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Syphilis, a treatise for practitioners online

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Treatment. — These graver lesions of ocular syphilis re-
quire sharp mercurialization, preferably by intramuscular in-
jection combined with repeated short, sharp courses of iodids.

For local treatment little can be done.^ Terrien speaks well
of pilocarpin hypodermically.

OPTIC NEURITIS

The optic nerve is said to contribute twenty-five per cent
of ocular syphilis. It is one of the common nerve lesions (cf.
page 372).

The symptoms of optic neuritis : viz., amblyopia, blind-
ness, flittering scotoma, and hemianopsia, may or may not be
due to lesions visible through the ophthalmoscope. Accord-
ingly, some cases (and they are the milder ones) are distin-
guished only by subjective symptoms, while others (and they
are the majority) show visible lesions of the papilla.

On the other hand, one may occasionally discover a choked
disk in a patient who shows no ocular symptoms.

Pathology. — Lesions of the optic nerve may be primary or
secondary; i. e., due to syphilis of the nerve itself or to lesions
of the surrounding parts. It is thus often associated with other
evidences of basilar meningitis, or gumma of the base of the
brain, or of the sphenoidal fissure, or within the orbit. The
commonest syphilitic cause of optic neuritis is basilar menin-

1 Subconjunctival injections of normal salt solution, gelatin (five per cent),
cyanid of mercury (i: 1,000), and iodo-iodid solution) iodin 0.02; potass, iodid.
2.; aq. ad 40) are commended for various ocular lesions. But the best authori-
ties do not favor such treatment. Cf. Bull, J.Am. Med. Ass'n., 1906, vol. xlvii,

P- 823.

29



420



SYPHILIS OF THE EYE



gitis. Although primary (intraocular) lesions of the nerve
are habitually associated with chorio-retinitis, and secondary
lesions with other evidences of syphilis of the nervous system,
it is not always possible to ascertain precisely the site of the
lesion; nor is it always a simple matter to decide whether a
secondary optic neuritis is due to syphilis or to brain tumor. ^
Apart from the diagnostic signs alluded to in the preceding
chapter (page 408) one must often apply the therapeutic
test.

The lesions visible by ophthalmoscope are neuro-retinitis,
papillitis, and optic atrophy. There is nothing distinctively
syphilitic about any of them. They may, therefore, be dis-
missed with brief mention.

Neuro-retinitis. — Already alluded to ; varies from sim-
ple hyperemia to marked congestion, edema, and blurring of
outline.

Papillitis. — Papillitis, or choked disk, is a condition of
marked edema. The nerve is much swollen and projects for-
ward from the surrounding retina. It is opaque, red, and
striated, its arteries small, its veins much congested, its edge
indistinct.

The cause of choked disk is interrupted venous return,
due in part to pressure upon, in part to inflammation of the
nerve. Its outcome, if neglected, is optic atrophy.

Optic Atrophy. — The optic nerve may atrophy " pri-
marily " or subsequently to chorio-retinitis or papillitis.

When the atrophy is " primary " the papilla gradually
loses its rosy color and becomes white or gray - ; its outline
is clean-cut, and the retinal vessels are not markedly changed.

Optic atrophy following papillitis, on the contrary, pro-

1 Bilateral optic neuritis is almost an infallible sign of basilar tumor or
meningitis.

2 Gray atrophy is usually due to tabes, white atrophy to cerebral cause; but
this rule is not without exceptions.



GUMMA OF THE UVEAL TRACT 421

duces a white or gray papilla with irregular vague outline,
and with tortuous retinal veins and slender sclerotic arteries.

Optic atrophy following chorio-retinitis shows the scars
of the choroidal exudate scattered over the fundus.

Symptoms. — There may be symptoms without ophthalmo-
scopic signs of optic neuritis, less often signs without symp-
toms, most often both together. The symptoms are similar
to those of chorio-retinitis, and consist chiefly of a gradual
loss of vision. Sudden and temporary improvement or diminu-
tion of vision is characteristic of disease of the optic nerve
rather than of the retina.

The disease may be checked by mixed treatment. But if
actual atrophy has occurred no treatment will restore sight.

Diagnosis. — The diagnosis is made by the ophthalmoscope,
with the reserve that the lesions are not always visible at the
onset.

Treatment. — As for the cerebral lesions, with which it is
usually connected.

GUMMA OF THE UVEAL TRACT

Iris. — Gumma of the iris has been mentioned; it is ex-
tremely rare.

