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buttocks, thighs, and forehead. Another early eruption is the papular.
The papules are small, hard, and do not ulcerate, while their favorite
seats are the scalp, chest, and dorsum of the tongue. The distribution
of these early syphilids is symmetric ; their outlines are rounded ; their
color like that of a slice of raw ham ("' coppery") ; they are polymor-
phous ; and, as a rule, they excite neither pain nor itching.

Other and later-appearing eruptions may be squamous, vesiculo-pap-
ular, pustular, and tubercular. These shoAv a tendency to bunch in
certain ar^as, and hence are less difiuse than the afore-mentioned erup-
tions. Several sub-varieties, however, may appear simultaneously.

The visible mucous membranes (angles of the mouth, tongue, gums,
pharynx, vulva, vagina, penis, and around the anus) and the skin
may show painful condylomata or mucous patches, and especially is
this the case in the mouth, where they often stubbornly resist treat-
ment. Recurrences at varying and ever-decreasing intervals are quite
common.

Other frequent symptomatic conditions arise during this secondary
period, such as iritis, laryngitis (frequently), choroiditis, retinitis, epi-
didymitis (more rarely), and alopecia. The hairs of the eylids and eye-
brows may fall off and the finger-nails become brittle.

The secondary symptoms last from two to three months (the usual
duration) to a year or more, and are followed by a period of apparent

^ " Himterian Lectures," Lancet, 1896, No. 3889.



SYPHILIS. 333

good health lasting for an exceedingly variable interval (from a few
months to many years) before the tertiary stage sets in. During the
secondary stage the symptoms may be severe, mild, or even absent. The
severity of an attack of syphilis depends upon the dose of infecting
virus on the one hand, and upon the condition (both local and general)
of the vital functions on the other. This fact explains why a single
organ or system, as the brain and cord, is attacked in one instance and
some other organ or system in another, and the effect of traumatism in
determining the topography of periosteal "nodes" is a good example.

(c) Tertiary Stage. — As I have already stated, the secondary period
is generally followed by a variable interval of freedom from symptoms,
but to this rule there are numerous exceptions, and among not uncom-
mon occurrences may be witnessed the appearance of tertiary symptoms
during the secondary stage. Belonging to the third stage are certain
skin-eruptions, especially the characteristic ruina, which first appears
in the form of pustules that break and form ulcers that are covered with
dry, laminated crusts " like an oyster-shell." To this stage also belongs
psoriasis, especially of the hands and feet. Pustules {tubercular) which
do not scale over also appear. These eruptions involve the true skin,
and in healing leave scars, but, unlike the secondary cutaneous lesions,
they are neither infectious nor contagious, are not, as a rule, symmetric,
and are more liable to be attended by itching. True gummata may
develop in the skin and subcutaneous tissue, and these break down and
form kidney-shaped ulcers which tend to spread in a serpiginous man-
ner. On healing (a process that is accomplished with difficulty), scars
result. Gummata may occur in the mucous membranes, and pass
through the stages of ulceration and cicatrization. When situated in
the larvnx or trachea their healino- is attended with narrowing of the
organ, and when in the lower bowel or the rectum dysenteric symptoms,
followed by actual stenosis, may result.

In the muscles gummata occur and form small hard tumors. They
may also cause periostitis and death of the bones, especially of the nose,
palate, and skull; "nodes " are thus formed, Avhich are situated chiefly
upon the tibia and the skull in larger or smaller numbers, and also,
though less frequently, upon other bones. These are exceedingly pain-
ful, particularly at night, and are very tender under the pressing finger.
They may be true gummata, but more often, if not absorbed, they either
become ossified or undergo fibroid change, while in rarer cases they
suppurate. Chronic enlargement of the lymphatics and of the testicle,
with little tendency to suppuration, may be noticed. The pregnant
female is apt to abort or miscarry, either as the result of the action of
the syphilitic virus upon the ovum or of the presence of gummatous
growths in the placenta.

Gummata also occur in the internal organs {visceral syphilis), and of
the latter I shall speak presently, taking up separately some of the
various organs and systems of the body. Amyloid degeneration is
frequently caused by the acquired form, particularly syphilis of the
rectum in women, but very rarely by the congenital.

Malignant Syphilis. — By this term is meant a virulent and a fatal
form of the malady, which is fortunately rare. The various stages
manifest themselves early, and especially the tertiary, as on the forty-



334 INFECTIOUS DISEASES.

fifth day in a case of Mauriac. The course is rapid and the condition
resists all forms of treatment. Roussel narrates a case in which death
occurred about one year after the commencement of the disease.

