Glass _ Book COPYRICHT DEPOSIT DIAGNOSIS OF SYPHILIS By GEORGE E. MALSBARY, M. D. Professor of Medicine Cincinnati Polyclinic and Post-Graduate School, Author of a "Text-book on the Practice of Medicine," and Monographs on "Treatment of Tuber- culosis," "The Rheumatisms," "The Septic Infections," "Meningitis" and "Cerebro-spinal Meningitis" (in Wood's "Reference Handbook of the Medical Sciences"), Member of the Academy of Medicine of Cincinnati, The American Medical Association, The Cincinnati Obstetrical Society, etc. CINCINNATI HARVEY PUBLISHING COMPANY 1911 Copyright, 1910, BY Harvey Publishing Co. &CLAS73114 PREFACE A PHYSICIAN in practice soon becomes deeply impressed with the great diagnostic importance of the recognition of syphi- lis. No disease may present greater diversity in appearance and symptomatology. Syphilis may involve practically every organ and tissue in the body. Hence, the disease is of diagnostic interest to medical men, whether they be in general or special practice. The diagnosis of syphilis has recently been illuminated by the discovery of the cause of the disease. The recognition of the spirochete pallida and the elaboration of the serum test, enable us to make a clear diagnosis in many cases that otherwise would remain obscure. In this work, the fact is emphasized that laboratory work supplements rather than supplants the clinical diagnosis. But the laboratory has proved a most valu- able adjunct, practically revolutionizing diagnosis in the cases that were formerly most difficult to recognize. This volume is based upon notes collected during a number of years, and an exhaustive study of the literature. Those who have attempted such a project will best appreciate the her- culean task involved in describing the kaleidoscopic picture that may be presented by syphilis, and the difficulties encoun- tered in selecting and arranging the points of diagnostic im- portance so that they may be found reliable in the elucidation of so complex a subject. In this work the subject is considered from various stand- points. First, attention is paid to laboratory diagnosis, special stress being placed upon the methods of recognition of the spirochete pallida, and the technic and relative value of the "Wassermann and other serum tests. Second, hereditary syphi- lis has received ample consideration. Third, the acquired form of syphilis is discussed in its various stages. Fourth, the syphi- litic affections of the various organs has received detailed de- scription. Fifth, there is appended an extensive recent bibli- ography bearing upon the subject. G. E. M. TABLE OF CONTENTS Page Synonyms — Definition 1 Bacteriology 1 Microorganisms in syphilis — Lustgarten bacillus — Syphilitic virus — Schaudinn — Hoffman — Spirochete pallida — Dark ground illumination — Giemsa stain — Marino stain — Proca stain — Goldhorn stain — Grunwald stain — Ghoreyer osmic acid stain — Spirochete refrigerans. Tissue setions — Levaditi stain. Spirochetes in the blood — Richards and Hunt — Acetic acid method — Flagella stain. The Serum Diagnosis of Syphilis 9 Relative value — Principles of reaction — Complement — Amboceptor — Antigen — -Complement deviation — Wassermann's theory — Inconsistencies, apparent and real — Wasserman's reaction — Porges-Meier test — Noguchi test — Klausner test — Mayer and Proescher test — Fleming test — Brieger test — Results of serum reactions — Reaction in milk — Reaction post-mortem — meiostagnin reaction. Bibliography of Spirochete Pallida and Serum Reaction.... 17 Methods of Infection 31 Inoculation — Sexual transmission — Surgical and obstetric infection — Infection through kissing — Common utensils and vessels — Watercloset Infection — Infection of physicians and nurses — Unclean circumcision. Hereditary syphilis — Inheritance from mother — Inheritance from father — nursing syphilitic child — Colles' law. Hereditary Syphilis 32 Hereditary syphilis — Congenital syphilis — Difference from acquired syphilis — Profeta's law — Congenital immunity — Syphilis hereditaris tarda — History of syphilis in parents — Spirochete pallida — Wassermann reaction — Abortions due to syphilis — Fertility of syphilitics — Transmission by father — Persistence of syphilis — Latent syphilis — Vaccinal syphilis — Idiocy and mental failure in hereditary syphilis — Paralytic dementia — Locomotor ataxia — Transmission to third generation — Mortality. Diagnosis of syphilis of fetus in utero. Diagnosis of syphilis in abortion. Diagnosis of syphilis at time of birth — Senile appearance — Hoarseness — Coryza — Eruptions. Diagnosis at birth or soon after — Peevishness and irritability — Icterus neonatorum — Harsh and difficult breathing — Snuffles — Sore mouth — Im- paired digestion — Emaciation — Senile appearance — Eruptions. V vi Table of Contents. Diagnosis during first year — Nocturnal peevishness and irritability — Hoarseness — Harsh and difficult breathing — Coryza — Eruptions — Erythema — Papules — Pustules — Mucous patches — Emaciation — Senile appearance — Visceral affections — Termination at end of second stage — Quiescence — Mal- nutrition — Stunted growth — Retarded development. Later symptoms of hereditary syphilis — Hutchinson teeth — Condylo- mata — Sores or pseudo-scars — Iritis — Choroides areolaris — Affection of bones — Eruption — Middle ear — Eustachian tube — Auditory nerve — Gastro- intestinal disturbances — Dactylitis. Syphilis tarda. ACQUIRED SYPHIXIS. Incubation 38 Length of period of incubation. First Stage of Syphilis 38 Diagnostic tripod: Incubation, induration, adenopathy — Varieties of induration — Absence of induration — Shape of induration — Other causes of induration. Chancre — Diagnostic table — Incubation — Derivation — Early appearance — Necrosis — Induration — Shape — Single and multiple — Secretion — Pain and discomfort — Adenopathy — Duration center of infection — Therapeutic test — Resolution — Spirochete pallida — Wassermann reaction — Non-syphilitic scars. Extra-genital infection — Mouth- — Tongue — Gums — Tonsils — Palate — Chin — Nose — Eyelids — Conjunctiva — Breast — Ear — Forehead — Extremities — Hands — Fingers — Toes — Anus. Chancre absent or obscured — Indurated edema. Genital syphilis — Male — Female. Adenopathies — Indolent buboes — Time of appearance — Suppuration — Location in genital syphilis — In extra-genital syphilis — Lymphatic vessels. Chancre in hairy regions — Scalp — Beard — Mustache — Due to razor cuts — Vaccino-syphilis — Mammary glands — Tonsils and fauces — Forearm —Thigh. Chancre and chancroid — Differential diagnosis — Confrontation — Incu- bation — Location — Early appearance — Multiple inoculations — Shape — Ulcer — Secretion — Induration — Pain — Course — Adenopathies — Lymphatic vessels — Resolution — Therapeutic test — Spirochete pallida — Wassermann reaction. Epithelioma and chancre — Ulcerating gumma and chancre — Simple abrasions with ulceration — Herpes progenitalis. Second Stage of Syphilis 47 Second incubation period — Abnormal incubation. Fever — Chill — Headache — Malaise — General depression — Weakness — Rheumatoid pains — Appetite-eruption — Anemia — Leucocytosis — Pernicious anemia — Wassermann reaction — Spirochete pallida — Cutaneous and mucous lesions. Table of Contents. vii Syphilides — Differentiation from non-syphilitic macules, papules, nodules, pustules, ulcers. Characteristics of syphilides — Hyperemia — Cellular infiltration. Primary and modified forms of syphilides. General symptoms during second stage of syphilis. Appearance at time of eruption of syphilides — Initial lesion — Indura- tion of glands — Adenopathy — Alopecia — Mucous patches. Later symptoms of second stage — Pains in hones — Bone lesions — Permanent alopecia — Cicatrices. Color of syphilides. Variety of lesions during first year — Evolution of syphilis — Early eruptions — Pain — Itching. Falling of hair — Affections of nails. Mucous patches — Affections of the eye. Spirochete pallida — Wassermann reaction. Third Stage of Syphilis 52 Skin eruptions — Gummatous growths — Amyloid degeneration. Gummata. Spirochete pallida — Wassermann reaction. SYPHILITIC AFFECTIONS OF THE VARIOUS ORGANS. Skin and Mucous Membranes 53 Syphilides — Macular syphilides — Pigmentary syphilides — Papular syphilides — Dry papules — Lenticular papules, giant papules, miliary papules — Moist papules, condylomata — Variations of papular syphilides: Vesicular syphilides, hemorrhagic syphilides, squamous syphilides, pustular syphilides. Macula syphilides — Time of appearancee — Location — Concomitant symptoms of syphilis — Differentiation from measles, ruhella, scarlet fever, drug eruptions, roseola balsamica, urticaria, tinea versicolor, non-syphilitic erythemata, tinea circinata, smallpox, macules produced by pediculi, and cutis marmorata livida. Pigmentary syphilides — Variations in color — Occurrence — Location — Duration — Distribution — Differentiation from chloasma, vitiligo and leuco- derma, and tinea versicolor. Papular syphilides — dry papules — distribution. Moist papules, condylomata — distribution. Small acuminate papules, differentiation from scabies, lichen planus, lichen pilaris, lichen scrofulosum, and punctate psoriasis. Giant papules — Lichen syphiliticus. Psoriasis palmaris. Moist papules — External genitals — Genitalcrural folds — Anus — Navel — Axilla — Pendulous breast — Toes — Ear. Squamous syphilides — Differentiation from tinea circinata, psoriasis, lichen rubor planus, eczema, molluscum contagiosum, arsenical keratosis, tyloma, and venereal papillomata. viii Table of Contents. Tubercular syphilides — Differentiation from large papular syphilide, palmar psoriasis, palmar eczema, lupus vulgaris, acne rosacea, epithelioma, and tubercular leprosy. Tubercular syphilide and lupus vulgaris — Differential diagnosis. Pustular syphilide — Differentiation from smallpox, acne vulgaris, acne varioliformis (Hebra), acne necrotica (C. Boeck), and acne cacbectioorum — Pemphigus serpiginoaus. Yaws. SYPHILITIC AFFECTIONS OF THE DIGESTIVE ORGANS. Month, including Tongne and Tonsils 65 First Stage of Syphilis. Initial lesion — Lower lip — Upper lip — Tongue— Mucous membrane of buccal cavity — Palate — Tonsils. Oral chancre — Differentiation from chancre and cancer. Lips — Differentiation between chancre and epithelioma. Lingual chancre- — Differentiation from cancer — Parenchymatous glos- sitis — Tuberculosis and traumatic ulcer. Second Stage of Oral Syphilis 68 Mucous [latches — Differentiation from trauma, patches due to cauteriza- tion or strong gargles, simple catarrhal angina, leucomata, aphtha, simple rashes, warty growths, lingua geographica, and diphtheria. Third Stage of Oral Syphilis 70 Gummata — Differentiation from cancer, tuberculosis, chancre, leuco- plakia, and decubital glossitis. Tertiary syphilis of the tongue — Differentiation from indurated chancre, psoriasis, smoker's tongue, dental glossitis, and epithelioma. Syphilitic atrophy — Nodes — Gummata. Deep gummata of tongue — Differentiation from fatty tumors, fibroid tumors, carcinoma, chronic abscess, and embedded foreign body. Epithelioma and gumma of tongue. Oral chancre — Gumma — Epithelioma — Tuberculosis. Syphilitic fissures and ulcers of the tongue. The teeth — Hutchinson's description of malformation. Tonsils — Chancre — Angina — Mucous patches — Gummata — Gummatous ulcer. Syphilis of the Esophagus 84 Chancre — Syphilides — Stricture — Gumma — Coincidence of carcinoma and gumma. Syphilis of the Stomach 85 Chancre — syphilitic ulcers and neoplasms — Syphilitic gastritis — Gastric hemorrhage. Table of Contents. ix Differentiation between syphilis of the stomach, neoplasm, infiltration, ulcer, and syphilitic gastric catarrh, simple chronic gastric catarrh, simple gastric ulcer, cancer of the stomach, tuberculosis of the stomach, and gastric neuroses. Syphilis of the Intestine 101 Syphilis of intestine- — Ulcer — Diarrhoea. Differentiation from intestinal catarrh due to anti-syphilitics, intestinal tuberculosis, internal cancer, simple intestinal catarrh, and simple ulcer. Syphilis of the Liver 104 Hepatic congestion — Syphilitic hepatitis — Syphilitic icterus — Acute yellow atrophy — Hepatic gummata — Perihepatitis — Syphilitic cirrhosis — Amyloid degeneration — Ascites. Pylephlebitis — Pigment liver — Diaphragmatic pleurisy — Cancer — Tuber- culosis of liver — Gallstones. Syphilis of the Pancreas 115 Hereditary syphilis — Pancreatis. Acquired syphilis — Pancreatis — Gumma. Syphilis of the Peritoneum 116 Peritonitis — Local — General. Syphilis of the Rectum and Anns 116 Chancre — Syphilides — Gumma — Stricture. Differentiation from cancer, rectal tuberculosis, fistulae, rectal abscess, hemorrhoids, prolapse, polypi, pruritus, ulcer, fissure, simple stricture, rodent ulcer, fecal impaction, villous tumor, neuralgia, sacrococcygeal arthralgia, and proctitis. SYPHILITIC AFFECTIONS OF THE RESPIRATORY ORGANS. Syphilis of the Nose 125 Chancre — Syphilides — Mucous patches — Catarrh — Gumma — Coryza — ■ Ozena — Sinking of nasal bridge — Destruction of tissue and contraction of cicatricial tissue — Deformity. Ozena syphilitica — Rhinitis syphilitica necrotica — Punaise. Differential diagnosis — Tuberculosis — Lupus — Rhinoscleroma — Carci- noma — Simple atrophic rhinitis — Glanders — Leprosy — Bacillus mallei — Bacillus leprae — Spirochete pallida — mallein test — Wasserman reaction. Differentiation of acute syphilitic rhinitis from common colds, toxic rhinitis, rhinitis of the acute infections, membranous rhinitis, hay fever, occupation rhinitis, phlegmonous rhinitis, acute edematous rhinitis, and simple ulcerative rhinits. Syphilitic chronic rhinitis — Differentiation from tuberculosis, glanders, leprosy, actinomycosis, rhinoscleroma, cancer, simmple chronic rhinitis, x Table of Contents. intumescent rhinitis, hyperplastic rhinitis, simple ozena, atrophic rhinitis, purulent rhinitis, nasal hydrorrhcea, and edematous rhinitis. Syphilitic nasal ulcer — Differentiation from simple catarrhal erosions, herpetic ulcerations, eczema, ulcer due to foreign bodies, neuropathic ulcers, scurvy, diabetic ulcers, varicose ulcers, cancer, tuberculosis, leprosy, glan- ders, diphtheria, measles, rheumatism, scarlet fever, smallpox, typhoid fever, typhus. Syphilitic affection of the accessory sinuses — Chronic purulent ethmoiditis — Empyema of sphenoidal sinus — Gummata. Syphilitic snuffles. Syphilis of the Nasopharynx 146 Chancre — Syphilides — Mucous patches — Syphilitic adenoids — Cervical glands — Gummata — Necrosis— Infiltration of velum — Syphilitic catarrh — Ulceration — Deformity — Affection Of sphenoid bone — Scar tissue. Differentiation from tuberculosis of the nasopharynx, lupus, cancer, gangrenous ulceration, simple tumors, polypi, glanders, actinomycosis, simple nasopharyngitis, atrophic nasopharyngitis, hyperplastic naso- pharyngitis, and affection of the nasopharynx in the infections. Syphilis of the Larynx 149 Chancre — Erythema — Mucous patch — Syphilitic ulcer — Gumma — Stenosis. Syphilitic laryngitis — Differentiation from simple acute laryngitis, laryngitis of the infections, rheumatic laryngitis, simple acute epiglottitis, traumatic laryngitis, suppurative laryngitis, edema of the larynx, mem- branous laryngitis, hemorrhagic laryngitis, simple chronic laryngitis, follicular laryngitis, atrophic laryngitis, hyperplastic laryngitis, simple hyperemia of the larynx, pemphigus of the larynx, tuberculosis of the larynx, and chondritis and perichondritis. Laryngeal ulcers — Gumma, tuberculosis, carcinoma. Laryngeal growths — Syphilomata — Differentiation from carcinoma, sarcoma, papilloma, adenoma, fibroma, chondroma, anginoma, lipoma, mucocele, and tuberculosis. Stenosis of the larynx — Syphilis — Cancer — Tuberculosis — Lupus — Trauma — Congenital — Occlusion. Syphilis of the Trachea 169 Syphilides — Gummata — Ulceration — Perichondritis and necrosis— De- formity — Perforation — Stenosis. Differentiation from tuberculosis, scleroma, cancer, glanders, and chronic non-syphilitic blenorrhoea. Syphilis of the Bronchi 170 Early bronchitis in the second stage of syphilis — Second and third stages of syphilis — Syphilitic bronchial stenosis. Syphilitic Affections of the Lungs 171 Table of Contents. xi Syphilitic pulmonary catarrh — Cough — Hemoptysis — Cachexia — Second- ary infection with influenza, tuberculosis, pneumonia. Differential diagnosis between pulmonary syphilis and pulmonary tuberculosis. Pleurisy — During second stage — During third stage! — Gummata. SYPHILITIC AFFECTIONS OF THE CIRCULATORY ORGANS. The Heart 174 Affection during second stage — Palpitation — 'Cardiac asthma. Affection during third stage — Gummata — Scleroses — Sudden death — Precordial anxiety — Myocarditis — Frequency of aortic lesions. Wassermann reaction. Syphilitic myocarditis — Differentiation from simple myocarditis. Syphilitic pericarditis — Differentiation from simple pericarditis, and from endocarditis, pleurisy, hypertrophy of the heart, mediastinal tumors and irritation or inflammation of the stomach. Syphilitic endocarditis — Differentiation from endocarditis due to other causes. The Blood Vessels 179 Syphilitic arteries — Arteriosclerosis — Aneurysm — Endartitis obliter- ans — Thrombosus — Rupture. Syphilitic phlebitis. The Blood 179 "Blood disease" — Spirochete pallida — Wassermann reaction — Syphilitic anemia — Chlorosis — Leucocytosis — Pernicious anemia — Non-syphilitic anemia in syphilitics. Cachexia 180 Syphilitic cachexia — Differentiation from cachexia due to malaria, syphilis, chronic sepsis, phthisis, lead poisoning, cancer, and infantile scurvy. Amyloid 180 Amyloid due to hereditary syphilis — Acquired syphilis — Tuberculosis. Affection of the blood vessels — Arteries and veins — Spleen, liver, kidneys, intestines. SYPHILITIC AFFECTIONS OF THE GLANDS. Lymphatic Glands 182 First stage — Order of involvement — Indolent buboes — Differentiation from the adenopathies of tubercle, cancer, chancroid, gonorrhoea, eczema, prurigo, and simple infected sores. Second stage — Regions involved. Scrofula — due to syphilis, tuberculosis, rarely due to leprosy, glanders. xii Table of Contents. Third stage — Gummata and syphilitic scars — Adenopathies due to infected gumma. Gummata of the lymphatics. Differential diagnosis — Buboes due to syphilis, inflammatory tuber- culosis, tuberculosis, cancer, leprosy, glanders. Syphilitic and inflammatory lymphangitis. Spleen 192 Syphilis — Malaria — Tuberculosis. Hereditary syphilis — Soft and indurated hyperplastic enlargements — Amyloid change. Acquired syphilis — First stage — Non-luetic enlargements — Second stage — Third stage — Gummata. Thymus Gland 192 Hyperplasia — Induration. Bibliography. Thyroid Gland 193 Syphilitic goitre — Non-luetic goitre — Gummata. Bibliography. Suprarenal Bodies 195 Gummata — Addison's disease. Wassermann reaction — Therapeutic test. Syphilis of the Breast 195 first stage — Chancre — Fissure — Multiple chancres — Due to nursing syphilitic child — Other causes — Chancroid. Second stage — Mucous patches — Infectious secretions — Lesion in the obese — Resemblance to chancroid — Pigmentary syphilide. Third stage — Gummata, circumscribed or diffuse — Indolence — Adeno- pathy — Slow growth — Disintegration — Ulceration — Deformity — Resem- blance to cancer. Wassermann reaction — Therapeutic test. SYPHILITIC AFFECTIONS OF THE URINARY ORGANS. Kidneys 197 Acute nephritis — Subacute nephritis — Chronic nephritis — Granular Kidney — Gummatous infiltration — Amyloid kidney — Perinephritis and para- nephritis — Hematuria — Hemoglobinuria. Ureter 198 Gumma — Dilatation — Obstruction. Bladder 198 Ulcers — Cystoscopic examination. Table of Contents. xiii Syphilis of the Urethra 199 Chancre — Differentiation from gonorrhoea, chancroid, and simple stricture. Second stage — Syphilides — Endoscopic examination — Papular syphi- lides — Erosions — Urethral herpes. Third stage — Gummata — Ulcers — Cicatrices — Differentiation from cancer and tuberculosis of the urethra. Differential diagnosis— Urethral chancre, gonorrhoea, chancroid, and stricture. Differential diagnosis — Urethral syphilides, herpes. Differential diagnosis — Urethral gumma, tuberculosis and cancer. THE MALE GENERATIVE ORGANS. Syphilis of the Penis 205 Chancre — Roseola — Papular syphilides — Gumma — Scars. Subpreputial ulceration in phimosis — Differentiation between chancre and non-syphilitic ulceration. The Testicles 215 Differential diagnosis — Syphilitic orchitis, traumatic orchitis, gonor- rhceal orchitis, epidemic orchitis, tuberculosis, and cancer. The Semen 225 Aspermda — Paternal transmission of syphilis — Syphilitic impotence and fertility. SYPHILITIC AFFECTIONS OF THE FEMALE GENERATIVE ORGANS. Syphilis of the Vnlva 226 Chancre — Differentiation from simple ulcer, chancroid, cancer, tuber- culosis and lupus. Syphilides — Mucous patches. Third stage — Gumma. Syphilis of the Vagina 232 Chancre — Syphilides — Gummata — Fistula?. Uterus 232 Chancre — Location — Rubber gloves — Manner of infection — Differentia- tion from cancer, chancroid, tuberculosis, simple ulcers, and gonorrhoea. Second stage — Syphilides — Papules — Endometritis. Third stage — Gummata. Fallopian Tabes 233 xiv Table of Contents. Primary sore — Catarrhal salpingitis in second stage — Gummata in third stage. The Ovaries 233 Third stage — Gummatous oophoritis — Cicatrices — Tumors. SYPHILITIC AFFECTIONS OF THE ORGANS OF LOCOMOTION. Periosteum 234 Simple periostitis — Periostitis syphiliticus ossificans — Absorption — Dis- integration — Wassermann reaction — Spirochete pallida — Myositis ossificans — Suppurative periositis — "Cold" abscesses — Tuberculosis. Gummatous periosititis — Sclerosis and hyperostosis — Erosion of bone — Perforation — Absorption — Ulceration — Caries and necrosis — Fistulse— Gum- matous Nodules. Bones 237 Simple syphilitic ostitis — Syphilitic osteomyelitis. Gummata — Osteoporosis — Sclerosis — Absorption— Caseation — Sequestra — Necrosis — Gummatous infiltrations. Syphilitic cachexia — Fragilitis ossium. Tumor — Fragility — Shortening and destruction of bone. The skull — Frontal bone — Parietal bones — Bones of nose and hard palate — Meningitis — Syphilitic tumors— Pressure symptoms — Mental dis- turbance — Orbital bones — Syphilis of the base of the skull — Facial bones — Nose and upper jaw. Spinal column — Cervical spine — Vertebral arches — Transverse proc- esses — Vertebral artery — Kyphosis. Syphilis of the long bones — Legs — Forearm — Ribs — Diaphysis — Toint affection — Trauma — Analogy to tuberculosis — Enlargement of bone — Noc- turnal pain. Small bones — Dactylitis syphilitica — Differentiation from paronychia, whitlow, gout, rheumatoid arthritis, enchondroma, tubercular dactylitis — Drumstick fingers — Toes — Ulcus pedans. Differentiation of syphilis from trauma, tuberculosis, sarcoma, rickets, osteomalacia, mercurial necrosis, phosphorus necrosis, actinomycosis, necrosis disseminata (Blasius). Differentiation between syphilitic osteitis and tubercular osteitis. Differentiation — Syphilis — Rickets. Osteoperiostitis — Differentiation between syphilitic and non-syphilitic. Joints 247 Preference of knee and elbow — Arthralgias during second stage of syphilis — Later arthralgias — Gummata — Chronicity — Spontaneous involu- tion. Pain — Swelling — Tenderness — Fever — Deformity of joint — Ankylosis — Ostitis and periostitis. Differentiation from joint tuberculosis, trauma, rheumatism. Table of Contents. xv Muscles 251 Second stage — Rheumatic pains — Myositis. Third stage — Gumma — Infiltration — Absorption — Extension of process — Sinous ulcer— Impairment of function — Adhesions — Interstitial infiltra- tion — Scar tissue — Syphilitic myositis ossificans — Atrophy of muscles. Differentiation from neoplasms, sarcoma — Actinomycosis — Trichinosis — Muscular rheumatism. Tendons 252 Gummata of muscles — Syphilitic affections of tendon sheaths — Hygro- mata — Syphilitic synovitis. Bursae 253 Hygromata — Gummatous bursitis. Fasciae 253 Nodular infiltration — Gummata of fasciae and muscles. SYPHILITIC AFFECTIONS OF THE NERVOUS SYSTEM. Brain and Cephalic Meninges 254 Second stage — Irritation of brain and meninges — Headache — Vertigo — General irritability — Nausea — Fever — Acceleration of pulse — Bands of pain — Irregularity of pupils — Irritation of choroid and retina — Spirochete pal- lida in blood and cerebrospinal fluid— Wassermann reaction. Third stage — Meningitis — Pachymeningitis — Pachymeningitis hemor- rhagica — Hydrocephalus internus — Syphilitic endarteritis — Softening of brain — Hemorrhages — Cerebral aneurysm. Gummata — Dura mater — Pia Mater — Adhesions — Infiltration — Menin- gitis gummosa basilaris diffusa — Cerebral nerves — Gummata of brain — Endarteritis obliterans. Ophthalmoplegia — Immobility of pupils — Atrophy of optic nerve — De- mentia paralytica — Locomotor ataxia. Headache — The pulse — Choked disk — Functional and focal symptoms — Basilar symptoms — Affection of cerebral nerves — Oscillating hemianopsis bitemporalis — Affection of cerebral peduncles — Crossed paralysis — Hemi- plegia alternans superior — Hemiplegia alternans inferior — Affection of the pons — Facial nerve — Disturbance of speech and deglutition — Acute bulbar paralysis — Affection of corpora quadrigemina — Oculomotors — Disturbances of equilibrium and coordination — Cerebellum — Medulla oblongata. Deeper portions of brain — Gumma — Softening — Hemorrhage — Affections in the region of the central ganglia. Syphilitic affection of the cerebral vessels — Endarteritis obliterans — Thrombosis — Sacculated and dissecting aneurysms. Cerebral symptoms — Headache — Vertigo — Insomnia — Mental irritabil- ity — Paresthesias, formication — Hemiplegia — Hemiparesis — Hemianesthesia xvi Table of Contents. Aphasia — Hemianopsia — Vacillating cerebral symptoms — Multiple lesions in syphilis of brain — Circumscribed and diffuse gummata — Syphilitic ar- teritis — Syphilitic basilar meningitis, extension of process to spinal meninges — The psychoses — Epilepsy and hysteria. Mental exertion — Worry — Excessive worship of Bacchus and Venus. The Spinal Cord and Meninges 261 Second stage — Spinal meningeal irritation — Pain and paresthesia? — Skin and tendon reflexes. Third stage — Gummata — Syphilitic vertebral periostitis — Spinal meninges — Spinal nerves — Blood vessels — Early symptoms of spinal syph- ilis — Location of affection of cord and various spinal tracts — Meningomye- litis syphilitica — Acute, subacute and chronic myelitis — Pseudo tubes syph- ilitica — Multiple sclerosis — Syphilitic progressive muscular atrophy — Syphilitic spinal paralysis of Erb — Spasmodic tabes dorsalis of Charcot — Tabes dorsalis — Wassermann reaction. Peripheral Nerves 265 Affection in cerebral and spinal syphilis, gummatous infiltrations of bones, periosteum, muscle and fascia. Neuralgia due to meningeal irritation — Peripheral neuralgia — Trigem- inal neuralgia — Neuralgias of spinal nerves — Neuralgia of occipitalis major — Nervus auricularis magnus — Neuralgia of brachial plexus — Inter- costal neuralgia — Sciatica — Visceral neuralgias. Paralysis due to brain and spinal syphilis — Syphilitic peripheral paralysis — Cranial nerves — Oculomotor paralysis — Facial paralysis, uni- lateral and bilateral — Auditory — Abducens — Trigeminus — Hypoglossal. SYPHILITIC AFFECTIONS OF THE ORGANS OF SPECIAL SENSE. Organs of Sight 274 Deep-seated affections of sight — Cerebral diseases — Affections of the optic nerve. The eye — Eyebrows — Initial lesion. Lids — Initial sclerosis — Papules — Ulceration conjunctiva — Preauricular and submaxillary lymphatic glands. Second stage — Lids — Macules — Papules — Pustules — Ulcers — Madarosis — Alopecia. Third stage — Gummatous infiltrations and ulcerations of lids — Hor- deola — Chalazion — Superficial flat infiltrations — Tumors — Tarsitis syphilit- ica deformity. Differentiation from nonsyphilitic hordeolum and chalazion — Lupus — Cancerous ulcer. Syphilitic blepharitis — Differentiation from blepharitis due to tuber- culosis, the exanthemata, anemia and malnutrition, external irritation, injuries, conjunctivitis, inflammation of lachrymal passages, disease of the rhinopharynx, eczema, eczema seborrhoticum, seborrhcea, or acne. Table of Contents. xvii Syphilitic dacryoadenitis — Differentiation from "colds" — Traumatism — Rheumatism — Mumps — Gout — Septicemia, and extension of inflammations from conjunctiva and cornea. Dacryocystitis. Conjunctiva — Chancre — Papular syphilides — Pigmented spots — Mucous patches — Nodular syphilides — Syphilitic ulcer — Gummata. Stricture of the nasal duct. Cornea — Keratitis parenchymatosa — Association with affections of ear and teeth. Iris — Syphilitic iritis — Syphilitic iritis papulosa — Extension to ciliary bodies and choroid — Gummata. Ciliary body — Iridocyclitis — Iridochoroiditis — Gummata. Choroid — Diffuse exudative choroiditis — Choroiditis centralis — Cloudi- ness of crystalline lens. Cornea — Keraltitis parenchymatosa syphilitica — Keraltitis parenchy- matosa tuberculosa — Extension of gummatous infiltration from conjunctiva or sclera. Sclera — Gummata— Differentiation from malignant neoplasms. Iritis — Local and general causes. Retina — Hyperemia and irritation in syphilis — Early hyperemia of optic nerve — Affection of retinal blood vessels — Amblyopia and amaurosis — Primary syphilitic retinitis— Syphilitic chorioretinitis — Retinitis pro- liferans. Crystalline lens — Cloudiness — Hyalitis syphilitica — Gummata. Gummata of the orbit. Opacities of the vitreous. Optic nerve — Intrabulbar optic neuritis — Retrobulbar neuritis — Choked disk — Simple optic neuritis. Causes of choked disk. Causes of optic neuritis. Retrobulbar neuritis — Acute or fulminant retrobulbar neuritis — Chronic retrobulbar neuritis — Differentiation between syphilitic and toxic retrobulbar neuritis. Causes of atrophy of the optic nerve. Affections of the ocular muscles — Syphilitic paresis — Muscular spasm — Innervational anomalies — Non-syphilitic causes of paresis and spasm. Organs of Hearing 287 Central changes. Ear — Chancre. Second stage — Muscles, papules, and pustules — Auditory canal — Drum membrane — Ulcerations — Cicatrices. Third stage — Gummata — Ulcerations — Infiltrations — Cicatricial con- tractions and deformities. The middle ear — Syphilides — Gummata — Occlusion of Eustachian tube — Deafness — Otitis media — Labyrinth — Caries and necrosis of tympanic cavity, mastoid, petrous portion of temporal bone. xviii Table of Contents. The internal ear — Auditory nerve — Labyrinth — Deafness — Vertigo — Disturbances of equilibrium. Disturbances of hearing and hallucinations in basilar meningitis. Organs of Smell 289 Alterations of sense of smell — Central disease — Basilar meningitis — Rhinitis syphilitica. Organs of taste 290 Central disturbances — Syphilis of tongue and palate — Syphilitic in- volvement of glossopharyngeal or fibres of chorda — Trigeminal neuralgia. Conclusions 29 1 Bibliography 292 Diagnosis of Syphilis Pox; Lues Venerea. The diagnosis of syphilis is usually easy, but at times may be very difficult. No disease shows a greater variety of symptoms, and there are few diseases but may resemble this multiform affection. Syphilis is a chronic infectious disease, due to the Spirochaete pallida. The disease may be transmitted through heredity (congenital syphilis), or through inoculation (ac- quired syphilis). BACTERIOLOGY. Microorganisms have been described in syphilis by nu- merous observers. In 1839 Donne described organisms that he compared to vibrios, which Metchnikoff believes corre- spond to the organism described by Schaudinn as the Spir- ochaete refrigerans. Later Donne became convinced that this was not the cause of syphilis. Microorganisms in syph- ilitic lesions have been described by Lustgarten (1884), Eve and Lingard, (1886), Disse and Taguchi (1886), Gol- asz (1894), Max von Niessen (1898), and by Fritz Schau- dinn and Erich Hoffmann, in May, 1905. The organism described by the last named observers, the Spirochaete pallida, is of paramount importance from a diagnostic standpoint, since it is the specific cause of syphilis. Other microorganisms are of importance, inso- much as they may operate as secondary infections. 2 Diagnosis op Syphilis. For a long time the Lustgarten bacillus was regarded by many as the specific cause of syphilis. Possibly color was given this belief by the cuts that appeared in medical literature, for when the Lustgarten bacillus is colored red, it looks much like the tubercle bacillus. And the simi- larity of man}' of the lesions of syphilis and tuberculosis may have been a factor in furthering the belief that the Lustgarten bacillus was the cause of sypliilis. But the Lustgarten bacillus resembles the tubercle bacillus more in the cuts than in bacteriological characteristics, such as cultural and staining properties. It resembles, if it is not identical with the smegma bacillus. Some general knowledge of the nature and size of the syphilitic virus preceded the discovery of the spirochete pal- lida. Thus, by passing the virus through filters, it had been determined that the syphilitic virus was larger than those microorganisms that pass through a filter, such as the bacillus of broncho-pneumonia of cattle. Furthermore, it was known that the virus could he destroyed by heating to 60° C. for half an hour. It is remarkable how soon Schaudinn's discovery* was accepted by the medical profession. Schaudinn was a zoologist, a member of the Imperial Coun- cil of Health, and Hoffmann a retired army medical offi- cer. Both were known as experts in the study of protozoa and spirochetes. Though Schaudinn lived only about a year after announcing his discovery, he lived long enough to see his work receive general recognition. The Spirochete Pallida. The Spirochaete pallida, triponema pallidum, measures from four to twenty microns long, and 0.25-0.50 micron in diameter. The average length is about that of the diameter *(Ueber Spirochaeten-Befunde im Lymphdriisensaft Syphilitiscker, F. Schaudinn and E. Hoffmann, Deutsche medizinische Wochenschrift, xxxi, No. 18.) Diagnosis op Syphilis. 3 of a red-blood corpuscle. The organism presents the ap- pearance of a very delicate spiral, a corkscrew, with from four to as many as twenty-six coils, and pointed extremi- ties. Goldhorn reported observing one that presented forty turns. Reports of such extreme lengths should be received with caution, since several organisms may be so coiled to- gether as to present the appearance of a single long spiril- lum with more than the usual number of turns. At times the line separating the bacteria and the pro- tozoa seems undulating rather than rigid. At any rate, in some respects the spirochete pallida resembles the bac- teria, e. g., in its analogy to the spirillum Obermeieri of relapsing fever, in the absence of an undulating membrane, the evidence of transverse division, and the failure to find an intermediate host. Formerly the organism was regarded as a protozoon, such a view being favored by the failures at cultivation, the resemblance to the trypanosomes, the presence of flagelke, and possibly longitudinal division. In an attempt to properly classify this organism, the recogni- tion of a new genus has been proposed. Such a necessity is suggested by the term triponema pallidum, proposed by Schaudinn and Veuillemin. The spirochete pallida may be found in smears or hanging drop preparations. For such an examination, the surface secretions and accumulations should be removed, since they contain so many saprophitic spirochetes, that would make the examination for the delicate spirochete pallida more difficult. The spirochete pallida may be readily recognized in fresh specimens examined microscopically with dark-ground illumination. Characteristic points are found in the size, shape, position of ends, and the motility of the organism. In fresh specimens, the windings of the spiral are very acute and regular. The spirochete pallida is pale, as indicated by its name, and the ends are sharp, and placed at the periph- ery of the spiral, rather than in the center, as is observed in some spirochetes. When the specimen is fresh, the — 4 Diagnosis of Syphilis. spirochete pallida is motile, showing rotation, rapid bend- ing and twisting, and also progression. The last named mo- tion is slower than that shown by some other spirochetes. When accuracy is desired, it is better to examine the specimen both fresh and stained. The Giemsa modification of the Romanowsky stain was the method first used by Schaudinn and Hoffmann. It is as follows : Giemsa's eosin solution, 2.5 cc. of 1% solution to 500 cc. distilled water. . . 12 parts Azur I, 1:1000 solution in water 3 parts Azur II, 0.8:1000 solution in water. . . 3 parts Method. — Thin smears are fixed in methyl or ethyl alco- hol for ten minutes and dried. The specimen is then stained for from one to twenty-four hours with a mixture of the stain, one drop to 1.0 cc. of water. Wash gently and mount. This stains the spirochete pallida a sort of pinkish color. The spirochete refrigerans is stained a deep blue. The tissue cells appear only slightly stained, the red cells being greenish and the white cells purplish. This method is not ideal. In the first place, it stains the spirochete pallida only faintly, so that their recogni- tion remains difficult. Secondly, it requires such a long time. This may be remedied by the addition of from one to ten drops of a 1 :1000 aqueous solution of potassium car- bonate to the water with which the stain is diluted, when the specimens may be stained in fifteen minutes. The Giemsa stain requires sixteen hours or more, and for that reason Metchnihoff* recommends the Marino technic, when more rapid results are desired. This consists in mixing a methyl alcohol solution of azure blue with a weak aqueous solution of eosin. This is not so distinct as the Giemsa *(Recherches microbiologiquessur la syphilis, E. Metchnikoff and E. Rous, Bulletin de l'AcadSmie, lxix, Ko. 26.) Diagnosis of Syphilis. 5 stain, but by this means a diagnosis can be made in fifteen minutes. A deeper stain is secured by Proca's stain, recommended by Ewing. It is as follows: Fix the specimen, in alcohol for thirty seconds, or in the vapor of 1% osmic acid for two to five seconds. Apply the mordant (a) for ten minutes. Wash. Stain with the gentian violet solution (b) for five minutes. Wash, dry and mount. (a) The mordant is prepared as follows: Carbolic acid 50 parts Tannin 40 parts Distilled water 100 parts Basic fuchsin, 25 parts dissolved in 100 of absolute alcohol. (b) The gentian violet solution is prepared as follows: Gentian violet, concentrated solution in alcohol 10 parts Carbolic acid 5 parts Distilled water 100 parts One of the best stains is that proposed by Goldhorn, which is prepared as follows: Lithium carbonate 2 grams Dissolve in distilled water 200 cc. Methylene blue 2 grams Heat in a double boiler over a slow fire, until a specimen examined against artificial light appears distinctly red in color. Allow to cool and then strain through cotton. Ren- der one-half of the solution slightly acid with 5% acetic acid solution, and then add the other half of the stain, which will secure a slight alkalinity. Add a weak eosin so- lution (0.5%) gradually while stirring, until a filtered spec- imen of the stain is of a pale bluish color with slight fluor- 6 Diagnosis of Syphilis. escence. Set aside for a day and then filter. The precipi- tate is permitted to dry on the filter paper at a temperature not exceeding 40° C. Dissolve the dry precipitate in wood alcohol, set aside for a day and filter. The quantity of alcohol used should make about a 1% solution. Method. — The Goldhorn stain gives better results when fresh. Without fixing, the smear is covered with the stain for four or five seconds. Carefully pour the stain off and place the specimen in clean water at room temperature for three or four seconds. Dry in the air. The spirochete pallida will present a violet color, which may be changed to bluish black by staining with gram solution for fif- teen or twenty seconds. The May Grunwald stain : Eosin 1.0 gm. and methylene blue 1.0 gm. are dissolved separately in 1000.0 cc. of distilled water for each stain. The two solutions are then mixed and let stand from two to seven daj's. The fluid is filtered and the sediment on the filter is washed until no more color comes away. It is then dried and dissolved in pure methyl alcohol to satura- tion. Method. — A few drops are placed on the specimen for from four to ten seconds, after which the specimen is rinsed, dried and mounted in balsam. This stain is highly recommended by Simonelli and Bandi.* The spirochetes are stained, the remainder of the specimen being almost colorless. *(Metodo rapido di colorazione della Spiroeha;te pallida, F. Simonelli, Gazzetta degli Ospedali, xxvi, No. 82.) Diagnosis of Syphilis. 7 The GJioreyer Osmic Acid Stain: * Solutions. — 1% aqueous solution of osmic acid. Liquor plumbi subacetatis, diluted 100 times with distilled water. The diluted solution should be fresh. 