SYPHILIS
Definition.--Virus.--ACQUIRED SYPHILIS--Primary period:
_Incubation, primary chancre, glandular enlargement_;
_Extra-genital chancres_--Treatment--Secondary period: _General
symptoms, skin affections, mucous patches, affections of bones,
joints, eyes_, etc.--Treatment: _Salvarsan_--_Methods of
administering mercury_--Syphilis and marriage--Intermediate
stage--_Reminders_--Tertiary period: _General symptoms_,
_gummata_, _tertiary ulcers_, _tertiary lesions of skin, mucous
membrane, bones, joints_, etc.--Second attacks.--INHERITED
SYPHILIS--Transmission--_Clinical features in infancy, in later
life_--Contagiousness--Treatment.
Syphilis is an infective disease due to the entrance into the body of a
specific virus. It is nearly always communicated from one individual to
another by contact infection, the discharge from a syphilitic lesion
being the medium through which the virus is transmitted, and the seat of
inoculation is almost invariably a surface covered by squamous
epithelium. The disease was unknown in Europe before the year 1493, when
it was introduced into Spain by Columbus' crew, who were infected in
Haiti, where the disease had been endemic from time immemorial (Bloch).
The granulation tissue which forms as a result of the reaction of the
tissues to the presence of the virus is chiefly composed of lymphocytes
and plasma cells, along with an abundant new formation of capillary
blood vessels. Giant cells are not uncommon, but the endothelioid cells,
which are so marked a feature of tuberculous granulation tissue, are
practically absent.
When syphilis is communicated from one individual to another by contact
infection, the condition is spoken of as _acquired syphilis_, and the
first visible sign of the disease appears at the site of inoculation,
and is known as _the primary lesion_. Those who have thus acquired the
disease may transmit it to their offspring, who are then said to suffer
from _inherited syphilis_.
#The Virus of Syphilis.#--The cause of syphilis, whether acquired or
inherited, is the organism, described by Schaudinn and Hoffman, in 1905,
under the name of _spirochæta pallida_ or _spironema pallidum_. It is a
delicate, thread-like spirilla, in length averaging from 8 to 10 µ and
in width about 0.25 µ, and is distinguished from other spirochætes by
its delicate shape, its dead-white appearance, together with its closely
twisted spiral form, with numerous undulations (10 to 26), which are
perfectly regular, and are characteristic in that they remain the same
during rest and in active movement (Fig. 36). In a fresh specimen, such
as a scraping from a hard chancre suspended in a little salt solution,
it shows active movements. The organism is readily destroyed by heat,
and perishes in the absence of moisture. It has been proved
experimentally that it remains infective only up to six hours after its
removal from the body. Noguchi has succeeded in obtaining pure cultures
from the infected tissues of the rabbit.
[Illustration: FIG. 36.--Spirochæta pallida from scraping of hard
Chancre of Prepuce. × 1000 diam. Burri method.]
The spirochæte may be recognised in films made by scraping the deeper
parts of the primary lesion, from papules on the skin, or from blisters
artificially raised on lesions of the skin or on the immediately
adjacent portion of healthy skin. It is readily found in the mucous
patches and condylomata of the secondary period. It is best stained by
Giemsa's method, and its recognition is greatly aided by the use of the
ultra-microscope.
The spirochæte has been demonstrated in every form of syphilitic lesion,
and has been isolated from the blood--with difficulty--and from lymph
withdrawn by a hollow needle from enlarged lymph glands. The saliva of
persons suffering from syphilitic lesions of the mouth also contains the
organism.
[Illustration: FIG. 37.--Spirochæta refrigerans from scraping of Vagina.
× 1000 diam. Burri method.]
In tertiary lesions there is greater difficulty in demonstrating the
spirochæte, but small numbers have been found in the peripheral parts of
gummata and in the thickened patches in syphilitic disease of the aorta.
Noguchi and Moore have discovered the spirochæte in the brain in a
number of cases of general paralysis of the insane. The spirochæte may
persist in the body for a long time after infection; its presence has
been demonstrated as long as sixteen years after the original
acquisition of the disease.
In inherited syphilis the spirochæte is present in enormous numbers
throughout all the organs and fluids of the body.
Considerable interest attaches to the observations of Metchnikoff, Roux,
and Neisser, who have succeeded in conveying syphilis to the chimpanzee
and other members of the ape tribe, obtaining primary and secondary
lesions similar to those observed in man, and also containing the
spirochæte. In animals the disease has been transmitted by material from
all kinds of syphilitic lesions, including even the blood in the
secondary and tertiary stages of the disease. The primary lesion is in
the form of an indurated papule, in every respect resembling the
corresponding lesion in man, and associated with enlargement and
induration of the lymph glands. The primary lesion usually appears about
thirty days after inoculation, to be followed, in about half the cases,
by secondary manifestations, which are usually of a mild character; in
no instance has any tertiary lesion been observed. The severity of the
affection amongst apes would appear to be in proportion to the nearness
of the relationship of the animal to the human subject. The eye of the
rabbit is also susceptible to inoculation from syphilitic lesions; the
material in a finely divided state is introduced into the anterior
chamber of the eye.
Attempts to immunise against the disease have so far proved negative,
but Metchnikoff has shown that the inunction of the part inoculated with
an ointment containing 33 per cent. of calomel, within one hour of
infection, suffices to neutralise the virus in man, and up to eighteen
hours in monkeys. He recommends the adoption of this procedure in the
prophylaxis of syphilis.
Noguchi has made an emulsion of dead spirochætes which he calls
_luetin_, and which gives a specific reaction resembling that of
tuberculin in tuberculosis, a papule or a pustule forming at the site of
the intra-dermal injection. It is said to be most efficacious in the
tertiary and latent forms of syphilis, which are precisely those forms
in which the diagnosis is surrounded with difficulties.
ACQUIRED SYPHILIS
In the vast majority of cases, infection takes place during the congress
of the sexes. Delicate, easily abraded surfaces are then brought into
contact, and the discharge from lesions containing the virus is placed
under favourable conditions for conveying the disease from one person to
the other. In the male the possibility of infection taking place is
increased if the virus is retained under cover of a long and tight
prepuce, and if there are abrasions on the surface with which it comes
in contact. The frequency with which infection takes place on the
genitals during sexual intercourse warrants syphilis being considered a
venereal disease, although there are other ways in which it may be
contracted.
Some of these imply direct contact--such, for example, as kissing, the
digital examination of syphilitic patients by doctors or nurses, or
infection of the surgeon's fingers while operating upon a syphilitic
patient. In suckling, a syphilitic wet nurse may infect a healthy
infant, or a syphilitic infant may infect a healthy wet nurse. In other
cases the infection is by indirect contact, the virus being conveyed
through the medium of articles contaminated by a syphilitic
patient--such, for example, as surgical instruments, tobacco pipes, wind
instruments, table utensils, towels, or underclothing. Physiological
secretions, such as saliva, milk, or tears, are not capable of
communicating the disease unless contaminated by discharge from a
syphilitic sore. While the saliva itself is innocuous, it can be, and
often is, contaminated by the discharge from mucous patches or other
syphilitic lesions in the mouth and throat, and is then a dangerous
medium of infection. Unless these extra-genital sources of infection are
borne in mind, there is a danger of failing to recognise the primary
lesion of syphilis in unusual positions, such as the lip, finger, or
nipple. When the disease is thus acquired by innocent transfer, it is
known as _syphilis insontium_.
#Stages or Periods of Syphilis.#--Following the teaching of Ricord, it
is customary to divide the life-history of syphilis into three periods
or stages, referred to, for convenience, as primary, secondary, and
tertiary. This division is to some extent arbitrary and artificial, as
the different stages overlap one another, and the lesions of one stage
merge insensibly into those of another. Wide variations are met with in
the manifestations of the secondary stage, and histologically there is
no valid distinction to be drawn between secondary and tertiary lesions.
_The primary period_ embraces the interval that elapses between the
initial infection and the first constitutional manifestations,--roughly,
from four to eight weeks,--and includes the period of incubation, the
development of the primary sore, and the enlargement of the nearest
lymph glands.
