have been  successfully fed with  tape-
worm eggs,  severe  intestinal  disturbances,  diarrhceal  evacua-
tions, general weakness, and  apparently also painful sensations
in the abdomen.
   The symptoms just mentioned were observed  in a young goat fed with the
tsenia  mediocanellata (saginata).  Extreme muscular weakness and trembling came
on,  and the animal became unable to maintain its standing position.  It recovered
very gradually and continued to grow.1
   The dissection of  a goat, which died  thirteen days after the first, five after the
second, and  two after the last feeding with segments of the taenia mediocanellata,
revealed an exquisite  hemorrhagic peritonitis, especially of the capsule of the liver.
The hepatic substance itself was riddled with worm  passages, which appeared on the
surface, through the capsule, as dark, brownish-red streaks; measles were found in
many of these passages; over some the capsule had given way, and the measles pro-
jected through the opening  into  the abdominal  cavity; numerous measles were
found free in the peritoneal sac.
   Leisering,2 too, in the case of a lamb which died on the fifth day after being fed
with the taenia marginata, found the liver swollen throughout,  and hyperaemic, and
embryos by the hundred in the widely dilated capillaries of the portal vein.
1 Zenker, Verhandl. d. phys.-med. Societat zu Erlangen, p. 88, 1872.
* Bericht iiber d. Veterinarwesen Sachsens, 1857-58, p. 22. 
CYSTICERCUS  CELLULOSE.
60S
   Leuckartl repeatedly saw animals—after being fed, of course, with an immense
number of tape-wonn germs—die during the first few days, sometimes even before
the expiration of twenty-four hours. The autopsy usually revealed intense capillary
injection of the viscera, especially of the liver and lungs, which at times showed
ecchymoses.
   Ulrich2 attributes the  diarrhoea and fever, which he found accompanying the
presence of numerous measles under the skin, to the migration of the embryos.
   At all events, careful  inquiry in proper cases  will be necessary to  solve  this
question.

    In most of the organs,  the  embryos which have penetrated  '
them cause  no disturbance of function,  after their metamorpho-
sis into cysticerci, and even  after having attained a considerable
magnitude,  unless  they  are present  in   large  numbers.  For
instance, they are of but  little importance in the subcutaneous
cellular  tissue,  often remaining unnoticed, even by the  person
affected,  until perhaps they are accidentally  discovered by the
physician in the course of his examination.
    They  produce grave symptoms only when in the brain and its
membranes, the spinal cord, and the eye.
    Whether the development of the parasite in the muscles pro-
duces morbid phenomena, is not yet positively determined ; it is
denied by  the majority ;   thus,  according  to  Stich,  no debility
ensues even after  complete  riddling of the muscles.   Probably
Ferber' s3 view,  that  cysticerci in  the human  muscles  may pro-
duce certain fixed symptoms,  is more correct.   In case  of  an
invasion  in large force,  such may take the form of a severe rheu-
matism or gout, with muscular debility and difficulty of motion,
or pain  may  be caused by both active and passive motion, or
perhaps  a febrile movement may also  be  present.  Any practi-
cal application  of  the views just  mentioned has thus far been
impossible.   The experiments on animals confirm this statement.
   It is extremely desirable,  in  cases in which numerous muscle-measles are  dis-
covered on  section,  that searching inquiry be instituted among the relatives for
the history  of earlier chronic affections ;  this information will not be very difficult
to  obtain, since, even in cases of well-preserved measles,  it would not probably
extend back further than from three to six years.
                 1 Parasiten, I., p. 101.
                 5 Ahg. Zeitschr. f. Psychiatrie. 1872, III.
                 * Virchow's Archiv. ?>2. p. 249. 
604    HELLER.—DISEASES FROM MIGRATORY PARASITES.

    The  description of cysticerci in the eye belongs  to the pro-
vince of ophthalmology.
    Concerning the presence of cysticerci in the heart (which is
not very infrequent) we know but little ; yet cases in which the
parasite is situated under the  endocardium can scarcely have
run their course without  symptoms ;  a more or less severe endo-
carditis must have occurred.
   Cysticerci of the surface of the heart usually cause but little disturbance, while
the consequences of those situated beneath the endocardium are exceedingly trouble-
some. In one such case the entire apex of the left  ventricle was  occupied by a
thick-walled, firm, fibrous tumor of about the size of a hazel-nut, and whose wall
seemed to consist entirely of thickened, sinewy endocardium; the  cavity,  which
was somewhat contracted about the middle, contained a well-preserved cysticercus,
whose form corresponded with  that of the cavity; for  a  considerable distance
around the tumor the endocardium showed marked opacity and fibrous thickening.

    Cysticerci of the brain  and its membranes  alone  require  a
separate consideration, although,  notwithstanding numerous val-
uable publications, our knowledge of the morbid conditions pro-
duced by them amounts thus far to scarcely anything.

                           Diagnosis.

    A positive  diagnosis  is possible  only when the cysticerci
occur in situations  accessible to sight or touch, especially in the
eye.  In such cases numerous, firm,  bean-like  swellings in the
subcutaneous  tissue should lead  us  to suspect  cysticerci; the
extirpation of  such a  tumor is  so trifling a procedure, that its
performance for diagnostic purposes  should always be readily
allowed.

                           Prognosis.

   The prognosis  is of importance only in cases of cysticerci of
the brain, and will be discussed under that head.

                           Treatment.

   We  have thus far been unable, by any therapeutical means,
to prevent the  development of measles.  They have been observed 
CYSTICERCUS CELLULOSE.
605
while the patient was  under treatment by inunctions, also when
under the influence of iodine, mercury, quinine, or arsenic ; no
change was noticeable in any case, but their  growth continued
undisturbed ;' even picric  acid seems  to  exert no detrimental
influence on them.11  Notwithstanding this, we should  not yet
give up  hope of finding a remedy which will  cause their death
without  injury to man,

                          Etiology.

   The etiology of the  disease induced by the presence of cysti-
cerci is  more satisfactory.   As the cysticercus cellulosae is the
larva  of the taenia solium, which  has  thus far been found only
in the small intestine of man, infection  of a man with  measles
can  only occur after the reception  of mature  eggs  of  the taenia
solium into his stomach.  The person affected may derive these
eggs either from a taenia  solium in his own small intestine,  or
from the tape-worm of some other  individual.
   The  former  mode of infection — self-infection — may occur
in two ways:  mature eggs,  either free  or accompanying the
detached and expelled  joint of a  tape-worm,  may be taken into
the  mouth and swallowed,  or mature egg-containing segments
may be  regurgitated into  the stomach during the act of vomit-
ing ; in  either  case, the  embryos,  armed  with three pairs  of
hooks, are  set  free  by the action  of the gastric juice, and locate
themselves in  some  suitable position, where  they  undergo the
above-described alterations.
   The walls and seats of public privies in railroad stations, and especially in hotels,
afford a sufficient explanation of the most common method by which self-infection
occurs; yet it may frequently be attributed to the second mode, as many men
regularly expose themselves to the danger  of vomiting by over-indulgence in the
use of wine and beer.
   By the second method, the eggs or segments of tape-worms
which have  escaped  from  another  individual,  are  likewise
brought, perhaps by contamination of the food or utensils, or  by
some other means (and  of these there are many) to the mouth
and stomach, there to undergo the same changes.
1 Stich, 1. c.
! Mosler, 1. c. 
606  "   HELLER.—DISEASES  FROM MIGRATORY PARASITES.
   Of von Grate's collection of eighty cases of cysticercus in the eye, only five or
six patients had been previously affected with tape-worm, whilst very frequently
other inmates of the room or house were giving lodgment to them.
   The ability of single detached  tape-worm segments to creep off, especially in
damp localities, and even to mount blades of grass and the like, considerably les-
sens the difficulty of explaining the modes of extension and infection.

   Cases of very numerous cysticerci in the body must be con-
sidered as having originated by swallowing an entire  tape-worm
joint, or at least a large part of one.
   Butchers, bakers,  and cooks who harbor tape-worms, are, in
consequence of their occupations, especially likely, from lack of
cleanliness,  to infect the food supplied or prepared by them, and
in this way  to bring about the measly infection.
   Every  person affected with tape-worm, not  only carries with
him danger to  himself, but is  also  constantly  threatening  the
health and life of his neighbors.
   Parasites in general, and brain cysticerci in particular, are  frequently found in
the insane,  and the  insanity may in many  cases be  attributed to  their presence.
Ulrich,1 however, very correctly insists that this view should not be  accepted with-
out qualification; but that, on the contrary, mental diseases predispose their sub-
jects to the  acquisition of cysticerci, by the filthy habit of dirt-eating, and also by
their proneness to  besmear themselves with both their own  faeces  and those  of
others.

                          Prophylaxis.

   Much may  be accomplished in the way of  preventing  the
formation of the larvae.   The presence of  measles in an individ-
ual, proves  that  a taenia solium must have been present,  either
in himself or some other person.   The  first point,   then, is to
avoid contracting a taenia solium,  which  threatens to  become a
constant  source of  measly infection for the "bearer"  himself, as
well as for every other person living in the same house with him,
and particularly for any one sleeping with him.
   In order to attain this object, the use  of raw or insufficiently
cooked pork must be  avoided ; a thorough preparation of the
meat, especially by boiling  or roasting, until there is  no longer
even a rosy, not  to say bloody, color remaining, kills  the mea-
'L, c. 
                    CYSTICERCUS CELLULOSE.                 607

sles ;  and they do not entirely resist ordinary pickling and smok-
ing.

   People become measly, then, not directly from the use  of measly pork, as we
even now sometimes read, but by the circuitous mode of the tape-worm developing
in the intestine.

   Should, however,  a  taenia  solium  be developed, it becomes
our duty,  in order to obviate danger, to accomplish the immedi-
ate expulsion of the worm ;  in doing this, vomiting must be
avoided,1 in order  that  no joints  be carried into the stomach,
and thus produce, artificially,  the very event which we are striv-
ing to prevent.  To guard against any further source  of  infec-
tion,  the greatest precaution must be exercised with reference to
the expelled segments,  and, whenever possible, these should be
killed with boiling water.
   As a third, more indirect, but not less important, measure, we
should take care that hogs are kept at a distance from priv-
ies, and in general  from  all  places where  there  might  be  an
opportunity for  them to devour human excrement, and thus to
infect themselves with measles.  The  man  who  raises hogs  has
it in  his  power, by careful attention  to his stock, to extirpate
the taenia solium and its larvae.
   An obligatory inspection of  meat would further the attain-
ment of this object,  and  is already being pressingly urged  on
account of trichinae.

                  CYSTICERCUS OF  THE BRAIN.

   The occurrence of  the cysticercus in  the brain  and its appen-
dages, is relatively very  frequent.  It may be found in all parts,
but is most frequently situated on the surface, and particularly
in the pia mater, but  in such a manner  that it seems to be sunk
in the cortical substance of the brain.
  Of eighty-eight cases collected by Kuchenmeister,3 from the literature of this sub-
ject, cysticerci were found forty-nine times in the  membranes of the brain (dura
mater six, arachnoid eleven,  pia mater twenty-three, and choroid plexus nine) ;

             1 See Vol. VII. of this Cyclopaedia.
             ! Oesterr. Zeitschr. f. prakt. Heilkunde, 1866 (S. A). 
 608    HELLER.—DISEASES FROM  MIGRATORY  PARASITES.
 fifty-nine times on the surface of the cerebrum, forty-one times in the cortical sub-
 stance, nineteen times  in the white substance, eighteen times in the ventricles and
 aqueduct, seventeen times in the corpora striata and anterior commissure, fifteen
 times in the optic thalami and gray commissure, four times each in the corpora
 quadrigemina and the pineal gland, twice each in the trigonia olfactoria, corpus
 callosum, and medulla oblongata, once in the olivary body, and eighteen times in
 the cerebellum.
    Usually only single cysticerci, or a few, are found; but some-
 times there are many,  even hundreds;  when very numerous,
 they are generally present in other organs also, especially in the
 muscles and in the subcutaneous cellular tissue.
    As a rule, the cysticercus is surrounded in the brain and  its
 membranes,  as in  other  organs,  by  a  firm  connective-tissue
 capsule ; the  brain  substance in its  vicinity is frequently per-
 fectly normal, in  other cases  apparently unchanged,  at  least
 to  the naked  eye ;  less frequently  somewhat spongy, grayish-
 red, or grayish-yellow ; frequently somewhat firmer or sclerosed.
 Under the microscope, we often find a more  or less abundant
 development of spherical granules, and at times, also, of corpora
 amylacea.  The youngest cysticerci  have capsules  which  seem
 very  thick,  on account of their  numerous  onion-like layers;
 the fine layers and lamellae must be detached before  the embryo
 itself is reached.   The laminae themselves consist throughout of
 extremely  delicate,  smooth,  pavement epithelial cells, which
 appear brownish on account of the haematoidine.
   A case of about sixty cysticerci of the brain, of various sizes and  stages of devel-
 opment, gave me, a short time ago, an opportunity to carefully investigate these
 circumstances;  numerous muscle cysticerci were found in the same individual;
 nothing was learned of the symptoms during life.

    In rare instances brain cysticerci are found without such con-
 nective-tissue  envelopes.  They  belong to the  above-described
 racemose cysticerci.   This variety appears in  the ventricles and
 at the base of the brain.  In the  former, they float free in the
 cavity; in the latter,  they are at times  firmly attached to  an
 arterial trunk.  The accompanying figures  represent a case  of
this sort, which was  found by Prof. Zenker.  The point at which
the cysticercus is  adherent to the artery  is especially interest-
ing ; the appearance here presented is that of a dilated spindle- 
CYSTICERCUS CELLULOSE.
609
shaped aneurism ;  the  wall of  the  artery is very  considerably
thickened, and  can scarcely be  distinguished
at the point of attachment, appearing there as
if broken through and  firmly united by gran-
ulation tissue to the cysticercus.   It may be
that the  embryo developing at this  point  had
at  some  previous  time  broken  through from
the interior of the vessel.
Fig. 22.
   Some authors, and among them Stich, absolutely deny
the occurrence of free (unencapsulated) cysticerci: there are,
however, a few  reliable observations of this variety.  G.
Merkel' found one such in the aditus ad infundibulum, in
the case of a boy  ten years of  age.  The boy (a strong and hearty one) had suffered
 A free cysticercus at the
base of the brain, adherent
to an artery. The five dark
points show the highly pig-
mented crown of hooks and
the still  more highly pig-
mented suckers.  Natural
size.
                                  Fig. 23.
The same (slightly magnified), showing very beautifully the characteristic wavy border, also the aneurismal
   dilatation of the artery, the wall of which is markedly thickened and eroded at the point of adhesion.
from frequent headaches the year before his death.  These occurred especially after
      1 Deutsches Archivf. klin. Med., III., p. 297.
Vol. III.—39 
610    HELLER.—DISEASES FROM MIGRATORY PARASITES.
violent bodily exertion, and were now and then accompanied by vomiting, but were
never so severe as to render it necessary to call for medical assistance.  One evening
he again had headache, but ate a hearty meal nevertheless, and went to sleep. After
a few hours he awoke with vomiting, delirium, and great restlessness; his speech was
inarticulate ;  complete loss of consciousness and death soon followed.  Post-mortem
examination revealed considerable hydrocephalus of all the ventricles; a delicate-
walled vesicle of about the size of a cherry was found lying free in the aditus ad
infundibulum ; the head-cone was of about the size of a pin's head ; the coronet of
hooklets was distinct; there were no taeniae in the intestine.  From the facts  that
could be obtained, it seemed probable that the boy's mother had had a tape-worm
two years previously.
   Amongst Kiichenmeister's eighty-eight cases, there were nine of free cysticerci.
   The presence  of brain  cysticerci  occasions  many lesions in
addition to those above mentioned, which  are to be considered
partly as direct, and partly as indirect results ;  there is nothing
characteristic  of cysticerci connected  with the  latter,  but they
are frequently found associated with them, and must perhaps be
attributed to their presence.
   Circumscribed thickenings and opacities of the membranes
are found when the parasite is  situated  in them, together with
hypertrophy of the dura mater and  arachnoid at the affected
points.  When located in the pia mater and in the  brain,  the
growing parasites  cause compression and atrophy of  the sur-
rounding  brain  substance, but rarely produce  purulent enceph-
alitis  in the vicinity.  When in the ventricles, or near them,
there  is always a more or  less  marked chronic hydrocephalus,
sometimes even when at a distance from  them, as in a cerebellar
hemisphere.1  If  the measles be found in only one  or more of
the ventricles, the effusion may be limited to these ; when in one
ventricle,  however,  it may also extend to several or  all;  the
ependyma is usually very much thickened and granular.
   An extensive pachymeningitis, with  sometimes hemorrhage
into the pseudo-membranes, has been  repeatedly observed, espe-
cially in cases of numerous  measles.   Chronic meningitis  and
meningeal oedema,  and even firm  adhesions of the pia mater to
the brain substance, are  not uncommon ;  hemorrhages, both as
numerous small capillary extravasations  and as large apoplectic
clots,  have been frequently found.
1 Merkel, Deutsches Archiv f. klin. Med., III. p. 294. 
CYSTICERCUS CELLULOSE.
611
   Tiingel and Ferber ' have already called attention to the increased predisposition
to disease of the brain caused by the presence of cysticerci.  This  depends partly
upon the changes occurring in the vicinity of the parasites; and, judging from the
habits of other varieties of larvae, must be in part attributed to the fact that the
embryos in the brain, before coming to rest, undertake more or less distant migra-
tions,  and in this may leave behind them extensive, but slight changes,  which
form the points of origin of these disturbances.

    In many cases the presence of measles,  even in  great num-
bers,  has  produced no  disturbances whatever;  in the  great
majority,  however, they bring on  either slight or severer symp-
toms ; and under some circumstances, may even cause death.

                         Symptomatology.

    The  symptoms which they induce  are exceedingly diverse,
both in  kind and in  severity; as also in the  peculiar  modes in
which they are grouped.  In numerous cases  they are observed to
range from  the most  trifling,  such  as  headache, debility,  som-
nolency, and giddiness,  to the severer, such as slight paralytic
phenomena,  alterations of disposition, slight cramps and convul-
sions,—to the most severe paralysis, with or without epilepsy,
and finally to mental derangements.
   Of Kuchenmeister's eighty-eight cases (1. a), sixteen (= 18 per cent.) were with-
out symptoms; in six they were but trifling; in five epilepsy alone was present; in
four epilepsy with psychical disturbances (chiefly mental  debility); in fifteen epi-
lepsy with paralytic symptoms; in twenty-four psychical disorders (insanity) with-
out epilepsy, of which seven were without  motor  or sensory disturbances; and
seventeen  with  them  (lameness,  cramps, hemiplegia, paralysis, muscular twitch-
ings).  Of all the eighty-eight cases, epilepsy occurred in twenty-four, and psychical
disturbances in twenty-four (resp. thirty).

    Notwithstanding such numerous, and, to  some extent, very
careful investigations, an exact analysis of the  symptoms  of the
disease has thus far failed to be of any essential practical utility,
because in most cases the  number of measles present in various
situations is  so great as  not to allow of any positive statement
as to the association of any given position in the brain with cer-
tain given symptoms.   All  the results  worthy of note will be
'Archiv d. Heilkunde, III., p. 130, 1862. 
612     HELLER.—DISEASES FROM MIGRATORY PARASITES.

summed up in the discussion of the diagnosis according to Grie-
singer and Kuchenmeister.
   In Kuchenmeister's entire collection of eighty-eight cases, a single cysticercus
was found in only thirteen, of which only two presented severe brain symptoms ;
in one of these there was a cysticercus of the size of a pigeon's egg in the fourth
ventricle; in the second, one the size of a hen's egg was found in the left lateral
ventricle.
   The pathology and physiology of the brain still require a very careful investiga-
tion ; a thorough study of the brain symptoms in cases of single measles is particu-
larly important;  yet for this purpose numerous and carefully observed cases are
necessary.
   Considered simply as  small tumors increasing to a certain
size, the symptoms of intracranial cysticerci are not distinguish-
able from those caused by other kinds of tumors.
   Without  regard,  however, to their  pobable migration as
embryos, they possess another peculiarity—the capability of con-
traction—by which  they are distinguished from all others.  Ac-
cording to Stich—even with Ferber to the contrary—we must pay
special attention to this peculiarity, particularly in cases of free
cysticerci.  Whoever has  once  witnessed the energetic,  some-
times  backward contractions  of  living cysticerci will  scarcely
doubt their  effect  on the  surrounding brain substance;  the
results will vary according to the  locations ; a contraction of all
the cysticerci " a tempo,'''  to which Ferber facetiously refers, is
not at all necessary.
   To Griesinger belongs  the credit  of having been the first  to
study closely the symptoms produced  by brain cysticerci, and
to examine carefully their value  in diagnosis.   His conclusions,
however, require numerous modifications to brr g  them  into
accord with  those  of Kuchenmeister, who  afterwards undertook
the same studies with far more abundant material.

                           Diagnosis.
   A positive diagnosis of the presence of  cysticerci in the brain
can be made only when measles become visible in the eye (by aid
of the ophthalmoscope), or in the tongue or subcutaneous tissues.
But even without these, we  may  suspect the existence of cysti-
cerci  in cases in which other brain affections  may be excluded, 
TRICHINAE.
613
their well known symptoms not corresponding with the ones ob-
served, while, on the contrary,  definite symptoms are present,
which point to the nature of the trouble.   It is especially epilep-
tiform attacks  and epilepsy, occurring in previously healthy
adults, for which no cause can be ascertained either in hereditary
predisposition  or  in other exciting causes,  such as  wounds,
syphilis,  cardiac or arterial diseases.  Ordinary  epilepsy  is a
disease  of childhood  and youth.   The epilepsy produced by
cysticerci frequently runs a singularly short and violent course,
ending in death ; the infrequent attacks of the early stage  sud-
denly become very frequent and  severe; or,  they appear suba-
cute  in   the beginning,  and afterwards come on at  constantly
shortening intervals, and more  violently, to  end  in death,  pre-
ceded by the appearance of other severe brain symptoms—deli-
rium, sopor,  and extreme debility.  An aura may often precede
an  attack of  epilepsy due to intracranial cysticerci, just as  in
the common form.
   A mental disturbance appearing  under  the  same circum-
stances,  and  characterized by depression  and confusion, impair-
ment of  hearing,  loss of  expression, photophobia,  strabismus,
variations of the pupils,  headache, dizziness,  somnolency, anom-
alous sensations in the  limbs, muscular twitchings,  or slight
cramps,  must at least arouse suspicion of cysticerci.  Proof of
the presence of a taenia  solium in the patient, or in any of the
inmates of the house,  either at this time or a short time  pre-
viously,  serves to strengthen the suspicion.

