CHAPTER X

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SYPHILIS.

The younger generation, when studying the subject of syphilis, should be referred back one hundred years or more to the time when the opinions held by John Hunter generally prevailed--when venereal diseases were grouped under one heading, and considered to be but three manifestations of the same morbid condition. It took years for the profession to break away from this mistaken teaching, and a generation had passed before gonorrhea was separated from the others. This left chancroid and syphilis still more or less confused in the minds of many, and until the middle of the previous century they were considered as different types of the same disease by some of the most experienced observers. Thus it happened that those who made a special study of this subject were grouped into two classes, the _unicists_ and the _dualists_, according as they held to the unity or duality of syphilis and chancroid. It was a question of importance, and differences of opinions led to bitter antagonisms. Its importance inhered in this: either all venereal sores were to be subjected to constitutional treatment, or else differences in treatment were to be made according to the local or constitutional nature of the malady. Men sacrificed their own health, even their own lives, in their willingness to make experiments upon themselves, and auto-inoculability was proved by one observer through some 1700 inoculations produced upon his own body. Such devotion to medical science has been rarely eclipsed. In the latter half of the eighteenth century came clearer distinctions, and toward its close there were none who ranked as authorities who held to the old view of the unity of these diseases.

Syphilis is a disease of ancient if not of respectable origin. We read much of the possibility of so-called pre-Columbian syphilis, implying by that term that the Spaniards who came over to this country found it here and carried it with them back to Europe. This is probably the case, and yet the disease antedates the Christian era, as may be established by familiarity with ancient literature, whether Arabian, Egyptian, or Hebraic. No one can read the Psalms of David, for instance, without finding therein intrinsic evidence that the writer thereof, whoever he may have been, suffered from this disease. Of its antiquity, however, as well as of its universal distribution, we need not speak. History has shown that whenever it has appeared in a community previously unaffected by it, it has assumed malignant and epidemic features, and has spread rapidly while claiming many victims; on the other hand, in those communities where it has long been domesticated, it assumes usually a milder type, as though a racial immunity were being gradually established.

_Syphilis is an infectious chronic disease, acquired either by inheritance or by contagion, mediate or immediate_, with a certain period of incubation, characterized by an initial lesion at the site of infection, which is followed in time by a series of systemic disturbances, usually quite characteristic, in a commonly determinate order. A large proportion of these consist of neoplastic lesions of the general type of the infectious granulomas. In the majority of instances it is of distinctly venereal origin, although not always. It is known among the common people as _pox_, while a frequent synonym for it in foreign literature is _lues venerea_, or often _lues_ alone, the adjective being _luetic_.

_Syphilis is always transmitted as such_ and is not interchangeable with leprosy, tuberculosis, or anything else, although it is not unfrequently complicated with them as well as with cancer. It has certain resemblances to the exanthemas in its periods of incubation, and in the fact that one attack is supposed to confer immunity, as well as that many of the typical symptoms of syphilis pertain to the skin and mucous membrane; further resemblances may also be found in each case.

Within certain limits the specific infection of syphilis, or, as it is frequently spoken of, the specific disease, passes through a somewhat regular program in which periods of activity and latency seem to alternate. The first visible lesion is at the point of entrance of the virus, in acquired cases, after a certain period of incubation, and is known always as the _chancre_. Of course, in inherited syphilis no chancre or primary sore is found. Then occurs a second period of incubation, during which there is a still more widespread general infection of the body, in which at first the lymphatic system seems to suffer most. This is characterized by a certain degree of fever, progressive anemia, malaise, tenderness and pain in bones and joints, all of which indicate a _progressive toxemia_.

=Manner of Contagion.=--The manner of contagion in acquired cases is naturally most often that of the sexual act, although contagion may come from many sources, including unclean utensils, pipes, etc., as well as the instruments of the dentist or the surgeon. Some abrasion of the infected surface is almost invariably presupposed, since it is not established that the virus of syphilis will enter an unbroken surface, though it may lurk thereon; but the abrasion may be trifling and occur in such situation, especially on the female genitalia, as to be undiscoverable or unnoticed. It is then possible that patients may speak truthfully when denying the existence in the past of any venereal sores. The transmission of infection from parent to offspring in the uterus will be discussed later.

=Nature of the Virus.=--That syphilis is a disease of parasitic character, _i. e._, _contagious_, there can, of course, be no question. The nature of the _contagium vivum_ which produces these changes, long unknown, is now believed to be revealed in the _spirochæta pallida_ recently described by Schaudinn and others; an organism 4 to 10 μ in length, ¹⁄₂ μ in width, possessing several curves like those of a corkscrew, with sharpened poles, mobile, its motions consisting of rotations and bendings. It has been demonstrated that primary lesions contain the organism, either constantly or in the majority of cases, while in skin and nearly all other lesions it can be also shown (Fig. 23).

[Illustration: FIG. 23

Spirochæta pallida (syphilis) in adrenal of child with congenital syphilis. (Gaylord.)]

=Evolution of the Disease.=--Ever since the days of Ricord’s writings on the subject it has been customary to group the manifestations of syphilis into three groups or stages: _the primary_, _the secondary_, _and the tertiary_. Less stress is laid upon these stages than previously, yet it is convenient to retain them for descriptive purposes. It should be emphasized, however, that between them there are no arbitrary limits of time or tissue. _Primary_ syphilis under this classification includes the first period of incubation and the symptoms and appearances of the initial lesions. _Secondary_ syphilis may be made to include the earlier constitutional symptoms which involve or at least become apparent upon the more superficial portions of the body, _i. e._, skin, mucous membrane, lymphatics, etc. Later comes the so-called _tertiary_ period, in which the body surfaces are not necessarily spared, but in which also deep lesions of the viscera, the bones, the brain, etc., are noted. Between the first and the second stages comes the so-called second period of incubation. The second and third stages are characterized by frequent neoplastic formations, which assume the type of the infectious granulomas and are commonly spoken of as gummas; these lesions are destructive in their tendency, and will so prove unless dissipated or aborted by suitable treatment.

_In the first and second stages of the disease it can be conveyed by inheritance and inoculation_; in the later stage such an occurrence is exceptional.

That syphilis is, _per se_, an infection is proved by the constitutional symptoms which accompany its earlier manifestations; the fever, usually mild, though sometimes well marked, which comes early in the course of the disease, the general lymphatic involvement, the malaise and depression, all indicate the systemic disturbances of a true toxemia.

The periods of quiescence between successive outbreaks of the disease are, moreover, characteristic, although they sometimes lull the patient and his physician into an inactive state, during which medication is too often suspended, so that when fresh disturbance arises vigorous treatment must be renewed.

_The infection of syphilis occurs on the instant of inoculation_, as in the case of tetanus. This is important, as upon it depends the question of early local treatment. While excision of the primary sore, or even of an area which might have become infected during exposure, and before the actual formation of the chancre, has been often practised and urged by some, experience has shown that it has little to commend it, since the general experience is that it does not prevent the development of the disease.

In its tendency syphilis is constantly progressive and destructive, although it often behaves in a capricious manner, sometimes when under efficient treatment and generally when treatment is inefficient. It is usually more virulent in the dissipated and those who are weakened by inheritance or poor constitutions, or by other disease. One reads in literature on the subject about the malignancy of some cases and the benignancy of others. Some cases seem to have a malignant aspect, while others run an unusually mild course, so much so as to raise the question whether the patient had syphilis. As far as the nature of the parasitic cause is understood, this would depend on differences in the make-up of the individual rather than in the actual virulence of the germ. In the extremes of life individuals are more susceptible. When implanted upon a tuberculous constitution it sometimes renders the tuberculous lesions more active; whether it acts as a mixed infection is not definitely known. Tuberculous lymph nodes frequently break down during the course of secondary syphilis, and consumptive patients grow rapidly worse. Syphilis, like alcohol, tends to play havoc with the bloodvessel walls, and their combined effects in this direction are greatly to be deprecated and should be prevented.

=The Lesions and Secretions which Convey Infection.=--As far as acquired syphilis is concerned _absolute contact_ is necessary between the infecting material and the infected area, while upon the latter must exist some abrasion of the surface. Chancres and the early eruptions or mixed lesions have been proved to be absolutely virulent. The genitalia of both sexes are frequently the site of wart-like lesions referred to as condylomas, which are usually kept more or less moistened by the secretion of the parts, and are fruitful sources of contagion. _The discharging lesion of those suffering from syphilitic disease should be regarded as capable of transmitting it_, while during the primary and secondary stages the blood and lymph should be regarded as probable sources of danger.

Inoculation with the blood of patients during these stages has been known to be successful. How long the blood retains its power of infection is uncertain; it is usually regarded as free from it when the disease is latent.

The _natural and physiological secretions of various organs_, _e. g._, saliva, milk, perspiration, tears, and urine, are not generally believed to _be capable of transmitting the disease_. The semen of syphilitic men may reproduce the disease by heredity but not by direct inoculation. It is possible under these circumstances for the father to transmit the disease to the ovum without previously infecting the mother; such infection of the ovum by diseased spermatozoa is quite different from the infection of the ovum by the mother who has acquired the disease, the father having escaped it.