Clinical Symptoms of Congenital Syphilis. — These may,
though rarely, be identical ^vith those of acquired syphilis, if we except
the chancre.^ Occasionally the characteristic symptoms are present at
birth. On the other hand, in the vast majority of instances they appear
between the first and fourth months of life [infra). The symptoms of
inherited syphilis may be grouped according to the time of appearance:

(1) In the New-born. — There is a lack of physical development.
The babe may be greatly emaciated, it has snuffles, and singultus occa-
sionally sets in soon after birth. Skin-eruptions are rare, except pem-
jjhigus neonatorum, which appears as bullae on the palms and soles;
among exceptional cutaneous phenomena are gummata around the radio-
carpal articulations, palmar psoriasis, and a fleeting roseola. Ulcers
and fissures (rhagades) may be noticed around the outlets of the body
(mouth, anus, etc.) ; the osseous system may show hyperostoses of the
long bones ; and the liver and spleen are enlarged. Comby reports 8
cases of pseudo-paralysis due to syphilis in the new-born.

(2) Early Post-natal Symptoms. — Most subjects of syphilis heredi-
taria are born plump and without taint. Romiceano - gives the results
of his observations of 723 cases of infantile syphilis in which the dis-
ease appeared chiefly between the first and fifth months, and only 27
times in all after the sixth month. Rogers's statistics show that among
249 cases, 217 showed symptoms before the end of the third month.
The first symptom is generally coryza (syphilitic rhinitis), Avhich is be-
trayed by a sero-purulent or bloody discharge and a peculiar form of
obstructed breathing (snuffles), rendering nursing difficult. The coryza
may in some cases be preceded by singultus lasting ten or twenty days
(Carini), and ulcers may form in the nose, leading to necrosis of the
bones and producing at last a sunken and deformed nose which is highly
significant. The coryza may extend to the middle ear and cause otitis
media, with deafness and otorrhea as the chief symptoms. The skull
may approach the natiform in shape, and the signs of diaphyso-epiphys-
eal inflammation develop.

The cutaneous symptoms appear early. The skin has a tawny hue,
and an erythematous eruption of the nates and genitals is frequently
seen ; this is patchy, with well-defined margins, and has the character-
istic coppery color. In the same localities papules may appear, while
pemphigus may attack the palms and soles. Syphilitic onychia may be
present, and the lips and angles of the mouth often show fissures that
are of real diagnostic Avorth. Other symptoms are ulcerations of the
skin and mucous surfaces, falling of the hair, and a moderate glandular
enlarc^ement.

Enlargement of the sjjleen is a frequent characteristic symptom, and
"White says that the enlargement of the organ when ''painless, subacute,
persistent, often preceding the eruptions, should be included in the list
of significant symptoms."

Swelling of' the liver may also be present, but is of little diagnostic
import. Syphilitic infants occasionally manifest a hemorrhagic tendency.

^ With prenatal syphilis ^ve are not concerned. ^ La ProgrU medicale, Paris.



SYPHILIS. 335

At birth bleeding from the umbilicus may occur ; later, into the sub-
cutaneous tissue and from the mucous membranes (gastro-intestinal,
vaginal, nasal, etc.). Hecker ^ considers an examination of the umbilical
cord important for the early recognition of syphilis in the offspring of
syphilitic parents ; if the microscope shows characteristic changes, time
may be gained for treatment; "these changes range from a decided
endarteritis or periarteritis or phlebitis to a simple round-celled infiltra-
tion of the blood-vessel walls or the surrounding tissue." As pointed
out by Osier, these cases must not be confounded with Winckel's disease.

Among nervous symptoms, restlessness, sleeplessness, and a harsh,
shrill cry which may be almost constant for days together and due most
probably to darting pains, are the chief. Anemia and other evidences
of syphilitic cachexia soon supervene.

(3) Late Symptoms. — The symptoms of syphilis hereditaria tarda
may be arranged in groups (Fournier) :

(1) Those Indicated by the Creneral Appearance. — There is a retarded
general development, as shown by the small stature, undeveloped muscles,
the graceful form, and infantile appearance at ages varying from four to
twelve or more years. The skin has an earthen tint, and the hair may
be scanty and late in its appearance on the face and genitals.