                  Prognosis and Treatment.
   The  prognosis  must be considered extremely unfavorable  in
all cases in which even only a probable diagnosis is possible.
   In regard to  treatment, there is nothing to be added to what
has already been said.

                      TRICHINAE.
                          Chapter I.

   The  literature concerning the  Trichina spiralis is so copious
that it would far exceed  my allotted space,  even omitting that 
614     HELLER.—DISEASES FROM  MIGRATORY  PARASITES.

which is entirely worthless, to give anything approaching a full
description of  the  multitudinous speculative  theories respecting
this  dreaded parasite;  I therefore limit my  quotations  to the
most important, yet others will occasionally be referred to.

Zenker, Virchow's Archiv, 18,  p. 561, I860.—Deutsches Archiv fiir  klin. Med., I.,
    p. 124, 1866.  Ibid., VIIL, p. 388.— Virchow, Archiv, 18,  p. 345, 32, p. 322,
    1860.  Lehre von den  Trichinen,  3 Aufl.  Berlin,  1866.—Leuckart, Unter-
    suchungen iiber d. Trichina spiralis, 2  Aufl.  Leipzig,  1866.—Pagenstecher, D.
    Trichinen, 2 Aufl.  Leipzig, 1866.—Rupprecht, Die Trichinenkrankheit im Spie-
    gel der Hettstadter Endemie.  Hettstadt, 1864.—Kratz, Die Trichinenkrankheit
    in Hadersleben. Leipzig, 1866.—Renz,  Die Trichinenkrankheit des Menschen.
    Tubingen, 1867.—Gerlach,  Die Trichinen.  Hannover, 1866.— Kiihn, Mittheil-
    ungen des  landwirthschaftl.  Instituts der  Univers.   Halle,  1865.—Wiener
    Comite-Bericht, Oesterr. Med. Jahrb., XIH., p. 53, 1867.


                              HISTORY.

   The  history of the trichina spiralis is naturally divided into
three periods of time.   The first comprises  the  time in which
only the  calcified  trichina capsules  were  discovered in the
muscles, without their  nature being  recognized—from 1821,  or
1828, to 1835.  The case reported by Tiedemann1  is disputed
because the description was superficial and the principal  stress
was  laid on  the  chemical  investigation.    In  the museum  at
Guy's  Hospital, London, we find Peacock's2  muscular prepara-
tion with calcified trichina  capsules, deposited in the year 1828.
Hilton3  in 1821 first described  the  calcified  trichina capsules,
but  considered them as  cysticerci.

   Tiedemann's  case seems to belong here, as he evidently only incidentally
described the exterior appearances, and  attached the principal importance to the
chemical examination; hence the accounts of the size of the lime concretions, which
far exceed those of the  capsulated trichinae.  Yet,  such great  enlargements have
frequently been observed in hogs,4 in part  as the result of inflammatory processes,
and in part  owing to  an excessive deposit of calcareous  matters.  Muller,6 for
1 Tiedemann, Froriep's Notizen, I., p. 64.
s Cobbold, Entozoa, Supplement, pp. 1-8.
3Hilton, Lond. Med. Gaz., 1833, XL, p. 605.
4 Berkhan, Virch. Archiv, 37, p. 1, 1866.
" Muller, Virch. Archiv, 37, p. 253,' 1866. 
TRICHINAE.
615
example, found concretions that were four or five times larger than usual, and in
one case he was able to prove positively the presence of trichinae.

    The second period—from 1835  to 1860—begins with the  dis-
covery by Pagetl of  the round worm contained in the capsule ;
Owen2 described it accurately, and gave  it  the name trichina
spiralis.  For further explanations of its  interior structure we
are  indebted to Bristowe and Rainey,3 A. Farre,4 and Henle.5
In 1847 Leidy6 discovered in a  hog  capsulated round worms,
wliich  did  not  differ  in any respect  from  the trichina spiralis
wliich he had often found in human muscles.   Luschka7 in 1851
recognized  the  finer end of the worm as the head,  in opposition
to previous observers  who  had  considered the blunt extremity
to be the head.
    Herbst8  reared muscle trichinae in young dogs  by feeding
them with trichinous flesh from a badger, yet  the account of his
experiments is  very unsatisfactory owing  to his inaccurate de-
scription of the worms, and to the fact of his  confounding them
with all other possible varieties  of round  worms.   In 1855  and
185G Leuckart9  saw, in mice which had been experimentally fed,
intestinal trichinse escape from their  capsules and increase to
double their former size.  Kuchenmeister 10 in 1855 declared his
belief  that the  trichina spiralis was the  larval state  of the  tri-
chocephalus dispar.  Leuckart "  then—1859—claimed that  by
feeding trichinous flesh  to  hogs he had bred trichocephali by
thousands ;  while Virchow 19 at the  same time saw the trichinae
fed  by him become, in the intestine of the  dog, mature, sexual,
   1 Cobbold, 1. c, and Lancet, 1866, p. 269.
   2 Owen, London and Edinburgh Phil. Magaz., 1835, p. 452, and Trans. Zoolog.
Society, Vol. I., p. 315, 1835.
   3 Trans. Path. Society London, 1854, V., p. 277.
   4 Farre, Lond. Med. Gaz., 1835-36.  (Froriep's Notizen, 48, No. 1035.)
   6 Henle, Midler's Archiv f. Anat., etc., 1835, p. 526.
   ' Leidy, Annals and Magaz. of Nat. History, XIX., p. 358, 1847.
   7 Luschka, Zeitschrift f. wissenschaftl. Zoologie, III., p. 69, 1851.
   B Herbst, Gottinger Gel.-Nachrichten, 1851, No. 19, and 1852, No. 12.
   9 Leuckart, Archiv f. Naturgeschichte, 1857, II., p. 188.
  10 Kuchenmeister, Parasiten, 1855, p. 269.
  "Leuckart, Compt. rend., 1859, t. 49, p. 452.
  " Virchow,  Deutsche Klinik, 1859, p. 430.-Compt. rend., 1859, t. 49, p. 660. 
616     HELLER.—DISEASES FROM MIGRATORY  PARASITES.

egg-containing  animals ;  their transformation, however, into tri-
chocephali he considered not impossible, but questionable.

   Leuckart,1 by the way, reduces this estimate from "thousands" to "dozens,"
which mistake had been brought about by an oral misunderstanding.
   It was in the course of this year that a very  considerable number of human
corpses with numerous capsulated trichinae were found; in England alone, up to
the year 1836,  fourteen cases2 were seen, and up to the  end  of  that decade,
twenty-four; trichinae  were found several times in  America by Bowditch3  and
Leidy,4 as also in numerous bodies in Germany by Virchow,5 Zenker,6 and others.

    The third period begins with  the year  1860; in this year a
decisive turning-point was reached in the history of  the trichina
spiralis.   Up to that time it had been considered more as a curi-
osity,  which at  best,  in common  with  many other  parasites,
roused a  purely  scientific  interest.  With  the  exception  of
Wood,7 who propounded the question, whether a case of severe
rheumatism  observed by him might not possibly be  connected
with the trichinae found, all had unanimously  considered them
innocuous, and some had positively affirmed that they produced
no disturbances whatever.6
    All of  a sudden the subject assumed an aspect of great prac-
tical importance  through  the publication  of Zenker's  famous
case ;9 and the  seemingly insignificant and harmless intruder was
unmasked as a formidable foe, threatening the health  and life of
man.   In a  girl admitted to the Dresden hospital as a case of
typhus, and who  died after remarkably grave symptoms, speci-
ally referable  to  the  muscular system,  Zenker recognized  the
freshly migrated trichinae in nearly all  the muscles as the cause
of the disease, found great numbers of mature intestinal trichinae
in  the intestinal  canal,  and pointed out  swine as  the  original

   1 Leuckart, Untersuchungen iiber Trichina spiralis, I. Aufl., p. 7, 1860.
   2 Pagenstecher, Die Trichinen, 2 Aufl., p. 8.  Leipzig, 1866.
   s Boston Med. and Surg. Journ., 1842-1844.  (Cobbold, 1. c, p. 429.)
   4L. c.
   6 Die Lehre von den Trichinen, 3 Aufl., p. 29, 1866—Archiv, 18, p. 330, 1860.
   8 Zenker, Deutsches Archiv f. klinische Med., VIIL, p. 389.
   1 Wood, Lond. Med. Gaz., 1835.
   • Cobbold, 1. c., p. 336.
   ■ Virchow's Archiv, 18, p. 561, I860. 
TRICHINAE.
617
carriers  of the  parasites, which taken  into the  intestine there
attain complete development.   Thus the whole theory of trichin-
osis was furnished  by the  leading  features of  one case ; at the
same time a clear light was thrown over a large  series of  obscure
cases of  disease,  and a secure foundation gained for the recogni-
tion of numerous groups of cases,  some of  which occurred at
that very time, and others since.

   A girl,  aged 20, previously healthy, had been ailing  from Christmas, 1859; she
was forced to go to bed on New-Year's day, and on January 11, 1860, was admitted
to the Dresden hospital.  The symptoms in the beginning were great debility, sleep-
lessness, loss of appetite, constipation, heat, and thirst. In the hospital high fever, a
swollen  and painful  condition of the abdomen, extreme tenderness of the muscular
system, especially of the extremities, contractions of the knee- and elbow-joints, and
oedematous swellings, especially of the leg below the knee, were observed.  Death
subsequently took place, with the symptoms of pneumonia.  The autopsy revealed
only an extensive collapse of the left lung, interspersed with  small infiltrated spots,
intense bronchitis, and marked  hyperaemia of the mucous membrane of the ileum.
The microscopic examination of the muscles showed in every preparation dozens of
the trichinae  lying in the muscular parenchyma in all forms, curled and extended,
and giving the most  positive signs of life.  Together with these there were many
shorter, broader, younger  specimens.  In every drop of intestinal mucus were nume-
rous sexually mature  trichinae, the males one and a half and the females four mm.
in length.  It was found, that, on the estate at which the girl  had served, a hog had
been killed December 21, 1859; Zenker discovered very  numerous capsulated tri-
chinae in the remaining preserved hams and sausages (previously to this time  only
Leidy had found trichinae once in swine; see above).  It then appeared that the
hostess, the proprietor, and the remaining inhabitants of  the place were sick at  that
time, the two former undoubtedly from trichinosis; the  butcher who had killed
the hog was  also taken very ill with symptoms of trichinous "gout."

    At the same time Virchow and Leuckart were engaged,  inde-
pendently of each other, in investigations on trichinae, and their
researches  were  of  exceeding value in  giving  us a  clearer and
fuller understanding of the subject.
    The  theory   of  trichinosis had  then  in its essential points
reached the following form :
    1.  Man becomes  infected with trichinae by the  use of trichi-
nous pork (Zenker).
    2.  The muscle-trichinae in  the stomachs of mice become freed
from  their capsules  (Leuckart), and develop,  in the intestines of 
618    HELLER.—DISEASES FROM MIGRATORY  PARASITES.

dogs and cats  (Virchow),  as also  in that of man (Zenker), to
mature sexual worms—intestinal trichinae—which
   3. Attain  their  full growth  at  the end of about seven days
and  give birth to living young (Leuckart) ;
   4. These young trichinae  migrate directly from  the intestine
in which they are situated  into the muscles of the same person
or animal (Zenker, Virchow), since
   5. During their  migration they are found in the mesenteric
glands, abdominal cavity, and pericardium (Virchow).
   6. They penetrate into the interior of the  muscular fibres
(Virchow),  and cause the destruction of the contractile  substance
(Virchow, Zenker).
   7. Within the muscles  they grow to perfect muscle-trichinae
(Zenker, Virchow, Leuckart);
   8. These migratory processes bring about in man a  severe
febrile disease—trichinosis (Zenker), which
   9. May result in death, both in man (Zenker) and in animals
(Virchow).
   10. Cases   of  capsulated trichinae  are  to be considered as
healed cases of trichinosis (Zenker).
   As the investigations of the three observers already mentioned—Leuckart, Vir-
chow, and Zenker—took place independently of each other, and in part almost simul-
taneously upon specimens from Zenker's case, it was not easy to determine the mer-
its of each from his publications; both Virchowl and Zenker2 were compelled to
defend their rights, in the matter of developing the theory of trichinosis, against
Leuckart,3 who was constantly appearing in print with incomplete notices.  After a
very  careful examination of the publications of these authors, I have endeavored
to convey a correct idea of their respective merits by appending their names, in their
rightful places, to the foregoing propositions.
   That trichinosis could hardly be an uncommon disease was to
be inferred  from  the frequent early discoveries  of capsulated
trichinae ; the  number,  however,  of single  cases  as  well as of
groups of cases (epidemics), which have either  come  to our no-
tice  recently, or of whose existence in earlier times we  have since
learned, is  unexpectedly large.   As regards  the latter, the evi-
dence is based in  part  on the careful reports of a series of epi-
   1  Virchow, Archiv, 32, p. 332, 1865.
   5  Zenker, Deutsches Archiv f. klin. Med., I., p. 90.
   3  Leuckart, Archiv des Vereins f. wissenshaftl.. Heilkunde, II., pp 57 and 235. 
TRICHINAE.
619
demic cases, and in part on the accidental discovery of  trichinae
in those who at that time had recovered from the disease.

   Among the epidemics now known with more or less certainty to have occurred in
the past, the oldest is probably the one in Wiirtemberg, in 1675, reported by Fehr;1
it occurred in the family of a miserly farmer. The cause was shown to a certainty to
have been pickled and smoked pork. The farmer and his son died; all the remain-
ing inmates of  the house who had partaken of  the meat were taken ill.  Of others,
a series of cases in Niedermitlau2 in the province of Hanau, 1834-1837 in Wurzen,
1858 in Breslau, 1858-62 in Magdeburg and vicinity, 1859-62 in Blankenburg, 1860
in Stolberg in the Harz, and many others are worthy of note.  A slight  epidemic
was proved to  have occurred in Hamburg in 1851, by the post-mortem examination
in 1865 of one who had recovered ;s another small group, which occurred, in 1845
after a meal at a school celebration, was discovered accidentally by Langenbeck
through an operation for epithelial cancer.4
   Especially  interesting was the epidemic in Wegleben6 near  Quedlinburg,  in
1849-50, which was subsequently  recognized;  it was  designated at that time as
"English sweat" or "black death."  How many trichina  epidemics (sit venia
verbo) may have been  concealed under the name of  English sweat can only be
determined by  a  careful study of the original records.  The descriptions of this dis-
ease present such  striking resemblances to those of trichinosis, that we are compelled
to consider them  as the  same, even if important symptoms be not mentioned, or if
others  seem to be grouped anomalously.6
   Le  Roy de Mericourt attributed acrodynia to trichinosis.7 By this name, or " mal
des mains et des  pieds," " erytheme gpidemique," " phlegmasie gastrocutanee aigue
multiforme," etc., is indicated a disease which was observed as a widespread epidemic
in Paris in  1828-29,  and  afterwards in various other districts of France, as for
instance in  Coulommiers, Fere-Champenoise, Montmirail, and Vitry;  in 1846 in
Belgium and in 1854 in  the Crimean army. Alibert designates the disease "erytheme
epidemique."  In order to recognize that this view is correct, it is only necessary to
read the name and to recollect  that the prevailing epidemic  in  Magdeburg and
vicinity in the year 1858 and subsequently was described by Sendler8 as "acute
epidemic  oedema of  the subcutaneous cellular tissue and  muscles."   We may
then compare  it  with  an epidemic  of " febris desquamat, typhodes," in 1863, in
   1 Fehr, Miscell. med.-phys. cur. acad. nat. cur. Dec, 1, ann. VI., 1677, observ. 191,
p. 269.
   2 Kojyp, Denkwiirdigkeiten aus d. arztl. Praxis, III., p. 75.
   3 Tiingel, Virchow's Archiv, 28, p. 391, 1863.
   * Lilcke, Vierteljahrschrift f. gerichtl. Medicin, XVII., p. 102, 1864.
   ' Mosler, Virchow's Archiv, 33, p. 414.
   •Compare  Hirscli, histor.-geog.  Path., I., p. 468, 1860, and Virch. Archiv, 8, p. 18.
   T Le Boy de Mericourt, Archives gener. de med., 1865, II., p. 620.
   "Sendler, Deutsche Klinik, 1862, p. 261, No.  27, 1863, No. 2. 
620     HELLER.—DISEASES  FROM MIGRATORY PARASITES.

Ziillichau and vicinity, described by Frank a as " epidemic morbid desquamation of
the epidermis," which without doubt is to be considered as trichinosis.
   According to Desnos2 there are three series  of symptoms in acrodynia : 1. dis-
turbances referable to the intestinal canal,  2. to the nervous system, 3. to' the cellu-
lar tissue of the external and internal coverings—skin,  conjunctiva, pharyngeal,
bronchial, and urethral  mucous membranes; in the beginning there  are digestive
disorders, loss of appetite, obstinate oedema of the face, at times conjunctivitis and
bronchitis, often vomiting and diarrhoea.   Then  follows stiffness of the joints, with
sensations of formication, which give way to superficial and deep hyperaesthesia,
painful, often convulsive sensations of different kinds, disorders  of  contractility,
difficulty in moving painful parts,  contractions,  convulsions, and  twitchings, and
widespread erythematous redness, especially of the hands and feet; subsequently,
hypersesthesia is replaced by anaesthesia, and the convulsive symptoms by weakness
or paralysis.   The previously present erythema of the skin gives place to a yellow,
blackish scaling of the thickened epidermis.  Fever  is usually absent;  often, not-
withstanding the obstinate sleeplessness, the intelligence remains unclouded.  The re-
covery is complete, though convalescence may be very tedious. Duration, from a few
days to five or six months.   Results of post-mortem examinations entirely negative.
   The epidemics especially worthy of notice since the  discovery of trichinosis are:
the one at Corbach in Waldeck, 1860 ; at  Plauen in Voigtlande, 1861-2, in Calbe on
the Saale, 1862; Posen,  Hettstadt, 1863-4; Hannover, 1864 ; Dessau, 1864 ; Gorlitz,
1865; Erlangen, 1870 ; Lobau, in Saxony, 1871;  Gottingen, 1871.  The largest one,
however, spreading terror far and wide, was that in Hedersleben, 1865, in which
of about 2,000 inhabitants, 337 persons were taken sick, and 101  died.
    Lesser epidemics and  single  cases have since been noticed all
over Germany and  Austria,3  but they have scarcely  yet  been
reported in medical journals.
    According to an oral report by Cobbold, trichinosis was diag-
nosticated for the  first time in England, in Northumberland,  in
1871.

                              Chapter II.

                           NATURAL HISTORY.