10% aqueous solution of sodium sulphide. Method. — Thin smear. No heat fixation is necessary. Cover with osmic acid solution for thirty seconds. Wash in running water. Cover with subacetate solution for ten sec- onds. Wash in running water. Cover with sodium sulphide solution for ten seconds. Wash in running water. Repeat this process three times. Apply osmic acid solution for thirty seconds. Wash in running water. Dry and mount in balsam. The osmic acid acts as a fixative. The lead unites with the albumin to form lead albuminate, which is insoluable in water. Sodium sulphid transforms the lead albuminate into lead sulphid, and stains the specimen brown. Osmic acid turns the brown color to black. Spirochetes, bacteria and cellular detritus are black. Tissue Sections. A good method of staining the spirochete pallida in sections, is that used by Livaditi: Sections 1.0 mm. thick are fixed in 10% formalin for twenty-four hours. Wash and harden in alcohol for twelve to sixteen hours. Wash in distilled water until the section sinks. Place at room temperature for two or three hours in a 1% solution of nitrate of silver in distilled water to which 10% of pyridin is added just before using. Wash rapidly in 10% of pyridin. Place for several hours in a 4% solution of pyrogallic acid in distilled water, containing 15% pyridin, with the addition of 10% acetone just before using. Harden in alcohol. Clear in xylol and mount in paraffin. *A new and quick method for staining spirochetes (treponemata in smear preparations. Albert A. W. Ghoreyer, Jour. A. M. A., liv, 1498, May 7, 1910. Diagnosis of Syphilis. Spirochetes in the Blood. Richards and Hunt* found the spirochete pallida in the blood in the second stage of syphilis, drawing the blood from a typical spot a few days after the appearance of the eruption. The skin was cleaned with soap and then with spirit, and the blood was received upon clean slides. The films were stained with Giemsa's stain one part in three parts of distilled water. Other cases were examined, and the blood was drawn from the spots on the abdomen, chest and arm. In these cases the spirochete had been previously found in the primary lesion. In some cases, a prolonged search is necessary, since the spirochetes do not occur in large numbers. Acetic acid may be added before the stain, t 1.0 cc. of blood is dissolved in 10.0 cc. of 0.3 per cent, acetic acid, and then centrifugized and the Giemsa stain ap- plied. The acetic acid does not interfere with the action of the stain, though the specimens be left in it for several hours. Flagella. Schaudinn J demonstrated flagella in the spirochete pallida. For this purpose he found the old Loeffler bacterial flagellum stain best. The spirillum pallida is the only one in which he found flagella at one or both ends. Some spirochetes show an undulating membrane, but he was unable to find this in the spirochete pallida. *(The occurrence of a spirillum in the blood of patients suffering from secondary svphilis. G. M. O. Richards and L. Hunt, Lancet, Septem- ber 30, 1905.) t(Zur Nachweis der Spirochete pallida im Blut Syphilitischer, C. T. Noeggerate and R. Staehelin, Munchener medizinische Wochenschrift, Hi, No. 31.) t(Zur Kenntnis der Spirochete pallida, F. Schaudinn, Deutsche medizinische Wochenschrift, xxxi, No. 42.) Diagnosis op Syphilis. THE SERUM DIAGNOSIS OF SYPHILIS. The serum reaction in syphilis is of very great diag- nostic value. But it is not so absolute as is the finding of the spirochete pallida. They may be compared to the blood test in typhoid fever and the finding of the tubercle bacillus in tuberculosis. The one is of relative diagnostic value; the other makes the diagnosis absolute. It is well known that when blood from another animal, so-called alien blood, is injected into an animal, the blood serum acquires properties that enable it to destroy the blood corpuscles of the animal from which the alien blood was obtained. The mixture becomes blood-stained, through the destruction of the corpuscles and the solution of the liber- ated haemoglobin. Complement is normally present in serum, and is de- stroyed by heating to 55° C. for half an hour. The immune body or amboceptor, which is present in the serum of the immunized animal, is not destroyed by heating to 55° C. for half an hour. Therefore, we may obtain the immune body free from complement by heating to 55° C. for half an hour, and the complement may be replaced at will by the addition of normal unheated serum. For example : If red-blood cor- puscles of the ox be injected into a rabbit, in a few days the blood serum of the rabbit will have the power of dissolv- ing the ox corpuscles, a process called haemolysis. But the immune rabbit serum, if heated to 55° C. (destroying the complement and leaving only the immune body), would not dissolve the ox corpuscles, unless normal rabbit serum (con- taining complement) be added, when haemolysis occurs. The body cells, in adaptation to alien substance of pro- toplasmic origin, elaborate antitoxins, antiferments, agglu- tinins, precipitins, and cytolysins (hemolysins, bacteriolysins, and special cytotoxins, such as spermatoxin, nephrotoxin, hepatoxin, etc.), which are formed of two substances: (1) complement, known also as alexin, addiment and cytase; and, 10 Diagnosis of Syphilis. (2) amboceptor, variously known as immune body, inter- mediary body, substance sensibilisatrice, Fixateur, Praepera- teur, copula, and desmon. If the alien protoplasmic substance (antigen) be mixed with serum containing its antibody, and complement added, the complement will disappear and there will be no haemoly- sis. This is known as complement deviation, and is the line along which Wassermann was working when he elaborated the test for syphilis that bears his name. Thus, the Wasser- mann reaction consists in mixing the blood serum of the suspected syphilitic with a water} 7 emulsion of the liver ob- tained from a case of congenital syphilis, in which the spiro- chete pallida is present in large numbers. If complement deviation occur, it is regarded as evidence that the spiro- chete pallida in the patient's body has stimulated the for- mation of antibodies, which reacted with the organisms present in the liver emulsion. There are some apparent inconsistencies with the theories upon which the Wassermann reaction is based. Thus, a re- action may be obtained with an emulsion of normal liver or of other normal organs, such as an emulsion of normal guinea-pig heart, instead of the watery emulsion of syphilitic liver. This would seem to controvert the theory that the reaction depends upon an antigen containing the spirochetes. Further, it has been observed that an alcoholic solution may be used, instead of the watery solution, which would indicate that the substance looked upon as an antigen is not albuminous. It has been suggested that these sub- stances may be lipoids, possibly lecithin. We must not roam too far in the realm of theory. It is possible that there is a difference between the Wassermann reaction and the reactions obtained with normal organs and alcoholic solutions, used instead of the syphilitic liver in watery solution. It has been observed that the results ob- tained by the two methods are not identical. Diagnosis of Syphilis. 11 Hecht* made use of the amboceptor and complement of human serum for sheep's blood, and employed an alcoholic extract of guinea-pig's heart as antigen. Modifications of this method have been used by a number of observers, Fleming, Levaditi, Sabrazes and Eckstein. Margarett declares this method to be superior to the original technique of Was- sermann. Antigen. — Use may be made of guinea-pig heart, rabbit heart, or human heart. The latter is preferred by some workers. The heart muscle, freed from fat, is washed free from blood and cut up in a mincing machine. Twenty grammes of the minced heart muscle is triturated in a mor- tar with the gradual addition of absolute alcohol to 100 cc, then transferred to a flask and well shaken. It is then placed on a water bath at 60° C. for two hours, and left at room temperature for twenty-four hours, then decanted. For use, this alcoholic extract is diluted with saline solution, the de- gree of dilution being determined by testing with known syphilitic and non-syphilitic serum, and choosing the dilu- tion that will prevent haemolysis with syphilitic serum but will have no effect on non-syphilitic serum. If kept in a well corked bottle and away from the light, the extract will remain useful for several months. The amount of dilution required can be determined only by testing. The sheep's corpuscles may be obtained twice a week. Five cc. of defibrinated blood is mixed with 100 cc. saline solution and kept in a cotton stopped flask in an ice chest. The flask should be shaken from time to time, to renew the oxygen. If haemolysis takes place, the fluid should be pipetted off and replaced by a fresh solution. For examination, 1 cc. or 2 cc. of blood is sufficient. Collect in small glass tubes, plug with cotton wool and keep in an ice chest. The serum will keep longer if separated from the clot. It should be examined soon, since sometimes the *(Eine Vereinfaehung der Kompliment-Bindung-Eeaktion bei Syphilis, Wiener klinische Wochenschrift, 1908, No. 50, p. 1742.) 12 Diagnosis of Syphilis. serum will lose its haemolytic power at the end of two or three days ; again, it may remain active for ten days. The test. Three tubes are used. Tube No. 1 — 100 cubic millimeters of serum. 100 cubic millimeters of saline solution. 100 cubic millimeters of antigen. Tube No. 2 — 100 cubic millimeters of serum. 200 cubic millimeters of antigen. Tube No. !3 — 100 cubic millimeters of serum. 200 cubic millimeters of saline solution. The tubes are incubated at 37° C. for an hour and a half, then 100 cubic millimeters of sheep's corpuscles are added to each tube, and the specimens are returned to the incubator until hemolysis takes place in the control tubes, usually from ten to thirty minutes. Place in an ice chest until sedimentation of the non-hsmolysed corpuscles takes place. Positive Result. — No haemolysis is in the first and second tube, but haemolysis in the third tube. Negative. — Haemolysis in all three tubes. A trace of haemolysis in the first tube, if the second remains clear, indicates a positive result. Com- plete haemolysis in the first tube and no haemolysis in the second, indicates a negative result. Cerebrospinal Fluid. Employ a unit of 150 cubic millimeters, instead of 100. A unit of fresh normal serum must be added, to complete the haemolytic system. Substitutes for tbe Wassermann Reaction. The original Wassermann reaction is difficult to per- form outside of a well-equipped laboratory. This has led to almost as many modifications, so-called, as there are work- Diagnosis of Syphilis. 13 ers in this field. Many of the "modified" Wassermann tests are practically as difficult as the true Wassermann test, and are of doubtful utility. One of the most convenient substitutes for the Wasser- mann reaction is the Forges Meier test. A one per cent, emul- sion of lecithin in normal saline solution is mixed with an equal quantity of blood serum and incubated for five hours, and left at room temperature for twenty hours. Syphilis is indicated by a precipitate. Noguchi believes this test to be about as accurate as the Wassermann reaction. Noguchi Test. — Use is made of the following re-agents : 1. Antihuman hemolytic immune body or amboceptor (serum from rabbit that has received injections of washed human corpuscles). 2. Complement (fresh guinea-pig serum). 3. Antigen (alcoholic extract of liver or a three per cent, solu- tion of lecithin in alcohol and normal saline solution). 4. Sus- pension of human corpuscles (one drop of normal blood in 4 cc. of saline solution). 5. Serum, from ten drops of the patient's blood. These re-agents have been prepared on filter paper for general use, properly standardized, and are said to keep indefinitely in a dry place. Absence or inhibition of haemolysis is regarded as a positive reaction. Results are reported comparable with those of Wassermann. Klausner Test.— A mixture of 0.2 cc. syphilitic serum and 0.7 cc. distilled water, gives a well-marked precipitate in from one to 15 hours ; normal serum gives a slight precipi- tate only after 24 hours. Emphasis is laid on the use of the exact proportions of serum and water, 2:7. Nobl regards this test as less decisive than the Porges-Meier test, which he be- lieves comparable to the Wassermann test. The Mayer and Proescher test is as complicated as the original Wassermann test, over which it does not seem to have any practical advantage. It consists in the use of sodium oleate as an antigen, and rabbit's blood immunized against corpuscles of the calf, to supply the immune body or amboceptor. Sheep's corpuscles are used for lysis, and guinea-pig serum to furnish complement. 14 Diagnosis of Syphilis. The Fleming test utilizes, (1) alcoholic heart extract, (2) blood serum, and (3) washed sheep's corpuscles. This uses only a small amount of human serum, and does not re- quire an immune serum. It is based on the normal hemolytic action of human serum on sheep's corpuscles, a characteristic that is variable and sometimes absent in the human blood. That is to say, the patient's blood may be relied upon to furnish the complement, but the amboceptor for sheep's cor- puscles is sometimes absent in human blood. Brieger * substitutes potassium chlorate for the hemolysin such as is obtained in the serum of rabbits that have received injections of sheep corpuscles. In the examination of sixty- five syphilitic and non-syphilitic cases, the findings were the same as when the Wassermann reaction is used. The Wassermann reaction should not be judged by stat- istics emanating from examinations that have been made by quasi Wassermann methods, so-called modifications of the Wassermann test. Some observers have reported finding the reaction in other protozoal infections, such as malaria, sleep- ing sickness, framboesia tropica, and in scarlet fever. Wasser- mann has recorded over a thousand cases in which the reaction was negative in non-syphilitics, and his observations have re- ceived ample confirmation. Bruck t insists that all the modifications of the Wasser- mann method are unreliable and should not be permitted to replace the original Wassermann-Neisser-Bruck technic. He attributes the positive reactions reported in diseases other than syphilis, such as framboesia tropica and leprosy, to faulty technic. A positive reaction may not be expected before the sixth week after infection, and indicates the general reaction of the body to the virus. The reaction is less likely to be found when the symptoms are slight or the disease is being actively * ( L. Brieger and H. Renz, Cblorsaures Kali bei der Serodiagnose der Syphilis, Deutsche medizinische Wochenschrift, Dec. 16, 1909.) t Die Serodiagnose der Syphilis, Dr. Carl Bruck, Privatdozent und Oberarzt, Dermatologische Universitatsklinik, Breslau. Berlin, Julius Springer, 1909. Diagnosis op Syphilis. 15 treated. In the "parasyphilitic" affections, the Wassermann reaction is often present, indicating that they are really cases of syphilis. Thus, Plaut obtained the reaction in one hundred and fifty-six cases of general paralysis, and in one hundred and thirty-nine out of one hundred and forty-seven cases in which the cerebrospinal fluid was examined; and Mott in forty-one out of forty-six cases of lumbar puncture. Plaut regards a negative finding in the cerebrospinal fluid as evi- dence that the disease is undergoing slow progress or tending to show remissions. The Wassermann reaction has also been found in a large proportion of cases of locomotor ataxia (Schiiltze), and in the paralytic and mental conditions where the condition seems to be due to hereditary syphilis. The Wassermann reaction is not always found in un- doubted cases of syphilis. Kaplan found the Wassermann reaction absent in seven per cent, of cases of syphilis, and the Noguchi test absent in eight per cent, of cases. J. Stopezanski,* from an experience with the Wasser- mann test in 103 cases of various dermatological affec- tions, found that the usual symptoms of syphilis disappear under specific treatment more readily than the serum reaction. Drever and Meirowsky (Deutsch med. Wochenschr., 1909, xxxv, 1698) applied the Wassermann reaction in one hundred registered prostitutes in Cologne. One feature of his find- ings is especially interesting. Fifty-six gave a syphilitic history, but in only one case did physical examination reveal manifest lesions. The Wassermann reaction was found in forty-five of these cases. In the remaining forty-three cases, that gave neither a history nor physical signs of syphilis, the Wassermann reaction indicated the presence of syphilis in thirty-two cases. Altogether, in the one hundred cases, gross lesions were found in only two cases, and the Wasser- mann reaction was present in seventy-seven cases. This agrees with the common observation, that practically all prostitutes * Beobachtungen iiber die Diagnose der Syphilis vermittels der Was- sermannschen Eeaktion, Wiener klinische Woehenschrift, xxii, No. 47, p. 1623-1662, Nov. 25, 1909. 16 Diagnosis op Syphilis. become syphilitic within three years. It has been claimed that chronic syphilis is often not contagious. Of course, not everybody exposed to infection of any kind becomes in- fected, but the only safe course is to regard all bearers of the spirochete pallida as extremely dangerous. Thomsen* found the Wassermann reaction in the human milk soon after delivery, but in many cases the reaction disappeared in a short time. He claims to have found a reaction in the milk in some non-s3'philitic cases, the reaction in these cases not being so pronounced as in the syphilitic cases. Conflicting results have been obtained upon applying the Wassermann reaction post-mortem, indicating that the reac- tion is a biologic phenomenon. This observation has been confirmed by Krefting f in the examination of one hundred cadavers. Meiostagmin Reaction. Intensely interesting is the observation by Ascoli, that the drop-forming property of the body fluids becomes modi- fied in certain pathologic conditions. Ascoli did some work along this line in typhoid fever and cancer. Izar J applied this method of examination in twelve cases of syphilis and fourteen non-syphilitics. The name of the reaction is derived from the Greek, "smaller" and "drop." For the antigen, Izar used an alcoholic extract of the spleen of a syphilitic fetus. 0.5 gm. of pulverized spleen was mixed with 50 cc. of alcohol, incubated for two hours, filtered and evaporated to 10 cc, and diluted to a one per cent, solution with 0.85% salt solution for use. A one per cent, solution of blood serum is made with the same salt solution. The number of drops contained in 9 cc. of the diluted serum is determined, * Wassermann-Reaktion med. Maelk, O. Thomsen, Hospitalstidende, lii, No. 41, p. 1289-1320, October 13, 1909. t Ligsera og den Was9ermann'ske syfilisreaktion, R. Krefting, Xor^k Magazin for La»gevidenskaben, January, 1910. } G. Izar, Spezifische Eigensehaft leutiseher Blutsera, Munchener medi- zinisehe Wochenschrift, Januarv 25, 1910. Diagnosis of Syphilis. 17 then 1 cc. of the diluted antigen is added, and the mixture is incubated at 37° C. for two hours. The number of drops is then again determined. From two to five more drops are found after the addition of the antigen. Izar found the reaction negative in two cases of leprosy, in which a positive Wassermann reaction had been reported. BIBLIOGRAPHY OF SPIROCHETE PALLIDA AND SERUM REACTION. Baetzman. Die bedeutung der Wassermannschen serum reaktion fur die differential diagnose der chirurgischen syphilis, Munch, med. Woch., 1909, s. 330-334. Ballner F. and von Decastello A. 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Parvu, M. Le sero-diagnostic de la syphilis, Tribune Med., Paris, 1908, 2s, tome xl, 566-568. Pedersen. Notes bearing on the value of the Wassermann test, Post Grad., N. Y., 1909, vol. xxiv, p. 679. Pick, L., & Proskauer, A. Die komplementbindung als hilf- smittel der anatmonischen syphilis diagnose, Med. Klinik, Berlin, 1908, Bd. iv, s. 539. Plant, F. Sero-diagnostik der syphilis. Zentralbl. f. Ner- venh. u. Psychiat., Leipzig, 1908, Bd. xxxi, s. 289. Plaut, F., Heuck, W., & Rossi. Gibt es eine spezifische prazipitalreaktion bei lues und paralyse? Miinchen. med. Woch., 1908, Bd. Iv., s. 66. Porges, O., & Meier, G. Ueber die rolle der lipoide bei der Wassermannschen syphilis-reaktion, Berl. klin. Woch., 1908, Bd. xlv, s. 731. 28 Diagnosis of Syphilis. Prowazek. Bemerkungen zur spirochaten und vaccinefrage, Centbl. f. Bakter. 1 Abt., Jena, 1908, Bd. xlvi, Orig, s. 229. Purckhauer, R. Wie wirkt die spezifische therapie der Was- sermann A. Neisser-Brucksche reaktion ein? Munch, med. Woch., 1909, 608-702. Quinby, W. C. The demonstration of the spirochete pallida by the method of dark-field illumination. Bost. Med. & Surg. Jour., 1908, vol. clix, p. 175. Rajat. Le sero-diagnostic de la syphilis, Centre med. et pharm., Gannat, 1908-9, tome xiv, 36. Rondoni, P. Beitrage zur theorie und praxis der Wasser- mannschen syphilis-reaktion 1 Mitteilung ueber den ein- fiuss der extraktivverdiinnung auf die reaktion, Berl. klin. Woch., 1908, Bd. xlv, s. 1968. Rosenberger, R. C. The present status of the aetiology of syphilis, the spirochete pallida, its biology and etiological relation to the disease, N. York Med. Jour., 1908, vol. lxxxvii, p. 391. Sachs, H., & Altmann, K. Ueber die Wassermannsche sero- diagnostik der syphilis, Deut. med. Woch., 1908, 529. Sachs & Altmann. Ueber die wirkung des oleinsauren natrons bei der Wassermannschen reaktion auf syphilis, Berl. klin. Woch., 1908, 494. Schalek. A practical value of modern conceptions of syphilis. J. Am. Med. Assn., 1908, 50, 1409-1411. Scheidemandel. Ueber die Wassermannsche sero-diagnostik der lues. Miinchen. med. Woch., 1908, Bd. lv, s. 2017. Schereschewsky, J. Zuchtung der spirochete pallida (Schau- dinn), Deut. med. Woch., 1909, 835. Scheuer. Fruhdiagnose der syphilis mittelst nachweises der spirochete pallida im dunkelfeldapparate. Wien. med. Woch., 1909, 1947. Schlimpert. Beobachtungen bei der Wassermannschen reak- tion. Deut. med Woch. 1909, 1386. Soutzo fils. Les nouvelles donnees relatives a la seroreaction, klin. Woch., 1909, 1116. Diagnosis of Syphilis. 29 Shishkina-Yavelin, Mme. P. N. Serum diagnosis of syphilis, Russk. Vrach., St. Petersb., 1908, vii, 641-645. Soutso fils. Les nouvelles donnees relatives a la seroreaction de la syphilis dans la paralysie generale par le methode de Wassermann, Ann. med-psychol., Paris, 1908, 9s, tome viii, 52-68. Spillmann, L., & Lamy. A propos du sero-diagnostic de la syphilis interpretation d'une reaction negative chez un syphilitique, Compt. rend. soc. de biol., Paris, 1908, tome lxiv. Stern, M. Zur technik der sero-diagnostik der syphilis, Berl. klin. Woch., 1908, Bd. xlv, s. 1489. Stern, M. Eine Vereinfachung und Verfeinerung der sero- diagnostischen syphilis-reaktion, Zeitschrift fur Immuni- tatsforschung, 1909, s. 422. Stone, W. J. The early diagnosis of syphilis and the tech- nique of examination for the spirochete pallida. Med. Rec, N. Y., 1909, vol. lxxv, p. 638. Stone, W. J. The technic for examination for the pale spi- rochete by dark-field illumination, J. Am. M. Assn., 1909, vol. lii, p. 960. Swift. A comparative study of serum diagnosis in syphilis, Arch. Int. Med., Chicago, 1909, vol. iv, p. 376-404. Taege, K. Die technik der Wassermann-Neisser-Bruckschen sero-diagnostik der syphilis, Munchen. Med. Woch., 1908, Bd. Iv, s. 1730. Towle, H. P. The serum diagnosis of syphilis, Boston Med. & Surg. Jour., 1908, vol. clix, pp. 474, 502. Tschernogubow, N. Eine einfache methode der serum-diagnose bei syphilis, Berl. klin. Woch., 1908, Bd. xxvi, s. 2107. Tschernogubow, N. A. Ein vereinfachtes verfahren der serum- diagnose bei syphilis, Deut. med. Woch., 1909, 668. Vadam, P. Les methodes de laboratoire appliquees a la clin- ique methodes bacterioscopiques confirmant le diagnostic de la syphilis, Medicin Prat, Paris, 1908, tome iv, 293. Wassermann, A. Ueber die entwicklung und den genenwartigen stand der sero-diagnostik geneniiber syphilis, Berl. klin. Woch., 1907, Bd. xliv, s. 1599, 1634. 30 Diagnosis op Syphilis. Wassermann, A. Ueber die sero-diagnostik bei syphilis, Wien. klin. Woch., 1908, Bd. xxi, s. 388. Wassermann, A. Ueber die sero-diagnostik der syphilis und ihre praktische bedeutung fiir die medizin, Wien. klin, Woch., 1908, Bd. xxi, s. 7-15. Wassermann, A. Ueber die sero-diagnostik der syphilis und ihre praktische bedeutung fiir die medizine, Heilkunde Berl., 1908, 349-354. Wechselmann. Postkonzeptionelle syphilis und Wassermannsche reaktion, Deut. med. Woch., 1909, 665. Weil, E., & Braun, H. Ueber antikorperbefunde bei lues tabes und paralyses, Berl. klin. Woch., 1907, 1570. Weil, E., & Braun, H. Ueber die entwicklung und den geneg- wartigen stand for der sero-diagnostik genenuber syphilis, Berl. klin. Woch., 1907, 1682. Weil, E., & Braun, H. Ueber die entwicklung der sero-diag- nostik bei lues, Wien. klin. Woch., 1908, Bd. xxi, s. 624. Weil, E., & Braun, H. Ueber positive Wassermann-Neisser A. Brucksche reaktion bei nichtleutischen erkrankungen, Wien. klin. Woch., 1908, Bd. xxi, s. 938. Weis, J. D. A rapid method of demonstration of the spi- rochete pallida for diagnosis, New Orleans Med. & Surg. Jour., 1907-8, vol. lx, p. 561 ; 1908, vol. lxi, p. 205. Whittemore, W. The Wassermann reaction for syphilis, Bos- ton Med. & Surg. Jour., 1909, vol. clx, p. 651. Wile, W. J. The spirochete pallida, its easy demonstrability and a brief review of its history, Jour. Cut. Dis., N. Y., 1909. vol. xxvii, p. 296. Wilson, D. S. Diagnostic importance of the spirochaete pal- lida or treponema pallidum, Louisville Month. Jour. Med. & Surg., 1908, vol. xv, p. 69. Wright & Richardson. Treponemata (spirochete) in syphilitic aortitis, 5 cases, 1 with aneurism, Bost. Med & Surg. Journal, 1909. vol. clx, p. 539. Zalla, M. La "precipitazione" della lectitina nella sero-diag- nosis della sifilide a delle affezioni metasifilitiche, Riv. di patol. nerv., Firenze, 1908, xiii, 385-389. Diagnosis of Syphilis. 31 METHODS OF INFECTION. Syphilis may be conveyed through inoculation. The abrasion need be but slight, so that it may have entirely disappeared by the time the patient comes under the obser- vation of the physician. Therefore the abrasion has often little diagnostic value. Infection may be transmitted through sexual intercourse, kissing, and through the use of common utensils and vessels, as for eating and drinking. No doubt infection may be conveyed by a contaminated water-closet seat, though this is comparatively rare. Physicians and nurses have been inoculated in the examination or treatment of cases of syphilis, especially in surgical and obstetrical practice. Oc- casionally syphilitic infection occurs during circumcision by an infected individual, when the operation is done after the fashion of the Mosaic law. All of this is of diagnostic import only in so far as the knowledge of the cause of the disease may lead to its recognition. Hereditary syphilis may be transmitted from either parent, in whom the disease may be either manifest or latent at the time. Syphilitic infection of a mother beginning at the seventh month of gestation, usually does not affect the fe- tus, although the fetus has been reported affected as late as the eighth month of gestation. The mother need not nec- essarily be affected by syphilis transmitted to the offspring from the father, and may possibly nurse the child without becoming infected, probably through having received a pro- tective inoculation without the development of the disease. The child may convey syphilis readily to a wet-nurse who has received no such protection. Jacobi states, without qualifica- tion, that an infant affected with hereditary syphilis will not infect its own mother and ought to be nursed. This is in ac- cordance with the observation of Colles, 1837 : CoIIes' Law. "One fact well deserving our attention is this : That a child born of a mother who is without obvious venereal 32 Diagnosis of Syphilis. symptoms, and which, without being exposed to any infec- tion subsequent to its birth, shows this disease when a few weeks old — this child will infect the most healthy nurse, whether she suckle it or merely handle and dress it ; and yet this child is never known to infect its own mother, even though she suckle it while it has venereal ulcers of the lips and tongue." The mothers of infants with congenital syphilis often show the Wassermann reaction, without other manifesta- tions of syphilitic infections. HEREDITARY SYPHILIS. Hereditary syphilis and congenital syphilis are not always synonymous. A distinction should be made between syphilis acquired with conception and syphilis acquired during intra- uterine life. Hereditary syphilis differs from acquired syphi- lis essentially in the absence of the initial lesion or chancre. The other stages of the disease are practically analogous in the two forms. We have already referred to Colles' law. The analogue of this, on the part of the child, commonly known as Prof eta's law, is attributed to Behrend by Hutchinson. It is based upon the observation that apparently healthy children may be born of mothers in the secondary stage of syphilis. Such cases of congenital immunity must not be confounded with cases of syphilis hereditaris tarda. In the last named condi- tion, syphilis is acquired by heredity, but does not become manifest until a long time after birth. The existence of such cases is doubted by some observers, who are inclined to believe that the reported cases are really cases of acquired syphilis and that the initial lesion has been overlooked. The history or evidence of syphilis in either parent may shed a valuable side light in a doubtful case; but such evidence or history is at times misleading. In general, its importance corresponds to the shortness of time between Diagnosis of Syphilis. 33 the infection of the parent and the time of conception. The probability of the disease being transmitted is greater when both parents are infected. Doubtful cases may be cleared up by finding the spirochete pallida, or by the Wassermann reaction. SPIROCHETE PALLIDA IN CONGENITAL SYPHILIS. M'Intosh found spirochete pallida in the lungs, liver, spleen, suprarenal gland, kidneys, and skin, in congenital syphilis. He declares that the large number of parasites in the liver, in congenital syphilis, suggests the maternal trans- mission of the infection through the placenta. He did not find the spirochete in the placenta. Levaditi found it once in thirteen cases, and Dohi twice in six cases. In a liver that had undergone maceration, no spirochetes were found, though the organ was studded with miliary gummata, and the maceration was but slight. Busghke and Fischer, 1905, and Levaditi, 1905-6, first demonstrated the spirochete pallida in the organs of a syph- ilitic infant. Their examinations were made with the Giemsa stain. The earlier examinations, made by the methods of Herxheimer and Hubner, 1905, and Giemsa, 1905, were only partially successful. Later Bertarelli, Volpino, and Bovero, using a modification of the van Ermenghem cilia stain, showed the parasites present in large numbers in the organs in con- genital syphilis. Probably the most satisfactory method of making these examinations is by the use of Levaditi's modi- fication of Ramon y Cajal's stain for the demonstration of nerve fibrils. A more rapid silver stain has been devised by Levaditi and Manouelian, but it is not so reliable as the other stain. Levaditi and Souvage have reported that the spirochete pallida may be found in the Graafian follicle, inside the ovum, in congenital syphilis. Direct infection of the ovum 34 Diagnosis of Syphilis. without its destruction is known to occur in tick (Ornitho- dorus moubata), with the spread of the tick fever. Babes and Panea found spirochete pallida, post-mortem in congenital syphilitics from one to four weeks old, in three cases. The spirochetes were most numerous where the syphilitic lesions were most marked. No spirochetes were found in the non-syphilitic children examined. A series of abortions may be due to syphilis. But there are other causes of abortion. Only too often syphilitic parents have large families. Syphilis of the placenta may cause abortion, commonly through death of the fetus. When abortion takes place before the fifth month, it is often impossible to make a diagnosis of syphilis in the fetus. It has been doubted (Hutchinson) whether syphilis is trans- mitted to offspring by the father if an interval of two years has elapsed since his disease was acquired. If this is the rule, there are many exceptions. It is well known that mothers may transmit the disease after a longer period. However, it is a matter of observation that the older children are most liable to inherit the disease. The younger members of syph- ilitic families more frequently escape the disease. The reported Bales and Panea, Ueber pathologische Veraderungen und Spirocha;te pallida bei eongenitaler Syphilis, Berliner klinische, Wocbenscrift, xlii, xlii, No. 27. Bertarelli, Volpino. and Bovero, Riv. d'ig. e. san publ., Roma, anno xvi, p. 561. 1905. Busghke and Fischer, Deutsche med. Wochenschrift, Leipzig, 1805, No. 20, s. 791. Finger and Langsteiner. Sitzungsb, d. k. Akad. d. Wissensch., Wien, Heft 4. Bd. cxv, s. 179, 1905. Giemsa, Deutsche med. Wochenschrift. Leipzig, 1905. No. 26, s. 1026. Herxheimer and Hubner, Deutsche med. Wochenschrift, Leipzig. 1905, No. 26, s. 1023. Levaditi, Compt. rend. Sec. de Biol., Paris. 1905, tome Ivii, p. 845. Levaditi. Ann, de l'lnst. Pasteur. Paris. 1906, tome xx. p. 368. Levaditi and ManoueUian, Compt. rend. Soe. de biol., Paris, 1906, tome lviii. p. 134. Levaditi and Sauvage, Adad. des Sciences, Paris. 1906, tome cxliii, p. 559. Levaditi and M'Intosh, Ann. de l'lnst. Pasteur, Paris. 1907, tome xxi, p. 784. M'Intosh. James. The occurrence and distribution of the spirocheta pallida in congenital syphilis, Journal of Pathology and Bacteriology, January, 1909. Ramon y Cajal, Compt. rend. Soc. de biol., Paris, 1904, tome lvi, p. 368. Diagnosis op Syphilis. 35 cases of long persistence of the syphilitic taint and trans- mission of the disease are open to the possibility of a repe- tition of the infection. So-called latent syphilis can exist only through the fact that we do not recognize the disease. This may be because prominent symptoms are lacking or because we do not examine the patient with sufficient care. Such a case was reported by Hutchinson, in 1874. The vaccinifer had been selected at a station as a specially healthy child, and remained apparently such after the vaccination, which conveyed syphilis to sixteen individuals. A careful search was then instituted, which revealed a condyloma at the anus. Such cases, of course, would not occur with the use of modern virus for vaccination. Idiocy and mental failure seem to be more common in cases of hereditary syphilis than in non-syphilitic cases. Hutchinson believes that many of these cases are examples of paralytic dementia developed during childhood. It is doubtful whether hereditary syphilis ever causes the aggressive degenerations, such as locomotor ataxia. Transmission of this form of syphilis to the third generation has been reported, but is doubtful. It has been estimated that at least one-third of syphilitic children are dead-born, and that one-fourth of those born alive die within six months. After the first six months, the child with hereditary syphilis usually lives to suffer disease or deformity as the result of its inheritance. It is usually impossible to make the diagnosis of syphilis of the fetus in utero. Jacobi declares that it is impossible to make a positive diagnosis of syphilis in cases in which abortion takes place before the fifth month. In case of abortion, a syphilitic fetus may show various evidences of the disease, especially skin eruptions (bulla and pemphigus) and visceral affections (parenchymatous infiltration of the liver, spleen, kidneys, heart and thymus gland). Near the end of term there is epiphyseal osteochondritis, especially of the lower extremities. The spleen may show gummatous tumors, cicatricial tissue, and there may be ad- herent peritonitis. 36 Diagnosis op Syphilis. At the end of term there may be palmar or plantar pemphigus and visceral changes of syphilis. Milder cases may show a pale red or brown exanthem on the face, feet, hands and genitals ; coryza ; rhagades of the lips and at the anus ; and often the spleen is enlarged. Abortion, especially repeated abortions, is often referred to as a valuable sign of syphilis. A more important sign is a higli infant mortality in a family, in the absence of any other adequate explanation of the cause of the deaths. Symptoms of syphilis may be present at the time of birth, especially : — Senile appearance, hoarseness, corj'za, and eruptions, especially pemphigus. At the time of birth, or soon after, icterus neonatorum may appear, to give a grave prognosis. Symptoms of hered- itary syphilis are often present at the time of birth, and usually may be observed during the first three months of life. It is not safe to base a diagnosis upon a single symp- tom. The important earl} - symptoms are peevishness and irritability at night, harsh and difficult breathing, snuffles, sore mouth and impaired digestion, with emaciation and the senile appearance. There may be characteristic eruptions, especially an erythema over the neck, face, extremities and genitals. During the period extending from about the end of the first month to about the end of the first year, cases of hereditary syphilis may show : — Nocturnal peevishness and irritability. Convulsions. Hoarseness, with harsh and difficult breathing. Corj'za (snuffles). Eruptions: erythema, papules, and pustules. Mucous patches, especially on the lips, tongue and cheeks. Diagnosis of Syphilis. 37 Emaciation and senile appearance. Visceral affections (liver, spleen, kidneys, heart, etc.). Many cases of hereditary syphilis that survive this stage of the disease, especially if they have been properly treated, appear to terminate at the end of the second stage, after the disease has lasted about a year or eighteen months. In other cases, the disease remains quiescent until the second dentition or until puberty, or possibly even later in life. This period is characterized by the absence of active symp- toms, evidences of malnutrition, stunted growth, and retarded development. Later important symptoms of hereditary syphilis are: — Hutchinson teeth. Condylomata. Sores or pseudo-scars radiating from the corners of the mouth. Iritis. Choroidea areolaris. Affection of the bones, especially at the junction of epiphyses and diaphyses. A dusky, scaly eruption. Affection of the middle ear and eustachian tube. Affection of the auditory nerve. Gastrointestinal disturbances (vomiting, diarrhoea, colic, anorexia, and emaciation — not pathognomonic). Dactylitis. From the second to the fourth year condylomata may develop. These may be caused either by hereditary or acquired syphilis. Small, thin cicatrices on the nose, are usually due to hereditary syphilis. Hutchinson's teeth may be due to other causes of malnutrition, and sometimes are not present in syphilis. There is profound anemia and a yellowish complexion. In the second stage of hereditary syphilis, condyloma 38 Diagnosis of Syphilis. and iritis are the most important single symptoms. Often a useful diagnostic tripod is formed by syphilitic rhinitis, sores or pseudo-scars radiating from the corners of the mouth, and the presence of a dusk}' scaly eruption. With the appearance of the teeth, a central crescent-shaped exca- vation in the permanent upper incisors denuded of enamel, is suggestive. However, notched teeth are not invariably due to syphilis. A choroidea areolaris is an important sign. The secondary and tertiary symptoms of hereditary syph- ilis are the same as those found in acquired syphilis. Syphilis tarda may be accompanied by a persistence of infantile testes with little or no pubic hair. The mammae may be small or infantile. The nose is often small and deformed. The lips present cicatrices. The hair is thick and dry. ACQUIRED SYPHILIS. Incubation. The period of incubation usually lasts from two to four weeks. Cases have been reported in which the incubation lasted only one week ; again, it has been reported as long as eight weeks. The length of the period of incubation is one of the most valuable points in diagnosis, but frequentty is not deter- minable because the patient's statement may be unreliable or misleading, and confrontation is rarely practicable. First Stage. At tins time the following is a valuable diagnostic tripod: (1) Period of incubation. (2) Induration of base of chancre, and (3) Adenopathy of nearest lymphatic glands. After the period of incubation, the beginning of the first stage of syphilis is announced by the appearance of the primary sore, ulcus durum, at the point of inoculation. The Diagnosis op Syphilis. 39 initial lesion usually appears as a slightly red infiltration, with sharply defined borders, induration (hence the term "Hunter's induration") and slight sensitiveness. This lesion is sometimes referred to as the hard, syphilitic or Hunterian chancre. At times the infiltration is in the form of a nodule, the so-called initial papule or syphilitic papule. In size, the initial lesion varies from that of a pea to a quarter. Usually the indura- tion soon shows necrosis of its centre, to constitute an ulcer. The induration may be: (a) laminated, thinner and less distinct than — (b) parchment induration, in which the base of the ulcer feels like parchment. (c) Nodular induration, the base of the ulcer feeling like a nodule of cartilage or wood. This is the most characteristic, (d) Annular indura- tion, in which the margins of the chancre form an indurated ring. In such cases the center of the ulcer may remain normal in elasticity. Traces of induration may remain for years. Ricord observed induration that persisted ten and fifteen years after the primary infection. The location has much to do with the character of the induration. Upon the labia majora induration is more pro- nounced than upon the labia minora or the fourchette. < Induration may be entirely absent. As a rule the chancre has a peculiar cartilaginous feel that is almost characteristic. This varies somewhat with the tissue in which the primary sore occurs. Thus, primary infection of a cervix previously deformed by the formation of scar tissue in an old tear, may be confusing, so far as diagnosis by touch is concerned. But usually even in these cases no little aid in diagnosis is afforded by the sense of touch. The shape of the induration is usually circular, but varies with the part involved. Thus, a primary sore in the urethra may cause a tubular induration. Induration may be caused by other things, such as inflam- mation or the use of caustics, or may be masked or changed by inflammation or gangrene. Under proper treatment, the primary sore disappears in 40 Diagnosis op Syphilis. four to six weeks. As a rule the induration does not persist longer than a month. When secondary infection has occurred, there may remain a simple thickening of the connective tissue. Sometimes the primary ulceration shows a serpiginous char- acter, believed by some observers to be due to gummatous changes. Or the ulcerative process may be greatly protracted by involvement of the lymphatics. The following are the more important diagnostic features of Chancre. 1. Incubation one week to two months, usually about two weeks. 2. Derived from a preceding case of syphilis by direct or indirect contagion. 3. Begins as an indurated infiltration or nodule at the point of inoculation. ■1. Necrosis of the center of the infiltration to form an ulcer ; rarely there may be no ulceration. The ulcer is usually superficial, without abrupt margins ; may be elevated. 5. Cartilaginous or parchment induration of the base of the chancre. 6. The shape of the infiltration is usually circular. 7. Chancre is usually single ; multiple chancres may result from multiple inoculations received at or about the same time, before immunity is established. 8. The secretion is scanty and serous ; does not cause auto-inoculation. 9. The pain and discomfort is slight compared with the size of the lesion. 10. Adenopathy : Indolent buboes usually appear in the neighboring lymphatics within two weeks after the appear- ance of the initial lesion. 11. Duration: Disappears in a few weeks under proper treatment. 12. Later appearance of the characteristic features of the second and third stages of syphilis: Syphilides and gummata. Diagnosis of Syphilis. 41 13. May lead to the infection of others, producing syphilis. 14. Responds to anti-syphilitic treatment : Mercury. 15. Undergoes resolution to leave a scar or circumscribed loss of pigment when located upon the skin ; may leave no visible scar or change when located upon mucous membrane. 16. The spirochete pallida is present, and may be most readily found in serum from the deeper parts of the chancre, such as may readily be obtained by scraping. When obtained in this way, the examination is easier, since the great bulk of the more superficial saprophytic spirochetes will be avoided. 