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TWENTIETH CENTURY

PRACTICE

AN INTERNATIONAL ENCYCLOPEDIA

OF

MODERN MEDICAL SCIENCE

BY

LEADING AUTHORITIES OF EUROPE AND AMERICA



EDITED BY



THOMAS L. STEDMAN, M.D.



NEW YORK CITY



IN TWENTY VOLUMES

VOLUME XVIII

SYPHILIS AND LEPROSY



NEW YOEK
WILLIAM WOOD AND COMPANY

1899



Copyright, 1899,
By WILLIAM WOOD & COMPANY






PRESS OF

THE PUBLISHERS' PRINTING COMPANY

82, 84 LAFAYETTE PLACE

NEW YORK



CONTENTS.



Acquired Syphilis, .

The Syphilitic Infection,

Pathology, .

Initial Lesions, . . .

Constitutional Syphilis,

Syphilitic Fever,

Cutaneous Syphilides,

Roseola Syphilitica, .

Papular Syphilides,

Leucoderma Syphiliticum,

Pustular Syphilide,

Gummata of the Skin and Subcutaneous Cellular Tissue

Mastitis Syphilitica Simplex et Gummosa, .

Syphilis of the Hair and Nails, .

Syphilitic Affections of the Digestive Organs,

The Oropharyngeal Cavity

The Gastroenteric Canal,

The Liver, .

The Pancreas,

The Peritoneum,

Syphilitic Disorders of the Respiratory Tract,

The Nose,

The Larynx, ....

The Trachea and Bronchi, .
Pulmonary Syphilis, .
Syphilis of the Circulatory System,

The Heart

The Blood-vessels,

The Blood,

Syphilitic Affections of the Glands,

The Lymph Glands,

The Lymph Vessels, .

The Spleen, ....

The Thymus and Thyroid Glands, Suprarenal Capsules

Syphilitic Affections of the Genitourinary Organs,

The Kidneys,

The Urethra, .

The Penis, ....

The Testicles,

The Female Generative Organs,

Syphilitic Affections of the Osseous System,



id Pineal Body,



PAGE

1



15

37

41

44

46

51

65

68

75

93

94

95

96

117

121

125

126

126

126

134

139

142

146

146

148

153

159

159

164

165

166

166

166

171

173

175

182

184



IV



CONTENTS.



Syphilitic Affections of the Joints.

The Muscles

Syphilis of the Nervous System,

The Brain and its Meninges.

The Spinal Coid,

The Peripheral Nerves,

The Organs of Special Sense,

The Eyes

The Ears

The Organ of Smell, .

The Organ of Taste, .

Abnormal Course of Syphilis,

Tuberculous and Cancerous Transformation of Syphil

Syphilitic Cachexia,

Amyloid Degeneration,

Treatment

Hygienic Treatment, .

Prophylaxis, ....

Local Treatment,

Constitutional Treatment, .

Formula?,

Lnheiuted Syphilis,

Foetal Syphilis

Secondary Symptoms,

Tertiary Symptoms,

Long Persistence of the Taint and Transmission,

Latent Syphilis, ....

Inherited Syphilis as a Cause of Idiocy,

Tabes Dorsal is

Transmission to the Third Generation,

Congenital Immunity,

Prevalence and Severity of Inherited Syphilis,

Syphilis Acquired in Infancy,

Treatment,

Leprosy

Synonyms and Definition, .

Types of Leprosy,

Etiology, .....

The Bacillus Leprae,

Sources of Infection, .

Heredity and Contagion,

.Modes of Infection,

Conditions Influencing Infection,

Symptoms and Course,

Period of Invasion or Incubation,

Prodromes, .....

Symptoms of Tubercular Leprosy,

Termination of Tubercular Leprosy,

Complications, ....

Symptoms of Antesthetic Leprosy,



itic Lesions



CONTENTS.



V



Termination of Anaesthetic Leprosy, .
Mixed or Complete Type of Leprosy,
Survival of Leprosy in Modified Forms,
Pathogeny and General Pathology,
Diagnosis, .
Prognosis, .
Treatment, .
Local Treatment,
Hygienic Treatment, .
Prophylaxis,
History,

Leprosy in Various Countries,
Methods of Dealing with Leprosy in Ancient and Modern Times
Geographical Distribution,
Statistics of Leprosy, .
Bibliography,
Index



PAGE

534
541
542
546
556
571
574
594
599
601
616
618
632
647
670
673
685



CONTRIBUTORS TO VOLUME XVIII.