(2) Skin-cicatrices. — Cutaneous scars, particularly if multiple and
extending over a circumscribed area, are important diagnostic signs.
Their form is usually round or serpiginous, and their chief location the
mouth, nose, soft palate, and lumbo-gluteal regions.

(3) Lesions of the Skeleton. — The natiform skull, " with a transverse
enlargement, lateral bulgings, and the flattening in the middle," is
almost pathognomonic. Asymmetric and hydrocephalic skulls are also
to be considered, in many cases, as signs of hereditary syphilis, as is a
sunken and deformed nose. The thickened, "sabre-shaped" tibia, due
to gummatous periostitis, is capital evidence of the disease, while the
chicken-breasted thorax is significant.

(4) The testicles show an arrest in development (infantile testicles).
This is a sclerotic atrophy.

(5) Hutchinson s triad, under which title come (a) the Hutchinson
teeth ; (6) ear-conditions ; and (c) affections of the eye.

(a) The Hutchinson Teeth. — The teeth may be late in appearing, and
the dental arch may be malformed, the teeth presenting various irregu-
larities in form and condition (dental dystrophy).

The incisors, especially the superior median of the second dentition,
are notched, and show a thinness of the free edge, an atrophy of the
summit, and crescent-shaped erosions. Fournier^ calls attention to the
absence of one, two, or more teeth in a great number of cases.

(b) Ear-conditions. — Otorrhea, secondary to naso-pharyngeal catarrh,
has already been mentioned, and, in addition, at or about the time of
puberty an incurable form of deafness may develop speedily, without
the presence of pathologic lesions to explain the same.

(c) Affections of the Eye. — These are interstitial keratitis and iritis,
affecting both eyes successively.

1 Ja/»-6./. A'incto-A., Bd. li., Heft 3.

^ Gaz. hebdoni. de med. et de chir., January 18, 1900.



336 INFECTIOUS DISEASES.



Visceral Syphilis.

Syphilis of the Brain and Cord. — Pathology. — The most characteristic
and not infrequent lesions are. the. syphilitic new-growths. Their size
varies from that of a bean to that of a chestnut, and they present irreg-
ular contours. They are usually situated either in the cerebral hemi-
spheres or on the pons, and rather superficially, connecting directly or
indirectly with the dura or pia mater. They may not infrequently orig-
inate in the dura mater. In gummata of average size a cut-section
shoAvs caseation in spots which are connected and surrounded by firm,
translucent, gray or reddish-gray, fibrous tissue ; and, according to
Gowers, the more irregular surfaces and the irregular caseation serve as
important distinctions from tuberculous tumors. When, as is usual, the
gummata touch the membranes, meningitis — subacute or chronic, with
much thickening — is combined.

As I have said, the condition may begin as a gummatous meningitis,
while in fewer instances it may start as a gummatous arteritis. On the
other hand, a gumma may secondarily involve a blood-vessel for a con-
siderable distance, weakening its walls, with resulting rupture and intra-
cranial hemorrhage ; or it may bring about cerebral thrombosis.

Histologically " the cerebral gumma differs from other similar bodies
chiefly in the presence of very large spider-like cells containing an exag-
gerated nucleus and a granular protoplasm which extends into the multi-
ple, branching, rigid prolongations " (Wood). The arteries, particularly
those of the base, may show syphilitic sclerosis ; this renders them thick,
hard, opaque-whitish, until their lumen is well-nigh obliterated.

Gummatous growths may attack the cord. In a case recently reported
by Osier a new-growth occupied the cord opposite the root of the third
cervical nerve. The other gross changes found in connection with
cerebral gummata and their secondary lesions (softening, collateral in-
flammation) are also observed in sj^philis of the cord.

Etiology. — Cerebral syphilis is usually a late (tertiary) manifestation —
appearing from one to thirty years after primary infection — " in middle
life " (Rothwell). Lydston and others have shown that nervous stigmata
may become evident during the secondary stage, even as early as three
months after initial infection. It oftenest develops in cases in which
the secondary symptoms have been slight, and may occur in those in
which both primary and secondary manifestations have been entirely
overlooked. Inherited syphilis affects the nervous system less frequently
than does the acquired form, but cerebral gummata have been noted at
all periods from the time of birth until after puberty.

Symptomatology. — Imhecility and idiocy may be due to inherited
syphilis, but they are probably too often attributed to this cause. The
other features simulate those of the acquired form.

The symptoms of the acquired for m^ are with few exceptions referable
to three affections : (a) epilepsy, (b) brain-tumor, and (<?) paralysis.