    The  trichina  spiralis  is  met with  under  two forms, the
intestinal trichina and the muscle-trichina.    The  adult,  sexually
mature  trichina (the  intestinal trichina)  is   an  extremely fine,
   1 Frank, Virchow Archiv,  26, p. 427, 1863.
   2Nouveau Dictionnaire de Med.  et de Chirurg. prat., red. Jaccoud.  Paris, 1864, I.,
p. 375, Article "Acrodynie."
   3 For particulars, see  Pagenstechcr, Trichinen, Leipzig, 1866, 2  Aufl., and Virchow,
Gurlt, and Hirsch's Jahresberichte. 
TRICHINAE.
621
           the
head of the intestinal
trichina.   (Highly
magnified.)
round, thread-like, slightly coiled worm, with a still finer head,
which gradually  decreases  in
thickness towards its point;  its
hinder extremity is rounded  off     ft Q U
rather abruptly;  the chitinous
integument  of  the   body  is
slightly annulated.
   The digestive canal is com-
posed of several divisions, but
there is  still  considerable dis-
pute regarding the arrangement
of these different parts.  It com-
mences  with a narrow, muscu-
lar,  oral aperture, which, grad-
ually widening, merges into the
oesophagus ; the latter, through-
out  its whole length, is  grasp-
ed by the  concave side  of the
so-called cell-body—a series of
colossal cells, probably a glau
dular apparatus—and, together
with the mouth,  is  lined with
a  fine  layer  of  chitine.   The
stomach is a continuation of the
oesophagus ; it begins as a flask-
shaped enlargement,  and is lin-
ed  with  small,  finely granular
cells ; at its commencement are
found  two  small  pear-shaped
culs-de-sacs   or  appendages,
which are lined with  an epithe-
lium similar to that found in the stomach
             Fig. 24.
  Sexually mature trichinae (male and female) and
two embryos from the intestine of man. (Slightly
magnified.)1
The latter, becoming
   1 The Figures 24 to 29, and 32 to 35, are after preparations from Zenker's epochal
case of trichinosis.  Figures 36 and 38 were drawn by M. Krantz after early Dresden
cases.  Figures 30, 31, and 37 are from drawings by Dr. Fiedler.  The beautifuUy
executed plates are to be found in the Pathological Collection of the Dresden City Hos-
pital.  I am indebted for them to the courtesy of Prof. Zenker, of Erlangen, and Dr.
Birch-Hirschfeld, of Dresden. 
622    HELLER.—DISEASES FROM MIGRATORY PARASITES.
               Fig. 28.
Portion of the caudal end of an intestinal trichina, five days
  61d—eggs still undeveloped.  (Highly magnified.)
constricted,  soon  merges  without any essential alteration of
structure into the intestine, which, in the hinder portion, usually
              figs. 26 and 27.               seems darker on account
Caudal end of a male,.with protruding cloaca- (Highly magnified.) q£ ^q abundant deposit
                                      of fine granules.   The last
                                      division,   the   rectum,
                                      again presents a distinct
                                      chitinous  lining, and, in
                                      the male, unites  with the
                                      seminal  ducts, forming a
                                      common cloaca.
                                         The  males   attain  a
                                      length of a millimetre and
                                      a half, and are furnished
                                      at the caudal extremity
                                      with two pointless, lobu-
                                      lar appendages, and a gen-
                                      ital  opening, which, to-
                                      gether with the end of the
rectum, forms an outlet directed forwards.   The internal sexual
             organs are  already  perfect, even in the  muscle-
             trichinae ; they consist of a  single testicle, which be-
             gins near the posterior extremity of the body, as a
             thick, knot-like  cul-de-sac,  then extends forwards,
             with gradual diminution in size, to  within a  short
             distance of  the cell-body, when it turns rather short
             upon itself, and  merges into the small seminal duct.
               The sac of the testicle is filled with small, highly
             refractive cells ;  the seminal  duct  either appears
             empty and  contracted, or near its extremity it has
             an enlargement filled with seminal elements.
               The females  are from three to four millimetres
             long;  their genital opening is  situated about at the
             junction of the first and second quarters of the whole
   fig. 29.      length of  the body.   Only a  part of the internal
tionheofmianleinPte^  sexual organs of the female are present in  the mus-
vrab\erichembrTosh  cle-trichina,  and part are formed during its sojourn
(Highly  magma-  in ^ intestine#   -phe apparatus consists of a single
 
TRICHINA.
623
            Fig. 32.
 A viable embryo, from the intestinal trichina
      of man. (Highly magnified.)

 ovary,  a uterus, and a va-
 gina.  The first is originally
 present   in the  muscle-tri-
 china in  the form of a bag,
 which commences at the ex-
 treme posterior end of  the
 body ;  anteriorly, before  it
 reaches   the  stomach,  it  is
 separated  from the uterus
 by a narrow  isthmus.  At
 its  anterior  extremity, in
 the  full-grown  muscle-tri-
 china, we find  the so-called
 " Farre's mass of granules,"
 a collection of dark  gran-
 ules, which is absent in the
 male muscle-trichina.  The
 eggs develop along  the en-
 tire length of the ovary,  but
 only on one wall; the young
 egg-cells are closely crowd-
 ed together in the form of a
 band, which is made to ap-
 pear darker by the  deposi-
 tion of numerous fine gran-
 ules.  The larger,  mature,
 free eggs are rounded, have
 delicate  walls,  and  contain
 each, in the midst of a per-
fectly clear yolk, a germinal
vesicle,  with a  very large,
oval nucleus ; these eggs are
         Fig. 30.          Fig. 31.
A female intestinal trichina   A male intestinal trichina.
 in the act of parturition.      (Highly magnified).
  (Highly magnified). 
624    HELLER.—DISEASES FROM MIGRATORY PARASITES.

pushed forwards and towards  the  side opposite to that upon
which they are formed.
    The  greater portion of the uterus lies farther back than the
commencement of  the stomach ;  it is lined with  a fine-celled
epithelium,  and  will be  found, if copulation has  taken place,
to  contain  the seminal  elements, particularly at  its posterior
extremity.   The uterus is gradually  lost in the vagina, the ante-
rior extremity of  which is furnished with a chitinous lining from
the vulva.
    The embryos of  the eggs develop in the uterus, and are born
from one end of it free and living.
    The birth of the embryos begins on the seventh day after  the
introduction of muscle-trichinse into the stomach, and may con-
tinue, as it  appears, for weeks.   Yet, a  repeated maturation of
eggs, as it were in crops, seems now and then to occur.1
    The embryos  do not long remain in the intestine, but soon
migrate, to settle  in the voluntary muscles.  The paths by which
they reach the muscles are still a matter of dispute ; according to
some writers,  part of them  penetrate the  intestinal wall and
wander from the peritoneal cavity through the loose connective
tissue towards  the  muscles, and a part  penetrate only into  the
submucous  tissue,  and  from  thence  into the  mesentery  and
onwards, between its layers, and  through the loose retro-peri-
toneal  connective tissue ; according to others, they reach their
destination  by entering the blood-vessels—either directly or by
way of the lymph-currents—in which they are carried passively
by  the  stream to different  parts of the body.   Probably  the
propagation occurs by both methods.

  The great  majority of investigators accept the route  through the intestinal
wall, the peritoneal cavity, and  the connective tissue, as that which is most fre-
quently taken ;  while  Fiirstenberg2 has  called special attention to the migration
through the mesentery.  Pagenstecher3 was unable to find the embryos in the con-
nective tissue except where it was in immediate contact with the muscle.   The
theory of distribution through the blood-vessels is decidedly  opposed by the

  1  Cohnkeim, Virch. Archiv, 36, p. 170, 1866.
  2  Fiirstenberg, Annalen der Landwirthschaft im preuss. Staate, V., 21, 1865, p. 191
(Virch. Archiv, 34, p. 469,  1864).
  3L. c, p. 91. 
TRICHINA.
625
Fig. 33.
A recent trichinous immigration into a human muscle; section of the muscle near its tendinous insertion.
a                                (Moderately magnified.)

           VOL. III.—40. 
626     HELLER.—DISEASES  FROM MIGRATORY PARASITES.

majority, mainly because they have not succeeded in discovering the embryos in the
lymph and blood ; they have, however, been found repeatedly in the blood,1 and by
Virchow2 in the lymphatic glands.  Tbe passage through the organs of circulation
is a priori so much more probable, that, notwithstanding such decided opposition,
we are compelled to accept it.  Fiedler, in particular, has proved by measurements of
the smallest embryos found in the muscles, that, even accepting the shortest time for
their journey through the connective tissue, they could not have occupied even that
length of time, for, if they had, they would be found of a much larger size.  Accord-
ing to numerous careful measurements, the embryos grow at least 0.07 mm. daily
during the first few days ;  suppose, now, that it would take only twenty-four hours
for an embryo  to travel by the shortest route  from the abdominal  cavity to  the
muscles of the  leg or forearm; it must even then have attained a length of 0.12 mm.
(the size of  the trichina in the peritoneal cavity) + 0.07 (increase of length for one
day) = 0.19 mm.; as long as the migration lasts, however, we are continually find-
ing embryos only 0.12 and sometimes only 0.108 mm. long.  Leuckart's3 objection
does not sufficiently explain this difference.

    Having  reached  the muscles they force  themselves into the
primitive fasciculi,  cause the disintegration of their contents,
increase in length and thickness, and finally roll  up in  coils  of
                                   greater or less size.  At the same
                                   time the sarcolemma of the mus-
                                   cular fasciculus around  the tri-
                                   china enlarges, and an aggrega-
                                   tion takes place within it of oval,
                                   vesicular-shaped muscle nuclei;
Isolated muscle-trichinae in various stages of de   the  tlicllina itself  SeeiUS to  be
      velopment. (Slightly magnified.)
                                   imbedded  in  a finely  granular
mass.    The sarcolemma becomes  considerably thickened  and
glossy,  and the  deposition of the muscle-nuclei on  the inner
surface  contributes  to its  strength  ; at  the  same time a free
cavity forms around the trichina  itself,  probably  owing to  its
sluggish motions.   The  sarcolemma sheath collapses above and
below the capsule, and finally  becomes obliterated.
   In abont fourteen days the muscle-trichinae attain the great-
est size  ever reached by the parasite while in that state; they
attain a  length  of  from  0.7  to  1.0 mm.,  and  they usually  lie
1 Fiedler, Archiv d. Heilkunde, V., pp. 5 and 472,1864, and Zenker, Kiihn, 1. c, p. 32.
2 Virchow, 1. c.
3L. c, 2 Aufl., p. 51 ;  Anmerkung.
 
TRICIIIX^E.
627
singly?  or, more rarely, two, three,  or even four, in one  capsule.
Their digestive canal, and  the sexual  apparatus, although  the
latter is not yet completely developed,  are  distinctly visible.
   As intestinal trichinae, the intruders have a very limited dura-
tion of life ;  they  very rarely live longer than
from five to eight  weeks.   Observations of  a
longer  existence may be explained on the sup-
position of a repeated importation.
   In the case of a rabbit, Pagenstecher! once found intestinal
trichinae even in the eleventh week.
   The  muscle - trichinae have a much greater
tenacity of life.  Their vitality is almost  unlim-
ited,  and frequently ends  only  after the  death
of the person affected.   In some  cases  they have
occasionally  been  found  living  even  after  the
lapse of decades."
   After  a  time,  a deposition  of  lime  salts,
especially of  carbonate of lime, usually  takes
place in  the capsule ; this causes  it  to become
cloudy and opaque, and,  after  a  time, the  tri-
china  is entirely hidden.    The capsules then
become  evident  to the naked eye as small white
dots  or  streaks, while  previous to the  calcifi-
cation  they  were  visible  only  to experienced
observers.  Small  collections  of fat cells  usu-
ally develop at  the extremities  of the capsule,
especially in well-nourished individuals.  Under
certain circumstances,  not yet positively  deter-
mined,  the trichinae die,  and  may decay, or a
deposition of lime salts may take place in them;
they petrify, break readily into pieces,  and their
former  nature  can  be recognized  only by  the
peculiar position occupied  by the fragments.'
   1 L. c, p. 89.
   *t>. Linstow, Virch. Archiv, 44, p. 379,  1868.—Klopsch,  Ibid., 35, p. 609, 1866.-
Muller, Ibid., 37, p. 253.—Tiingel, Ibid., 28, p. 391, 1863. —Groth, Ibid., 30, p.  265,
ISQ4.—Liicke, 1. c.
   * Luschka, Zeitschrift f. wiss. Zool., III.,  Plate III., Fig. 6.
     Fig. 35.
  A single primitive
bundle, with two tree
trichmaj within the sar-
colemma. (Highly mag-
nified.) 
628    HELLER.—DISEASES FROM MIGRATORY PARASITES.

   If, then, the capsulated muscle-trichinae  be introduced into
the stomach of  a proper animal, they will  be freed from their
                                    capsules, become sexually
                                    mature  within  a few (usu-
                                    ally two and a half) days,
                                    copulate, and the females
                                    will  bring  forth  living
                                    young  after five days, that
                                    is,  seven days  after their
                                    importation.

                                       In addition to men and
                                    swine, the trichina has been
                                    observed in  the  cat,  ra,
                                    mouse,  marmot,  polecat,
                                    fox, marten, badger, hedge-
                                    hog, and raccoon. By feed-
                                    ing them experimentally,
                                    the trichina has been suc-
                                    cessfully bred  in rabbits,
                                    guinea-pigs, sheep,  calves,
                                    and  dogs;  in  the  three
                                    latter  animals,  however,
                                    the experiments seem  to
                                    have been only  exception-
                                    ally successful;  as a rule,
                                    the  formation  of    intes-
                                    tinal  trichinae  is  the full
                                    extent of the infection  in
                                    dogs.
                                       As  regards  geographi-
Capsulated muscle-trichinse. with calcification of the cap- Cal dlSt?'ibution.  it  COin-
        sules.  (Magnified 80 diameters.)
                                    cides, as it seems, with the
dispersion of its principal "bearers;"  like  man,  the hog, and
the rat, it is cosmopolitan,  and is found  scattered over  the
whole earth.  It has been discovered in almost  all countries in
which  any general investigations  have  been  instituted.   In
Europe, it has been observed particularly in Germany, England,
 
TRICHINAE.
629
Scotland, Denmark,1 and  Sweden ;2 but France,3 Russia,4 Italy,
and  the  Principalities  of the Danube,6 are not free from  the
scourge.   It  is  notoriously  frequent in  North  America;   the
case  occurring   on  a  Ham-
burg  vessel,  which  was  oc-
casioned by  a hog taken on
board at  Valparaiso,  proves
that South America6 does not
escape the disease.  Thus far,
from  Africa we have accounts
of the presence of the parasite
in Algiers only.7  It  appears
to be frequent in India,8  and
has been  observed in  Austra-
lia also.

      Fig. 37.
  Capsulated and  calci-
fied muscle-trichinae. (Na-
tural size.)
      Fig. 38.
  Capsulated and calcified
muscle-trichina? from  the
biceps muscle of a man.
(Slightly magnified.)
   Its frequency in England has been previously mentioned.8
   From Scotland, Turner 10 reports that during  the last five years he has found
trichinae in from one to two per cent, of all the dead bodies he has examined.
   Of all the autopsies made in  Dresden, Fiedler " found trichinae in  from two
to two and a half per cent. ; Wagner,12 of Leipzig, found one in every thirty or
forty bodies.  As early as  1859, Virchow13 had found  numerous cases  of capsu-
lated trichinae.   Zenker14 had discovered that 1.79 per cent, of the bodies examined
in Dresden were trichinous.
   Even Italy is not to be omitted, as was thought  by Sangalli,16 for Jauch ,B reports
 1 Leuckart, 1. c, p. 51.
 2 Key, Virch. Archiv, 41, p. 302, 1867, and Key and Odenius, Ibid., 41, p. 302.
 » Cruveilhier, Anat. pathol., II., p. 64.
 ♦ Rudnew, Virch. Archiv., 35, p. 600, 1866.
 • ScJieiber, Ibid., 55, p. 462, 1872.
 6 Tiingel. Ibid., 27, p. 421, 1863.
 7 GaiUard, Mouv. med., 1867. p. 490 (Gaz. hebd., 1867, No 41).
 B Gordon, Lancet. VI., p.  387.
 6 See p. 616.
10 Turner, Edinb. Med. Journ., Sept.  1860.
11 Archiv d. Heilkunde, VII., p. 448, 1866.
"Ibid., VI., p. 503, 1805.
13 Archiv, 32, p. 322.
14 Deutsches Archiv f. klin. Med., VIIL. p. 389.
16 Sulla organizzazione.morbosa del corpoumano.  Pavia, 1865.
16 Jauch, Annali univers. di med., 1869, p. 72. 
630    HELLER.—DISEASES FROM MIGRATORY PARASITES.

cases of trichinae in Rovecchia (Canton of Tessin), which, although  belonging to
Switzerland, must be considered geographically as a part of Italy.
   Its frequent discovery in American exported pork speaks positively for its prev-
alence in North America, as was corroborated in Rostock * and in Kiel, and also by
the reports already referred to.2
   Among 150 dissections in St. Petersburg, Rudnew found trichinae three times.
                         Chapter III.

                         TRICHINOSIS.

                       Symptomatology.

   The symptoms of trichinosis vary with the different  stages
of the disease, and follow  pretty closely the phases of develop-
ment of the trichinae.   It has been suggested that, in accordance
with  this,  we  should  discriminate sharply between three well-
defined periods.  The  first stage  (Rupprecht's stage of ingres-
sion)  corresponds  to  the introduction into  the digestive  canal
and the development of the intestinal trichina?; symptoms refer-
able to the digestive canal  are the most prominent.  The symp-
toms of  the second stage  (Rupprecht's stage of digression) are
brought about by the beginning of the migration of the trichina
embryos, and by their penetration into the muscles ; as a result
of this, they appear in the  connective tissue and in the muscular
system.  The third stage (Rupprecht's stage of regression) cor-
responds with the end of the migration of the trichina embryos
into  the muscles ; the immigrants come to rest, and the capsulat-
ing process begins.  The symptoms then subside.
   This  division  into  stages  may indeed  be  verified  in some
cases; in general, however, a  marked irregularity  prevails, both
as to the time  of appearance of  the symptoms after the  intro-
duction of muscle-trichinae into the  digestive canal, and also as
to the order of  the symptoms in general ; the course is a uni-
form one only in severe cases; in light forms the single stages
merge into each other, and the first especially is  often entirely
   1 Petri, Virchow's Arch., 57, p. 269, 1873.
   2 Bowditch, 1. c.—Buck, New York  Med. Record, March 1, 1869, pp.  7-9.—Groth^
Virch. Archiv, 29, p. 602, 1864. 
TRICHINAE.
absent.   The course is by no means
so typical as in acute infectious dis-
eases.
   In many light cases,  trichinosis
runs  its  course  without  any fever
whatever, but in severe forms there
is always a considerable elevation of
temperature,  not, however,   during
the first few days.  The fever curve
bears a marked similarity to  that of
an ordinary case of typhoid fever,' yet
lighter  cases present almost an inter-
mittent type, on account of  the con-
siderable  morning  remissions.3   A
chill at the outset of the attack is in-
frequent, oftener there is only a slight
shivering.  The pulse  corresponds to
the temperature ; in the beginning it
varies from 80  to 90, soon mounting
up to 100 or 120 beats  in a minute.
   The  accompanying  charts  may
serve as  examples of the course of
the fever in slight and severe cases.
   We  think it judicious—according
to Kratz's example—to  consider the
symptoms of the disease in the order
of the  different organs and  systems
affected,  and to commence with the
digestive apparatus as that in which,
as a rule, the first disturbances apr
pear.
   The  symptoms  referable  to  the
digestive system are exceedingly vari-
able ; even after  the  introduction of

   1 Fiedler, Archiv d. Heilkunde, VI., p. 503,
1865.
   J Maurer, Deutsches Archiv f. klin. Med.,
VIIL, p. 308, 1871. 
632
HELLER.—DISEASES  FROM MIGRATORY  PARASITES.
the same  quantities of the infected flesh, they  do not occur
with equal intensity ; they depend, of course, in great part, both
on the quantity of the meat introduced, on the number of trich-
inae taken in which are capable of development, and, finally, on
the mode  of preparation to which the meat has been subjected.
At one time there may be an entire absence of  any symptoms, at
another they may be very mild, and still again  they may be
present in a very high  degree.  The gravity  of the succeeding
Day of
disease.
9  10   11   12
Fahr.
105.8°
104°
102.2°
100.4°
98.6°
    ESSSSI       ■■■■■
mBSOBm
         97°
                            Fig. 40.
             Fever curve of a mild case of trichinosis (Maurer, 1. c., Fig. 3).

illness bears no positive relationship to  the severity of the first
symptoms.  They often appear only a few hours after the infect-
ing meal.  Sensations of uneasiness, fulness, and  nausea, even
to retching or vomiting, are present in the beginning ;  the latter
symptom occurs sometimes  even after a few hours,  and  at
other times only after  several days; it may be  repeated fre-
quently,  and last for whole days, or may occur only a single time
or a few times.
   The appetite is exceedingly variable ;  often it seems entirely
gone ; at  other  times, it is  not  only present,  but even keen ;
during convalescence a ravenous appetite is commonly observed.
There is almost always an increase of thirst.
   Diarrhoea is very frequent; at the outset the discharges are
still feculent ;  subsequently they become very thin, clay-col-
ored, and in some cases  almost like rice water.  The diarrhoea 
TRICIIIX.E.
633
 continues  much longer than the vomiting ; sometimes it lasts for
 many weeks ; not  infrequently, after a short duration, it gives
 place to  an obstinate constipation; sometimes this is present
 from the beginning.
    The majority complain of an unpleasant pasty taste in  the
 mouth ; many of a loathsome, putrid odor. * The tongue presents
 nothing characteristic of the disease.
    The difficulties of  chewing and  swallowing,  which appear
 later, and  increase so much that only fluid nourishment can be
 given, are accounted for by the parasites having  migrated  into
 the muscles concerned in these acts.
   Ebstein • attributes the gastric and duodenal ulcers, found after death in a few
 cases of trichinosis, to the intense irritation of the mucous membrane of the stomach
 and intestines produced by the trichinae.

    The symptoms  connected with the muscular system are the
 most important, next to those of the digestive apparatus.
    As a single  constant symptom  at the outset  of trichinosis,
 one that is present in  the most  severe  as  well as in the light
 cases, Kratz mentions  a  flabby condition of the  muscles  and
 painful sensations  in them on motion,—a " muscular lameness ;"
 —this muscular lameness has no connection with the emigration
 of the trichinae into the muscles, since it appears much earlier.
    The muscular symptoms  brought about by this  invasion  are
 very changeable ; while in the lighter forms they are but trifling,
 or  perhaps wholly absent, they are extremely violent in mode-
 rate and in severe  cases.   They make their  appearance at  the
 earliest on the tenth day ; it is rare for them  to appear first after
 a much longer  interval (as late as the forty-second  day, Kratz).
 The muscles present various degrees of swelling and hardness, de-
 pending on the number  of  trichinae  scattered throughout them,
 and they are  extremely sensitive to pressure ; the  extremities,
 and especially their flexors, are the parts chiefly affected, so that
 the joints  are kept in a bent  condition;  in severer cases  per-
 manent contractions occur.  The  patients lie with  their knees
drawn up  and with the arms sharply bent, unable to move,  so
that  they  present  a picture  of the greatest helplessness.  The
1 Ebstein, Virch. Archiv, 40, p. 289, 1867. 
634    HELLER.—DISEASES FROM MIGRATORY PARASITES.

difficulties of chewing and swallowing, which  often permit  the
reception of only fluid  nourishment,  are very striking ; they
sometimes amount to trismus.
   Together with these perceptible objective  symptoms in  the
muscles, there are usually more or less violent muscular pains,
which are but trifling in a state of rest,  but become extremely
severe on motion or on attempts to stretch the  limbs.  This sen-
sitiveness is most  marked during the fifth and sixth weeks.
   Numerous, and in some points characteristic,  symptoms  are
observed in connection  with  the  nervous system.   The  most
prominent, and perhaps  the most  detrimental  symptom is  the
almost absolute sleeplessness of the patients, to which children
only  form an exception, as  they, on  the contrary, often pass
through almost the entire attack in a dormant condition.
   An abnormal stale of mind is not uncommon ;  it shows  itself
especially in a condition of  apathy with  reference  to the  sur-
roundings.
   During the first few days of the disease, repeated neuralgic
attacks—neuralgia mesenterica—have been observed.   More fre-
quently  there  are attacks of  "coeliac neuralgia," which last  for
various  periods and return at  irregular intervals, sometimes as
often as six times in twenty-four hours ; they appeared especially
during the second week,  and usually at night.

