gonococcus. It is not an uncommon sequence of gonorrhoeal infection and
is serious in its effects. It usually occurs during the attack of a gonorrhoeal
infection of the urethra or vagina but has been observed to follow gonorrhoeal
conjunctivitis in children. It seems to be more common in men than in
women and may not appear until late in the attack or even during the chronic
stage of the infection. One or more joints may be attacked and the inflam-
mation at times involves articulations seldom affected by acute articular
rheumatism such as the intervertebral, temporo-maxillary, sterno-clavicular,
etc.

Pathology. The morbid changes present are by no means uniform.



132 THE INFECTIOUS DISEASES.

The inflammation may involve the tissues without the joint and spread along
the tendon sheaths or it may be intra-articular. In each case the synovial
membranes are affected and pus may or may not be present. From the ex-
udate the gonococcus may be grown and this organism is at times associated
with the common bacteria of suppuration.

Symptoms. A number of different clinical varieties of gonorrhoeal arthritis
have been described but it will suffice to mention two principal types, the
acute and chronic.

a. Acute gonorrhoeal arthritis differs in severity in different cases.
It may be evidenced only by slight pain and stiffness or in the more acute
instances one or more joints may become suddenly involved in severe inflam-
mation with pronounced pain, tenderness, redness and swelling. Intra-articular
fluid may be demonstrable upon palpation. If the exudate is purulent con-
stitutional symptoms are usually present. In the extra-articular form the
inflammation is prone to extend along the sheaths of the tendons. The
symptoms are persistent and ankylosis, more or less marked, may follow.

In general gonorrhoeal infection suppurative arthritis and endocarditis
may co-exist.

h. Chronic gonorrheal arthritis. In this condition there may be a
serous joint effusion or a chronic inflammatory process may involve the intra-
and extra-articular structures; in the former condition there may be little or
no pain but in the latter pain is usually present and associated with swelling
extending to some distance above and below the joint.

Gonorrhoeal arthritis is especially prone to affect the knees, wrists and
ankles and relapses are frequent. Its course is often protracted and
obstinate.

Complications are not rare and may be serious. Iritis, pericarditis, myo-
carditis, endocarditis, pleurisy and septic pneumonia have been observed.

The diagnosis when there is present a iu:ethral discharge is simple, but
in other instances must be based upon the presence of gonococci in the blood
or in the articular effusion. In the acute form the pain is more severe and the
tendency to periarticular involvement greater than in acute articular rheu-
matism; the latter is said to be more likely to affect several joints in succes-
sion while an arthritis of a single joint is to be considered as more prob-
ably of gonorrhoeal origin.

Treatment consists firit in the employment of local measures with the
intent of curing the local genital inflammation if this is present. In general
constitutional infection iodine is the most reliable agent and good results
may be obtained by the administration of the syrup of hydriodic acid in doses
of ^ an ounce (15.0) half an hour before meals in two ounces (60.0) of water.
The mode and time of administration are important since the drug is some-
what irritant to the stomach. If not well borne 10 percent, of resublimed



I



GONORRHCEAL INFECTIONS. I33

iodine in oil of sesame may be employed in doses of 10 to 20 minims (0.66 to
1.33) every three hours. Iodine so given is taken into the blood stream as is
proven by the fact that the saliva gives the starch-iodine reaction within 20
minutes after the administration of a dose per rectum. The above treatment
is also to be prescribed in gonorrhoeal arthritis and endocarditis in connection
with inunctions of colloidal silver ointment (unguentum Crede), | an ounce
(15.0) into each affected joint three times a day. Within 6 to 10 days after
the commencement of such treatment a noticeable improvement in the arthritic
symptoms should be apparent.

Syrup of iron iodide in doses of 10 minims (0.66) to one drachm (4.0) three
times a day has also been recommended and the internal administration of
the preparations of mercury has its advocates. The salicylates seem to be
wholly useless.