17. The Wassermann reaction is not present before the sixth week after infection. In diagnosis, it must be remembered that not all genital scars are due to syphilis. The use of caustics or the destruc- tion of tissue by septic infections or other non-syphilitic processes may leave scars. Upon mucous membrane, it is often impossible to detect any scar after the disappearance of the initial lesion of syphilis. Upon the skin, the site of the primary sore may be marked more or less permanently by a scar or by a circumscribed spot containing less pigment than the normal tissue. The primary sore is usually single, but may be multiple. As stated, the primary sore appears at the point of inoculation. Therefore, the initial lesion is most frequently found upon the genitals. But extra-genital infection is not uncommon. The most frequent extra-genital location of the^ primary sore is the mouth. The corners of the mouth and the tongue are favorite seats. The gums, tonsils and hard palate are less frequently involved. Occasional cases are found upon the breast, the face, especially the chin, nose, eyelids or con- junctiva; the ear, forehead; the arms, and upon the extremi- ties, the hands, fingers, and even the toes. In some cases the initial lesion may be either wholly want- ing or so slight as to escape observation. The presence of a chancre in hereditary syphilis would be a curiosity because of its rarity. 42 Diagnosis op Syphilis. Sometimes the initial sore is accompanied by an indurated edema (oedema indurativum of Sigmund ; cedeme sclereux of Fournier). This may involve the penis, rarely extending to the scrotum; and in women it may affect the labia majora, the prepuce of the clitoris and more rarely the labia minora. In women the edema may be unilateral. In genital syphilis, the male usually shows primary involve- ment of the prepuce, glans or urethra. In the female the sore is usually on the inner side of the labia, or the clitoris, or on the vaginal portion of the cervix. Extra-genital chancre occurs most frequently at the anus, and more frequently in this locality in women than men. The lymphatics in the neighborhood of the primary sore are enlarged, and suppura- tion may occur both in the primary sore and in the adjacent lymphatics. The enlarged lymphatic glands, commonly known as indo- lent buboes (as distinguished from inflammatory or painful buboes), are usually to be found within two weeks after the initial lesion. Sometimes these enlargements appear at the same time or soon after the primary sore ; or they may be delayed, rarely longer than two weeks. One, more often several, buboes of varying size up to that of a walnut, appear and remain for months or } r ears. Suppuration of the primary sore or of the lymphatics may be caused by secondary infection. In genital syphilis, the lymphatic glands of the groin are most frequently enlarged, and as a rule, but not invariably, the enlargement of the glands is most marked upon the side of the primary sore. Other lymphatic glands may be enlarged, especially the femoral glands and the iliac glands. In extra-genital syphilis, in which the initial sore appears upon the fingers, nipple, lips, tongue, eyelids, etc., the en- larged lymphatic glands are found in the region of the elbow, axilla, neck, or the preauricular glands. The nearest lymphatics are sometimes apparently normal in size, the next series of glands being enlarged. Thus, in genital syphilis, the groin may be clear and the pelvic glands enlarged. Diagnosis of Syphilis. 43 Adenopathy may be caused by other things, such as by inflammation of a sore, in which instance the glands are usually tender; the syphilitic bubo, too, may be painful in cases of mixed infection. Sometimes the affection of the lymphatic vessels may be detected, especially on the under side of the penis, in genital syphilis. This is the indurated lymphangitis of Lang. In the female, these lymphatics may sometimes be detected be- tween the labia and the glands of the groin. The affection of the lymphatic vessels usually does not persist so long as the affection of the lymphatic glands. Suppuration of the lymphatic vessels is rare. Chancre in hairy regions, such as the scalp or parts of the face covered by the beard or moustache, may resemble ecthyma. After shaving, such a chancre will be found glazed, flat or elevated. Later induration and lymphadenitis proclaim the syphilitic nature of the process. s When razor cuts heal and later reopen, syphilis should be suspected. Pseudo-furuncles, acneiform pustules, cracks around the nares, etc., when characterized by painlessness and persistence, the presence of bloody crusts and an areola of subinflammatory edema, require only the characteristic adenopathy to justify the diagnosis of chancre. Vaccino-syphilis has become rare since the adoption of bovine virus for vaccination. In such cases, the chancre appears after the vaccination has run its course. When a vaccine sore reopens or persists unduly long, and does not respond to antiseptic treatment, chancre should be suspected, especially if humanized lymph has been used for vaccination. The diagnosis is confirmed by induration and adenopathy. Mammary chancre, due to suckling a syphilitic child, ad- mits of confrontation as an aid to diagnosis more frequently than in any other class of cases. In suspicious cases, we should never fail to examine the child, if possible. Chancre of the tonsils and isthmus of the fauces is most frequent in women. In seven cases reported by Mackenzie, six were women. 44 Diagnosis op Syphilis. Upon the forearm, chancre is found most frequently upon the anterior surface. Upon the thigh, chancre occurs most frequently upon the anterior surface in men, and upon the posterior surface in CHANCROID. 1. Due to inoculation from chan- croid ( ulcer, bubo or ljinphitis ) . Syphilitica are not exempt, so that both lesions often occur in the same patient. 2. Incubation period of a num- ber of hours, usually not more than a day or two. 3. Usually confined to the geni- tals; extra-genital chancroid is rare. 4. Chancroid ulcer begins as a nodule, that forms a pustule and breaks down, to form a deep, pain- ful ulcer with an unclean base. 5. May be single, but often are multiple, frequently as the result of auto-inoculation. The chancroid ulcers are often successively multi- ple. 6. May be round or oval, but usually less symmetrical than chan- cre ; borders often described by seg- ments of large circles. 7. The edges are clean cut, ir- regular, sometimes undermined, pre- senting a punched-out or crater- shaped appearance. S. The chancroid ulcer is rough and uneven, with reddened and swol- len edges and base, covered by a grayish pultaceous discharge. 9. The secretion is abundant and purulent. 10. Induration is the exception, and when present is caused by caus- tics or inflammation, and seldom feels like the induration of chancre. 11. The chancroid ulcer is pain- ful. 12. Chancroid ulcer runs an ir- regular course; phagedena are more common. Confers little or no immunity, so that second attacks are common. CHANCRE. 1. Confrontation: Due to inocu- lation (direct or indirect) from a case of syphilis. Chancre, chancroid and gonorrhoea frequently co-exist. 2. Incubation from one week to two months; usually two or three weeks. 3. Appears at the point of inocu- lation — most frequently upon the genitals, less frequently upon the anus, mouth, face, breast, extremi- ties, etc. 4. Chancre liegins as an indura- tion, that undergoes central necrosis to form an ulcer. Rarely remains a papule or tubercle without ulcera- tion. 5. Almost always single. Occa- sionally multiple, due to multiple inoculations received at the time of exposure; rarely successively multi- ple. Auto-inoculation is almost un- known in chancre. 6. Symmetrical in shape, usually round or oval. 7. The ulcer is usually superfi- cial, a simple cup-shaped depression without abrupt margins; may be elevated. 8. The surface of the ulcer is smooth, shining, red. glazed, often covered with a scab or a diphthe- ritic membrane. 9. The secretion is scantv and 10. The induration of the base, with its peculiar cartilaginous elas- ticity, is one of the principal diag- nostic characteristics of chancre. 11. Chancre causes little or no pain. 12. Chancre runs a fairly regu- lar course, and confers marked im- munity, so that second attacks are rare. Diagnosis op Syphilis. 45 13. Affection of the lymphatic 13. Affection of the lymphatic glands occurs in about one-third glands is the rule in chancre, re- of the cases of chancroid; when af- suiting usually in indolent buboes, fected, the glands usually suppurate, Much more often multiple than in and the pus from them is infee- chancroid. tious. 14. Affection of the lymphatic 14. Affection of the lymphatic vessels shows more inflammatory re- vessels causes little or no percepti- action than in chancre. ble inflammatory reaction. 15. Chancroid is a more serious 15. Chancre tends to undergo res- local lesion, because of the greater olution, to be followed later by the persistence and destruction of tissue, general symptoms of syphilis. but it is not followed by general symptoms. 16. Local treatment is curative. 16. Mercury is specific. 17. Chancroid streptobacillus of 17. Spirochete pallida present. Ducrey.* Spirochete pallida absent. Possibility of mixed infection, except when syphilis is present. 18. Wassermann reaction absent, 18. Wassermann reaction is not except when there is a co-existing present before the sixth week after syphilis. infection. Syphilis and the non-syphilitic venereal ulcer may co-exist. Not infrequently we are called upon to differentiate between these affections, especially when the lesion is located upon the genitals. Chancroid is comparatively rare extra-genitally, e. g., upon the lips or face. The ulcerated initial lesion of syphilis may bear some resemblance to the venereal ulcer. The primary sore of syphilis appears after an incubation of a number of days, usually about two weeks. The incu- bation of venereal ulcer is a matter of hours, as a rule a day or two. We have already referred to the appearance of the primary sore of syphilis. The ulcer of chancre is char- acterized by smooth edges, often elevated, sloping, adherent, and not undermined. The non-syphilitic venereal ulcer begins as a small nodule at the point of infection and rapidly be- comes a pustule. The breaking down of the pustule leaves an ulcer, deep and painful, with an unclean base. The edges are clean-cut, irregular, more perpendicular, and sometimes * Chancroid streptobacillus of Ducrey: Short, thick bacilli, with rounded ends and a slight constriction in the center. Usually found out- side the cells, sometimes within them. Stains readily with fuchsin or gentian violet; decolorized by Gram. 46 Diagnosis of Syphilis. undermined. The secretion of chancre is scanty, serous or serosanguinolent, save when irritation or mixed infection causes it to become purulent ; the secretion of chancroid is copious, purulent, and irritating in the early stage, becoming laudable when the ulcer is healing. Auto-inoculation of the non-syphilitic venereal ulcer is common. Affection of the lymphatics usually does not follow, but when the lymphatic glands are involved they usually suppurate, and the pus from them is infectious. When the lymphatic vessels are involved, they show more inflammatory reaction, as a rule, than in syphilis. More rarely we are called upon to differentiate the initial sore of syphilis from a beginning carcinoma. In this con- nection, it must be remembered that cases have been observed in which carcinoma has developed upon the primary lesion of sj'philis. Such cases are rare. Epithelioma may resemble chancre somewhat, but usually may be readily distinguished by the more rapid development of chancre, the early aden- opathy, and the course of the affections. Doubtful cases justify excision of a piece of tissue for microscopic examina- tion. (See differential diagnosis between syphilis and cancer of the lips.) An ulcerating gumma may resemble chancre, but there is usually the history or evidence of the longer duration of the disease. The lesion begins as an indolent tumor or mass that slowly ulcerates and forms a deep suppurating ulcer. There is not the same induration of the base as in chancre, the borders are more soft and ragged, and there is little or no affection of the neighboring lymphatic glands. Simple abrasions that terminate in ulceration may bear some resemblance to chancre. They run a different course ; septic infection may lead to adenopathy, and there may be some induration, but not so marked as in the base of chancre. They are usually more irregular in shape than chancre. Herpes pro genitalis is usually a multiple lesion, consisting of several vesicles. The base of the vesicles is reddened, but not indurated as in chancre. Later the vesicles become pustules and rupture, to become covered with a scab. There may Diagnosis op Syphilis. 47 be affection of one or more neighboring lymphatic glands, which become enlarged and are usually more tender than in chancre. Involution is more rapid than in chancre, taking only a few days at the most. The condition is due to fric- tion, irritation by discharges or secretions, cold or fever, or possibly a neurosis. Chancre sometimes appears as a herpeti- form lesion, but there is not so distinct grouping of the vesicles as in herpes, the base is more indurated, the borders more thickened, and there is more marked affection of the neighboring lymphatics in the form of indolent buboes. Second Stage. Usually in from six to twelve weeks the constitutional symptoms of the second stage of syphilis are observed.* Fever is usually present, probably due to the discharge of the diseased contents of the lymphatics into the blood. Sometimes fever is delayed or absent, possibly because the poisonous material is emptied into the circulation more grad- ually. As a rule the fever of invasion begins about seven or eight weeks after infection. This fever is sometimes known as the fever of syphilitic eruption, because the eruption on the skin and mucous membranes appears about this time. As a rule the fever appears without a chill, and is accompanied by headache, malaise, general depression and weakness, and rheumatoid pains. The appetite may be increased or decreased. The increase of temperature usually occurs in the afternoon or at night, reaching 104-5° F. or more in the evening, with morning remissions to near normal. The fever of invasion lasts from two to four days as a rule. The temper- ature begins to fall with the appearance of the eruption, the fever disappearing in a day or two. Frequently, during the course of syphilis, secondary infec- tions cause fever, usually of an irregular type. *Long incubation. — Simpson recently reported a case showing ten days for the first period of incubation and 132 days for the second period. That is, the" total length of time from inoculation to the beginning of the second stage of the disease was 142 days. (Quarterly Bulletin, North- western Medical School, December, 1909.) ■18 Diagnosis of Syphilis. Anemia is one of the prominent symptoms in syphilis. Syphilitic anemia is often present at the very beginning of the second stage, when it is sometimes called syphilitic chlorosis, and is accompanied by symptoms of general weakness, the patient becoming easily tired and appearing pale. Leucocytosis or lymphatic anemia is often present, es- pecially in the presence of strumous lymphadenitis. At times the spleen is enlarged, giving the appearance of a leukaemia ; or there may be a true syphilitic leukaemia. In some cases, an actual pernicious anemia has been reported in syphilis. During the second stage of syphilis, the Wassermann reaction is present, and the spirochete pallida may be found in the various ulcerations and in the blood, especially when drawn from the eruptive spots. The cutaneous and mucous lesions of syphilis are more or less characteristic. The most prominent of these are the syphilitic macules, papules, and pustules ; the squamous syphil- ides, condylomata, and falling of the hair ; the mucous patches, stomatitis, and sore throat. Syphilides. Syphilides may be differentiated from non-syphilitic ma- cules, papules, nodules, pustules, ulcers (with scales and crusts) in many instances, chiefly by the course of the disease. Kaposi describes the syphilides as "sharply defined, dense and uniform (cellular) infiltrations of the papillary body and corium, that differ from one another only in size. These cells are not fitted to undergo permanent organi- zation (into connective tissue), but always undergo involu- tion and disappear either by absorption or purulent degenera- tion. The syphilitic infiltration of the skin always enlarges and disappears in the same direction, viz., centrifugally. Hence the peripheral parts are relatively the most recent and exhibit all the characteristics of the fresh infiltration. Diagnosis op Syphilis. 49 The oldest parts are in the center and are the first to dis- appear." The two chief characteristics of the syphilides are hyper- emia and cellular infiltration. Hyperemia is found especially during the first two years of the disease. Some cellular infil- tration may be found during the early months of the disease, in the superficial layers of the skin, and later in the deeper layers. Syphilides occur as macules, papules, pustules, bulla?, and tubercles, and these lesions are modified by pigmentation, scaling, crusting, ulceration and cicatrization. As a rule the general symptoms are not marked during the second stage of syphilis. The syphilitic fever appears with the syphilitic roseola, as the most common general symptom of syphilis during the second stage. Sometimes a marked eruption is preceded by slight fever, loss of appetite, pains in the muscles and bones, and lateral headache. At the time of the eruption of syphilides, we may find: The initial lesion; or, if it has healed, the induration or scar, where the chancre existed. Induration of the glands in the region of the primary inoculation. Adenopathy in various parts of the body, especially the cervical and epitrochlear glands. Syphilitic alopecia. Mucous patches, especially about the anus, genitalia and mouth. Later in the second stage, especially after the first year, there may be: Pains in the bones. Bone lesions. Permanent alopecia. Cicatrices, and other symptoms of syphilis. The color of the syphilides varies greatly, depending upon the stage of the eruption and upon the complexion 50 Diagnosis of Syphilis. and health or cachexia of the patient. At first the early eruptions are usually a pinkish red, fading later to a yellowish or reddish brown ; or the eruption may have this color at first. The papular eruptions are usually a brownish red, the so-called copper or raw ham color. In the presence of poor circulation, blood stasis, which is found especially' in the lower extremities, the color is often a bluish or dull liver red. In general, blondes show a brighter and redder color ; brunettes, brownish colors ; and in the presence of cachexia the color is more likely to be livid or bluish red. The pigmentation left varies from light brown to almost black. The brownish pigmentation of the syphilitic scars fades gradually, to leave later a white glistening scar. During the early stages of syphilis, especially during the first year, we frequently find a great variety of lesions; macules, papules, pustules, crusts and scabs occur frequently side by side or in different parts of the body at the same time. The multiplicity and variety of these lesions speaks for sj-philis, especially during the first j-ear. In later years these features are not so marked. An important factor in the diagnosis of syphilis is found in the method of evolution of the disease. The sequence of chancre, syphilides and gummata is well recognized. A new set of lesions often develops before the disappearance of a pre- ceding set. In general, the syphilitic eruptions develop more slowly than the simple inflammatory affections of the skin. Syphilitic lesions often remain for a long time, when the patient is not under specific treatment. The early eruptions of syphilis are usually rounded in form and tend to group in circular patches or curved lines. This is especially true of the small papular syphilides. The large papular and tubercular syphilides often show a circular or crescentic arrangement, due to the lesion clearing up in the center and spreading at the periphery. The earlier eruptions are usually more symmetrical and more widely and evenly distributed than the later manifestations of the disease. Usually syphilitic lesions are characterized by little or Diagnosis of Syphilis. 51 no pain, or itching. Where the syphilides develop rapidly, as in the papular and pustular syphilides of the scalp and the genital mucous patches, there may be marked itching. And where there is more or less constant friction and irritation, as in lesions of the mouth and genitals, and sometimes ulcer of the leg, pain may be a prominent symptom. Falling of the hair may be caused by syphilitic involve- ment of the scalp and other hairy parts, or through disturb- ance of nutrition due to the syphilitic infection. There may be a defluvium capillorum or an alopecia, which may involve not only the scalp but also the eyebrows, eyelashes, and the hair of the axillas and pubes. Not infrequently falling of the hair in syphilitics is due to the ordinary seborrhcea sicca. Falling of the hair, except when due to the presence in the scalp of macular, papula or gummata, is of little value in the diagnosis of syphilis, save as a symptom fre- quently found in the infections and in depraved conditions of the general nutrition. Affections of the nails, notably onychia and paronychia syphilitica, are usually confined to single toes or fingers, but may be multiple. Palmar and plantar syphilides may be accompanied by dullness, discoloration, irregular deformities, splitting and splintering of the nails. The so-called mucous patches are really papular eruptions upon mucous membranes. These are most frequently lo- cated on the lips, cheeks, tongue (especially the border and tip), soft palate, the lingual and faucial tonsils, and the posterior wall of the pharynx. In the presence of cleanliness, the mucous patches disappear in from two to four weeks without leaving a trace. In the absence of cleanliness, more particularly when irritated by tobacco, decayed teeth, etc., they may persist for months, and frequently recur. Mucous patches may occur upon any mucous membrane. The affection of the mouth has been emphasized at this time, because stomatitis and sore throat are prominent symptoms of syphilis in the second stage. Affections of the eye are of diagnostic value during the 52 Diagnosis of Syphilis. second stage of syphilis, especially iritis, keratitis, and affec- tions of the optic nerve. Sometimes affections of the ear assume importance in diagnosis at this time. Occasionally there is epididymitis and parotitis. The importance of examinations for the spirochete pallida, and the Wassermann reaction, during the second stage of syphilis, can not be overestimated. Third Stage. The more prominent symptoms of the third stage of syph- ilis are skin eruptions, gummatous growths in the viscera, and amyloid degeneration. The gumma is the characteristic lesion of the third or tertiary stage of syphilis. This stage of the disease is not preceded by prodromal or general symp- toms. The gummata differ markedly from the secondary lesions in that they are not regularly or symmetrically dis- tributed. Usually they seem to prefer one side of the body. They may appear first in the skin and mucous membranes, or in the joints, or in the viscera. At first the gummata may feel elastic to the touch ; later they are harder. They show a marked tendency to degeneration. The subcutaneous and submucous gummata tend to undergo mucoid degenera- tion ; those in the glandular organs, liver, testes, and in the brain or muscles, tend to undergo fatty degeneration. Gummata may appear as earl}' as four or five months or as late as two or three decades, most frequently three or four years after the primary infection. They seem to prefer the face, scalp, shoulders, neck, arms, thighs and legs ; but no part of the body is exempt. Clinically, there are four periods in the life of a gumma: Formation, softening, ulcera- tion and repair. Gummata vary in size from one to four or five centimeters, usually not exceeding two centimeters, in diameter. The name is derived from the peculiar rubbery elasticity of the tumors and their gummy contents. At first the overlying skin appears normal. During the period of softening, the gumma becomes doughy and there may be Diagnosis of Syphilis. 53 fluctuation. The overlying skin becomes reddened, thinned, and finally ulceration occurs, to permit the gradual escape of the gumma through the perforation. Repair takes place by the deposition of granulation tissue, beginning in the bottom and gradually filling the cavity. The general shape of the cavity is rather conical, the apex of the cone being at the perforation, and the base in the deeper tissues at the bottom of the cavity. Cicatrization leads to more or less depression and adhesion to deeper structures, often binding skin and bone together. The spirochete pallida may be found in tertiary syphilis, but the examination is much more difficult in this stage than during the first and second stages of syphilis. The Wassermann reaction may be found in the third stage of syphilis. The reaction may be absent when the process is quiescent, or when the patient receives vigorous anti- syphilitic treatment. MANIFESTATIONS ON THE PART OF VARIOUS ORGANS. Skin and Mucous Membranes. We have already paid attention to the primary lesion, chancre. At this time we will consider especially the second stage of syphilis, as manifested by syphilides in the skin and mucous membrane. The more important syphilides are: 1. Macular syphilide. 2. Pigmentary syphilide. 3. Papular syphilide. A. Dry papules. a. Lenticular papules. b. Giant papules. c. Miliary papules. B. Moist papules (condylomata). 54 Diagnosis of Syphilis. 4. Variations of the papular syphilide: a. Vesicular syphilide. b. Hemorrhagic syphilide. c. Squamous syphilide, and d. Pustular syphilide. We will take these up more in detail. Macular Syphilide. Syphilis cutanea maculosa, maculae syphilitica?, commonly known as the syphilitic roseola or erythema, may be the first objective symptom of the second stage of syphilis. This erup- tion appears about forty days after the initial lesion, sometimes later, and especially during the first year of syphilis. The appearance of this eruption is too well known to merit descrip- tion. The recognition of the syphilitic nature of the eruption is usually favored by the presence of the initial lesion and indolent buboes. The syphilitic roseola may resemble the roseola of some of the acute exanthemata, notably measles and rotheln. The acute exanthemata show high fever witli the eruption, or preceding the appearance of the exanthem ; and the eruption is usually most marked in the head and face, which are not favorite localities of the syphilitic roseola. Furthermore, there is usually a difference in the appearance of the eruptions. Usually an early recognition of the exan- themata is afforded by the appearance of the enanthem. A use- ful diagnostic point is the fact that cold makes the eruption plainer in syphilis, whereas similar non-syphilitic erythematous eruptions are blanched by cold. The macular syphilide seems to prefer the chest and abdomen, the upper extremities and neck, and is more prominent upon the flexor surfaces. It spares the back of the hands and the dorsal surfaces of the feet, and is rarely found upon the face. After a week or ten days the eruption fades, the evolution being hastened by mercury. Itching, pain and constitutional symptoms are slight or entirely absent. Diagnosis op Syphilis. 55 At the time of the appearance of the macular syphilide, there may be concomitant symptoms of syphilis, such as evi- dence of the existence of the primary lesion, adenopathies, crusts and papules, especially upon the scalp, falling of the hair and eyebrows, mucous patches on the tongue, lips, fauces, and around the anus, and possibly the history of headache, and pains in the bones and muscles. The macular syphilide must be differentiated from : 1. Measles, in which the eruption appears first upon the face and neck, and blanches upon exposure to cold ; there is catarrh, especially of the respiratory tract; cough, and a characteristic fever and enanthem. 2. Rubella (Rtitheln, German measles, French measles), distinguished by its mildness, the absence or slightness of prodromata and fever, the enanthem, the diffuse, rose-red rash, and the enlargement of the cervical lymphatics early in the course of the disease. Prefers youth, from five to fif- teen years. 3. Scarlet fever, in which the punctate hyperemia appears first upon the neck and chest, to involve later the extremities ; and there is a fairly characteristic fever and enanthem. 4>. Drug eruptions. The use of mercury, internally -or externally, is sometimes followed by a bright red eruption. This eruption, however, is usually confined to certain spots and is accompanied by burning and itching, and an eruption of minute vesicles. A roseola balsamica sometimes follows the internal use of copaiba, cubebs, santal oil, and the various balsamic prepara- tions. The eruption in these cases is usually characterized by rounded or irregular bright spots separated by appar- ently normal skin. There is great burning, itching and the formation of extensive urticaria. There is often disturbance of the stomach. These eruptions usually seem to prefer the dorsum of the hands and feet and the regions of the joints. The drug eruptions disappear upon discontinuing the offend- ing drug. 56 Diagnosis of Syphilis. 5. Urticaria. This eruption is characterized by the formation of wheals, and the presence of marked itching. The period of evolution is short, the urticaria appearing and disappearing in a comparatively short time. 6. Tinea versicolor. This eruption will rarely cause difficulty in diagnosis. It tends to spread peripherally, is usually fawn-colored and scaly and prefers the uncleanly. In case of doubt, the microscope will reveal the characteristic parasite in scrapings from the skin. 7. The non-syphilitic eryihemata are rarely diffuse, change their form and shape, are of a brighter color, undergo a more rapid evolution, and do not give the history of syphilis. Erythema iris and annulare occur with special frequency upon the backs of the hands and feet, where we do not so often find the roseola of syphilis. The erythema disappears in about two weeks without treatment. 8. Tinea circinata may be recognized by the presence of the trichophyton in the scales and hair. 9. The fresh scars left by a recent attack of smallpox have been mistaken for the roseola of syphilis — a mistake that seems scarcely justifiable. 10. The bluish maculae produced by pediculi pubis may be explained by finding the nits or the insect upon the pubes. 11. Cutis marmorata livida and the various angioneurotic eruptions do not show the same course as syphilis. Pigmentary Syphilide. In some cases pigmentation assumes prominence, and this fact has led some writers to describe a pigmentary syphilide. The color of the pigmentation varies from a light yellowish brown to a dirty gray. It is not a common form of syphilide, and is found mostly in women, especially upon the sides of the neck, occasionally upon the face, forehead, and exceptionally upon the chest, trunk and thighs. It seems to affect the latter regions more frequently when it attacks males. The pigmentary syphilide is found most frequently during the first Diagnosis of Syphilis. 57 year, though it may occur during the second year or even later. The pigmentation remains for months or years. At first the pigmentation is evenly distributed over the affected area, but later white spots appear and gradually increase in size until the pigmentation appears only in wavy lines, giving the appearance of a piece of lace with large uneven meshes. Differential diagnosis calls for separation from: 1. Chloasma, usually found upon the face, which is rarely the seat of the pigmentary syphilide. 2. Vitiligo and leucoderma, which are not so symmetrical as the pigmentary syphilide. 3. Tinea versicolor, usually scaly and sometimes causes itching ; appears especially over the front of the chest and abdomen, regions that are not so often affected by the pig- mentary syphilide. Doubtful cases may be settled by the microscope. Papular Syphilide. A — The syphilitic papular eruption appears as (1) Dry papules, the usual form on the trunk and exten- sor surfaces of the extremities, may occur as — Lenticular papules, giant papules, and miliary eruption, lichen syphiliticus. (2) Moist papules, papulas humidae, condylomata, occur especially about the external genitals, the genitocrural fold, the perineum, anus, depression of the navel, the axilla?, beneath a pendulous breast, between the toes, the furrow of an ingrow- ing toenail, and in the external auditory canal in the pres- ence of moisture (otorrhcea), or in any part of the body that is kept moist and macerated. B — Variations of the papular syphilide: (1) Vesicular syphilide. (2) Hemorrhagic syphilide. 58 Diagnosis of Syphilis. (3) Squamous syphilide, and (4) Pustular syphilide. A papular eruption rarely develops from the syphilitic macules. More frequently the papules follow a roseola. A slight fever may precede the papular eruption. The papules may be classified according to size, as small or miliary papular syphilides, and large or lenticular syphilides. The color of the papular eruption varies, at first reddish, later becoming more of a dark blue or brownish color ; or the papule may present little change in color from the surrounding parts. Depending chiefly upon the location of the eruption, the papules may be dry or moist. The dry papules, which occur mostly on the trunk and extensor surfaces of the extremities, undergo retro- grade changes and desquamation, to gradually disappear in a number of weeks, leaving sometimes a discoloration of the skin that fades in the course of a few weeks. Often these spots are marked by an absorption of pigment that may persist for months or years. The lenticular papules are the more frequent of the two forms of the papular eruption in syphilis. Small Acuminate Papules. Should be differentiated from: 1. Scabies, which causes intense itching, presents a peculiar history, scratch marks, burrows ; and the insect may be demonstrated. 2. Lichen planus is characterized by larger papules, which are umbilicated, more deeply pigmented, and itch intensely. 3. Lichen pilaris has pale papules, not arranged in groups, located over a hair follicle, and with greater tendency to scale. 4. Lichen scrofulosum is comparatively rare and prefers childhood ; characterized by pale yellow papules, that disappear without marked pigmentation ; usually confined to the trunk. 5. Punctate psoriasis is more scaly than this form of syphilide ; spreads from the periphery, and bleeding may be Diagnosis op Syphilis. 59 caused by scratching. Psoriasis frequently involves the scalp and is found over the knees and elbows. The spots are large, covered with dense white scales. Larger papules, from the size of a pea to that of a bean, the so-called giant papules, are regarded as an unfavor- able early eruption. Still more unfavorable, from the standpoint of prognosis, is the small or miliary syphilitic eruption, the lichen syphil- iticus. These small papules usually persist longer than the lenticular papules. And it is the rule for them to leave a scar. The papular syphilide may show many variations, e. g., vesicular, hemorrhagic, squamous and pustular syphilides. A papular eruption on the palmar surfaces of the hands and the plantar surfaces of the feet is sometimes one of the early symptoms of the second stage of syphilis. These surfaces usually present a circumscribed erythema and flat infiltrations, rather than raised papules. Later, desquamation is prominent over these surfaces. As a rule, this eruption is bilateral, affect- ing both hands, or both feet, or both hands and feet. The papular eruption in these localities runs a slow course, con- stituting the affection known as psoriasis palmaris or plantaris. Not infrequently the flexor surfaces and the nails are involved, and the rhagades and fissures are painful. Islolated papules in thickly calloused parts may present striking appearances ; on the feet these may at times resemble a beginning perforat- ing ulcer. Moist papules, papula? humida?, occur especially about the external genitals, the genitocrural folds, the perineum, anus, the depression of the navel, the axilla?, beneath a pendu- lous breast, between the toes, in the furrow of an ingrowing toenail, in the external auditory canal in the presence of otorrhoea, or in any part of the body that is kept moist and macerated. These papules attain a larger size, as a rule, than the dry papules, sometimes reaching the size of a silver dime, or larger. The fact that these papules are broad and flat has led to the term condylomata lata. Often these papules, through maceration, secrete considerable pus, which 60 Diagnosis of Syphilis. led the older writers to refer to them as pustula foeda. Not infrequently the flat papules coalesce, e. g., in condylomata of the anus, so that the diagnosis is based largely upon the examination of the finger-like projections. Breaking down of the moist papule ma} 1 occur, to constitute the ulcerated papule or syphilitic ulcer. Squamous Syphilide. Should be differentiated from: 1. Tinea circinata. 2. Psoriasis vulgaris. 3. Lichen rubor planus, -i. Eczema. 5. Molluscum contagiosum. 6. Arsenical keratosis. 7. Tyloma, the ordinary callus. 8. Venereal papillomata. These affections would not present the spirochete pallida nor the Wassermann reaction, except in the presence of a concomitant syphilitic infection. 1. The squamous syphilide may resemble somewhat tinea circinata or a patch of psoriasis. In a case of doubt, micro- scopic examination would reveal mycelia in tinea. It is rare that any confusion will arise between ringworm and syphilis. Psoriasis is more often puzzling. Psoriasis vulgaris more frequently affects the scalp and the extensor surfaces of the extremities, less frequently the palmar and plantar surfaces, when the affection has become general. 2. In psoriasis vulgaris the scales are broadly lamellated and frequently heaped up, contrasting with the fine lamellation of the papular syphilide. Furthermore, in syphilis pigmenta- tion is the rule; in psoriasis vulgaris pigmentation is infre- quent. In the rare cases of a spot or spots of psoriasis vulgaris on the genitals, the dry, smooth surface and gleaming redness of the eruption are quite different from the appearance of the syphilitic eruption. Diagnosis of Syphilis. 61 3. Lichen rubor planus, especially of the genitals, may be confusing. This eruption is composed of small, tough, waxy, shining nodules with a central depression, arranged in groups; there is itching in many cases that is often intense; and the eruption persists for a long time. After disappearance of the nodules, there may be a bluish patch of pigmentation left, that is not infrequently adjoined or surrounded by another crop of the nodules. Desquamation is slight, vesicles and pustules do not form, and any ulceration is the result of acci- dent. Lichen is exceptionally found upon mucous membranes. 4. Not infrequently patients come to us with an eczema, especialty of the palms, under the impression that it is a palmar syphilide. There is some resemblance when the eczema is desquamating. But eczema is characterized by itching, and observation for a few days will reveal the formation of little millet-seed vesicles. 5. Molluscum cotagiosum presents a firm, slightly umbili- cated, shining yellowish nodule, with creamy contents. 6. Arsenical keratosis and 7. The ordinary callus, tyloma, need only be mentioned. 8. Venereal papillomata are not syphilitic, but may conceal syphilitic papules, in the presence of which they have a tendency to grow luxuriantly. Tubercular Syphilide. Differentiate from: 1. Large papular syphilide appears earlier and undergoes evolution more rapidly ; retrogresses differently, flattens and desquamates, or may desquamate repeatedly. On the other hand, the tubercular syphilide shows a distinct tendency to remain globular in shape, does not erode, and undergoes reso- lution to leave pigmentation. 2. Palmar psoriasis is usually found associated with psori- asis in other parts of the body. True psoriasis is rare on the palms. 3. Palmar eczema presents scaling, Assuring, burning and 62 Diagnosis of Syphilis. itching, and a serous exudation. Eczema tends to extend beyond the palms, and the edges of eczematous patches are not so well defined as in the tubercular syphilide. 4. Lupus vulgaris, especially of the face, may be confus- ing. Both affections may occur in the same localities ; both may undergo interstitial atrophy and disappear without ulceration ; both may extend at the edges to run a serpiginous course. Lupus usually appears before puberty and runs a slower course than the tubercular syphilide. As to color, lupus is more of a pink color, the outlines are not so well defined, and the inflammation about the tubercles shades off gradually. In lupus the ulcers are not so painful and bleed easily, and the secretions and crusts are less abundant. Lupus heals more slowly, and the scars are puckered, thick and hard, differ- ing from the smooth, sliining and often depressed scars of syphilis. In some locations the differential diagnosis is very difficult in some cases, for instance, upon the nose. Lupus usually begins on the outside, whereas syphilis may begin in the bone; lupus may destroy the cartilage, but rarely attacks the bone, whereas syphilis often shows a distinct pref- erence for the bone. Syphilis is more prone to be accom- panied by ozena. 5. Acne rosacea tuberosa shows less clearly defined nodules, situated in an area of thickened and reddened epidermis among dilated capillaries, and does not present the destructive changes of sj'philis. The syphilitic lesions are smoother, more glassy, firm and clearly marked in outline. 6. Epithelioma is usually single, the edges are hard and everted, the base is often granulating and fungous, the disease prefers the aged, and is accompanied by adenopathy and cachexia. 7. Tubercular leprosy, especially upon the forehead, face and ears, may resemble syphilis. The leprosy tubercles usually show a distinct anesthesia of the center, extending often over a small area around it. The tubercular syphilides are not so large and protuberant, and are harder. Diagnosis of Syphilis. 63 Tubercular Syphilide. 1. Occurs after puberty. 2. The lesions are opaque, of a deep brownish red color. 3. Ulceration occurs within a month or two, the ulcers hieing usually distinct, deep, circular, with perpendicular edges. 4. The secretion is abundant, often offensive. Large greenish crusts. 5. The scars are smooth, shining, often depressed, soft, white, circular. 6. The tubercles are distinctly circumscribed. 7. More painful and less inclined to bleed than lupus. 