Plate 9. Syphilis. Synonyms.—Pox; Mal-Venerean; Lues Venerea.

Definition.—A specific infectious disease, weeks or months being occupied in its development; contracted by inoculation,—acquired syphilis, or hereditary,—congenital syphilis, and characterized by three distinct stages: Primary; Secondary; Tertiary.

Primary Stage.—This stage is characterized by the appearance of the initial sore or chancre at the seat of inoculation, in from twenty to thirty days after the introduction of the virus, and lasting on the average about six weeks.

Secondary Stage.—In this stage, constitutional symptoms occur in from sixty to ninety days after the primary lesion, in the form of fever, cutaneous eruptions, ulcerations of mucous surfaces—especially of the mouth, tongue, and throat, loss of hair, and frequently iritis.

Tertiary Stage.—This stage is characterized by inflammatory products, gummata, which develop from the third to the sixth year, and last from one to twenty years, or a lifetime, and which appear in the skin, muscles, the various viscera, and in the bones.

History.—In all probability, syphilis is as old as the human race; for we can readily believe that illicit intercourse was practiced in the cities of the ancient world when the morals of the people were more lax than those of to-day. Our knowledge of this disease, however, dates from the fifteenth century. Breaking out among the troops of Charles VIII, King of France, it rapidly spread over Europe. From then to the present day our knowledge of the disease has grown, till today we are able to classify and separate the various lesions resulting from illicit and promiscuous intercourse. All forms of venereal disease were included under the name of syphilis till Ricord, in 1831, demonstrated to the profession that gonorrhea and syphilis were two distinct lesions.

Etiology.—Predisposing causes are injuries or abrasions of the mucous surfaces of exposed parts, for the disease can originate in only one way, by inoculation.

The primary cause is now regarded, generally, as a bacillus, though the claim of Lustgarten and Van Neissen as discoverers of the syphilitic bacillus has not been verified. The contagion resides in the blood and morbid products of the individual suffering from syphilis. It reproduces itself for months and years, and, while it grows less malignant with age and finally loses its infecting principle, we have not yet been able to determine that fortunate period of time. In some it may remain for life.

The contagion can not be transmitted to the lower animals, man being the only animal subject to this loathsome and degrading disease. One attack generally renders one immune, though not always, and a mother who has borne a syphilitic child becomes immune, though there be no visible proofs of the disease, and she may handle or suckle a syphilitic baby with impunity.

Modes of Infection.—There are three modes of infection: 1, Illicit intercourse : 2, Heredity; 3, Accidental.

Illicit intercourse is responsible for the great proportion of cases, though the patient declares that it has occurred accidentally. The lustful gratification of the passions is perhaps responsible for seventy-five per cent of all cases of syphilis.

Accidental.—Kissing.—The reprehensible and general habit of kissing is responsible, not only for diphtheria, scarlet fever, and a host of other contagious diseases, but also for this plague of the world, and lip chancre is not uncommon.

Nursing.—A syphilitic wet-nurse may convey to her charge the disease, or the babe may infect through the nipple her nurse. The physician who is called to treat all classes of patients may, through an abraded finger, receive the infection while administering to a patient in confinement.

A very rare, though possible cause, would be through shaving, or the use of the thermometer, though the stropping of the razor makes this very unlikely, and the wiping and dipping in cold water each time after taking the temperature would also seem proof against contagion by this means. Recently there has been quite an agitation for individual communion-cups in the religious rites of administering the Lord's Supper, to prevent this and other diseases. I am inclined to believe that such tales by patients are to hide their own' lust and indiscretion. Neither am I inclined to believe that vaccination has been such a prolific source of the disease, although I admit its possibility. Dr. Robert Cory, chief vaccinater to the National Vaccine Establishment, England, in his experiments, as recorded in Keating's Encyclopedia of Children, showed how little danger there is from vaccination.