Favorable results have been reported from the treatment of gonorrhoeal
arthritis by means of Bifr's method of passive congestion. The technique
of the treatment consists in the application of an Esmarch bandage just long
enough to encircle the limb two or three times at the desired tension and
provided with strap and buckle at either end. The bandage is applied just
above the affected joint and is secured when the desired degree of congestion
has been obtained. The skin may be protected by a few turns of an ordinary
bandage, and to avoid stasis in parts where it is not needed that part of the
limb which lies peripherally to the infected area may be snugly bandaged.
The congested limb should not be allowed to become cold to the touch and
the patient should not be made uncomfortable. The congestion should be
continued for from 10 to 12 hours at a time and, while the strap is off, the
limb should be elevated to reduce the oedema which the constriction has
produced. Upon the subsidence of acute symptoms massage and passive
motion should be instituted. In general the duration of the stasis should
depend upon the effect obtained. If the pain is relieved in an hour or two
and motion becomes less difficult, this length of time is sufficient, but if the
symptoms soon return a longer application of the bandage is necessary. In
the chronic effusion following acute inflammation this form of treatment is
useless.

With regard to local treatment other than that by the silver inunctions,
absolute rest of the affected joints is to be insisted upon and it may be advisable
to apply a splint. This, however, should not be allowed to remain in place
long enough to cause ankylosis. The continued application of a 10 percent,
ichthyol ointment in the intervals of the silver inunctions may assist in the
reHef of pain.

The more chronic forms of joint involvement may be relieved by counter-
irritation by blisters or the thermo cautery, baking in the hot air apparatus
is to be recommended and the absorption of the effusion may be facilitated



134 THE INFECTIOUS DISEASES.

by massage and passive movements. These last also are an excellent means
combating the tendency to ankylosis.

Constitutional treatment by means of iron, arsenic, quinine and strych-
nine is important, especially in the chronic cases.

Surgical treatment, consisting of opening the joint, evacuating the effusion
and irrigating with mild antiseptics or sterile saline solution, has its advocates
and in many instances has achieved excellent results. r

SYPHILIS.

Syyionynis. The Pox; Lues Venerea.

Definition. A specific constitutional disease of slow course resulting
from inoculation or from hereditary transmission. The disease when inocu-
lated is known as acquired syphilis and when conferred by inheritance as
hereditary s}'philis. In the acquired form there appears at the site of inocula-
tion the so-called initial lesion or chancre which is usually an ulcer possessing
special characteristics. This is followed within a month or two by consti-
tutional manifestations and lesions of the skin and mucous membranes, the
symptoms of the secondary stage, and after months or years by gummatous
growths in the various tissues and organs, the tertiary lesions, and finally there
may appear various morbid conditions in the nen'ous system such as locomotor
ataxia and general paresis, which are known as quaternary lesions.

.etiology. AATiile several micro-organisms have been described, which
have been thought responsible for this disease, their connection with the infec-
tion has not yet been definitely proven. Recently Schaudinn and Hoffmann
have drawn attention to micro-organisms of the genus spirochaeta, which they
have found in primary and secondary S}-philitic lesions, both at their surfaces
and in their deeper parts and in the adjacent lymphatic glands. The former
observer considers that the spirochsetae are related rather to the protozoa
than to the bacteria and must, therefore, be clearly distinguished from the
spirilla. He describes two varieties, one found only in S}^hilitic lesions, the
other, saprophytic in nature and constantly met in stagnant secretions such
as those occurring about the genitals. The former is termed the spirochcBta
pallida, the other the spirochceta rejringens. The former is much the smaller
and is seen only wnth the higher powers of the microscope and even then,
with difficulty.

Metchnikoff and Roux have found identical forms in experimental syphilitic
lesions in monkeys and other observers have wholly confirmed the work of
Schaudinn and Hoffmann. The spirochaeta pallida has been found in the
blood and organs of infants suffering from congenital syphilis and in acquired
syphilis in the blood procured by splenic puncture on the day before the
roseolar rash appeared, proving that it reaches the skin through the blood-



SYPHILIS. 135

vessels. Later it has been demonstrated in the circulating blood. In acquired
syphilis it is found only during the primary and secondary stages, practically
never during the tertiar}^ Most authorities agree that the spirochseta is never
to be found in non-s\^hilitic lesions, one or two have, however, encountered
it in other conditions. The balance of evidence seems to favor the aetiologic
relation of the spirocheta pallida to syphihs and the most conservative admit
that it probably plays some part in the causation of the disease.