Jonathan Hutchinson, M.D., LL.D., F.R.S., F.R.S.C, London.

Consulting Surgeon to the London Hospital ; Senior Surgeon, Hospital for
Diseases of the Skin, Blackfriars ; Consulting Surgeon, Royal London Oph-
thalmic Hospital ; Emeritus Professor of Surgery in the London Hospital
Medical School.

Eduaed Lang, M.D., Vienna.

Professor of Dermatology and Syphilology, University of Vienna.

Prince A. Morrow, M.D., New York.

Professor of Genitourinary Diseases in the University and Bellevue Hospital
Medical College ; Attending Physician to the Department of Skin and Vene-
real Diseases, New York Hospital ; Surgeon to the City Hospital ; Consult-
ing Dermatologist to St. Vincent's Hospital.



ACQUIRED SYPHILIS.



BY

E. LANG,

VIENNA.



Vol. XVIII.— 1



ACQUIRED SYPHILIS.



Definition. — We have every reason to look for a living organism in
the syphilitic contagiuni ; but as we have not as yet found it, we are
unable to give a precise definition of syphilis. We must at present be
satisfied to characterize the disease by enumerating the effects pro-
duced by the contagium — and this is the task to which we shall have
to devote the greater part of the following study.

The Syphilitic Infection.

During a limited period the pathological products and many of
the physiological elements of those affected by syphilis contain a fixed
contagium, which, inoculated into a healthy person by accident or
design, is capable of reproducing the disease. It seems that the con-
tagium does not penetrate the intact epithelial layer of the skin or of
the mucous membrane, but that an inoculation is effected only in parts
deprived of epithelium or when the contagious principle is introduced
beneath the epithelial lay er. But it is reasonable to suppose that the
contagium may also penetrate alongside of the roots of the hairs or
into the opening of a follicle, and so gain entrance into the organism.

At the point of entrance of the specific virus — the point of infection
— a typical local change develops, which is usually followed by gene-
ral symptoms of a special character. This contagium then reproduces
itself for many years within the diseased organism, and also retains
its virulence for a period of time which cannot as yet be fixed accu-
rately. During this period it is so far unchanged that, transferred
to healthy persons, it may produce the same morbid symptoms.

The general disorders (constitutional syphilis) are manifested by
a chain of symptoms continuing for years, sometimes for life. Dur-
iug this time there are periods of relative, apparently complete health,
without anything abnormal being observed — the so-called "latent
periods." In many cases, however, probably in most, syphilis dies
out after a relatively short period.

The typical initial local changes produced by the syphilitic virus
are rarely missing, but in some exceptional cases they cannot be
found. Syphilitic semen, in producing conception, may at the same



4 LANG — ACQUIRED SYPHILIS.

time infect the woman and cause constitutional syphilis without the
occurrence of an initial lesion, and the same is true as regards women
who have become syphilitic during pregnancy by retroinfection from
the foetus. The initial symptoms are always absent if the virus is
introduced with the generative cell, in which case the advance of the
disease coincides with the development of the foetus, and we encoun-
ter only general disorders without local lesion. This syphilis devel-
oping during intrauterine life is the inherited, hereditary, or con-
genital form, which differs from acquired syphilis in various other
ways as well.

Whether or not the contagium of syphilis can be transferred to the
second generation, appears to me to be as yet undetermined.

If the coutagium penetrates the skin or the mucous membrane at
a point where desquamation has occurred or where there is a chap or
crack in the integument, an accidental or artificial injury, or an open
follicle (?), then an infiltration occurs, constituting the initial syphi-
litic manifestation. But this does not occur, provided no other infec-
tious material is inoculated at the same time, until after a symptom-
less period of days or weeks; and, furthermore, the lesion appears
only at the point of infection.

This incubation period usually lasts two, three, or four weeks;
occasionally, however, it has been observed to last only one week,
sometimes five or six weeks, or even eight weeks (J. Hutchinson).

After the initial lesion has existed a few days, there arises a usu-
ally painless swelling of the nearest lymph bodies or those of the
second remove— the indolent bubo, sclerosis of the glands, scleradeni-
tis; at the same time we frequently enough see the lymphatic vessels
between the initial lesion and the bubo changed into thick, knobby
cords — sclerosis of the lymphatic vessels, sclerotic lymphangitis.