Dr. Cory believed it impossible to convey syphilis by vaccination; to prove which, he repeatedly vaccinated himself from children who were plainly and actively syphilitic. A number of these were barren of results, but finally, on July 6, 1881, he was not so fortunate in escaping. He vaccinated himself in three places from the lymph taken from a three-months old child that had eruptions and' sores which were evidently syphilitic. In three weeks syphilitic papules appeared at the seat of two of the punctures, and were followed in due time by sore throat, roseola, and other positive evidence of constitutional syphilis,—thus proving that, while it is possible to acquire syphilis by vaccination, it must occur very rarely in active practice.

Hereditary Transmission.—In hereditary transmission, nature plays some queer and unexplainable pranks. Two conditions are so well known that they have come to be recognized as established laws: Profeta's and Colle's,—the former, in which syphilitic parents beget a healthy child, the offspring acquiring immunity during gestation, which protects it from either parent; the other, Colle's law, is where a mother bears a syphilitic child, and she herself becomes immune, and can not be infected, even though she presents no signs of the disease.

The most frequent form of transmission is from the father, the mother being free from infection. This is known as sperm infection. Here, again, we see strange results; for a decidedly syphilitic father may beget a healthy child, while, on the other hand, a man, who may have had syphilis in his early life, but apparently had recovered after treatment, not presenting a single phase of his old trouble for years, may transmit to his offspring the characteristic lesion of the disease.

The earlier the offspring is begotten, after the appearance of the primary sore, the greater the danger from infection, while, under judicious treatment, the danger is but slight after four years. The more remote from the initial lesion, the less the danger, and a parent suffering from tertiary lesion may beget a healthy child.

Infection from the mother, known as germ infection, is also quite common, the father being free. In most cases, however, both father and mother are infected, the latter by the former;. in which case the child is very apt to show infection.

Where the mother becomes infected after conception, the offspring may show infection, when it is known as placental transmission.

Pathology.—Chancre.—The initial lesion consists of an infiltration of small round cells, together with larger epithelial cells, giant cells, and the bacilli of Lustgarten. The inflammatory process causes thickening, and sometimes obliteration, of the smaller arteries and veins, which give rise to sclerosis. This is soon followed by degeneration of the epithelium, causing the small, round, shallow ulcer about the size of a split pea, the hard, indurated convex surface forming its base. The near lymphatics are soon involved, becoming infiltrated and indurated, which in turn may caseate and break down.

Secondary Lesions.—The most common are ulceration of mucous surfaces and cutaneous eruptions. The favorite location for mucous patches is the mouth and anus. They vary in size from a pin-point to a half-dollar, their edges being slightly indurated. Iritis is quite a common attendant.

Tertiary Lesion.—Inflammatory products, known as gummata, characterize the third stage. These bodies are made up of round cells, and vary in size from that of a millet-seed to that of a walnut. They are found upon the bones and periostium, and called nodes, or they may be found in the skin, muscles, liver, kidneys, lung, heart, brain; in fact, in any of the viscera of the body. Usually they are firm and indurated, though in the skin and viscera they may break down, forming ulcers.

A cross section of one of these products reveals a grayish white mass, firm in consistency, the center being caseous, while the outer border consists of translucent, fibrous tissue.

Acquired Syphilis.—Primary Stage.—The period of incubation, or the time from exposure to the appearance of the initial lesion, the chancre, is from three to five weeks, the average time being from twenty-eight to thirty days. The first evidence is a small red papule, which early reaches its full development, then undergoes central necrosis, giving rise to the ulcer. The outer edges become indurated and feel like cartilage; hence the name, "hard chancre." The glands in the near neighborhood become enlarged and indurated, to be followed by general glandular infection; next in order are those of the axilla, to be followed by the cervical and occipital. If the chancre be located in the urethra and is small, it may escape detection. During this stage the general health is not impaired.

Secondary Stage.—This is usually announced by a light fever, from six to twelve weeks after the appearance of the initial lesion. Generally the fever is not very high, 103° or less, although occasionally it may reach 104° or 105°. The patient complains of headache, muscular pains, loss of appetite, impaired digestion, and less in weight. There is anemia, more or less pronounced, while the color becomes a dirty yellow, the well-known syphilitic cachexia.