Ciliary Body. — Panas ^ has collected thirty cases. The
gumma appears as a complication of iritis. The tumor in-
volves and pierces the sclerotic, appearing as a little granulat-
ing mass; it also invades the iris. It may be distinguished
from tuberculosis by the history and associated lesions. Instil-
lations of atropin and sharp mixed treatment are demanded.

Choroid. — Terrien has collected six cases, and says: " The
ophthalmoscope reveals a white neoplasm in the fundus. The
gumma is soon complicated by iritis, optic neuritis, and even
by rupture of the sclera at the point affected. It may be mis-

1 Arch, d' Ophthal., 1902, August, p. 485.



422 SYPHILIS OF THE EYE

taken for sarcoma, but the progress of the disease and effi-
ciency of (mixed) treatment should prevent this error,"



CONJUNCTIVAL SYPHILIS i

Slight congestion of the conjunctiva may accompany the
first general secondary outbreak; severe congestion, simulating
trachoma, is extremely rare.

Papular conjiinctiz'itis is a rare complication of iritis (or
of a papular eruption upon the skin of the eyelids). The
papules may be movable or attached (episcleritis).

Mucous papules and ulcers are sometimes seen upon the
edge of the eyelid.

Conjunctii'al guniinata have been noted. They are usually
single and situated at some distance from the cornea : they arise
from the subconjunctival tissue.

KERATITIS AND SCLERITIS

Interstitial keratitis is so uncommon in acquired syphilis, ^
and so characteristic of inherited syphilis that we may defer
its description (page 531).

Episcleritis without conjunctivitis is extremely rare. One
or more small tubercles appear near the cornea and adherent
to the sclera. It is usually a complication of iritis. It is dif-
ferentiated from rheumatic episcleritis by the absence of sen-
sitiveness (Terrien).

Scleritis is constituted by one or more similar tubercles
embedded in the sclera. Panas has suggested that these are
actually an extension of a gumma of the ciliary body.

Gumma of cornea and sclerotic are alleged, but not proven
to exist.

' Cf. Pusey, J. Am. Med. Ass'n., 1907, vol. xlix, p. S28.
2 ;My records contain only two cases.



ORBITAL LESIONS 423

SYPHILITIC TARSITIS

Occurs in the latter stages of syphilis, and is to be regarded
as a gummatous infiltration of the tarsus. Develops grad-
ually, and without noticeable pain. At its height there is
great enlargement of the lids, and their skin is reddened and
stretched. The tarsus itself feels hard, and does not allow
eversion of the lid, for examination; also appears pale and
lardaceous. The lashes fall out. The preauricular glands
swell. The course is tedious, affection lasting some weeks,
but yielding to specifics.

THE LACRYMAL APPARATUS

The Lacrymal Gland. — Syphilitic dacryoadenitis is ex-
tremely rare. It is characterized by a painless infiltration of
the gland, forming a little tumor in the upper and outer por-
tion of the lid. It is usually mistaken for tuberculosis.

The Tear Duct. — Syphilis of the lacrymo-nasal duct oc-
curs only in connection w^ith extensive ulcerations of the nose
or destruction of the nasal bones. The resulting stricture (after
the inflammation has been controlled) requires dilatation.

ORBITAL LESIONS

Osteoperiostitis and gumma of the orbital bones are im-
portant chiefly on account of their effect upon the eye.

Inflammation in the edge of the orbit excites the usual
symptoms of bone syphilis, i. e., localized pain and swelling,
and involves the lower lid in the inflammation. Deeper in
the orbit it may cause exophthalmos, optic neuritis, diplopia
(by muscle or nerve involvement), and even neuro-paralytic
keratitis, etc. It may terminate in resorption, gummy degen-
eration, or suppuration.



CHAPTER XXVIII

SYPHILIS OF BONE

Bone syphilis and brain syphilis resemble each other in
this important particular; either may manifest itself first by
pain (osteocopic pains, headache) at the time of the first gen-
eral outbreak of symptoms, and later the disease may follow
one of three courses, viz. :

1. The pain having been relieved by time or treatment no
further bone (or brain) lesions may appear, or

2. The pain may be followed (with or without an interval
of remission) by grave bone (or brain) lesions, or

3. The grave lesions may attack a bone (or brain) in
which no pain was felt at the onset of secondary symptoms.

Thus the early osteocopic pains, which have been already
described (page 263) need concern us here only inasmuch as
they may precede a graver lesion.