(a) Epilepsy coming on after the twenty-fifth year, not dependent
upon alcohol nor uremia, is usually due to the ravages of syphilis, and
a careful search for traces of scars and of the entire body-surface for



SYPHILIS OF THE LIVER. 337

bone-lesions, etc. should be instituted. The appearance of the disease
may be preceded by psychic disturbance, headache, dizziness, and loss
of memory. Hysteric manifestations may also be presented, being
probably provoked by the specific lesions. On the other hand, a pro-
tracted torpor which may last for a few days or as many weeks may
develop. In one of my own cases periods of marked mental excite-
ment, that persisted for three or four days, alternated with periods of
almost complete insensibility of about equal duration.

(b) Brain-tumor. — The symptoms pointing to brain-tumor will be dis-
cussed under this head in the section on Nervous Diseases. The syph-
ilitic nature of the cerebral growth cannot be determined with any
degree of certainty except in the presence of a clear history of syphilis
— congenital or acquired — and the characteristic symptoms or traces of
the primary, secondary, or tertiary lesions. In such cases the diagnosis
is almost undoubted.

It must be remembered that the secondaries are either sometimes
absent or go unnoticed, and if the patient has had a primary sore, the
presence of the characteristic symptoms of brain-tumor (headache, optic
neuritis, convulsions, etc.) make the existence of specific nerve-lesions
highly probable. The chancre may also be overlooked or denied, and
it is in such instances as the latter that the occurrence of convulsions
in persons over thirty should excite suspicion, and lead to a trial of the
antisyphilitic treatment for further confirmation.

(c) Paralysis. — This may take the form of hemiplegia (due to cerebral
hemorrhage or tumor) or of general paralysis {dementia paralytica).
The relation that these afi"ections bear to syphilis will be indicated in
its appropriate place in this work in the description of Nervous Dis-
eases. The fact may here be pointed out that syphilis may induce pre-
cisely the same changes met with in general paralysis of the insane.

The history of syphilitic infection, together with symptoms of an
atypical type of spinal tumor, points to gumma of the cord. Syphilitic
myelitis usually develops within five years after infection, and may pur-
sue an acute or subacute course, though oftener it takes the form of
chronic myelitis. The latter attacks by preference the lumbo-dorsali
section of the cord — a fact corroborated by the character of the symp-
toms. The clinical features, however, are not distinctively syphilitic ;
and the process is uninfluenced by the most vigorous antisyphilitic
measures. When the etiologic influence of syphilis can be shown,
especially in the absence of other causes, the diagnosis of syphilitic
myelitis rests upon more certain ground. Acute syphilitic myelitis
gives an unfavorable prognosis.

General Diagnosis. — The onset in nervous syphilis may be acute or
subacute, and the symptom-complex embraces a multiplicity of phenom-
ena, there being an especially erratic distribution of the ocular and
other attending palsies and early marked impairment of the mind.

Syphilis of the Liver.

In my experience the liver, with comparative frequency, bears the
stress of visceral syphilis.

Pathology. — The lesions may be thus classified : [a) Diffuse Syph-
ilitic Hepatitis. — This is met with chiefly in congenital cases, though I



338 INFECTIOUS DISEASES.

have seen an instance in an adult who died of cerebral hemorrhage,
the occurrence of which in adult life has been questioned by some.
The liver is uniformly enlarged, firm, and resists the cutting knife. Its
color is grayish-yellow.

The microscope shows a marked increase in the connective tissue and
a cell-infiltration throughout. From intense, focal cellular infiltration
miliary gummata may result ; these undergo contraction, diminishing
somewhat the size and altering the shape of the organ.

(b) Gummata. — These may be seen in congenital cases (chiefly the
miliary gummata). As seen in the adult, hepatic gummata are dissem-
inated nodules, with the usual central, cheesy mass surrounded by a zone
of grayish fibrous tissue and varying in size from a hazelnut to an apple.
They form separate tumors, whose favorite seats are the convex surface
of the organ, especially near to the suspensory ligament, and in the
region of the portal vessels. They are usually tertiary lesions, and
do not appear until a number of years (two, three, or four) after
infection. These so-called syphilomata in the advanced stage con-
tract, and the liver will be found smaller than the normal. Deep
furrows due to contracting fibrous bands traverse the organ in difi"erent
directions and divide it into lobes of various dimensions. Gummata
frequently undergo fibroid change, but more rarely they soften and
liquefy (Wilks). On the other hand, before contraction occurs the
liver is increased in size and the gummata form protuberances on its
surface.