After a few more weeks — the so-called second incubation — there
appear symptoms of general infection, which may involve any organ
and any tissue, either singly or in combination. These symptoms
may last, with brief or protracted interruptions (sometimes of years),
for a variable period. This is general or constitutional syphilis,
characterized by latent periods and relapses. Sometimes we see in
this so-called second incubation — which I prefer to call the " inter-
mediary stage" — at a variable period after the initial symptoms, the
development of characteristic (intermediary) syphilitic lesions.
These are either interjected prodromes of the general eruption, or
they have to bo considered as the result parth' of regional active or
passive migration of the contagium, and partly of accidental or inten-
tional infection — postinitial infection.

In some accurately described cases of experimental infection of



PATHOLOGY; 5

syphilis, the intervals between the infection and the appearance of the
initial symptoms (first incubation), and between this and tin first
symptom of general infection (second incubation), can be exactly
determined. Thus the duration of the first incubation period was,
minimum, ten days (in one case) ; maximum, forty -two days (in one
case) — the average being between three and four weeks. That of the
second incubation period -was, minimum, between one and two weeks
(once); maximum, one hundred and fifty-nine days (once) — average
from six to twelve weeks. As we shall see later, it is not always easy
to determine the moment of the general infection. Undoubtedly the
character of the generalization makes some difference. It is therefore
not a matter for surprise that clinical experience shows great variety
in this respect.

PATHOLOGY.

Various pathological changes are effected in the tissues in conse-
quence of the entrance and generalization of the specific virus in the
body. Hypersemia is very frequent, but is usually of short duration ;
if it does not disappear soon, there follows a slight degree of infiltra-
tion, which is to be regarded as a transition stage leading to a mild
inflammatory process.

Like the hypersemia, these inflammations of mild degree end in
resolution, the infiltrate becoming absorbed and the original normal
condition being reestablished. Sometimes, however, the infiltrate
assumes the form of a long-continued or even permanent enlargement
of either connective tissue or bone, according to the location of the
initial process. Occasionally, under certain conditions, we find a
breaking down or suppuration in the infiltrated parts, and if these
parts are superficial the resultant abscesses break through and form
ulcers ; or the disintegration begins on the surface and the infiltra-
tion leads immediately to ulceration, without abscess ; but in both
cases recovery without especial loss of substance is the usual result.
These conditions are identical with those of simple congestion,
inflammation, or hyperplasia, and are therefore regarded by Virchow
as of irritative character. Histologically they differ but little from
other inflammatory processes. We frequently see the elements of the
blood-vessels prominently concerned in the process of proliferation,
and this results in thickening of the walls of the vessels, and even nar-
rowing or obliteration of their lumen.

Essentially different from these irritative processes is another
series of processes caused by syphilis, most of which belong either to
the gummata or to the syphilitic callosities.

Gumma is usually an infiltration which produces destruction of the



fi LANG — ACQUIRED SYPHILIS.

normal intermediate tissue, and which is either absorbed (with inevi-
table destruction of the tissue), or remains as a caseous thickening,
or bursts and discharges the contents externally. Gumma appears
either as a new formation from tin- size of a grain of wheat up to
a large tumor, with sharply circumscribed outlines or with radiating
processes, or as a diffuse infiltration. It forms a whitish to a red-
dish-gray soft mass, consisting of a tender, gelatinous, here and there
fibrous, intercellular substance, with proliferated cells, which arise
from connective tissue, or from the migrating elements of the small-
est blood and lymphatic vessels, or from emigrated white blood cells;
they look like granulation cells or colorless blood corpuscles, where-
fore gummata have been classified by Virchow as granulation tumors,
granulomata, and by Klebs as leucocytomata.

Besides these cells resembling white corpuscles, there are larger
formations in a gumma, epithelioid forms, and some which look like
giant cells. According to their histological composition, there is an
undeniable analogy between gummata and the neoplasrnata of glan-
ders, pearl disease, tuberculosis (scrofula, lupus), and leprosy ; and as
the infectious nature of these diseases cannot be denied, these neo-
plasms may also be called " infectious tumors," as Klebs names them.
Wagner, however, regards the gumma as a specific new formation,
which he calls "syphiloma."