In a general way it may be held that secretions of organs, or even of lesions, which are non-specific, are not contagious except as they happen to be mixed with blood or with disintegrated portions of actual syphilitic lesions; thus, for instance, vaccinal lymph might be safely taken from a syphilitic subject if there were absolutely no admixture of blood. _But the difficulty of securing pure lymph is such as to make its use inadvisable because of its danger._

_Suppuration frequently complicates syphilitic_ lesions. This is to be regarded as in the nature of a secondary and pyogenic infection. It has not been established that the germ of syphilis is by itself a pyogenic organism.

_Gonorrhea or chancroid is often simultaneously contracted with syphilis_, with resulting clinical complications that are perplexing as well as difficult to treat. The contagion of chancroid acts promptly, as will be stated in the chapter on Chancroid; and so it may happen that the sore which begins as a chancroid is gradually converted into a true chancre, the change taking place so gradually that it is difficult to state when it begins or is completed. In this way result the so-called _mixed sores_, which may give rise to so much doubt that the surgeon feels it wise to wait for some secondary manifestations before deciding that syphilis has been acquired. Confusion is often created by preliminary treatment which the local lesion has received previous to its examination by the surgeon. Patients, especially in the lower walks of life, frequently go to a druggist or to someone who will cauterize the sore and thus mask its characteristics to a degree which makes prompt diagnosis impossible. Again, patients are often uncertain regarding the matter of time, which is of great importance; thus the sore which appears within a few days after exposure may be chancroidal, while one which comes on twenty or thirty days afterward may be syphilitic. These periods, however, afford little help when there have been repeated exposures, by which confusion may be caused; but an accurate and complete personal history will be helpful toward a correct diagnosis.

=Location of Primary Lesions.=--Owing to the greater delicacy of the mucous membranes they are more frequently the site of primary lesions than the skin: 85 to 90 per cent. of all primary sores occur about the genitalia; in men, especially on the inner side of the prepuce, the glands, and the sulcus behind it; externally, chancre may occur upon any part of the surrounding skin; in women, the tissues about the vulva are most frequently its seat. Occasionally it is found within the vagina, but rarely upon the os. The so-called extragenital chancres are met with anywhere, especially on the most exposed parts, as the lips, tongue, tonsils, eyelids, and nipples. Syphilis is occasionally conveyed to a wet-nurse by the infected mouth of an infant suffering from hereditary disease; even multiple chancres sometimes occurring. Conversely, children have been infected by wet-nurses with syphilitic lesions about the nipple. The disease has been conveyed by bites, as upon the face and fingers. Surgeons and obstetricians are peculiarly exposed, as are also nurses, to this disease, especially occurring upon the fingers and hands. Infants have been known to be inoculated during parturition. These are all examples of _direct_ or _immediate_ contagion. On the other hand, the disease may be positively conveyed by utensils in common use between different individuals, as table-ware or tobacco-pipes; by tools of trade which are passed from one person to another, as, for instance, the blowpipe in glass factories; and by cigars as they are made in some places, the wrapper being moistened from the mouth of the cigarmaker. These are examples of its _indirect_ transmission. Physicians are familiar as well with instances where the disease has been conveyed by instruments, either surgical or those of the dentist. So possible is this last form of contagion that dentists are trained to sterilize their instruments as carefully as does the surgeon.

Possibility of conveying syphilis by vaccinal lymph has been alluded to as occurring only in those instances where the blood of the syphilitic patient is mingled with the lymph. The production of vaccinal virus is now, however, so well regulated that it is rare that the surgeon employs humanized lymph. Some cases considered vaccinal have been due to the _use of infected instruments_; hence the necessity for extreme caution in this regard. When the disease is acquired in a non-venereal manner it is called _syphilis insontium_, or syphilis of the innocent; this, however, is an unfortunate expression, as it tends to cast reflections upon other cases which may be, in effect, just as innocent.

=Symptoms of the Ulcer.=--In all probability the initial sore and the ensuing lymphatic involvement are due to the parasite and to its toxic products. These latter are quickly taken into the general circulation and are held to confer the immunity which syphilitics enjoy before the outbreak of the general eruption. Anemia, malaise, and other like symptoms are evidences of a progressive intoxication or toxemia, while the earlier eruptions, which tend to evince the contagious element in a rather virulent form, may be due to the germs alone, or combined with their toxins. On this hypothesis can be explained the partial or complete immunity evinced by mothers who bear syphilitic children, the infection coming from the father.

From the first evidence of infection the whole syphilitic process gives evidence of its infectious character. The bloodvessel walls undergo a thickening of their coats and more or less obliteration of their lumen, and this, of course, causes a disturbance in the nutrition of the parts supplied by them. This vascular change can be recognized even in the minute vessels of the initial lesion, and thereafter pertains to most if not all specific manifestations of the disease.

Our knowledge of the nature of this disease would be more complete were it possible to convey it to animals, but these are practically exempt from it, for the few and rare instances where, it is said, the disease has been inoculated upon the higher quadrumana furnish insufficient data. In this respect the disease is like the exanthemas, of whose parasitic origin there can be no question.

_The First Period of Incubation and the Chancre._--The time which elapses between the exposure and the first appearance of the initial lesion is known as the _first period of incubation_. _This varies, within wide limits, from ten days to forty or fifty_; some writers have made it even seventy days. The average period varies from three to four weeks. There is often uncertainty as to when the induration began, and patients, women especially, may easily make a mistake of several days in fixing this date.

_Every case of acquired syphilis begins with an initial sore_, though this may be so located or so complicated with some other lesion as to be overlooked. The character of the induration varies somewhat with the location, _i. e._, whether upon the skin or mucous membrane. The amount of moisture or maceration to which it is exposed will also influence its appearance. It may be minute, so as to almost elude observation even on visible parts, or it may spread and involve an area 1 Cm. in diameter. The lesion is _usually solitary_, but when several abraded spots are infected at the same time there may be multiple sores. When a surgeon sees a lesion of this character it has usually changed its original appearance--perhaps by some previous treatment, perhaps by maceration. There is one invariable feature upon varying expressions of which diagnosis is based, and that is _induration_. The instances in which this fails are very rare; on the other hand, it is possible that it may be the result of treatment already undergone, and for this reason the recent history of the case should be obtained; in other words, _the typical chancroid is always indurated_, but an indurated sore does not of itself necessarily indicate syphilis if it can be satisfactorily accounted for in other ways. The presence of an active primary lesion seems to confer immunity to subsequent infection for a period co-equal with the active manifestations of the disease, although even in this respect exceptions are occasionally to be noted.

The induration of syphilis develops beyond and beneath the limits of the superficial lesion, and gives the sensation, when grasped between the fingers, of a piece of firm material embedded in the skin or membrane. It is firm, slightly elastic, with usually well-defined boundaries, which accounts for the expression, _parchment induration_. Ordinarily no pain or other sensations accompany its formation or attract attention; hence the frequency with which it escapes observation for some time and the uncertainty which the patient feels regarding the dates. The surface of the induration usually becomes moist or abraded and frequently ulcerated; but these surface lesions tend eventually to heal, even if let alone, except in those parts, _e. g._, the lips, where they are constantly bathed by discharge.

The characteristic induration disappears slowly in a few weeks or months, leaving ordinarily no trace of its existence, although sometimes a small scar, occasionally pigmented, is left to mark its site.

There are two or three classical varieties of chancre which deserve more minute description. As ordinarily seen upon the genitalia, a chancre may assume the following types:

A. Dry, scaly papule.

B. Superficial erosion.

C. Hunterian, or ulcerating chancre.

A. =Dry Papule.=--The _dry papule_ commences as a small rounded area of redness, becoming infiltrated and rising above the surface, gradually developing into a nodule the size of a pea or larger, over which the superficial skin seems to be thickened. Should the summit of this nodule become abraded there will escape a serous fluid, which dries and forms a thin scab. This papule may disappear more slowly than it came, or may become more infiltrated, while its surface breaks down into an ulcer, whose area will be dropped a little below that of the surrounding tissue. In this case the induration is produced almost entirely by new round-cell infiltration, as in the other varieties; when it ulcerates these cells are the ones mainly to suffer, so that there is not much destruction of the original elements, and but little scar remains.

B. =Superficial Erosion.=--The superficial erosion is the most common of the primitive sores, but is not often seen so early as to have its first appearance noted. It begins as a well-defined, dark-red area, which loses its epithelium and exposes a raw surface, with a trifling depression whose edges are usually on a level with the surrounding skin, while in the previous case the edges are generally characterized by an elevated margin. The base of this sore is also indurated, and partakes usually of the parchment-like character already described.

C. =Hunterian Chancre.=--The Hunterian chancre, so named after John Hunter’s description of it, is the most distinct and typical of these primary lesions. It begins as a papule, with some erosion, increasing slowly in size, sharply outlined, with a somewhat flat top. As it grows larger it increases in firmness until its base is extremely dense. In color it is greenish or bluish red, and this color appearance is more distinctive than in the other forms. In from one to three weeks its surface epithelium is usually loosened by maceration, and serous discharge is the consequence, or else it becomes covered with a grayish exudate, which, by its location, is rarely allowed to form a scab. The centre of the ulcer becomes deeper, its edges more elevated, and in typical cases a minute crater is formed by a characteristic destructive process. While the Hunterian chancre tends in ordinary cases to slowly disappear of itself, this involution can be materially hastened by local and constitutional treatment, and usually heals, when properly treated, with but slight local evidence of its previous existence.