Syphilis is an extremely contagious disease but a solution of the continuity
of skin or mucous membrane is necessary' to its inoculation. The secretions
of the primary- and secondary lesions as well as the blood of the syphilitic
patient are capable of transmitting the infection but the authorities differ as
to whether the products of the tertiary manifestations, the gummata, are
infectious. It is probable, however, that they are. Normal secretions, such as
milk, tears, etc., unless contaminated by the secretions of specific lesions are
not capable of conferring the disease. The spermatozoa or ova of syphihtic
individuals are, however, infectious.

In most instances the acquired form of the disease resuhs from sexual
congress but the infection may be acquired innocently through the use of
infected drinking cups or other utensils, by kissing, by the physician during
operation or while handling infected patients, and in various other ways.
The wet nurse may be infected by the s^-phihtic child, the initial lesion appear-
ing upon or near the nipple and the disease has been transmitted by vaccina-
tion with humanized virus.

Hereditary specific disease is most commonly transmitted through the
father in which case it is termed sperm infection. A syphilitic father may
beget diseased oft'spring during the tertiary stage when all symptoms seem to
have disappeared but he is most likely to beget a s}^hihtic child soon after
the beginning of his infection; on the other hand the child of a syphilitic father
may show no evidence of the disease when begotten diiring the tertiary stage
or even when begotten while the disease is at its height. No certain assertion
can be made that a father once infected with syphihs will not transmit the
disease to his children but it may be stated that the greater the period since
the occurrence of the initial lesion, the less likely are the children to be
afiected. At least three years, during which the individual should undergo
proper treatment, should elapse between the initial lesion and marriage.

S>3)hilis transmitted through the mother is termed germ infection and is
more likely to prove fatal than sperm infection. A child may also be infected
during its passage through the parturient canal or, the mother acquiring the
disease during pregnancy, the child may escape or may become infected
through the placenta. It is a curious fact (Colles' law) that a s)Tphilitic infant
bom of a non-syphihtic mother cannot transmit the disease to her, even
though she nurse it while there exist syphilitic lesions upon its lips or withm



136 THE INFECTIOUS DISEASES.

its mouth. This is probably due to an immunity possessed by the mother
and which has been conferred without the manifestations of any symptoms
whatever.

Children born of parents who are both s}^hilitic are ver}^ unlikely to escape
the disease.

Pathology of acquired syphilis. The lesions of this form of the
infection occur in stages the first being that of the primary lesion or chancre.
This appears at the site of the inoculation and usually about three weeks
after this occurrence. At first it consists of an abrasion upon which a papule
or vesicle appears; later this disintegrates at its center and an ulcer results, the
base and edge of which are firm and indurated. It varies in size and may
be unnoticed if it occurs within the urethra and is especially likely to be over-
looked in the female. In the male it is usually upon the penis and frequently
upon the prepuce, while in females a frequent site is upon the labia or upon
the cervix. Microscopically the indurated tissue is found o be the lesult of
an infiltration of the connective tissue with small round cells, some of which
may later become epithelioid or even giant cells. The intima of the vessels
is thickened and the nerve fibres may be the seat of pathological change.
The neighboring lymph ganglia are enlarged, hardened and may sup-
purate.

The lesions of the secondary stage consist of a cutaneous eruption or syphil-
ide. This rash occurs in a variety of difi'erent forms, macular, papular,
pustular, squamous and tubercular; the hue of these is characteristic and
may be described as ham or copper color. The macular s^philide usually
lasts one or two weeks and is especially apparent upon the chest, abdomen
and flexor surfaces of the arms; the papular eruption occurs upon the face
as well as upon the body and like the others tends toward a symmetrical distri-
bution. The pustular rash is not unhke that of variola and the squamous
syphilide possesses nothing t}^ical except its color; it is a rare form and its
favorite situation is upon the extensor surfaces of the limbs. AU forms
of the eruption are characterized by a tendency to symmetrical distribution
and to leave behind a more or less permanent discoloration.