Ulceration of the mouth and throat early appears in the form of white patches. On the tongue they may be ragged and irregular in appearance, with a firm base. There is usually but little pain from this source. About this time the rash, syphilitic roseola, appears upon the trunk, being profuse upon the chest, arms, and forehead. In color they are a dingy red or copper. It is not only a hyperemia, but also an infiltration, and when the finger is passed over them, there is a distinct sensation of their infiltrated character. This usually lasts from a few days to two weeks, though in exceptional cases it is present for months.

The papular syphilide may follow in order or appear simultaneously, or may appear without the roseolous rash having preceded it. The papules are found in the scalp, face, and body, and vary in size from that of a pinhead to that of a pea. They are firm, hard, and painless. Following this we may have the pquamous, the vesiculo-papular, pustular, and tubercular. These may follow in order or be developed independently of each other. There may be fissures or mucous patches about the anus, vulva, or vagina, that occasion a great deal of discomfort to the patient.

Alopecia is one of the frequent, and, to the patient, deplorable conditions of this stage. Not only loss of hair from scalp, but the hairs of the eyelids and brows may also drop out, giving the patient a ludicrous appearance, and one to be dreaded. Iritis is not an uncommon condition of this stage.

The secondary stage may disappear in two or three months, or it may occupy a year or more in its various evolutions.

Tertiary Stage.—It is impossible to draw the dividing line between the various stages of syphilis. Usually some time elapses between the second and third stage, sometimes years intervening, during which time the patient will experience a season of health. At other times the tertiary lesions appear before the secondary have passed from view. These are the later syphilides, gummata, and amyloid degenerations.

The eruptions in this stage are more irregular and involve deeper tissues. Rupia, the most characteristic, is covered by dry crusts, beneath which are the ulcers involving the skin and deeper tissues. These are slow in healing, and leave behind a cicatrix, a constant reminder of man's indiscretion.

Gummata may develop in the mucous membrane, skin, subcutaneous tissues, muscles, viscera, brain, cord, and bones. Where they develop superficially, ulceration and cicatrization occur. In the muscles they develop as tumors. In the viscera they undergo fibroid degeneration, attended by puckering and more or less deformity, thus impairing their function. They appear as nodes on the bones, the tibia and skull-bones being the favorable locations. These are painful to the touch, and with the approach of cold weather the patient desires to toast his shins, to relieve the chill and ache which attend these changes. The pains are worse at night.

Where the deposits are in the brain, they are usually located near the surface and are generally attached to the dura or pia mater. They vary in size from that of a pea to that of a walnut. A cut section reveals a mass, caseated and surrounded by a fibrous tissue. Where these masses come in contact with the meninges, meningitis almost invariably follows.

While gummata may appear in the cord, it is far more rare than in the brain. The arteries becoming occluded, arteritis follows. These lesions of the brain are usually slow in developing, years elapsing after the initial lesion. Persistent headache, resisting the ordinary treatment, should call attention to the nature of the trouble. Delirium may follow or precede the neuralgia. Dizziness is often encountered, and vomiting is a common attendant. Following a lesion of the cord, locomotor ataxia is the most serious result.

Gummata of the digestive tract throughout its entire course is not uncommon, though the deposits may ,be found in any portion. The orifices are the most frequently affected; in fact, they rival the skin in evidence of their presence.

The lips, mouth, and pharynx have already been mentioned as being the first to feel the force of the poison. Deposits in the esophagus, though not frequent, give rise to stricture. The selection of the stomach and intestinal tract for the deposit is quite rare, though the last inch of the bowel is a favorite site for the deposit. Like that of the esophagus, stricture is apt to result.

Liver.—The liver may be the seat of either diffuse or circumscribed deposits. The kidneys may also be involved. When the heart feels the force of the poison, we' find warty excrescences, producing endocarditis. Deposits may also take place on the valves.

The respiratory tract is also invaded by this foe of the human race, the nose in rare cases showing the characteristic deposit. The larynx, as well as the trachea and bronchi, are occasionally involved. The lungs prove no exception to the general rule, the deposits usually selecting the middle and lower lobes rather than the apices, as in tuberculosis.

Testicles.—The gummatous deposits frequently select the testes as a fruitful soil for a display of their action, forming indurated masses in the body of the organ. The gland is swollen and enlarged, though but little painful. There is but little tendency to degeneration. The location of the deposit enables one to recognize it from tuberculosis, which seeks the epididymis as a nesting-place.