=The Mixed Chancre.=--Chancroid will now be described, and its consideration will include the statement that it may be followed by true syphilitic chancre. Such a lesion is known as _mixed chancre_ or _mixed sore_, and indicates a simultaneous infection by two distinct infecting agencies; it may easily cause confusion, for if seen early it will lack the characteristic induration of syphilis. This latter will only appear about the time that the chancroidal ulcers should be healed, if promptly and properly treated. Supposing this treatment to consist at least in part of caustics, the surgeon may be in doubt as to whether the induration is due to this agency or to developing syphilis. It seems justifiable to imagine causes of this kind while awaiting the further developments of the case, and to postpone vigorous antisyphilitic remedies until the diagnosis is established. It is a serious thing to condemn to a long course of mercurials a patient who perhaps does not need such drastic drugs. Instances arise where the situation is to be carefully considered in view of these possibilities. Should the healing and apparently healthy ulcer, however, take on an indurated base and develop the typical scleroses of chancre, it may be supposed that all doubt has been removed. The possibility of syphilitic infection being implanted upon a chancroidal base by subsequent exposure should also be taken into consideration. This will require an accurate history and a faithful narration of the same by the patient.

There are, also, the _extragenital chancres_, which may be met with upon the hands, upon the breasts, in the oropharynx, as well as about the eyelids. Chancres on those surfaces of the body where tissues are loose may attain considerable size and ulcerate early, the discharge drying into scabs or crusts, which mask the underlying ulcer. Around the margins of the nails these lesions show but slight induration. Sometimes suppuration and granulation are profuse. When appearing upon the tonsils there is nearly always ulceration, with considerable swelling and often a false membrane. A patient with this lesion will complain of sore throat, and involvement of the surrounding lymphatics is usually extensive.

When _chancre appears upon the lips_ there is usually extensive induration; the lesion attains considerable size, with protrusion, unless recognized and treated, and ulceration takes place early and deeply. It may be confused here with _epithelioma_. The latter occurs during the later period of life, is slower in its evolution, and its involvement of the neighboring lymph nodes. The local changes which often precede cancer, _e. g._, hyperkeratosis and papilloma, will be lacking in chancre of the lip.

Sometimes at the site of the original chancre, which may have healed, there will be found one of the later lesions of the disease, which may be mistaken for another primary sore occupying the site of the first one. It may be distinguished by its central ulceration, its tendency to extend, and by the absence of the lymphatic involvement which is met with in the early stages of the disease.

=Pathology of the Chancre.=--The chancre should be regarded as the first neoplastic evidence of a disease which is throughout characterized by its tendency toward new-cell formation. In the developed chancre there is a well-defined cell proliferation in the skin or mucous membrane, whose bloodvessels show the same character of change already mentioned, since in the walls, both of the minute arteries and veins, are found many new cells, some of which were originally leukocytes, but most of which are products of cell division, as shown by their numerous mitoses. All the coats of the vessels are involved and even the perivascular spaces are involved and obliterated. Essentially, then, the chancre consists of a local infiltration of the superficial tissues by cells, most of which are of the round type; the whole constitutes what may be spoken of as the initial sclerosis, which remains or disappears as such unless infected secondarily. This sclerosis should be carefully sought in every suspected region when the patient is first examined. It may range in bulk from a millet-seed to that of a good-sized grape; it is usually movable upon the tissues beneath; it may ulcerate deeply, and, should it persist for a long time, it may seem unusually active just before the outbreak of the so-called secondary symptoms.

But little can be predicted with regard to the future course of the disease from the size, number, or appearance of the primary sores. The nature of the tissues upon which the virus has been implanted is a more important feature in the evolution of the disease than anything pertaining to its primary lesions, so far as appearances go. In patients of depraved habits or vitiated constitutions the chancre may often become gangrenous or phagedenic.

=Lymphatic Involvement.=--Soon after the appearance of the primary sore, or coincident with it, the enlargement of the adjoining lymphvessels and nodes begins. This is noted first in those which are in closest communication with the site of the chancre, usually in the groin. Occasionally thickened lymphvessels may be felt as cords extending along the dorsum of the penis. There may be enough involvement of the perivascular spaces to produce this appearance and sensation even around the bloodvessels. This lymphatic involvement is exceedingly significant, and yet may be found to some degree after chancroid and even after herpes of the genitals. It is, of course, an expression of a travelling infection--in the first case produced by the syphilitic virus; in the second, by the chancroidal virus; and in the third, by ordinary pyogenic organisms which enter through the pathway afforded by the herpes.

The involved lymph nodes of syphilis suppurate much less often than do those of chancroid, and suppurating bubo is, therefore, not common in syphilis. The term _bubo_ generally means an involvement of the lymphatics in the groin, although, strictly speaking, it implies a similar condition in any part of the body. _Syphilitic bubo_, therefore, is to be distinguished from chancroidal as well as from non-specific bubo. These lymphatic lesions are sometimes spoken of as constituting the characteristic _adenopathy_ of the disease, but this is an unfortunate expression, as it implies _glandular_ involvement, and the term lymph gland should never be used, since the structures are not glandular in any respect. The enlargement and persistence of these lymph nodes constitute peculiar features of the disease, and may be noted long after the subsidence of active manifestations.

=Treatment.=--With the earliest possible recognition of a syphilitic chancre or sore there is need for active and prolonged constitutional treatment, in addition to whatever may be required locally. If the diagnosis can be made, _constitutional treatment should commence at once_; only in cases of doubt is it advisable to wait. The local treatment is a matter of ordinarily small importance; the sores tend to heal spontaneously and quickly when the system is brought under the influence of mercurials. There are few authorities who recommend excision of the primary lesion or believe it is possible to abort syphilis by anything that can be done to the chancre. It is advisable to make mild antiseptic applications only. A chancre, however, in a location which makes it difficult to keep the parts clean, should be exposed to treatment by a minor operation, as an incision of the prepuce, circumcision, or a dilatation or incision of the hymen. Aside from such operation the indication is for surgical cleanliness; soap and water followed by hydrogen peroxide, which may be continued as an application, or dusting with calomel, will usually prove sufficient. Various antiseptic solutions may be used. Dry applications, however, are the most convenient and usually the most serviceable; iodoform should be avoided on account of its penetrating odor; and pure, dry calomel will sometimes prove a mild caustic, and is best reduced with one to three parts by weight of bismuth subnitrate. The stronger applications, especially caustic, are only employed when there is unhealthy ulceration. If the sore is gangrenous it should be cocainized, then the surface thoroughly treated with some powerful caustic like nitric acid, and thereafter kept moist with aqueous antiseptic solutions. When the surface is practically healthy, dry preparations or unguents may be employed, preferably the mercurial ointments. There is greater difficulty in preserving cleanliness about the female genitalia, and here the use of antiseptic cotton or gauze will probably be necessary in addition to the other precautions. Surfaces should be kept apart by their aid, and it is well to use frequent antiseptic douches or occasionally to insert a suppository containing an antiseptic drug. Of the various preparations used those containing mercury in some form are doubly serviceable. The inguinal lymphatics should be kept anointed with a mercurial ointment, which should be thoroughly rubbed in, and the parts afterward protected with oiled silk.

While these local measures are being employed vigorous general treatment should be promptly instituted. This will be discussed when dealing with treatment of the constitutional features of the disease.

There are locations in which chancre gives rise to considerable distress, as, for instance, upon the lip and tonsils. Great improvement and relief of pain in these lesions is afforded by proper use of auxiliary drugs.

In regard to local precautions, the patient should be impressed with the virulent and infectious character of the discharge from every primary lesion, and given minute and cautious directions so that its transmission to others can be prevented. This will mean the use of separate utensils, as well as soap, towels, etc., possibly the temporary isolation of the patient.

CONSTITUTIONAL SYPHILIS.

Between the time of appearance of the primary sore and the development of widespread constitutional symptoms there intervenes a period of latency, the _second period of incubation_. This is more variable in duration than the first. The shortest time on record is about two weeks, and the longest about two hundred days, the average time being six or seven weeks. The _secondary symptoms_ indicate complete generalization of the syphilitic poison, and follow the early manifestations in almost every case; nevertheless, there are instances in which they are either wanting or are so trifling as to escape observation. A careful examination during the second period will usually show, however, that the lymph nodes throughout the body are gradually becoming enlarged, especially those in the neck, along the border of the sternomastoid, the occipital nodes, those in the axilla and groin, and particularly one or two small ones above the inner condyle of the humerus, known as the _supracondyloid_ or _epitrochlear_ nodes. When these latter become involved without evident and local cause, syphilis is always to be suspected or even diagnosticated. This node is to be found by bending the patient’s elbow and feeling for it on the inner side, above the condyle, in the interval between the biceps and the triceps. The other lymph nodes of the body might also be found involved if they could be as easily palpated. This lymphatic involvement is quite independent of skin or other lesions, and does not yield as readily to mercurial treatment. The enlargements are usually movable, distinct in outline, and never suppurate unless locally and secondarily infected. In tuberculous patients, however, they may break down. This generalized involvement of the lymphatics is also of importance in diagnosticating old syphilitic infections.

During the second period of incubation there is generally a certain degree of malaise and progressive anemia. Examination of the blood will show diminution of hemoglobin, and a relative if not actual leukocytosis, due to reduction in the number of the red corpuscles. Occasionally the anemic features become pronounced; the patient may complain of weakness, lassitude, sleeplessness, failure of appetite, and of pain and discomfort in the bones and joints, more pronounced at night, and often regarded by patients as “rheumatic.” The painful joints may also show a slight swelling due to increase of the joint serum.