8. History and further evidence of syphilis may aid in diagnosis. 9. Anti-syphilitic treatment spe- cific. Local treatment of compara- tively little value. 10. Upon the nose, syphilis usu- ally begins in the bone, and shows a distinct preference for bone. More prone to cause ozena. 11. Spirochete pallida may be found. 12. Wassermann reaction pres- ent. Lupus Vulgaris. 1. Usually begins before puberty. 2. More translucent and of a pink color, with outlines not so well defined. 3. Ulcers develop more slowly, requiring several months or longer, and the ulcers are more often con- fluent, shallow, irregular in form. 4. Slight inoffensive secretion. Thin, dark colored crusts. 5. The scars are puckered, dis- torted, irregular, thick and hard. 6. The inflammation about the lupus nodules shades off gradually. 7. The ulcers are not so painful and bleed easily. 8. It should be remembered that syphilitics are not exempt from lupus. 9. Tuberculin specific. Local treatment important. 10. Lupus usually begins on the skin, may destroy the cartilage, but rarely attacks the bone. 11. Spirochete pallida absent, except in the presence of syphilis. 12. Wassermann reaction absent, except when there is a co-existing syphilis. Pustular Syphilide. Should be differentiated from: Smallpox. Acne vulgaris. Acne frontalis seu varioliformis (F. Hebra). Acne necrotica (C. Bceck). Acne cachecticorum. These affections do not show the spirochete pallida, nor the Wassermann reaction, except when they occur in syphilitics. Pustular syphilides result from infection of the papular syphilides by the ordinary pyogenic micro-organisms. In all these cases I have examined, the staphylococcus pyogenes aureus was the organism of secondary infection. The staphyl- ococcus pyogenes albus has also been reported. 64 Diagnosis op Syphilis. The pustular syphilitic eruption may resemble smallpox. Both diseases have an eruptive fever, which is, however, usually more intense in smallpox. Usually the diagnosis is made through associated symptoms. The occurrence of small- pox in a syphilitic patient may be intensely interesting. Acne vulgaris may at times resemble acne syphilitica, but the two affections run entirely different courses. More difficult to differentiate is acne frontalis seu varioliformis (F. Hebra) and acne necrotica (C. Baeck). These are re- garded by some as identical or related forms of acne. They may persist for a long time and leave scars. Differential diag- nosis often must rest upon accompanying symptoms. Acne cachecticorum is often accompanied by other symptoms, es- pecially caries of the bones and joints, multiple adenitis, and other symptoms of a depraved constitution, which may be found in grave cases of syphilis. Furthermore, this acne may occur in a patient that has or has had syphilis. In such cases the differential diagnosis will depend upon con- comitant symptoms and the result of treatment. Pemphigus serpiginosus may at times resemble rupia syph- ilitica, but the former does not show the same ulceration and maceration of the skin that we have in syphilis. The ulcer may closely resemble the gummatous ulcer. Yaws. Many observers believe yaws to be a form of syphilis, modified by race and climate. The spirochete pertensis, be- lieved to be the cause of yaws, bears a marked resemblance to the spirochete pallida, of syphilis. Silver stained specimens can scarcely be distinguished. In yaws, the spirochetes are found most abundantly in the superficial layers of the lesion, especially in the fibrinous crust among the leucocytes and the degenerated epitheliub, less abundantly in the spithelium about the ulceration, and only rarely in the papilla. In the pri- mary sore of syphilis, the spirochete pallida seems to prefer the connective tissue and the neighborhood of blood vessels. Diagnosis op Syphilis. 65 In the initial lesion of yaws, the epithelium shows greater hypertrophy than in chancre. Polymorphonuclear leucocytes are found in greater abundance in the lesion of yaws ; the plasma cells are more generally distributed and do not show the vascular distribution noted in syphilis. There are fibrinous exudates in yaws, and few or none of the vascular changes, save a simple dilatation. SYPHILITIC AFFECTIONS OF THE DIGESTIVE ORGANS. Mouth, Including Tongue and Tonsils. The initial lesion occurs, in the order of frequency, upon the lower lip, the upper lip, the tongue, the mucous membrane of the buccal cavities, the palatal arches, and the tonsils. The neighboring lymphatic glands, especially the submental and submaxillary glands, later the superficial and deep glands of the neck and nucha, are extremely enlarged, compared with the size of the lesion. The glands are firm, whereas tubercu- lous glands often show some softening. The glands are usually indolent buboes, although at times sensitive patients complain of some discomfort from them. Especially when located upon the lips or tongue, the primary sore may markedly interfere with speech, mastication and deglutition. Even in these cases the pain is usually not great ; there is a disagreeable tension rather than pain. Still less disturbance of function may be caused by a primary lesion upon the arches of the palate or the tonsils, unless the lesion is large, when deglutition is inter- fered with and speech becomes palatal and nasal in character. Oral chancre should be differentiated especially from: 1. Chancroid and cancer. 2. Lingual chancre may resemble: — 3. Cancer. ' 4. Parenchymatous glossitis. 5. Tuberculous ulcer, or traumatic ulcer. 66 Diagnosis of Syphilis. Mucous Patches. These must be diffentiated from: 1. Trauma. 2. Cauterization, use of strong gargles, etc. 3. Simple catarrhal angina (after the patch sheds the whitish coat). 4. Leucomata. 5. Aphtha. 6. Simple rashes. 7. Warty growths (especially upon the tongue). 8. Lingua geographica. 9. Diphtheria. Gummata. Should be differentiated from: 1. Cancer. 2. Tuberculosis. 3. Chancre. 4. Leucoplakia and 5. Decubital glossitis. It is not always easy to differentiate the primary sore of syphilis in the mouth from chancroid, since the induration of the base of the ulcer may be absent, especially in old and decrepit patients. Usually chancroid shows multiple lesions, whereas the primary lesion of syphilis is usually single. The lymphatics are usually painful in chancroid and more fre- quently suppurate than in syphilis. Further, the primary sore is sooner or later followed by the secondary symptoms of syphilis. Especially upon the lips, at the junction of the skin and mucous membrane, the initial sore presents an irregu- lar appearance, partaking both of the nature of the lesion in the skin and in the mucous membrane. In such cases it may be important to make a differential diagnosis from cancer. Such a differentiation may also become important in an initial Diagnosis of Syphilis. 67 lesion of the palate or tonsillar region, when the advisability of pharangotomy would be discussed in the case of cancer. Mikulicz and Kiimmel mention such a case that terminated fatally. Upon the tongue, the primary sore is most frequently located upon the anterior part of the dorsum, less commonly on the tip, sides, or underneath. Two forms may be distin- guished, the smooth and the ulcerated. Less common are the fissured sores, found especially in smokers. Sometimes there is marked induration resembling cancer or parenchyma- tous glossitis. Usually the glands upon the same side are most involved ; rarely the glands upon the opposite side are most affected. However, these variations in the affections of the lymphatics are due to their anastomoses, and may be observed in other diseases, notably in cancer. The rapid appearance of the sore, the induration, the enlargement of the lymphatics, and the secondary symptoms of syphilis, especially the rash, are usually sufficient for diagnosis. Before the appearance of the secondary symptoms, syphilis of the tongue may be mistaken for a traumatic or a tuberculous ulcer. LIPS. Chancre. 1. There may be the history of exposure to syphilis. 2. Odor not marked. 3. May involve either lip. 4. Affects either sex. 5. Any age, but occurs especially during adolescence. 6. General health may be good. 7. The lesion is characterized by little or no pain. 8. Chancre usually presents a regular outline, smooth surface, and the base is sharply circumscribed and presents the characteristic car- tilaginous feel. Epithelioma. 1. No such history necessary. There is frequently the history of exposure to cancer. 2. Odor offensive; may be less marked under proper treatment. 3. Usually upon lower lip. 4. Distinct preference for males. 5. Rare before middle life. 6. General health usually im- paired. 7. The patient usually complains of pain, which may be sharp, burn- ing, or lancinating. 8. Epithelioma is irregular in outline, usually ragged and bleeds easily, and the base is less circum- scribed, more extensive, and does not feel so cartilaginous as in chan- cre. 68 Diagnosis of Syphilis. 0. Chancre develops in a number of days or weeks. 10. The neighboring lymphatic glands are involved early. 11. Mercury hastens the disap- pearance of chancre. 12. Microscopic examination of the secretion may reveal the spiro- cheta pallida. The microscopic ex- amination of a section of tissue shows the structure of chancre, that is not pathognomonic, but differs markedly from epithelioma. 13. Spirochete pallida present. 14. Wassermann reaction not present before the sixth week after infection. 0. Epithelioma may develop rap- idly, but usually requires months. 10. The neighboring lymphatic glands are usually not enlarged un- til after the first three or four months, or longer. 11. Mercury does not benefit epithelioma; may be deleterious. 12. Microscopic examination re- veals endocytes and the character- istic cancer pegs and nests. There is a distinct ingrowing of the epi- thelial cells. 13. Spirochetes have been ob- served, but not the spirochete pal- lida.* 14. Wassermann reaction absent, except when there is a concomitant syphilis. * Spirochetes have been found in ulcerating carcinoma, but they dif- fer from the spirochete pallida found in syphilitic lesions. (Vorkom- men von Spirochivten bei ulcerierten Carcinomen, E. Hoffmann, Berliner klinische Wochenschrift, xlii, Xo. 27.) Among the most characteristic secondary lesions are the mucous patches (plaques opalines, plaques nuiqueuses, or broad condylomata). These have been described as resembling spots produced by touching with the stick nitrate of silver. Usually they are more delicate than this description would indicate. The whitish coating of the patches may not be detached with- out causing bleeding. The base is reddened and swollen. In size the patches may exceed that of a quarter; but they do not seem to enlarge while under observation, as a rule. In general, the largest patches are upon the tonsils and palatal arches, next at the angles of the mouth, and usually smaller upon the mucous membrane of the cheek and lips and the edges of the tongue, and still smaller on the surface of the tongue, the floor of the mouth, and the alveolar processes, and smallest at the base of the tongue, where they may occur in miliary patches. This also represents approximately the order of frequency, the tonsils, palatal arches and the uvula being most frequently affected. The patient may complain of no symptoms ; or there may be more or less burning during Diagnosis of Syphilis. .69 deglutition, or interference with speech, especially when the tongue is involved. Especially when the ulcers present an atypical appear- ance, they may resemble the simple ulcers due to pressure. But there is not the characteristic induration. Further- more, the history would be of value, which would probably be sufficient to rule out trauma or cauterization and the use of strong gargles, etc., that might produce similar appear- ances. Later, with the disappearance of the whitish coating, the ulcer may resemble a simple catarrhal angina. In all of these cases, it is important to remember that enlargement of the lymphatics would speak for syphilis. The metastases cause disturbance that is slight in proportion to the size of the glandular masses. In doubtful cases, the therapeutic test may be made. Anti-syphilitic treatment may make the diagnosis more difficult for a time, since the patches at first may continue to develop and become thicker, more ragged and lardaceous. It must be remembered that the mucous patches occur in secondary and in hereditary syphilis. No age is exempt. Mercurial ulcers depend upon the use of the drug. Of more importance is the differentiation from leucomata, aphthae, and rashes and warty growths (especially upon the tongue). The whitish mucous patches are not so trans- parent as the bluish-white patch of leucoma. Upon the tongue, the mucous patches occur especially upon the borders ; leucoma prefers the dorsum. Ulceration is more marked in mucous patches than in leucoma. The thick, raised, leucomas, which most resemble mucous patches, are usually harder and dryer. Furthermore, leucoma usually runs a much more protracted course than the mucous patches. The presence of other symptoms of syphilis may make the diagnosis, or hinder it, in cases of leucoma occurring in asso- ciation with syphilis. Aphtha also presents white patches. Aphtha occurs in children and the debilitated ; syphilis more frequently in adults and those who are not in bad health. In syphilis there may be other symptoms of the disease. Doubt- ful cases may be cleared up by the use of the microscope. 70 Diagnosis of Syphilis. Lingua geographica will rarely be confused with mucous patches. The general gray color of the tubercle and its greater elevation above the surrounding tissue, are charac- teristic. Diphtheria may be definitely ruled out by making a culture, and the presence of the fever and general symp- toms of that disease. The presence of the ordinary warts in the mouth, especially upon the tongue, may at times be confusing. These are more common on the dorsum of the tongue, and are not affected by antisyphilitic treatment. The therapeutic test would not be thought of, save in the pres- ence of other symptoms of syphilis, which may make the diagnosis. In the third stage of syphilis, the tertiary lesions of the mouth involve especially the hard palate, the soft palate, and the tongue. This is the stage of gummata. Syphiloma of the hard palate usually occurs at the thinnest part of the bone, as a rule near the median line, and frequently causes perforation. The process of perforation may require weeks or months. Usually a sequestrum is thrown off before heal- ing occurs. The throwing off of the diseased bone is a slow process, requiring two months or longer under good treat- ment. A syphiloma upon the gums or alveolar process may ulcerate and cause the formation of a sequestrum. Even small perforations of the hard palate cause considerable difficulty, since fluid and food escape through the nose, and air passing through the perforation may affect the speech. Sometimes it is possible to prevent perforation of a gumma of the hard palate by instituting energetic anti-syph- ilitic treatment. Gumma of the soft palate rarely comes under observation before ulceration. Differing from gumma of the hard palate, in which a single gumma is the rule, in the soft palate the gummata are more often multiple, being scattered over both palatal arches or tonsils and frequently involving the base of the uvula, causing considerable deformity of the pharynx and the nasopharyngeal space. The gummata are often large in this region, and the inflammatory sj'mptoms are Diagnosis of Syphilis. 71 often pronounced. Often there is great destruction of tissue, and not infrequently there is perforation of the soft palate. Later, with cicatrization, there is great deformity. From this description of gumma of the soft palate, it must be evident that there is marked interference with speech in these cases. This is often an early symptom. The infiltration of the soft palate causes nasal speech, and also permits the regurgitation of food, more especially of fluid, into the nasopharyngeal space during deglutition. Tertiary Syphilis of the Tongue. Tertiary sclerosing glossitis may be superficial (cortical), or deep (parenchymatous), or generalized (syphilitic macrog- lossia). Should be differentiated from: 1. Indurated chancre. 2. Psoriasis. 3. Smokers' tongue. 4. Dental glossitis. 5. Epithelioma of the tongue. Tertiary syphilis of the tongue also appears as : (a) Syphilitic atrophy of the lymph gland follicles at the base of the tongue, behind the lingual V. (b) Nodes and nodules of various size, the result of the contraction of old syphilitic lesions. (c) True gummata of the tongue, superficial or deep. Deep gummata of the tongue must be differentiated from: 1. Fatty tumors. 2. Fibrous tumors. 3. Carcinoma. 4. Chronic abscess. 5. Embedded foreign body. More rarely the tertiary lesions involve the tongue. A preference is shown for males. The affection known as syphilitic plaques and sclerosing glossitis, is probably more 72 Diagnosis op Syphilis. common than the reported cases would indicate. Fournier states that the tertiary plaques precede and cause the deep fissures and furrows not infrequently observed in old syphilitics. Tertiary sclerosing glossitis may be superficial (cortical), or deep (parenchymatous). Superficial sclerosing glossitis is a superficial induration in the derma of the mucous membrane. These plaques may be single, islolated, multiple or confluent. Usually the spots are not painful. The affection is chronic, and finally leaves white patches. The so-called deep or paren- chymatous scleroses are usually both deep and superficial, though they may be limited to the deeper parts. At first they cause swelling on the dorsum of the tongue, which later atrophies. The lobulation of the dorsum of the tongue in these cases has been compared to the liver in cirrhosis. This mammilated, lobulated appearance of the tongue is quite char- acteristic. Usually the dorsum is the part affected, but the borders are not exempt. Deep induration may resemble cancer. The mucous membrane becomes wine-red and smooth. Erosion and ulceration of the furrows and fissures may occur. In generalized sclerosing glossitis, which is comparatively rare, the tongue is swollen and hard, constituting the so-called syphilitic macroglossia. The sclerosing inflammations of the tongue are chronic, and untreated they tend to break down and ulcerate, though the ulcers are rarely deep nor difficult to heal. The lymphatic glands are usually not involved, save possibly in the presence of inflamed and ulcerated plaques. Sclerotic glossitis is not likely to be mistaken for indurated chancre, psoriasis, smoker's tongue, dental glossitis, nor epithelioma of the tongue. Should any of these affections be resembled, the presence of other signs of syphilis will be of aid in making a diagnosis of that disease, though these various affections and syphilis may co-exist. In cases of doubt, the therapeutic test is justifiable. Syphilitic atrophy of the lymphatic gland folicles of the base of the tongue, behind the lingual V, was described by Virchow, 1863. The epithelium is apparently normal in these cases and there is no small-cell infiltration. Diagnosis op Syphilis. 73 Nodes and nodules may appear as lumps of various sizes and shapes, produced by the contraction of old syphilitic lesions ; or there may be true gummata. Gummata of the tongue may be superficial or deep (parenchymatous). Males are most frequently affected, usu- ally four or five years after the first stage of the disease. Superficial gummata of the tongue appear especially upon the dorsum, rather than the tip or sides, forming nodes and nodules the size of a pin-head to that of a pea, in the mucous and submucous tissue. To the touch, they are often not well defined from the adjacent tissue. At first they usually cause no pain and may be unrecognized for a long time. In the papillary region, the overlying mucous membrane may be papillated. When the gumma extends towards or above the surface, the overlying mucous membrane becomes smooth, at first natural in color, later reddened. Gummata of the tongue are usually multiple, but not invariably. With the breaking down of the gummata, ulcers are formed. The depth of the resulting ulcer depends upon the size of the gumma and how deep it is located. Superficial gummata cause a relatively larger destruction of mucous membrane, when they ulcerate, than the deeper gummata. In diagnosis, it is well to remember that the gummata are often located in parts that are not subjected to irritation. Irregular forms, such as a superficial gumma of the edge of the tongue, may resemble other affections. Associated symptoms of syphilis, the use of the therapeutic test, and the microscopic exami- nation of a particle of the growth, make the diagnosis. Deep or parenchymatous gummata of the tongue are more difficult to diagnosticate. They may occur anywhere in the muscular part of the tongue, but tend towards the dorsum. Men in middle life are most frequently affected ; but they may appear in women, and even in children in con- genital syphilis. Cases have been reported in infants. They vary in size from masses imperceptible to the touch to tumors the size of a walnut or even larger, though the larger masses are usually caused by the conglomoration of a number of 74 Diagnosis of Syphilis. gummata. In practice, the masses seen are usually larger than those observed in the superficial variety. They usually do not cause pain, and are not tender. They are possibly more frequently multiple than single. They tend to ulcerate, but this process may be delayed several months or even years. They have been reported (Fairlie Clark) to become calcareous and remain quiescent, but such cases must be exceedingly rare. The deep gummata not infrequently give the sense of fluctuation upon palpation. The tongue may be greatly swollen, especially when the mass approaches near the surface and is about to break down. An appearance resembling macroglossia may be caused, more especially by multiple gummata, but is not common. Deep gummata must be differentiated especially from fatty and fibrous tumors and carcinoma. The simple tumors are often polypoid, and usually they are more clearly defined, elastic, and more easily separated from the adjacent tissue. On the other hand, gummata are not sharply defined from the adjacent tissue, and they are more frequently indolent and inelastic. Innocent tumors are more often single and sometimes lob- ulated; gummata are more frequently multiple, and may seem to be lobulated only when close together. As com- pared with gumma, cancer is more often single, shows a pref- erence for the side of the tongue, and frequently is located near some source of irritation, such as a carious tooth. Furthermore, cancer appears more frequently after forty ; gumma between twenty-five and thirty-five years of age. Diagnosis op Syphilis. 75 THE TONGUE. Epithelioma. 1. Most cases occur after forty; may occur earlier. 2. Often a family history of cancer, or a history of association with cases of cancer. There may or may not be the history or evidence of syphilis. 3. Epithelioma is usually single and confined to one side of the tongue. 4. May be found on the under surface or any part of the tongue. 5. Sometimes there is presented early the appearance of lingual psoriasis. Usually the epithelioma begins as a hard superficial swelling that tends to rapid ulceration. Sometimes an epitheliomatous ulcer or fissure appears without the pre- vious history of swelling or indura- tion. 6. The surface of epithelioma bleeds readily; the discharge is pro- fuse, offensive and irritating. 7. As a rule the more marked in- duration follows ulceration. 8. The edges are thickened, ele- vated and irregular. 9. Pain is a marked feature, usually lancinating in character and often radiating toward the ear. 10. Disturbances of deglutition, mastication and speech. 11. Cachexia. 12. The submaxillary lymphatic glands are progressively enlarged and indurated. 13. The microscope reveals endo- cytes, the ingrowing of the epithe- lium, and the cancer nests. 14. Anti-syphilitic treatment is useless or harmful. 15. Does not present the spiro- chete pallida, nor the Wassermann reaction, except in the presence of syphilis. A syphilitic is not immune from epithelioma. Gumma. 1. Most cases occur before forty; but later age is not exempt. 2. As a rule the cancer history is negative. Usually there is the history or evidence of syphilis. It should be remembered that cancer and syphilis may co-exist. 3. Lingual gummata may be single, or multiple and bilateral. 4. Prefers the dorsum or side of the tongue. 5. Gumma begins as a nodule sit- uated more or less deep in the tis- sue, with subsequent softening and ulceration, to open on the surface as a deep excavation with a larger base than apex; the gummatous dis- charge differing markedly from the discharge of cancer. 6. The gummatous ulcer does not bleed so easily, is covered by an ir- regular slough; and the compara- tively slight secretion is not so of- fensive nor irritating. 7. Induration precedes ulcera- tion. 8. The edges are more sharply defined and abrupt. 9. There is comparatively little pain; even a large gumma may be present without pain. 10. Comparatively little of such disturbance. 11. Usually absent. 12. The adenopathy is compara- tively slight; the glands may be swollen and tender, especially as the result of mixed infection. 13. The microscope shows an ir- regular accumulation of granulation tissue, very different from the pic- ture of epithelioma. 14. Anti-syphilitic treatment is specific. 15. The spirochete pallida is dif- ficult to detect in the third stage of syphilis, but may be found. The Wassermann reaction is present, ex- cept when the case is quiescent or in the presence of active anti-syph- ilitic treatment. 76 Diagnosis op Syphilis. Chronic abscess is more clearly defined from the adjacent tissue than gumma, and is usually more rounded in shape. Doubtful cases may be cleared up by puncture or the thera- peutic test. Rarely, an embedded foreign body resembles a gumma in general appearance, but the other symptoms of syphilis are lacking. Oral Chancre. Possibly history or evidence (gonorrhoea, chancroid, etc.) of exposure to syphilitic infection. Confrontation : Often valueless because of attempted deception. Derived from a preceding case of syphilis, directly or indirectly. Regular outline, smooth surface, sharply circumscribed base with cartilaginous induration. Incubation usually about two weeks ; may vary from one week to two months. Early involvement of neighboring lymphatics ; adenopathies usually appear within two weeks after the appearance of the chancre. Microscopic examination : Spirochete pallida present. Therapeutic test : Mercury is specific. Pain and discomfort comparatively slight. Duration : A few weeks. Termination : Recovery by resolution. Often leaves no visible scar or change, when located upon mucous membrane. Later appearance of second and third stages of syphilis, unless the disease is cured. Infectious : May result in infection of others. Oral Gumma. Usually firm to the touch. Usually occurs before forty. History or evidence of first and second stages of syphilis. Induration precedes ulceration. Diagnosis op Syphilis. 77 Little or no pain. Microscopic examination : Granulation tissue ; possibly spirochete pallida. Wassermann reaction. Oral Epithelioma. Usually occurs after forty. May develop upon a syphilitic scar. Family history of cancer may be obtained. Often there has been association with cases of cancer. Induration usually more marked after ulceration. The edges are usually not - so sharply defined as in the gummatous ulcer. Cancer may occur in syphilitics. Pain is prominent. Greater interference with mastication and speech than in gumma. Cachexia more prominent than in gumma. Adenopathy usually more marked than in gumma. Microscopic examination : Endocytes, ingrowing epithe- lium and cancer nests. Spirochetes may be found, but not the spirochete pallida, except in syphilitics. Wassermann reaction absent, except in syphilitics. Odor: More pronounced than in syphilis, but may be largely obviated by treatment. General health: Impaired to a greater degree than in syphilis. Neighboring lymphatics: Usually not involved until after the first three months. Therapeutic test for syphilis is negative, except possibly the mercury may prove deleterious Sexual contact does not produce syphilis. 78 Diagnosis of Syphilis. Leucoplacia buccalis, variously known as leuplasia buccalis, smoker's tongue, and ichthyosis, keratosis, and psoriasis of the tongue, is characterized by sharply circumscribed white patches of cornified epithelium. Ordinarily the patches are flat and raised. Sometimes they become more or less detached, leaving cracks or denuded surfaces. They are not confined to the tongue, but may occur on the lips and cheeks. They may occur in syphilitics, and possibly syphilis may be a factor in etiology, but they frequently occur in non-syphilitics. Exces- sive smoking seems to be a prominent factor in their causation, and most cases occur in men who are smokers. But the disease has been observed in men who do not smoke, and rarely in women. It is stated that in countries where women smoke as much as men, the disease shows the same preference for men, hardly ever affecting women. It is not affected by anti-syphilitic treatment. The spirochete pallida and the Was- sermann reaction are not present, except in concomitant syphilis. Oral Tuberculosis. Search for the tubercle bacillus is difficult, but makes the diagnosis absolute when found in the tissue. Tuberculin test positive in tuberculosis, but only indicates that the patient is suffering from a tubercular infection. Wassermann reaction absent, except in syphilitics. Syphilis and tuberculosis often co-exist. Adenopathy: Swelling of the lymphatics indicates tuber- culosis rather than late syphilis. Glossitis. Glossitis may be either superficial or deep ; and acute, subacute, or chronic. These inflammations may be due to many different causes. If the cause is not known, an appeal may be made to the therapeutic test for syphilis. The spirochete pallida and the Wassermann reaction speak for Diagnosis of Syphilis. 79 syphilis, but do not exclude other causes of glossitis. Usually the diagnosis is easy, through a knowledge of the cause. Thus, in decubital glossitis, the knowledge of decubitus may aid in diagnosis. SYPHILITIC FISSURES AND ULCERS OF THE TONGUE. Second and Third Stages. Syphilitic fissures of the tongue are most frequent during the third stage of the disease. The fissures of the second stage are usually located upon the borders of the tongue, being caused largely by the rubbing of the teeth. In this way a fissure may follow the ulceration of a mucous patch that is irritated by a tooth. The syphilitic tongue seems prone to inflame and ulcerate. The sores and fissures show little inflammation, but they are usually very sensitive. Usually the fissures and ulcers are multiple. Tuberculous fissures are usually single. The secondary syphilitic fissures leave scars, usually depressed and smooth, sometimes thickened and raised white lines and patches, which may break down later to form new sores and fissures. These may again break down. Tertiary syphilitic fissures are more frequent. These may result from the breaking down of gummata. Deep and long fissures of the tongue are usually indicative of tertiary syphilis. Carcinoma more frequently causes a distinct tumor, which may become fissured or ulcerated. There is not the early appear- ance of long fissures and deep clefts observed in syphilis. Tuberculosis occasionally causes large ulcerated clefts, but not until the case is far advanced, when the diagnosis of tuber- culosis is usually easy. As a rule, the tuberculous fissure is small. The lymphatic glands are usually not enlarged, except accidentally, in either secondary or tertiary fissure of the tongue. 80 Diagnosis of Syphilis. Secondary syphilitic ulcers of the tongue may result from the breaking down or injury of mucous patches; or they may occur as simple abrasions or cracks or fissured ulcers on the tip and borders. Injury from the teeth is a prominent cause. The ulcers due to breaking down of mucous patches, occur especially upon the tip and borders of the tongue, which are most exposed to injury by the teeth through rubbing or biting. Deep ulcers, especially, are frequently surrounded by a zone of infiltration, but this is rarely notice- ably harder than the normal tissue. Even in the presence of marked irritation, syphilitic ulcers show comparatively little inflammation, as a rule. Deep and ugly lesions may occur without marked inflammation. The small excoriations of the dorsum of the tongue, which occur near the tip and edges, or upon the tip and border of the tongue, may occur either in syphilis or other consti- tutional maladies. These may assume the form of small cracks or fissures. Usually there is little or no inflammation. Irri- tation by the teeth is a prominent cause. The ulcers are sensitive, though they show little or no inflammation. They may remain a long time without change in size, or they may slowly grow ; they do not readily undergo spontaneous improvement. In differential diagnosis, the presence of other signs of syphilis often is important, especially ulcers of the anus, nodes upon the tibia, or a syphilitic iritis. Many of the symptoms and signs found in syphilis, such as some of the ulcers just described, are not found only in syphilis, but may be present also in other affections. The tertiary syphilitic ulcers of the tongue may be superficial or deep, and leave deep furrows and marked deform- ity of the tongue. There is usually a preceding gumma, but this may be overlooked by the patient and not be observable at the time the case comes under treatment. Single ulcers may resemble tuberculosis or carcinoma of the tongue. Es- pecially when irritation is caused by a tooth, it may be difficult to recognize the syphilitic process and be sure that the ulcer Diagnosis of Syphilis. 81 is not caused wholly by the tooth. The tertiary ulcers, like the gummata, have a preference for the dorsum, and may occur far back on the tongue. In these locations they are not likely to be mistaken for other ulcers. Men are most fre- quently affected, especially in middle life. But women, and even children, are not exempt. Gummatous ulcers usually do not show enlargement of the lymphatic glands. Tertiary syphilis of the salivary glands is usually recog- nized definitely by the therapeutic test. The glands most fre- quently involved are the sub-lingual gland, more rarely the sub-maxillary gland, and the Blandin-Nuhn (mucous) gland at the tip of the tongue. In general, syphilitic tumors of the mouth are characterized by firmness to the touch, and the absence of tenderness and acute inflammatory symptoms. Most difficulty is encountered in the tertiary affections of the palate, the roof of the pharynx, and the tongue. In the differentiation from carci- noma, it must be remembered that a syphilitic person may have cancer; and that a carcinoma may develop upon a syphilitic scar. In cases of doubt, the microscope should be used. Localized tuberculosis is even more difficult to diagnosti- cate at times. Unfortunately, in such cases it is often desirable to make the diagnosis without resorting to the therapeutic test, which would be debilitating. In such cases the tuberculin test is invaluable. The search for the tubercle bacillus in sections is difficult, but makes the diagnosis absolute when these are found in the tissue. However, it must be remembered that syphilis and tuberculosis may co-exist. Swelling of the lymphatics speaks for tuberculosis rather than for late syphilis. Redness and swelling are more marked in gumma than in tuberculous infiltration. This is not invariable, but the swelling in tuberculous ulcers is usually less than in gummatous ulcers. Late syphilis of the mouth must be differentiated from chancre, leucoplakia, and decubital glossitis. 82 Diagnosis of Syphilis. Teeth. A peculiar malformation of the upper incisor teeth was described by Hutchinson. These are the so-called notched teeth. "Single vertical notches in their edges which, whilst themselves evidence of the atrophy of the middle tentacle, are often attended by a general dwarfing of the whole tooth, which is both too short and too narrow from side to side. In many cases this peculiar dwarfing and the central notch are suffi- ciently well marked to justify a diagnosis in themselves, but in many others they amount only to a suspicious condition and require corroboration by other facts. Such corroboration may be afforded by the physiognomy, by the keratitis, by deafness, or by the parental history." It must be remembered, however, that syphilis may cause notching of other teeth: and, furthermore, a similar condi- tion may be caused by non-syphilitic affections that impair the nutrition. Tonsils. Chancre of the tonsil has been observed, the inoculation occurring directly through coitus ah ore. musing from an affected breast, etc., or indirectly through the use of contami- nated utensils (cups, forks, spoons, etc.), or instruments. Usually the cases have been unilateral, though in some in- stances both tonsils may be involved. Founder describes four appearances of the tonsillar chancre: Anginous, diphtheroid, eroded, and ulcerative. In general, chancre of the tonsil causes that organ to be enlarged, indurated, reddened and painful. The characteristic adenopathy of chancre of the tonsil is a painless enlargement of one or several gland- at the angle of the jaw. In the throat there may be a sharp inflammatory reaction with dysphagia, painful adenitis, and fever. Such a case may present, at first, the appearance of a simple angina. But it is more persistent, and soon the characteristic changes appear in the tonsil. Sometimes chancre of the tonsil appears Diagkosis of Syphilis. 83 first as a slight tonsillitis with a pseudo-membrane, resembling somewhat diphtheritic tonsillitis. Beneath the pseudo-mem- brane is the erosion and the indurated base of the chancre. In such cases the cervical glands are swollen, there is little pain, the affection is unilateral, does not extend beyond the tonsil, and runs its course in two to three weeks. Sometimes the chancre appears as an erosion or a more or less extensive ulceration upon an indurated base, with the characteristic adenopathy. Epithelioma shows also ulceration, induration and adenopathy, but the course is altogether different. The glands are affected earlier in syphilis, and there soon supervene the secondary symptoms of the disease. During the second stage of syphilis, the tonsils may be involved in an angina that some observers believe to be syph- ilitic. Others believe this to be a simple angina. The secondary syphilitic tonsilar lesions that are generally recog- nized are tonsillar hypertrophy and mucous patch of the tonsil. The hypertrophy resembles simple hypertrophy of the tonsil, is bilateral and causes little pain. Mucous patches may appear upon the enlarged tonsils, and there may be ulceration where the tonsils come together in the median line. There is cervical adenitis. The process may run its course in a few days or persist to become chronic. The mucous patch may appear upon the tonsil in various forms : Eroded, papulo-eroded, papulo-hypertrophic, and ul- cerative. The eroded and ulcerative forms are most common. The mucous patches seem to prefer smokers, drinkers, and those who use irritating substances in the mouth. Occasionally the hypertrophic patches may become exaggerated, to resemble diffuse papillomata. During the third stage of syphilis, the tonsil may be the seat of gummata and their resulting ulcerations. Gumma of the tonsil at first causes the tonsil to become enlarged, with little or no pain. Soon there is ulceration, usually by the time the case comes under the observation of the physician. The gummatous ulceration has a tendency to involve the edge of the tonsil and extend to affect the pillars of the fauces, 84 Diagnosis op Syphilis. the velum, the pharynx or the base of the tongue, extending both in area and depth. The ulcer is clean-cut, the edges more or less red, inflamed and infiltrated, and it is covered with a pultaceous yellowish exudate, beneath which is a sanious, reddish, fungating surface. These cases of ulcerating gumma remain remarkably free from adenopathies, which is an important point in differentiation from chancre, epithelioma and tuberculosis of the tonsil. Sometimes the gumma assumes considerable proportions before it softens and ulcerates. Thus, Mackenzie mentions an extension of the softening of a gumma so as to involve the vertebral artery. Before ulceration, the softened gumma may present distinct fluctuation ; the overlying mucous membrane is injected, purplish-red in color. A gummatous ulcer shows little tendency to heal under the ordinary local treatment for simple ulcer, such as nitrate of silver, acid nitrate of mercury, etc., save when the patient is under general treatment for syphilis. Mackenzie regards the diagnosis as almost positive when such a suspicious ulcer persists in this way for four or five weeks. Esophagus. More careful and complete examinations of the esophagus will probably reveal syphilitic affection more often than the paucity of the literature would indicate. It is conceivable that a primary syphilitic sore might occur in the esophagus, for instance, through inoculation with an infected esophogeal bougie, esophagoscope, or other instrument introduced into the esophagus. Such an accident ought not to occur in practice. No cases of primary syphilis of the esophagus have been reported. During the second stage of syphilis, syphilides may occur in the esophagus. Such cases are rare ; they would be recognized by the presence of dysphagia, possibly by exami- nation through an esophagoscope, by other signs of syphilis, and by the therapeutic test. Diagnosis of Syphilis. 85 Gumma have occasionally been observed in the esophagus, during the third stage of syphilis. There will usually be the presence and history of other signs and symptoms of the disease. The chief symptom is dysphagia. The gumma may be recognized by the use of the esophagoscope and the therapeutic test. The destructive lesions of syphilis may cause stricture of the esophagus. It is a pretty good general rule to think of syphilis in all cases of dysphagia. The dysphagia of syphilis is usually due to syphilitic affection of the pharynx or larynx. A neurotic dysphagia was observed by Wilson in a case of syphilis. In that case the paralysis of the esophagus responded to the therapeutic test. Maury and Bryant have recorded cases in which syphilitic stenosis of the esophagus necessitated gastrostomy. But in all cases, when practicable, it is well to resort to the therapeutic test, which has relieved or cured a number of cases. In the differentiation from carcinoma, it is well to remember the case noted by A. Weichselbaum, in which Podrazki made a diagnosis of syphilis of the esophagus, in a case of stricture, and the autopsy revealed a carcinoma. It has been suggested that this may have been a case in which a carcinoma devel- oped upon a gummatous infiltration. Stomach. No case of primary syphilitic sore in the stomach has been recorded. It is apparent that a primary inoculation of the stomach might occur through the use of an infected instrument, such as a stomach tube, gastrodiaphane, gastric electrode or gastroscope, that had not been properly sterilized after use in a case of syphilis. During the second and third stages of the disease, syphilitic ulcers and neoplasms may occur in the stomach. These are comparatively rare. In suspected cases, the presence or history of other signs or symptoms of the disease may be suggestive. The therapeutic test and the Wassermann reac- tion are of most value. 