The bone may be secondarily involved by syphilis of the
surrounding tissues, or the inflammation be primary in the
bone itself or in its periosteum. Of the secondary lesions, the
only important ones are the bone lesions of nose and palate
already described (page 363). The chief primary lesions are
indicated in the table on the opposite page.

In this table all lesions, whether unilateral or bilateral,
periosteal or medullary, productive or gummatous, are grouped
together.

Bilateral Lesions. — Though .bilateral, symmetrical, peri-
osteal tenderness is preeminently an early symptom; bilateral
424



SYPHILIS OF BONE



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426 " SYPHILIS OF BONE

graver lesions are distributed relatively late. Of 37 recorded
bilateral lesions (31 tibial), 11 are of unknown date, 9 oc-
curred in the first three years, 8 in the next three, 3 in the
ninth, and i in the tenth, twelfth, thirteenth, fifteenth, and
twenty-first years.

Multiple Lesions. — Though diffuse lesions are not uncom-
mon, multiple, discrete lesions d piece of bone is
attempted, this may result either in leaving behind bone which
will subsequently necrose or in stirring up the lesion to re-
newed activity. The best plan is to push systemic treatment
and not to attempt the removal of sequestra until they are
freely movable. The only exception to this rule is the case in
which a large sequestrum encourages suppuration, especially
if it be in a cranial bone. For such a case prompt operation
is indicated for the removal of the sequestrum.^

Prognosis. — The prognosis depends almost entirely upon
the treatment. Bone lesions, however shocking in appearance,
are marvelously amenable to medication with the iodids. But
if the lesion is untreated, it is impossible to foretell in the
beginning how far it will go or exactly what character it will
assume ; whether it will be diffuse or circumscribed, productive
or destructive.

If treatment is begun at the onset, the lesion may be cured
and practically no scar remain. If a productive periosteal
lesion has already formed exostosis or hyperostosis before it
is controlled by treatment, we may not expect to reduce these
deformities any more than to dissolve the bones themselves.

Thus when a patient presents himself with extensive, irreg-
ular enlargement of a bone, and examination shows this en-
largement to be insensitive while the X-ray reveals it to be
composed of dense, eburnated bone, the patient should be put
upon a mild course of mixed treatment in order to eliminate

1 Voss, Dermat. Zeitschr., 1905, vol. xii.



LESIONS OF SPECIAL BONES



439



any possible remaining active process within this bone and to
minimize the probabihty of relapse; but he should not be en-
couraged to expect from any treatment the reduction of this
permanent deformity.

The only stage at which bone syphilis demands immediate
heroic treatment is when a gumma is developing rapidly and
threatening to soften or to break through the skin. Under
such conditions iodid should be pushed rapidly in the hope of
preventing the scar which will result if the skin is broken.
But, even though such lesions are brought rapidly under con-
trol, the unbroken skin may be left thinned and adherent to the
underlying bone and leave a scar almost as disfiguring as if
ulceration had occurred.

LESIONS OF SPECIAL BONES

The preceding description applies to bone syphilis in gen-
eral, but the lesions of certain special bones show peculiar char-
acteristics that merit some attention. We may note par-
ticularly the lesions of the cranial bones, of the fingers, of the
inferior maxilla, of the sternum, and of the vertebral column.

Cranial Bones. — Syphilitic lesions of the cranial bones
commonly affect the frontals and the parietals. They are often
multiple, are usually gummatous in character, and, as a rule,
begin in the periosteum covering the external table, though
they may originate in the diploe or upon the internal table.

When projecting externally, these lesions show no very
peculiar characteristics except their disfiguring character (great
swellings upon the head), and the rapidity with which they eat
into the bone, leaving it riddled and worm-eaten, as shown
in Fig. 57.

When they project within the cranium, however, whether
beginning on the internal surface or in the diploe, or having
eaten through the whole bone from the external surface, they



440



SYPHILIS OF BONE



promptly involve the meninges, and thence the brain, causing
localized headache and epileptiform convulsions, according to
the region of the brain involved.

If the lesion is entirelv internal, there may be no external
manifestation beyond a certain tenderness to pressure, and later,




^ij«J







Fig. 57. — Extensive Gummatous Destruction of Skull. (Lebert.)

as the bone becomes eaten away, a crackling of the outer shell,
as this yields under the finger.

If, on the other hand, the bone has been eroded and the
skin ulcerated, rapidly fatal, septic meningitis may result,
though it is surprising how frequently even these cases resist
infection.