_The secondary period_ varies in duration from one to two years, during
which time the patient is liable to suffer from manifestations which are
for the most part superficial in character, affecting the skin and its
appendages, the mucous membranes, and the lymph glands.
_The tertiary period_ has no time-limit except that it follows upon the
secondary, so that during the remainder of his life the patient is
liable to suffer from manifestations which may affect the deeper tissues
and internal organs as well as the skin and mucous membranes.
#Primary Syphilis.#--_The period of incubation_ represents the interval
that elapses between the occurrence of infection and the appearance of
the primary lesion at the site of inoculation. Its limits may be stated
as varying from two to six weeks, with an average of from twenty-one to
twenty-eight days. While the disease is incubating, there is nothing to
show that infection has occurred.
_The Primary Lesion._--The incubation period having elapsed, there
appears at the site of inoculation a circumscribed area of infiltration
which represents the reaction of the tissues to the entrance of the
virus. The first appearance is that of a sharply defined papule, rarely
larger than a split pea. Its surface is at first smooth and shiny, but
as necrosis of the tissue elements takes place in the centre, it becomes
concave, and in many cases the epithelium is shed, and an ulcer is
formed. Such an ulcer has an elevated border, sharply cut edges, an
indurated base, and exudes a scanty serous discharge; its surface is at
first occupied by yellow necrosed tissue, but in time this is replaced
by smooth, pale-pink granulation tissue; finally, epithelium may spread
over the surface, and the ulcer heals. As a rule, the patient suffers
little discomfort, and may even be ignorant of the existence of the
lesion, unless, as a result of exposure to mechanical or septic
irritation, ulceration ensues, and the sore becomes painful and tender,
and yields a purulent discharge. The primary lesion may persist until
the secondary manifestations make their appearance, that is, for several
weeks.
It cannot be emphasised too strongly that the induration of the primary
lesion, which has obtained for it the name of "hard chancre," is its
most important characteristic. It is best appreciated when the sore is
grasped from side to side between the finger and thumb. The sensation on
grasping it has been aptly compared to that imparted by a nodule of
cartilage, or by a button felt through a layer of cloth. The evidence
obtained by touch is more valuable than that obtained by inspection, a
fact which is made use of in the recognition of _concealed
chancres_--that is, those which are hidden by a tight prepuce. The
induration is due not only to the dense packing of the connective-tissue
spaces with lymphocytes and plasma cells, but also to the formation of
new connective-tissue elements. It is most marked in chancres situated
in the furrow between the glans and the prepuce.
_In the male_, the primary lesion specially affects certain
_situations_, and the appearances vary with these: (1) On the inner
aspect of the prepuce, and in the fold between the prepuce and the
glans; in the latter situation the induration imparts a "collar-like"
rigidity to the prepuce, which is most apparent when it is rolled back
over the corona. (2) At the orifice of the prepuce the primary lesion
assumes the form of multiple linear ulcers or fissures, and as each of
these is attended with infiltration, the prepuce cannot be pulled
back--a condition known as _syphilitic phimosis_. (3) On the glans penis
the infiltration may be so superficial that it resembles a layer of
parchment, but if it invades the cavernous tissue there is a dense mass
of induration. (4) On the external aspect of the prepuce or on the skin
of the penis itself. (5) At either end of the torn frænum, in the form
of a diamond-shaped ulcer raised above the surroundings. (6) In relation
to the meatus and canal of the urethra, in either of which situations
the swelling and induration may lead to narrowing of the urethra, so
that the urine is passed with pain and difficulty and in a minute
stream; stricture results only in the exceptional cases in which the
chancre has ulcerated and caused destruction of tissue. A chancre within
the orifice of the urethra is rare, and, being concealed from view, it
can only be recognised by the discharge from the meatus and by the
induration felt between the finger and thumb on palpating the urethra.
_In the female_, the primary lesion is not so typical or so easily
recognised as in men; it is usually met with on the labia; the
induration is rarely characteristic and does not last so long. The
primary lesion may take the form of condylomata. Indurated œdema, with
brownish-red or livid discoloration of one or both labia, is diagnostic
of syphilis.
The hard chancre is usually solitary, but sometimes there are two or
more; when there are several, they are individually smaller than the
solitary chancre.
It is the exception for a hard chancre to leave a visible scar, hence,
in examining patients with a doubtful history of syphilis, little
reliance can be placed on the presence or absence of a scar on the
genitals. When the primary lesion has taken the form of an open ulcer
with purulent discharge, or has sloughed, there is a permanent scar.
_Infection of the adjacent lymph glands_ is usually found to have taken
place by the time the primary lesion has acquired its characteristic
induration. Several of the glands along Poupart's ligament, on one or on
both sides, become enlarged, rounded, and indurated; they are usually
freely movable, and are rarely sensitive unless there is superadded
septic infection. The term _bullet-bubo_ has been applied to them, and
their presence is of great value in diagnosis. In a certain number of
cases, one of the main _lymph vessels_ on the dorsum of the penis is
transformed into a fibrous cord easily recognisable on palpation, and
when grasped between the fingers appears to be in size and consistence
not unlike the vas deferens.
_Concealed chancre_ is the term applied when one or more chancres are
situated within the sac of a prepuce which cannot be retracted. If the
induration is well marked, the chancre can be palpated through the
prepuce, and is tender on pressure. As under these conditions it is
impossible for the patient to keep the parts clean, septic infection
becomes a prominent feature, the prepuce is œdematous and inflamed, and
there is an abundant discharge of pus from its orifice. It occasionally
happens that the infection assumes a virulent character and causes
sloughing of the prepuce--a condition known as _phagedæna_. The
discharge is then foul and blood-stained, and the prepuce becomes of a
dusky red or purple colour, and may finally slough, exposing the glans.
_Extra-genital or Erratic Chancres_ (Fig. 38).--Erratic chancre is the
term applied by Jonathan Hutchinson to the primary lesion of syphilis
when it appears on parts of the body other than the genitals. It differs
in some respects from the hard chancre as met with on the penis; it is
usually larger, the induration is more diffused, and the enlarged glands
are softer and more sensitive. The glands in nearest relation to the
sore are those first affected, for example, the epitrochlear or axillary
glands in chancre of the finger; the submaxillary glands in chancre of
the lip or mouth; or the pre-auricular gland in chancre of the eyelid or
forehead. In consequence of their divergence from the typical chancre,
and of their being often met with in persons who, from age,
surroundings, or moral character, are unlikely subjects of venereal
disease, the true nature of erratic chancres is often overlooked until
the persistence of the lesion, its want of resemblance to anything else,
or the onset of constitutional symptoms, determines the diagnosis of
syphilis. A solitary, indolent sore occurring on the lip, eyelid,
finger, or nipple, which does not heal but tends to increase in size,
and is associated with induration and enlargement of the adjacent
glands, is most likely to be the primary lesion of syphilis.
[Illustration: FIG. 38.--Primary Lesion on Thumb, with Secondary
Eruption on Forearm.[1]]
[1] From _A System of Syphilis_, vol. ii., edited by D'Arcy Power and
J. Keogh Murphy, Oxford Medical Publications.
#The Soft Sore, Soft Chancre, or Chancroid.#--The differential diagnosis
of syphilis necessitates the consideration of the _soft sore_, _soft
chancre_, or _chancroid_, which is also a common form of venereal
disease, and is due to infection with a virulent pus-forming bacillus,
first described by Ducrey in 1889. Ducrey's bacillus occurs in the form
of minute oval rods measuring about 1.5 µ in length, which stain readily
with any basic aniline dye, but are quickly decolorised by Gram's
method. They are found mixed with other organisms in the purulent
discharge from the sore, and are chiefly arranged in small groups or in
short chains. Soft sores are always contracted by direct contact from
another individual, and the incubation period is a short one of from two
to five days. They are usually situated in the vicinity of the frænum,
and, in women, about the labia minora or fourchette; they probably
originate in abrasions in these situations. They appear as pustules,
which are rapidly converted into small, acutely inflamed ulcers with
sharply cut, irregular margins, which bleed easily and yield an abundant
yellow purulent discharge. They are devoid of the induration of
syphilis, are painful, and nearly always multiple, reproducing
themselves in successive crops by auto-inoculation. Soft sores are often
complicated by phimosis and balanitis, and they frequently lead to
infection of the glands in the groin. The resulting bubo is ill-defined,
painful, and tender, and suppuration occurs in about one-fourth of the
cases. The overlying skin becomes adherent and red, and suppuration
takes place either in the form of separate foci in the interior of the
individual glands, or around them; in the latter case, on incision, the
glands are found lying bathed in pus. Ducrey's bacillus is found in pure
culture in the pus. Sometimes other pyogenic organisms are superadded.