Sometimes intermittent fever accompanies these cases, especially during the early eruptive period. The rise of temperature is noted mainly in the evening, when it may reach 104° or even 105° F. It does not last long, and often precedes the appearance of a well-marked and characteristic eruption. It is a peculiar feature of the syphilitic poison that it seems to attack points of least resistance in each patient, as is the case with that of influenza. In one patient fibrous tissues will suffer most; in another, joints; in others there will be headache or expressions of perverted nerve activity, as vertigo, convulsions, disturbances of sensation, temporary paralysis; again there occur disturbances like mild pleurisy, splenic enlargement, or jaundice. Occasionally there will be a typhoidal condition, during which the kidneys are seriously compromised. Morbid conditions are intensified by an attack of syphilis. During rheumatism and the various forms of neuritis, and during almost all affections of the central nervous system, symptoms are, under these circumstances, frequently aggravated. In malarial countries it is said that latent syphilis sometimes becomes active when malaria is present. Lesions of the bones and joints are occasionally influenced, while some claim that fractures occur more readily in syphilitic subjects, and it is generally conceded that delayed union of fractures is often due to this cause. I have seen fracture, apparently spontaneous, of both tibiæ, one after the other, in a patient with syphilitic disease of the cord and bones. I have also seen exuberant callus form around a fracture in a syphilitic subject, as it never does under ordinary circumstances. Injury seems sometimes to localize the manifestations of the disease; thus chronic irritation at the site of old syphilitic lesions frequently becomes a point of development for epithelioma, or some other expression of malignant growth. This is seen particularly in cancer of the tongue, which sometimes follows the change in the epithelium known as _leukoplakia_.

The _influence of an attack of erysipelas_ upon certain specific lesions is remarkable. In many instances eruptions and ulcerations have been known to subside, and gummas and exostoses to disappear, after an attack of erysipelas involving their site, but these lesions are likely to reappear after the disappearance of the acute infectious process. The temporary effect of the toxins of erysipelas upon syphilitic lesions is similar to their influence upon some malignant growths.

=Syphilis of the Skin.=--Passing now to the lesions of early constitutional syphilis as manifested in particular regions or organs of the body, we take, first, the skin. When syphilis seems to have ended its existence during the primary stage (Fordyce) no further disturbances are expected, and only by waiting can the termination of the disease be determined.

The malignancy of the disease may be estimated by noting the rapidity with which the destructive lesions appear; thus gummas which appear early in the skin or mucous membranes, or elsewhere, indicate a serious type of the disease. So also does profound cachexia, including in this term more than mere anemia. The devastations of the disease in Europe during the fifteenth century show that it presented at that time a severe type.

The eruptions of syphilis have been grouped under distinctive terms, and are usually referred to as _syphilides_ or _syphilodermas_. It has been already stated that among the new formations of syphilis are those known as syphilodermas; any of the former which are distinctly due to syphilis may be syphilomas. Thus, we may have syphiloma in the skin, in the bones, in the viscera, etc. It has been customary to speak of the syphilides as simulating the non-specific eruptions and identify them by placing before them the adjective syphilitic. Thus writers formerly described syphilitic psoriasis, syphilitic erythema, etc.; but these terms have been abandoned, because it is recognized that the skin lesions of syphilis while imitating most of the features of the non-specific diseases are yet distinctly different from them. We speak, therefore, now of a macular, vesicular, papular, squamous syphilide, etc., implying thereby that it is vesicular, scaly, or otherwise, as the case may be, and at the same time that it is a cutaneous expression of syphilis.

[Illustration: PLATE VIII

Grouped Miliary Papular Syphilide.]

[Illustration: PLATE IX

Mixed Papular and Papulopustular Syphilide.]

[Illustration: PLATE X

Tuberculous Ulcerating Syphilide, showing Lesions in Different Stages.]

The _syphilodermas have certain peculiarities_ which are striking and distinctive; they are symmetrically distributed; their color is characteristic, and is due to the disease of the bloodvessel walls, which has been referred to, by which stasis is favored and exudation encouraged. The pigmentation is often striking, and, whatever it may be at first, it assumes a tint described by the terms “raw ham” or “coppery.” Dark pigmentation may take the place of the lighter colored, as the sole evidence of the existence of the previous lesion. Occasionally, however, the normal pigment of the skin disappears and a bleached-out area marks the site of the previous lesion. This is often irregular in shape and considerable in size. Such a spot is spoken of as _leukoderma_. Again, the syphilodermas are generally _polymorphous_, and seem to be capable of imitating almost every known non-specific skin affection; so close is the resemblance that it often requires careful study of the case to permit of diagnosis. The absence of itching is also a feature of most of these cases.

The early syphilides are superficial, distributed generally and symmetrically, and disappear spontaneously.

When skin lesions are clustered, as in the macular and papular forms, they usually group themselves symmetrically and in more or less circular outline. When, however, they are too regularly arranged, it may be taken as evidence of their older and more relapsing character.

The later skin lesions of syphilis differ in several respects from the earlier. They are less regularly grouped; they involve a greater depth of tissue; they tend to ulcerate and to leave permanent scars; and they have around them a more infiltrated area, probably because they are deeper. They are, however, not so infectious as the earlier lesions, and it is rare that they are of serious menace to others. (See Plates VIII, IX, X.)

Fordyce and others have pointed out that the prompt and specific influence of mercury and even of iodine upon these eruptions is an instance of the selective action of certain drugs, and nothing could be more conspicuous in demonstrating it.

Certain types of syphilide are common in the earlier stages and others in the later; there may be a well-defined limit between the two, since in not a few instances all types seem to be combined.

The first eruption of so-called secondary syphilis assumes the erythematous or macular type, and has been referred to as _roseola syphilitica_. It appears as a generalized eruption, in spots varying from 0.5 to 1 Cm. in size, which are of a vivid color and scarcely elevated above the surface. It commences usually upon the abdomen, proceeds to the chest, and then to the extremities. It does not often appear upon the face. Two or three weeks may be consumed in its generalization over the entire body. If let alone it has a duration of a few days to several weeks, and may then fade away, leaving nothing to indicate its presence save a slight pigmentation.

Of more pronounced character is the _papular_ eruption, which commences as a small papule, and is described as _lenticulopapular_ and _miliary papular_. At first these are generalized, then become circumscribed, and exhibit transition forms from the early to the later type of lesions. The papules vary in size from that of a millet-seed to that of a split pea; even this type may disappear without ulceration or suppuration.

Lichen planus may be mistaken for papular syphilide, but may be distinguished from it by intense itching and by lack of the pigment changes which characterize the syphilide.

The _squamous syphilide_ is sometimes a continuance of the papular, and sometimes it begins as such. It is characterized by a variety of scaly macules and papules, which strikingly resemble the lesions of psoriasis. The latter are seldom seen on the palms and soles, while the squamous syphilide is very frequently seen in these locations. Moreover, along with the squamous lesions are frequently associated other skin lesions, which give the case a complex type, resembling at one point one of the non-specific affections, and others at other points. Such changes are mainly expressions of various stages in the involution or degeneration of the papule, but they may give the case a variegated appearance, in which pigmentation may be prominent.

Some years ago Biett described a form of syphilide which he claimed was unmistakable and indicative. Since he described the lesion it has been known as _Biett’s collarette_. It appears in from ten to twenty weeks after the secondary symptoms are fully declared, is superficial, usually situated upon the trunk and extremities, but never upon the palms or soles. It consists of a flat papule almost level with the skin, 1 to 2 Cm. in diameter, rounded in contour, while around it there is seen a zone of white epidermal scales pretty sharply defined and giving it the name of collarette. The area within is dry and painless, and the ring itself narrow. There is little or no itching. It may be followed by some other skin lesion. The lesion is often so mild as to pass unnoticed.

At other times _pustulocrustaceous syphilides_ will appear above the level of the skin, surrounded by a series of narrow concentric rings, not scaly, but composed of a number of small pustules, the first ring being perhaps an inch from the centre of the inner lesion. This is seen more often in males than in females, and it seems as though the smaller pustules were the result of an auto-infection of ordinary pyogenic character. In the presence of either of these lesions a positive diagnosis of syphilis can be made.

The _pustular syphilide_ may give rise to large or small pustules, which soon become superficial ulcers, often irregular in shape, with an unhealthy floor which may be livid or gangrenous, or may resemble a diphtheritic lesion, while from its surface exudes a mixture of blood, debris, and pus, which dries into dark-colored crusts and constitutes the lesion known as _ecthyma_. These lesions are often deceptive, since while scabbing seems to be occurring over the surface the ulceration may be extending beneath. This is an intermediate or earlier tertiary rather than a secondary lesion.

Another type of pustular syphilide is that known as _rupia_, where the ulcers are larger and are covered with concentric layers of crust resembling an oyster-shell. These lesions begin as papules and undergo changes which make them bullæ or pustules and then open ulcers. The peculiar scabs are somewhat conical in shape when not disturbed, and are greenish or brownish in color. If they are dislodged, irregular, indolent, and often sensitive ulcerated areas will be found beneath them. Even when these ulcers heal they are irregular in outline and show a white scar often surrounded by an areola of pigment. This rupia is the most visible lesion of syphilis, as no other skin disease assumes any such type.