Although through the chronicity of its course the gumma is usu-
ally of long duration, nevertheless a limit to its existence is set by the
fact of its inevitable disintegration. It disappears gradually in one
of three different ways : either the cells forming the gumma become
fatty degenerated, or they break up into a granular mass and are
absorbed, or they increase in size and become confluent, forming
the so-called giant cells, which also fmalh r disintegrate and are
absorbed. But as the gumma cells, after a long period, destroy also
the original tissues between them, consisting of blood-vessels, muscle
fibres, gland cells, etc., it follows that after the absorption of a rather
chronic gumma, a portion of the parenchyma, in which the gumma
was located, is also absorbed. The part where this loss of tissue has
occurred shrinks, aud in this way deformities of the most varied
character are produced.

The fatty degenerated gumma ma}- also become fluid and be trans-
formed into a purulent mass, discharge externally, and so lead to the
formation of an ulcer, which then cleans up and heals, leaving a scar
after the necrotic parts have sloughed away and if no new infiltrations
appear.

The gumma follows a different course, if, as happens frequently,
a new formation of connective tissue occurs around it, and by a proc-



PATHOLOGY. i

ess of gradual shrinking forms a hard mass. The gumma is inside
of this fibrous mass, and its absorption is thereby often rendered diffi-
cult. The disintegrated constituents of the gumma thicken into a
fatty, granular mass, with destroyed cells and nuclei, assume a cheesy
character, and either remain as inorganic matter, or the caseous
mass, like a foreign body, excites inflammation and suppuration, as
a result of which it is finally cast out, leaving an ulcer with indurated
borders.

The gumma is thus a cellular new growth, the elements of which
assume at one period a grouping similar to that of a tumor; but the
tumorous character corresponds only to one phase of the gumma,
which usually does not become organized, but eventually heals
through either absorption or ulceration, or else thickens finally into
a dry cheesy mass. I think it is better for clinicians to regard gum-
ma as a chronic inflammatory process.

The tumor-like character of the gumma is absent when it is pro-
duced very slowly by an infitration, the elements of which are not
massed in great numbers, but are found rather spread out over a
broad superficial area. Such gummatous infiltrations also often lead
to a new formation of connective tissue in the neighborhood, which
slowly thickens and assumes in the soft parts the form of a fibrous,
cicatricial, often contracting body. This product, in which the gum-
ma is thrust into the background, represents the syphilitic induration
par excellence. It appears under the microscope as a dense connec-
tive-tissue mass, in the fibres of which we find, according to the time
of our examination, more or less numerous young cells, or such as
have already undergone fatty degeneration (as in the gumma) . In
the bones an analogous process leads to sclerosis.

Syphilitic induration and gumma, however, often combine in
various ways, sometimes the one prevailing, sometimes the other.

We have not as yet succeeded in obtaining a perfect understand-
ing of the mutual relations of the various pathological processes which
appear during the course of syphilis, probably because we have not
yet acquired a clear knowledge of the character of the syphilitic con-
tagium. According to the present state of science we must suppose
the syphilitic contagium to be a living organism, which has the
faculty of multiplying in healthy individuals. I advanced this view
as early as the year 1871, on the occasion of my inaugural address
when appointed professor at the University of Vienna, and endeavored
at that time to prove, by the clinical course of syphilis and by cer-
tain special properties of the contagium, the following conclusions :
The contagium, coming from the point of infection, gaining entrance
into the circulation, probably by way of the lymph channels, is taken



8 LANG— ACQUIRED SYPHILIS.

by the blood to all the various tissues, whereby some mostly trivial
ami harmless changes are effected — irritative conditions. Gradually
the virulence of the contagium deposited in the tissues diminishes,
but it still possesses the property of exciting new disorders of similar
nature, as the result of some as yet unknown influences, i.e., to pro-
duce relapses. Later the contagium loses entirely its destructive
quality, when we have perfect recovery; or partially only, when we
have merely improvement. In these cases the contagium undergoes
the further change that it loses in a certain, so far unknown time the
power to propagate the disease in healthy persons — that is to say, it
loses the power of infection. Although it would be highly important
for the practitiouer to know this time exactly in certain cases, it is as
yet impossible. The supposition that the danger of infection ceases
after syphilis has lasted for two, three, or four years, is based upon
very insecure premises; and although the disease does usually die
out after a few j^ears, cases occur (rarely it is true) in which a syphi-
litic person infects a healthy one after six, ten, or even more years.
But even if the poison loses its power of infection, it may remain la-
tent, until by some often external cause it is stimulated to new growth
and produces in a definite part a very characteristic reaction, which
represents the late form of syphilis; the semicircular and circular
(serpiginous) forms of the later syphilitic manifestations justify the
conclusion that the power of propagation by the microorganism is
still preserved. This point of view explains sufficiently the usual
symmetrical distribution of the early symptoms, and the mostly
asymmetrical late symptoms of syphilis.