With the cutaneous manifestations an involvement of the mucous membranes
and of moist skin surfaces occurs; this is termed the mucous patch or broad
condyloma [condyloma latum). These appear upon the buccal and pharjmgeal
mucous membranes and at the muco-cutaneous junctions about the lips,
anus, etc., and consist of a cellular infiltration of the epidermis and corium.
The mucous patch is a flat or slightly convex pearl colored elevation, with a
surface resembling mucous membrane, the secretion of which is highly
contagious. The condylomata are exaggerated mucous patches and consist
of rounded discs, reddish or grayish in color, granular of surface and slightly
elevated. The secretion of these is also pronouncedly infectious. The



SYPHILIS. 137

venereal wart* or condyloma acuminatum is also a manifestation of the second-
ary stage.

The lesions of the third stage may involve any of the deeper tissues or
organs and consist of discrete tumors (gummata). These are usually firm
in consistency and vary in size from that of a pin point to a diameter of from
one to iv70 inches (3 to 5 cm.). On section they are seen to consist of a central
area firm and caseous, surrounded by a layer of fibrous tissue outside which
is an external layer of cellular granulation tissue.

Such gummata are common in the skin, muscles, periosteum, bone — ^where
they are termed nodes — and in the connective tissue of the brain and viscera.
When situated in submucous tissues ulceration or suppuration may result
with destruction of tissue such as is observed in syphilitic disease of the
nasal or palatal bones.

Arterial changes also occur as a result of tertiary syphilis. These will be
considered in the section devoted to arterial disease (p. 593).

Symptoms of acquired syphilis. These occur in stages and are intimately
associated with the morbid changes above described. The incubation
period of the disease is usually about three weeks, that is to say about this
time intervenes between the inoculation and the appearance of the primary
lesion or chancre. This and the associated glandular enlargements have
been considered.

The symptoms of the secondary stage usually appear in from 6 to 12 weeks.
First there is a pharyng' al congestion with soreness of the throat. Sluggish
ulcerations of a gray color are seen upon the mucous membranes of the throat
and larynx, those in the latter situation being likely to cause deformity of
the part upon healing. Mucous patches and condylomata may be present.
There is usually a moderate febrile movement which seldom rises higher
than 101° F. (38.3° C.) although temperatures of 104° to 105° F. (40° to
4o.5°C.) have been observed. The temperature is usually continuous or
remittent; less frequently it is intermittent and may be mistaken for malaria.
The pharyngeal inflammation may involve the middle ear by extension
through the Eustachian tube.

Cutaneous lesions now appear; the most frequent is the macular syphilide
previously mentioned. The rash lasts for two or three weeks and may be
followed by other forms of the syphilitic eruption. Recurrences of the rash
may occur at intervals even as late as 11 years after the initial lesion. The
hair often falls and there may be a syphilitic onychia. Iritis is common
and may be serious. Choroiditis and retinitis are more rarely observed.
Joint symptoms, at times so marked as to suggest acute articular rheuma-
tism, and pains in the limbs are not unusual. Jaundice, nephritis, parotitis
and epididymitis may occur. Anaemia is very common.

The tertiary stage cannot be distinctly separated from the secondary.



138 THE INFECTIOUS DISEASES.

During this stage the characteristic manifestations are various cutaneous
eruptions, amyloid degenerations and involvement of the viscera by gummy
tumors.

The tertiary syphilides are usually deep seated, tend to ulcerate and may
subsequently heal, leaving scars. They may be scattered over the body and
are seldom symmetrical. Syphilitic rupia consists of pustules, ulcerated
at the base and covered by a laminated crust.

Hereditary sjrphilis may be evidenced by all the morbid changes and
symptoms which are met in the acquired form of the disease except the pri-
mary lesion. Still-births and abortions are very frequent consequences of
foetal syphilis but the appearance of the newly-born syphilitic child is often
that of health, the syphilitic manifestations appearing after a month or two;
at other times the subject of syphilitic inheritance is poorly developed^
ill-nourished and shriveled in aspect; skin eruptions are frequent and the
so-called pemphigus neonatorum, a bullous rash about the wrists and ankles,.
hands and feet, is typical. The liver and spleen are enlarged, the lips are
wrinkled, fissured and ulcerated and the child snuffles; the discharges are
infective and may be sero-purulent or sero-sanguinolent; bone necrosis at
the bridge of the nose may lead to the characteristic deformity. Middle-ear
involvement may take place through the Eustachian tube. If the child is
apparently healthy at birth the above described symptoms may appear up
to the sixth month.