In the last-described and ulcerative forms of syphilide there is a possibility of septic infection, or at least of septic intoxication by absorption; hence the need for care in this direction. In fact, into the treatment of every pustular indication of syphilis the elements of local protection and local antisepsis should enter.

=The Mucous Membranes.=--Here the manifestations of syphilis are of great importance because of their extreme infectiousness. The earlier manifestations are seen mainly about the mouth. When an eruption appears upon the skin a condition corresponding to it may often be recognized in the pharynx and upon the uvula and soft palate. This will be accompanied by discomfort, and the patient complains of “soreness of the throat.” These throat lesions are chronic, liable to recur, and disappear slowly, unless the patient is vigorously treated; they sometimes cause dryness of the fauces, followed by a free flow of mucus. The dusky discoloration of the rash is quite distinctive.

The congested areas have a dusky hue on the skin and are spoken of as “coppery” or “raw-ham” in tint. They are usually well outlined; should the disease progress they become eroded. “Syphilitic sore throat,” as this condition is often called, may be aggravated by the use of tobacco and by unclean mouths. The involvement of the cervical lymphatics will be proportionate to the vividness of the lesion.

TERTIARY OR CONSTITUTIONAL SYPHILIS.

There is no distinctive time limit between the so-called secondary and the tertiary symptoms of syphilis. Generally the lesions disappear with but little treatment; in many instances they will fade away without any. In most cases, however, the patient, even under poor management, takes enough medicine to disperse the lesions more quickly than they would spontaneously subside. If he discontinues medicine for several weeks, sometimes many months will elapse before there are any active manifestations of the disease. During this period, however, the lymphatic enlargements will not decrease perceptibly, and there may be evidence of advance in this direction. The so-called tertiary symptoms appear usually without fever or other symptoms, and not often in less than five or six months after the commencement of the disease. On the other hand, their advent may be delayed for years, even when the early treatment of the case has been but partially effective.

No organ or tissue in the body is exempt from the ravages of tertiary syphilis. Even the finger-nails and the hair may suffer, while the teeth are affected in the hereditary manifestations. Affections of the skin occur, according to Haslund, in about 12 per cent. of the cases.

The _mucous membranes_ are liable to exhibit those lesions above described, known as _mucous patches_, usually regarded as late secondary symptoms. The description applies equally well to the tertiary lesions. They occur about the oropharynx, upon the tongue, the lips, the nostrils, and the eyelids. They are frequently found also about the rectum, anus, and genitalia of either sex. In general they present about the same appearance. They commence usually with a slight elevation of the surface and at several points, sometimes simultaneously and successively. These surfaces ulcerate superficially, and thus are produced irregular but rounded patches, with uneven edges, of grayish-yellow surface, which ordinarily are not sensitive, but occasionally extremely so. They may disappear under local treatment, but in that case tend to recur at frequent intervals. If unnoticed or not properly cared for the ulcers may become deeper and assume an unhealthy appearance. In the mucus-lined cavities affected the condition of these ulcers will depend upon the personal habits of the patient. In mouths where tartar has accumulated upon the teeth, or where the toothbrush is seldom used, the patches may become large and foul.

_These lesions are extremely infectious_ and the disease may be conveyed by kissing, by the common use of small domestic utensils, by the pipe, by dentists’ instruments, etc. Patches occurring at the junction of the skin and mucous membrane may extend over onto the latter and become deep, specific ulcers. Lesions of this character need judicious local as well as constitutional treatment. They will often disappear under the latter alone, but it should be combined with local measures. These consist in cleanliness and the use of various antiseptic solutions or applications. An antiseptic mouth wash, as diluted hydrogen dioxide, or of water given a mahogany color by tincture of iodine, should be frequently used. There should be an application of a 5 per cent. solution of silver nitrate, or some other astringent, stimulating, or mild caustic.

[Illustration: FIG. 24

Grouped papulopustular syphilide and numerous pigmented spots from former lesions. (Fordyce.)]

=The Skin.=--The late syphilides of syphilis belong to the _gummatous_ or _tuberculous_ types (_i. e._, tuberculous in the anatomical sense, or nodular). The latter may occupy the entire thickness of the skin or lie even deeper. Such lesions may begin as papules and develop into distinct and circumscribed nodules, while these may coalesce into considerable masses. These tend to break down and leave scars after they have disappeared. There is little difference, microscopically, between the nodule and the gumma. Clinically, the tuberculous lesions spread usually in a serpiginous manner, producing a more or less curvilinear outline. (See Figs. 24 to 27.) These ulcerations undermine the tissues to a greater or less extent, and pus and debris will be formed in consequence. In this way they imitate considerably the lesions of lupus, and it may require a careful study of the case and of its history to make a diagnosis. Some of these lesions are extremely slow in their course and long in duration. When scars form they are usually white and smooth, with irregular borders, but sometimes are surrounded by pigment that makes them characteristic. The extent of the scar is no criterion as to the size of the originating lesion, the former being always smaller than the latter.

[Illustration: FIG. 25

Ulcers resulting from deep ecthymatous syphilide. (Fordyce.)]

=The Gumma of Syphilis.=--This is as characteristic of late syphilis as is the _condyloma_ of the earlier stage. By this term is meant a new formation which may vary in size from a millet-seed to a large mass. Sometimes it is diffuse, or it may be circumscribed. It seems to originate from connective tissue, and may be met in all parts of the body. Microscopically it consists of a delicate stroma filled with small, round cells, the mass being furnished usually with bloodvessels, also of new formation. Such a gumma may pass through various stages of integration and disintegration. The cells sometimes undergo fatty changes by which the entire mass is softened, and its interior contains a puruloid material resembling pus. The gumma, as it increases, will replace other tissues and cause them to disappear, and thus it happens that when it disappears the region previously occupied by it seems to have diminished in size. Sometimes, however, cicatricial tissue takes its place and not only distorts an organ or part but impairs its function. Thus softening and melting may occur at one time and a dense scar or mass at another.

The degree of infectiousness of gummatous and other late syphilitic ulcerations is uncertain. The later they occur, the less infectious. It would be safe, however, to assume that they are all dangerous.

=The Gummatous Syphilide.=--This begins, as a rule, as a subcutaneous gumma which quickly proceeds to and involves the skin. At first it appears as an induration, developing into a distinct tumor, becoming more indurated and firmly implanted as it grows, the overlying skin becoming reddened and swollen. After a time there occurs softening in the interior of the mass, and upon incision there will escape not pus but viscid, puruloid fluid, yellowish gray in color, which may contain corpuscles resembling those of pus. It is the content of such a tumor as this which has given it its peculiar name, _gumma_. Should proper treatment be rapidly pushed, it is possible for a softened gumma to disappear by absorption, but if ulceration or evacuation has taken place, there remains usually a permanent disfigurement at the site of the mass; like tuberculous gummas these growths may undergo caseous or even calcareous degeneration.

A gumma of the skin will open at one or several points, and, becoming thus secondarily infected, may give exit to sloughing tissue and foul discharge. If the skin directly overlies the bone, then the tumor may involve the latter as well; and when it ulcerates, the bone will be exposed. In the healing process, however brought about, deformity from cicatricial contraction may cause much disfigurement. When a gumma appears beneath the true skin and then disappears it may leave areas of depression, with more or less adherent, bleached-out scars, perhaps with a pigmented margin. The appearance of such scars is suggestive of the disease even without a definite history.

The gummas form the most important features of syphilis, at least from a surgical standpoint, since they frequently appear in the depths as well as on the surface of the body, without any other symptoms, and they often cause no little perplexity in diagnosis. Syphilomas, tuberculous gummas, phlegmons, innocent and benign tumors, as occurring especially in and upon the bone, in the muscles, tongue, the breast, the testicle, and elsewhere, may be difficult of diagnosis. Of course, a history of syphilis is a great help. Doubt frequently arises when such a history cannot be obtained. Scarcely any other disease will produce multiple lesions such as are seen in syphilis, and when multiple they are usually distributed, with some appearance of symmetry. Ulcers formed by their breaking down are often extremely sensitive, but do not bleed easily, nor show a tendency to exuberant granulation. In cases of doubt the most successful test is perhaps the therapeutic, and consists in giving mercurial or mixed treatment to the point of toleration and noting its effect.

[Illustration: FIG. 26

Tuberculous serpiginous syphilide resembling lupus vulgaris. (Fordyce.)]

[Illustration: FIG. 27

An ulcerating gumma of the leg. (Fordyce.)]

In many patients, especially of the hospital class, scars, which are strongly suggestive, will be visible upon the legs. It does not follow, however, that an old scar upon the legs, even if surrounded by a pigmented area, is necessarily of syphilitic origin. Old ulcers of the limbs are frequently seen in connection with varicose veins, and may show exceedingly chronic tendencies; moreover, it is possible for chronic and non-specific ulcers to occur in old syphilitic subjects when the course of the local lesions may be influenced by the old affection, although they are not specific ulcers. Benefit, however, will in such cases accrue by the reasonable administration of antispecific treatment, but it should be combined with suitable local measures.

=The Vascular System.=--The lesions which are encountered in the bloodvessel walls in chancre and early syphilis have been described. The heart and vessels are liable to suffer, as they contain connective tissue. Gummas have been noted in the heart, while the poison also may produce thickening of the valves, and disease of the coronary arteries, the endocardium and the myocardial structure.