It is probable that the virus retained in the lymphatic glands and
in other tissues may remain inactive for a considerable time, and then
be gradually destroyed ; but if it reaches the circulation through the
vasa deferentia, which it may do after years, then relapses occur in
remote tissues. These recurrent lesions may, according to the amount
of virus, be plentiful and symmetrical, or appear only in one part.
The activity of the virus may also be revived in the lymphatic glands
themselves, and so occasionally produce late symptoms.

The connection between the contagium thus conceived and the
pathological symptoms of syphilis, therefore, is as follows:

In the beginning the generalization of the contagium produces the
irritative conditions, which show themselves in hyperemia, slight
inflammation, infiltration, and hyperplasia. Usually these lesions re-
cede, but occasionally they are not absorbed and may then form more
or less permanent nodules in the skin and mucous membranes (tophi).

The gumma requires for its development a residuum of the syphi-
litic virus in the tissue, probably very much changed, and which may,



PATHOLOGY. 9

excited by some cause to renewed activity, produce certain gumma-
tous lesions. And although it is probable that their origin is usually
a germ which may have remained for a long time inactive on the site
of the future gumma, it is also possible that such a remnant of conta-
gium may be carried to some other place and produce the gumma
there. But while the irritative processes only very rarely lead to
permanent new growths of connective tissue, yet connective-tissue
products become often very prominent in the parts about the gumma,
and the more so the more this is diffused (hepatic, testicular, and
muscular indurations, osseous sclerosis, etc.). We may easily imag-
ine that the contagium can even become extinct in places where there
remain permanent formations of connective tissue induced by irritative
or gummatous processes.

This appearance of gumma infiltrations before the irritative symp-
toms have completely run their course is to be explained, on the basis
of our conception of the contagium, by the fact that it undergoes
certain changes in some parts earlier than in others ; and that in such
cases the virus, stimulated by external influences, has progressed so
far that it may produce a gumma, while in other places it causes
irritative conditions.

These conditions may explain another fact. It has been asserted
that the contagium of syphilis retains its faculty of reproduction in
healthy persons only for a certain time, probably coinciding with the
time during which it may produce symptoms of irritation in the
syphilitic subject. Since we find gummatous products in certain
parts, while in others there are yet symptoms of irritation, we must
explain the possible existence of infection by the assumption that it
remains only in that part of the virus which has not yet lost • its irri-
tative property. But as conditions of irritation in organs which are
not accessible to careful observation may escape discovery, it is not
certain that the infectiousness existing at a time when apparently only
gummatous symptoms exist, is associated with those lesions.

As we assume that the essence of the syphilitic virus consists in
a microorganism, so we have to consider a series of symptoms to
which the host (the infected person) is exposed by the products of
metabolism of these microorganisms. Although we shall not be able
to judge of these conditions accurately until we have learned more
of this microorganism, and especially of its biological character, it
is plain that we may reason by analogy from other well-known infec-
tious diseases and may apply the conclusions thus arrived at to syphi-
lis. It has been demonstrated in the case of various pathogenic
microbes that they furnish certain active products of metabolism
(toxins), which are by no means indifferent in their action, and it is



10 LANG — ACQUIRED NYrHILIS.

more than probable that various disorders of the system are based not
so much on the multiplication of the parasites as on the poisonous
effect of their products (toxins). The malaise usually accompanying
the generalization of syphilis, the general depression, the fever (as I
noted as early as 1884 in the first edition of my lectures on syphilis),
certain alterations in the nervous system, and various other disturb-
ances may well be the result of such a product of metabolism of the
syphilitic microorganism. It is more than probable that grave and
permanent disorders of the nervous system or elsewhere may arise
therefrom.

Besides this noxious influence of the supposed product of the



Online LibraryThomas Lathrop StedmanTwentieth century practice; an international encyclopedia of modern medical science by leading authorities of Europe and America (Volume v. 18) → online text (page 1 of 77)