After the bubo has been opened the wound may take on the characters of a
soft sore.
_Treatment._--Soft sores heal rapidly when kept clean. If concealed
under a tight prepuce, an incision should be made along the dorsum to
give access to the sores. They should be washed with eusol, and dusted
with a mixture of one part iodoform and two parts boracic or salicylic
acid, or, when the odour of iodoform is objected to, of equal parts of
boracic acid and carbonate of zinc. Immersion of the penis in a bath of
eusol for some hours daily is useful. The sore is then covered with a
piece of gauze kept in position by drawing the prepuce over it, or by a
few turns of a narrow bandage. Sublimed sulphur frequently rubbed into
the sore is recommended by C. H. Mills. If the sores spread in spite of
this, they should be painted with cocaine and then cauterised. When the
glands in the groin are infected, the patient must be confined to bed,
and a dressing impregnated with ichthyol and glycerin (10 per cent.)
applied; the repeated use of a suction bell is of great service.
Harrison recommends aspiration of a bubonic abscess, followed by
injection of 1 in 20 solution of tincture of iodine into the cavity;
this is in turn aspirated, and then 1 or 2 c.c. of the solution injected
and left in. This is repeated as often as the cavity refills. It is
sometimes necessary to let the pus out by one or more small incisions
and continue the use of the suction bell.
_Diagnosis of Primary Syphilis._--In cases in which there is a history
of an incubation period of from three to five weeks, when the sore is
indurated, persistent, and indolent, and attended with bullet-buboes in
the groin, the diagnosis of primary syphilis is not difficult. Owing,
however, to the great importance of instituting treatment at the
earliest possible stage of the infection, an effort should be made to
establish the diagnosis without delay by demonstrating the spirochæte.
Before any antiseptic is applied, the margin of the suspected sore is
rubbed with gauze, and the serum that exudes on pressure is collected
in a capillary tube and sent to a pathologist for microscopical
examination. A better specimen can sometimes be obtained by puncturing
an enlarged lymph gland with a hypodermic needle, injecting a few minims
of sterile saline solution and then aspirating the blood-stained fluid.
The Wassermann test must not be relied upon for diagnosis in the early
stage, as it does not appear until the disease has become generalised
and the secondary manifestations are about to begin. The practice of
waiting in doubtful cases before making a diagnosis until secondary
manifestations appear is to be condemned.
Extra-genital chancres, _e.g._ sores on the fingers of doctors or
nurses, are specially liable to be overlooked, if the possibility of
syphilis is not kept in mind.
It is important to bear in mind _the possibility of a patient having
acquired a mixed infection_ with the virus of soft chancre, which will
manifest itself a few days after infection, and the virus of syphilis,
which shows itself after an interval of several weeks. This occurrence
was formerly the source of much confusion in diagnosis, and it was
believed at one time that syphilis might result from soft sores, but it
is now established that syphilis does not follow upon soft sores unless
the virus of syphilis has been introduced at the same time. The
practitioner must be on his guard, therefore, when a patient asks his
advice concerning a venereal sore which has appeared within a few days
of exposure to infection. Such a patient is naturally anxious to know
whether he has contracted syphilis or not, but neither a positive nor a
negative answer can be given--unless the spirochæte can be identified.
Syphilis is also to be diagnosed from _epithelioma_, the common form of
cancer of the penis. It is especially in elderly patients with a tight
prepuce that the induration of syphilis is liable to be mistaken for
that associated with epithelioma. In difficult cases the prepuce must be
slit open.
Difficulty may occur in the diagnosis of primary syphilis from _herpes_,
as this may appear as late as ten days after connection; it commences as
a group of vesicles which soon burst and leave shallow ulcers with a
yellow floor; these disappear quickly on the use of an antiseptic
dusting powder.
Apprehensive patients who have committed sexual indiscretions are apt to
regard as syphilitic any lesion which happens to be located on the
penis--for example, acne pustules, eczema, psoriasis papules, boils,
balanitis, or venereal warts.
_The local treatment_ of the primary sore consists in attempting to
destroy the organisms _in situ_. An ointment made up of calomel 33
parts, lanoline 67 parts, and vaseline 10 parts (Metchnikoff's cream) is
rubbed into the sore several times a day. If the surface is unbroken, it
may be dusted lightly with a powder composed of equal parts of calomel
and carbonate of zinc. A gauze dressing is applied, and the penis and
scrotum should be supported against the abdominal wall by a triangular
handkerchief or bathing-drawers; if there is inflammatory œdema the
patient should be confined to bed.
In _concealed chancres_ with phimosis, the sac of the prepuce should be
slit up along the dorsum to admit of the ointment being applied. If
phagedæna occurs, the prepuce must be slit open along the dorsum, or if
sloughing, cut away, and the patient should have frequent sitz baths of
weak sublimate lotion. When the chancre is within the meatus, iodoform
bougies are inserted into the urethra, and the urine should be rendered
bland by drinking large quantities of fluid.
General treatment is considered on p. 149.
#Secondary Syphilis.#--The following description of secondary syphilis
is based on the average course of the disease in untreated cases. The
onset of constitutional symptoms occurs from six to twelve weeks after
infection, and the manifestations are the result of the entrance of the
virus into the general circulation, and its being carried to all parts
of the body. The period during which the patient is liable to suffer
from secondary symptoms ranges from six months to two years.
In some cases the general health is not disturbed; in others the patient
is feverish and out of sorts, losing appetite, becoming pale and anæmic,
complaining of lassitude, incapacity for exertion, headache, and pains
of a rheumatic type referred to the bones. There is a moderate degree of
leucocytosis, but the increase is due not to the polymorpho-nuclear
leucocytes but to lymphocytes. In isolated cases the temperature rises
to 101° or 102° F. and the patient loses flesh. The lymph glands,
particularly those along the posterior border of the sterno-mastoid,
become enlarged and slightly tender. The hair comes out, eruptions
appear on the skin and mucous membranes, and the patient may suffer from
sore throat and affections of the eyes. The local lesions are to be
regarded as being of the nature of reactions against accumulations of
the parasite, lymphocytes and plasma cells being the elements chiefly
concerned in the reactive process.
_Affections of the Skin_ are among the most constant manifestations. An
evanescent macular rash, not unlike that of measles--_roseola_--is the
first to appear, usually in from six to eight weeks from the date of
infection; it is widely diffused over the trunk, and the original dull
rose-colour soon fades, leaving brownish stains, which in time
disappear. It is usually followed by a _papular eruption_, the
individual papules being raised above the surface of the skin, smooth or
scaly, and as they are due to infiltration of the skin they are more
persistent than the roseoles. They vary in size and distribution, being
sometimes small, hard, polished, and closely aggregated like lichen,
sometimes as large as a shilling-piece, with an accumulation of scales
on the surface like that seen in psoriasis. The co-existence of scaly
papules and faded roseoles is very suggestive of syphilis.
Other types of eruption are less common, and are met with from the third
month onwards. A _pustular_ eruption, not unlike that of acne, is
sometimes a prominent feature, but is not characteristic of syphilis
unless it affects the scalp and forehead and is associated with the
remains of the papular eruption. The term _ecthyma_ is applied when the
pustules are of large size, and, after breaking on the surface, give
rise to superficial ulcers; the discharge from the ulcer often dries up
and forms a scab or crust which is continually added to from below as
the ulcer extends in area and depth. The term _rupia_ is applied when
the crusts are prominent, dark in colour, and conical in shape, roughly
resembling the shell of a limpet. If the crust is detached, a sharply
defined ulcer is exposed, and when this heals it leaves a scar which is
usually circular, thin, white, shining like satin, and the surrounding
skin is darkly pigmented; in the case of deep ulcers, the scar is
depressed and adherent (Fig. 39).