The arteries often suffer from _arteriosclerosis_, which is either diffuse or nodular. Endarteritis is a common manifestation of syphilis and leads frequently to the formation of aneurysm. Sometimes this appears as a single and large lesion; at other times hundreds of small aneurysms will form in the arterial system of the brain, so that the arteries are studded with them. The explanation of aneurysm under these circumstances is that the arterial walls, being weakened, dilate under the influence of blood pressure. Thus the arteries, from the largest to the smallest, also may suffer. The veins likewise are subject to syphilitic phlebitis, which is frequent in the superficial veins of the extremities.

=Bones and Joints.=--Syphilitic manifestations in bones are frequent, but are not so common in the joints. While early syphilitic periostitis is not infrequent the actual lesions of the bone are mostly expressions of late syphilis. Nearly all of them are painful. The pain is worse at night, and is called the osteocopic pain of syphilis. At first these bone lesions are hyperplastic, because of the connective tissue in the bone. Periostitis is a common manifestation, and here, again, the neoplastic tendency of the disease is manifested, in that the periosteum is thickened as well as the bone beneath, and swellings called _nodes_ are thus formed. Nodes are met with more often on the tibia and the sternum than elsewhere, but are frequent upon the skull and clavicles. No bone is exempt from these lesions. They often form at points where there has been previous injury. These swellings are ill-defined, and usually quite tender, while the skin over them is easily movable unless secondary infection has occurred and suppuration is present. The nocturnal pains in these lesions, of which patients often complain, are sometimes excruciating. Should suppuration occur, with subsequent formation of ulcer, there may be necrosis of the exposed bone. Another bone lesion of syphilis assumes the type of _ostitis_. Physiologically this consists essentially of gummatous involvement of the connective tissue, which may be either localized or diffuse. When this undergoes retrocession there occurs a rarefaction of the bone, by which it is weakened and easily broken, so easily in fact that we have to deal sometimes with what is referred to as _spontaneous fracture_. There is frequently a thickening and condensation of the entire bone, with some distortion, so that the actual weight of the bone may be nearly doubled. _Dactylitis_ is the name given to syphilitic ostitis of the phalanges, which increase in size and become tender and useless, while the skin becomes glazed. Occasionally the disturbance appears to involve the extra-osseous tissues rather than the bones themselves. Bones which are spongy are liable to this disease. Some of the bones in the face are peculiarly susceptible; hence the loss of the bridge of the nose, or of a portion of the hard palate, by the ulcerative processes so common in this disease.

The joints are subject to changes somewhat similar to those occurring in tuberculous disease. There may be either a gummatous synovitis or an arthritis, or else destruction of articular surfaces. These joint lesions of syphilis are all slow in their course, and sometimes difficult of distinction from tuberculous and other lesions. They have so much in common with the joint expressions of tabes that some writers believe that tabes is necessarily an expression of syphilis of the cord.

As long as no active destruction has occurred within a bone or joint these cases are usually amenable to treatment, but for the actual destructions caused here or elsewhere by syphilis there is no repair possible, and the harm once done cannot be undone. Plastic operations and injections of paraffin may have to be practised for cosmetic purposes and relief of disfigurement.

=Muscles and Tendons.=--It is the connective tissue of muscles which suffers most in the luetic affection of these structures. It may be met with as a diffuse process or as a gumma. In the former cases the muscle becomes irregular in shape and size, and in the latter distinct tumors are formed. As such growths advance and contract adhesions to surrounding structures, there is interference with muscle play.

_Syphilitic myositis_ causes little pain, and patients with gummas in muscles are often not seen until ulceration has begun.

The dense fibrous structure of _tendons_ and _aponeuroses_ is frequently involved in late syphilis, causing pain and disability. Little is discovered on physical examination, but considerable loss of function may result. Points of tenderness sometimes are noted along junctions with the adjoining periosteum. Such a _tendoperiostitis_ may be painful, and even crippling.

=Bursæ.=--Bursæ are prone to be involved in syphilis, especially those in front of the patella. A gumma frequently develops at this point, where it constitutes a painless, somewhat tender enlargement, which may be dense or elastic. After it has become adherent to the skin it is usually infected, and a chronic ulcer results at this point, which may often manifest gangrenous tendencies. This constitutes one form of so-called _housemaid’s knee_.

=The Eye.=--Of the manifestations of syphilis in particular organs the eye sometimes suffers severely. _Iritis_ is the most common and serious manifestations of constitutional syphilis. It has been estimated that nearly 60 per cent. of all cases of iritis are due to this cause. It may occur in two months after the primary sore; it is usually acute, and rarely begins in both eyes at the same time, but may involve one after the other. The ciliary body is frequently associated in the lesion, and _iridocyclitis_ occurs. It commences with congestion of the conjunctiva, photophobia, and lacrymation. The pain is not always severe. Inspection of the iris will show beads of lymph, a small pupil, with loss of contractility, or the dull iris may appear infiltrated and inflexible. The pain in some cases is extreme. Where treatment has been only partially effective relapses are common. The greatest danger to be feared is formation of adhesions between the anterior surface of the lens and the margin of the pupil, _i. e._, anterior synechiæ. These are detrimental, and serve as the cause of many irritations.

The treatment of these affections is constitutional; locally solutions of atropine of sufficient strength to ensure dilatation of the pupil should be used, not only to relieve the pain, but to carry the margin of the pupil from the central portion of the lens and prevent adhesions. The patients should be kept in the dark because of their photophobia. Atropine may be substituted by duboisine if the former tends to produce congestion. Leeches applied to the temples will also give relief from pain.

The _cornea_ is often affected by a deposit on its posterior surface of particles of debris, which give it a punctate appearance known as keratitis punctata. It also becomes the seat of opacities which materially interfere with vision, and prove only partially amenable to treatment. Lesions of the cornea are frequent in hereditary syphilis.

_Retinitis_ and _choroiditis_, of either acute or chronic type, are the most common syphilitic lesions of the fundus. They are usually associated and involve both eyes. They come on so insidiously that they are often far advanced when first discovered. The lesions consist of patches of exudation and areas of atrophy, accompanied by some haziness in the vitreous. Vision is affected in proportion to the area involved.

The _movements of the eyes_ are interfered with by lesions which pertain, however, rather to the brain and the ocular nerves than to the eye itself. The sixth nerve, lying on the floor of the skull, is affected by syphilitic disease at the base of the bone. As a result of these nerve lesions paralysis is often seen, or at least disturbances of motility from which _diplopia_ results. _Ptosis_ occurs from affection of the third nerve. In lesions situated below the aqueduct of Sylvius, the paralytic condition which Hutchinson has spoken of as _ophthalmoplegia_ is likely to appear. _Optic neuritis_ is also a late manifestation of syphilis, and may be either chronic and mild, with a small disturbance of vision, or acute, with rapid loss of eyesight.

=The Ear.=--The ear may suffer in various ways. The external ear may

## participate in affections of the adjoining skin. The middle ear may

be affected as a result of extension of trouble from the nasopharynx, while in the late stages of the disease patients may suffer from labyrinthine disease, with partial or almost total deafness.

=The Nose.=--The lesions of syphilis in the nose are numerous and offensive. Ulceration is frequent and followed by perforation through the septum or into the mouth. When the vomer is involved the bridge of the nose falls in. In neglected cases the whole substance of the nose may be involved and subsequently lost. The bone is often exfoliated. These ulcerations of the mucous membrane and periosteum give rise to a characteristic condition known as _ozena_, with its characteristic discharge.

=The Oropharynx.=--The tongue may be the site of intermediate and late syphilitic lesions. Men suffer more than women, apparently because of their use of tobacco. Mucous patches, deep ulcers, and even gummas, single or multiple, are seen here. Gummas in the tongue are inclined to undergo superficial ulcerative infection and become abscesses. In these lesions there will be notable involvement of the adjoining lymphatics. The appearance of smooth, bluish-gray patches upon the mucous membrane of the tongue and cheeks is known as _leukoplakia_ or _leukokeratosis_. These lesions do not respond readily to treatment; they give rise to little or no complaint, and are often followed by malignant disease.

It is difficult to distinguish between gumma of the tongue and epithelioma. Usually the latter is a single lesion; the former often multiple. In epithelioma the ulcer is superficially painful, with more elevated and indurated edges, while the pain is sometimes intense and radiates toward the ears.

_Interstitial glossitis_ is a late manifestation of a sclerosis beginning in the connective tissue and involving the muscle fibers, leading to enlargement of the tongue and later to atrophy and inflexibility.

=The Larynx.=--Syphilis of the larynx appears either as one or more ulcers, as gumma, or as _chondritis_ or _perichondritis_, often with necrosis of cartilage. When ulcers form they are deep and destructive, involving even the intrinsic muscles of the larynx, and causing harshness or loss of voice, with dyspnea. Subsequently they lead to cicatrization, often leaving a stricture which may call for tracheotomy. The epiglottis is also liable to ulceration and gummatous lesions.

In these cases, aside from the general treatment, there is need also for local applications of combined antiseptic and anodyne character. Cocaine or one of its less toxic substitutes may be used in spray or by insufflation, in connection with an antiseptic powder, morphine or heroine. Edema of the glottis may be subdued by the local use of adrenalin.