86 Diagnosis of Syphilis. Chronic gastritis is a common symptom of syphilis. In such cases there is not always a direct syphilitic involvement of the stomach. Indeed, it has been suggested that the majority of cases are due to circulatory disturbances, passive congestions, hemorrhages, etc., produced by syphilis of other digestive organs, notably the liver, spleen and pancreas. It has been observed that a syphilitic gastritis frequently im- proves under the therapeutic test with mercury and the preparations of iodin, whereas non-syphilitic gastritis is usually made worse by these remedies. Depending upon whether there was involvement of the stomach wall in the syphilitic process, Chiari has divided these cases of gastritis into direct and indirect syphilis of the stomach. Ulcer of the stomach is not usually due to syphilis. But syphilis may cause ulcer of the stomach, either through the breaking down of a syphilide or gumma, or through increas- ing the predisposition to the formation of non-specific ulcera- tion from erosions, endarteritis, diminution of hemoglobin, reduction of the alkalinity of the blood, .and increase and disintegration of the leucocytes. Syphilitic ulcers some- times cause increased symptoms at night. Thus, Rosanow reported a case in which gastralgia occurred only at night; and Bartumeus emphasized the importance of nocturnal emesis in diagnosis. In all suspected cases it is important to exclude tuberculosis, alcoholism, chlorosis, and the various common causes of the non-syphilitic ulcer of the stomach. When this is possible and the therapeutic test is positive, the diagnosis is reasonably certain. Gumma of the stomach is a comparatively rare affection. But a number of cases have been reported, and in all sus- pected cases the therapeutic test should be considered. Usu- ally gumma of the stomach has been accompanied by a similar affection of other organs, especially the liver and lungs. There are usually signs or symptoms of the disease in other parts of the body. The gastroscopic appearance is somewhat suggestive, since the gummatous ulcer is usually irregular and not so clear cut as the simple ulcer of the stomach. Diagnosis of Syphilis. 87 It is interesting to note that Birch-Hirschfeld and Chiari have reported cases of gumma of the stomach due to inher- ited syphilis. Gastric hemorrhage sometimes, though rarely, occurs in the course of syphilis. Such cases are benefitted by anti-syph- ilitic treatment, which is a useful point in diagnosis. In such cases, the hemorrhage may be due to congestion caused by involvement of other organs, such as the liver and spleen. Let us now take up the diagnostic points that are of value in differentiating between the various syphilitic affec- tions and the non-syphilitic affections of the stomach. A distinction should be made between simple ulcer of the stom- ach in a syphilitic and a gummatous ulcer with gastric catarrh. Furthermore, it should be remembered that various lesions of the stomach may co-exist. Thus, tubercle bacilli may become implanted upon a syphilitic lesion, just as they may grow upon carcinomatous or typhoid ulcers. Let us now consider briefly the following affections : (a) Syphilis of the stomach: 1. Syphilitic neoplasm or infiltration. 2. Syphilitic ulcer. (b) Syphilitic gastric catarrh, so-called indirect syphilis of the stomach, due to syphilis, but without direct involve- ment of the stomach. (c) Simple chronic gastric catarrh. (d) Simple gastric ulcer. (e) Cancer of the stomach. (f) Tuberculosis of the stomach. (g) Gastric neuroses. 1 . Duration. (a) S3 r philis of the stomach is of indefinite duration, but must be regarded as a chronic affection. The affection of the stomach occurs both in inherited syphilis and in the acquired form of the disease, during the second and especially the third stage. 88 Diagnosis op Syphilis. (b) Syphilitic gastric catarrh is also of indefinite dura- tion, usually chronic, and may develop from repeated attacks of acute gastritis. It may be an early symptom of syphilis, and occurs during the second and third stages of the disease. (c) Simple chronic gastric catarrh is of indefinite, fre- quently of long duration. (d) Simple gastric ulcer is of indefinite duration. The attacks are of short duration, but relapses and repetitions are frequent, so that the disease frequently lasts for years. (e) Cancer of the stomach is of comparatively short duration, the patients rarely living longer than six months or a year after the recognition of the disease. (f) Tuberculosis of the stomach may occur as a part of a miliary tuberculosis, or as a tuberculous ulcer (which is rare). The first of these affections is of short duration and often resembles the course of typhoid fever. The second is of indefinite duration. Third, the stomach is fre- quently affected in pulmonary tuberculosis, giving the picture of a toxic gastric catarrh. In such cases the outlook depends largely upon the condition of the stomach. On the other hand, the duration of the stomach affection in such cases depends largely upon the treatment of the tuberculosis. In the cases of tuberculosis that are curable, the stomach affection disappears with the recover}' of the patient from the tuberculosis. In the cases that are not curable, the duration may be placed at about two years. (g) The gastric neuroses vary in duration. Nervous gastralgia presents recurring attacks of rarely more than three or four days' duration. Hyperchlorhydria is of long duration. 2. Sex. (a) Syphilis of the stomach shows no marked preference for either sex. In private practice (excluding prostitutes) most cases of syphilis occur in males. (b) Syphilitic gastric catarrh shows no marked difference between the sexes. Diagnosis op Syphilis. 89 (c) Chronic gastric catarrh is more frequent in males. (d) Gastric ulcer is more frequent in women, in the proportion of about 2:1. (e) Cancer of the stomach occurs about equally in the two sexes. (f) Tuberculosis of the stomach is most frequent in males, in the proportion of 16:3 (Letorey), The toxic gastric catarrh of pulmonary tuberculosis I have observed most frequently in females. (g) The gastric neuroses vary in the two sexes. Thus, nervous gastralgia is most frequent in women, whereas hyper- chlorhydria is more frequent in men. 3. Age. (a) Syphilis of the stomach is found in all ages. Thus, the stomach may be involved in the very young, in hereditary syphilis. In the acquired form of the disease, the stomach is involved most frequently from twenty-five to forty years. (b) Syphilitic gastric catarrh is also found at all ages, in the very young in hereditary syphilis, and from early adolescence on, in the acquired form of syphilis. Occurs most frequently between the third and sixth month of the disease. (c) Chronic gastric catarrh is a disease of mature age. (d) Ulcer of the stomach is more rare in youth, fre- quently increasing progressively from puberty to advanced age. (e) Cancer of the stomach is found especially in middle and advanced life. (f) Tuberculosis of the stomach prefers children and young adults. (g) The gastric neuroses: Nervous gastralgia prefers the years from eighteen to thirty-five. Hyperchlorhydria may occur at any age, but is rare in youth. 90 Diagnosis of Syphilis. (a) Coated in syphilis of the stomach. (b) Coated, slightly furred, in syphilitic gastric catarrh. (c) Coated grayish white in simple chronic gastric catarrh, frequently showing impression of the teeth. This is frequently observed also in syphilis. (d) In ulcer of the stomach the tongue may be dry and red with a white stripe in the middle, or it may be smooth and moist, or slightly furred. (e) Cancer of the stomach is marked by a heavily coated tongue comparatively early in the course of the disease. (f) In tuberculosis, the tongue is coated as a rule. (g) The appearance of the tongue varies in the gastric neuroses. It is usually normal in nervous gastralgia. In hyperchlorhydria the tongue may he clean or slightly furred. •"/. Sensations. (a) Syphilis causes a variety of subjective symptoms. Their chief characteristic seems to be that they are mild compared with the extent of the lesions. Some have ob- served that gastralgia occurs especially at night in cases of syphilis. (b) Syphilitic gastric catarrh may be accompanied by gastralgia and headache. (c) Chronic gastric catarrh presents the familiar picture of pressure, fullness and distention. (d) In gastric ulcer there may be burning in the stomach, and circumscribed boring pains, frequently radiating to the back. (e) Cancer of the stomach is marked by an exaggera- tion of the symptoms of catarrh in conjunction with pain, that is of variable character and later radiates toward the shoulder. (f) Tuberculosis may cause nothing abnormal in the Diagnosis op Syphilis. 91 way of sensations, or there may be anorexia, indigestion, nausea, distention, or vomiting. (g) The neuroses are marked by a great variety of sensations. Nervous gastralgia may cause feeling of hot or cold. Hyperchlorhydria is marked by sensations of heat and burning, and at times by pyrosis and distention. 6. Appetite. (a) In syphilis of the stomach there is comparatively little impairment of the appetite. (b) Indirect syphilis of the stomach is sometimes asso- ciated with polydypsia, and rarely with bulimia. (c) Simple chronic catarrh of the stomach tends to impair the appetite, so that it is usually absent. (d) Gastric ulcer does not impair the appetite. The patients often restrict their eating to the point of causing emaciation, because they fear the food may cause pain. (e) Cancer destroys thee appetite, and this is a marked characteristic of the disease. (f) In miliary tuberculosis and tuberculous ulcer the appetite is impaired. In miliary tuberculosis the patient is often too sick to care to eat. In pulmonary tuberculosis the appetite is often remarkably good ; sometimes there is early impairment of the appetite ; sometimes there is anorexia, which may be complete or partial, i. e., for all foods or for only certain foods. Thus, there may be anorexia for digestible articles, while indigestible delicacies may be craved. In some cases a seemingly voracious appetite is satisfied with a few mouthfuls of food. (g) The appetite varies in the neuroses. In nervous gastralgia the appetite is normal during the intervals ; in hyperchlorhydria the appetite is often increased. 7. Epigastric Pain. (a) In syphilis there is gastralgia. In syphilitic ulcer, gastralgia occurs especially at night (Rosanow). 92 Diagnosis op Syphilis. (b) There may be gastralgia in syphilitic gastrict catarrh. (c) In chronic gastric catarrh, epigastric pain may be present but is not regularly pronounced. More often there is only diffuse tenderness. Atrophic gastritis may present lancinating pains. (d) In ulcer the epigastric pain is intense, especially after eating, and becomes more severe upon pressure. The pain disappears after digestion is completed and the stomach is empty. (e) Cancer causes less intense pain, but it is more continuous and there are seldom periods of perfect freedom from pain, such as are observed in ulcer. (f) The epigastric pain is usually diffuse in miliary tuberculosis. The pain may be localized in tuberculous ulcer. The toxic gastritis observed in pulmonary tuberculosis usually presents a diffuse tenderness in the epigastric region. (g) The epigastric pain of nervous gastralgia is not dependent upon the taking of food, is relieved by pressure, and there are intervals of a number of days during which there is complete freedom from pain. In hyperchlorhydria, the epigastric pain appears from one to three hours after meals, and is relieved by antacids. 8. Regurgitation. (a) Not characteristic in syphilis of the stomach. (b) May be present in syphilitic gastric catarrh. (c) Frequently present in chronic gastric catarrh. (d) At times present in gastric ulcers. There is fre- quently water-brash and pyrosis. (e) There is no water-brash in cancer of the stomach; pyrosis may be quite intense. (f) Present in some cases, bitter, acid, pungent, espe- cially late. (g) Not present in nervous gastralgia. In hyperchlor- hydria water-brash and pyrosis are frequent. Diagnosis op Syphilis. 93 9. Blechmg. (a) Frequent eructations in syphilis of stomach. (b) Frequently present in syphilitic catarrh of the stomach. (c) Frequent copious eructations in chronic gastric ca- tarrh. (d) Usually absent in ulcer, and when present is with- out bad odor. (e) Usually present in cancer of the stomach, often asso- ciated with disagreeable, sometimes fetid odor. (f ) Present in some cases of tuberculosis. ( g ) Variable in nervous gastralgia ; excessive in hyper- chlorhydria. 10. Fever. (a) Usually there is fever in syphilis of the stomach. (b) Rare in syphilitic gastric catarrh, except when due to complications. (c) Rare in simple chronic catarrh of the stomach; some- times the temperature is subnormal. (d) In gastric ulcer there may be fever, in the presence of adhesive inflammation caused by perforation of the ulcer, or in connection with large hemorrhages. (e) Rare in cancer, except towards the close of the scene. The temperature may be subnormal. (f) Fever is present in tuberculosis, especially in the evening. (g) The gastric neuroses do not cause fever. 11. Taste. (a) Not characteristic in syphilis, frequently resembles that of catarrh. (b) Variable in syphilitic gastrict catarrh. (c) Pasty, decomposed, sour, bitter, in chronic gastric catarrh. (d) Normal in ulcer of the stomach. 94 Diagnosis of Syphilis. (e) Resembles that of catarrh, but exaggerated in cancer. Often bitter and sour. (f) Often eructations of bad tasting material in tuber- culosis. (g) Normal in the gastric neuroses. / .'. Hematemesis. (a) Rare in syphilis of stomach. Hayem reports a case in which the hemorrhage ceased after the administration of iodide of potash. Hematemesis in syphilitica is usually dw to hepatic congestion. (b) Absent in syphilitic gastric catarrh. (c) Absent in chronic gastric catarrh. (d) One of the characteristic symptoms in ulcer. Almost all cases show blood upon microscopic examination of the stomach contents. Often these patients vomit large quantities of blood, either clear red or coffee ground in color. After a hemorrhage, there may be hematemesis, also on the following day, but when arrested the hematemesis does not reappear for quite a long period. (e) Blood may frequently be found microscopically in cancer. In gross hematemesis the quantity of blood is rela- tively >mall, usually coffee ground in color, decomposed, fre- quently of fetid odor. Recurrences are frequent, with short intermissions. (f) Hematemesis is absent in miliary tuberculosis, rare in tuberculous ulcer of the stomach, and absent in the toxic gas- tric catarrh of pulmonary tuberculosis, save the vomiting of blood from a pulmonary hemorrhage. (g) Absent in the neuroses. 13. Secretory Function. (a) Various alterations have been observed in syphilis, the most common being a reduction or arrest of the gastric secre- tion, probably due to an associate catarrh. Diagnosis of Syphilis. 9"> (b) There is no characteristic change observed in indirect syphilis. (c) Chronic catarrh of the stomach tends to arrest the secretion, except in gastritis acida. (d) In gastric ulcer the secretion of hydrochloric acid is usually increased, lactic acid is absent, and the ferments are increased. (e) Cancer of the stomach is marked by early absence of free hydrochloric acid, the presence of lactic acid, and the absence of the ferments. (f) In tuberculosis the secretory function of the stomach is little or not at all impaired. In extreme cases of phthisis the hydrochloric acid is often reduced. (g) The neuroses show great variations in the secretory function. Nervous gastralgia shows a variable amount of hydrochloric acid, absence of lactic acid, and the ferments are normal. Hyperchlorhydria is marked by an increase of hydro- chloric acid, and the ferments are also increased. lJf. Vomiting. (a) Vomiting is not characteristic in syphilitic neoplasm or infiltration ; may take place a few hours after eating. In syphilitic ulcer, Bartemeces observed vomiting especially at night. (b) There may be vomiting in indirect syphilitic catarrh, but it is not characteristic, save that it is benefited by anti- syphilitic treatment. (c) In chronic catarrh of the stomach, vomiting is espe- cially frequent in the cases due to alcohol. (d) Gastric ulcer does not show vomiting as a marked feature ; it usually occurs after meals, if at all. (e) Cancer shows vomiting as a marked feature, not after meals, but once or twice a day or once every day or two, the quantity being often very large. (f) In tuberculosis there is often retching and vomiting, especially with the morning spell of coughing. 96 Diagnosis of Syphilis. (g) Nervous gastragia shows no regularity in the appear- ance of vomiting ; absent in hyperchlorhydria. 15. Perforation. (a) Rare in syphilis. (b) Absent in indirect syphilis of stomach. (c) Absent in chronic catarrh. (d) May take place in ulcer after a short period of ill- ness, or at any time in the course of the disease. (e) Occurs in cancer, late in the course of the disease. (f) Absent in miliary tuberculosis, and rare in tubercu- lous ulcer. (g) Absent in the neuroses. 16. Tumor. (a) In some of the reported cases of syphilis of the stom- ach, the tumor has been large enough to palpate. The edges of syphilitic ulcers are usually more thickened than the edges of simple ulcer of the stomach. (b) Syphilitic catarrh does not cause a tumor. (c) There is no tumor in chronic catarrh of the stomach, save the thickening of the stomach walls that may be present in the hyperplastic form. (d) Ulcer of the stomach does not cause a tumor; when near the pyloris, the latter may be thickened so that it feels like a smooth elongated body. (e) The presence of tumor is one of the most reliable signs of cancer of the stomach. Usually the tumor soon becomes large enough to be palpable, presenting an uneven surface, painful to pressure, and easily movable early in the course of the disease. (f) Tuberculosis is marked by single or miliary nodules that are not palpable. Tumor is absent in tuberculous ulcer. (g) Tumor is absent in the neuroses. Diagnosis of Syphilis. 97 17. Complexion, Cachexia and Changes in the Blood. (a) Syphilis is marked by anemia, reduction of the eryth- rocytes and hemoglobin, and late cachexia. Eruptions. (b) In syphilitic gastric catarrh there is reduction of the erythrocytes and hemoglobin, which is a prominent cause of the malnutrition in syphilitics. (c) In chronic gastric catarrh, the patients are pale and show malnutrition. (d) In gastric ulcer the complexion is more fresh than in catarrh ; there is anemia after severe losses of blood. (e) Cancer is marked by a sallow, yellowish complexion, dry skin, and the early appearance of cachexia. (f) In tuberculosis there is anemia, hectic, and cachexia. (g) In nervous gastralgia the complexion is pale during the attacks, and normal during the intervals. In hyperchlor- hydria the complexion may be pale or normal. 18. Stools. (a) Not characteristic. There may be colic and diarrhoea in recent syphilis. (b) There may be colic and diarrhoea in syphilitic gastric catarrh. (c) Constipation alternating with diarrhoea is a common picture in chronic gastric catarrh. (d) In ulcer constipation is the rule; the stools may be tinged with blood. Indeed, blood may usually be found in the stools microscopically. (e) There may be constipation or diarrhoea in cances; the stools may contain blood. (f) Usually there is constipation in tuberculosis. (g) The stools vary in the neuroses, usually normal in nervous gastralgia, constipated in hyperchlorhydria. 98 Diagnosis of Syphilis. 19. Urine. (a) The condition of the urine varies in syphilis of the stomach. Usually the urine is concentrated, reduced in quan- tity ; the urates and phosphates are reduced in some cases ; indican is increased in the presence of ulceration. (b) Indirect syphilis of the stomach does not cause marked changes in the urine. Sometimes the urine is increased in quantity, of light specific gravity, but this is not constant. (c) In chronic gastritis the total acidity of the urine is lessened, and there is a reduction of urates and phosphates. (d) In ulcer the quantity is reduced and the urine con- tains indican. (e) Cancer is marked by a concentrated dark urine, of neutral or alkaline reaction ; indicanuria, acetonuria, sometimes peptonuria ; the preformed and ethereal sulphates are increased. (f) In tuberculosis the urine often contains phosphates in excess. The reduction in the quantity of urine is in ratio to the temperature, as a rule. (g) The condition of the urine varies in the neuroses. Nervous gastralgia presents little change, save that the quan- tity may be increased during the attacks. In hyperchlor- hydria the urine is often neutral or alkaline ; the phosphates are increased. 20. Tissue Fragments. (a) In syphilis of the stomach the contents may contain pus and necrotic tissue. (b) Syphilitic catarrh of the stomach presents nothing characteristic, except possibly some mucus and a few leuco- cytes. The latter, at least may often be accounted for by the deglutition of the discharge from the retropharynx. (c) In chronic catarrh of the stomach, lavage may reveal fragments showing chronic inflammation. (d) In ulcer, lavage usually reveals no tissue fragments. The microscope may show minute traces of blood. Diagnosis of Syphilis. 99 (e) In cancer, tissue fragments may sometimes be found in the stomach contents showing microscopically the structure of the neoplasm. (f) Tissue fragments are usually absent in tuberculosis. (g) Usually absent in the neuroses. It has been claimed that they may be present in hyperchlorhydria, showing gland- ular hypertrophy in two-thirds of the cases. 21. Microscopic Examination. ( a ) Syphilis of stomach : Pus cells ; necrotic tissue, pos- sibly fragments of a gumma. The spirochete pallida should be looked for. The presence of the Wassermann reaction would indicate syphilis, but would not exclude a non-syphilitic affection of the stomach. (b) Syphilitic catarrh of the stomach: Leucocytes, and possibly fragments showing inflammation of the mucous mem- brane. (c) Chronic gastric catarrh: Leucocytes, and fragments showing chronic inflammation of the mucous membrane. (d) Ulcer: Usually some red blood cells may be found. (e) Cancer: Possibly fragments of neoplasm. Opper-Boas bacillus. (f) Tuberculosis: Tubercle bacilli, especially from in- gested sputum. (g) Gastric neuroses: Usually none. Hyperchlorhydria may present fragments, in two-thirds of cases, showing proli- feration of glands. 22. Dorsal Pain Points. (a) Not characteristic in syphilis of the stomach. May be present in syphilitic ulcer, but then usually not so marked as in simple ulcer. (b) Absent in syphilitic catarrh. (c) Absent in chronic catarrh. 100 Diagnosis of Syphilis. (d) Present as a valuable diagnostic point in ulcer, one inch to the left of the twelfth dorsal vertebra. (e) The pain in cancer is diffuse and not characteristic. (f) Not present in tuberculosis, except in the rare cases of tuberculous ulcer of the stomach. (g) There is no characteristic dorsal pain in the neuroses. 23. Administration of Mercury and the Iodides. (a) Beneficial in syphilis. It has been suggested that if the condition improves under the iodide of mercury and be- comes worse when the drug is discontinued, to again improve when the drug is again administered, the diagnosis of syphilis is reasonably certain. (b) Beneficial in syphilitic catarrh. In this respect in- direct syphilis of the stomach differs from the gastric catarrh due to injudicious use of the anti-syphilitics, in which condi- tion their further administration is injurious, at least for a time. (c) Injuring in chronic catarrh. (d) Injurious in ulcer. (e) Usually there is little effect in cancer. Sometimes anti- syphilitics are injurious. Again, in some cases improvement has been noted for a time, especially under the use of large doses of preparations of iodine. (f) Not beneficial, and often absolutely injurious in tuberculosis. (g) The neuroses are not benefited by anti-syphilitic treatment, as a rule ; when there is such improvement, it suggests the possibility of syphilis as an etiological factor. 2£. Prognosis. (a) Syphilis of the stomach: Improvement under anti- syphilitic treatment. In these cases there is ofen syphilis elsewhere, especialy in the liver. Diagnosis op Syphilis. 101 (b) Syphilitic gastric catarrh: Disappears under anti- syphilitic treatment. (c) Improvement under dietetic treatment occurs in chronic gastric catarrh. (d) Marked improvement under dietetic treatment is ob- served in ulcer. (e) Usually any improvement is only temporary in cancer. A few cases have ben apparently recued by early surgery. (f) The outlook is bad in miliary tuberculosis and tuber- culous ulcer of the stomach. The toxic gastritis of pulmonary tuberculosis improves under creosote, fresh air, and the use of tuberculin. (g) The neuroses show marked improvement under treat- ment. We have referred to the frequency of affection of the liver in syphilis of the stomach. In cancer of the stomach, the liver is also frequently involved. Both cancer of the stomach and chronic gastric catarrh are often accompanied by catarrhal jaundice. In miliary tuberculosis of the stomach there is often affec- tion also of other parts of the body, especially the intestines. Tuberculous ulcer of the stomach is usually, if not invariably, accompanied by pulmonary tuberculosis. Intestine. Of the syphilitic affections of the intestines, we are most familiar with ulceration of the small intestine. This occurs most frequently in hereditary syphilis, though cases have been observed in adults. Altogether, syphilitic affection of the in- testine is probably more common than syphilis of the stomach. Not infrequently syphilis of the intestine accompanies syphilitic affection of the stomach; but syphilis of the intestine may occur independent of affection of the stomach. In diagnosis, the presence of a persistent diarrhoea that is relieved or cured by anti-syphilitic treatment, is suggestive. 102 Diagnosis of Syphilis. Care must be taken to differentiate the affection of the intestine so frequently observed during the treatment of syph- ilis, in which the diarrhoea is due to the administration of anti- syphilitics. Syphilitic affection of the intestine seldom causes perfora- tion or peritonitis. (Syphilis of the rectum will be considered later.) Syphilis of the intestine should be differentiated especially from : 1. Intestinal catarrh due to anti-syphilitics. 2. Intestinal tuberculosis. 3. Intestinal cancer. 4. Simple intestinal catarrh. 5. Simple ulcer. 1. Intestinal catarrh due to the administration of anti- syphilitics, is made worse by a continuance of these remedies. Direct syphilitic affection of the intestine is improved by specific treatment. The intestinal catarrh due to these rem- edies, disappears upon their discontinuance. 2. Intestinal tuberculosis is marked by pain, which is much less conspicuous in syphilitic affections of the intestine. Tuber- culosis of the intestine is always, or almost always, accom- panied by pulmonary tuberculosis. Anti-syphilitic remedies do harm rather than good; recovery or improvement follows anti-tubercular treatment. These cases often show constipa- tion ; syphilis of the intestine almost always is marked by diarrhoea. Frequently tuberculosis of the intestine is part of a miliary tuberculosis, with evidence of the affection in other parts of the body. Some of the most interesting cases, from the standpoint of differential diagnosis, are those in which there is evidence of affection of the intestine in indi- viduals who suffer from both pulmonary tuberculosis and syphilis. In such cases we must take into consideration the possibility of the affection of the intestine being due to the injudicious use of anti-tubercular remedies. Such cases are distinctly injured by a continuance of such remedies, and also Diagnosis op Syphilis. 103 by the use of the anti-syphilitics. Sometimes affection of the intestine apparently results from the swallowing of sputum, in pulmonary tuberculosis, presenting the picture of an ordi- nary intestinal catarrh. S. Intestinal cancer involves most frequently the rectum, and will receive further consideration in connection with the differential diagnosis from syphilis of the rectum. Carcinoma of the intestine, aside from the affection of the rectum, is not nearly so common as carcinoma of the stomach. However, it is the most frequent intestinal neoplasm. Often the disease may exist for some time before symptoms are noticed. The most characteristic symptoms are the early cachexia, the presence of a tumor, malnutrition, and obstruc- tion of the bowel. The obstruction of the bowel may dis- appear under treatment to reappear again later. The condi- tion is progressive. Sometimes a tumor may not be detected. The other symptoms depend largely upon the location of the carcinoma. Aside from syphilis, carcinoma of the intestine should be differentiated from tuberculosis, dysentry, typhoid fever; carcinoma of the pyloris or gall-bladder, pancreas or omentum; echinococcus of the omentum, retroperitoneal neo- plasms, neoplasms of the uterus and its adnexa, intestinal con- cretions (gall-stones, feces), appendicitis, and tumors of the kidney or spleen. Intestinal sarcomata and lymphosarcomata are rare, and are usually found in the small intestine. (Carcinoma is more frequent in the large intestine). There is a marked tendency to metastases, and the course is more rapid than in carcinoma or syphilis. Benign intestinal neoplasms (adenomata, fibromata, lip- omata, papillomata, angiomata, myomata, fibromyomata, myxomata, and fibromyxomata) may cause diarrhoea, with the discharge of mucus, pus, or blood; or intestinal obstruction and hemorrhage. All of these non-syphilitic affections are benefited little or not at all, or absolutely injured by the administration of anti-syphilitics. Often the microscopic examination of the 104 Diagnosis of Syphilis. stools will reveal characteristic fragments of tissue that will make the diagnosis. 4. Simple intestinal catarrh may sometimes resemble syph- ilitic affection of the intestine. Aside from indirect syphilitic catarrh of the intestine, simple intestinal catarrh is made worse by the continued administration of anti-syphilitics, especially the iodides. In simple catarrh most may be accomplished by dietetics ; in syphilis, by specific treatment. The fact must not be lost sight of, in diagnosis, that syphilitic patients may suffer from simple intestinal catarrh. However, symptoms of syphilis in other parts of the body are often of value in leading to the recognition of syphilis of the intestine. 5. Ulcer of the intestine may be due to a great many causes. Aside from catarrhal and follicular ulceration, which may be considered exaggerated forms of intestinal catarrh, syphilitic ulcers of the intestine must be differentiated from duodenal ulcer, embolic and thrombotic ulcers, amyloid ulcers, tuberculous ulcers, toxic ulcers, and the ulcerations of typhoid fever, dysentery, and cancer. If we except the rectum, which we will consider later, syphilitic ulcers occur most frequently in the small intestine in infants with hereditary syphilis, and result from the breaking down of gummata. They have also been observed in adults. Liver. Other organs, especially the liver, are frequently involved in syphilis of the stomach. From a diagnostic standpoint it is unfortunate that this is also true of other diseases of the stomach, notably cancer. It is important to bear this fact in mind when called upon to make a differential diagnosis between cancer and syphilis. In the time of Galen, congestion of the liver was be- lieved to be a prominent cause of syphilis. Some observers (Gubler, Leudet, Moulard), have described the icterus that frequently occurs early in the course of syphilis. Some be- lieve this to be the first sign of syphilitic hepatitis. This Diagnosis op Syphilis. 105 icterus is not always preceded by digestive disturbances, though at the same time the liver may be tender to pressure. Senator has suggested that such an icterus may be due to swelling of the bile ducts caused by a syphilitic erythema. Virchow has observed that it is probable that gummata generally de- velop upon soil prepared for them by the earlier syphilitic manifestations of syphilis. In some cases icterus may be caused by enlargement of the lymphatic glands of the portal vein (Engel-Reimers). Probably the most frequent cause of icterus in syphilis is a simple catarrh of the gall-ducts. The fact must not be overlooked that such a catarrh may be caused by the injudicious internal administration of medicines or by indiscretions regarding the ingesta. The latter explanation will account for many cases, since syphilitics are not infre- quently alcoholics. Further, it is possible that chemical poisons formed by the syphilitic process may cause icterus through irritation, possibly during excretion, without an active syphilitic process being present in the liver. This possibility has given rise to the term syphilotoxic icterus. A similar icterus has been described in a number of infections and in ptomaine poisoning. An acute yellow atrophy of the liver has occasionally been reported early in the course of syphilis. In these cases there is marked atrophy of the liver, frequently with enlargement of the spleen and the presence of cerebral symptoms. Senator points out that tyrosin is more frequent in the urine in this condition, whereas it is absent or present only in traces in phosphorus poisoning. During the third stage of syphilis, gummata may occur in the liver. The gummata may be either diffuse or circum- scribed. Rindfleisch has suggested that the diffuse hepatitis of heriditary syphilis may be a cause later of cirrhosis in young persons, the gummata being converted into connective tissue. This is also possible in the acquired form of the disease. Circumscribed gummata vary in size up to that of a walnut. In diagnosis, it is important to remember that these may occur either upon the surface or edge of the organ or 106 Diagnosis of Syphilis. deep in the substance of the liver, where they may not be palpated. These may undergo cheesy degeneration or soften and become absorbed. The resulting fibrous tissue then con- tracts and distorts the liver. Fibrous bands formed in this way, may isolate portions of the liver, that may remain ap- parently normal or undergo fatty or amyloid change. So there may be a marked diminution in the size of the liver. Or the liver may be enlarged, especially in amyloid degen- eration. Perihepatitis frequently causes the formation of adhesive bands, especially upon the convex surface, sometimes binding the liver to the diaphragm, less frequently forming adhesion with the stomach or colon. Syphilis of the liver is frequently accompanied by other manifestations of the disease, especially enlargement of the spleen, amj'loid changes in the kidneys, and enlargement of the lymphatic glands. There are also frequently other signs and symptoms of the disease. We have already referred to icterus. During the third stage of syphilis, even in the presence of gumma of the liver, icterus is frequently absent. On the other hand, when icterus occurs as the result of the pressure of a gumma or the resulting cicatricial contraction, it will prove stubborn, probably disappearing only with the destruction of the involved secreting portion of liver tissue. Usually syphilis causes first an increase in the size of the liver, followed by a diminution of its size. Sometimes palpation may detect nodules or irregularities of the surface or border of the organ. Ascites may result from pressure involving the portal vein, which at times may cause hemorrhages from the stomach and intestines. In suspected syphilis of the liver, the diagnosis may be influenced by evidence of the disease in other parts of the body, by enlargement of the spleen, amyloid disease of the kidneys with consequent albuminuria and cachexia. Often it is important to differentiate between syphilis and Diagnosis op Syphilis. 107 cancer of the liver. Usually cancerous nodules are of rapid growth compared with the syphilitic nodules. Furthermore, in cancer of the liver there is more constant pain, a more rapid breaking down of the tissue, and a greater degradation of the strength than in syphilis, whereas enlargement of the spleen and the presence of albuminuria would speak for the latter disease. In diagnosis, it may be important to recognize: 1. Hepatic congestion. 2. Hepatitis. 3. Perihepatitis. 4. Pylephlebitis. 5. Pigment liver. 6. Diaphragmatic pleurisy. 7. Icterus (various causes). 8. Gummata. 9. Cancer of liver or gall-bladder. 10. Tuberculosis of liver. 11. Gall-stones. 12. Cirrhosis (various causes). 13. Amyloid disease. In making these differentiations, it should be remembered in syphilis we may find the spirochete pallida and the Was- sermann reaction. The spirochete pallida may be found in the blood. The examination is often difficult, requiring a pro- longed search. When found, the evidence of syphilis is con- clusive, but it does not indicate positively that any certain affection is syphilitic ; it may be a non-syphilitic affection occurring in a syphilitic patient. The last remark holds good with reference to the Was- sermann reaction. As a working rule, we may rely upon this reaction being present in syphilis, unless the disease is quiescent or the patient has been subjected to anti-syphilitics. Syphilitic hepatitis may be interstitial or parenchymatous ; syphilotoxic or gummatous. 1. The simplest affection of the liver is congestion, marked 108 Diagnosis of Syphilis. clinically by pain in the right shoulder and loin, sensations of weight and tension in the right hypochondrium especially after meals, and the presence of nausea and vomiting. With this there is derangement of the bowels, frequently diarrhoea, coated tongue, flatulency, depression of spirits, loss of appe- tite and strength, some enlargement of the liver, and possibly slight jaundice. 2. Hepatitis presents a similar array of symptoms, with the addition of fever. There may be enlargement of the spleen and the presence of albuminuria. The liver is slightly tender to pressure, but the pain is of a dull character, and not so marked as in perihepatitis. Both hepatitis and peri- hepatitis may be due to syphilis. A useful point in diagnosis is the fact that syphilitic affection of the other abdominal viscera, notably the intestine and stomach, is almost invariably accompanied by hepatic syphilis. It is not always easy to make a differentiation between congestion and actual inflam- mation of the liver. As stated the chief clinical difference is the presence of fever in hepatitis. But fever may be due to some other cause, so that there may be congestion and fever without actual inflammation. 3. Primary perihepatitis is almost invariably syphilitic. Secondary hepatitis results from extension of disease from other parts, notably from the stomach, intestine, diaphragm, and pleura ; or it results from a chronic peritonitis, or from disease of the liver. The chief symptoms are tenderness upon pressure, motion or inspiration, sometimes the presence of a friction sound, and enlargement of the liver. Jaundice is absent and there is slight fever. 4. Pylephlebitis may resemble hepatitis. The most use- ful diagnostic signs, as a rule, are the presence in pylephlebitis of acute and painful enlargement of the liver, jaundice, thin and copious stools, irregular fever and profuse sweats, occa- sional chills, emaciation, enlarged spleen, typhoid symptoms, pain in the epigastrium or right hypochondrium or radiating to the lumbar or sacral regions, later swelling of the veins of the abdominal walls, and possibly septic fever and peri- Diagnosis of Syphilis. 109 tonitis. Suspicion may be aroused by the knowledge of a previous affection of the intestines or of the appendix or spleen or other organ having connection with the portal cir- culation. Enlargement of the spleen is a marked feature. 5. Hepatitis must be differentiated from pigment liver. The latter is due most frequently to malarial poisoning, and is marked by extra-hepatic symptoms, such as grave cerebral disturbance, albuminuria, hemorrhage from the bowel, profuse diarrhoea and enlarged spleen. There is slight jaundice, and the fever is often intermittent. 6. Diaphragmatic pleurisy may resemble hepatitis, or more especially perihepatitis. However, the pain of dia- phragmatic abscess is more intense than in either of the other affections. There is nausea and vomiting, dry cough, and the respiration is difficult, often amounting to orthopnoea. Jaundice is usually absent. There may be singultus, great anxiety, possibly delirium, paroxysmal cough, and the sardonic grin. Friction sounds may be detected. Often the physical signs are out of all proportion to the intense general symptoms. There may be a few fine moist rales in the lower part of the lung. The disease usually is announced by a chill; there is more or less fever. Usually the pain on pressure is located not only over the liver but also further towards the sternum, perhaps reaching within less than two inches of the linea alba. There is usually most tenderness in the region of the tenth rib, at the insertion of the diaphragm at this point. It has been claimed that up- ward pressure over the liver in these cases relieves the pain, which would be a valuable diagnostic point. Often expectora- tion is difficult. Pressure on the neck may elicit tenderness, and shooting pains may be complained of along the clavicle and in the region of the superficial cervical plexus and the phrenic nerve of the affected side. As stated, this is elicited especially by pressure. 7. Icterus may be due to a great variety of causes. Syphilitic icterus may be hepatogenous or hematogenous. Hematogenous syphilitic icterus is ascribed to syphilotoxines. 