[Illustration: FIG. 39.--Syphilitic Rupia, showing the limpet-shaped
crusts or scabs.]
In the later stages there may occur a form of creeping or _spreading
ulceration of the skin_ of the face, groin, or scrotum, healing at one
edge and spreading at another like tuberculous lupus, but distinguished
from this by its more rapid progress and by the pigmentation of the
scar.
_Condylomata_ are more characteristic of syphilis than any other type of
skin lesion. They are papules occurring on those parts of the body where
the skin is habitually moist, and especially where two skin surfaces are
in contact. They are chiefly met with on the external genitals,
especially in women, around the anus, beneath large pendulous mammæ,
between the toes, and at the angles of the mouth, and in these
situations their development is greatly favoured by neglect of
cleanliness. They present the appearance of well-defined circular or
ovoid areas in which the skin is thickened and raised above the surface;
they are covered with a white sodden epidermis, and furnish a scanty but
very infective discharge. Under the influence of irritation and want of
rest, as at the anus or at the angle of the mouth, they are apt to
become fissured and superficially ulcerated, and the discharge then
becomes abundant and may crust on the surface, forming yellow scabs. At
the angle of the mouth the condylomatous patches may spread to the
cheek, and when they ulcerate may leave fissure-like scars radiating
from the mouth--an appearance best seen in inherited syphilis (Fig. 44).
_The Appendages of the Skin._--The _hair_ loses its gloss, becomes dry
and brittle, and readily falls out, either as an exaggeration of the
normal shedding of the hair, or in scattered areas over the scalp
(_syphilitic alopœcia_). The hair is not re-formed in the scars which
result from ulcerated lesions of the scalp. The _nail-folds_
occasionally present a pustular eruption and superficial ulceration, to
which the name _syphilitic onychia_ has been applied; more commonly the
nails become brittle and ragged, and they may even be shed.
_The Mucous Membranes_, and especially those of the _mouth_ and
_throat_, suffer from lesions similar to those met with on the skin. On
a mucous surface the papular eruption assumes the form of _mucous
patches_, which are areas with a congested base covered with a thin
white film of sodden epithelium like wet tissue-paper. They are best
seen on the inner aspect of the cheeks, the soft palate, uvula, pillars
of the fauces, and tonsils. In addition to mucous patches, there may be
a number of small, _superficial, kidney-shaped ulcers_, especially along
the margins of the tongue and on the tonsils. In the absence of mucous
patches and ulcers, the sore throat may be characterised by a bluish
tinge of the inflamed mucous membrane and a thin film of shed epithelium
on the surface. Sometimes there is an elongated sinuous film which has
been likened to the track of a snail. In the _larynx_ the presence of
congestion, œdema, and mucous patches may be the cause of persistent
hoarseness. The _tongue_ often presents a combination of lesions,
including ulcers, patches where the papillæ are absent, fissures, and
raised white papules resembling warts, especially towards the centre of
the dorsum. These lesions are specially apt to occur in those who smoke,
drink undiluted alcohol or spirits, or eat hot condiments to excess, or
who have irregular, sharp-cornered teeth. At a later period, and in
those who are broken down in health from intemperance or other cause,
the sore throat may take the form of rapidly spreading, penetrating
ulcers in the soft palate and pillars of the fauces, which may lead to
extensive destruction of tissue, with subsequent scars and deformity
highly characteristic of previous syphilis.
In the _Bones_, lesions occur which assume the clinical features of an
evanescent periostitis, the patient complaining of nocturnal pains over
the frontal bone, sternum, tibiæ, and ulnæ, and localised tenderness on
tapping over these bones.
In the _Joints_, a serous synovitis or hydrops may occur, chiefly in the
knee, on one or on both sides.
_The Affections of the Eyes_, although fortunately rare, are of great
importance because of the serious results which may follow if they are
not recognised and treated. _Iritis_ is the commonest of these, and may
occur in one or in both eyes, one after the other, from three to eight
months after infection. The patient complains of impairment of sight and
of frontal or supraorbital pain. The eye waters and is hypersensitive,
the iris is discoloured and reacts sluggishly to light, and there is a
zone of ciliary congestion around the cornea. The appearance of minute
white nodules or flakes of lymph at the margin of the pupil is
especially characteristic of syphilitic iritis. When adhesions have
formed between the iris and the structures in relation to it, the pupil
dilates irregularly under atropin. Although complete recovery is to be
expected under early and energetic treatment, if neglected, _iritis_ may
result in occlusion of the pupil and permanent impairment or loss of
sight.
The other lesions of the eye are much rarer, and can only be discovered
on ophthalmoscopic examination.
The virus of syphilis exerts a special influence upon the _Blood
Vessels_, exciting a proliferation of the endothelial lining which
results in narrowing of their lumen, _endarteritis_, and a perivascular
infiltration in the form of accumulations of plasma cells around the
vessels and in the lymphatics that accompany them.
In the _Brain_, in the later periods of secondary and in tertiary
syphilis, changes occur as a result of the narrowing of the lumen of the
arteries, or of their complete obliteration by thrombosis. By
interfering with the nutrition of those parts of the brain supplied by
the affected arteries, these lesions give rise to clinical features of
which severe headache and paralysis are the most prominent.
Affections of the _Spinal Cord_ are extremely rare, but paraplegia from
myelitis has been observed.
Lastly, attention must be directed to the remarkable variations observed
in different patients. Sometimes the virulent character of the disease
can only be accounted for by an idiosyncrasy of the patient.
Constitutional symptoms, particularly pyrexia and anæmia, are most often
met with in young women. Patients over forty years of age have greater
difficulty in overcoming the infection than younger adults. Malarial and
other infections, and the conditions attending life in tropical
countries, from the debility which they cause, tend to aggravate and
prolong the disease, which then assumes the characters of what has been
called _malignant syphilis_. All chronic ailments have a similar
influence, and alcoholic intemperance is universally regarded as a
serious aggravating factor.
_Diagnosis of Secondary Syphilis._--A routine examination should be made
of the parts of the body which are most often affected in this
disease--the scalp, mouth, throat, posterior cervical glands, and the
trunk, the patient being stripped and examined by daylight. Among the
_diagnostic features of the skin affections_ the following may be
mentioned: They are frequently, and sometimes to a marked degree,
symmetrical; more than one type of eruption--papules and pustules, for
example--are present at the same time; there is little itching; they are
at first a dull-red colour, but later present a brown pigmentation which
has been likened to the colour of raw ham; they exhibit a predilection
for those parts of the forehead and neck which are close to the roots of
the hair; they tend to pass off spontaneously; and they disappear
rapidly under treatment.
#Serum Diagnosis--Wassermann Reaction.#--Wassermann found that if an
extract of syphilitic liver rich in spirochætes is mixed with the serum
from a syphilitic patient, a large amount of complement is fixed. The
application of the test is highly complicated and can only be carried
out by an expert pathologist. For the purpose he is supplied with from 5
c.c. to 10 c.c. of the patient's blood, withdrawn under aseptic
conditions from the median basilic vein by means of a serum syringe, and
transferred to a clean and dry glass tube. There is abundant evidence
that the Wassermann test is a reliable means of establishing a diagnosis
of syphilis.
A definitely positive reaction can usually be obtained between the
fifteenth and thirtieth day after the appearance of the primary lesion,
and as time goes on it becomes more marked. During the secondary period
the reaction is practically always positive. In the tertiary stage also
it is positive except in so far as it is modified by the results of
treatment. In para-syphilitic lesions such as general paralysis and
tabes a positive reaction is almost always present. In inherited
syphilis the reaction is positive in every case. A positive reaction may
be present in other diseases, for example, frambesia, trypanosomiasis,
and leprosy.
As the presence of the reaction is an evidence of the activity of the
spirochætes, repeated applications of the test furnish a valuable means
of estimating the efficacy of treatment. The object aimed at is to
change a persistently positive reaction to a permanently negative one.
#Treatment of Syphilis.#--In the treatment of syphilis the two main
objects are to maintain the general health at the highest possible
standard, and to introduce into the system therapeutic agents which will
inhibit or destroy the invading parasite.