=The Alimentary Tract.=--Between the mouth and the rectum the intestinal canal is rarely involved in syphilitic disease. In the _rectum_, however, ulcers, as well as gummatous infiltrations, are frequently encountered. If the ulcers are low, within two inches of the anus, they will cause great pain. Higher up the rectum is not so well supplied with sensory nerves. Ulceration may involve the entire circumference of the anus.

In the rectum chronic ulcers are liable to be followed by stricture, which will call for surgical relief. (See chapter on the Rectum.)

In the _colon_ chronic ulcers have been so serious as to lead to dysentery, followed by stricture formation. It has been suggested to make an artificial anus at the cecum and allow the large intestine to rest, treating it at the same time with irrigation through the opening.

=The Viscera.=--Of the solid viscera the _liver_ is more commonly affected than the spleen or kidneys. Chronic _interstitial hepatitis_ may lead to cirrhosis, the new tissue being less distinctly distributed than when due to alcohol, the liver consequently becoming irregular, with a deep separation between its lobes. The pain is sometimes intense.

On the other hand isolated _gummas_, or confluent masses of smaller gummas, may be found beneath the capsule or in the substance of the liver. From one or both of these cases combined this viscus may attain an enormous size, with acute pain. Under these conditions there may occur albuminuria and evidences of amyloid disease.

Likewise in the _spleen_ there may be diffuse or localized trouble. Here the lesions cause but slight distress.

The mercurials are of greater importance than the iodides in treatment of these lesions. The kidneys suffer less often than the spleen. Syphilitic patients do not lose their liability to renal disorders, but there seems to be but small, direct connection between syphilis and the common changes in these organs.

=The Genitalia.=--In both sexes the genitalia are subject to gummatous involvement during the later stages; in the male more frequently in the _corpora cavernosa_ and _testicle_. In the latter a chronic induration, with some enlargement of the epididymis, is one of the manifestations of constitutional disease. Most of the enlargements of the testicle are slow and painless, and occasionally some fluid will collect. The _prostate_ and the _seminal vesicles_ are rarely involved in syphilis, but frequently in a tuberculous process. This is an important diagnostic point.

In the ovaries there may occur a diffuse cirrhotic process.

=The Nervous System.=--Here the manifestations of syphilis are often serious and widespread. They are produced by the same new tissue to which we have so often alluded, with its tendency at first to degeneration and later to sclerosis. They are always insidious. Gummatous thickening may occur at any point, springing often from the pia of the brain and cord. The arterial walls are frequently so affected, and at many points, that multiple minute aneurysms are produced, any one of which may give way and produce the fatal results of a cerebral hemorrhage. In diffuse gumma of the membranes or cortex the process is slow, and likely to involve areas which may be recognized by cerebral localization. Many cases presenting the features of brain tumor will yield to antisyphilitic treatment, and thus show themselves to be syphilomas.

In the _spinal canal_ implication of the membranes is more likely to occur than in the vessels. In the _cord_ these sclerotic changes are also quite common and produce symptoms strongly suggestive of tabes; in fact, there are those who hold that tabes is of specific origin.

In the motor and sensory nerves much connective tissue is present, and consequently these nerves are not exempt from sclerotic changes with pressure symptoms, which will give the clinical picture of a _neuritis_.

SYPHILIS IN CHILDREN.

Syphilis appears in young children under the following circumstances:

_A._ The disease may have been transmitted from the father to the ovum, at the time of conception, by infected spermatozoa.

_B._ From the mother, who may have acquired it before impregnation or during the early part of her pregnancy. In the latter case the infecting influence is transmitted through the placental circulation.

_C._ From the mother at the time of its birth, from a recently infected puerperal tract.

_D._ From some possible extrinsic source, a short time after its birth, as, _e. g._, through the umbilicus.

The later the mother acquires the disease after conception, the less likelihood that the child will be infected. If infection takes place from the placenta, then it also will be found to be diseased.

=Profeta’s “Law.”=--Profeta first made the statement that the child of an infected mother who acquired the disease late in her pregnancy may not only be born healthy, but may be immune to subsequent infection, as are other healthy children of syphilitic parents. But, on the other hand, such a child may be anemic, puny, with small resisting power, or it may develop a late hereditary syphilis. When the ovum is infected by the father the healthy mother may escape, or she may acquire the disease through the placenta in her own uterus, or she may suffer from a mitigated form of syphilis whose principal features will appear as late manifestations of the disease.

=Colles’ “Law.”=--Colles, in 1837, made the statement that such a mother may remain healthy with an acquired immunity to subsequent infection. The statements above made have often been alluded to as Profeta’s and Colles’ “laws.” These should, however, be regarded simply as statements of what usually occurs, and too much dependence should not be placed upon them. In fact, the immunity which the mother or the child may enjoy under conditions mentioned above is not likely to be permanent, though it may last for a varying period of time. There is no limit to the time when a parent may transmit syphilis to the child. The five-year limit given for the father is often overstepped, and the longer the man waits before marrying after acquiring the disease, and the more thoroughly he submits to judicious treatment, the less likely he is to convey it to offspring. This is the strongest kind of argument that can be used to _delay marriage of syphilitics_.

_The indication of syphilis on the part of the mother_ is, in addition to those already given above, a tendency to miscarriage or abortion. The earlier she acquires the disease the earlier will the mishap occur. Should she escape the child may go on to full term, or it may die and be expelled as a dead fetus two or three months before the expiration of term. Should a child be born alive with hereditary syphilis, the evidences may appear at birth or within three months. Should a child apparently escape for six months it may grow up to be puny or develop some form of late hereditary disease, or it may possibly remain well. These children usually show developmental defect in some direction, and manifest a much weakened resisting power to other diseases; moreover, the spleen will usually be found enlarged.

Among the changes which may occur are the following: The _skin_ becomes loose and resembles that of an old person. This is partly because it grows even faster than the tissues beneath it, so pronounced is the emaciation. _Snuffles_, or _nasal catarrh_, is one of the earliest features. This is due to specific swelling of portions of the Schneiderian membrane. Snuffles _may_ occur in children without syphilis, but syphilis will nearly always produce snuffles, which may last for some time, and cause a widening at the root of the nose which will persist through life. Following the snuffles there usually appears a rash over the trunk and thighs and about the anus, accompanied by mucous patches. This will have the same bright, coppery tint as roseola syphilitica, already mentioned, which it much resembles. Sometimes it assumes the mixed type of eruption, while upon the palms and soles appears the so-called pemphigus syphiliticus. Should the child live nodular or gummatous syphilides may develop.

In the bone and cartilage characteristic changes are met at the lower end of the femur and at the costochondral junctions. This consists of an _osteochondritis syphilitica_. At the affected points enlargements take place, which may disappear under treatment or may go on to ulceration and necrosis. In the fingers and toes there are manifestations already described as syphilitic _dactylitis_.

The bones of the skull are likely to be involved in thickenings, especially about the anterior fontanelle, where they form the so-called Parrot’s nodes. These may disappear, with or without treatment, and the affected bone may undergo atrophy or may entirely disappear.

Among the viscera the _spleen_ generally becomes affected first and then the liver. Syphilitic iritis may occur early, but is rather rare; ocular changes occur more often in the choroid. In the brain distinctive lesions may occur to such an extent as to lead to considerable thickening of the dura, with or without hydrocephalus, and subsequent imbecility or idiocy.

_Deafness_ is not infrequent in hereditary syphilis. It may begin suddenly and at any age, even during infancy. It is produced by deep lesions which do not yield readily to treatment, and sometimes leads to deaf-mutism, especially when it occurs before the child has learned to talk.

Among the later manifestations of hereditary syphilis are opacities of the cornea from _interstitial keratitis_. This may occur in children who are apparently in good health and free from other signs of hereditary disease. The condition is rather obstinate, but it can be made to disappear under suitable treatment. _Retinitis_ occurs frequently in young women, and is likely to lead to atrophy or detachment.

=The Teeth.=--The permanent teeth often show peculiar changes that are distinctive, especially in those who have shown signs of corneal involvement, which, having been first described by Hutchinson, are frequently alluded to as _Hutchinson’s teeth_. When they first appear they are smaller than natural and irregular. Later they become notched. The crescentic notches show best upon the incisor teeth. Sometimes the canines are also affected, being narrow, rounded, and peg-like, with jagged edges. These teeth are usually so formed that they do not meet properly, and so small that they scarcely touch each other. The most characteristic changes are met with in the upper incisors, which may be affected when all the others are fairly normal. In such cases they will be found narrow and short, with a single broad notch at the edge, with perhaps a furrow passing from it upward and on both anterior and posterior aspects. Notching is usually symmetrical. No conclusions can be drawn from the teeth if they are normal, as they may be, but when they present the above-described features they prove a very important indication.

The relations between syphilis and rickets have attracted much attention, and there is little doubt but that rachitic changes are prone to occur in subjects with inherited syphilis. The two conditions are sometimes blended in various degrees and ways, and yet it is not safe to say that rickets is always an expression of inherited syphilis.

TREATMENT OF SYPHILIS.

There is no question but that some of the above-described lesions constitute as disgusting and repelling diseased conditions as the physician or surgeon is ever called upon to treat. In spite of these circumstances, however, it is generally believed that syphilis is a most satisfactory disease to treat. This is because of the almost mathematical certainty with which results can be predicted and estimated. There is nothing more satisfactory in therapeutics than the rapidity with which many pronounced and serious manifestations of syphilis will disappear under the influence of proper treatment. These statements, however, should be modified to make room for exceptional cases, where the disease assumes a malignant type, owing probably to some defect in the patient’s constitution, or where patients show peculiar idiosyncrasies and susceptibilities to the influence of mercury and iodine. Such cases happen occasionally and prove difficult of solution, while they sorely try the surgeon’s ingenuity and resources.