   Kratz, who particularly observed this neuralgia, saw it only in the  most severe
forms of the disease. He once saw it as the initial symptom in the case of a boy ; he
awoke with a loud cry of distress, rolled around repeatedly in a convulsive manner,
and between his reiterated shrieks, pointed anxiously to his abdomen and repeatedly
compressed it.
   Kratz found the attacks of " neuralgia  cceliaca" to correspond exactly with
Romberg's description: Suddenly, or after a previous sensation of compression, a
violent griping pain comes on at the  pit of the stomach, generally extending to the
back, with faintness, a sunken  countenance, coldness of the hands and feet, and
small, intermittent pulse.

   Very often there is hyperesthesia of the skin, in the  form of
pruritus or formication, either  extending over the  whole body or
limited to single portions of the lower extremities.  In some cases
pruritus appears very early, before the migration of the parasite.
Anaesthesia is very infrequent; it increases very gradually, and 
TRICHINAE.
635
 in a few days, after having attained its greatest intensity, again
 gradually disappears.
    Sometimes mydriasis is noticed, but it is by no means con-
 stant.   Ecchymoses of the conjunctiva are not uncommon.   In
 all severe cases there are pains  in the ocular muscles, especially
 on motion of the eye, and they are present in about the same
 degree as in other muscles.
    At times, a loss  of hearing is observed, probably caused by
 single trichinae in the stapedius muscle.
    Of the symptoms connected with the circulatory apparatus,
 edema  in different  parts of the  body deserves  chief mention, as
 being among  the most characteristic and  pathognomonic of  the
 phenomena of trichinosis.   This symptom is seldom absent, or so
 insignificant and transitory as to be overlooked.  Most frequently
 and earliest—on the seventh day—oedema  of the eyelids and face
 sets in, which vanishes after  from two to five days, to return
 again, in some cases, after a few weeks.
    The  oedema of the  extremities is usually more  marked and
 more lasting ;  it comes on, at the earliest,  on the ninth day after
 infection, and increases constantly, especially  in severe cases,
 while in the  lighter forms  it,  like  the facial oedema, sometimes
 disappears only  to  return in a few days more markedly than
 before.  Even during convalescence, after  standing or walking,
 slight oedema not infrequently arises in the feet and legs, which
 disappears on lying  down.
   The explanation of the oedema  as collateral has  been repeatedly rejected as
 untenable.  According to Klob,1 it is dependent either on thrombosis of the finer
 lymph-vessels or on a plugging with trichinae which have entered them;  or, again,
 on the circumstance that the force, which is necessary to keep the lymph in motion,
 fails just at the time when the transudation is augmented in consequence of the irri-
 tation of the tissues.
   Friedreich2 maintains as  exceedingly probable the opinion that the  oedema is
 dependent on an infection of the blood with a pernicious substance contained in the
 capsules of the trichinae that have been eaten, which substance,  by a special influ-
 ence on certain points of  the vaso-motor nervous centre, engenders this  transitory
 disturbance of circulation.  He calls attention to the existence of irritating substances
in Xematodcs, as  ascertained  by vanous observations, and declares that  the great
                  1 Klob, Oesterr. med. Jahrb., I860, p. 98.
                  s Friedreich, 1.  c. 
636    HELLER.—DISEASES FROM MIGRATORY  PARASITES.
constitutional disturbance, especially as it occurs in the beginning of the disease,
can scarcely be accounted for by the existing irritation in the intestinal canal, and
that, particularly, the intensity of the fever bears no proportion to the insignificance
of the local symptoms of disease in the digestive apparatus, at a time when the
migration into the muscles has not yet occurred.

   Hemorrhages are, on the  whole,  infrequent, and  usually de-
pend upon the existence of other affections.   Intestinal hemor-
rhages and epistaxisx are sometimes observed.
   Changes in the composition of the blood frequently come on
early, on account of the enormous consumption of muscular sub-
stance and the non-absorption of nutritious matters; marasmic
thromboses are not at all uncommon.
   A large  number of the deaths from trichinosis  are due to
insufficiency  of respiration, a consequence of  the direct migra-
tion of numbers of trichinae into the respiratory muscles, especi-
ally into  the diaphragm and the muscles  of the  larynx.  The
frequent  attacks  of dyspnoea, which afflict  the  patients,  even
at an early stage, are dependent partly  on the very same causes,
and in some degree on the  violent bronchial catarrh, which,
almost without  exception,  develops  exceedingly  early.   On
account of  the  inability to expectorate freely,  brought about in
some  measure by the weakened  and  painful  condition  of the
respiratory  and auxiliary  respiratory muscles,  the  secretion
collects in large quantities.
   A more or less severe hoarseness, often amounting to complete
aphonia, is very frequently produced by a marked  invasion of
the laryngeal muscles.
   Hypostatic and simple catarrhal pneumonias,  involving a
certain number  of lobules, are not uncommon, and present noth-
ing characteristic of trichinosis; the physical  signs of these com-
plications are rendered difficult of recognition by the trouble and
pain occasioned by moving the patient; "pleuritis sicca," with
severe stitches in the side, is less common.
   Kratz' has observed purulent pleurisy with  abundant exudation.

   Embolic pneumonia and metastatic abscesses must be consid-
1 Friedreich, 1. c.
aL. c, p. 91. 
TRICHIX.E.
637
ered  as  rare occurrences, and not peculiar to trichinosis ; they
occur as the result of the decubitus, as  may  happen in the later
stages of any of the various exhausting diseases.
   The symptoms attributable  to the  urinary  apparatus  are
insignificant.   The amount of urine  is absolutely reduced, even
from the second week on ; the urine is intensely  red, containing
considerable sediment, but never albumen.  Its  increase again
takes place during convalescence—in the fifth or sixth week.

   Unfortunately there exist very few careful analyses of  urine, which might  give
interesting explanations of its  positive physiological and pathological relations to
the enormous consumption of muscular substance.

   In regard to  the sexual organs,  abortion, which  not infre-
quently follows,  deserves special mention ; yet pregnancy often
runs its entire course regularly to the end, with the normal puer-
peral period.  Irregularities of the  menses are sometimes  ob-
served, yet they are by no means constantly present, since in
many patients that  function remains entirely undisturbed;
sometimes the menses appear prematurely; usually, however,
they come on at  the proper time, then  they may fail once,  but
not often more than that.

   In cases of abortion no trichinae have ever been discovered in the foetus.

   Among the most troublesome, and in most cases never-failing
symptoms,  are the profuse sweats,  which appear even in  the
earliest days of the disease, and continue throughout its whole
course.
   Eruptions  on the slcin are tolerably frequent, especially  the
miliary and pustular ; other forms, as herpes, petechiae, and pru-
rigo,  are less  common ;  after the disappearance  of the oedema,
acne, ecthymatous pustules, and furuncles are of common occur-
rence.  Mention  has been made  of hyperaesthesia in connection
with the nervous system.
   Bed-sores are tolerably  common, but they seldom, however,
attain a great size.
   The scaling off of the skin is especially noticeable during
convalescence. 
 638    HELLER.—DISEASES FROM MIGRATORY  PARASITES.

             Course,  Duration, and  Termination.
   The duration of the incubation varies from a few hours to
 several weeks, according to the number of trichinae introduced ;
 as a rule, it is only in the severer cases  that there is an approxi-'
 mative uniformity in the time of  appearance of certain  symp-
 toms, a fixed similarity of the course.   It is known that man
 may tolerate a considerable number of  trichinae without becom-
 ing ill; even a large number, both of intestinal trichinae in  the
 digestive  canal and also of  migrated embryos  in the muscles,
 may be borne in the beginning without any special disturbances,
 while, in  case of increase of  the latter by a continuous influx,
 the bounds of tolerance will at last be  suddenly overstepped, and
 severe, even threatening symptoms may then appear.  Violent
 disturbances of the digestive  canal occur only when a very large
 number of intestinal trichinae are present.
   In that case, the time of appearance of the symptoms depends
 upon the degree  of  development of  the muscle-trichinae intro-
 duced.  The trichinae must have attained a certain size, in  order
 not to be digested in the intestine, and to be capable of develop-
 ment.  The so-called "young trichinous"  flesh causes no illness.
 Even should the trichinae be  sufficiently mature to be capable of
 development, but  should not yet  have attained that degree of
 maturity which they are capable of reaching as muscle-trichinae,
 they must make up the deficiency in the intestine and  conse-
 quently require a longer time for the development of embryos.
 Finally, if the capsules be much calcified, it  seems to require a
 longer time to free the contents.
   The duration of the disease is just about as inconstant as  the
 time of appearance of the different groups of symptoms.  While
 in some very light cases the patients  may go through the whole
 course of trichinosis without  being confined to bed, and be con-
 sidered even in the third week as cured, in the majority of  cases
 the course is very  slow.  In  the  milder cases, convalescence
 begins in the fifth or sixth  week ; in  more  severe and in  the
gravest forms it is deferred for four  months, and even then  the
 convalescents  frequently do not regain  their full strength for a
 long time. 
TRICHINAE.
639
   A fatal  termination of trichinosis is very common,—in single
groups of cases as high  as thirty per cent.   It occurs most fre-
quently in the fourth, fifth,  or sixth week,  and  generally as  a
consequence  of paralysis of  the  respiratory  organs ;  cases  of
death after the seventh week are rare.
   Of Kratz's 280 cases, the disease began: in 98 cases, in from 1 to 5 days, in 76,
in from 6 to 10, in 67, in from 11 to 20, in 33, in from 21 to 30, and in 6, later, up
to 50 days. Of 196 recoveries,  convalescence occurred:  in 1 case in from 1 to 5
days, in 5, in from 11 to 20, in 9, in from 21 to 30, in 46, in from 31 to 40, in 27,
in from 41 to 50, in 19, in from 51 to 60, in 16, in from 61 to 70, in 15, in from 71
to 80, in 27, in from 81  to 90, in 23, in from 91 to 100, in six, after the 100th
and in  two, after the 120th day.  Of 84 fatal cases, 10 died in from 11 to 20
days, 35 in from 21 to 30, 21 in from 31 to 40, 12 in from 41 to 50, and six later,
of whom one died after the 120th day.
   So tardy an appearance of the first symptoms as that quoted by Kratz* excites
suspicion of a later infection superimposed upon the first.

   The number of deaths depends on all  the above-mentioned
conditions governing the severity of the disease,  then upon the
number of those  who  have  partaken  of  trichinous pork,  and
whether they partook of  it freely ; in this connection it is also a
matter of  importance to know whether the hog was slaughtered
alone  for immediate sale while fresh,  or whether its flesh, either
alone  or together with the flesh of other animals, was used  in
part for fresh food, and in part preserved as sausages, hams, and
the like.

                           Diagnosis.

   In  single  cases the diagnosis  of the trichina  disease in the
beginning is very difficult; it  becomes easier when they occur  in
groups, and still more so  in case of an epidemic outbreak.
   In  the  beginning of severe cases, the symptoms of a more or
less  violent gastro-intestinal catarrh are almost always present,
frequently accompanied by a very slight fever or none at all; at
the same time, even  during the first few days, an almost constant
symptom is the remarkable  increase  of perspiration.   The so-
called muscular lameness has already  been mentioned as the
'L. c, p. 107. 
640     HELLER.—DISEASES FROM MIGRATORY PARASITES.

most marked initial symptom present in the mildest as well as
in the most severe cases.
   Trichinosis is distinguished from cholera by the profuse per-
spiration and by the peculiar muscular symptoms, from simple
rheumatism by the symptoms of gastro-intestinal catarrh and by
the general exhaustion.
   With the appearance of oedema of the face and eyelids on the
seventh day, trichinosis must naturally be suspected, and the
diagnosis may then be made with greater certainty.   Other dis-
eases which may have similar symptoms  can be easily excluded,
especially as unilateral and chronic oedema need not be consid-
ered.  Bilateral oedema of the eyelids and face occurs especially
in hydraemic conditions (as in morbus Brightii) and in disturb-
ances of the circulation, as  produced by disease of  the heart,
lungs, or pleura;  such disease  can  be easily excluded;  the
urine in trichinosis  is  always  free  from albumen.   Similar
cedemas occur in inflammations  of  the face and scalp, and also
in diseases of the conjunctiva.  Inflammations and neoplasms in
the retrobulbar  fatty  tissue, even when present,  are very rarely
bilateral.   So,  also,  oedema produced  by thrombosis of  the
orbital veins, or by thrombosis  of the cavernous sinus, or by
compression  of it, is of very infrequent occurrence.
   The further progress is so characteristic that the diagnosis can
scarcely remain in doubt.  The marked general prostration with-
out  any noticeable  disturbances  of internal organs, the extra-
ordinarily violent muscular symptoms, the attacks of  dyspnoea,
the hoarseness,  the bronchial catarrh, the profuse sweats, and
the sleeplessness scarcely admit  of  a doubt as to what we have
to deal with.
   The diagnosis becomes indisputable on the discovery of single
intestinal trichinae in the stools,  or upon the observation of  mus-
cle-trichinae in excised portions of muscle.  Yet a negative result
of the examination  of the discharges, and of small pieces of mus-
cle, is no evidence against the correctness of the  diagnosis ; it is
to be remembered, on the other hand, that a positive diagnosis of
the trichina disease may be made without these observations.
   Well-preserved intestinal trichinae are very seldom discharged at stool.
   The examination of the muscular tissue is naturally the most judicious procedure 
                           TRICHI1SLE.                       641
 in order to ensure the diagnosis in doubtful cases; two methods—excision and the
 use of Middeldorpff s harpoon—are recommended- for obtaining small pieces; the
 former is much to be preferred, as a small incision heals no less easily than a punc-
 tured wound, while a larger piece of muscle can be obtained, affording a greater
 likelihood of finding muscle-trichinae; we should, however, if the diagnosis be not
 otherwise doubtful, refrain even from this interference.

    Proof that the patient has partaken of trichinous pork or
 ham helps to establish the diagnosis.


                           Prognosis..

    There is, perhaps, scarcely any other disease in which it is so
 difficult to form a prognosis which is in some measure positive,
 as in the trichina disease; this fact is due  to many diverse cir-
 cumstances which can  scarcely be determined at  the outset of the
 illness.
    The severity, duration, and termination of each single case
 depend  first of all upon the number  of living  muscle-trichinae
 introduced ; this  depends on the number of trichinae in the meat
 eaten, on the amount  of it,  and upon the mode of its prepara-
 tion.  The  less thoroughly the  meat  is prepared, and the less
 exposed to  heat, the more severe, ceteris paribus, will  be the
 illness ;  the most violent cases  of the disease always  happen
 after the use of entirely  raw minced meat, as is customary in  a
 large portion of Saxony.  This  quasi-cannibalism has  reacted
 terribly, as shown by the numerous victims  of the epidemics.
    No positive conclusions can be drawn from the severity or
 the premature  appearance of the initial   symptoms ;  yet,  in
 general,  the more speedily they occur after eating, and the more
 violent they are, the less  favorable is the prognosis ; on the other
 hand, the later they appear,  the  more  propitious is it.  A long-
 continued diarrhoea  is especially unfavorable, while a profuse
 diarrhoea at the  beginning is to be considered  as a  fortunate
 event.  Diseases previously present in other organs aggravate
the prognosis considerably.
    Severe symptoms attributable to the nervous system, such as
coma, delirium, and sopor, are, almost without exception, har-
bingers of approaching death.
          VOL. III.—41 
642    HELLER.—DISEASES FROM MIGRATORY PARASITES.

   The prognosis is more favorable in cases in which sleep and
appetite are  maintained, and in those in which the symptoms
referable to the respiratory organs remain but slight.
   In children a favorable termination is the rule.

                          Treatment.

   At  the present  time the treatment of  trichinosis  does not
afford  a hopeful outlook.  It should consist in following out two
indications.
   In the first place, the object should be  to Mil the intestinal
trichinm, or  at  least to  drive  them away from their abode in
the intestine, and thus  prevent the birth and migration of the
embryos.
   The prospect of killing the intestinal trichinae  with anthel-
mintics, or of removing  them from  the  bowels by purgatives,
seemed very  promising.   Unfortunately,  this hope has not thus
far been realized.   Various remedies have been tried ; they were
in part allowed to exert their influence  directly on the muscle-
or intestinal trichinae, and the  results  tested  either by feed-
ing experiments or with the microscope  ; to some  extent, also,
the animals which  had been fed with the  trichinous flesh were
treated with the various medicaments ; all these experiments
have given negative  or very doubtful results  ; we  have not yet
succeeded in finding a remedy  which, in a quantity innoxious to
man, will positively kill the trichinae
   Observation having shown that in patients, who in the begin-
ning had a profuse diarrhoea, the disease  ran a more favorable
course, it was hoped that better results would be  obtained by
the employment of purgatives.  But this expectation also has
not been fulfilled.
   The prospect of killing the migrated  muscle-trichinae is thus
far just about as hopeless.
   Nevertheless we  should not give  up the  hope  of finding a
remedy which will kill the trichinae in the intestine.
   Picric acid, in the form of picronitrate of potassa and soda, is recommended by
Friedreich ' as a very efficient anthelmintic even in the treatment of intestinal tri-
1 Friedreich, Virch. Archiv, 25, p. 399. 
TRICHINAE.
643
chinae;  according to Fiedler's experiments, it prevents neither the development of
the intestinal trichinae nor the formation and migration of the embryos.
   Mosler ' has seen  favorable  results from  benzine in a few experiments ; yet
these have not been confirmed either on more accurate experimental examination or
at the bedside (Kratz).2  Compare Fiedler's experiments.a
   Glycerine which causes the shrivelling and death of the trichinae by depriving
them of water, proved of no value in two of Fiedler's experiments; yet in a number
of other cases it seems to have exercised decided effects.  Mature intestinal trichinae
ten days  old, live, at  the furthest, a quarter of an hour in a mixture of one part of
glycerine  to  four parts  of water; they are then, however,  distinctly shrivelled; in
mixtures of one part of glycerine to three of water, they shrivel in a few minutes ;  it
may be asked whether it is advisable  to administer  it continuously for any length
of time, a single day, for instance, in a sufficiently concentrated solution to cause the
shrivelling of the intestinal trichina},—in other words, to administer for some length
of time pretty large quantities of glycerine in the strength of not less than one part
in three or one part in two of water, as the solution is weakened still more by the
absorption of water from the organism.  Thus far no experiences have been recorded
bearing on this point; a  colleague, however, suffering from diabetes, has taken pure
glycerine  in tablespoonful doses without detriment.
   In addition to these,  cold, warmth, and electricity are recommended, then com-
mon salt, calomel, santonine, oil of turpentine, and in particular the various cathar-
tics, and an almost incredible number of other remedies ; even less success  is to be
expected from all of these than from those already mentioned.

    The  results obtained  by treatment of  the  symptoms  do not
seem to be any more favorable.
    We  cannot recommend  allaying the vomiting and  diarrhea
in the  beginning with  opium, as perhaps  a number of trichinae
may thus be expelled in  a purely mechanical manner; subse-
quently, in the long-continuing  exhausting diarrhoea, mucilagin-
ous decoctions and emulsions are proper ; in treating the persist-
ent  constipation  which  is  met with so frequently, the different
purgatives, especially  calomel, should be given.
    In case of muscular jiains little can be done ; mild embroca-
tions with warm oil, and irritation of the  skin sometimes produce
temporary relief.
    For  the treatment  of the insomnia, as  also of  the profuse
   1 Mosler, Helmintolog. Studien und Versuehe, p. 57,  and Berlin, klin. Wochenschr.,
1864, No. 32, and Leuckart, Virch. Archiv, 29, p. 467.
   - Kratz, 1. c, p. 114.
   3 Fiedler, Archiv der Heilkunde, V., p. 18, 1864, and Virch. Archiv, 26, p. 573, 1863. 
644    HELLER.—DISEASES FROM MIGRATORY PARASITES.

sweats, Kratz recommends a  cool regimen, especially frequent
cold baths of the whole body; hydrate of chloral will also be of
service.
   On the occurrence of attacks  of dyspnea, expectorants are
indicated, after which the benzoated tincture of opium may be
administered, in  doses of from thirty to sixty drops in water.
   Bandaging alleviates the troublesome edema of the limbs.
   The occurrence of bed-sores is to be prevented by the use of
large rubber water-pillows.
   Pneumonia and pleurisy require, in particular,  a tonic treat-
ment.
   The most careful  attention should be  paid to the diet; it
should be light  and nutritious; meat and good wine must be
given to keep up the strength, so as  to  preserve the life of the
patient until the disease reaches the period when the parasites
become capsulated.

                   PATHOLOGICAL ANATOMY.

   The number  of  careful dissections made of those who have
died  of trichinosis is  still proportionately small, and our infor-
mation is especially lacking  as to the conditions found in those
who have died in the first few weeks of the disease.  According
to experiments on animals, as well as to the clinical symptoms,
there can  only be a moderately marked  injection of the gastric
and intestinal mucous membranes.
   Peritonitis has not been seen by any of the careful investigators of the disease in
man, or in the innumerable experiments on animals; for that reason the general
peritonitis observed  by Leuckart in his first experiment on a hog may be attri-
buted to some other cause.
   In case of moderate infection of rabbits, during the first weeks, we find scarcely
any increased redness of the  intestine, either of  the mucous membrane or of the
serous ; only the follicular apparatus is somewhat swollen, and the serous surfaces
are generally moister.