LESIONS OF SPECIAL BONES



441



Syphilitic Dactylitis. — Syphilis of the phalanges may at-
tack one or more fingers or toes. It is usually single, and
attacks the index or middle finger. The proximal phalanx is
almost always the one attacked (Fig. 58). The toes are much
less frequently afifected than the fingers.

As Taylor has shown, the lesions of syphilitic dactylitis
may begin in any of the tissues of the fingers, but it usually
involves the whole of the phalanx, beginning as a periosteal
lesion or as an osteomyelitis. Taylor states that, if the process
begins in the soft parts, there is simply a chronic fusiform thick-
ening of all the tissues of the finger, the bone finally becoming




Fig. 58. — Syphilitic Dactylitis. (Piffard.)



involved; and this involvement of the bone beginning near the
metacarpo-phalangeal joint.

In the more common form of dactylitis that begins in the
bone, the external appearance is very much the same. The
finger is swollen but not reddened, and the process exists a



442 SYPHILIS OF BONE

long time before gummatous softening and ulceration occur.
Indeed, in some cases, spontaneous resolution may terminate
the inflammation.

Taylor states that the progress of syphilitic myelitis is
much more rapidly destructive than that of periostitis.

All of these lesions are much more common in children
than in adults, and therefore are usually seen in hereditary
rather than in acquired syphilis.

On account of the youth of the patient and the relative
painlessness of the inflammation the process is often neglected
for many months, and, as a result, the phalanx may be greatly
disfigured, either by destruction of the shaft of the bone or
by implication of the joints at either extremity. But when
seen early, it yields quite as readily as does any other form of
bone syphilis.

Inferior Maxilla. — The lower jaw may be affected by
osteoperiostitis or by gumma in any or all of its parts. But
the common lesion is destructive of a portion of the alveolar
border by acute gvmimatous inflammation. The process is sim-
ilar to necrosis of the palate and nasal septum.

The lesion begins with a swelling around the root of one
or more teeth. These soon become loose, and then in a few
days or weeks a portion of the alveolar process is shed and
the loosened teeth fall with it. Exceptionally, the inflamma-
tion may be checked with loss of little or no bone and with a
resultant deformity in the gum, which may not seriously impair
the vitality of the adjacent teeth; but, as a rule, even if
attacked early, one may expect to lose at least one tooth.

Of the three cases of syphilis of the upper jaw which I
have recorded, two were of this same nature, i. e., necrosis of
the alveolar process; the third was a gumma in the antrum.

Sternum. — In early sj^philis tenderness of the sternum, due
to periostitis and excited by tapping upon that bone, is only
less common than tenderness of the shins. But the later, more



LESIONS OF SPECIAL BONES 443

serious lesions of the sternum are far less common. There
may be osteoperiostitis or periosteal gimiina, or gumma of the
diploe.

The chief and most important peculiarity of these lesions
is that when they begin on the internal surface of the bone,
or extend thereto, they may invade the anterior mediastinum
and cause various symptoms, such as pericardial pain, attacks
of dyspnea, asthma, angina, or circulatory disturbances, on
account of pressure or of involvement of the pericardium or
pleura.

Vertebral Column. — Lesions of the vertebral column are
extremely rare. They have been most often recorded in the
cervical and in the dorsal region. Most of the cer\'ical lesions
are due to gumma of the posterior pharyngeal wall, whether
primarily periosteal or submucous.

The lesions are almost always found in the bodies of the
vertebra, though syphilis of the transverse and spinous proc-
esses has been recorded. The lesion assumes one of the fol-
lowing clinical types :

1. Pain. — Localized pain, often accompanied by sensitive-
ness and with the typical nocturnal exacerbation, is the com-
monest symptom, and may stand alone for many months.

2. Syphilitic pseudo-Pott's Disease. — Syphilis may imitate
Pott's disease of the spine very closely, destroying the bodies
of one or more vertebrae, causing pain, anchylosis, deformity,
secondary cold abscess (gumma) formation, with exudation
of fragments of bone and secondary invasion of the cord.
Such lesions occur almost exclusively in children, and may be
diagnosed from tuberculosis of the spine by the evidences of
other syphilitic lesions in the child or in its parents ; which evi-
dence is fortified by the beneficial effect of antisyphilitic treat-
ment.



CHAPTER XXIX

SYPHILIS OF JOINTS, MUSCLES, TENDONS AND APONEU-
ROSES, BURS^ AND TENDON SHEATHS

SYPHILIS OF THE ARTICULATIONS

Syphilis simulates every joint disease from rheumatism to
tuberculosis. Its lesions may be classified under the following
types :

Arthralgia.