Congenital Syphilis.—The same conditions, expressed by similar symptoms, are to be found in congenital as well as in acquired syphilis, with the exception of the initial lesion, the chancre. The disease may show its characteristics while yet in utero, at birth, a few weeks later, or at puberty. The lesion will be considered in this order.

In Utero.—That the fetus feels the force of the virus while yet in utero, and shares in its destructive powder, is seen in frequent abortions and the presence at birth, or a few days later, of bullae on the hands and feet, pemphigus neonatorum.

There are changes that take place in the viscera, and, though rare, are corroborated by such men as Gubler, Rochenbrome, Barensprung, and others. Hutchinson says: "Of these, a parenchymatous infiltration—fibroplastic—of the liver, for the most part without large gummata, is the most common. It is sometimes attended by anasarca, and similar lesions occur in the lung. If not actually present at birth, it may develop soon afterwards, and may then lead to jaundice and death.

Infiltrations of the same kind may be found also in the spleen, the kidneys, the thymus gland, and even in the heart. Occasionally larger and more circumscribed deposits are found, and sometimes softening occurs and abscesses form. These pathological processes occur chiefly during the later period of intra-uterine life, and are no doubt responsible for the majority of cases being born dead at, or near, full time. They may also occur during the first few weeks of life. At this age jaundice is sometimes observed, and is a symptom of great danger.

As a rule, these early manifestations of the disease result in death, either at birth or at an early period, the number surviving being very small.

At Birth.—While the majority of syphilitic babies are born apparently healthy, being rosy and plump, the visible effects not appearing till the end of the fourth week, a certain number come into the world with the characteristic syphilitic cachexia. Their puny, feeble, emaciated bodies put so great a handicap upon them in the battle for existence, that few survive the struggle but a few weeks. The sallow or jaundiced skin is wrinkled and flabby, giving the child a prematurely old look.

Snuffles render the respiration difficult, the child breathing through the mouth, and frequently interfering with the child's nursing. Ulcers and fissures appear at the orifices of the body, especially at the mouth and amis. With the exception of pemphigus neonatorum, skin eruptions are rare. There is generally enlargement of the liver and spleen. Disease of the bones is often seen, with separation of their epiphyses.

Early Manifestations.—After four, six, or eight weeks of apparent robustness, the child develops a nasal catarrh, syphilitic rhinitis, which greatly interferes with nursing and respiration. This condition, known as snuffles, is attended by a mucopurulent or bloody secretion. This may be followed by ulceration and necrosis of the nasal bones, resulting in a depression at its base, which is characteristic of congenital syphilis. The catarrh may extend to the middle ear, giving rise to otitis media, followed by deafness and otorrhea.

The cutaneous symptoms early make their appearance, usually about the nates, either as an erythema, eczematous patches, or papules. They are of the characteristic coppery color. With these several symptoms the hair on the head and eyebrows may fall out, while the finger-tips become red and inflamed, and the nails finally separate and fall off. Ulcers or fissures about the mouth now make their appearance, the discharges from which are highly infectious, and, if nourished by a wet-nurse, transmit to her the disease. Other members of the family also may become infected by kissing and fondling the babe.

The spleen is usually enlarged, as may be the liver, though this is not characteristic. There is not so apt to be glandular enlargement in this as in the acquired form. The child becomes restless, sleeps poorly, and has a sharp, shrill cry, due partly to pain, and partly to obstructed respiration.

Later Developments.—The child may seemingly recover from these early lesions, and for a time seem to have outgrown the effects of his early troubles; but during second dentition or puberty the old trouble again reappears. Development is arrested or retarded, and the child takes on a shriveled or withered appearance, and presents a stunted growth.

The brain is so unfavorably impressed by the infection, that proper development is retarded, and the patient retains childish peculiarities after reaching manhood. The testicles are atrophied or infantile. The forehead is prominent, the frontal eminences project, and the skull is asymmetrical. This outward appearance resembles that produced by a combination of tuberculosis and rickets, which results in slow development, emaciation, and a jaundiced appearance. Dentition is delayed, and is characteristic, the Hutchinson teeth being peg-shaped and notched, the dentin being revealed at the notch.