    The bodies of those who die in the fourth week usually show
moderate  oedema of  the lower  extremities ; in the case of those
dying in the fifth and sixth weeks, the oedema is excessive ; the
rigor mortis is characterized by a rigid contraction of the arms ; 
TRICHINAE.
645
bed-sores of more or less extent are not uncommon;  the blood
has very little tendency to  coagulate; in the pericardium, and
in the abdominal and thoracic cavities, large effusions are found ;
putrefaction sets in very early.
   The mucous membrane of the small intestine, as a rule, pre-
sents here and there a  distinct  reddening, with sometimes slight
ecchymoses ;  still later it is for the most part pale, and  the soli-
tary follicles  are frequently swollen, and the mesenteric glands
swollen and pulpy ; we meet with intestinal trichinae in the large
and small intestine as late as the eighth week.
   The cases  in  which living intestinal  trichinae containing  embryos  have been
found in the eleventh week may perhaps be attributed to repeated introductions of
trichinous meat.
   The spleen is either not at all  enlarged, or  but  very little.
After the  fifth  week  the liver  shows  a well-pronounced fatty
degeneration  ; the surface appears entirely smooth and pale yel-
low, and the  tissue poorly supplied with blood, and of a doughy
consistence;  surface of section bright yellow.   Microscopically
all the liver-cells prove to  be filled with larger  and smaller fat
globules.
   The connection between trichinosis and fatty liver has not  yet been explained.
Cohnheim ' supposes that on account of its great propensity to  react with all varia-
tions of  nourishment and changes of  texture, this alteration of the liver may be
explained by the enormous and rapid destruction of muscular substance.
   As a rule, the kidneys present a marked opacity of  the cor-
tical substance.   The muscular tissue of the heart seems for  the
greater part tolerably  firm, though  sometimes it  is rather flabby
and weak ; microscopically we  frequently find a distinct granular
cloudiness.  At a later date, about the eighth week, Cohnheim
once found extensive fatty metamorphosis of the  kidneys and of
the heart.
   Answering to the respiratory symptoms, a severe bronchial
catarrh is commonly found; the mucous membrane, even down
to the finest ramifications, seems of a dark-red color, and covered
with  abundant,  tenacious mucus.   The dependent portions  of
the lungs generally present the results of hypostatic processes:
   1 Cohnheim, Virchow's Archiv, 36, p.  161, 1866.—Zenker, 1. c—Fiedler, 1. c. 
 646     HELLER.—DISEASES FROM MIGRATORY PARASITES.

 quite frequently  simple, indolent infiltrations, or isolated lobular
 hepatizations.  In  very rare  cases hemorrhagic infarctions and
 gangrene are observed.

   The gangrenous mass found in the lung in the case at Plauen (Bohler, p. 70)
 was dependent, undoubtedly, upon the gangrenous bed-sore.

   During the first few  weeks  the muscles show  no constant
 changes,  yet they  often  appear paler  and somewhat  cloudier;
 their consistence is variable;  at one time they  are soft, at
 another, uncommonly hard;  changes visible to the naked eye
 appear  from the end of the fifth week on, and then only in
 severe cases ; fine, clear, grayish streaks, of from one-half to one
 or even two millimetres in length, appear running in the  direc-
 tion  of the muscular fibres, and the more  distinct  they are, the
 darker the remaining muscle.   These appearances are the optical
 expressions of the changes wrought in  the individual  muscular
 fibres by the trichinae.   In slighter cases small, widely separated,
 pale—changing to  gray—specks are only sometimes visible on
 the surface of the  muscle.  At a still later date, in  the tenth
 week, for instance, the  muscles are shrunken to  the greatest
 extent, and generally very pale ; in these, even if not yet clearly
 defined, are the delicate capsules, recognizable even to the naked
 eye,  and they give the muscle a peculiar scaly appearance.
   In the slighter cases the distribution of the trichinae over the
muscular system is unequal.   They are generally most numer-
 ous in the diaphragm, the intercostal muscles, and  the muscles
 of the neck and  larynx ; and they are found least often in the
distant  muscles  of  the extremities.  In severer cases no differ-
ence can  be recognized;  whole muscles are so thickly spotted
that  sometimes far fewer fibres seem free than occupied.  In the
superficial layers of single muscles, especially, however, toward
their tendinous  extremities,  the  trichinae  are  more numerous
than in the remaining  portion.  This condition reminds  us of
Zenker's apt comparison to  a picture  of  a herd of cattle or a
crowd of men, whose  advance is suddenly  checked  by  some
obstacle ;  the tendons are such an impediment to the  trichinae.
This stoppage demonstrates at the same time that the trichinae
travel in the direction of the fibres. 
TRICHINAE.
647
   The muscles have been arranged according to the frequency of infection and
 number of trichina? found in them.  According to Cohnheim, the most frequently
 affected is the diaphragm, then the intercostal and the cervical and laryngeal mus-
 cles, and after them the muscles of the eye.

   The microscopic  appearance' of  the muscles  has,  to some
 extent, been previously mentioned.  During the first few days
 after immigration, the substance  of the muscular fibre appears
 altered around the trichina, which lies still in an extended posi-
 tion within it ; it has lost its  transverse and longitudinal striae,
 and  is converted into a more or less  finely granular  mass ;
 the muscle nuclei seem beyond a doubt to have increased  in
 number ; in addition  there is  a proliferation of  the  nuclei  in
 the  intermuscular connective  tissue; fine spindle-shaped  cells
 arranged in rows are found, and between them are single ribbon-
 like cells, each containing several nuclei.
   Subsequently  the sarcolemma becomes  thickened over the
 places occupied by the trichinae ; there is formed around them a
 dense network of vessels; the muscle  nuclei around the coiled
 trichinae increase  so much in number that the animals seem to be
 imbedded  altogether in them;  between the nuclei may still be
 seen, although only in slight  amount,  a very finely granular,
 light-yellowish mass.
   The sarcolemma is  continued, in both directions, for a long
 distance between the glittering normal  muscular fibres, as a col-
 lapsed  tube with  doubly  contoured shining walls, and  dark,
 granular (fatty)  contents.  In  the seventh week Zenker  found
 heaps of these crowded, small, round cells around the pole of the
 capsule, while  they  were absent in the  remaining muscular
 tissue.
   Later, the much-thickened  sarcolemma is further strength-
 ened  from without by a  layer of connective-tissue  nuclei  and
 spindle cells ; in  the interior the muscle nuclei are deposited in
numerous, regular layers (perhaps plastered over by a chitinous
exudative  product of the trichinae),  and  form the boundary of
the free cavity.
   While these changes are taking place both in those muscular
1 Zenker, Deutsches Archiv f. klin. Med., VIIL, p. 393.- Fiedler, 1. c. 
648     HELLER.—DISEASES  FROM MIGRATORY  PARASITES.

fibres  which are occupied  by  trichinae, and  in  those  in  their
immediate neighborhood,  simple fatty degeneration  sets  in  in
many  other bundles; the fibres lose their transverse  striae and
seem to become atrophied.
   Then follows occasionally the waxy degeneration, which Zen-
ker  has described  as occurring in the  muscles, particularly  in
typhoid fever ;  it never occurs,  however, in so marked a degree,
or so  uniformly distributed.   A few bundles of fibres lose  their
transverse striae, and become waxy and dull in appearance ; their
transverse diameter  is increased, and they very easily fall  into
larger   and  smaller  fragments,  of similar appearance,  around
which the sarcolemma sheath still remains.

   The  waxy degeneration of the muscles has occasioned  much discussion; it has
been denied by some that it is a morbid change appearing during life.  In a rabbit
which had for many months outlived the infection with trichina?, waxy degenera-
tion was found which had evidently  persisted in a peculiar  manner since the
time  of the  illness; whole muscles, especially those of the abdominal walls, were
thickly  set with trichina?,  and appeared coarse,  whitish,  speckled,  and striped.
Microscopically, at first sight, these places presented exactly the appearance of a
well-marked waxy degeneration; the muscular fibres had to some extent maintained
their form over large tracts, yet without the transverse striae, and with small and
large fissures in places on the  margin; here and there large and small fragments
were found  in the  sarcolemmatous sheaths, of the form, appearance, and position
found in waxy degeneration, only all  these pieces appeared, like the remaining
fibres, far more glassy, diaphanous, and  inflexible.  It was finally ascertained that
they had all  become fixed in these forms through calcification.  The preparation is
now  in  the Pathological Museum at Erlangen.


                             ETIOLOGY.

   At  the same time with  the detection of the trichina disease,
Zenker showed also that the source of  man's infection  was the
hog, in wliich, up to  that time, trichinae had been seen  only once.
Although it has  since then been proved that  numerous  wild
animals are affected, yet  in  Europe  these can  be  considered
in connection with  man only in the case of gypsies,  and under
exceedingly abnormal  conditions  of civilization.  First of  all,
therefore, we are interested in the hog.
    To determine the question, to what extent trichinae are pres- 
TRICHINAE.
649
ent in hogs,  would require a more general microscopic inspection
of meats than  has thus far been practised ; yet the results of
such examinations are even now sufficient  to show how wide-
spread the prevalence of trichinae among hogs may be.
   In the city of Brunswick J 93,099 hogs were examined microscopically between
1866 and  1872, of  which  number 18 were trichinous, that is, one in 5,172; in
Blankenburg, during the same period, seven out of 17,933 hogs were trichinous, i.e.,
1: 2,562.  In Rostock,2 of 4,034 hogs examined in  the half-year 1867-68, 12  were
found trichinous.  In  Sweden,3 from  0.38 per cent, to  1.6 per cent, of all  hogs
inspected were infested.

    The use of salted American bacon, which is now  imported in
large quantities, seems to be exceedingly dangerous.
   Of 622 sides of American bacon  examined in Rostock,4 12 were found tri-
chinous  (1 :52); of  210  imported  into Gothenburg,6 8 showed trichinae; in
Elbing,6 one in every twenty contained them ; in Holstein, too, numerous specimens
of American bacon  were trichinous.
   In 1873, in Bremen, 40 persons were taken ill  with trichinosis,  caused by the
use of a ham imported from America.

    The question of next greatest importance is, whether the hog
is the  original  host of  the trichinae, and, if not,  where and in
what manner it acquires them.  It  was  formerly supposed that
certain breeds  of  hogs were the only carriers ;  but, with the dis-
covery  of  trichinae in  neighborhoods into which these breeds
had never  been introduced, and with the proof also that trichina
epidemics had occurred at a time previous to the importation of
these species, this theory was abandoned.
   Gerlach (L c, p. 74) claims that the Chinese hogs were the original "bearers"
of trichinae, and considers it very probable that they brought the parasites to
Europe, as the time  of the first discovery of the trichinae coincides with that of the
importation of this breed.

   Some writers—especially those but little versed in  the natural
1  Uhde, Virch. Archiv.
2 Petri, Ibid.
3 Axel Key, Ibid., 41, p. 302, 1867.
4 Petri, Ibid., 57, p. 296, 1873.
5 Axel Key, 1. c.
8 Jacobi, Vierteljahrsschrift f.  gerichtl. Med., etc., N. F., 20, p. 103, 1874. 
650    nELLER.—DISEASES FROM MIGRATORY PARASITES.

sciences—have endeavored to establish a connection of the tri-
chinae with all other varieties of round worms ;  in their opinion
the round worms  in  the red beet, the earthworm, that  in the
mole, the different round worms in birds, etc., were but develop-
mental  stages of  trichinae, and were  capable  of infecting the
hog.  All these suppositions were very soon disproved.'
   Leuckart's successful experiments  in feeding the hog with
intestines containing  trichinae seemed to afford the most  simple
explanation of the way and means by which the hog is infected.
From the known habit of  this animal to wallow around in filthy
places, and to devour vegetable and animal products of all kinds,
it  seemed very obvious that it became affected by  swallowing
intestinal trichinae which had been evacuated by those suffering
from  the  disease.  This mode  of  infection must certainly be
extremely infrequent,  for, first of all, intestinal trichinae have
but rarely been found in the discharges ; and besides,  investiga-
tions of this subject  have shown that intestinal trichinae, like
embryos, are infallibly destroyed in the stomach.  The success-
ful experiments depended most probably on feeding at the same
time with muscle-trichinae which had not yet escaped from their
capsules, and had been prematurely discharged in consequence
of diarrhoea.
   Amongst those animals which are often the bearers  of  tri-
chinae, attention  was  particularly directed  to  rats as the true
source of the hog's infection.   Not only was their ready sus-
ceptibility  experimentally proved, but spontaneously  trichinous
rats were discovered in all the various places in which they had
had opportunity of feeding upon trichinous meat.    Investiga-
tions  made  upon  a large scale among wild rats resulted in the
discovery that these also were  frequently found to be infested,
and often very severely diseased, even in neighborhoods in which
the trichina disease in man had not been at all  observed, or  but
seldom.  The well-known voracity  of the  hog, and its  special
fondness for meat, made it extremely probable that these rats
were  occasionally devoured; and it was afterwards proved  (by
Kiihn, 1. c.) that such was really the case.  Reasoning from these
1 Virchow, Archiv, 32, pp. 349-351.—Fiedler, Archiv d. Heilkunde, V., p. 345. 
TRICHINAE.
651
observations, the theory that hogs,  and  indirectly also  man,
derived their trichinae from rats, appeared to be sufficiently sup-
ported to be accepted with  more or less confidence by the ma-
jority  of investigators.   "According  to this 'rat theory'  (Zen-
ker), the trichime are originally and essentially parasites of  the
rat.  They are directly kept up in the  rat species by  continual
propagation from rat to rat (independently of their importation
from other sources, such as trichinous flesh).   Trichinae, indeed,
are communicated from rats to other animals,  especially  to
swine  (but  also to cats, foxes, etc.),  and indirectly to man; but
this is not essential to the maintenance of the trichinous species.
Without a  continual fresh importation from rats, the trichinae
in these other animals would soon die out."
    "To exterminate  the rat is to exterminate trichinae"  (Lei-
sering).
   The most decided representative of this view,  to which he still  adheres, is
Leuckart.  Leisering,1 to whom we are  indebted for the fundamental material to be
hereafter mentioned, likewise  defends it, but  does not consider it as yet completely
established.  Virchow takes a similar position with reference to it.

    Zenker,2 making use of Leisering's data, has given convincing
proof of the incorrectness  of the "rat theory," and has shown
that the rats which  have  been found  trichinous  came, almost
without exception,  from flaying places,  slaughter-houses, etc., in
short, from  places where the flesh of dead and slaughtered hogs
is always met with  ; that they therefore derive their trichinae in
the first place from the  flesh of other trichinous animals, and not
from  their own species ; hence the fact (according to Gerlach),
that it is only in times  of great scarcity of animal  food that rats
feed upon the bodies  of their own species,  which cannot  of
course be the case in the places mentioned.  The objection, that
no swine  are delivered to the flaying yards, is refuted by  a ref-
erence to the lists of those places.    Gerlach's proposition, that
" whenever trichinae are found among rats, there must have been
trichinous  hogs or other carnivora within their reach," is fully
   1 Leisering, Bericht iiber das Veterinarwesen im Konigreich Sachsen fiir d. Jahr 1865,
p. 97.
   2 Zenker, Deutsches Archiv f. klin. Med., VIIL, p. 401. 
6^2     HELLER.—DISEASES FROM MIGRATORY PARASITES.

maintained.   The hog is the  peculiar and original bearer of tri-
chinae ; in it the whole course of evolution of the trichinae takes
place ;  in it the trichinae are propagated from generation to gen-
eration, and from it, as a rule, man, the rat, and the cat derive
their trichinae.
   Of 704 rats collected from 29 different districts of Saxony, Bavaria, and Austria,
and from one place in Wurtemberg, 59 were trichinous, = 8.3 per cent.
   Of these 208 rats from flaying yards,   46 were trichinous = 22.1 per cent.
        "   224  "     slaughter-houses, 12 "     "    = 2.3
        "   272  "     other localities,   1 was    "    = 0.3   "
   The one trichinous rat from another locality was, however, " found dead in the
street" in Vienna,  and therefore proves very  little. Rats from eighteen different
flaying places were examined, and those coming from fourteen of them were found
trichinous;  the negative results in the remaining  places were probably due to the
small number examined.
   After the figures just given, Leuckart's adherence to the rat theory (Archiv fur
Naturgeschichte, 1871, 2  Band, p. 431), and  his observations upon it, are entirely
inexplicable.
   While, therefore,  the hog is the only source of man's infec-
tion,  it (the hog) may acquire the trichinae in different ways.
   Among  such we  may mention :  1st, the infection induced by
swallowing the excrement  of men and hogs suffering  from tri-
chinosis,  and with it intestinal trichinae and embryos, but pro-
bably also muscle-trichinae which  have  not  yet escaped  from
their capsules.
   This mode of  infection has not succeeded with the  majority of  experimenters,
but nevertheless it seems to have done so in a few cases (Gerlach, 1. c, p. 14).
   The  second  mode of infection  is  by eating  the trichinous
flesh of another hog.  This may occur  in two ways.  First of all,
Zenker has  proved  that, under  the present modes   of manage-
ment, " the flaying yards, in which swine  are crowded, are the
most prolific  breeding-places  for   trichinous  hogs that can be
imagined," for the  flayers  are permitted  to  feed the  scalding
meat to  the dogs, poultry, and  hogs  on their premises.   That
they should see nothing wrong in thus disposing of  or even sell-
ing hogs which to them seem innocuous, is  only natural, and,  as
a  rule, these hogs  pass through several hands before  they are
slaughtered, so that the place from wliich they originally came
cannot always be correctly traced. 
TRICHINAE.
653
   It is therefore not at all remarkable that the number of trichinous hogs manifestly
traceable to flaying places should already be tolerably large;l  the first  group of
cases of trichinosis positively recognized in Corbach, in 1860, originated  in a hog
bought from a flayer; and the same was true of the hog which occasioned the
llettstadt epidemic.  In Holstein four  trichinous hogs were traced to flaying yards,
two each in two successive years.2

    Zenker  very correctly supposes that hogs  which have died
in some other way  have likewise  been used by  butchers  and
breeders as food for the remaining hogs on their places.
    The third mode, to wliich Zenker calls special attention, is
the custom which prevails not only in the yards but also in the
slaughtering establishments of feeding the hogs with the waste
meat.3  The  practice of  pouring into the  feeding-trough the
water with which the tables, boards, chopping-blocks, and imple-
ments have been washed is widespread and  perhaps universal;
and in  this way the numerous small pieces contained in the fur-
rows on the surface of the chopping-block are removed with the
water, and, in case they come from a trichinous hog, maybe suffi-
cient to infect others.  Even if the infection be only moderate, it
may still bring on severe illness ; and, if the same  course  be pur-
sued after slaughtering one of these animals,  the remaining hogs
will be for the second time supplied with trichinae, and so on.
    The discovery of trichinous droves is convincing proof of the
foregoing views ; by this  we mean,  cases in which hogs have
repeatedly become trichinous in  one and  the same  sty, on the
same premises, at intervals of months, a year, or more.  Virchow
had  already directed attention to  this  and similar practices,
which caused the infection of hogs  by the intestinal discharges
of men suffering from trichinosis.  Zenker's explanation of the
origin,  namely, by feeding the  waste scraps  in slaughtering, is
more simple and obvious.  A  series of such experiences might
be readily adduced.
   Of those cited by Zenker, the case occurring in Basedow, Mecklenburg-Schwerin,
in which twenty-three trichinous swine were found in one yard, is particularly inter-
  1 Zenker, 1. c.
  5 Bockendahl, Generalbericht iiber das  offentlich. Gesundheitswesen der Prov.
Schleswiff-Holstein.  Kiel, 1872, p. 7, and 1873, p. 6.
  3 Compare also Gerlach, 1. c, p. 67. 
654     HELLER.—DISEASES FROM MIGRATORY PARASITES.
esting.  It was expressly observed in this case that they had been fed upon kitchen
garbage.  Compare also Bockendahl, 1. c.
   We shall not, of  course, deny that hogs occasionally become
infected by eating trichinous rats ;  yet this is but a slight devia-
tion from the general rule,  and it is not at all probable that the
modes mentioned cover all  the possible methods of infection.
   The innocuousness of  fly larvae, in connection with the extension of trichinae,
is positively determined by the frequently repeated  observation, that  the trichinae
are perfectly digested in their intestinal canal.1

                          Prophylaxis.

    In view of the present hopeless state of  our treatment, pro-
phylaxis becomes of all the greater  importance.   Its object is
a double  one ;  the  first  is, to protect  man  himself from the
trichina-disease, and the second, to guard the  hog, whose flesh
cannot be excluded  from  our  food, from  the acquisition of tri-
chinae.
    In order to accomplish  the former object, first of all the sale
of trichinous meats  must  be prevented.  This can be  attained
only by an  obligatory microscopic inspection of  meat, such  as
has been demanded  ever since the  discovery of the trichina-dis-
ease,2 and,  guided by this,  it is to be hoped that no one will ever
again witness such  terrible  sacrifice  of  life as was once caused
by this malady.  The objections to this are, of course,  numerous,
and the difficulties encountered in  its general execution extraor-
dinarily great;  these, however, should not prevent it from  being
carried  out,  for the experience of  several cities has  shown that
these difficulties are by  no means insurmountable.
    In the first place, droves of trichinous hogs are  to be carefully
watched.
   A voluntary microscopic inspection of meats is  only a half-way measure, wdiich
usually lulls the population into  a false sense  of security, and, as a rule, is soon
neglected altogether.
  1  Probstmayr, Virch. Archiv, 30, p. 265, 1864.
  2  Virchow, Trichinen, 3 Aufl., p. 70.—Zenker, Deutsches Archiv f. klin. Med., VIIL
p. 3^2.-Gerlach, 1. c, p. 75. 
TRICHIXjE.
655
   The microscopic examination has been practised in the duchy of  Brunswick
since 1863, and has produced excellent results.1
   It has acted similarly in other localities.