110 Diagnosis of Syphilis. Hepatogenous syphilitic icterus may be due to gummata, syphilides, or to changes caused in the liver by the poisons of syphilis. The presence of other symptoms of syphilis may help or hinder the diagnosis of syphilitic jaundice. We must remember that syphilitics may suffer from non-syphilitic jaun- dice, for syphilis confers no immunity against the other causes of jaundice. Indeed, the individuals most frequently affected with syphilis, are especially liable to other causes of jaundice. Vices are gregarious. For instance, syphilitics are often alco- holics. The most common cause of jaundice is catarrhal in- flammation of the smaller ducts and the common bile duct, that is so often found associated with gastro-duodenal catarrh. Among the common causes of hepatogenous jaundice are: First, gall-stones or inspissated bile in the common duct or the radicles of the common duct ; second, malignant new growths of the liver, stomach, pyloris, duodenum, pancreas, kidney, or secondary infiltration of the glands in the trans- verse fissure ; third, gastric or duodenal catarrh ; fourth, abdom- inal aneurisym ; fifth, hydatid cysts ; sixth, accumulation of feces ; seventh, ovarian or uterine tumors ; eighth, lyinpha- denoma; ninth, perihepatitis, and tenth, syphilis (gummata, syphilides, cicatricial tissue). Hematogenuos jaundice may be caused by: First, yellow fever, typhus, scarlet fever, dengue, relapsing fever, pneu- monia, and possibly the severe forms of all the infections. It occurs in the severe forms of malaria and septicennia. Thus, jaundice is sometimes present in acute ulcerative endo- carditis, a form of septicemia. Second, there are many toxic causes of hematogenous jaundice. Possibly the infections might be placed in this class, inasmuch as the jaundice in those cases is probably due to the action of toxines. Other toxic causes are: snake bite, phosphorus, copper, mercury, an- timony, chloroform, ether, poisoning by the coal-tar products, chlorate of potassium, and mushroom poisoning. Third, acute yellow atrophy of the liver ; fourth, cirrhosis of the liver ( in the later stages) ; fifth, various neuroses (joy, grief, fear, and passion) ; sixth, icterus neonatorum. Diagnosis of Syphilis. Ill Icterus neonatorum may be due to syphilis, but it is more frequently due to other causes. In the ephemeral cases, that clear up in some ten days or two weeks, some ascribe the jaundice to a decrease in the blood-pressure; others believe it to be due to some mild infection. It is possible that both these may be causative factors. The cases due to severe infection usually succumb. Among the common severe infec- tions are septicemia (umbilical infection) and hereditary syph- ilis (especially hepatitis). In the cases due to hepatic dis- ease the urine is usually stained with bile and the stools are light. Among the rare causes is congenital stenosis or absence of the common or hepatic duct. Concussion of the brain has been reported to cause jaundice. Icterus also sometimes appears in the course of diabetes, possibly due to changes in the pancreas, or to some poison cir- culating in the blood or eliminated through the liver, or as a simple complication. In acute yellow atrophy, the early symptoms are those of gastro-intestinal catarrh: loss of appetite, nausea, vomiting, constipation, pain and tenderness over the liver. Later there is jaundice in two-thirds of the cases, beginning in the face and gradually extending over the body. Sometimes there is an initial rigor. There may be general weakness, pains in the muscles, a tremulous tongue, and epistaxis. Later there are cardiac asthma and an irregular pulse with increased tension. Later marked nervous symptoms supervene — restlessness, de- lirium, coma, irregular breathing, which becomes sterterous, and the scene is closed by death. The liver, which at first may have shown some increase in size, becomes greatly atro- phied as a rule. However, death may supervene before there is marked atrophy of the liver. Sometimes atrophy of the liver can not be detected when there is an accompanying hyperplasia of the connective tissue. Hemorrhages occur in more than half the cases, usually in the form of hematemesis. The early symptoms of acute yellow atrophy are those of catarrhal jaundice. The characteristic symptoms begin later; severe jaundice, hemorrhage, and nervous symptoms. Leucin 112 Diagnosis of Syphilis. and tyrosin are usually to be found in the urine. The ob- jective symptoms, with the decreased hepatic dullness and the increased size of the spleen, make the diagnosis clear. The chief affection of the liver during the second stage of syphilis, is marked by hepatitis and icterus. We have already referred to these in connection with hereditary syphilis. They also occur during the second stage of the acquired form of syphilis. More marked are the tertiary syphilitic affections of the liver, notably gummata and syphilitic cirrhosis. These are much more common in practice than affection of the liver during the second stage of syphilis. 8. Gummata of the liver may be latent or may produce various symptoms. Usually the onset is insidious, so that it is difficult for the patient to state when the symptoms began. It is possible for gummata to develop without disturbing either the circulation of the blood or bile. There may be such disturbances, due to syphilitic affection of the connective tissue and perihepatitis. Usually the first symptoms are emaciation, malaise, disturbances of digestion, and pain in the region of the liver, slight and dragging, or severe and lancinating. The more severe pain is usually indicative of perihepatitis. Physi- cal examination reveals an enlarged liver. Perihepatitis may cause friction sounds. The enlargement of the liver is ir- regular and the organ is often altered in shape. Palpation may reveal nodules and depressions, and the liver is firmer than normal, sometimes to amount to a woody induration. Interference with the circulation and bile may cause ascites, the formation of a caput Medusas and the presence of jaundice. Death may result from cachexia or from syphilitic lesions in other parts of the body, especially the kidneys and brain. 9. Hepatic gummata should be differentiated especially from cancer of the liver. The age, history, and associate symptoms may be suggestive. Cancer of the liver shows more marked jaundice, ascites, and pain. The liver increases more rapidly in size, and the nodules are usually larger and firmer than in syphilis. Diagnosis of Syphilis. 113 10. Primary tuberculosis of the liver is rare, but sec- ondary tuberculosis of the liver is a rather common affection, occuring in acute military tuberculosis and also in chronic tuberculosis of the lungs and bones. The tubercles are small, so that usually they may not be recognized with the naked eye. The largest are rarely larger than a pea. Large solitary tubercles, that probably may be regarded usually as instances of primary infection, may resemble the nodules of cancer or gummata. Several cases have been reported in which a car- cinoma occurred upon a tubercle in the liver. Large nodules, containing cavities the size of a walnut, may result from tuberculosis of the bile ducts. Tuberculosis of the liver may be acute, subacute, or chronic. The symptoms are usually slight, so that they may be overlooked, being overshadowed by the miliary tuberculosis or the chronic tuberculosis of the lungs or bones with which the liver affection is associated. The presence of icterus or the rapid development of a pain- less ascites may arouse suspicion. In children the liver may be enlarged and sensitive. 11. Gall-stones will rarely become confused with hepatic syphilis. Calculi in the gall-bladder may produce no symp- toms. Post-mortems show gall-stones in about one-tenth of all cases, most frequently in the female sex. The most ob- trusive symptom is pain, gall-stone colic. An over distended gall-bladder may be painful. The attack of gall-stone colic begins with a feeling of discomfort, which gradually increases to absolute, often excruciating pain, in the right hypochon- drium or epigastrium. There is interference with digestion, sometimes vomiting. Often the patient complains of pain at the angle or inner margin of the scapula. There are obstipation and tympanites. There is a slight rise of tem- perature, 99°-99.5°F. Usually there is no icterus. As a rule, gall-stones do not cause colic, except when there is impaction of the stones in the cystic duct. When the gall-bladder is enlarged it may be felt as a tumor. 12. Syphilitic cirrhosis may resemble alcoholic cirrhosis of the liver, and the differential diagnosis is often further em- 114 Diagnosis op Syphilis. barrassd by the fact that not infrequently syphilitic patients are addicted to the use of alcoholic beverages. Alcohol and syphilis are frequently companions. Cirrhosis of the liver must be differentiated especially from pyelophlebitis, p3'elo- thrombosis, thrombosis, hypertrophic cirrhosis, diffuse chronic peritonitis, hyperemia, amyloid liver, hepatic carcinoma, and the simple atrophy of marasmus. The early symptoms of cirrhosis of the liver are those of a gastro-intestinal catarrh : eructations of gas, gastric pain, coated tongue, nausea and vomiting, and diarrhoea alternating with constipation. At first the liver may be larger than normal, but with the contraction of the cicatricial tissue the liver becomes reduced in size and the surface uneven. There is hepatic tenderness and pain radiating toward the right shoulder. The patient is pale, emaciated, and experiences early fatigue. The symptoms are due chief!}' to the obstruc- tion of the portal circulation through the liver. Damming back the blood in the gastric vein, this causes morning sick- ness, dyspepsia and hematemesis. Engorgement, due to ob- struction to the flow of blood through the spleenic vein, is marked by pain and some enlargement of the spleen, though this may be difficult to detect. Engorgement of the mesenteric vein leads to ascites. The obstructed venous circulation, through the inferior mesenteric vein, leads to the formation of hemorrhoids. The subcutaneous abdominal veins become dilated, especially along the margin of the ribs and around the umbilicus (the caput Medusae). The urine may at first be increased in quantity, but soon becomes scanty, high- colored, and of high specific gravity. The reaction is strongly acid and urates are present in abundance. The amount of urea is decreased ; urobilin and uric acid are increased. There are peptonuria, sometimes glycosuria and albuminuria, from passive congestion and cachexia. With great diminution in the quantity of urine there may be symptoms of toxemia. There is more or less jaundice, especially late in the course of the disease. Fever may be present in acute cases or may be caused by perihepatitis or catarrh of the bile ducts. Diagnosis of Syphilis. 115 The above symptoms are indicative of cirrhosis, either of the syphilitic or alcoholic variety. The differentiation between these forms of cirrhosis is often difficult. Pain is more prominent in syphilitic cirrhosis, being due to affec- tion of the peritoneal capsule of the liver. Other symptoms of syphilis may help in diagnosis, but it must be remembered that syphilitics are not immune from alcoholic cirrhosis. Syphilis, like alcohol, must simply be regarded as a promi- nent toxic cause of cirrhosis of the liver. 13. Amyloid disease is due to prolonged suppuration in some part of the body. Tuberculosis and syphilis are frequent causes. Amyloid liver is usually associated with a similar involvement of the spleen, kidneys, and intestines. As a rule the liver is enlarged and firm upon pressure, and the surface is smooth. The bile is diminished in quan- tity and poor in quality, with consequent intestinal dis- turbance and tympanites. There are some anemia and leucocytosis. Suspicion may be aroused by amyloid disease in other organs, especially the spleen, kidneys, or intestine. Characteristic of amyloid liver is the great enlargement of the liver, with firmness upon pressure, rounded border, free- dom from pain or tenderness upon pressure, and the presence of a chronic suppuration somewhere in the body. Syphilis of the liver, especially perihepatitis, may cause pain or tenderness upon pressure. Pancreas. In hereditary syphilis, congential syphilitic pancreatitis has been observed as early as the fifth month. In an early report, Birch-Hirschfeld found the disease thirteen times in twenty-three cases of congenital syphilis. Later the same observer was able to report only twenty-nine instances in an additional series of 124 cases. In acquired syphilis, there is a wide divergence of opinion regarding the frequency of pancreatitis. It is in- teresting to note that in a number of cases with a history 116 Diagnosis op Syphilis. of syphilis, the pancreatitis was possibly due to a co-existing cancer of the stomach or pancreas. In a number of instances gumma and scar tissue have been found in the pancreas. Fatty diarrhoea, glycosuria, and epigastric pain would be suggestive, especially in the presence of other signs and symptoms of syphilis. Peritoneum. Peritonitis is rare. Occasionally a localized peritonitis may be caused by syphilis of the liver, intestine or spleen. Still more rare is general peritonitis, though this may result from syphilis of the intestine, especially of the small intestine, with or without perforation. RECTUM AND ANUS. Too strong emphasis cannot be placed on the importance of examinations for the spirochete pallida and the Wasser- mann reaction. While these diagnostic factors do not elimi- nate the possibility of non-syphilitic affections, they may be relied upon in making a diagnosis of syphilis. We must then decide whether the patient's syphilis is responsible for the lesion that confronts us. A negative examination for the spirochete pallida or the Wassermann reaction, does not necessarily imply that the disease is not syphilis. Syphilis most frequently affects the two extremities of the alimentary tract. All stages of the disease may be represented in affections of the rectum and anus. Hence the importance of using proper precautions, such as the protection of the hands by rubber gloves when making rectal examinations. 1. Syphilis of the rectum: (a) chancre; (b) syphilide; (c) Gumma. 2. Cancer of the rectum. 3. Rectal tuberculosis. Diagnosis op Syphilis. 117 4. Fistulae. 5. Rectal abscess. 6. Hemorrhoids. 7. Prolapse. 8. Polypi. 9. Pruritus. 10. Ulcer and fissure. 11. Stricture. 12. Rodent ulcer. 13. Fecal impaction. 14. Villous tumor. 15. Neuralgia. 16. Sacro-coccygeal arthralgia. 17. Proctitis. 1. a. The primary syphilitic sore may occur in this region through unnatural intercourse or through infection by contact with anything that is contaminated with the syphilitic virus. Possibly there is no more dangerous habit than the common use of syringes. Nowadays no physician would think of using a rectal speculum that had not been sterilized. The same precaution should be extended to the common syringe. The indurated chancre may break down, to form a painful fissured ulcer. Later, especially in the anal ring, there may be contraction that is obtrusive. 1. b. The second stage of syphilis is more frequent in the rectum and anus. The syphilides, however, usually do not cause annoyance. Indeed, this seems to be one of the characteristics of the lesion in this region. Sometimes there may be tenesmus and a discharge of mucus and pus. On the other hand, even a bleeding, ulcerated papule may cause little or no discomfort. Frequently there is a distinct separation between the papules of the anus and those situated higher up in the rectum. 1. c. The third stage of syphilis is the one that most frequently involves the rectum and anus. Gummata often 118 Diagnosis of Syphilis. occur in this locality and frequently lead to ulceration. In diagnosis, differentiation from cancer is important. Mathews has stated that in cancer of the colon there is frequently diarrhoea, whereas in syphilis of the colon there is more often constipation. Syphilis of the rectum and anus is more frequent in women than men. As compared with cancer, rectal gummata are of much slower growth. The irritation of an ulceration may cause watery, bloody stools, the presence of tenesmus and the loss of the abdominal sensation resulting in the involuntary discharge of the feces. Digital examination might arouse the suspicion of an ulcer, because of the puffiness and irregularities of the mucous membrane. The diagnosis of ulcer would be made absolute by the use of the proctoscope. The breaking down of gummata in the perirectal tissue may lead to perforation into the rectum or vagina or ex- ternally to constitute a fistula. In this way there may be formed rectoperineal and rectovaginal fistula 1 . Sometimes the anorectal syphiloma (Fournier) takes the form of a syphilitic callosity, an anorectal infiltration with the formation of cicatricial tissue that contracts and thereby reduces the size of the lumen of the rectum. This process usually does not affect the region of the sphincter. The rectum, however, may be converted into a narrow tube, with the consequent symptoms of stricture. Syphilis not infrequently causes stricture of the rectum or anus ; but not every rectal or anal stricture is syphilitic. 2. Cancer of the rectum is comparatively rare before the age of thirty-five ; and men are more frequently affected, in the proportion of six to five. The early symptoms of cancer of the rectum are a feeling of weight and heaviness in the pelvis and more or less ill defined annoyance at the time of defecation and immediately after. Later the annoy- ance becomes actual pain. The stools become altered ; there is alternating constipation and diarrhoea. The passages con- tain mucus, pus, sometimes blood. Depending largely upon the extent of the disease, and more especially upon the Diagnosis of Syphilis. 119 location of the destructive process, there may be loss of sphincter control. All of these symptoms may be slight until the cancer is pretty well advanced, and they may all be present in syphilis and other diseases of the rectum. Emaciation and cachexia may be observed in syphilis, but they usually are more marked and occur earlier in cancer. It is important to make the diagnosis before these symptoms are present, since any operative work for the cure of cancer must be done early. In the differentiation from cancer, great importance must be attached to the physical examination. This will frequently test the acumen of the diagnostician. Cases may frequently be cleared up by the mircoscopic examination of particles of the diseased tissue, which may be readily removed through the proctoscope. In syphilis, as well as in dysenteric and simple ulcer, there is comparatively slight induration, the edges of the ulceration are usually soft and flexible, and the general contour of the mass is more regular than in cancer, which usually shows more marked induration and hard, irregular borders, the induration extending beyond the edges of the ulcer and gradually fading into the surrounding tissues. It is difficult to describe the differential diagnosis by palpation, since there are so many variations in both diseases, and often the judgment must be based upon comparative findings. This is especially true in the early differentiation between syphilis and cancer of the rectum. In these cases the microscopic examination of the affected tissue is often of very great value. Above all, we must recognize and impress upon our patients the importance of making the diagnosis early, when there is a suspicion of cancer. To this end, we should not hesitate to make a rectal examination in such cases, especially after the age of thirty-five. 3. At times it becomes necessary to differentiate be- tween syphilitic and tubercular affection of the anus and rectum, especially in the presence of fistulae. In difficult cases the search for the tubercle bacillus and the use of 120 Diagnosis of Syphilis. the therapeutic test for syphilis assume importance. The tuberculin test is also of value in these cases. Tuberculosis of the rectum must be regarded as very rare in the absence of pulmonary tuberculosis. On the other hand, syphilis and tuberculosis may co-exist. I have seen a case in which both diseases involved the rectum. 4. Rectal fistulae may be external (complete) or internal (blind). As stated, they may be due to the breaking down of gummata. More frequently they are tubercular. They are more frequent in men than in women. Trauma seems to play an important role in etiology. Sometimes they result from abscess. Other etiological factors are injury by foreign bodies that have been swallowed, or by kicking, falling or other form of trauma. They occur especially in individuals of low resistance, especially in the presence of a vitiated condition of the blood. The degree and character of pain varies, being acute in the cases due to the rapid formation of abscesses, and little in the syphilitic or the simple tubercular fistula, unless the fistula involves the sphincter muscle, or becomes closed and filled with the pus. Usually the discharge is thin and watery, but it may be purulent, sometimes tinged with blood, possibly fecal. It may or ma}' not be possible to detect an external opening. The sinus may be felt as an indurated cord or mass, usually running a tortuous course. May be single or multiple. The internal opening is usually between the two sphincters, but it may be difficult to detect. It has been stated that in tuberculous fistula? the external and internal openings are large, but this is not an invariable characteristic. The same remark holds good concerning the statement that in phthisis the hair around the anus is long and silky. Such a condition is often present late in phthisis, but is found in other cases and is usually not to be observed during the early stages of tuberculosis. 5. Rectal abscess may be acute or chronic. Clinically we may consider as abscesses, cavities that are filled with either pus or broken down tissues. The latter are the so- Diagnosis of Syphilis. 121 called cold abscesses. The pain is sharp and lancinating in acute abscess. So-called cold abscess may cause only a sense of discomfort rather than actual pain. The pus is thick in acute abscesses; thin and watery in "cold" ab- scesses. The "cold" abscesses are almost invariably tubercular. There is constipation, because defecation is painful. At first palpation will detect a mass, due to inflammatory exuda- tion; later there is a collection of pus. In acute abscess, palpation will detect increased heat and elicit pain. The "cold" abscesses show fluctuation. Not infrequently these abscesses empty into the bowel. Preceding the rupture of the abscess into the bowel the patient will experience a sense of weight and pain, and rectal examination will reveal tenderness, and irritability of the sphincter. Acute abscess is marked by high temperature and rapid pulse. "Cold" abscess may be accompanied by a normal or subnormal tem- perature, and feeble low pulse. 6. Hemorrhoids may occasionally enter into the question of differential diagnosis, especially when inflamed and ulcer- ated. Hemorrhoids may be external or internal. The external hemorrhoids may be either simple skin enlargements or venous tumors. The internal hemorrhoids may be large or small, and they may or may not be hemorrhagic. Among the causes of inflammation of external hemorrhoids are irritation from friction, cold, diarrhoea, dysentery, excesses in venery, alcohol, smoking, straining at stool, and obstruction of the venous circulation. The internal hemorrhoids are almost invariably just within the sphincter, and may be readily recognized upon rectal examination. The external hemorrhoids not infrequently cause pain, through affection of the sphincter. Internal hemorrhoids are seldom marked by pain, save in the presence of inflammation or some complication. External hemorrhoids are usually not marked by discharge, save possibly some blood and mucus, if the surface is broken. The small internal hemorrhoids often bleed ; the larger ones are characterized rather by the discharge of mucus. In hemorrhoids there may be either constipation or diarrhoea, 122 Diagnosis of Syphilis. and not infrequently there is constipation alternating with diarrhoea. Externa] hemorrhoids may appear as simple tags of skin, often inflamed, or as a dark bluish tumor. The internal hemorrhoids are usually lighter in color, and when they protrude through the sphincter they may be readily returned. Often the internal hemorrhoids cannot be detected by the sense of touch, when in the bowel, unless they are in- flamed. The patient with external hemorrhoids complains of pain and the presence of a tumor, frequently with pain in walking and at stool. Internal hemorrhoids cause more indefinite symptoms, such as pain in the back and thighs, loss of energy, and possibly mental anxiety. These patients not infrequently fear that they have cancer. The sphincter is usually contracted in j'outh and relaxed in the aged. 7. Prolapse of the rectum is not a very common affection. It is more frequent in children, often apparently due to intestinal parasites, especially thread worms. A diminished sacral curve has been declared to be a cause. There is very little pain, unless there is strangulation. There is a dis- charge of mucus, possibly tinged with blood. Generally there is diarrhoea. Excessive diarrhoea sometimes is a causative factor. The prolapsed tissue protrudes as a soft, velvety mass, entirely surrounding the anus. The patient may complain of a burning sensation. 8. Polypi have sometimes been mistaken for syphilis, but more frequently for cancer, especially when inflamed and ulcerated. Examination will reveal a tumor attached to a pedicle. When the polypus protrudes past the sphincter, the patient will experience some pain. The mass is easily replaced. The discharge consists of mucus, sometimes blood. Diarrhoea is more common than constipation. A protruding polypus may resemble a berry in appearance, and may be hard or soft to the touch. It is distinguished from other tumors by the fact that it is attached to a pedicle. They are most frequently mistaken for piles. 9. Pruritus may at times be confused with syphilis, especially condyloma. Pruritus is aggravated by discharges. Diagnosis op Syphilis. 123 The patient complains of a burning sensation rather than actual pain. There is usually more or less laceration of the skin, due to scratching for the relief of itching. The anal folds may be roughened, and the pruritus may extend to the scrotum and buttocks. The margin of the rectal mucous mem- brane is reddened and irritated, and the itching often extends up into the rectum. At times pruritus may bear some resem- blance to eczema, and there may be a weeping surface. There is often increased pigmentation. 10. Rectal ulcer and fissure are comparatively common affections, and are due to many things beside syphilis. There is practically no difference in the frequency of affection of the sexes. The most common cause is trauma, anything that will tear or cause a lesion of the rectal mucous mem- brane. Rectal ulcer is located above the sphincter but within its grasp. Pain is out of all proportion to the lesion, beginning perhaps twenty minutes after defecation and last- ing for hours. There is often no discharge, but usually there is a discharge of mucus tinged with blood. Painful defecation leads to constipation. Examination of the anus will often reveal a swollen tag of skin, that appears as a small white tumor. The ulcer is higher up, and can be readily inspected with the speculum, a red and inflamed ulcer on or above the sphincter. A fissure may extend down to the anus. The dorsal portion of the rectum is most frequently affected, though no part is exempt. There may be symptoms on the part of the bladder, prostate and urethra. 11. Stricture of the rectum may be simple or accom- panied by ulceration. Syphilis is the most common cause of the ulcerated strictures. Cancer is another prominent cause. Other etiological factors are traumatism and long continued pressure. Simple stricture of the rectum in females is often due to pressure of the uterus. There is little or no pain, but rather a feeling of weight in the rectum. There may be diarrhoea or constipation. Often there is alternating constipation and diarrhoea. There may be no discharge. A mucous discharge may be present in simple stricture and 124 Diagnosis op Syphilis. is the rule in ulcerated stricture, becoming later muco- purulent. There is not much blood. There are no external signs, save in the presence of fistula or pruritus. Simple stricture can be felt digitally as an annular constriction, often like a cord extending around the bowel. In ulcerated stricture there is ulceration above and below the stricture. The stricture is hard and fibrous but not nodular. Nodules would speak rather for cancer. Constipation characterized by chronicity is often due to simple stricture. The syphilitic ulcerated stricture begins usually as a gumma, and the patient often seeks advice first because of constipation or diarrhoea. 12. Rodent ulcer may resemble syphilis. It is a com- paratively rare disease. Pain is caused by ulceration. There is a slight discharge of blood and mucus. Diarrhoea. Nothing may be found externally, but examination of the interior of the rectum reveals a large ragged ulcer, irregular and sensi- tive to the touch. 13. Fecal impaction is due to loss of tone of the muscles in the intestinal wall, and is found most frequently in the aged. There is indistinct pain, described usually as a dull heavy pressure at the anus. There may be severe reflex pain. Discharge is usually absent, save in the presence of ulceration. There is usually the diarrhoea of constipation. Usually nothing may be observed externally. Some have de- scribed a nipple-shaped anus. Examination shows a hard doughy mass above the sphincter. There may be considerable general disturbance in these cases, such as indigestion, loss of flesh, possibly night-sweats. 14. Villous tumor is rare. There is little pain. There is a discharge of mucus, and especially of blood. These tumors may cause diarrhoea to present the picture of a dysentery. Sometimes these tumors descend so as to be visible externally. Examination with the speculum reveals the characteristic villous tumor. These bleed freely and may or may not be attached by a pedicle. There is often anemia due to the loss of blood. 15. The chief characteristic of neuralgia is pain, gnaw- Diagnosis of Syphilis. 125 ing, teasing and distressing in character. Any discharge is due to ulceration or some organic lesion. Bowels may be normal. Rectal neuralgia is comparatively rare, and effects especially the nervous and irritable, though the robust are not exempt. 16. Sacro-coccygeal arthralgia may be neuralgic or rheumatic. Pain is constant and is not usually relieved by any position the patient may assume. No discharge. The diagnosis is made by digital examination. Trauma and child-birth are prominent causes. 17. Proctitis may be due to any of the numerous causes of inflammation. There is a dull, heavy pain in the rectum. Reflected pain may be experienced in other organs and in the back and thighs. The discharge may be bloody or mucous or muco-purulent. There is diarrhoea, often dysenteric in character. The diagnosis is made by rectal examination. SYPHILITIC AFFECTIONS OF THE RESPIRA- TORY ORGANS. Nose. All stages of syphilis may affect the nose. The first stage is represented by the chancre, which may be found upon the tip or ala of the nose. "Cases have also been reported in which the chancre has been found in the interior of the nose, the naso-pharynx and upon the septum. Usually there is enlargement of the submaxillary glands; less frequently the preauricular glands are affected. In the reported cases, the finger has generally been the medium of infection. A number of cases have resulted from the use of contaminated handkerchiefs and towels. The danger of using unclean instruments is not to be lost sight of. Infection has been conveyed by the eustachian catheter.,- Syphilitics should be instructed not to lend their atomizers, when these are pre- scribed. In general, the syphilitic patient should be impressed 126 Diagnosis of Syphilis. with the contagious character of his malady. In doubtful cases, the therapeutic test for syphilis and the microscopic examination of the affected tissue is justifiable, in order to make an early differentiation from cancer and tuberculosis. Usually an examination for the spirochete pallida and the Wassermann reaction will determine whether or not the patient is a syphilitic. The second stage of syphilis frequently involves the nose, but is often overlooked because it usually does not cause much inconvenience. All the various secondary erup- tions of the skin and mucous membrane may be represented in the nose. These patients frequently suffer from "colds," coryza. Indeed, a nasal catarrh is not infrequent during the first stage of syphilis. During the second stage, catarrh and ulceration of the nasal mucous membrane may often be found. The coryza of syphilis is not always a symptom of iodism. But usually the nasal symptoms of the second stage of syphilis are comparatively mild. The ulcerations of the nasal mucous membrane during this stage are usually superficial. In the nose, the third stage of syphilis is most important. The sunken bridge of the nose is a prominent sign of syphilis. Gummata may occur in any part of the nose. These may block the nose and lead to extensive destruction of tissue and deformity. Gumma of the skin has already been de- scribed. Gumma of the skin of the nose may cause destruc- tion of the skin and also of the underlying cartilage and bone. The same is true of the mucous membrane. Gumma of the mucous membrane may lead to destructive changes in the cartilage and bone. On the other hand, it is remarka- ble what large ulcers will sometimes result from the breaking down of gummata without destruction of the cartilage or bone of the nose. The cartilage and bone are much more liable to damage in gumma of the mucous meembrane than in gumma of the skin. Gumma occurring primarily in the cartilage or bone is regarded as rare. Of the cartilage of the nose, the cartilaginous septum is most frequently affected Diagnosis op Syphilis. 127 by the ulceration of gummata, often with consequent per- foration of the septum. Less frequently there is destruction of the ala or tip of the nose. Gumma may also lead to perforation of the palate. Perforation of the roof of the nose, externally, is more rare. The ulceration and destruction of bone occur with especial frequency during the tertiary syphilitic affections of the nose. Gumma of the nasal bones frequently leads to necrosis. So it is not strange that the third stage of syphilis is often marked by an intractible rhinitis, that may persist for months or years. Sometimes the gumma produces pain. The more marked symptoms, as a rule, are the obstruction to breathing, the rhinitis, and the destructive processes. It is interesting to note that de- struction of the bone has been, observed as early as the seventh month of syphilis. At times ozena is a conspicuous symptom of syphilis. Great destruction of bone may occur without marked external deformity. On the other hand, sinking of the bridge of the nose may be caused by destruction of the perpendicular plate of the ethmoid bone and the subsequent contraction of cicatricial tissue. Further deformity may be caused by destructive changes involving the vomar and the cartilaginous septum, when the entire nose appears sunken through the subsequent contraction of the cicatricial tissue. The contraction of cicatricial tissue probably plays an im- portant role, for it is remarkable what great destruction of tissue may occur without external deformity Not every ozena is syphilitic. But syphilis may produce a marked ozena, ozena syphilitica, due to a rhinitis syphilitica necrotica or atrophica. The French call the condition punaisie, comparing the odor to that of a crushed bedbug (punaise). Frequently these patients do not, themselves, perceive the odor of their ozena, while at the same time they may or may not be able to recognize other odors. The differential diagnosis has to do chiefly with tuber- culosis, especially lupus ; rhinoscleroma, and carcinoma. Lupus usually occurs at an earlier age than acquired syphilis, but syphilis may occur at any age. The diagnosis of tuberculosis 128 Diagnosis of Syphilis. rests upon the demonstration of the bacillus in the discharge or in the growth. There may be tuberculosis elsewhere, espe- cially in the lungs, larynx, mouth, tongue, or pharynx. Lupus presents a history different from that of syphilis, and is often accompanied by cutaneous lupus. The growth is slow. The nodular character of the lupus lesion, and its manner of spreading at the circumference and cicatrizing in the center, are characteristic. Rhinoscleroma is rare in this country. Recognition depends upon finding the bacillus of rhinoscleroma. The affection is confined to the nose, and is characterized by hardness, sharp outlines, slow develop- ment, absence of adjacent inflammation and of constitutional symptoms. Pain is absent. The diagnosis of carcinoma is made absolute by the histological examination of the growth. The specimen of tissue taken for microscopic examination, should extend from the diseased into the apparently healthy tissue. In cases of carcinoma, the Wassermann reaction is negative, except when the patient is a syphilitic. There is pain, sometimes lancinating in character. Early in the course of the affection, the lymphatic enlargement is slight compared to that observed in syphilis. The course of the disease is very different from that of syphilis. Doubtful cases may be cleared up by the Wassermann reaction, the therapeutic test for syphilis, and the microscopic examination of the affected tissue. Ozena may be due to simple atrophic rhinitis. Often there is a history of preceding hypertrophic rhinitis. Exami- nation reveals the mucous membrane thinned, often covered with crusts. Ulcers are not common. There is cirrhotic atrophy of the erectile tissue. Among the rare causes of ozena are glanders and leprosy. The diagnosis of glanders is made absolute by finding the bacillus mallei. The mallein test, when carefully made, is of value. A history of exposure to inoculation may aid in diagnosis. The general symptoms are marked by their severity, far exceeding those commonly observed in syphilis. Leprosy usually presents antecedent affection of other parts Diagnosis of Syphilis. 129 of the body, the nasal affection being secondary to the cutaneous and general invasion. The bacillus lepras makes the diagnosis, but is difficult to detect in the tissue. In these affections (glanders and leprosy), the spirochete pal- lida and the Wassermann reaction are absent, except in syphilitics. Rhinitis. Differential diagnosis may call for the recognition of: 1. Syphilis: a, chancre; b, syphilides; c, gumma. 2. The common "colds." 3. Toxic rhinitis, especially iodism. 4. Rhinitis of the acute infections and constitutional diseases. 5. Membranous rhinitis. 6. Hay fever. 7. Occupation rhinitis, due to dust and vapors. 8. Phlegmonous rhinitis. 9. Acute edematous rhinitis. 10. Ulcerative rhinitis. 1. In hereditary syphilis, inability to nurse is sometimes referred to as a symptom of syphilitic rhinitis. This symp- tom is also present in simple rhinitis. In syphilitic rhinitis there may be the history or evidence of syphilis in one or both parents. Such history or evidence is not essential in simple acute rhinitis. In syphilitic cases the child is ill developed, small, shriveled, and presents the senile appearance. The skin is sallow and unhealthy in appearance. There are various other syphilitic lesions, such as condylomata, mucous patches, skin eruptions, copper colored blotches, onychia, alopecia or brittle hair that has lost its luster, enlargements of the bones, and possibly subcutaneous hemorrhages. The liver and spleen are enlarged. The voice is often described as characteristic. At any rate, the voice is feeble and the child does not seem as happy as a normal child, and is fretful and wakeful at night. Nutrition is impaired. There 130 Diagnosis op Syphilis. is a painless enlargement of the lymphatic glands, most readily recognized in the cervical, submaxillary, inguinal and axillary regions. Usually there is no fever. The course of the disease is characteristic. There is a tendency to ulcera- tion of the mucous membrane, cartilage and bone, with flat- tening of the nose. The discharge is purulent, contains shreds of necrotic tissue, is offensive and often streaked with blood. The alffi present fissures and ulcers. In simple acute rhinitis there is no characteristic eruption, the associate symptoms of syphilis are absent, the liver and spleen are not enlarged, and the child is more normal in appearance. There may be some disturbance of sleep, but this is not so marked as in syphilis. There is little or no impairment of nutrition. There is no general enlargement of the lymphatic glands ; the maxillary glands may be en- larged and painful, but this is not usual. At first there is slight fever, and the affection runs an irregular course. The inflammation of the mucous membrane soon terminates without ulceration or flattening of the nose. There is a discharge, but it is rarely or never markedly purulent; it is not offensive and rarely streaked with blood. There are not the fissures and ulcers of the alae, nor the formation of crusts such as we find in syphilis. Chancre and gumma are accompanied by rhinitis, when these occur in the nose, but in those cases the rhinitis is overshadowed by the essential lesion, chancre or gumma. 2. Syphilitic patients not infrequently come to us with a syphilitic rhinitis, under the impression that they have an acute "cold." The acute "colds" run a short course and respond to simple remedies, whereas syphilitic rhinitis is more obstinate to these remedies and responds readily to antisyphilitic treatment. 3. A toxic rhinitis will sometimes prove interesting, from a differential diagnostic standpoint, especially when such a rhinitis occurs in a syphilitic. This not infrequently occurs when we are pushing the iodides. Bromism is also frequently Diagnosis of Syphilis. 131 encountered. These cases of toxic rhinitis improve readily upon the discontinuance of the offending drug. 4. Rhinitis is present in a number of infections and constitutional diseases, notably : Measles, whooping-cough, scarlet fever, small-pox, typhoid fever, diphtheria, tuberculosis, diabetes mellitus, erysipelas, scurvy, influenza, and rheumatism. To this list may be added the rare cases of caseous rhinitis. Syphilis, of course, is a prominent cause of rhinitis, but we must not forget that rhinitis may be due to many other causes, and that these causes may be active both in the syphilitic and the non-syphilitic. Thus, rheumatism and asthma are often prominent causes of rhinitis. Differential diagnosis may demand the recognition of these various diseases. 