The second of these objects has been achieved by the researches of
Ehrlich, who, in conjunction with his pupil, Hata, has built up a
compound, the dihydrochloride of dioxydiamido-arseno-benzol, popularly
known as salvarsan or "606." Other preparations, such as kharsivan,
arseno-billon, and diarsenol, are chemically equivalent to salvarsan,
containing from 27 to 31 per cent. of arsenic, and are equally
efficient. The full dose is 0.6 grm. All these members of the "606"
group form an acid solution when dissolved in water, and must be
rendered alkaline before being injected. As subcutaneous and
intra-muscular injections cause considerable pain, and may cause
sloughing of the tissues, "606" preparations must be injected
intravenously. Ehrlich has devised a preparation--neo-salvarsan, or
"914," which is more easily prepared and forms a neutral solution. It
contains from 18 to 20 per cent. of arsenic. Neo-kharsivan,
novo-arseno-billon, and neo-diarsenol belong to the "914" group, the
full dosage of which is 0.9 grm. As subcutaneous and intra-muscular
injections of the "914" group are not painful, and even more efficient
than intravenous injections, the administration is simpler.
Galyl, luargol, and other preparations act in the same way as the "606"
and "914" groups.
The "606" preparations may be introduced into the veins by injection or
by means of an apparatus which allows the solution to flow in by
gravity. The left median basilic vein is selected, and a platino-iridium
needle with a short point and a bore larger than that of the ordinary
hypodermic syringe is used. The needle is passed for a few millimetres
along the vein, and the solution is then slowly introduced; before
withdrawing the needle some saline is run in to diminish the risk of
thrombosis.
The "914" preparations may be injected either into the subcutaneous
tissue of the buttock or into the substance of the gluteus muscle. The
part is then massaged for a few minutes, and the massage is repeated
daily for a few days.
No hard-and-fast rules can be laid down as to what constitutes a
complete course of treatment. Harrison recommends as a _minimum_ course
of one of the "914" preparations in _early primary cases_ an initial
dose of 0.45 grm. given intra-muscularly or into the deep subcutaneous
tissue; the same dose a week later; 0.6 grm. the following week; then
miss a week and give 9.6 grms. on two successive weeks; then miss two
weeks and give 0.6 grm. on two more successive weeks.
When a _positive Wassermann reaction_ is present before treatment is
commenced, the above course is prolonged as follows: for three weeks is
given a course of potassium iodide, after which four more weekly
injections of 0.6 grm. of "914" are given.
With each injection of "914" after the first, throughout the whole
course 1 grain of mercury is injected intra-muscularly.
In the course of a few hours, there is usually some indisposition, with
a feeling of chilliness and slight rise of temperature; these symptoms
pass off within twenty-four hours, and in a few days there is a decided
improvement of health. Three or four days after an intra-muscular
injection there may be pain and stiffness in the gluteal region.
These preparations are the most efficient therapeutic agents that have
yet been employed in the treatment of syphilis.
The manifestations of the disease disappear with remarkable rapidity.
Observations show that the spirochætes lose their capacity for movement
within an hour or two of the administration, and usually disappear
altogether in from twenty-four to thirty-six hours. Wassermann's
reaction usually yields a negative result in from three weeks to two
months, but later may again become positive. Subsequent doses of the
arsenical preparation are therefore usually indicated, and should be
given in from 7 to 21 days according to the dose.
When syphilis occurs in a _pregnant woman_, she should be given in the
early months an ordinary course of "914," followed by 10-grain doses of
potassium iodide twice daily. The injections may be repeated two months
later, and during the remainder of the pregnancy 2-grain mercury pills
are given twice daily (A. Campbell). The presence of albumen in the
urine contra-indicates arsenical treatment.
It need scarcely be pointed out that the use of powerful drugs like
"606" and "914" is not free from risk; it may be mentioned that each
dose contains nearly three grains of arsenic. Before the administration
the patient must be overhauled; its administration is contra-indicated
in the presence of disease of the heart and blood vessels, especially a
combination of syphilitic aortitis and sclerosis of the coronary
arteries, with degeneration of the heart muscle; in affections of the
central nervous system, especially advanced paralysis, and in such
disturbances of metabolism as are associated with diabetes and Bright's
disease. Its use is not contra-indicated in any lesion of active
syphilis.
The administration is controlled by the systematic examination of the
urine for arsenic.
_The Administration of Mercury._--The success of the arsenical
preparations has diminished the importance of mercury in the treatment
of syphilis, but it is still used to supplement the effect of the
injections. The amount of mercury to be given in any case must be
proportioned to the idiosyncrasies of the patient, and it is advisable,
before commencing the treatment, to test his urine and record his
body-weight. The small amount of mercury given at the outset is
gradually increased. If the body-weight falls, or if the gums become
sore and the breath foul, the mercury should be stopped for a time. If
salivation occurs, the drinking of hot water and the taking of hot baths
should be insisted upon, and half-dram doses of the alkaline sulphates
prescribed.
_Methods of Administering Mercury._--(1) _By the Mouth._--This was for
long the most popular method in this country, the preparation usually
employed being grey powder, in pills or tablets, each of which contains
one grain of the powder. Three of these are given daily in the first
instance, and the daily dose is increased to five or even seven grains
till the standard for the individual patient is arrived at. As the grey
powder alone sometimes causes irritation of the bowels, it should be
combined with iron, as in the following formula: Hydrarg. c. cret. gr. 1;
ferri sulph. exsiccat. gr. 1 or 2.
(2) _By Inunction._--Inunction consists in rubbing into the pores of the
skin an ointment composed of equal parts of 20 per cent. oleate of
mercury and lanolin. Every night after a hot bath, a dram of the
ointment (made up by the chemist in paper packets) is rubbed for fifteen
minutes into the skin where it is soft and comparatively free from
hairs. When the patient has been brought under the influence of the
mercury, inunction may be replaced by one of the other methods, of
administering the drug.
(3) _By Intra-muscular Injection._--This consists in introducing the
drug by means of a hypodermic syringe into the substance of the gluteal
muscles. The syringe is made of glass, and has a solid glass piston; the
needle of platino-iridium should be 5 cm. long and of a larger calibre
than the ordinary hypodermic needle. The preparation usually employed
consists of: metallic mercury or calomel 1 dram, lanolin and olive oil
each 2 drams; it must be warmed to allow of its passage through the
needle. Five minims--containing one grain of metallic mercury--represent
a dose, and this is injected into the muscles above and behind the great
trochanter once a week. The contents of the syringe are slowly
expressed, and, after withdrawing the needle, gentle massage of the
buttock should be employed. Four courses each of ten injections are
given the first year, three courses of the same number during the second
and third years, and two courses during the fourth year (Lambkin).
_The General Health._--The patient must lead a regular life and
cultivate the fresh-air habit, which is as beneficial in syphilis as in
tuberculosis. Anæmia, malaria, and other sources of debility must
receive appropriate treatment. The diet should be simple and easily
digested, and should include a full supply of milk. Alcohol is
prohibited. The excretory organs are encouraged to act by the liberal
drinking of hot water between meals, say five or six tumblerfuls in the
twenty-four hours. The functions of the skin are further aided by
frequent hot baths, and by the wearing of warm underclothing. While the
patient should avoid exposure to cold, and taxing his energies by undue
exertion, he should be advised to take exercise in the open air. On
account of the liability to lesions of the mouth and throat, he should
use tobacco in moderation, his teeth should be thoroughly overhauled by
the dentist, and he should brush them after every meal, using an
antiseptic tooth powder or wash. The mouth and throat should be rinsed
out night and morning with a solution of chlorate of potash and alum, or
with peroxide of hydrogen.
_Treatment of the Local Manifestations._--_The skin lesions_ are treated
on the same lines as similar eruptions of other origin. As local
applications, preparations of mercury are usually selected, notably the
ointments of the red oxide of mercury, ammoniated mercury, or oleate of
mercury (5 per cent.), or the mercurial plaster introduced by Unna. In
the treatment of condylomata the greatest attention must be paid to
cleanliness and dryness. After washing and drying the affected patches,
they are dusted with a powder consisting of equal parts of calomel and
carbonate of zinc; and apposed skin surfaces, such as the nates or
labia, are separated by sublimate wool. In the ulcers of later secondary
syphilis, crusts are got rid of in the first instance by means of a
boracic poultice, after which a piece of lint or gauze cut to the size
of the ulcer and soaked in black wash is applied and covered with
oil-silk. If the ulcer tends to spread in area or in depth, it should be
scraped with a sharp spoon, and painted over with acid nitrate of
mercury, or a local hyperæmia may be induced by Klapp's suction
apparatus.