Hydrarthrosis.

Pseudo-rheumatism.

Tertiary arthritis and osteoarthritis.

Deforming arthritis.

Syphilitic Arthralgia. — The special characteristics of syphi-
litic arthralgia are :

1. There is no discoverable lesion sufficient to account for
the pain.

2. Nocturnal exacerbation and relief by exercise.

3. Frequent in larger joints (shoulder, knee, elbow), rare
in smaller ones ; if polyarticular, one joint is usually much
more painful than any other.

4. Common with first onset of secondary symptoms; rare
later.

5. Unaffected by mercury; promptly relieved by small doses
of iodid.

Little need be added to this brief characterization unless

it be the statement that the pain varies greatly in intensity and

may not show the typical nocturnal exacerbation. Thus I have

recently been treating a man who, in the third year of his dis-

444



SYPHILIS OF THE ARTICULATIONS 445

ease, and while under systematic mercurial treatment, has per-
sistently complained of slight and indescribable sensations
about the left knee. No objective signs of disease could be
elicited, and the discomfort continued for fully six months
until he was put upon potassium iodid, gr. v, t.i.d. In two
days the discomfort disappeared.

Hydrarthrosis. — Syphilitic hydrarthrosis consists of a pain-
less joint effusion. It is quite rare. It is scarcely ever seen
except in the knee. If slight, the patient may overlook it ; even
if marked, it is rapidly absorbed under iodic medication.

The absence of trauma and of all sensitiveness differen-
tiates it from the ordinary traumatic hydrarthrosis. . More-
over, it occurs almost always in the first months of syphilis
and in connection with other lesions of the disease.

Syphilitic Pseudo - rheumatism. — " Secondary pseudo-
rheumatic arthropathy " (Fournier) is extremely rare. It sim-
ulates acute articular rheumatism in its local symptoms (heat,
swelling, pain, tenderness, redness), but it usually strikes only
one joint, never more than two or three. The knee is the joint
most often affected, the wrist, elbow, and ankle less frequently.

The notable distinction between syphilitic and true rheu-
matism consists in the absence of systemic disturbance or of
generalization in the former. There is never much fever, usu-
ally none ; no sweats ; no concentrated urine ; no cardiac impli-
cation. Moreover, the syphilitic lesion is an early one and
yields rapidly to iodids.

Tertiary Syphilitic Arthritis. — Tertiary syphilitic arthritis
is much more common than the secondary hydrops and rheu-
matism just described. My records show four cases of sec-
ondary hydrarthrosis of the knee during the first year and one
in knee and one in elbow during the second, while the tertiary
lesions are distributed as follows : ^

> The numbers in parentheses indicate numbers of cases when more than one.



446 SYPHILIS OF JOINTS, MUSCLES, ETC.

Knee, 14 cases at one, four (2), five, six, seven (2), eleven,
twenty-six, thirty-three years.

Elbow, 5 cases at four (2), five, six, fourteen years.

Shoulder, 2 cases at seven, twelve years.

Ankle, 2 cases at four, seven years.

In one case both knees were involved at seven years ; in one
ankle and elbow were involved at four years ; in one elbow and
knee at six years.

Pathology. — Tertiary syphilis of the joints usually origi-
nates in the capsule or ligaments, less often in the bones, rarely
in the synovial membrane or subserous tissue.

In the synovial membrane the lesions are congestion and
the production of warty excrescences, especially in the folds
and pockets. The warty growths may become fibrous
and form " joint mice " if neglected. There are subserous
infiltrations, and perhaps gummata, which open into the
joint. There is always considerable effusion. Long-neglected
cases result in a stiff joint from adhesions of the inflamed
serosa.

The cartilages are often the seat of gummata, which soften,
discharge, and finally heal, leaving rounded, depressed scars
quite characteristic of syphilis.

In the capsule there is general thickening with circum-
scribed areas of hard, fibrous infiltration. These are spoken
of as gummata, but they rarely break down.

The bone involvement is usually slight. In five of the syphi-
litic knees there was marked involvement of the condyles of
the tibia, in one the femur was implicated. The lesions are
the usual osteoperiostitis or gumma (Fig. 56) ; a slight degree
of the former is present in all severe cases.

Symptoms- — There is painless, usually gradual, enlarge-



Online LibraryEdward L. (Edward Loughborough) KeyesSyphilis, a treatise for practitioners → online text (page 31 of 41)