The principles and practice of modern surgery

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).

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.

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.