    The microscopic  investigation  should be  made before the
meat of the animal is manufactured into the various  prepara-
tions, and sold.  It is  always best to choose certain  portions of
each animal, such as the muscles of the larynx and  diaphragm.
Butchers and meat inspectors should be required to keep a care-
ful record of the hogs ;  the former  should  especially  note the
source of each hog, in order, by means of  those found to be tri-
chinous, to point out the stables,  and thus destroy other droves
coming  from  them.   The  microscopic  inspection  should be
undertaken only by persons particularly skilled in
the use of the instrument, especially by physicians,
veterinary surgeons, apothecaries,  or other  persons
peculiarly fitted  in this respect.
    The proper method of making a  microscopic in-
spection of meats must be learned ; but it is not too
difficult for those who  are not  altogether  inapt.
Small  portions, following the direction of the fibres
of the muscle to be examined, should be removed
with  fine  scissors, and  placed upon a glass slide,
with a  little  water; the fibres may  be easily sepa-
rated.  A thin glass,  smaller than the slide, is used
as  a cover, and lig atly pressed down upon the pre-
paration, which can then be seen with a low magni-    a Minscherian
                                                     sac, from a pig.
lying  power, while  any  suspicious  points  can  be  ^atelynias-
examined more carefully with a stronger lens.  The
addition of a solution of soda or of  caustic potash  renders the
muscle more translucent.
    There are  different  sources  of error  to be guarded against,
chief among which  are the Miescherian  (or Rainey an or psoros-
permian) sacs.  These  were first  found in 1843 byMiescher9 in
mice, in 1847 by Rainey3 in hogs, and afterwards in numerous
other animals (horses, sheep,  cows,  rats,  etc.).  They  are sau-
     1 Uhde, Virch. Archiv, 35-58.
     a Verhandlungen der naturforsch.  Gesellschaft zu Basel, 1843,  p. 143.
     3 Philosoph. Transact., 1857, p. 114.
 
 656    HELLER.—DISEASES  FROM MIGRATORY PARASITES.

 sage-shaped  bodies,  of  various  lengths, which  lie  within  the
 primitive bundles of muscular tissue, but do not fill them com-
 pletely.   They seem to be furnished superficially with irregular
 transverse lines, and with  a  delicate  homogeneous  border.   I
 have  examined fresh preparations, and those hardened by alco-
 hol and  chromic acid, but I have been as unsuccessful  in seeing
 any glittering investment as have Virchow and others.
   The statements made with reference to this point depend upon a delusion, and
 its source appears to be in that portion of  muscular substance yet remaining in the
 sarcolemma sheath around the  Miescherian sac.  This almost  constantly presents
 a more finely striated appearance than do other parts of the same fibre; for example,
 within five divisions of the eye-piece micrometer I counted, at three different por-
 tions of this remaining muscular fibre, 12, 13, and  12 transverse  lines, and in other
 portions of the same fibre  of corresponding size,  8, 9, and 9.   At the end of the sac
 the transverse striae of the muscular substance seem very indistinct and irregular.

    On being  cut or torn, these  sacs  discharge numerous  little,
 crescentic, boat-shaped, or kidney-shaped bodies—the  so-called
 pseudo-naviculae—wliich are capable of changes of form.   Their
 nature,  origin, and  development  are still completely vailed in
 darkness.  Wo morbid derangements caused by  eating meat con-
 taining these sacs have yet been observed.  It is only in the hog
 that their presence in large numbers may occasion such troubles.
   In a rabbit, which had been fed with highly trichinous meat, Zenker l saw, in
 addition to numerous living trichinae in the muscles, a number  of trichinae evidently
 dead and decayed, yet still retaining their form, and distinctly recognizable.  They
 had a granular appearance, which was caused  by their  being crowded with such
 corpuscles, like the Miescherian sacs.  Zenker propounds the question, whether these
 sacs should not be considered as dead animal parasites, in whose investment the
thickly crowded (probably vegetable) parasites develop.  Kiihn2 has made similar
 observations.

   The peculiar concretions described by Virchow,3 as the "gua-
nine-gout" of  swine, form another  source  of  possible  error.
They consist of needle-like crystals  closely heaped together ;  on
the addition of hydrochloric  acid they dissolve,  and leave  the
muscular substance with  its fibres seemingly unchanged.
       1 Verhandlungen der phys. -med. Societat zu Erlangen, 1865-67, p. 20.
       5 Kiihn, 1.. c., p. 68.
       3 Virch. Archiv, 35, p. 358; 36, p. 147 ; 43, p. 548. 
TRICHINAE.
657
   In one hog innumerable white chalky granules were found deposited by the side
of, and  in and  around, the  knee-joint.   Without entering upon a chemical dis-
tinction, these changes  bear a decided resemblance to those of human gout.  The
reactions are very similar to  those of guanine; when treated with  fuming nitric
acid, the latter  is colored intensely red, and on evaporation a yellow residue is
formed,  which, on the addition of caustic  soda, becomes red, and on heating, pur-
plish red.  Kuhn found  several  properties,  such  as partial  solubility  in strong
ammonia, which seem to indicate hypoxanthine.

    Other  concretions sometimes met  with  consist  of carbonate
and phosphate of  lime, with an admixture of  oleine and  stearine
(Gerlach,  1. c),  or  of stearine and margarine (Leuckart) ; still
other concretions have proved to be dead calcified trichinae, with
hyperplasia of the connective tissue in the neighborhood.'

   A round worm, named by Diesing Stephanurus dentatus,  but which  has lately
been described  by Verrill and Fletcher!  as Sklerostoma pinguicola, frequently  ap-
pears in American hogs; it is most generally found capsulated in the neighborhood
of the pelvis of  the kidney, or even in the latter itself, but also occurs in the fatty
tissue, and in other  places.  The animals affected are often lame in the hips.  The
worm occurs frequently in Australia also.  It will scarcely ever be the occasion of
mistakes.

    In regard to the  authority for the  adoption  of  an obligatory
meat inspection, legal decisions have been variously interpreted ;3
yet the authority is  perhaps scarcely doubtful.   An  indirect
proof of it is, the  judicial condemnation of butchers for  careless
killing in the sale of trichinous meat."

   A remarkable decision has been made  by  a court in Bremen ; it  is, that, under
No. 7, section 367, of  the penal  code, only  the  retailing of  trichinous  meat, not,
however, the wholesale  dealing in it, is illegal;  and that therefore the former and
not the latter is punishable.  A definitive legal solution of  this question  is a press-
ing necessity.

    The efficiency  of  the  obligatory  microscopic  inspection  is
more   controverted than  the legal  authority for it.   Of  course,
there can  be  no doubt  that single trichinous hogs may escape the

   1  WMerholt, Virchow's Archiv, 23, p 549, and Muller, Ibid., 37. p. 253.
   s Silliman's American Journal, 1871, I., pp. 223 and 433.
   3 Compare Jacobi, Vierteljahrschrift f. gerichtlich. Med., N. F., 20, p. 103, 1874.  and
G. Merkd, Aerztl. Intell. -Blatt f. Bayern, 1866, No.  12, p. 161, and Rem, 1. c.
   4 Otto, Memorabilien, 1869, No. 10 (Jahresbericht, 1S79, I.,  p. 448).
            VOL. III.—42 
658     HELLER.—DISEASES FROM  MIGRATORY PARASITES.

notice  of  the  most scrupulous  inspector, if   the number of
parasites be very small.   Such meat will, however, never pro-
duce very severe  illness, since the number of trichinae taken by
one  person must be exceedingly limited.   Culpable negligence '
may also occasion such an occurrence, but this should not be
placed to the charge of the regulation itself.
   The assertion that the distribution of the trichinae throughout the hog is alto-
gether irregular, is entirely incorrect; on the contrary, it is so constant that we can
positively declare that, if no trichinae be found in the muscles above recommended
for examination, none will be discovered in  other parts of the hog, or, if any, they
will occur only in very exceptional cases.
   The case at Calbe '2 only serves as a caution against improper inspections.

   A microscopic inspection of American  bacon is an indipensa-
ble measure.
   Of about equal importance with the microscopic inspection of
the meat,  are the  precautions  by  which  to guard individuals
from the acquisition of  trichinae.  In the  first  place, the use of
raw or  partially raw pork  is most decidedly to  be condemned;
only well boiled  or roasted meat  should be eaten.   Experience,
as well  as extensive investigation, has taught  us that  trichinae
will tolerate a high degree  of heat without losing their  capabil-
ity of development, as very frequently, by the common modes
of preparation, large pieces of uncooked meat  may be obtained
from the interior of the mass.  According to Fiedler s investiga-
tions, trichinae are  surely killed by a temperature  of  from  142°
to 155°  F. (perhaps at  even a lower temperature ; according to
Gerlach at 133°  F.).  Such a temperature, however, is obtained
in the  interior—especially in  the  neighborhood  of bones—only
after long roasting or boiling.   It will  suffice, as a general rule,
when the  inside  of the meat  is  no longer red or rosy, much
less  bloody, but gray or grayish-white.   Sausages and cutlets,
which become dry and tasteless on long cooking, are particularly
dangerous,  and   their   use should  either  be  entirely  desisted
from, or only carefully examined meat should be used  in making
them.
   Salting and smoking, unless  done very thoroughly, afford no
1 Compare Jacobi, 1. c.
3 Simon, Virch. Archiv, 34, p. 623. 
TRICHINAE.
659
 protection against infection; only a long continuance of these
 processes, which depend  essentially on the  exclusion of water,
 kills the trichinae.  The common  smoking alone,  such as is cus-
 tomary in preparing the  various kinds  of sausages,  like  the
 " quick curing," guarantees no protection whatever.   According
 to Haubner,  the curing  by heat is the only mode which secures
 from infection.

   Those who may have  any interest  in reading the numerous experiments can
 find  them recorded in the works of  Rupprecht, Haubner, Gerlach, Fiedler, and
 others.
   Tasting raw meat, as practised by butchers and cooks, has already made numer-
 ous victims; such bits of meat  should never be swallowed.

    The second object, that of guarding the hog from  the acqui-
 sition  of  trichinae,  must be attained by  stopping all possible
 sources from which it may receive them.
    First, it is the duty of  the sanitary police authorities to close
 those abundant sources in the  flaying yards.  For this purpose,
 there  must be clear and unequivocal legal authority, which  will
 positively prohibit the flayers from holding, feeding, and slaugh-
 tering hogs, either for their own  use or for sale.  The enforce-
 ment of this  rule will entirely control it.
   Hogs found trichinous should be boiled under  police super-
 vision, and the refuse, in which  a few trichinae may still be found,
 should be buried in such a  manner  that animals—rats in parti-
 cular—can never reach it.
   Such measures should be carried out very carefully, on account of the great
 power which trichinae possess of withstanding putrefaction ; they still live in per-
 fectly fluid putrefying flesh, and remain capable of development as long as a hun-
 dred  days.1

   Then, too, swine must  be kept at a distance from  all places
where there  might be an  opportunity of  eating  excrement or
garbage of any  kind; in  general,  they should be kept cleaner
than has been the custom hitherto.
   The infection of hogs by feeding the waste matter in slaugh-
tering to the remaining swine, can only be  averted by the judg-
' Wiener Comite-Bericht, Oesterr. med. Jahrb., VIIL, p. 74, 1867. 
660     HELLER.—DISEASES  FROM MIGRATORY PARASITES.

ment and conscientious sense of the farmer.  In order  to  attain
this end,  instructions should be furnished both in agricultural
journals  and in  schools; Zenker's  concise axiom must be made
part of the farmer's flesh and blood :  " When slaughtering hogs,
nothing,  not  even  the  least of  the  cuttings, and none  of the
kitchen garbage at the time, or for some time after the slaughter,
should be thrown into  the hogs' feeding-trough.  Therefore, on
these  occasions,  even dish-water  should  be kept  away from
them."
   It is scarcely necessary to mention that rats  should be kept
away from piggeries,  in  order to close such  accessary  sources ;
their extirpation is particularly indicated in places in which tri-
chinous swine  are already  present, and where  whole droves of
hogs have become infected.
   All these measures are rendered the  more important by the
fact that, according to the uniform results of numerous experi-
ments, the  recognition of the trichina disease in hogs is gener-
ally impossible, or possible only in the severest cases.

  Note.—During the correction of this article I have received, through the kindness
of Prof. Jiirgensen, "Miller, Dissert, inaug., Tubingen, 1874," in which  the  case of
echinococcus multilocularis mentioned on page 566 is reported. The patient was a
woman, forty years of age. The duration was one year.  It began with jaundice during
the puerperal period.   There was  an enormous  hepatic  tumor,  with  fluctuation.
Simon's operation was performed.  Death occurred ten days afterwards.  A cyst, of the
size of a child's head, was found in the ulcerating echin. multiloc. in the right lobe of
the liver.  In the  fluid, urea, chloride of sodium, chloride of potassium, 0.2 per cent.
of albumen, etc., were found. 
INDEX.
Abildgaabd, 318.
Abortion in trichinosis, 637.
Actuarius, 473.
Adam, 441, 448, 450, 467.
Adams, W., 164.
Aetius, 473.
Age in echinococcus, 567;  in  cysticercus cellulosae,
    601; influence of, in syphilis, 72; influence of, in
    prognosis of syphilis, 203.
Alibert, 129,  619.
Allbutt, C, 218.
Almenar, J., 39.
Alpin, 449.
Ambrosoli, 234.
Anatomy,  minute, of the primary affection of syphilis,
    109.
Andreas of Carystos, 433.
Andrew, 1S7.
Anglerius, 9.
Anstie, 576.
Anthrax of animals, 372 ;  in man, 404.
Aphthae epizootics,  see Foot-and-Mouth Disease.
Apsyrtus, 317.
Aquilanus, 12.
Arendt, 508.
Aristophanes, 596.
Aristotle, 433, 472, 595.
Armand, 19.
Armstrong, 5-17.
Astruc, 8,  17, 120, 248.
Audouin, 374.
Aurelianus, Ceelius, 434, 419, 472.
Auspitz, 41, 60, 65, 101, 110.
Avicenna,  434, 473.

Babington,  G., 85.
Bacteria in anthrax of animals, 377, 285: in glanders
    in horses, 330.
Bagge, 321, 328, 348.
Balfour, 16.
von Bamberger, 253.
Bardeleben, 422.
Barensprung, 27, 44, 50, 56. 57, 76, 89, 118, 182,  237,
    244, 279,  290.
Bargione, 171.
Barker, 573.
Barnes. 252.
Baron, 319.
Barrier, 571.
Bartels, 507, 571, 582.
Barthelemy, 318.
de Bary, 377, 385.
Bassereau, 8, 9, 17, 87, 123, 251. 279.
Basset. 88.
Bassi, 319.
Bastian,  496.
Baumler on syphilis, 3.
Bayle, 405.
Beer, A., 184, 227.
Bees, sting of, 533.
Bell, Benjamin, 16, 229.
Bender, 515.
van Beneden, 557, 595.
Bergmann, E.,  422.
Berkhan, 614.
Berndt, 479.
de Berry, Gerard, 13.
Bertin, 374.
Bidenkap, 92, 95,  97, 245, 251.
Biesiadecki, 110, 117, 134. 141, 246.
Biett, 293 ; on classification of syphilitic affections of
    the skin and mucous membranes, 133
Bilharz, 506.
Billroth, 327.
Bircher,  517, 527.
Birch-Hirschfeld. 568.
Blaine, 441, 456, 508.
de Blegny, 288.
Blood,  changes in, in anthrax  of animals,  399; in
    anthrax in  man, 419, 422 : in glanders in horses,
    342; in hydrophobia in man, 498 ;  in trichinosis,
    636.
Blood-vessels, larger, affections of, in syphilis, 217.
Bochdalek, 185.
Bockendahl, 653.
Bocker, 568.
Bodecker, 558.
Boeck, 18, 53, 92,  97, 308.
Bohler, 646.
Bollinger on infection by  animal poisons,  313; on
    anthrax of animals,  372;  on anthrax in man,
    404; on glanders in horses,  317;  on glanders in
    man, 348 :  on the foot-and-mouth disease in ani-
    mals, 513 :  on the foot-and-mouth disease in man, 
662
INDEX.
     521; on hydrophobia in animals, 431 ;  on hydro-
     phobia in man, 472; on infection by the bite or
     sting of poisonous animals, 532; on stings of in-
     sects, 532;  on snake-bites, 539.
 Bones, affections  of,  in glanders  in  man,  362;  in
     syphilis, 166.
 Bonhomme, 601.
 Borgarutius, 185.
 Borstieber, 407, 428.
 Bosquillon, 443.
 Botallus, L., 175.
 BOttcher, 666.
 Bouchard, 233.
 Bouchut, 577.
 Boudin, 441, 449, 481.
 Bouley, 319, 325, 377,  386, 470, 482,  592.
 Boullet, 542, 545.
 Bourgelat, 318,  437.
 Bourgeois,  406, 413, 414.
 Bourgoigne, F., 59.
 Bourrel, 448.
 Bowditch, 616, 630.
 de Brackenau, 6.
 Bradley, S. Messenger, 41, 228.
 Brain, cysticercus cellulosae of,  607; echinococcus of,
     579;  in anthrax in man, 420, 423 ; in hydrophobia
     in animals,  462, 465;  in hydrophobia in man, 495;
     in snake-bite, 550.
 Brandis, 284.
 Brassavolus, 8, 17, 101.
 Brauell, 375, 380.
 Brefeld, 506.
 Breschet, 441, 446, 479.
 Briancon, 562.
 Briscoe, 528.
 Bristowe, 615.
 Broca, 407.
 Bronchial tubes, affections of, in syphilis, 210
 Brosche, 521.
 Bruce, A., 165.
 Bruckmiiller, 319, 467.
 Brugnone, 374.
 Brunton, 547.
 Brunzlow, 348.
 Buck, Albert H., 630.
 Budd, 185, 427.
 Buhl, 111, 381, 401, 406, 418, 422.
 Buisson, 508, 509.
 Bumstead, 106, 273.
 Burger, A., 166.
 Bursae, affections of, in syphilis, 175.
 Busnot, 479.

 Oagiola, 61.
 Caillenx, 568.
Callinac, 440.
 Calmeil, 599.
 Cambieri,  18.
 Campbell, 54.
 Cantu, 9.
 Capivaccius, Hieronymus, 15, S5.
 Carbunculus contagiosus, see Anthrax in Man.
 Carganico, 374, 415.
 Carmichael, 33, 263.
 Castlenau, 333.
 Cataneus,  12, 57, 288.
 Cauvet, 383.
 de Cazelles, Marsars, 499.
 Cazenave, 14, 27, 30, 126, 149. 260, 272, 293.
 Celsus, 13, 433, 472, 507, 509.
 Centipedes, bite of, 538.
 Chabert, 318, 374, 404,  435, 482.
 de Chaignebrun, 374.
 Charbon, see Anthrax.
 Chaussier, 374.
 Chauveau, 40, 324, 331, 344.
 Children born alive, syphilis in,  238.
 Christian, 480.
 Christot, 330, 332.
 Clapton, 204.
 Clerc, 87, 91, 116, 123.
 Cobbold, 566, 579, 616,  620.
 Cohn, F., 377, 388, 389, 392.
 Cohnheim, 34, 624, 645, 647.
 Colberg, 223, 556.
 Coleman, 324.
 Colin, 384.
 Colles, 69.
 Colon, 332.
 Cornil, 227.
 Coulson, 178.
 Cruveilhier, 567, 029.
 Cullerier, 52, 76,  204, 308.
 Cumanus, Marcellus,  6, 160.
 Cutts, 566.
 Cysticercus cellulosae, 595.

 Dalange, 535, 539.
 Dammann, 524.
 Danielssen, 13, 18, 100:
 Davaine,  376,  383, 386, 393, 409.  421, 425, 566, 508
    573, 575, 581, 589.
Davy la Chevrie, 405.
Decroix, 331, 332, 350, 478.
Delafond, 374, 376, 503.
Delarbeyrette, 332.
Delicado, 7, 9, 278.
Delore, 601.
Delpech, 245.
Democritus, 433.
Depaul, 55, 214.
Desnos, 620. 
IND1
Despres, A., 275.
Diagnosis of anthrax of animals, 402;  of anthrax in
    man, 424;  of cysticercus cellulosae, 604, 612; of
    the echinococcus disease, 572,  580, 585, 587,  588,
    594; of foot-and-mouth  disease in  animals, 520;
    of foot-and-mouth disease in man, 530; of glan-
    ders in horses, 346; of glanders in man, 366; of
    hydrophobia  in  animals, 467; of hydrophobia in
    man, 498 ; of syphilis, 254 ; of trichinosis, 639; of
    viper bites, 545.
Diday, 50, 55, 57, 70, 72, 204.
Diesing, 057.
Diseases  of Animals, 313; bibliography, 313 ;
    general considerations, 313.
Glanders in Horses, 316 ; bibliography,  316 ; his-
    tory, 317;  etiology,   320 ;  mode  of infection,
    321 ; question of spontaneous development, 325 :
    nature  of the poison, 330 ; communicability to
    other animals, 332 ; distribution and frequency of
    the disease, 332 ; pathological anatomy, 333 ; the
    tubercular  form, 334; inflammatory form, 337 ;
    lesions  in the  nasal  vessels, 339; infiltration of
    the  lungs,  340 ; of  the skin  and subcutaneous
    cellular tissue and muscles, 340 ; complications,
    341 ; the mucous membranes,  341  ; different or-
    gans,  342 ; symptomatology, course, duration,
    and termination, 343 ; diagnosis, 346 ; prognosis,
    347 ; treatment, 347.
Glanders in Man, 348; history, 34s ;  etiology, 849:
    modes of infection,  349;  communication from
    man to man, 351 ; susceptibility to the disease,
    351 ;  symptomatology,  352 ;  incubation,  353 ;
    acute glanders, 354 ; initiatory symptoms, 354 ;
    cutaneous  affections,  355 ;  the mucous  mem-
    branes,  356 ; glandular  affections,  357 ; gastro-
    intestinal catarrh, 357 ; respiratory changes, 357;
    pulse and temperature, 357 ; nervous symptoms,
    357; albuminuria  and abortion,   358;  chronic
    glanders, 358 ; general symptoms, 358 ; cutaneous
    affections, 359 ;  affections of the nose, 359 ; the
    respiratory organs, 359 ;  the fever, 360 ; different
    modes of termination of  the  disease, 360 ; patho-
    logical anatomy, 361 ; cutaneous  changes, 361;
    the  bones  of the skull  and face,  362; mucous
    membranes, 362 ; the lungs, 362 ;  the muscles,
    363 ; cartilages and bones, 363 ;  the serous mem-
    branes, 364 ;  the spleen, 364 ; the liver. 364 ;  ner-
    vous system,  364 ; genital  organs,  364 ;  the  kid-
    neys, 364 ; the eye, 364 ; lymphatic glands, 364 ;
    resemblance  of  the  disease  to pyasmia,  365;
    diagnosis, 366 ;  occupation of  the  patient, 366;
    differential   diagnosis,   366 ;  prognosis,   367;
    treatment,   369;  prophylaxis,  369;  local  and
    general treatment, 370.
Anthrax or Animals, 372; bibliography, 372;  his-
    tory, 373; etiology, 378;  influence  of soil, 378;
ex.                                         663