5. Membranous rhinitis may be due to nasal diphtheria. In cases of doubt it is safer to consider such cases diphtheria until the diagnosis is clear. The differentiation is made by examination for the bacillus diphtherias. There are marked, usually severe, constitutional symptoms. The source of in- fection may not always be known. The affection of the nose is rarely primary, being usually secondary to affection of the pharynx, fauces or soft palate. Albuminuria is the rule. The cervical glands are enlarged. The membrane is grayish or dirty white in appearance, involves the deeper layer of the mucous membrane, is closely adherent, and leaves a bleeding surface when removed. There may be ulceration and a subsequent scar. The nasal discharge is fetid. Some- times the condition becomes chronic. There may be subse- quent paralysis, especially of the soft palate. Prefers youth and early adolescence. Sporadic cases of membranous rhinitis are met with, that are due to neither diphtheria nor syphilis. Such a croupous rhinitis will present mild constitutional symptoms. The affec- tion of the nose is usually primary, and the affection remains limited to the nose. There is no albuminuria, no enlargement of the cervical glands, and the affection of the mucous mem- 132 Diagnosis of Syphilis. brane is superficial. The membrane is readily detached with- out bleeding (as a rule), and there is no ulcer nor subsequent scar. The membrane is lighter in color than in diphtheria. The discharge is not especially fetid. These cases may occur at any age and may become chronic. There is no subse- quent paralysis. 6. Hay fever is marked by severe stubborn rhinitis. The nasal mucous membrane is hyperesthetic. Diagnosis may be aided by a knowledge of the periodicity of the attacks, and possibly by finding the exciting cause of the condition. 7. Occupation rhinitis occurs especially in those exposed to dust and irritating vapors, such as chlorin, ammonia, iodin, bromin, etc. It is found especially in those predisposed by occupation to pneumonokoniosis, such as millers, coal miners, wood-carvers, brush makers, weavers, hat makers, individuals who are exposed to a dusty atmosphere. It may be caused by the fumes of bichromate of potassium, mercury, arsenious acid, and osmic acid. Hay fever might be included under this class, since irritation by the pollen of plants is a promi- nent factor in that disease. However, it is probable that hay fever is due to some microorganism that grows upon the pollen of certain plants. The possibility of an occupation or a traumatic rhinitis should be considered when making a diagnosis of syphilitic rhinitis. 8. Phlegmonous rhinitis presents a localized swelling, usually on one or both sides of the septum. It runs the course of an acute abscess. 9. Acute edematous rhinitis may be caused by the inhala- tion of steam, irritating fumes, or anything that may cause a sudden change in the vascularity of the tissue and conse- quent watery infiltration, such as injuries of the mucous membrane or the bony framework of the nose. In such cases, a knowledge of the cause may be an aid in differential diagnosis. 10. Ulcerative rhinitis deserves separate consideration, since nasal ulcer is frequently due to syphilis. Diagnosis of Syphilis. 133 Chronic rhinitis may be due to: 1. Syphilis. 9. Intumescent rhinitis. 2. Tuberculosis. 10. Hyperplastic rhinitis. 3. Glanders. 11. Ozena. 4. Leprosy. 12. Atrophic rhinitis. 5. Actinomycosis. 13. Purulent rhinitis. 6. Rhinoscleroma. 14. Nasal hydrorrhcea. 7. Cancer. 15. Edematous rhinitis. 8. Simple chronic rhinitis. 1. All stages of syphilis may be represented by lesions in the nose. Chancre is rare, and for this reason is often not recognized as syphilitic until the appearance of the later symptoms of the disease. At times the history is of value in making a diagnosis ; again, it may be doubtful or unre- liable, so as to obscure the diagnosis. Taking into consi- deration the appearance of the lesion, and the presence of indolent buboes in the neighboring lymphatics, we may arrive at a diagnosis by exclusion. Suspicious cases may be cleared of by finding the spirochete pallida. Nasal syphilides are often overlooked. Macular syphilides may cause only slight disturbance. The papular and pust- ular syphilides are often accompanied by ulceration and marked symptoms. In any case, there may be the history of infection, the evidence or history of a primary lesion, and the presence of syphilides in other parts of the body, to- gether with constitutional symptoms. In doubtful cases, a positive reaction to the therapeutic test is one of the most valuable points in diagnosis. We have described the tertiary syphilitic lesions that are found in the nose. The history of the case, the presence or evidence of other syplulitic lesions, the necrotic character of the nasal lesions, the odor, and the response to the iodides are valuable points in diagnosis. However, it should not be forgotten that a syphilitic patient is not immune to other diseases. Rhinitis is one of the most important symptoms of heredi- 134 Diagnosis of Syphilis. tary syphilis. The presence of "snuffles," the history or evidence of syphilis in one or both parents, the senile ap- pearance of the child, the presence of other syphilitic lesions, and the response to anti-syphilitic treatment are useful diag- nostic points. Hereditary syphilis may later cause symptoms similar to those of the third stage in acquired syphilis. There is marked destruction of tissue and deformity of the nose, offensive odor, the presence or evidence of other syphilitic lesions and the response to anti-syphilitic treatment. Lupus must some- times be considered in differential diagnosis. 2. Infection by the tubercle bacillus may cause ulcers, or tumors composed of masses of tubercles, or the clinical picture known as lupus. The tubercular ulcer will be referred to later. Nasal tuberculosis is comparatively rare, is always due to the tubercle bacillus, and occurs almost exclusively in the presence of pulmonary tuberculosis, and frequently in association with tubercular lesions in the mouth, tongue, pharynx or larynx. The histor} r of syphilis and tuberculosis are entirely different. However, syphilitics may have tuber- culosis, and tubercular patients are not exempt from syphilis. A positive diagnosis may be made by finding the tubercle bacillus in the affected tissue. Aside from syphilis, differential diagnosis has to do chiefly with cancer, which is marked by a more rapid course and greater pain. Usually tuber- culosis occurs at an earlier age than cancer. Lupus of the interior of the nose usually occurs in asso- ciation with a similar affection of the exterior of the nose. The affection is marked by its chronicity, the presence of small elevated nodules that tend to spread, coalesce, and ulcer- ate. Sometimes absorption takes place and there is subse- quent atrophy. Lupus is not characterized by the history of syphilis, nor by the presence of syphilitic lesions, and it is not influenced by anti-syphilitic treatment. The disease must be differentiated also from cancer, which runs a more rapid and painful course, and usually occurs later in life. Diagnosis of Syphilis. 135 The ordinary nasal polypi will cause little difficulty in diagnosis. 3. Glanders is a comparatively rare disease in man. In- fection by the bacillus mallei occurs almost exclusively in those who associate intimately with horses. There are severe constitutional symptoms, and the presence of granulation tumors in the mucous membrane, which tend to rapid ulcera- tion and cause an offensive discharge. A positive diagnosis may be made by finding the bacillus mallei. Usually there is a reaction to mallein, similar to the reaction to tuberculin in tuberculosis. The diagnosis is not difficult to make if the disease is suspected. There are more marked constitutional symptoms than are characteristic of syphilis, and the disease does not respond to the therapeutic test for syphilis. Typhoid fever may at times be thought of, but the other symptoms of that disease are lacking. It should also be differentiated from septicemia and cancer. 4. Leprosy is a rare disease with us, but it is increasing in frequency in this country. In the nose, it may at times resemble tertiary syphilis, but the history and course are different. Usually there are preceding cutaneous and systemic symptoms of the disease. The demonstration of the bacillus lepras in the affected tissue would make the diagnosis positive. Leprosy should be differentiated from syphilis, and also from iodism, morphcea, sarcoma, molluscum fibrosum, lichen planus, dysidrosis and Morvan's disease (if this be not, indeed, a va- riety of leprosy, or leprosy a causative factor of Morvan's dis- ease). The history of the possibility of infection may be of value in diagnosis. But usually the disease has lasted several years before the nose is affected. There may be extensive le- sions, ulceration and absorption of bone, with little or no pain, especially in the anesthetic form of leprosy. There is the offensive discharge, in these cases, such as is observed in the presence of destructive syphilitic lesions of the nose. 5. Actinomycosis has probably not been reported in the nose. But it has been observed in other parts of the upper respiratory tract, and the possibility of it occurring in the 136 Diagnosis of Syphilis. nose should not be overlooked. The diagnosis would be made by finding the ray fungus. 6- Rh'moscleroma is comparatively rare with us. A positive diagnosis may be found by demonstrating the bacillus of rhinoscleroma in the affected tissue. The disease is char- acterized by the deposition of hard nodules in the submucosa of the mucous membrane and the deeper layers of the skin. Like syphilitic lesions, rhinoscleroma is comparatively pain- less. There is little or no discharge, and ulceration is rare. The disease runs an extremely slow course, and constitutional symptoms are lacking. There is not the history of syphilis, and rhinoscleroma does not respond to anti-syphilitic treat- ment. Epithelioma runs a more rapid course, and is more prone to bleed, soften and ulcerate. Keloid may often be differentiated only by a search for the bacillus of rhinoscleroma. 7. Cancer is one of the most important diseases of the nose, especially from the standpoint of early differential diagnosis. An early diagnosis is made by the microscopic examination of a section of the diseased tissue. Such a sec- tion should extend from the healthy tissue into the patho- logical growth, and it should be removed with as little laceration and irritation as possible. The secretion is not so tenacious, stringy and adherent to the growth as in tubercular lesions. Carcinoma may be limited to the nose but is likely to invade adjacent structures. The growth is irregular and tends to ulceration. There is severe pain, the ulcers do not tend to heal, and the disease is not affected by the therapeutic test for syphilis. Syphilis shows lesions in remote parts of the body. The syphilitic lesions are usually fairly firm, with surrounding areas of inflammation. In syphilis there is a tendency to ulceration, but these tend to heal, are not especially painful except when irritated, and respond to the therapeutic test for syphilis. Fibroma is usually a painless growth, dense and firm, often pedunculated, that does not tend to ulceration and does not respond to anti- syphilitic treatment. Diagnosis of Syphilis. 137 8. Simple chronic catarrh of the nose may be caused by an acute catarrh becoming subacute and later chronic. Thus the causes of acute catarrh of the nose, when long continued, may produce a chronic catarrh. Common causes are bad ventilation, dust, tobacco, and snuff. The symptoms are less intense than in acute catarrh of the nose and of longer duration. Diagnosis calls for differentiation from acute catarrh, polypus, and syphilis. Inspection reveals the mucous membrane swollen, especially over the turbinated bones, and covered more or less by secretion. There may be ulcers or erosions of the mucous membrane. Syphilitic catarrh of the nose is characterized by lesions involving the deeper struc- tures as well as the mucous membrane. In syphilis, there are frequently evidences of the disease elsewhere. Doubtful cases justify the therapeutic test. 9. Intumescent rhinitis, a form of chronic catarh char- acterized by rapid swelling of the nasal mucous membrane, especially over the turbinates and the septum, is more liable to be mistaken for iodism than for syphilis. Intumescent rhinitis is not relieved by withdrawing iodin, and the attacks usually occur during the spring and fall. The swelling of the mucous membrane is due to an exudate, that may gravitate from one side to the other. The breath is often offensive, the tongue coated, and there may be gaseous eructa- tions and digestive disturbances. 10. Hyperplastic rhinitis is characterized by hypertrophy of the turbinates with an increase of the connective tissue elements of the submucosa. The condition has been compared to hypertrophic cirrhosis of the liver. This is not to be confused with the hypertrophic stage of atrophic rhinitis, which corresponds to the hypertrophic stage of cirrhosis of the liver. Hyperplastic rhinitis differs from the simple exuda- tive rhinitis inasmuch as the hyperplastic tissue does not contract upon the application of cocaine or adrenalin, or at any rate there is not so great contraction as is observed in the simple exudative forms of rhinitis. Indentations, such as may be made with a probe, show a firmer tissue that more 138 Diagnosis of Syphilis. slowly returns to the normal than in simple exudative rhinitis. Hyperplastic rhinitis does not present the appearance of any of the syphilitic lesions ; there is not so great deformity, nor the tendency to the destruction of tissue that is common in syphilis. 11. Ozena is a much abused term. Early in the evolu- tion of nosology, ozena was regarded as a disease of the nose characterized by an offensive odor. At the present time ozena is more properly considered as a symptom, characterized by a nasal stench or fetid odor, that may be perceptible to the patient or to those about him, or to both ; that may be unilateral or bilateral, constant or intermittent, and that may or may not be influenced by the application of disin- fectants. Syphilis, especially through the destruction of bone, is one of the most prominent causes of ozena. Ozena may assume importance in atrophic rhinitis. The presence of dead bone from any cause, suppurative sinusitis, glanders, coryza caseosa, cancer, benign neoplasms, congenital mal- formations, and foreign bodies in the nose may cause ozena. Sometimes it is due to the extension of dental caries to the nose. The odor is readily recognized ; the chief problem is to find the cause. 12. Atrophic rhinitis is marked by atrophy of the nasal mucous membrane ; tbe turbinates appear reduced in size, the interior of the nose is larger than normal, and there is usually ozena, due to decomposition of the secretions of the nose. This form of rhinitis should be differentiated especially from lupus, syphilis, frontal, ethmoidal and maxillary suppurative sinusitis, and from rhinoliths and foreign bodies in the nose. The ozena of syphilis differs in odor from that of atrophic rhinitis. Syphilitic ozena is due to the presence of dead bone ; the ozena of atrophic rhinitis, as stated, is due to the decom- position of the nasal secretions. Syphilis is marked by ulcera- tion and destructive changes, rather than by simple atrophy of the mucous membrane. Syphilis more frequently involves the septum ; atrophic rhinitis affects the turbinates. Doubtful cases justify the therapeutic test. Diagnosis of Syphilis. 139 13. Frequently there is a purulent rhinitis in syphilis. But there are many other causes of purulent rhinitis. The condition may be due to trauma or the presence of foreign bodies in the nose. It may be regarded as a septic infection of the nose. The characteristic feature is the discharge from the nose of a thick, tenacious mucopurulent material, often of a yellow color. There may be some fever with the attack. The discharge is irritating, and often causes excoriation and even ulceration of the upper lip with which it comes into contact. There is little odor, which is increased if the dis- charge becomes more tenacious so that it remains in the nose and undergoes decomposition. There is little, if any obstruc- tion of the nose. 14. Nasal hydrorrhoea would hardly be mistaken for either syphilis or iodism. The history is entirely different from either of these diseases. The constant and abundant discharge of clear fluid, occuring often in attacks that show more or less periodicity, is characteristic of hydrorrhoea. The affection is obstinate to treatment, and is not affected by the exhibition or withdrawal of the iodides or other anti-syphilitics. 15. Chronic edematous rhinitis is marked by swelling of the turbinates, intermittent or constant, with consequent in- terference with nasal respiration. The swelling is due to a watery infiltration into the connective tissue. Any interference with the venous or arterial circulation may be a causative factor. Thus, affections of the liver, kidney, heart, and lungs may enter into the etiology of this condition. Nasal ulcer may be caused by chancre. This is rare. It has been described as granular in appearance, or hard and cartilaginous, with an ulcerating surface. There is epistaxis and occlusion of the nose. Involvement of the alas is followed by deformity. During the second stage, ulcer of the nose may be due to the mucous patch, or superficial ulcers may be formed by the breaking down of papular or pustular syphilides. The mucous patch may cause little or no discomfort, and presents the general appearance of that lesion on other mucous mem- 140 Diagnosis op Syphilis. branes. The superficial ulcer is not so common. It is usually situated upon the septum, but may be found upon the floor of the nose or on the turbinates. It has well-defined borders, and the surrounding mucous membrane is apparently healthy. The surface of the ulcer may be somewhat depressed, of a grayish-pink color, covered with thick, stringy, yellowish gray mucopus. There is slight sensitiveness to touch. The lesion bleeds easily, but there is no tendency to extend. During the third stage of syphilis, a superficial ulcer may be due to the breaking down of a superficial gumma. But during this stage of the disease the more characteristic lesion is the deep ulcer with bony necrosis, due to the disintegration of deeper gummata. As is common with syphilitic ulcers, there is a preference for the septum, though other parts of the nose, especially the turbinates, are not exempt. These ulcers usually occur some ten or fifteen years after the primary infection, so that we will frequently find the history or evi- dence of other syphilitic lesions. Nasal Ulcer. Syphilitic nasal ulcer should be differentiated from : 1. Catarrhal erosions. 11. Leprosy. 2. Herpetic ulcerations. 12. Glanders. 3. Eczema. 13. Diphtheria. 4. Ulcer due to foreign bodies. 14. Measles. 5. Neuroparalytic ulcers. 15. Rheumatism. 6. Scurvy. 16. Scarlet fever. 7. Diabetic ulcers. 17. Smallpox. 8. Varicose ulcers. 18. Typhoid fever. 9. Cancer. 19. Typhus. 10. Tuberculosis. 1. The simple non-syphilitic catarrhal ulcer usually occurs near the anterior nares, upon prominences, such as exostoses of the septum, or where the mucous membrane is thinned by pressure, as by enlarged turbinates that encroach upon the Diagnosis of Syphilis. 141 septum, or in the presence of retained secretions. The ulcer is sensitive, and the nasal discharge is profuse. The diagnosis is aided by the painful character of the simple ulcer, the de- tection of the cause, and the absence of symptoms or evidence of syphilis. Simple catarrhal ulcers may occur in syphilitics ; in such cases the diagnosis is based chiefly upon the appear- ance of the lesion. The catarrhal ulcer is more sensitive and does not present the infiltration observed in syphilitic lesions. There may be epistaxis, but occlusion of the nose is not so prominent in these cases as in the ulcers due to syphilis. 2. Herpes may be a cause of nasal ulcer. The course and appearance are so different from those presented by syphilitic ulcer, that mistakes in diagnosis are not likely to occur. The herpetic ulcer is due to the breaking down of herpetic vesicles. These may be confluent. There is a rise of temperature and pulse, and considerable local discomfort. 3. Nasal ulcer may be caused by eczema. "Eczema" is a term that has been so much abused that we almost hesitate to use it. The disease may be acute, but is usually chronic. There may be irregularly scattered or closely aggregated papules, vesicles and pustules, or a diffuse redness and swell- ing, the surface scaly, covered with papules, vesicles and pustules, and weeping or covered with yellow, gummy crusts. The diagnosis is aided by finding the cause of the eczema, such as an irritating discharge from the eye. Often children will show eczema on the upper lips and cheeks. Irritation of the bowels, by ascarides or by improper diet, may be etiological factors. The nasal crusts are accompanied by irri- tation, that often causes the patient to pick the nose, and this increases the irritation and prolongs the disease. The nasal discharge may or may not be copious, and usually is without marked odor. Adults often seem to suffer from malaise, especially after eating, thus presenting the picture of gastric catarrh. Usually there is an excess of urates in the urine. These points, especially the discovery of a cause of the eczema, with the general appearance of the lesion and the 142 Diagnosis of Syphilis. absence of symptoms or evidence of syphilis, suffice to make the diagnosis. 4. Foreign bodies mby cause nasal ulcer. The diagnosis is made by the discovery of the foreign body, or the history of its presence. When the ulcer does not heal immediately upon the removal of the foreign body, it presents the appear- ance of a simple catarrhal ulcer. 5. Neuroparalytic nasal ulcer may be due to paresis or paralysis of the fifth nerve. The ulcers vary in size, are dry and sluggish, and show little tendency to heal. Epistaxis and loss of smell have been reported in these cases. 6. Nasal ulcer due to scurvy is rare ; more frequently there is a traumatic or catarrhal nasal ulcer in cases of scurvy. The diagnosis is based upon the presence of an epidemic, the character of the food, the presence of other symptoms of scurvy, and the improvement following the use of proper food. The nasal lesion leads to a fetid, offensive discharge. The ulcer is fungoid in appearance, bleeds easily, and the edges are hard, thick and shiny. The ulcer shows a tendency to extend. 7. Diabetes may be accompanied by nasal ulceration, usu- ally near the anterior nares, due to picking the nose for the relief of the nasal irritation common in diabetes. The diag- nosis is made by the detection of glycosuria and the recogni- tion of other symptoms of diabetes. 8. Venous stasis may lead to the formation of varicose ulcers, especially upon the turbinates, and sometimes on the posterior border of the soft palate. The ulcers are indolent, irregular in outline, shallow, and bleed easily. The mucous membrane is cyanotic, and a search may disclose the cause of the venous stasis. 9. Cancer is one of the most important causes of nasal ulcer, and the differentiation between this condition and syph- ilitic ulcer ma}- be difficult. Should the appearance of the lesion and the concomitant symptoms and history not suffice to make the diagnosis, we are justified in removing a section for microscopic examination and also in making the therapeutic Diagnosis of Syphilis. 143 test. We should not forget that cancer may develop in a syphilitic and even upon a syphilitic lesion. Furthermore, when the iodides are pushed they sometimes cause a temporary retrogression of cancerous growths. The cancerous ulcer does not tend to heal, and the pain is severe. In syphilis, the ulcer tends to heal, and usually there is little or no pain save upon irritation. 10. Tubercular ulcers are rare in the nose. They occur especially upon the septum, sometimes upon the turbinates. The ulcer is grayish white in appearance, with an irregular, ill-defined outline. Sometimes miliary tubercules may be seen in the mucous membrane outside of the ulcer. The ulcers bleed easily. The therapeutic test is often a valuable diag- nostic aid. Usually there is pulmonary tuberculosis, and some- times there is general miliary tuberculosis. At any rate, cases presenting a tubercular ulcer respond to the tuberculin test. 11. Uulcer of the nose is not uncommon in leprosy. The leprous ulcer is accompanied by a very offensive bloody, watery discharge. There may be great deformity, perforation of the septum and destruction of the- alae. Bleeding is often an early symptom. The diagnosis is usually easy because of other leprous lesions. The tertiary syphilitic ulcer presents a different history. Doubtful cases should be subjected to the therapeutic test. 12. Nasal ulcer is rarely due to glanders. The diagnosis may be aided by a knowledge of the occupation of the pa- tient — possibility of contact with diseased animals or with patients having the disease. The course and history differ markedly from syphilis. The incubation is usually three or four days. The point of inoculation shows swelling and red- ness with inflammation of the lymphatics. Nodules form in the nasal mucous membrane and break down to form ulcers, from which there is a muco-purulent discharge. Papules, which soon become pustules, appear on the face and over joints. The patient experiences chilly sensations, fever head- ache, and prostration. Mallein, a product of the glanders bacillus, is used in the diagnosis of glanders, much as tuber- Hi Diagnosis of Syphilis. culin is used in the diagnosis of tuberculosis. Should mallein not be accessible, a male guinea pig may be inoculated, or better, several of them. The inoculation is made into the abdominal cavity. Two to five days after inoculation, the testicles and their sheaths become swollen and purulent. Glanders does not respond to the therapeutic test for syphilis, and this may be of value, especially in cases of chronic glanders that may cause nasal ulcers and often also laryngeal symptoms. 13. Diphtheria may cause nasal ulcer either primarily or secondarily. The presence of an epidemic, and the history of exposure to infection and absence of previous attack, are valuable aids in some cases. A false membrane is usually present, but in the nose it may not be visible. The diagnosis rests chiefly upon the recognition of the bacillus diphtheria, in the presence of symptoms of systemic intoxication. Chronic croupous or fibrinous ulcer is sometimes apparently due to chronic nasal diphtheria. Such cases seem to depend largely upon lowered bodily resistance to the bacillus, due to defective nutrition. 14. Nasal ulcer may be due to measles, but in such cases the question of differentiation from syphilis will seldom arise. Sometimes an eczematious nasal ulcer follows measles. 15. Rheumatism may cause nasal ulcer. Such cases are probably due to the streptococcus. At any rate, a strepto- coccus of low virulence may be found in these cases. The ulcer responds readily to topical treatment and proper atten- tion to the rheumatism. 16- Scarlet fever may cause nasal ulcer, which is usually due to hemorrhagic inflammation. Streptococci are usually present. The appearance, history and course suffice to make the diagnosis. 17. Smallpox may cause ulcer and great nasal deformity. The concomitant symptoms will scarcely permit of confusion with syphilis. The prevalence of an epidemic, the history of a previous attack, inoculation or successful vaccination, are points that aid in diagnosis. The sudden onset of the disease Diagnosis of Syphilis. 145 with chills or rigor, followed by fever, headache, pain in the back, epigastric tenderness, and vomiting, is suggestive. The appearance of the eruption on the third day, first upon the upper part of the face, extending rapidly over the body, changing from macules and papules to vesicles, which are umbilicated and later become pustules, stamps the disease. With the exanthem there appears an eruption upon the nasal mucous membrane, and upon all the mucous membranes that are exposed to the air (mouth and pharynx, sometimes in the vagina, rectum and urethra). The temperature falls with the appearance of the eruption. The nasal ulcer is accompanied by nasal swelling, pain, tenderness, and discharge. 18. Nasal ulcer may occur in cases of typhoid fever, and may be due to the typhoid bacillus or to secondary infection, especially by streptococci. The ulceration is often severe, associated with chondritis or perichondritis. There may be affection of the turbinates. The involvement of the nasal cartilage and bone is followed by deformity. The history and course differ markedly from syphilis. 19. Typhus fever may cause nasal ulcer. The acknowl- edge of the existence of the disease in the neighborhood is of value in diagnosis. Isolated cases are sometimes difficult to recognize, especially in the absence of an eruption. The sud- den onset, great prostration, with the dense cloud about the brain, and the peculiar eruption, appearing about the third day and sparing the face, and the crisis at the end of the second week, are characteristic. Accessory Sinuses. Affections of the accessory sinuses most frequently assume prominence during the third stage of the disease. Thus, a chronic purulent ethmoiditis or an empyema of the sphenoidal sinus may be due to syphilis. Disease of the ethmoid, during the third stage of syphilis, should be considered syphilitic unless proven otherwise. The iodide of potassium test is im- 146 Diagnosis of Syphilis. portant. The ethmoidal turbinated bone is gummatous more frequently than the ethmoidal cells. When the ethmoidal cells are gummatous, the process usually attacks the bone and soon causes cerebral symptoms. The other accessory sinuses are less frequently affected by syphilis. Cases of doubt may be subjected to the therapeutic test. Syphilitic Snuffles. The syphilitic "snuffles" of hereditary syphilis usually, but not invariably, occur within a week of birth. This rhinitis resembles an ordinary cold. The discharge, at first watery, becomes muco-purulent, and causes irritation of the margin of the nostril and the upper lip. Later the diagnosis is con- firmed by the wizened, old-man appearance and the cachexia. The anus, less frequently the mouth, may show mucous patches. The therapeutic test should be considered in all doubtful cases. NASOPHARYNX. We have already referred to the oropharynx. The naso- pharynx is frequently involved in the second and third stages of syphilis. The primary lesion in this locality is rare. But infection may be conveyed by a contaminated hand or dirty instruments. Chancre of the nasopharynx causes nasal obstruction, which is more pronounced than in acute catarrh. The nasal voice is more marked and of longer duration. There is dysphagia, but the deglutition is not so painful as in some cases of acute catarrh. With these symptoms of obstruction there is swelling of the cervical lymphatic glands at the angle of the jaw and along the sterno-cleido-mastoid muscle. Usually the location of the enlarged glands, and whether they are swollen on one or both sides of the neck, seems to depend upon the location of the chancre, and whether it is located in Diagnosis of Syphilis. 147 the middle of the nasopharynx or to one side. But some- times, probably through the anastomoses of the lymphatics, a chancre located upon one side of the nasopharynx may cause enlargement of the lymphatic glands upon the opposite side of the neck. Simple adenitis would not show the same rapid formation of indolent buboes, with distinct separation of the glands from one another. During the second stage of syphilis, syphilides occur in the nasopharynx, though they are apparently not so common as about the fauces. Mucous patches may occur in this region, especially upon Luschka's tonsil. It should be remembered that adenoids may be syphilitic. Such hypertrophies of the adenoid tissue respond to anti-syphilitic treatment. The swell- ing of the cervical lymphatic glands is less marked than during the first stage. The nasopharynx is most frequently affected during the third stage of syphilis. Gummata, with subsequent deposition of scar tissue, are the most frequent manifestations of the disease in this locality. Necrosis of bone is also common. Gumma of the nasopharynx is usually circumscribed, but may be diffuse. Depending upon its location, there will be the presence of a more or less well-marked tumor, obstruction to the nose, and frequently pains due to pressure. Thus there may be earache, pain in the back of the head, and dysphagia. Diffuse gumma may cause infiltration of the velum, with immobility of the pillars of the fauces. The mucous mem- brane is wine-red in color. The catarrhal form of tertiary syphilis of the naso-pharynx differs from a simple adenoiditis by the gangrenous appear- ance and the subsequent ulceration. Ulceration may be regarded as the rule in gumma of the nasopharynx, though occasionally cases occur in which the gumma undergoes sclerotic changes without ulceration. Fre- quently the ulceration is extensive, causing great deformity, at times opening up the large vessels of the neck, or involving the vertebras. Most frequently the ulceration attacks the velum. The Eustachian tubes may be affected. 148 Diagnosis of Syphilis. It may be necessary to differentiate syphilis of the naso- pharynx from a number of other diseases, notably : 1. Tuberculosis of the nasopharynx; Lupus. 2. Cancer of the nasopharynx. 3. Gangrenous ulceration. 4. Simple tumors ; polyps. 5. Glanders. 6. Actinomycosis. 7. Simple nasopharyngitis. 8. Atropine nasopharyngitis. 9. Hyperplastic nasopharyngitis. 10. Affection of nasopharynx in infection. In obscure cases, if we do not know that the patient is a syphilitic, the diagnosis may be cleared up by searching for the spirochete pallida, or by making the Wassermann test. But we should not forget that syphilitic patients may present non-syphilitic affections. In tertiary necrosis of the sphenoid bone, Moure has noted severe lancinating pains referred to the fundus of the eye, diplopia, and often profuse suppuration. Such cases are not cured by specific syphilitic treatment until the sequestrum is removed. Cicatricial tissue may be deposited in various quantities. A nasal fossa may be occluded or the entire nasopharynx may be obliterated. The most frequent change is immobility of the velum. This causes a persistent marked nasal voice. The differential diagnosis of tertiary syphilis of the naso- pharynx may be rendered easy by the previous history of the case, the comparative indolence of the disease, and the absence of adenopathy. The ulcerations of tuberculosis are painful and occur late in the disease. Cancer of the nasopharynx is comparatively rare, shows indurated granulating borders that may be readily broken down and bleed easily. They show more marked dysphagia and cachexia. Gangrenous ulceration is a more acute affection, runs a more rapid course, Diagnosis of Syphilis. 149 with marked pain and the characteristic odor of the breath. In both this affection and cancer, the isthmus of the fauces is more frequently involved than in tertiary syphilis of the nasopharynx. Syphilitic cicatricial tissue would rarely be mistaken for a malformation. The appearance and the his- tory of the case would practically exclude such a possibility. Lupus is of comparatively slow growth, and its ulcerations are usually more superficial than those of syphilis. Doubtful cases may be subjected to therapeutic tests with anti-syphilitics and tuberculin, and the microscopic examination of the affected tissue. LARYNX. All stages of syphilis may involve the larynx. Chancre of the larynx is extremely rare. Bosworth was able to find but one reported case. In that case the lesion occurred upon the left side of the epiglottis. The second stage of syphilis is represented in the larynx, especially by the erythema, the mucous patch, and the super- ficial ulcer. Erythema, laryngitis syphilitica erythematosa, commonly known as syphilitic catarrh, occurs usually from four to six months after the primary infection. It may be present as early as one month, or as late as two years or longer in appearing. The severity of the inflammation and the symp- toms vary greatly. The secretion may be little or great. There may be only an erythema and infiltration, possibly with erosions ; or the infiltration may extend so deep as to involve the muscles and cause paresis. In the presence of little secre- tion, there may be the formation of crusts, which may adhere to the vocal cords and agglutinate them. Furthermore, the erythema is usually general, involving the entire larynx; but it may be localized, limited to a part of the larynx, as the epiglottis, the aryepiglottic folds, the false vocal cords ; or the erythema may be general over the larynx, but more in- tense in certain parts. 150 Diagnosis op Syphilis. The erythema produces changes in the voice, ranging from simple hoarseness to absolute aphonia. There is usually cough, the character of which depends largely upon the amount of secretion. In the presence of erythema, inspection of the larynx re- veals a change in color, which is a darker red than is observed in the simple acute forms of laryngitis. Often there is a mottled appearance that is almost characteristic. Venous turgescence is especially marked over circumscribed spots. The cases of extensive infiltration show more uniformly diffuse swelling than is found in simple inflammation of the mucous membrane or simple perichondritis. These character- istics, with the clinical history of the case, possibly with a resort to the therapeutic test, suffice to make the diagnosis of syphilitic erythema of the larynx. The mucous patch is much more rare than erythema of the larynx. The mucous patches may be single or multiple, and occur from six weeks to a year after the primary infec- tion. They are most frequently located on the upper surface of the vocal cords, less frequently upon the epiglottis, the arytenoids, and the ventricular bands. The lesion appears as a small, superficial, grayish patch, slightly raised, possibly surrounded by a red areola. The superficial ulcer may occur in the second or third stage of syphilis, developing from a mucous patch or result- ing from the breaking down of a superficial gumma. It occurs from two to seven years after primary infection. The chief characteristics are the chronicity, the slow destruction of tissue, and the comparatively few symptoms produced by the lesion. There may be some impairment of the voice, and the secretion may contain pus and blood. Relapses are fre- quent, constituting the relapsing ulcerative syphilitic laryn- gitis. Bosworth believes that the relapses are catarrhal exacer- bations rather than true relapses. Inspection of this lesion, which is not common, shows a roundish ulcer, but slightly excavated, covered with a bright yellow coating, possibly tinged with blood, and without a marked areola. The superfi- Diagnosis of Syphilis. 151 cial ulcer is most frequently situated upon the vocal cords, where it is most difficult to recognize because of the slight lesion and comparative absence of membrane and areola. Furthermore, the lesion may occur in the presence of a tuber- culous process. The third stage of syphilis of the larynx is marked by gumma, with the formation of superficial or deep ulcers and subsequent cicatricial stenosis. These lesions do not occur until late, usually five or ten years or longer after infection. They constitute by far the most frequent serious syphilitic affections of the larynx. The gummata develop especially in the deeper tissues, the mucosa and periosteum, and vary in size from microscopic nodules to masses as large as a cherry, or larger, that may completely occlude the larynx. The gum- mata usually appear rather suddenly. I saw a case, in which the gumma almost entirely closed the larynx, that the patient declared developed within an hour's time. The tumors are smooth, rounded, and may be single or multiple. The over- lying mucous membrane may remain comparatively healthy in appearance, or the whole mass may break down, to constitute a superficial or deep ulcer, depending upon the depth at which the gumma develops. The history of other symptoms of syphilis may aid in diagnosis. Differential diagnosis calls especially for the exclusion of tuberculosis and cancer. In all doubtful cases the therapeutic test should be applied. The superficial ulcer has already received consideration under the second stage of syphilis of the larynx. The deep syphilitic ulcer of the larynx is one of the most important lesions with which we have to deal. The deep ulcer appears usually from five to ten years after infection, and results from a breaking down of a gumma. A gumma of the larynx usually breaks down within a short time, although they may remain unulcerated for as long as two years. Upon ulceration, the secretion contains pus and necrotic tissue. Usually there is no marked hemorrhage. The lesion involves most frequently the epiglottis, vocal cords, ventricular bands, and the arytenoid commissure. 152 Diagnosis of Syphilis. Involvement of the superficial tissues — the soft parts of the larynx — is marked by edema and vascular tumefaction ; affection of the deeper parts results in perichondritis and necrosis. In general, simple ulceration occurs in the earlier years of syphilis of the larynx ; and perichondritis and necrosis occur later, usually after there is more or less cicatricial stenosis. Inspection of a deep ulcer reveals a deep, excavated ulcer with sharp edges, profuse secretion, and dark red areola. The tuberculous lesion does not show the areola, but rather a grayish ulcer, usually not markedly excavated, with com- paratively little tenacious secretion, and the surrounding mucous membrane is comparatively pale. Lupus is irregular in outline, usually without ulceration, as a rule with only a slight injection of the mucous membrane. Sarcoma shows the presence of a tumor, with or without ulceration, but usually without the distinct ulceration and pus secretion observed in the deep ulcer of syphilis. Carcinoma causes a tumor that usually is more nodular and not so regular in outline as the gumma, and the carcinomatous ulcer is more irregular and does not show the sharp edges nor the areola of the syphilitic ulcer. In carcinoma there is marked tendency to hemorrhage after ulceration has begun ; the cervical lymphatics are in- volved and cachexia rapidly develops. Gumma of the larynx may be either circumscribed or diffuse. The diffuse form, especially, resembles at times scleroma of the larynx, which is comparatively rare and may be recognized by finding the rhinoscleroma bacillus. It is well to bear in mind that the spirochete pallida and the Wassermann reaction may be found in all stages of syphilis. Cicatricial stenosis of the larynx occurs late in the third stage of syphilis, most frequently, and might be classed among the lesions of the fourth stage of the disease, along with amyloid changes in various parts of the body. The diagnosis of the syphilitic origin of scars in the larynx is usually easy, because of the presence of the symptoms or evidences of other Diagnosis op Syphilis. 