_In the majority of instances syphilis is a curable disease._ A patient should be first impressed with the necessity of faithfully following the directions of his physician, and continuing under treatment for a period of at least three years after the disappearance of the last manifestation of the disease. The disease is curable, but only by the judicious combination of two principal remedies, _i. e._, _mercury_ and _iodine_. Those rare instances in which cure seems to have followed lines of treatment which do not include the use of these two drugs are so exceptional and misleading that they should not be considered criteria. Mercury and iodine are powerful remedies, needing to be administered with caution and judgment. Unfortunately there is no arbitrary limit of time for any given case. The time stated above is that usually considered requisite. While syphilis may be curable in some cases in less than the stated time, it is better to give it longer treatment than is absolutely required rather than the reverse. The treatment entails no unpleasant consequences. Warnings as to the approach of toxic symptoms from the drugs can be easily recognized.

Of the two drugs the preparations of mercury are the more important. The surgeon may adopt as his motto, _mercury, more mercury, and again mercury_, and if he begins with this measure early in the disease he may be able to conduct it to a successful termination with but little resort to iodine. Iodine is effective rather in those cases where treatment has been begun relatively late, and where it seems necessary to make a double impression upon the disease.

When the nature of the primary lesion is positive treatment should begin with the first visit of the patient to the surgeon. When there is uncertainty regarding the character of the venereal sore, treatment _may_ be postponed until the appearance of the first eruption. As soon as this has appeared the treatment should be hastened. It is necessary to begin with mercury. The patient’s mouth should be examined by a dentist and all tartar removed from the teeth, especially from the gingival borders, at which lines the gums are likely to become sore when mercury is too freely used. All diseased teeth should be extracted or filled, and the mouth and its contents should be put in normal condition. The dentist should be informed as to the reason for the visit. Smoking should be discontinued, especially when there are mucous patches, since it is apt to irritate and make subsequent lesions of the mucous membrane more likely to occur. The habits of the patient should be regulated as to alcohol and other indulgences, and he should be warned as to the infectious nature of the disease, _in order that others may be protected_. In many instances tonic, even roborant treatment may be advantageously combined with the antispecific. It will be found that the anemia so characteristic of well-marked secondary syphilis will improve materially under the influence of mercury alone.

Should the disease occur in a married person, or develop after marriage, caution should be given as to the danger to offspring, and to the other associate in the marriage relation, which might follow the occurrence of pregnancy.

Mercury may be given by the _mouth_, by _inunction_, by _hypodermic injection_, or by _fumigation_. The intent should be to get the patient under its influence as rapidly as is consistent with safety. The most effective of these methods to which patients will ordinarily submit is that by _inunction_. This consists essentially in the use of _mercurial ointment_ (blue ointment), of which 15 Gm. may be used daily or nightly, which should be thoroughly rubbed into some area of the body; the areas selected being changed at perhaps three-day intervals, in order that irritation, which its prolonged use produces, may be avoided. It takes considerable effort to so completely rub this in as to make most of it disappear, and it can be done more easily upon those parts of the body which are free from hair. It can be best done by employing someone for the purpose, but patients can be easily taught to use it themselves. There are upon the market, ointments containing mercury made with other excipients than lard, which are less uncomfortable to the skin and seem to be absorbed better; among these is a preparation made with a petroleum compound called vasogen, which may be procured in different strengths; that containing 33 per cent. or 50 per cent. is the best.

Inunction should be practised at least once every twenty-four hours, until either the gums become tender or swollen, with an offensive odor of the breath, or until the skin is irritated. The mouth should be protected by use of an astringent antiseptic mouth-wash, such as the following: Carbolic acid 10 parts, oil of wintergreen 1 part, tincture of myrrh 50 parts. A little of this solution in a tablespoonful or more of water makes a serviceable wash, which should be used several times a day. There are sanitaria and springs, or health resorts, in this country where a specialty is made of this manner of treatment. At these resorts inunction is practised freely and thoroughly, but the benefit which is obtained comes rather from the attention which patients give to the treatment, and their abstention from business or dissipation, than from any inherent medicinal features either in the mineral water or climate.

Under the influence of mercurial ointment alone, if a patient is willing to persist in its use, many cases of syphilis may be conducted to a successful termination; but its use is disagreeable to some people, and it may be impossible to resort to it for any great length of time. It has its inconveniences and disadvantages, but it should be applied in at least the first stages of the disease.

When mercurial ointment is seen to have made a distinctive impression upon the constitution of the patient it may be discarded and the treatment changed to the internal administration of the drug.

Mercurials may be given internally in any one of several different preparations. Hutchinson has recommended _gray powder_, in doses of ¹⁄₄ to ¹⁄₃ Gm. three or four times a day. _Corrosive sublimate_ is a reliable form in which to administer mercury in doses which can be tolerated, from 1 to 2 Mg., three or four times a day. The red iodide may be given in similar doses, or the green iodide may be administered in doses of 0.15 to 2 Cg. These preparations sometimes irritate the intestinal tract and produce a certain amount of colic or looseness of the bowel. For the latter some astringent may be combined with the mercury, while intestinal pain may be checked by the use of extract of conium.

The _hypodermic use of mercury_ can be made effective, but there are but few preparations which can be used that do not cause pain and subsequent irritation. Perhaps that which gives least pain is the sozoiodolate of mercury. This is sparingly soluble in water, dissolving in about 500 parts by weight. As the dose is 9 or 10 Cg., the amount of water necessary for this solution is so bulky that the dose should be injected into the gluteal region. Corrosive sublimate is also used in 1 per cent. solution, made up in common salt solution of the usual strength of 9 to 1000. Of this 10 minims represent a suitable dose to commence with, which may be increased to 30 or 40 minims when necessary. This should be given in the same region, the needle being driven in its full length perpendicularly to the surface. When this is done an injection is made into the muscle, where it seems to be more effective than in the subcutaneous fat. When the dose is increased to more than 20 minims a 2 per cent. solution may be used and the amount of fluid correspondingly reduced.

_Fumigation_ is a method now not often adopted, calomel being used for the purpose, an ordinary cabinet hot-air bath confining the vapor about the patient. One treatment a day by either of these methods is usually sufficient.

About the _initial sore_ dry calomel, pure or reduced with bismuth subnitrate, may be used. The condylomas met with about the perineum will often shrink and disappear under the influence of this application. _Mucous patches_ should be treated with absolute cleanliness; in the mouth a wash of diluted hydrogen dioxide may be used, and the patches touched with a strong nitrate of silver solution, pure carbolic acid, or camphophenol. This will not prevent contagion from such a source, but will reduce it to a minimum beneficial in every respect.

The various eruptions of syphilis will disappear gradually under the influence of a local application of one of the mercurial preparations, either the ordinary mercurial ointment or ammoniated mercury.

In cases of _inherited syphilis_, especially in young children, a reduced mercurial ointment, or the use of gray powder (mercury with chalk) will give the best results. The dose should be regulated by the age of the patient; for instance, of the latter 1 to 2 Cg. for an infant. The iodides have also proved successful.

_Iodine_ and its preparations have by many authorities been held to be useful in the later and especially in the gummatous lesions of syphilis. There are patients who cannot take iodine to any extent without suffering from such disturbance of mucous membranes, especially in the nose and intestines, as to make it an exceedingly unpleasant remedy.

The iodides have not proved as successful as the mercurials; nevertheless, the combination is a popular one and sometimes of peculiar value. The potassium salt is the one generally used, as it is cheaper than the sodium compound. The latter, however, is less irritating and often more available. The lithium compound is ideal in some respects, but very expensive. The iodides may be given in large doses, to the extent of 30 Gm. or more (an ounce or more) in twenty-four hours. Large doses are sometimes necessary in the treatment of late syphilis of the nervous system. When it is necessary to put the patient rapidly under the influence of antispecific medication the combined use of these two drugs, as for example by mercurial inunction and the use of one of the iodides internally, will most speedily bring about the desired result. This result may be overreached, and sore mouth or other toxic manifestations may appear suddenly and unexpectedly.

The mercuric salts are soluble in solutions of the iodides, and what is known as _mixed treatment_ is often employed. The salts may be combined in any desired preparation. Donovan’s solution is exceedingly valuable, the arsenic which it contains seeming to reinforce both the mercury and the iodine.

The iodides produce eruptions or rashes which strongly simulate both syphilitic and non-syphilitic skin diseases, and confusion may arise from their use. In those who are sensitive to the iodides, and in whom catarrh of the mucous membranes is easily produced, it is best to begin with small doses, increasing them as circumstances may warrant. Some patients cannot take iodine in any form. When iodides irritate the stomach they should be given in essence of pepsin.

Of the various vegetable remedies some are unreliable and of little value. Certain combinations can, however, be effected in some cases by which the value of the effective agents may be enhanced. _Zittmann’s decoction_ or _McDade’s formula_ will occasionally prove of service. In aggravated cases the former is believed to be the most effective of all methods of administering mercury. Tonics or any other medicines which may be called for in particular cases should be given judiciously. There is nothing in antisyphilitic treatment which precludes other treatment when needed.

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