Keratitis develops first in one eye, then in its fellow. This begins as a hazy condition, and may result in permanent impaired vision, or, after a long period, may gradually clear up, with a complete restoration of sight. Iritis also frequently occurs.

Incurable deafness may now develop, together with otorrhea. These three conditions, teeth, eye, and ear lesions, have been termed the triad of Hutchinson.

General Diagnosis.—In making our diagnosis, we are to remember that direct questioning will give negative results, for if we ask the patient, "Have you had syphilis?" the almost universal reply will be an emphatic denial. Man's veracity, therefore, may safely be questioned when syphilis is the subject of interrogation. To obtain much information from the patient requires some tact on the part of the physician.

In place of the direct question, "Have you had syphilis?" carefully question as to pimples (papules), eruptions in general, falling of the hair, sore throat, mouth, or tongue. Examine throat, mouth, and tongue for old cicatrices, and the occipital region for enlarged glands; also the groins; inspect the shins for old scars or nodes. When eruptions are present, inquire as to pruritis, if any, bearing in mind that syphilitic eruptions rarely itch. We are not to forget, however, that associated with the characteristic eruptions there may be eczema, with its accompanying pruritis.

In women, repeated abortions may throw some light on the case. In congenital syphilis, the characteristic snuffles the first few weeks, and the eruption, together with fissures and ulcers of the mouth or lips, will be conclusive evidence. When the symptoms are delayed till second dentition or puberty, the general cachexia, and the childish appearance and actions, which do not correspond with the age of the patient, the imperfect development of the subject, the Hutchinson teeth (peg), keratitis, and otitis are symptoms that can not be overlooked.

Prognosis.—The prognosis is more favorable than in former years, and, with judicious treatment, the ravages of former times are not seen. The congenital form does not yield so readily to treatment. The vitality seems to have suffered so severely that the frail body is unable to resist the inroads of the virus, and the weakling succumbs to the inevitable in a large per cent of the cases.

Treatment.—My experience in venereal diseases has been quite limited, and I will give the remedies as used by our school. About the only mercurial remedy we give is the small amount found in Donovan's solution. Other than this we believe patients do far better without the mercurials, and are satisfied that much harm has been done in their administration.

Berberis aquifolium is an agent of undoubted value in this trouble, Dr. Webster regarding it as a specific. Under the judicious administration of this remedy, the patient's appetite is improved, the loss of flesh and strength is arrested, and the visible evidences of the disease disappear. If you do not impress your patient with the necessity of taking the remedy for a year or more, however, you lose the early effects by its reappearing.

Syphilis is a disease which needs medication constantly for a year and a half to two years, if we wish to avoid the tertiary manifestations. Thuja was used quite extensively by Dr. Goss, both internally and locally. Corydalis formosa is also a great remedy with Eclectics; to prevent the severe lesions of the tertiary state there are few agents of equal value. It may be given singly or combined with berberis aquifolium. The old compound syrup of stillingia and iodide of potassium was a favorite with the fathers in the tertiary stage, and it would be difficult to persuade some of our older members that the iodide of potassium in ten-grain doses, minus the stillingia, would be nearly so efficacious.

Echinacea, in half teaspoonful doses, gradually increasing the dose to a teaspoonful, is also an excellent remedy. The iodide of potassium may be given in combination with stillingia, corydalis, or berberis aquifolium. The remedy is to be used in the tertiary stage. As to the local treatment, I am not in favor of escharotics. You may destroy, by an escharotic, a chancre, but remember that the poison is doing its work in the system at large, and nature is using the local manifestation as a waste-gate. Dress it with boracic acid and hydrastis, or touch it with a saturated solution of thuja. Where the ulcers or chancres are beneath a contracted foreskin, make a free incision, allowing the foreskin to roll back and bring into view the local trouble; after this a free use of warm boracic acid solution will be beneficial. The parts may be dusted with boracic acid and hydrastin. The parts must be kept clean and free from pent-up secretions.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.