_In lesions of the mouth and throat_, the teeth should be attended to;
the best local application is a solution of chromic acid--10 grains to
the ounce--painted on with a brush once daily. If this fails, the
lesions may be dusted with calomel the last thing at night. For deep
ulcers of the throat the patient should gargle frequently with chlorine
water or with perchloride of mercury (1 in 2000); if the ulcer continues
to spread it should be painted with acid nitrate of mercury.
In the treatment of _iritis_ the eyes are shaded from the light and
completely rested, and the pupil is well dilated by atropin to prevent
adhesions. If there is much pain, a blister may be applied to the
temple.
_The Relations of Syphilis to Marriage._--Before the introduction of the
Ehrlich-Hata treatment no patient was allowed to marry until three years
had elapsed after the disappearance of the last manifestation. While
marriage might be entered upon under these conditions without risk of
the husband infecting the wife, the possibility of his conveying the
disease to the offspring cannot be absolutely excluded. It is
recommended, as a precautionary measure, to give a further mercurial
course of two or three months' duration before marriage, and an
intravenous injection of an arsenical preparation.
#Intermediate Stage.#--After the dying away of the secondary
manifestations and before the appearance of tertiary lesions, the
patient may present certain symptoms which Hutchinson called
_reminders_. These usually consist of relapses of certain of the
affections of the skin, mouth, or throat, already described. In the
skin, they may assume the form of peeling patches in the palms, or may
appear as spreading and confluent circles of a scaly papular eruption,
which if neglected may lead to the formation of fissures and superficial
ulcers. Less frequently there is a relapse of the eye affections, or of
paralytic symptoms from disease of the cerebral arteries.
#Tertiary Syphilis.#--While the manifestations of primary and secondary
syphilis are common, those of the tertiary period are by comparison
rare, and are observed chiefly in those who have either neglected
treatment or who have had their powers of resistance lowered by
privation, by alcoholic indulgence, or by tropical disease.
It is to be borne in mind that in a certain proportion of men and in a
larger proportion of women, the patient has no knowledge of having
suffered from syphilis. Certain slight but important signs may give the
clue in a number of cases, such as irregularity of the pupils or failure
to react to light, abnormality of the reflexes, and the discovery of
patches of leucoplakia on the tongue, cheek, or palate.
The _general character of tertiary manifestations_ may be stated as
follows: They attack by preference the tissues derived from the
mesoblastic layer of the embryo--the cellular tissue, bones, muscles,
and viscera. They are often localised to one particular tissue or organ,
such, for example, as the subcutaneous cellular tissue, the bones, or
the liver, and they are rarely symmetrical. They are usually aggressive
and persistent, with little tendency to natural cure, and they may be
dangerous to life, because of the destructive changes produced in such
organs as the brain or the larynx. They are remarkably amenable to
treatment if instituted before the stage which is attended with
destruction of tissue is reached. Early tertiary lesions may be
infective, and the disease may be transmitted by the discharges from
them; but the later the lesions the less is the risk of their containing
an infective virus.
The most prominent feature of tertiary syphilis consists in the
formation of granulation tissue, and this takes place on a scale
considerably larger than that observed in lesions of the secondary
period. The granulation tissue frequently forms a definite swelling or
tumour-like mass (syphiloma), which, from its peculiar elastic
consistence, is known as a _gumma_. In its early stages a gumma is a
firm, semi-translucent greyish or greyish-red mass of tissue; later it
becomes opaque, yellow, and caseous, with a tendency to soften and
liquefy. The gumma does harm by displacing and replacing the normal
tissue elements of the part affected, and by involving these in the
degenerative changes, of the nature of caseation and necrosis, which
produce the destructive lesions of the skin, mucous membranes, and
internal organs. This is true not only of the circumscribed gumma, but
of the condition known as _gummatous infiltration_ or _syphilitic
cirrhosis_, in which the granulation tissue is diffused throughout the
connective-tissue framework of such organs as the tongue or liver. Both
the gummatous lesions and the fibrosis of tertiary syphilis are directly
excited by the spirochætes.
The life-history of an untreated gumma varies with its environment. When
protected from injury and irritation in the substance of an internal
organ such as the liver, it may become encapsulated by fibrous tissue,
and persist in this condition for an indefinite period, or it may be
absorbed and leave in its place a fibrous cicatrix. In the interior of a
long bone it may replace the rigid framework of the shaft to such an
extent as to lead to pathological fracture. If it is near the surface of
the body--as, for example, in the subcutaneous or submucous cellular
tissue, or in the periosteum of a superficial bone, such as the palate,
the skull, or the tibia--the tissue of which it is composed is apt to
undergo necrosis, in which the overlying skin or mucous membrane
frequently participates, the result being an ulcer--the tertiary
syphilitic ulcer (Figs. 40 and 41).
_Tertiary Lesions of the Skin and Subcutaneous Cellular Tissue._--The
clinical features of a _subcutaneous gumma_ are those of an indolent,
painless, elastic swelling, varying in size from a pea to an almond or
walnut. After a variable period it usually softens in the centre, the
skin over it becomes livid and dusky, and finally separates as a slough,
exposing the tissue of the gumma, which sometimes appears as a mucoid,
yellowish, honey-like substance, more frequently as a sodden, caseated
tissue resembling wash-leather. The caseated tissue of a gumma differs
from that of a tuberculous lesion in being tough and firm, of a buff
colour like wash-leather, or whitish, like boiled fish. The degenerated
tissue separates slowly and gradually, and in untreated cases may be
visible for weeks in the floor of the ulcer.
[Illustration: FIG. 40.--Ulcerating Gumma of Lips.
(From a photograph lent by Dr. Stopford Taylor and Dr. R. W. Mackenna.)]
_The tertiary ulcer_ may be situated anywhere, but is most frequently
met with on the leg, especially in the region of the knee (Fig. 42) and
over the calf. There may be one or more ulcers, and also scars of
antecedent ulcers. The edges are sharply cut, as if punched out; the
margins are rounded in outline, firm, and congested; the base is
occupied by gummatous tissue, or, if this has already separated and
sloughed out, by unhealthy granulations and a thick purulent discharge.
When the ulcer has healed it leaves a scar which is depressed, and if
over a bone, is adherent to it. The features of the tertiary ulcer,
however, are not always so characteristic as the above description would
imply. It is to be diagnosed from the "leg ulcer," which occurs almost
exclusively on the lower third of the leg; from Bazin's disease (p. 74);
from the ulcers that result from certain forms of malignant disease,
such as rodent cancer, and from those met with in chronic glanders.
_Gummatous Infiltration of the Skin_ ("Syphilitic Lupus").--This is a
lesion, met with chiefly on the face and in the region of the external
genitals, in which the skin becomes infiltrated with granulation tissue
so that it is thickened, raised above the surface, and of a brownish-red
colour. It appears as isolated nodules, which may fuse together; the
epidermis becomes scaly and is shed, giving rise to superficial ulcers
which are usually covered by crusted discharge. The disease tends to
spread, creeping over the skin with a serpiginous, crescentic, or
horse-shoe margin, while the central portion may heal and leave a scar.
From the fact of its healing in the centre while it spreads at the
margin, it may resemble tuberculous disease of the skin. It can usually
be differentiated by observing that the infiltration is on a larger
scale; the progress is much more rapid, involving in the course of
months an area which in the case of tuberculosis would require as many
years; the scars are sounder and are less liable to break down again;
and the disease rapidly yields to anti-syphilitic treatment.
[Illustration: FIG. 41.--Ulceration of nineteen year's duration
in a woman æt. 24, the subject of inherited syphilis, showing active
ulceration, cicatricial contraction, and sabre-blade deformity of
tibiæ.]