    modes of infection, 382; individual susceptibility,
    385; nature of the poison, 385; peculiarities of
    the anthrax bacteria, 389; their behavior in the
    living  body,  392; modes  of  entrance into the
    body, 393; tenacity of the poison, 393; appear-
    ance and spread  of the disease, 394;  symptoma-
    tology, 395; different forms of the disease, 396;
    period of  incubation,  397; the  apoplectiform
    cases,  397;  acute anthrax, 397;  mortality, 398;
    pathological  anatomy,  399; differences  in the
    changes  in the horse and  in cattle, 400; minute
    anatomy of the carbuncles, 400 ; prognosis, 401;
    diagnosis, 402; prophylaxis, 402; treatment, 404,
 Anthrax  in Man,  404;  (malignant pustule),  his-
    tory, 404 ; etiology, 405; direct inoculation of the
    poison, 407 ; eating the flesh of diseased animals,
    408; transmission of  the  poison  to man  by in-
    sects, 419; inoculation from man to man, 409;
    internal  infection, 409;  sites of external  infec-
    tion, 410 ; predisposition of man to the disease,
    410;  influence of the  seasons, 411;   symptoms
    and course of the disease, 411; incubation, 412;
    symptoms of the anthrax carbuncle, 412; of the
    malignant anthrax oedema, 414 ; symptoms fol-
    lowing internal infection.  415; pathological an-
    atomy, 418;  the  skin, 418; the blood, 419; the
    mucous membranes, 419 ; lymphatic glands, 419;
    the lungs,  419;  the heart, 419; the abdominal
    cavity, 419;  stomach  and intestines, 420;  the
    spleen, 420; the  kidneys,  420; the brain,  420;
    the presence of  internal  without external car-
    buncles,  421 ;  the results  of microscopic  exam-
    inations, 421 ; diagnosis,  424;  differential diag-
    nosis, 425; prognosis, 426;  treatment, 427 ;  pro-
    phylaxis, 427; treatment of the external  forms,
    428; general treatment, 429.
 Hydrophobia in Animals, 431; bibliography,  431;
    history, 433;  general  definition, 435;  etiology,
    436;  the theory of spontaneous  origin,  436;
    changed  nervous  influences as causes, 437; in-
    fluence of sex, 437; congenital hydrophobia, 440;
    intermediate vehicles of  the poison,  440 ;   indi-
    vidual predisposition, 441;  inoculation, 441; de-
    nial of the existence  of the disease, 443; nature
    and mode of action of the poison, 444; action of
    the poison within the animal economy, 447 ; the
    disease in animals besides  the  dog,  448;  geo-
    graphical distribution, 448; influence of season,
    450 ; symptomatology, 451; incubation, 451; the
    violent form of the disease in dogs, 452 ; the pro-
    dromic or melancholic  stage, 452: the violent or
    maniacal stage, 454 ;  the paralytic stage, 457; the
    sullen form in dogs, 458: the disease in other do-
    mestic and  in wild  animals,  459; pathological
    anatomy, 461; the brain, 462; the mouth, 4(53;
    the throat, 463 ; the lungs,  463 ; pericardium and 
664
INDEX.
    heart,  464;  the  liver,  464; the  spleen, 464; the
    kidneys and bladder, 464; the genitals, 465 ; the
    stomach and intestines, 465;'  diagnosis, 467 ;  dif-
    ferential diagnosis, 463; the value of inoculation,
    470 ; general conclusions, 470;  prognosis, 471;
    treatment, 471.
Hydrophobia in  Man,  472;  history, 472; etiology,
    473; individual  predisposition.  476;  influence
    of  sex, 477;  influence  of  seasons,  478;  con-
    sumption  of  the  meat  of  diseased  animals,
    478; communication from man to man, 478:  dif-
    ferent views concerning the nature and mode of
    origin of the disease, 479; frequency of hydropho-
    bia in  man, 481; incubation, 482; symptomatol-
    ogy. 483 ; the premonitory stage, 483 ;  the stage of
    excitement, 485; analysis of symptoms of stage of
    excitement,  4S8;  the  stage  of  paralysis, 492;
    duration of  the disease, 493; pathological ana-
    tomy, 495 ; the site of the wound, 495 ; the brain
    and its membranes, 495;  the mucous membranes,
    496; the stomach,  497;  the  spleen, 497;  the
    liver, 497; the heart.  497 ; the  blood,  498 ;  the
    lungs, 498; the kidneys, 498; lymphatic glands,
    498 ; diagnosis, 498 ; differential diagnosis, 499;
    prognosis, 501;  prophylaxis, 502;  in animals,
    503; in man, 505; treatment, 505; prophylactic
    treatment, 505 ; therapeutical treatment, 509.
The Foot-and-Mouth  Disease in Animals, 513;
    bibliography, 513;  nature of  the  poison, 514;
    etiology, 514; incubation, 515;  symptomatology,
    515 ; affections of  the  mucous membranes, 515 ;
    affections of the teats, 516 ;  the temperature, 516;
    affections of the hoofs, 517; alterations  in  the
    milk, 517; course,  duration, and termination of
    the disease, 518;  its mode of spreading, 518; pro-
    phylaxis, 518; pathological anatomy,  519;  the
    mucous membranes, 519;  the  hoofs, 519;  the
    liver, 520; the kidneys and spleen, 520 ; the res-
    piratory apparatus, 520 ; the heart, 5;0; diagno-
    sis, 520 : prognosis, 520 ; treatment,  520.
The Foot-and-Mouth Disease  in  Man, 521; etiol-
    ogy, 521; the use of milk from diseased animals,
    521 ; the use of meat of diseased animals, 523 ; di-
    rect  inoculntion of a wound,  523; predisposition
    to the  disease, 524; its frequency,  524;  symp-
    tomatology,  525;  incubation, 525 ; the vesicular
    eruptions, 526 ; course,  duration, and termination
    of the  disease, 529; diagnosis,  530 ,•  prognosis,
    530 ; prophylaxis,  530 ,■  treatment, 531.
Dioscorides, 434, 472, 474.
Dittrich, 185, 214, 319,
Dixon, 225.
Dokahl, 407.
Donne, 517.
Duffin, 177.
Dupuy, 319, 332.
Dupuytren, 411, 599.
Dubois, 500.
Dubois, V., 185.

Ear, affections of, in syphilis, 225, 239; in trichinosis,
    635.
Earle, 448.
Eberth, 185.
Ebstein, 033.
Echinococcus, 556.
Eck, 348.
Ehrenberg, 377, 389.
Eichborn, 495.
Binike, 393.
Elliotson, 349.
Emmert, 568.
Enaux, 374.
Engel, 319.
Epicharmus, 433.
Ercolani, 319, 382.
Erdt, 319, 326.
Essroger, 474.
Estlander, 221.
Etiology of  anthrax of animals, 378; of  anthrax in
    man, 405, of the echinococcus, 578; of the foot-
    and-mouth disease in  animals, 514; of the foot-
    and-mouth disease in man, 521;  of  glanders in
    horses, 320 ; of glanders in man,  349; of hydro
    phobia in animals, 436 ; of hydrophobia in man,
    473 ; of syphilis, 39 ; of trichinosis, 648.
Eudemus, 433.
Eulenberg, 63, 507.
Eye, affection of, in glanders in man, 364 ; in syphilis,
    221, 239; in trichinosis, 635; local treatment of,
    in syphilitic diseases, 303.
Fabricius, O., 596.
Faber, 469, 479, 508.
Fagge, Hilton, 187,  575.
Falke, 319.
Fallopia, 8, 35, 130, 175.
Fangel,  528.
Farre, A., 615.
Fauvel,  449.
Faye, 308.
Fayrer,  547,  550.
Fehr, 619.
Ferber,  603,  611.
Fereol, 422, 566.
Ferguson. 72, 2V.t.
Fernelius, 4, 57.
Ferro, Alfonso, 8.
Fessler, 440.
Fiedler, 576, 626, 629, 631, 643,  650, 658.
Fleming, 449.
Fletcher, 657.
Foetus, affections of, in syphilis, 23T. 
INDEX.
666
Fontana, 542, 545, 546.
Foot-and-mouth disease in animals, 518 ; in man. 521.
Forel, 395.
Forget, 599.
Forster, 575.
Forster, A., 333.
Forster, Cooper, 114.
Forster, R,, 1C6, 204, 213, 293.
Fournier, 59, 77, 78, 83, 91, 113, 117, 121,126, 131,162,
    116, 182, 220, 282, 374, 404, 406.
France, 221.
Franck, 330, 401, 465.
Frank, 620.
Frankel, E., 53, 236.
Franque, 443, 450.
von Frantzius, 537.
Frascatorins,  4, 17.
Frerichs, 466, 590.
Fricke, 279.
Friedberg, 10.
Friedreich, 561, 565, 635, 642.
Fuchs, 482, 507, 524, 530.
Furstenberg, 624.

(iAI)DESDEN, J., 13.
Gail lard, 629.
Gains, 4'i3.
Galen, 434.
Galezowskl, 224.
Galligo, 76.
(! alius, Antonius, 60.
Gamberini, 66.
Gamgee, 327.
Garsault, 318.
Gaskoin, 8.
Gaspard, 510.
Gaspardin, 374.
Gaupp, 528.
Gayet, 409, 422.
Genital organs, affections of, in syphilis, 229.
Gerhardt, 210.
Gerlach, 320, 322, 324, 325, 328, &31, 332,  370, 374, 3S3,
    397, 619, 654, 657,658.
Gibert, 44, 46, 76.
Gilinus, Conradinus, 6.
Girard, 443.
Girtanner, 8.
Glanders in horses, 316; in man, 34S.
Glands,  lymphatic,  in  anthrax in man, 419;  in glan-
    ders in horses, 344 ; in glanders in man, 357, 364;
    in hydrophobia in man, 498; in secondary syphilis,
    180; enlargement of, in region of primary affec-
    tion  of syphilis, 117:  salivary  affections of,  in
    syphilis, 205.
Glanstrtfm, 374.
Glaser, 374
Goheir, 318, 446, 478.
Goodridge, 193.
Gordon, 629.
Gordonius, 13,
Gosselin, 205.
Goubaux, 328.
Goze, 557, 595.
Graefe, 223, 224, 241, 600, 606.
Grassi, 33.
Greese, 409, 425.
Greve, 438, 446, 448, 456, 469.
Griesinger, 564, 612.
Grossheim, 348.
Groth, 027, 630.
Griinbeck. J., 175.
Gubler, 186, 192.
Gueniot, 171.
Gueiin, A., 205.
Guipon, 400. 414.
Guisan, 508.
Giinther, 327.
Giintz.  J. E.,  13, 125. 306.
Guyenot, 44, 76.
Gnyon, 449, 535.
Guyot,  535.

Hackel, 378.
Hahn, 333.
Hair, affections of, in syphilid, 161.
Halford, 546,  547, 551.
Hallier, 40, 42, 330, 377.
Hamann, 449.
Hamilton, 482.
Hammond, 50.
Hardy,  300.
Harms, 346.
Hartmann, 596.
Haubner, 346, 402, 595.  059.
Hauff, 356, 362, 368.
Hausbrand, 409.
Heart, changes  in the, in anthrax of animals, S99;
    in anthrax  in man, 419; in foot-and-mouth dis-
    ease in animals, 520 ;  in hydrophobia in animals,
    464: in hydrophobia in man, 497;  in snake-bite,
    550; in syphilis, 215 ;  in trichinosis, 645 ;  echino-
    coccus of, 586; cysticercus cellulosae of, 604.
Hebra, IS. 44, 76, 88, 118,  276, 291.
Hecker, 213.
Heckford, 575.
Heintz, 558.
Heinzel, 535, 53S, 542, 545.
Helbich, 409.
Heller on cysticercus cellulosae,  595; on the echino-
    coccus, 550 ; on trichinae, 613.
van Helmont, 317, 509.
Henle, 615. 
666
INDEX.
 Hennig, 233, 234. 237.
 Hensler, 8.
 Herberger. 517.
 Herbst, 615.
 Hering, 320, 324, 326, 328, 449, 525.
 Hermann, J., 275.
 Hernauld, 470.
 Hertwig, 323, 435,  441, 445, 454, 456, 477, 506, 508, 521,
     525.
 Heschl, 566.
 Heubner, 218.
 Heusinger, 373, 375, 395, 406, 408, 415, 418, 525.
 Hewett, Prescott, 228.
 Hildebrandt, 374, 524.
 Hill, Berkeley, 50,  93, 182, 246, 273,  294.
 Hilton, 614.
 von Hippel, 224.
 Hirsch, 18, 19, 20,  60.
 Hirschberg, 221.
 Hislop, 527.
 History of anthrax in animals, 373;  of cysticercus cel-
     lulosae, 595 ; of the echinococcus, 557 ; of glanders
     in horses, 317 ; of glanders in man, 348; of hydro-
     phobia in animals, 433; of hydrophobia in  man,
     473 ;  of syphilis, 5 ;  of trichinae, 614.
 Hjaltelin, 575, 579.
 Hjort, 308.
 Hofacker, 331.
 Hoffmann,  H., 377, 388, 409.
 Hoffmann,  J. F., 374.
 Hofmokl, 574.
 Holm, 528.
 Horace, 433.
 Horand, 472.
 Homer, 225.
 Hornets, sting of, 533.
 von Hiibbenet, 44.
 Huber, 230, 564,  589.
 Hiibner, 425.
 Hugenberger, 70.
 Humphry, 245, 273.
 Hunter, Charles, 276.
 Hunter, John, 16, 52, 68, 84, 245, 272, 435, 476.
 Hutchinson, Jonathan, 28, 32, 53, 55, 60, 63, 67, 70, 80,
    116, 174, 197, 208, 222, 224, 226,  239,  242, 258, 264,
    274, 277, 296.
 Hiiter, 245,  273.
 von Hutton, U., 175, 278.
 Huzard, 318.
 Hydrophobia in animals, 431.
 Hydrophobia in man, 472.
Hydro-therapeutics in syphilis, 305.

Incubation in anthrax of animals, 397; in anthrax in
    man, 412 ; in foot-and-mouth disease in animals,
    515; in foot-and-mouth disease  in man, 525; in
     glanders in horses, 343 ; in glanders in man, 353 ;
     in hydrophobia in animals, 451 ; in hydrophobia in
     man, 482;  in syphilis, 74, 124; in trichinosis, 638.
 Infection, mode of, in anthrax  of animals,  382;  in
     anthrax in man, 407;  in glanders in horses, 321;
     in glanders in man, 349;  in hydrophobia in ani-
     mals, 441; in syphilis, 57.
 Intestines, affections of, in anthrax  of  animals, 399;
     in anthrax in man, 420 ;. in hydrophobia in  ani-
     mals. 465 ; in syphilis, 203, 204.
 Iodide of potassium in syphilis, 295.
 Iodoform in treatment of syphilitic ulcers, 302.
 de Isla, Diaz, 7.

 Jackson, Hughlings, 220, 225, 241, 298.
 Jacob, 521.
 Jacobi, 649, 657.
 Jacobson, 558.
 Jaillard, 377.
 Jakowlewa, 222.
 Jauch, 629.
 Jessen, 32S.
 Joints, affections of, in syphilis,  175.
 Jonassen, 574.
 Jones, J., 549.
 Jones, Sydney, 60.
 Joukoffsky, 66.
 Jousset, 535.
 Kaposi, 93, 139, 140.
 Karus, 93.
 Kausch, 374, 405.
 Kessel, 409.
 Key, 629, 649.
 Kidneys,  affections of,  in anthrax in  man, 420;  in
     foot-and-mouth disease in animals,  520 ;  in glan-
     ders  in  horses, 342; in glanders in man, 364;  in
   .  hydrophobia in animals, 464, 466; in hydrophobia
     in man, 498; in trichinosis, 645.
 Kiener, 330, 332.
 Kircher, Athanasius, 40.
 Klebs, 498, 565.
 Klob, 599, 635.
 Klopsch, 627.
 Kluge, 52, 279.
 Kobner,  41,  53, 59, 66, 70, 92, 94, 96, 107,  171, 246.
    276.
 Kochlin, 439, 450, 467.
 KShne, 327.
Kolb, 407.
van  der Kolk, Schroder, 561.
Kopp,  619.
 Koranyi, 349, 367, 380, 406, 411, 425, 426.
Kratz, 631, 633, 634, 639, 644.
Kreutzer,  319, 525.
Kuchenmeister,  557, 561, 562, 595, 607, 612, 615.
Kiihn, 650, 056. 
INDEX.
667
 Kussmaul, 175, 250, 275
 Kiittner, 327, 349, 368.

 Lafosse, 318.
 Lagneau, G., 20.
 Laisne, 326.
 Lamirault, 320.
 Lancereaux, 42,  126,  178, 184,  1*3, 206, 216, 218, 227,
     234, 238, 251, 302, 422.
 Langenbeck, 273, 330, 619.
 Langlebert, 271.
 Laroyenr.e, 88.
 Larrey, 374, 449.
 Larynx, affections of, in syphilis, 208.
 Lassaigne, 291.
 Laubender, 374.
 Lavena, 517.
 Lawrence, 223.
 Lebert, 290.
 Lee, 327.
 Lee, Henry, 48, 51, 70,  72, 78, 91, 93, 114, 117, 121,
     288.
 Legros, Charles, 42.
 Lehmann, 185.
 Leidy, 615.
 Leisering, 319, 332, 333, 339, 449,  602, 651.
 Lengyel, 380,  426.
 Leonhardt, 379, 382.
 Leonicenns, 5, 12.
 Lepine, 233.
 Leplat, 377.
 Le Roy de Mericourt, 619.
 Lesser, 348.
 Lessona,  446, 448.
 Leube, 406, 409, 416,  418, 429.
 Leuckart, 557, 502, 569, 599, 603, 615, 617, 626, 629,
     644, 651, 057.
 Lcuret, 327.
 Lewis, 231.
 Lewin, G., 291.
 Lewis, 555.
 Liebig, 39.
 Ligaments, affections of,  in syphilis, 175.
 Lindemann, 45, 76.
 von Lindwurm, 44, 47, 76, 82, 273.
 von Linstow, 627.
 Littre, E., 13.
 Liver,  affections  of,  in  anthrax in man, 423;  in
    echinococcus disease, 589 ; in  foot>and-mouth dis-
    ease in animals, 520; in glanders  in  horses, 342;
    in  glanders in men, 364 ; in hydrophobia  in ani-
    mals, 464 ;  in hydrophobia in man, 497 ; in snake-
    bite, 550 ;  in syphilis, 185;  in trichinosis, 645.
Livingstone, David, 19.
Locher, J. H., 404.
L8ffler, 479.
 Loloff, 328.
 Lombard, 517.
 Lorain, 213.
 Lorin, 348.
 Lorinser, 415, 443, 479.
 Lostorfer, 34, 40, 141.
 Liicke, 558, 619, 627.
 Lungs, affections of,  in anthrax in man, 419;  in
     echinococcus disease, 582; in foot-and-mouth dis-
     ease  in animals, 520 ;  in glanders in horses, 340,
     342,  346;   in glanders in man, 362;  in hydro-
     phobia in animals, 463, 465; in hydrophobia in
     man, 498;  in snake-bite, 550 ;  in syphilis, 211;
     in trichinosis, 636, 645.
 Luschka, 615, 627.
 Lymphatic system, affections of,  in syphilis, 117, 180.
 Lyssa, see Hydrophobia.

 Magendie, 441, 479, 510.
 Magawly, 221.
 Maisonneuve, 202, 234.
 Maliasmus, see Glanders.
 Malignant Pustule, see Anthrax in Man.
 Malleus humidus,  see  Glanders.
 Malpighi, 596.
 Mamma,  affections of, in syphiliF, 233.
 Maratray. 91.
 Marochetti, 497.
 Marranen, 11.
 Marriage, propriety of, in syphilitic persons, 270.
 Marshall, J., 302.
 Marston, 50, 78, 197.
 Martinet, 577.
 Martini, 0., 302.
 Marx, 433.
 Maschka, 443.
 Mason, Erskine, 205.
 Massmann, 380.
 Matton, Donat., 440.
 Maurer, 631.
 Mamiac, C, 170, 251.
 Mayer, 510.
 Maynardus, Petrus, 85.
 McBride, J. A.,  524.
 Menecier,437, 442.
 Menschel, 427.
 Meppis, 11.
 Mercury in syphilis, 280.
 Merkel, G., 609, 051.
 Merkel, J., 253.
 Meschede, 203, 555.
 Meyer, 408.
Meyer, L., 480, 499.
de Meyes, 9.
Meynell, 435, 450.
Michaelis, 93. 
668                                         INDEX.
 Miescher, 655.
 Migratory Parasites, Diseases from, 555;
     introduction, 555.
 Echinococcus, 556 ; bibliography, 556; history, 557;
     natural history, 557;  general  pathology, 567:
     age and sex, 567;  location of the disease. 507 :
     its influence on the tissues involved, 569; devel-
     opment and growth, 570 ;  symptomatology, 571;
     diagnosis, 512;  prognosis,  574;  treatment, 574;
     etiology and prophylaxis, 578.
 Echinococcus of the brain,  579;  of the spinal cord,
     581; of the respiratory  organs,  582;  of the cir-
     culatory apparatus, 686; of  the spleen, 587 ; of
     the kidney, 587 ;  of the suprarenal capsule, 589 ;
     of the liver, 589.
 Cysticercus Cellulose,  595;  bibliography, 595;
     history, 595 ; natural history, 596 ; general path-
     ology, 601 ; age and sex, 601; location of the dis-
     ease, 601 ; its influence  on  the tissues involved,
     602;  symptomatology,  602;  diagnosis,  604;
    prognosis,  604;  treatment, 604; etiology, 605;
    prophylaxis, 606; cysticercus of the brain, 607.
 Trichina, 613;  bibliography,  614;  history, 614;
     natural history, 620.
 Trichinosis, 630; symptomatology, 630;  stages of
     the disease, 630 ; temperature, 631 ; the digestive
     system, 631; the muscular  system, 633 ; the ner-
     vous  system, 634;  the  skin, 634,  637; the eye
     and ear, 635; circulatory apparatus, 635 ; organs
     of respiration, 636;  urinary organs, 631;  sexual
     organs, 637; course, duration, and termination,
     638; diagnosis, 639; prognosis,  641;  treatment,
     642; pathological  anatomy,  644; the  mucous
     membranes, 644 ;  the spleen, liver, and  kidneys,
     645 ; the  heart,  645 ;  the  lungs, 646 ; the mus-
     cular system,  646;  etiology,  648;  prophylaxis,
     654.
 Milk, as a cause of the foot-and-mouth disease in man,
    521.
 Milk, changes in,  in  the foot-and-mouth  disease in
    animals, 517.
 Milzbrand, see Anthrax.
 Mireur, 577.
 Mitchell, S. W., 547.
 Montanus, 8.
 Montejo, 7, 8.
 Montfils, 374, 404, 407.
 Montesaurus, 12.
 Monti, 277, 304.
 Morgagni, 211, 218.
Morgan, J., 49, 90, 05.
Mosler, 220, 569, 605, 619, 643.
Moulinie, 580.
Mouth, affections of, in syphilis, 195 ;  local treatment
    of affections of, in syphilis,  300.
Moxon, 184, 187, 191, 213.
 Mucous membranes, affections of, in anthrax in man,
    419;  in foot-and-mouth disease in animals, 515,
    519;  in foot-and-mouth disease in man, 526;  in
    glanders in horses, 341 ; in glanders in man, S56,
    359, 302; in hydrophobia in man, 496 ;  in syphilis,
    129; in trichinosis, 644.
 Muller, 614, 627.
 Muller, G. W., 386.
 Muller, Julius, 291.
 Muller, W., 4C6, 416, 418, 422, 425.
 Munch, 417.
 Munn, 176.
 MuBoz, 9.
 Murchison, 576.
 Muscles, affections of,  in glanders in man, 363;  in
    syphilis, 179;  in trichinosis, 633, 646.