The cartilages of the ribs and those of the epiphyses of the long bones
are very commonly affected and even epiphyseal separation may take place.
The child nurses poorly, is restless and a typical cry described as harsh and
high-pitched has been observed. Haemorrhages into the skin, from the mucous
membranes or from the umbilicus (syphilis hcsmorrhagica neonatorum) are a
rather rare manifestation.

If the child survives its growth is stunted and it is likely to present the
appearance of premature age. Under proper treatment recovery may take
place and while development may be delayed the disease may not give further
symptoms. As a rule, however, further syphilitic manifestations appear
at the time of second dentition or at puberty. The subject of hereditary
syphilis who survives childhood is under-developed and looks younger than
his age (infantilism), the frontal region is prominent, the frontal bosses protrude,
the bridge of the nose is depressed (saddle-nose) and its tip turned up. Cran-
ial asymmetry may be present and the teeth are notched (Hutchinson teeth).
Those particularly affected are the upper central incisors which are peg-
shaped and notched at the edges, the enamel often being wanting over the
notches.

Amongst other manifestations which are late in appearance are bone
deformities, especially of the tibiae which are thickened and curved antero-



SYPHILIS. 139

posteriorly, the convexity being forward; nodes may be present upon the
bones; interstitial keratitis, iritis, syphilitic deafness and gummata of the
nervous system or of the viscera may be observed.

The diagnosis of syphilis is not difficult in the presence of a history of
exposure or of heredity. There may be difficulty in deciding upon the char-
acter of the initial sore, consequently it is well to wait until the appearance of
secondary lesions before beginning treatment. The test of treatment by
mercury and iodine will usually clear the diagnosis in doubtful cases.

Justus' test consists in first estimating the haemoglobin content of the blood,
then ordering a mercurial inunction or injection and subsequently making a
second haemoglobin estimation. In cases of syphiHs there will be a reduction
of from 10 to 20 percent. This test is based upon the fact that mercury
causes a destruction of the haemoglobin which is rapidly replaced under
normal conditions. In the syphilitic subject, however, this power of repro-
duction is greatly diminished.

The prognosis in acquired syphiUs under early and proper treatment is
good but the length of time necessary to assure a cure is at least two years;
consequently syphilitics should be strongly advised against marriage within
two years after the appearance of the initial lesion; if active symptoms remain
at the end of this period marriage should be forbidden as long as these per-
sist. Even in individuals who have undergone thorough treatment it is
not unusual to observe late compHcations referable to the nervous system.
The prognosis of infantile syphilis is not so good as that of the infection in
adults and hereditary infantile syphilis is much more grave than that acquired
after birth. Even the subjects of hereditary syphihs who survive are ren-
dered so weak of constitution by the disease that they fall an easy prey to
even slight intercurrent affections.

Treatment. The prophylaxis of syphilis acquired through illicit inter-
course can only be instituted by insisting upon the absolute importance of
sexual purity. The physician who advises the performance of the sexual act
under illegitimate conditions cannot be too strongly condemned. The
young man who finds his fleshly lusts too vigorous to be denied may do much
to subjugate them by working hard physically and mentally.

Practitioners associating with syphilitics in a professional capacity cannot
be too guarded in their handling of specific lesions.

Much may be done toward the prevention of hereditary syphilis by treating
the mother during pregnancy if she has ever been affected with the disease
or if the father is syphilitic. Syphilitic lesions of the genital tract should
be cleansed and cauterized previous to labor. Should the child be born
healthy it should never be nursed by a suspected mother or wet nurse, it should
not be kissed by nor sleep with diseased parents and the greatest care should
be exercised in rendering utensils and other objects with which the child comes



I40 THE INFECTIOUS DISEASES.

into contact above reproach. No syphilitic child shoiild be allowed to nurse
from a healthy woman.

The treatment of the primary lesion consists in the endeavor to heal it as
soon as possible. This is to be accomplished by simple cleanliness. The
sore sjioiild be washed with a i to 2 or 3000 mercury bichloride solution