_Tertiary lesions of mucous membrane and of the submucous cellular
tissue_ are met with chiefly in the tongue, nose, throat, larynx, and
rectum. They originate as gummata or as gummatous infiltrations, which
are liable to break down and lead to the formation of ulcers which may
prove locally destructive, and, in such situations as the larynx, even
dangerous to life. In the tongue the tertiary ulcer may prove the
starting-point of cancer; and in the larynx or rectum the healing of the
ulcer may lead to cicatricial stenosis.
Tertiary lesions of the _bones and joints_, of the _muscles_, and of the
_internal organs_, will be described under these heads. The part played
by syphilis in the production of disease of arteries and of aneurysm
will be referred to along with diseases of blood vessels.
[Illustration: FIG. 42.--Tertiary Syphilitic Ulceration in region of
Knee and on both Thumbs of woman æt. 37.]
_Treatment._--The most valuable drugs for the treatment of the
manifestations of the tertiary period are the arsenical preparations and
the iodides of sodium and potassium. On account of their depressing
effects, the latter are frequently prescribed along with carbonate of
ammonium. The dose is usually a matter of experiment in each individual
case; 5 grains three times a day may suffice, or it may be necessary to
increase each dose to 20 or 25 grains. The symptoms of iodism which may
follow from the smaller doses usually disappear on giving a larger
amount of the drug. It should be taken after meals, with abundant water
or other fluid, especially if given in tablet form. It is advisable to
continue the iodides for from one to three months after the lesions for
which they are given have cleared up. If the potassium salt is not
tolerated, it may be replaced by the ammonium or sodium iodide.
_Local Treatment._--The absorption of a subcutaneous gumma is often
hastened by the application of a fly-blister. When a gumma has broken on
the surface and caused an ulcer, this is treated on general principles,
with a preference, however, for applications containing mercury or
iodine, or both. If a wet dressing is required to cleanse the ulcer,
black wash may be used; if a powder to promote dryness, one containing
iodoform; if an ointment is indicated, the choice lies between the red
oxide of mercury or the dilute nitrate of mercury ointment, and one
consisting of equal parts of lanolin and vaselin with 2 per cent. of
iodine. Deep ulcers, and obstinate lesions of the bones, larynx, and
other parts may be treated by excision or scraping with the sharp spoon.
#Second Attacks of Syphilis.#--Instances of re-infection of syphilis
have been recorded with greater frequency since the more general
introduction of arsenical treatment. A remarkable feature in such cases
is the shortness of the interval between the original infection and the
alleged re-infection; in a recent series of twenty-eight cases, this
interval was less than a year. Another feature of interest is that when
patients in the tertiary stage of syphilis are inoculated with the virus
from lesions from these in the primary and secondary stage lesions of
the tertiary type are produced.
Reference may be made to the #relapsing false indurated chancre#,
described by Hutchinson and by Fournier, as it may be the source of
difficulty in diagnosis. A patient who has had an infecting chancre one
or more years before, may present a slightly raised induration on the
penis at or close to the site of his original sore. This relapsed
induration is often so like that of a primary chancre that it is
impossible to distinguish between them, except by the history. If there
has been a recent exposure to venereal infection, it is liable to be
regarded as the primary lesion of a second attack of syphilis, but the
further progress shows that neither bullet-buboes nor secondary
manifestations develop. These facts, together with the disappearance of
the induration under treatment, make it very likely that the lesion is
really gummatous in character.
INHERITED SYPHILIS
One of the most striking features of syphilis is that it may be
transmitted from infected parents to their offspring, the children
exhibiting the manifestations that characterise the acquired form of the
disease.
The more recent the syphilis in the parent, the greater is the risk of
the disease being communicated to the offspring; so that if either
parent suffers from secondary syphilis the infection is almost
inevitably transmitted.
While it is certain that either parent may be responsible for
transmitting the disease to the next generation, the method of
transmission is not known. In the case of a syphilitic mother it is most
probable that the infection is conveyed to the fœtus by the placental
circulation. In the case of a syphilitic father, it is commonly believed
that the infection is conveyed to the ovum through the seminal fluid at
the moment of conception. If a series of children, one after the other,
suffer from inherited syphilis, it is almost invariably the case that
the mother has been infected.
In contrast to the acquired form, inherited syphilis is remarkable for
the absence of any primary stage, the infection being a general one from
the outset. The spirochæte is demonstrated in incredible numbers in the
liver, spleen, lung, and other organs, and in the nasal secretion, and,
from any of these, successful inoculations in monkeys can readily be
made. The manifestations differ in degree rather than in kind from those
of the acquired disease; the difference is partly due to the fact that
the virus is attacking developing instead of fully formed tissues.
The virus exercises an injurious influence on the fœtus, which in many
cases dies during the early months of intra-uterine life, so that
miscarriage results, and this may take place in repeated pregnancies,
the date at which the miscarriage occurs becoming later as the virus in
the mother becomes attenuated. Eventually a child is carried to full
term, and it may be still-born, or, if born alive, may suffer from
syphilitic manifestations. It is difficult to explain such vagaries of
syphilitic inheritance as the infection of one twin and the escape of
the other.
_Clinical Features._--We are not here concerned with the severe forms of
the disease which prove fatal, but with the milder forms in which the
infant is apparently healthy when born, but after from two to six weeks
begins to show evidence of the syphilitic taint.
The usual phenomena are that the child ceases to thrive, becomes thin
and sallow, and suffers from eruptions on the skin and mucous membranes.
There is frequently a condition known as _snuffles_, in which the nasal
passages are obstructed by an accumulation of thin muco-purulent
discharge which causes the breathing to be noisy. It usually begins
within a month after birth and before the eruptions on the skin appear.
When long continued it is liable to interfere with the development of
the nasal bones, so that when the child grows up there results a
condition known as the "saddle-nose" deformity (Figs. 43 and 44).
[Illustration: FIG. 43.--Facies of Inherited Syphilis.
(From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_.)]
_Affections of the Skin._--Although all types of skin affection are met
with in the inherited disease, the most important is a _papular_
eruption, the papules being of large size, with a smooth shining top and
of a reddish-brown colour. It affects chiefly the buttocks and thighs,
the genitals, and other parts which are constantly moist. It is
necessary to distinguish this specific eruption from a form of eczema
which occurs in these situations in non-syphilitic children, the points
that characterise the syphilitic condition being the infiltration of the
skin and the coppery colour of the eruption. At the anus the papules
acquire the characters of _condylomata_, also at the angles of the
mouth, where they often ulcerate and leave radiating scars.
_Affections of the Mucous Membranes._--The inflammation of the nasal
mucous membrane that causes snuffles has already been referred to. There
may be mucous patches in the mouth, or a stomatitis which is of
importance, because it results in interference with the development of
the permanent teeth. The mucous membrane of the larynx may be the seat
of mucous patches or of catarrh, and as a result the child's cry is
hoarse.
_Affections of the Bones._--Swellings at the ends of the long bones, due
to inflammation at the epiphysial junctions, are most often observed at
the upper end of the humerus and in the bones in the region of the
elbow. Partial displacement and mobility at the ossifying junction may
be observed. The infant cries when the part is touched; and as it does
not move the limb voluntarily, the condition is spoken of as _the
pseudo-paralysis of syphilis_. Recovery takes place under
anti-syphilitic treatment and immobilisation of the limb.
Diffuse thickening of the shafts of the long bones, due to a deposit of
new bone by the periosteum, is sometimes met with.
[Illustration: FIG. 44.--Facies of Inherited Syphilis.]
The conditions of the skull known as Parrot's nodes or bosses, and
craniotabes, were formerly believed to be characteristic of inherited
syphilis, but they are now known to occur, particularly in rickety
children, from other causes. The _bosses_ result from the heaping up of
new spongy bone beneath the pericranium, and they may be grouped
symmetrically around the anterior fontanelle, or may extend along either
side of the sagittal suture, which appears as a deep groove--the
"natiform skull." The bosses disappear in time, but the skull may remain
permanently altered in shape, the frontal and parietal eminences
appearing unduly prominent. The term _craniotabes_ is applied when the
bone becomes thin and soft, reverting to its original membranous
condition, so that the affected areas dimple under the finger like
parchment or thin cardboard; its localisation in the posterior parts of
the skull suggests that the disappearance of the osseous tissue is
influenced by the pressure of the head on the pillow. Craniotabes is
recovered from as the child improves in health.