(c) Gummatous Arteritis. — Briefly, this may affect both the portal
vein and hepatic artery, though syphilitic endarteritis is situated chiefly
in the smaller branches of the latter.

{d) Perihepatitis. — Here Grlisson's capsule is thickened, owing to aug-
mentation of its connective-tissue elements. From the latter there dip
into the hepatic tissue cicatricial bands, particularly along the portal
canals, which may change someAvhat the shape of the organ. Section shows
admirably the pale scar-like tissue (wicfg Diseases of the Liver).

Clinical History. — The affection may exist without symptoms.
In the congenital form, however, we have signs of hepatic enlargement,
with icterus, the spleen being likewise large and firm, as a rule. The
history and associated lesions are necessary to a certain diagnosis.

In the adult syphilis of the liver does not usually attract attention
until the gummata interfere with the portal circulation. As they un-
dergo contraction they tend to occlude some of the portal branches, or
they may, on account of their situation, exert pressure upon the vena
porta itself. In either event the evidences (ascites and splenic enlarge-
ment) of portal obstruction will develop as in alcoholic cirrhosis. The
gastro-intestinal symptoms common to the latter disorder are also pres-
ent, and obstructive jaundice may supervene, though it is, compara-
tively speaking, rare. Pain, usually localized to some particular spot
over the right hypochondrium, is sometimes complained of, and may be
quite severe, while pressure over the painful area elicits great tenderness.

Physical Examination. — In the early stage, while tne organ is en-
larged, flattened, irregular protuberances may be detected by the pal-
pating fingers. At a more advanced period ascites may interfere with
palpation, and in such cases an aspiration of the fluid will enable one



SYPHILIS OF THE ALIMENTARY TRACT. 339

to feel the syphilomata. Finally, in the stage of contraction the results
of palpation are obviously negative.

There is a group of cases in Avhich the clinical picture is that of
advanced amyloid disease of the viscera. The liver and spleen are
enlarged, the urine is increased in amount and contains albumin and
tube-casts, and finally dropsy supervenes.

Diagnosis. — This rests upon the etiology, the presence of scars in
the throat or on the skin-surface, bone-lesions (especially irregularities
of the tibial surfaces), or other evidences of the ravages of the disease,
and upon moderately good general health. The most important local
symptoms are the hemispheric prominences on the surface of the liver
and the localized pain.

The diagnosis between syphilitic disease of the liver and echinococcus-
cysts is sometimes extremely difficult. R. Lennhoff has noted in a
number of cases of echinococcus-cyst that on deep inspiration a furrow
forms above the tumor, between it and the edge of the ribs.

The clinical findings resemble those of cancer of the organ. I have
contrasted the main dissimilar points in the subjoined table :

Syphilis of the Liver. Caxcer.

History of heredity or of infection. History of heredity or of primary

growth.

Occurs con'genitally, or. if acquired, at Xever congenital. Usually occurs after

any age. the age of forty.

Often accompanied by symptoms of ter- Often preceded by the primary growth

tiary syphilis — alopecia, rupia, etc. in pylorus, uterus, mammary gland.

Jaundice and ascites are common, espe- Jaundice and ascites are rare. Marked

cially the latter. No cachexia. cachesia.

The margin, on palpation, is markedly Often the margin reveals the presence of

irregular, and neither nodular nor um- umbilicated nodules.

bilicated.

Recovery may follow, or the aflFection Always fatal. Duration usually from a

may last for years. few months to a year.

The course and the results of antisyphilitic treatment are of value
from a diagnostic view-point. The course is slow and often interrupted,
while appropriate treatment may lead to recovery, as in three of mv
cases.

Syphilis op the Alimentary Tract.

The lesions in the mouth have been for the most part considered.
In the tongue gummata often develop. A decidedly fissured appearance
of the organ and whitish scar-like patches upon the surface may be ob-
served in syphilis, but have no essential connection with that disease.
Gummata also appear on the posterior wall of the pharynx and lead to
ulceration, which may cause fatal hemorrhage by erosion of adjacent
large blood-vessels (internal carotid, etc.). The Avails of the esophagus
may also be invaded, resulting usually in stenosis.

The stomach-walls may be infiltrated, though they are rarely ulcer-
ated. Einhorn, Fournier, and others, have met gastric ulcer in syphilis ;



Online LibraryJames Meschter AndersA text-book of the practice of medicine → online text (page 44 of 175)