 Nageli, 377.
 Nails, affections of, in syphilis, 161
 Nasal cavities, affections of, in glanders in horses, 344;
    in  glanders in man,  356, 359; in syphilis, 207,
    239; local treatment of, in syphilis, 301.
 Naunyn, 558, 573.
 Nervous system, affections of, in glanders in man,
    364; in snake-bites,  544,  549;  in syphilis, 218,
    241; in trichinosis,  634.
 Neumann, 255.
 Neyding, 425.
 Nicolai, 379, 382, 406, 409, 426.
 Niddathal, 379.
 Nordstrom, 332.
 Nozeran, 527.
 Obermeier, 392.
 Occupation in diagnosis of glanders in  man, 366.
 Oedmanson, 178.
 Oemler, 379, 382.
 Oertl, 439, 450, 467.
 (Esophagus, affections of, in syphilis, 202.
 Oesterlen, 587.
 Oewre, A., 308.
 Ogle,  550.
 Oppolzer,  185, 475, 476,  477.
 Oribasius, 13.
 Oser,  203.
 Otto,  657.
 Ovary, affections of, in anthrax of animals, 40O.
 Overbeds, 175, 250.
 Ovid, 433.
 Oviedo, 8.
 Owen, 615.

 Pacchiotti, 61.
 Pagenstecher,  624, 627.
Paget, 296, 615.
Pallas, 557.
Pancreas,  affections of,  in syphilis. 205. 
INDEX.
66!)
Paracelsus, 52.
Parker, Langston, 51, 288.
Parrot, 171, 406.
Pasteur, 40, 387.
Pathology of anthrax of animals, 399 ; of anthrax in
    man, 418; of the echinococcus, 567 ; of glanders
    in horses, 333; of glanders in man, 361 ; of hydro-
     hobia in animals, 461;  of  hydrophobia in man,
    495 ;  of syphilis, 74 ;  of trichinosis, 644.
Paul, 577.
Paul of vEgina, 473.
Pausanias, 433.
Payne, J. F.,  189.
Peacock,  614.
Pean, 573, 587.
Pearson, 288.
Pellicier,  9.
Pellizzari, 47, 76.
Peritoneum, affections of, in syphilis, 206.
Perty, 525.
Petrow, 220.
Fetri, 630, 649.
Petry, 60.
von Pettenkof er,  315, 381.
Peuch, 441, 412.
Pfoiffer, 3S0.
Pharynx, affections of, in syphilis, 201.
Philippe, 319.
Phrisius,  5, 13.
Pick, 92.
Pillwax, 437, 442, 448, 479.
Pinctor, Petrus,  127, 275.
Placenta, affections of, in syphilis, 235.
du Plessis, C95.
Pleura, affections of, in trichinosis, 030.
Pliny, 433, 472.
Plutarch, 433,  472.
Poisonou-t  animals, sting or bite of, 532.
Stings of Insects, 532; bibliography, 532; infection
    by the sting of  insects, 533;  by the sting of bees,
    wasps and hornets, 533;  by the sting of scorpions,
    534;  by the  bite of  spiders, 536; by the bite of
    centipedes, 538 ; treatment of the above, 538.
Snake-bites,  539;  libliography,  539;  classification
    of the venomous snakes, 541; viper bites, 542;
    symptomatology, 543;  nervous symptoms, 544;
    mortality.  544;  sequelae,  544;  diagnosis,  545:
    treatment, 545; bites of other venomous snakes,
    547;  their general characteristics,  547;  symp-
    tomatology and patliology,  549;  treatment, 550.
Pollender, 375, 385.
Pollini, 299.
Porter, 50.
Posada-Arango, 536.
Precy, 529.
Preyer, oS9.
Prinz, 464.
Probstmayr, 054.
Prognosis of anthrax of animals, 401;  of  anthrax in
    man, 420;  of  cysticercus cellulosae, 004,  012 ;  of
    echinococcus disease, 574, 581,  585, 589,  594;  of
    foot-and-mouth  disease of animals, 520 ;  of  foot-
    and-mouth disease in man, 530;  in glanders  in
    horses, -347; in glanders in man, 367 ; in hydropho-
    bia in animals, 471; of hydrophobia in man, 501; of
    syphilis, 259;  of trichinosis, 641; in viper bites, 544.
Proksch, 275.
Prophylaxis of anthrax  of animals, 402; of anthrax
    in man, 427 ;  of cysticercus cellulospe, 6J6; of the
    echinococcus  disease, 578 ;  of footand-mouth dis-
    ease in animals, 518; of foot-and-mouth disease in
    man, 530; of glanders in man, 369; of hydropho-
    bia in animals, 503 ;  of hydrophobia in man,  505;
    of syphilis, 266; of trichinosis, 654.
Prumers, 292.
Puccinia in glanders in horses, 330.
Pulse in trichinosis, 631,
Purdon, H. S., 274.
Putz,  546.

Rabies, see Hydrophobia.
Radi, 437.
Raikem, 517.
Raimbert, 383, 409, 421, 424.
Rainey, 615,  655.
Ranvier, 171.
Rasch, A., 71.
Ravitsch, 319.
Rayer, 226, 349.
von Recklinghausen, 410, 418, 558.
Rectum, affections of, in syphilis, 204.
Reder, 93.
Reeb, 575.
Regnault, 323.
Reinelt, 381.
Remer, 374,
Renault, 319, 325, 331, 384, 414, 441, 440. 476.
Renz, 057.
Respiratory organs, affections of,  in glanders in man,
    357, 359; affections of, in syphilis, 206.
Rey, 446.
Reynal, 524.
Rhazes, 434.
Richards, 550.
Richardson, 548, 566. 579.
Richet, 232, 2)4.
Ricord, 16, 26, 33, 43, 44, 4S, 52.  55, 69, 85,  87,  116,
    149,109,  245,  277, 292, 303, 317:
Ricordi, 5S.
Rindfleisch, £6, 1C0, 172, 330.
von Rinecker, 45, 76, 165.
Rivolta, 332. 
370
INDEX.
Robert, Melchior, 88, 92.
Robin, 213.
Rohrbach, 11.
Roll, 319, 350, 459.
Rollet, 59, 88, 94.
Romberg, 509.
Rose, E., 480, 500.
Rose, Thomas, 279.
von Rosen, 53, 54, 240
Rosenstein, 558.
Rosner, 44, 76.
Rostan, 2U0.
Roth, 204.
Rother, 593.
Rudnew, 400, 029.
Rupprecht, 030, 659.
Rust, 348.
Ruyssenaers, 561.

Sagab, 521.
Salisbury, 40.
Sanchez, 8, 9.
Sanderson, Burdon, 40.
Sangalli, 629.
Sanger, 558.
Sanson, 377.
von Schaller, 508.
Scheiber, 629.
Scherenberg, 573.
Scheuthauer, 560.
Schilling, 332, 348.
Schmarda, 378, 536, 537. _
Schmaus, Leonhard, 7, 278.
Schmidt, Maximilian, 438, 450, 460.
Schneider, J., 523.
Scholler, 568.
Schrader, 437, 438.  441.
Schuh, 482.
Schuster, 386, 425.
Schwab, 408.
Schwimmer,  203.
Scrotus,  Michael, 14.
Scyllatius, 7.
Scorpions, sting of, 534.
Seasons, influence of, in anthrax in man, 411;  in hy-
    drophobia in animals, 450.
Sebastian, 62.
Sebastiany, 539.
Seidel, 568, 574.
Seidler, 348.
Semmer, 317.
Sendler, 619.
Sex  in cysticercus cellulosae,  601;  in echinococcus,
    567; in hydrophobia in animals,  437; in  hydro-
    phobia in man, 477; in syphilis, 72 ; influence of,
    in prognosis of syphilis, 263.
Shortt,  547.
Sibson, 581.
von Siebold, 557, 566.
Siederer, 409.
von Sigmund, 18, 73, 77, 140, 181,  182, 245, 273, 28?
    292, 302, 304.
de Silvestri, 332.
Simon, 576, 589, 658.
Simon, A. F.,  12.
Simon. J.,  443.
Skin, affections of, in anthrax in man, 418; in glan-
    ders in horses,  340; in glanders in man, 355, 359,
    361; in syphilis, 129;  in  trichinosis, 634,  637;
    local treatment of affections of, in syphilis, 302.
Skrzcecka, 480.
Smee, 221.
Smith, 573.
Smith, Thomas, G3.
Snakes, bite of,  539.
Soleysel, 318.
Sporino, 307.
Spiders, bite of, 536.
Spigelberg, 573.
Spinola, 319, 327, 332.
Spleen, affections of, in  anthrax of animals, 399 ; in
    anthrax in man,  420,  423 ;  in foot-and-mouth dis-
    ease in animals, 520 ;  in glanders in horses, 342;
    in glanders in man, 357, 364 ; in hydrophobia in
    animals, 464; in  hydrophobia  in  man, 497; in
    syphilis. 183 ; in trichinosis, 645.
Stadthagen, 499.
Staub, 292.
St. Cyr, 318, 325, 441.
Stern, 551.
Stewart, Grainger, 187.
Stich, 600,  603, 605, 609, 612.
Stomach, affections of, in anthrax in man, 420 ; in the
    foot-and-mouth disease in animals,  519 ; in hydro-
    phobia in man, 497 ; in syphilis, 203.
Stohr, 253.
Stone, 422.
Strassmann, 236.
Sturgis, Fred. R., 5S.
Suprarenal capsules, affections of, in syphilis, 184.
Suprarenal capsules, echinococcus of, 589.
Susrutas, 14.
Sydenham, 15.
Symptomatology of anthrax of animals, 395; of an-
    thrax in man, 411; of cysticercus  cellulosae, 602,
    611; of the echinococcus, 571,  580, 582, 584, 586,
    588, 592 ;  of glanders in horses, 343 ;  of glanders
    in man. 352; of hydrophobia in animals, 451 ; of
    hydrophobia in man, 483; snake-bites, 543, 549;
    of syphilis, 74 ; of trichinosis,  630.
SypHili*, 3;  bibliography, 3, 5, 33, 39,  51, 61, 77,
    86,  109, 125, 129,  166, 179, 180, 185,  194, 206, 215 
INDEX.
671
218, '.'21, 220, 229, 235, 271, 307;  definition of the '
disease, 3 ;  history, 5 ;  geographical distribution,
19;  influence of  climate, 20 ; general course of
the disease, 21; different stages, 26; general patho-
logical anatomy, 33 ; the blood, 33 ; local  mani-
festations, 34 ;  etiology, 39 ;  the poison, 39 ;  its
vehicles of contagion,  42;  hereditary transmis-
sion, 51;  different modes of infection, 57; by vac-
cination, 61 ; susceptibility to the poison, 69; dis-
position in general to incur infection, 69; local pre-
disposition, 73 ; pathology, 74 ; symptomatology,
74 ; period of incubation, 74 ; the primary affection,
77:  doctrines of unityand duality of the syph-
ilitic and chancre poisons, 86; conclusions, 104;
microscopic anatomy of theprimary affection, 109;
enlargement of lymphatic glands in the region of
primary affection, 117;  the so-called second incu-
bation,  123; its duration, 124 ; the syphilitic erup-
tion fever; 125: its frequency, 126 ;  general symp-
toms, 127;  location of the disease in the different
organs, 129;  affectio?is of the skin and mucous
membranes, 129;  the  color, 130:  polymorphous
character of the eruption, 131 ; its annular form,
132; absence  of itching, 132;  classification of
affections  of the skin  and  mucous membranes,
133; the macular syphilide, 134;  the  papular
syphilide,  137;   the  squamous  syphilide, 146;
lichen,  148 ; acne, 150 ;  impetigo, 151; pemphigus,
152 ; ecthyma, 153; rupia, 154 ; tubercular syphi-
lide (gummous formation), 156 ;  affections of the
hair and nails, 161 ; affections of the subcutaneous
and submucous tissues, fascia?., 164 ; affections of
the  bones, 166;  affections of the ligaments, ten-
dons, bursa and joints,  175; affections of  the
muscles,  179 ;  affections of the lymphatic appa-
ratus, 180; affections  of the  I'ver, 185;  diffuse
infiltration, 186 ;  circumscribed infiltration, 186;
gummy tumor,  187 ; amyloid degeneration, 192;
general signs of  disease, 192 ;  the digestive tract,
194 ; the mouth and fauces, 195:  the tongue, 195;
teeth, 197 ;  isthmus faucium, 198 ; tonsils, 199;
pharynx,  201 ;  oesophagus,  202;   stomach, 203;
small intestine, 203 ;  large intestine,  204;  the
rectum, 204; salivary glands and pancreas, 205;
the peritoneum, 206; the respiratory organs, 206;
nasal cavities, 207 ; the larynx, 208 ; trachea and
bronchi, 210;  the lungs, 211;   the circulatory
system,  215 ;  the heart, 215; the  larger blood-
vessels,  217; the jiervous system,  21S;  organs of
special sense, 221; the  sense of  smell, 221 ;  the
eye, 221;  the ear, 225 ;  the winary organs, 220;
the genital  organs, 229; the testicles, 229;  the
female organs, 232;  the mammary gland, 233;
hereditary syphilis, 235; the placenta, 235;  the
foetus,  237:  children  born  alive, 238;  general
retrospect,  244;   diagnosis,   254;  the  primary
    stage, 255 ; the secondary stage, 250 :  the tertiary
    period, 257 ;  visceral affections, 257 ;  hereditary
    forms, 257; prognosis, 259; influence  of age, 263;
    sex, 263; habits, 263;  treatment, 264 ;  the ques-
    tion of cure, 264; treatment, 266 ; prophylaxis,
    200; regulation of prostitution, 206 ; vaccination,
    269 ;  choice of wet>nurses, 270 ; question of mar-
    riage, 270 ;  treatment of the initial  lesion, 212:
    mercurial treatment, 280 ; general hygienic rules,
    283 ;  modes of administration of mercury, 285 ;
    inunction,  285;  fumigation, 288;  baths,  289;
    internal administration, 2S9;  hypodermic method,
    291;  the co?nbinalio?is of iodine and mercury,
    292;  contra-indications  to use of mercury, 294;
    use of iodide  of potassium, 295; other  iodide
    salts,  298;  other remedies, 299; local manifesta-
    tions  and their treatment, 300;  treatment of here-
    ditary syphilis, 303; hydro-therapeutics in general
    treatment,  305; syphilization, 307.
Swanzy, 224.
Swediaur, 52, 130, 252.

Tardieu, 349,  360, 474, 470, 502.
Tarnowsky, 50.
Tatum, 179.
Taylor, R. W.,  144.
Teeth, affections of, in syphilis, 197.
Teissier, 349.
Temperature in the  foot-and-mouth  disease in ani-
    mals,  516; in glanders in man, 357, 360 ; in hydro-
    phobia in man, 491; in cases of snake-bites, 549;
    in syphilitic  eruption  fever, 126; in trichinosis,
    631.
Tendons,  affections of, in syphilis, 175.
Testicles,  affections of, in glanders in horses, 342; in
    syphilis, 229.
Thamhayn, 440, 474, 470, 471, 482.
Themison, 433.
Thiersch,  422.
Thomann, 253.
Thomassin, 374, 404, 409.
Thomson, J., 279.
Thorstensen, 567.
Thymus gland,  affections of, in syphilis, 185.
Thyroid gland,  affections of, in syphilis, 184.
Tiedemann, 614.
Tongue, affections of, in syphilis,  195.
Tonsils, affections of, in syphilis,  199.
Torella, 9, 58.
Trachea, affections of, in syphilis, 210.
Travers, 349.
Treatment of anthrax of animals, 404 ; of anthrax in
    man, 427; of cysticercus cellulosae, 604, 613; of
    echinococcus, 574, 581, 586, 587, 5S9, 595 ; of foot-
    and-mouth  disease in animals,  520 ; of foot-and-
    mouth disease in man, 531;  of glanders in horses, 
672
INDEX.
     347: of glanders in man, 369; of hydrophobia in
     animals, 471;  of hydrophobia in man, 509;  of
     snake-bites, 545* 550;  of  stings of  insects, 538;
     of syphilis, 266 ; of trichinosis, 642.
 Trichinae, 613.
 Trichinosis, 6..0.
 Trousseau, 349.  577.
 Tscherning, 321, 348, 438.
 von Tschudi, 439.
 Tiingel, 227, 611, 619, 627, 629.
 Turenne, Auzias, 41, 76, 271, 307.
 Turner, 629.
 Turpin, 517.
 Ucke, 5-37.
 Uhde, 649, 653.
 Ulrich, 603, 606.
 Ungefug, 350.
 Urinary organs, affections of, in syphilis, 227 ;  in tri-
     chinosis, 637.
 Urine in hydrophobia in man, 492.
 Uterus, affections of, in anthrax of animals, 400.

 Vaccination, a means of transmission of syphilis, 61,
     269.
 Valleix, 171.
 Vassal, 52.
 Vegetius, 317.
 Veith, 348.
 Velpeau, 571.
 Verneuil, 176,  205, 232, 233.
 Verrill, 657.
 Verson, 111.
 Viand Grand-Marais, 542, 515.
 Viborg, 318, 323. 324, 328, 331.
 Vidal, 50, 101, 214.
 Viennoif, 68.
 de Vigo, J., 6,  85.
 Villalobos, 84.
 Villemin, 319.
 Vines, 319, 326.
 Vipers, bite of, 542.
 Virchow, 27, 34, 166, 170, 172, 182,184, 187, 203, 205.
     206, 213, 215, 216, 217, 230, 235, 239, 245, 217, 250,
     317, 319, 331, 333, 339, 349, 362, 306, 367, 375, 406,
     414, 418, 422, 437, 441, 496, 500, 509, 557, 561, 564,
     505, 599, 615, 616, 617, 626,  629, 650, 651, 654, 056.
 Virgil, 433.
 Visconti, 580.
 Vogt, P., 273.
 Viilckers, 556.
 Volkmann, R., 127, 174.
Vulpian, 466.

Wagener, G.,  561.
 Wagner, E., 35, 183, 186, 203, 213, 217, 406,  413, 416,
     418, 420, 422, 511, 556, 629.
 von Wahl, 410, 418.
 Wald, H., 380, 381.
 Waldau, 60.
 Waldenburg, 327.
 Waldeyer, 171, 406, 416, 418, 422, 573.
 Waldinger, 348.
 Wallace, 43, 278, 280.
 Waller, 44, 46, 76,  89.
 Waspa, sting of, 533.
 Wasservogel, 408,  412.
 Weber, C. O., 217.
 Weber, F., 213.
 Weber, H., 190.
 Wecker, 221.
 Wedi. 41.
 Wegeler, 01.
 Wegner, G., 170, 236.
 Weil, 183.
 Weiss, 348, 427.
 von Welz, 41.
 Wendroth, 425.
 Werner, 595.
 Westphal, 480, 501, 580.
 Wet-nurses, choice of, to prevent  spread  of  syphilid
     270.
 White, J., 323.
 White, R., 443.
 Widmann, 275.
 Wiederholt, 657.
 Wilde, 573, 577, 587.
 Wilks, S., 32, 186,  218.
 Winkler, 415.
 Wolff, 348.
 Wood,  616.
 Wood,  H. C, 538.
 Wright. 537.
 Wyss, O., 332, 364.

 Xenophon, 433.

 Youatt, 435, 441, 442,  448.
 Yvaren, 126, 211, 234.

 Zambaco, 126.
 Zeissl, 28, 42, 49, 54, 55, 92, 116, 136,  143, 149, 152,
     160, 231,  232, 238,   253, 274, 280, 289, 290, 291,
    300, 302.
Zenker, 184, 188, 556, 569, 599, 602,  608,  616, 617, 629,
    047, 651, 653, 654, 656.
Zittmann, decoction of, 299.
Zoeros,  449.
Ziirn, 330, 529 
 
 
 
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