Between the ages of three and six months, certain other phenomena may be
met with, such as _effusion into the joints_, especially the knees;
_iritis_, in one or in both eyes, and enlargement of the spleen and
liver.
In the majority of cases the child recovers from these early
manifestations, especially when efficiently treated, and may enjoy an
indefinite period of good health. On the other hand, when it attains the
age of from two to four years, it may begin to manifest lesions which
correspond to those of the tertiary period of acquired syphilis.
#Later Lesions.#--In the skin and subcutaneous tissue, the later
manifestations may take the form of localised gummata, which tend to
break down and form ulcers, on the leg for example, or of a spreading
gummatous infiltration which is also liable to ulcerate, leaving
disfiguring scars, especially on the face. The palate and fauces may be
destroyed by ulceration. In the nose, especially when the ulcerative
process is associated with a putrid discharge--ozæna--the destruction of
tissue may be considerable and result in unsightly deformity. The entire
palatal portions of the upper jaws, the vomer, turbinate, and other
bones bounding the nasal and oral cavities, may disappear, so that on
looking into the mouth the base of the skull is readily seen. Gummatous
disease is frequently observed also in the flat bones of the skull, in
the bones of the hand, as syphilitic dactylitis, and in the bones of the
forearm and leg. When the tibia is affected the disease is frequently
bilateral, and may assume the form of gummatous ulcers and sinuses. In
later years the tibia may present alterations in shape resulting from
antecedent gummatous disease--for example, nodular thickenings of the
shaft, flattening of the crest, or a more uniform increase in thickness
and length of the shaft of the bone, which, when it is curved in
addition, is described as the "sabre-blade" deformity. Among lesions of
the viscera, mention should be made of gumma of the testis, which causes
the organ to become enlarged, uneven, and indurated. This has even been
observed in infants a few months old.
Occasionally a syphilitic child suffers from a succession of these
gummatous lesions with resulting ill-health, and, it may be, waxy
disease of the internal organs; on the other hand, it may recover and
present no further manifestations of the inherited taint.
_Affections of the Eyes._--At or near puberty there is frequently
observed an affection of the eyes, known as _chronic interstitial
keratitis_, the relationship of which to inherited syphilis was first
established by Hutchinson. It occurs between the ages of six and sixteen
years, and usually affects one eye before the other. It commences as a
diffuse haziness or steaminess near the centre of the cornea, and as it
spreads the entire cornea assumes the appearance of ground glass. The
chief complaint is of dimness of sight, which may almost amount to
blindness, but there is little pain or photophobia; a certain amount of
conjunctival and ciliary congestion is usually present, and there may be
_iritis_ in addition. The cornea, or parts of it, may become of a deep
pink or salmon colour from the formation in it of new blood vessels. The
affection may last for from eighteen months to two years. Complete
recovery usually takes place, but slight opacities, especially in the
site of former salmon patches, may persist, and the disease occasionally
relapses. _Choroiditis_ and _retinitis_ may also occur, and leave
permanent changes easily recognised on examination with the
ophthalmoscope.
Among the rarer and more serious lesions of the inherited disease may be
mentioned gummatous disease in the _larynx and trachea_, attended with
ulceration and resulting in stenosis; and lesions of the _nervous
system_ which may result in convulsions, paralysis, or dementia.
In a limited number of cases, about the period of puberty there may
develop _deafness_, which is usually bilateral and may become absolute.
_Changes in the Permanent Teeth._--These affect specially the upper
central incisors, which are dwarfed and stand somewhat apart in the gum,
with their free edges converging towards one another. They are tapering
or peg-shaped, and present at their cutting margin a deep semilunar
notch. These appearances are commonly associated with the name of
Hutchinson, who first described them. Affecting as they do the
permanent teeth, they are not available for diagnosis until the child is
over eight years of age. Henry Moon drew attention to a change in the
first molars; these are reduced in size and dome-shaped through dwarfing
of the central tubercle of each cusp.
#Diagnosis of Inherited Syphilis.#--When there is a typical eruption on
the buttocks and snuffles there is no difficulty in recognising the
disease. When, however, the rash is scanty or is obscured by co-existing
eczema, most reliance should be placed on the distribution of the
eruption, on the brown stains which are left after it has passed off, on
the presence of condylomata, and of fissuring and scarring at the angles
of the mouth. The history of the mother relative to repeated
miscarriages and still-born children may afford confirmatory evidence.
In doubtful cases, the diagnosis may be aided by the Wassermann test and
by noting the therapeutic effects of grey powder, which, in syphilitic
infants, usually effects a marked and rapid improvement both in the
symptoms and in the general health.
While a considerable number of syphilitic children grow up without
showing any trace of their syphilitic inheritance, the majority retain
throughout life one or more of the following characteristics, which may
therefore be described as _permanent signs of the inherited disease_:
Dwarfing of stature from interference with growth at the epiphysial
junctions; the forehead low and vertical, and the parietal and frontal
eminences unduly prominent; the bridge of the nose sunken and rounded;
radiating scars at the angles of the mouth; perforation or destruction
of the hard palate; Hutchinson's teeth; opacities of the cornea from
antecedent keratitis; alterations in the fundus oculi from choroiditis;
deafness; depressed scars or nodes on the bones from previous gummata;
"sabre-blade" or other deformity of the tibiæ.
#The Contagiousness of Inherited Syphilis.#--In 1837, Colles of Dublin
stated his belief that, while a syphilitic infant may convey the disease
to a healthy wet nurse, it is incapable of infecting its own mother if
nursed by her, even although she may never have shown symptoms of the
disease. This doctrine, which is known as _Colles' law_, is generally
accepted in spite of the alleged occurrence of occasional exceptions.
The older the child, the less risk there is of its communicating the
disease to others, until eventually the tendency dies out altogether, as
it does in the tertiary period of acquired syphilis. It should be
added, however, that the contagiousness of inherited syphilis is denied
by some observers, who affirm that, when syphilitic infants prove
infective, the disease has been really acquired at or soon after birth.
There is general agreement that the subjects of inherited syphilis
cannot transmit the disease by inheritance to their offspring, and that,
although they very rarely acquire the disease _de novo_, it is possible
for them to do so.
#Prognosis of Inherited Syphilis.#--Although inherited syphilis is
responsible for a large but apparently diminishing mortality in infancy,
the subjects of this disease may grow up to be as strong and healthy as
their neighbours. Hutchinson insisted on the fact that there is little
bad health in the general community that can be attributed to inherited
syphilis.
#Treatment.#--Arsenical injections are as beneficial in the inherited as
in the acquired disease. An infant the subject of inherited syphilis
should, if possible, be nursed by its mother, and failing this it should
be fed by hand. In infants at the breast, the drug may be given to the
mother; in others, it is administered in the same manner as already
described--only in smaller doses. On the first appearance of syphilitic
manifestations it should be given 0.05 grm, novarsenbillon, injected
into the deep subcutaneous tissues every week for six weeks, followed by
one year's mercurial inunction--a piece of mercurial ointment the size
of a pea being inserted under the infant's binder. In older children the
dose is proportionately increased. The general health should be improved
in every possible direction; considerable benefit may be derived from
the use of cod-liver oil, and from preparations containing iron and
calcium. Surgical interference may be required in the destructive
gummatous lesions of the nose, throat, larynx, and bones, either with
the object of arresting the spread of the disease, or of removing or
alleviating the resulting deformities. In children suffering from
keratitis, the eyes should be protected from the light by smoked or
coloured glasses, and the pupils should be dilated with atropin from
time to time, especially in cases complicated with iritis.
#Acquired Syphilis in Infants and Young Children.#--When syphilis is met
with in infants and young children, it is apt to be taken for granted
that the disease has been inherited. It is possible, however, for them
to acquire the disease--as, for example, while passing through the
maternal passages during birth, through being nursed or kissed by
infected women, or through the rite of circumcision. The risk of
infection which formerly existed by the arm-to-arm method of
vaccination has been abolished by the use of calf lymph.
The clinical features of the acquired disease in infants and young
children are similar to those observed in the adult, with a tendency,
however, to be more severe, probably because the disease is often late
in being recognised and treated.