153 manifestations of the disease. But at times the diagnosis of the specific origin of the cicatricial tissue may be extremely difficult. The syphilitic scars, especially the cicatricial dis- tortions following deep ulceration, cause marked deformity of the larynx. There , is not the same great deposition of scar tissue in cancer or tuberculosis. One form of tuberculosis, lupus, may cause some deformity through cicatrization. But the process is not so marked in lupus as in syphilis. There are cases of syphilis in which there is compara- tively little destructive change, and in such cases the clinical history may be of value in the differentiation from the cicatrization of lupus. LARYNGITIS. Finding the spirochete pallida and the Wassermann reac- tion will often clear up obscure cases. But syphilitics enjoy no immunity against non-syphilitic affections. At first the patient with syphilitic laryngitis often be- lieves that he has an ordinary "cold." This is the diagnosis that he often brings us, and it only serves to emphasize the danger of accepting the diagnosis made by the patient, before we have arrived at an opinion through a careful exam- ination of the case. The syphilitic erythema appears in the larynx usually within six months after the primary lesion, as a rule just after the subsidence of the skin eruption. Laryngoscopy reveals an erythema, uniform or mottled, in- volving part or all of the posterior surface of the epiglottis, the aryepiglottic folds, the false cords, and possibly the true vocal cords, which are sometimes infiltrated and swollen. The patient complains of few symptoms. There is no pain, deglu- tition is not interfered with, and usually the cough is not troublesome. There may be hoarseness or aphonia. If we but suspect the disease, the diagnosis may be readily made by the therapeutic test. Ulcers may be recognized by inspection. The superficial 154 Diagnosis op Syphilis. syphilitic ulcer often shows a tendency to extend, new ulcers forming as the old ones heal. These are the so-called cases of recurrent ulcerative laryngitis. It often requires careful inspection to recognize ulcers on the vocal cords, when they involve only the thin mucous membrane in this region. Mucous patches are comparativeely rare in the larynx, and are usually associated with a similar involvement of the tongue or pharynx. They occur most frequently upon the upper sur- face and the free margins of the epiglottis, the aryepiglottic folds and the vocal cords. Condylomata are rare, and may be recognized as small, yellowish pimples, with an elevated base. Syphilitic laryngitis should be differentiated from: 1. Simple acute laryngitis. 2. Laryngitis of the infections. 3. Rheumatic laryngitis. 4. Simple acute epiglotitis. 5. Traumatic laryngitis. 6. Suppurative laryngitis. 7. Edema of the larynx. 8. Membranous laryngitis. 9. Hemorrhagic laryngitis. 10. Simple chronic laryngitis. 11. Follicular laryngitis. 12. Atrophic laryngitis. 13. Hyperplastic laryngitis. 14. Simple hyperemia of the larynx. 15. Pemphigus of the larynx. 16. Tuberculosis. 17. Chondritis and perichondritis. 1. The objective and subjective symptoms of acute laryn- gitis are usually amply sufficient to enable us to make a diagnosis. There is an absence of the cutaneous eruption and the other symptoms of syphilis observed in cases of syphilitic laryngitis. Cough is more often troublesome in these cases, and usually assumes greater prominence than in syph- Diagnosis of Syphilis. 155 ilitic erythema. There is more or less hoarseness and dyspnoea. The diagnosis is often aided by a knowledge of the cause. Among the etiological factors may be mentioned confinement indoors, especially in a vitiated atmosphere; exposure to cold and damp ; mouth breathing, excessive use of the voice, abuse of tobacco, alcoholic beverages and hot drinks ; irritating fumes or vapors and dusty air. Often the syphilitic patient is peculiarly susceptible to simple laryngitis on every expo- sure. However, such a susceptibility is more common in tuberculosis and rheumatism. 2. An acute catarrhal laryngitis is not uncommon in a number of the infections, notably erysipelas, measles, scarlet fever, smallpox, typhoid fever, typhus, influenza, malaria and rheumatism. Erysipelas of the larynx may be primary or due to extension from the fauces or the nose. In such cases the diagnosis is sometimes cleared up by the extension of the disease to the face. Examination of the pus will reveal the streptococcus. There may or may not be symptoms of syphilis or the evidence or history of that disease. Erysipelas may occur in syphilitics. Laryngitis in measles is a part of the inflammatory affection of the upper respiratory tract, and is not likely to be confused with the laryngitis of syphilis. The symptoms resemble more those of iodism. There may be a hyperemia or slight catarrhal laryngitis in scarlet fever. There may be, especially in severe and grave cases, a laryn- gitis with edema, ulceration, or the formation of a pseudo- membrane, and rarely gangrene. The mild cases are most difficult to recognize. (a) Smallpox may cause a catarrhal laryngitis, or more severe involvement of the larynx, marked by edema, paralysis, swelling, destructive lesions, the formation of pseudomembrane, and possibly subsequent cicatricial contraction. The diag- nosis is usually readily made by the presence of other symp- toms of smallpox, the prevalence of an epidemic, the history of a previous attack, inoculation, or vaccination, and the char- acteristic skin eruption beginning on the third day, first upon the upper part of the face and extending rapidly over the 156 Diagnosis of Syphilis. body, changing from macules and papules to vesicles, which are umbilicated and later become pustules. (b) Typhoid fever is sometimes accompanied by an acute laryngitis. There may be ulceration, that sometimes extends to cause chondritis and perichondritis. Edema may occur, as an alarming symptom. In typhus there is sometimes laryn- gitis, and in these cases ulceration is peculiarly destructive, involving the cartilages and greatly increasing the gravity of the prognosis. Concomitant symptoms usually make the diagnosis. (c) Influenza and hay fever are prominent causes of laryngitis. The symptoms resemble iodism more than syphilis. The diagnosis of influenza may be readily made absolute by finding the influenza bacillus. The periodicity of hay fever attacks is a striking characteristic. Both these diseases, of course, may occur in syphilitics as well as in non-syphilitics. (d) Malarial laryngitis seems especially prone to involve the epiglottis and cause edema. In suspected cases, the diag- nosis may be settled by an examination of the blood and the exhibition of quinin. 3. Rheumatism may cause laryngitis, which is often marked by involvement of the laryngeal articulations. The vocal cords may be immobile, the articulations swollen and tender. There are often evidences of rheumatic affections of other parts of the body. Usually there is an accompanying tonsillitis. There is more or less lassitude and the patient feels below par. The patient may observe more or less roughness of the laryngeal articulations, and there may be distinct de- posits in these articulations, especially in the crico-arytenoid joints. There may be stiffness and aching of the muscles of the neck. 4. Reference has been made to cases of laryngitis in which the inflammation was largely confined to the epiglottis. Epiglottitis often seems to be a part of an inflammation of the lingual tonsil. Such cases may present no laryngeal symptoms, save possibly laryngeal spasm upon attempting to swallow. The diagnosis is made by inspection. Diagnosis of Syphilis. 157 5. Traumatic laryngitis is usually diagnosticated through a knowledge of the traumatism. There is usually more or less involvement of adjacent structures. The most common causes are burns, scalds, wounds, and foreign bodies. 6. Suppurative laryngitis is usually readily recognized by the history of the case, the septic symptoms, the localized point of tenderness, and the course of the affection. The spot of tenderness may be recognized externally, and there may be some external swelling. Possibly the most common cause is syphilis, the recognition of which would depend upon the presence of additional symptoms of that disease. Many cases are due to typhoid fever, most frequently following the disease. 7. Edema of the larynx may be due to many causes. The more important are trauma, fractures of the larynx, and injuries through the inhalation of irritating steam, fumes or vapors, or through laryngeal application of irritating sub- stances, or the entrance of such substances into the larynx during deglutition ; adjacent inflammations, such as ton- sillar or peritonsillar abscess, inflamed lymphatic glands, wounds or foreign bodies at the base of the tongue, in the pharynx or involving the lingual tonsil ; neighboring tumors, causing pressure or interfering with the venous circulation ; foreign bodies in the esophagus at the level of the larynx; chondritis or perichondritis ; the infections, especially typhoid fever ; and, possibly above all, in circulatory disturbances caused by dis- eases of the heart, kidneys, or liver. Diphtheria, scarlet fever, and localized septic infection are prominent causes. Acute edema is often accompanied by acute inflammation. Chronic edema of the larynx may occur in the absence of local in- flammation, and is usually due to retardation of the venous circulation through disease of the heart, kidneys, or liver. The diagnosis is easily made by inspection. Most important is the recognition of the cause. Syphilis is not a prominent cause of edema of the larynx, but may cause the condition through involvement of the larynx, or by interfering with the laryngeal venous circulation (gummatous infiltration, cica- 158 Diagnosis of Syphilis. tricial contraction, or affection of the blood vessels), or by impairment of the circulation through affection of the heart, kidneys or liver. Chronic edema of the larynx is usually due to syphilis, tuberculosis, cancer, or chronic diseases of the heart, kidneys, or liver. The syphilitic causes are recognized by excluding the other possible causes and the recognition of the evidence or history of other signs and symptoms of syphilis. 8. Membranous laryngitis is usually diphtheria, which is recognized by the demonstration of the bacillus. Any ulcer of the larynx may become covered by a membrane, that may be due to the bacillus diphtheria or the streptococcus or other organisms. Septic membranous laryngitis may occur in scarlet fever, measles, or in simple traumatic ulcer of the larynx. 9. We will refer to laryngeal hemorrhage at this time in order to emphasize the distinction between this condition and hemorrhagic laryngitis. When practicable, laryngoscopic examination will usually suffice to determine whether or not the hemorrhage is from the larynx. Having determined that we are dealing with a laryngeal hemorrhage, we must next try to find the cause. Among the more prominent causes of laryngeal hemorrhage are syphilis, tuberculosis, cancer, trauma and the presence of foreign bodies. These causes act through causing ulceration or the wounding of a blood vessel. Some- times the hemorrhage is due to a sudden acute inflammation or a sudden distension of the blood vessel. Thus, among the etiological factors are those conditions that cause an increased blood pressure, such as interstitial hepatitis, Bright's disease, valvular disease of the heart, fibroid lung, and violent exer- cise or strain. True hemorrhagic laryngitis is due to rhexis of a vessel or vessels leading to hemorrhagic infarction. The laryngitis is secondary to the hemorrhage. If the extravasation is suffi- cient to interfere with breathing, it is considered a hema- toma rather than a simple infarction. If the hemorrhage finds exit to the surface, the expectoration will be tinged with Diagnosis op Syphilis. 159 blood. If not discharged in this way, the infarct may be recognized upon laryngoscopic examination. Syphilis may play an important role in the etiology of hemorrhagic laryng- itis, through affection of the blood vessels. The symptoms are comparatively slight, as a rule. There may be some cough, and more or less alteration of the voice, depending largely upon the site and extent of the extravasation. In a case of bleeding from the larynx, inspection will exclude hemorrhage from the naso-pharynx, pharynx, tonsils (pharyngeal, faucial, and lingual), and possibly we may be able to recognize the source of the hemorrhage in the larynx. When blood issues from the larynx, and bleeding may not be detected above the vocal cords, and there are no pulmonary rales, the hemorrhage is probably from the larynx below the cords, or from the trachea. 10. Simple chronic laryngitis may be differentiated from syphilitic laryngitis by the history and the therapeutic test in early cases. Syphilis is more prone to cause destructive lesions and subsequent scar formation with deformity of the larynx. 11. Follicular or granular laryngitis is found especially in individuals who use the voice excessively. There is usually a similar inflammation of the pharynx in these cases. The condition is readily recognized upon laryngoscopic exam- ination. 12. Atrophic laryngitis may cause nocturnal cough, espe- cially during the stage of mucus accumulation and crust formation. This is not observed during the stage of dimin- ished secretion, which is marked by an aggravating dry cough. The diagnosis is readily made by laryngoscopy. Crusts should not be mistaken for ulcerations. 13. Hyperplastic laryngitis is marked by hypertrophy of the laryngeal tissue, with consequent symptoms of obstruc- tion and interference with the mobility of the larynx. The therapeutic test would exclude syphilis. 14. Hyperemia of the larynx may be due to many of the causes of laryngitis, when they are not sufficient to cause an actual inflammation. The condition is found especially in 160 Diagnosis of Syphilis. plethoric patients, those who use the voice excessively, or who use tobacco or alcohol habitually. 15. Laryngeal pemphigus is usually accompanied by a similar affection of the pharynx and fauces. The herpetic eruption is accompanied by a rise of temperature and general symptoms. The throat is sore, the voice altered, there is dysphagia, and the eruption is recognized upon inspection. The vesicles rupture in a few hours, to leave superficial ulcers. The eruption may occur anywhere in the larynx, but is most frequent upon the ventricular bands and the arytenoids. 16. Tuberculosis of the larynx is characterized by ulcera- tion rather than by inflammation, and will be considered later. However, in pulmonary tuberculosis there is often greater susceptibility to laryngitis. Syphilis and rheumatism show a similar predisposition. 17. Chondritis and perichondritis may be due to syphilis, tuberculosis, actinomycosis, glanders, typhoid fever, smallpox, diphtheria, cancer, benign tumors, traumatism, embolism, rheu- matism, and the presence of foreign bodies. It has also been ascribed to decubitus in the aged. Exposure to cold and damp, and excessive use of the voice are also causes. Syphilitic chondritis and perichondritis may be recognized by the historj', and the evidence of syphilis in other parts of the body. Syphilis presents more external swelling, and also more tendency to heal than is observed in tuberculosis. Tuber- culous chondritis and perichondritis are rare in the absence of pulmonary tuberculosis. The worm-eaten appearance of the tuberculous ulcerations is more marked than in syphilis. The exposure to tuberculous patients, the possibility of infec- tion by tubercle bacilli, may be of diagnostic importance. The finding of tubercle bacilli in the sputum would speak for tuber- culosis in the respiratory tract. Such bacilli are usually from the lungs. There is not much discharge of tubercle bacilli from the laryngeal tissue. When due to typhoid fever, chon- dritis and perichondritis usually follows that disease or occur late in the course of the disease, so that the history materially aids the diagnosis. In cases of chondritis or perichondritis Diagnosis of Syphilis. 161 due to rheumatism or gout, there are usually evidences of these diseases in other parts of the body, and often the examination of the urine will aid in diagnosis. Traumatism and exposure to cold are readily recognized by the history. LARYNGEAL ULCERS. Gummatous Ulceb. 1. Acute development of ulcer, within a few days. 2. Swelling: marked, irregular, inflammatory or edematous. 3. In affections of the epiglottis, a prefer- ence is shown for the upper surface. 4. The syphilitic ul- cer is usually single, sometimes double, rare- ly more than this in number. 5. Ulceration extends from center to periph- ery, and from above downward. <5. Ulcer is deep, round or oval in shape, and usually reaches a diameter of l.O-l.o cm. 7. Cachexia may be observed late in the course of the disease. 8. Frequently there is the history or evidence of syphilis. It should be remembered that any or all these diseases may co-exist. 9. A n t i - syphilitic treatment specific. 10. Spirochete pallida and Wassermann test reveal syphilis. Tuberculous Ulceb. Cabcinomatous Ulceb. 1. Slow development, after throat symptoms for several months. 2. Swelling: uniform, pale ; resembles an infil- tration. 3. Lower surface of epiglottis most fre- quently affected. 1. The ulcer develops in the course of a few weeks. 2. Nodules situated in the midst of an acute catarrhal inflam- mation of the mucous membrane. 3. May involve any part of the epiglottis. 4. Usually multiple. 4. Usually single 5. Ulceration usually 5. Ulceration is ir- extends upward. regular in its course. 6. Ulcer is usually 6. Ulcer is irregular round, 2.0-3.0 mm. in in shape, usually 2.0-3.0 diameter. mm. in diameter. 7. Habitus phthisieus 7. Cachexia assumes and advanced cases may prominence early in the show cachexia. S. Practically all cases present pulmo- nary tuberculosis. disease. 8. Frequently family history of cancer, or the history of associa- tion with cancer cases. 9. A n t i - syphilitic 9. A n t i - syphilitic treatment of no value, treatment not specific. Most may be accom- plished by tuberculin and operative treat- ment. 10. Tubercle bacilli 10. The histological ind tuberculin test show examination of tissue the presence of tuber- makes the diagnosis ab- culosis. solute. 162 Diagnosis op Syphilis. Syphilitic laryngeal ulcers are usually unilateral, except when they involve the epiglottis, where they are usually central and most often on the upper surface. The ulcers develop rapidly and are accompanied by irregular inflammatory swell- ing and edema. The uleers are usually single, ovoid in shape, rather deep, and usually not more than one-half to one inch in diameter. Tubercular laryngeal ulcers present the history and symp- toms of tuberculosis, rather than of syphilis. The ulcers develop slowly, and are preceded by a uniform swelling of the mucosa resembling an infiltration. The ulcers are rather pale, compared with the syphilitic ulcers. The preceding swelling of the mucosa is accompanied b}' laryngeal irritation, so that there is the history of such irritation for some time before the ulcer appears. Tubercular ulcers in the larynx are usually bilateral. The ulcers are small, compared with the syphilitic ulcers, being usually less than 3 mm. in diameter, save when they coalesce, when they may reach 4 mm. in diameter. The ulcers are round, rather than ovoid. When syphilis and tuber- culosis co-exist, small individual ulcers in the larynx may at times be confusing. Lai^-ngeal ulcer due to cancer usually develops more rap- idly than tubercular ulcer and slower than the syphilitic ulcer, requiring a few weeks. The ulcer is preceded by tumefaction, and nodules extend beyond the area of ulceration. There is generally considerable inflammation of the surrounding mu- cosa. The ulcers are 2 to 3 cm. in diameter, solitary and irregular in shape. Sarcoma of the larynx causes tumefaction, and possibly there may be some denudation of the surface, but there is no distinct ulcer formation. Diagnosis op Syphilis. 163 LARYNGEAL GROWTHS. Syphiloma of the larynx usually does not come under ob- servation before ulceration. The pain is usually slight, very different from the constant lancinating pain of carcinoma or the severe dysphagia of tuberculosis. Around the ulcer there is some induration. There is little or no edema. The ulcer is clear cut and deep, often involving the cartilage. The surrounding mucous membrane is hyperemic and injected. Stenosis is not common, but may be caused by the subsequent contraction of scar tissue. Usually there are the evidences and history of syphilitic lesions in other parts of the body, and doubtful cases respond readily to the therapeutic test. Indeed, the ready response to the iodides makes it seldom necessary to resort to the removal of a section for microscopic examination in order to differentiate syphiloma from other tumors or masses in the larynx. In a tumor of the larynx of doubtful nature, if the sputum does not contain tubercle bacilli and the patient does not react to the tuberculin test; if we can not find the spirochete pallida, and the Wassermann reaction is negative, and especially if the tumor is growing and does not respond to the therapeutic test for syphilis, we are justified in making section of the growth for microscopic examination. For this purpose, it is usually better to remove the tumor, since the benign tumors of the larynx are peculiarly liable to become cancerous. The section is then made through the epithelium and fibrous tissue, since the microscopic diagnosis depends largely upon whether or not there is an invasion of the fibrous tissue by epithelial cells. At times it is necessary to differentiate between syphilomata and malignant or benign growths in the larynx, notably: 1. Carcinoma. 6. Chondroma. 2. Sarcoma. 7. Angioma. 3. Papilloma. 8. Lipoma. 4. Adenoma. 9. Mucocele. 5. Fibroma. 10. Tuberculosis. 164 Diagnosis of Syphilis. 1. Carcinoma at first presents the signs of a simple growth in the larynx, depending largely upon the location and size of the neoplasm. Adenopathy is observed earlier in extrinsic than in intrinsic growths. Ulceration occurs comparatively early, usually within the first six months. With ulceration, hemorrhage assumes prominence. We have already referred to the cancerous ulcer. The breath becomes exceedingly of- fensive. Pain begins early, especially in extrinsic cancer, and is a prominent symptom. Later there is cachexia, which comes on earlier than in other laryngeal growths, and is more marked in extrinsic cancer. Carcinoma of the larynx affects men more often than women, and occurs most frequently after fifty. The voice shows early impairment. There is dyspnoea. Cough is caused by the mucous or seromucous discharge. The breath is offensive (the odor has been described as musty), and there is more or less hemorrhage. As a rule there is pain, and sometimes there is difficult deglutition. Cachexia comes on late or may be absent. Inspection reveals the hyperemic mucous membrane of the larynx. A new growth will be found within the laryngeal cavity, growing from any part of the larynx. Ulceration is slower than in syphilis, and extends in all directions and involves all tissues in its course. Stenosis is common. The therapeutic test for syphilis is negative; sometimes there is a slight response to excessive use of the iodides. There is late involvement of the cervical glands. 2. Sarcoma at first resembles symptomatically a bengin tumor, the dysphagia, dyspnoea, and interference with the voice depending at first upon the location and size of the tumor. At first there is little cough, of an irritating, spasmodic, hacking character; after ulceration the cough in- creases. In sarcoma of the larynx, there is usually early ulceration, followed by more or less continuous hemorrhage. A sarcoma beginning in the larynx is not so prone to involve adjacent tissue; when beginning in the adjacent tissue there is a tendency to involve the larynx. The pain is usually Diagnosis op Syphilis. 165 more marked than in syphilis, but not so continuous and prominent as in carcinoma. Cachexia occurs as the result of deficient nutrition, due to the interference with respiration and the dysphagia. Sarcoma occurs in the larynx very rarely. The majority of the reported cases have occurred in men. The ages of the patients have ranged from nineteen to seventy-four years, most of the cases occurring between forty and sixty. The symptoms are not especially characteristic. At first the voice becomes hoarse, sometimes aphonic. There are dyspnoea, cough, sometimes dysphagia. There may be slight hemorrhage and some pain. Late in the course of the disease there may be some cachexia. Involvement of the cervical lymphatics is usually absent. A positive diagnosis may be made by microscopic examination. Scleroma of the larynx is rare, and is associated with scleroma of the pharynx and nose. Finding the rhinoscleroma bacillus makes the diagnosis. 3. Papillomata may occur in any part of the larynx, frequently in the anterior portion of the vocal cords. Usually interference with phonation is a prominent early symptom. There may be dyspnoea, due to the location and size of the growth. Hemorrhage is comparatively rare, and there is little or no pain. 4. Benign adenoma of the larynx is comparatively rare. It must be remembered that adenomata and papillomata and all of the benign growths in the larynx, including syphilomata, are peculiarly prone to become cancerous, possibly because of the irritation and friction to which they are subjected. 5. Laryngeal fibromata show a preference for the vocal cords. The cases usually come under observation while the growth is small, because of the interference with phonation. There is cough, and little or no pain. Ulceration and hemorrhage may occur but are not common in benign fibro- mata. From a diagnostic standpoint, it may be well to remember that papillomata and fibromata are the most common tumors of the larynx, and that they show a preference for 166 Diagnosis of Syphilis. early life. Fibroma occurs usually as a sesile growth with a smooth vascular surface; papilloma is usually more promi- nent and the surface more irregular. 6. Chondromata usually involve the cricoid cartilage, less frequently the thyroid, epiglottic and arytenoid cartilages. They present a hard, dense, lobulated tumor, of slow growth. Usually we may not find the cause. The tumors usually occur early in life, are of slow growth, and are not accompanied by inflammation, save such as may be caused by obstruction. Edema is absent or comes on late. The growth remains localized, without adenopathy or tendency to spread. 7. Angioma is rare in the larynx. Such growths have occurred in the ventricular bands, and the epiglottis, usually as small bright red tumors. 8. Lipoma is exceedingly rare in the larynx. The re- ported cases have usually occurred within the laryngeal cavity, and have not presented any marked difference from the appearance of lipomata in other parts. The epithelial cover- ing may be thickened. When incompletely removed, there is a tendency to recurrence. 9. Myxomata, fibromyxomata and myxofibromata cause laryngeal irritation similar to that produced by a foreign body. Alteration of the voice and possibly interference with phonation will be caused, depending largely upon the location of the growth. The larger growths may cause actual dyspnoea. Pain and hemorrhage are comparatively rare. 10. Tuberculosis is one of the most important affec- tions of the larynx, from the standpoint of differential diag- nosis. Tuberculosis of the larynx is rare in the absence of pulmonary tuberculosis. The sputum usually contains tubercle bacilli. Tuberculosis in the larynx or in any part of the body will cause a reaction to the tuberculin test. Therefore, in a doubtful case, we should hesitate to make a diagnosis of tuberculosis of the larynx if there are no tubercle bacilli in the sputum, and if the patient does not react to the tuberculin test. Tuberculosis may co-exist with either syphilis or carcinoma, or with both of these diseases. Diagnosis op Syphilis. 167 The patient with laryngeal tuberculosis suffers severe pain on deglutition as soon as ulceration occurs. At first the voice becomes altered, weak, sometimes aphonic. The use of the voice requires great effort. There may be an in- voluntary change from a low tone to a falsetto note, which may be maintained for a short time (Moure). The emacia- tion caused by the pulmonary tuberculosis, which usually precedes the affection of the larynx, is increased, and the expression of the patient becomes anxious. With extension of the disease, deglutition becomes difficult and painful. De- struction of the epiglottis may permit food to enter the larynx. Laryngoscopic examination reveals a pale mucous membrane. Small spots of induration may be observed, espe- cially in the interarytenoid space and at the base of the arytenoid cartilages. These are soon followed by marked edema, involving the arytenoids. The ulceration is compara- tively slow, and is broad rather than deep. Laryngeal stenosis is comparatively rare. There is no response to the iodides, unless there is a co-incident infection with syphilis. Lupus is due to the tubercle bacillus and may be regarded as a form of chronic tuberculosis. In the larynx it causes little or no pain. At first it appears as nodular masses, which may appear in any part of the larynx. There is little or no edema, and ulceration is slow or entirely absent. When an ulcer does occur, there is little or no discharge, in this respect differing from the common tubercular ulcer, which is usually covered with a thick mucopurulent secretion. In lupus, the surrounding mucous membrane is injected. There is little impairment of the general health. In these cases lupus of the skin is probably more frequent than pul- monary tuberculosis. However, a careful examination of the lungs will reveal chronic pulmonary tuberculosis, usually localized in one or both apices, more often than the literature would seem to indicate. Lupus does not respond to the therapeutic test for syphilis. 168 Diagnosis op Syphilis. Stenosis of the Larynx. Syphilis may occlude the larynx in a number of ways. Occlusion due to edema may occur at any time in the course of the disease. The commonest form of syphilitic cicatricial stenosis is due to cicatricial tissue uniting the vocal cords or the ventricular bands, less frequently involving other parts of the larynx. There is more or less hoarseness and impair- ment of the voice, and possibly interference with respiration, depending upon the location of the cicatricial bands and the degree of stenosis. There is usually marked pain and dysphagia, with spasmodic cough and scanty expectoration. The cicatricial syphilitic stenosis comes on late in the course of the disease, so that there usually is the history and evidence of other syphilitic lesions. The therapeutic test, of course, is valueless. On the other hand, occlusion of the larynx by a large papule or a gumma, responds to the therapeutic test. Cancer may occlude the larynx, but does not often lead to cicatricial contraction. Tuberculosis of the larynx, also, does not tend to cause stenosis through the deposition of cicatricial tissue. The chief danger in tuberculosis is from edema. Lupus, which may be regarded as a form of chronic tuberculosis of the larynx, since it is due to the tubercle bacillus, may lead to cicatricial stenosis of the larynx. In these cases the mucous membrane is usually anemic, with nodules of inflammation here and there. There is usually little or no dysphagia or dyspnoea, and there is as a rule comparatively little change of the voice. The cicatricial stenosis of lupus is usually above the glottis, whereas that of syphilis, and also of tuberculosis, is usually below the glottis. Furthermore, in lupus stenosis of the larynx, there is often lupus of the face. Stenosis of the larynx may be caused by trauma. In these cases the history is usually amply sufficient to lead to a correct diagnosis. Among the traumatic causes are Diagnosis of Syphilis. 169 injuries by foreign bodies, attempts at suicide by cutting the throat, and injury by inhaling steam or caustic vapors, and swallowing hot or caustic substances. Finally, stenosis of the larynx may be congenital, due to arrested or faulty development of the larynx. When such a stenosis is not complete, the patient may not come under observation until later in life. In such cases the stenosis is usually due to webs or bands across the glottis, in the anterior commissure as a rule; sometimes between the vocal cords or the ventricular bands. The diagnosis must be based largely upon the history and the absence of other adequate explanation of the stenosis. Trachea. The second and third stages of syphilis have been ob- served in the trachea. Syphilides, representing the second stage of the disease, are far less common than in the pharynx or larynx ; but they are probably more common than the reported cases would indicate, since the trachea is not often inspected in cases of syphilis. Gummata are more frequently reported in this region. The diffuse gummata seem to be especially frequent, and ulceration is comparatively common in these cases. Perichon- dritis and necrosis have been observed in a comparatively large number of cases. In this way a number of the cartilaginous rings of the trachea may be destroyed. Gross lesions may cause great subsequent deformity, through cicatricial con- traction and consequent distortion of the trachea. Stenosis may be caused by infiltrations or the deposition of scar tissue. The severity of the symptoms of syphilitic affection of the trachea vary within wide limits, depending upon the location and character of the lesion. When large areas of the tracheal mucous membrane are involved, especially if there is ulceration, there will be increased muco-purulent secretion, cough due to a tickling sensation, often tracheal rales, and possibly pain behind the sternum. Stenosis of the trachea may cause dyspnoea. Suffocation may occur from the occlusion of the larynx by necrotic cartilage. Per- 170 Diagnosis of Syphilis. foration of gummata into the mediastinum or the surround- ing connective tissue, or into the esophagus or the arch of the aorta or the vena cava, may cause serious or fatal se- quellae, such as mediastinitis, pneumonia, and hemorrhage. Inspection should be attempted in all cases of suspected syphilis of the trachea. In the presence of stenosis, the voice is altered chiefly through a diminution in its volume, and there is more or less dyspnoea, which is usually inspiratory in character. There is an absence of the d} r sphagia and localized tenderness experienced in stenosis of the larynx. The stenosis of the trachea is slow in development, as a rule. There is not such marked excursions of the larynx as are observed when the stenosis is higher up, in the larynx. However, syphilis seems to affect the trachea more frequently in the presence of syphilitic lesions higher up in the respiratory tract, especially in the larynx, pharynx, and the nose. Cicatricial stenosis of the trachea usually means syphilis. Differential diagnosis may require the ex- clusion of tuberculosis, scleroma, cancer, glanders, and chronic nonsyphilitic blenorrhcea. Tuberculosis of the trachea occurs almost exclusively late in the course of pulmonary tuberculosis. The finding of tubercle bacilli would aid in diagnosis, though the two affections may co-exist. In scleroma, the diagnosis might be made by finding the rhinoscleroma bacilli. Cancer runs a much more rapid course than syphilis. The ulcers of glanders are rare in this location. It is probable that the only chronic blenorrhoea that might give rise to any difficulty in diagnosis is that due to scleroma. In any case, great assistance in diagnosis may be afforded by the clinical history, the serum reaction and the therapeutic test for syphilis. Bronchi. Frequently the entire respiratory tract seems irritated early in the second stage of syphilis, possibly due to the excretion of poisons through the pulmonary mucous membranes. The second and third stages of syphilis may produce the same changes in the bronchi as have been observed in the trachea. The symptoms may be limited to one side Diagnosis of Syphilis. 171 of the chest when a single bronchus is involved, or be bilateral in affection of both bronchi, in which event there will be a general resemblance to affection of the trachea. This is especially true of stenosis. In stenosis of a single bronchus, there may be lessening of the respiratory movement upon the affected side. Lungs. During the second stage of syphilis, there are often the symptoms of pulmonary syphilides. Frequently one of the earliest symptoms of this stage is a pulmonary catarrh. The literature would seem to indicate a greater frequency of tertiary syphilitic pulmonary lesions. This is probably only apparent, since the grave pulmonary lesions of syphilis are more frequent during the third stage. These are the case of pulmonary gummata, which usually become manifest some five to fifteen years after the primary infection. There are usually the symptoms of pulmonary catarrh, and an increasing difficulty of respiration that comes finally to amount to actual dyspnoea. There supervene cough with slight expectoration, and pain. These symptoms may persist for a comparatively long time, frequently with nocturnal exacerbations. The pain is usually slight, and there is little or no fever. Percussion may show normal resonance or dull- ness. The respiratory sounds may be normal, weakened, or there may be bronchial inspiration with diminished expira- tion with reduction of the respiratory movement. The breaking down of a gumma may result in cavity formation. Then the expectoration becomes more copious and there is an increase of the dyspnoea, cough and pain. There may be hemoptysis, but this is apparently much more rare than in tuberculosis. General degradation of the health and strength of the patient, with cachexia, announce that the case has become one of syphilitic pulmonary phthisis. The scene is usually closed by tuberculosis or pneumonia. Often in- fluenza plays an important part as a secondary infection. There has been remarked a frequent disproportion between the physical signs of disease of the chest, in pulmonary 172 Diagnosis op Syphilis. syphilis, and the subjective symptoms experienced by the patient. Thus, severe asthma or dyspnoea may be due to enlarged glands, that may not be detected upon physical examination ; or these symptoms may be due to stenosis from the contraction of scar tissue, which may not be recognized by the examiner. Cardiac asthma, due to aortic endarteritis, need but be mentioned at this place. In the differentiation from tuberculosis, it may be remem- bered that syphilis of the lung seems to show a distinct preference for the middle of the lungs, and is most frequently found upon the right side. But the exemption of the apices is not absolute evidence of syphilis ; and, in some cases, syphilis involves the apices. The clinical history, the examination for the tubercle bacillus, the therapeutic and tuberculin tests are all of value. Syphilis shows the Wassermann reaction, and it ma}' be possible to find the spirochete pallida in the sputum. Unfortunately, tuberculosis and syphilis often co- exist, which fact must be well taken account of in differ- ential diagnosis. PULMONARY SYPHILIS May present symptoms resem- bling tuberculosis, pneumonia, or asthma. In the cases resembling tuberculosis, the onset may be sud- den or insidious, but the progress of syphilitic phthisis is usually slower than tubercular phthisis. Cough is not so constant nor persistent as in tuberculosis. Expectoration is less than in ad- vanced tuberculosis. Hemotysis may occur, but is not so common as in tuberculosis. Tubercle bacilli may be found in the presence of an intercurrent tu- berculosis. Syphilis predisposes to tuberculosis. Elastic tissue may be found when there is much breaking down of lung tissue, but it is not so common nor abundant as in advanced tu- berculosis. PULMONARY TUBERCULOSIS. Mi>^t cases begin with bronchitis. Cough, at first dry and hacking, oc- curs especially in the morning and evening, upon changing posture. Expectoration at first absent, be- comes abundant; at first mucoid, later mucopurulent, and possibly containing blood. Hemoptysis usually means tuber- culosis. Tubercle bacillus in the sputum; later elastic tissue. Frequently the first symptom noticed is dyspepsia, often associated with anemia, chlorosis, amenorrhoea, and general degradation of health. Often insidious onset, so that the patient does not seek medical advice until the disease is far advanced. One of the early symptoms is shortness of breath upon exertion. Later there is dyspnoea, due to cardiac weakness, sometimes asso- ciated with cyanosis. Pain in the chest may be due to pleurisy, or to neuralgia caused by toxemia. Diagnosis of Syphilis. 173 Pulmonary Syphilis — Cont'd. Dyspepsia is common in syphilis, and is benefited by anti-syphilitic treatment; such treatment is dis- tinctly injurious in the dyspepsia of tuberculosis. Anemia is usually not so great in pulmonary syphilis as in tubercu- losis. Loss of strength is not so marked in pulmonary syphilis as in tuber- culosis that is far advanced. The onset of tuberculosis is often more insidious than syphilis; the latter presents extra-pulmonary le- sions. Night sweats are comparatively rare in pulmonary syphilis. Hectic is less common, but may occur in the presence of a mixed infection, as when cavities are filled with pus. Loss of weight usually comes on later than in tuberculosis, and it is not so marked. Physical examination will usually reveal extra-pulmonary evidence of syphilis. Examination of the chest reveals various rales, and the evi- dence of consolidation or breaking down of tissues, much as in tuber- culosis. Syphilis shows an early preference for the lower lobes or root of the lungs. (Berg frequently found the upper lobe of the right lung in- volved. ) Doubtful cases justify the thera- peutic test with the iodides or prep- aration of iodine. Wassermann reaction. Spirochete pallida. Pulmonary Tuberculosis — Cont'd. The temperature is at first nor- mal or subnormal in the morning; shows early a rise sometime during the day, usually in the afternoon. Night sweats. Hectic; streptococcus curve. Pulse at first corresponds with the temperature; with increased weakness becomes rapid, compressi- ble and readily influenced by exer- cise. Loss of weight is often an early symptom, and later is marked. Physical signs at first are entirely absent. Inspection may reveal the habitus phthisicus, now regarded as evidence of the existence of the dis- ease rather than a so-called predis- position. Palpation : lessened mobility, with defective expansion on one or both sides. With consolidation, vocal fremitus is increased. In cases of pleural exudate the vocal fremitus is diminished or absent. Percussion: defective resonance, especially in the region of the clavicle In advanced cases, dullness from consolidation, or a cracked pot sound in the presence of cavities. Auscultation: as a rule prolonged expiration early in the disease; later there are all sorts of rales. An important early sign is accentua- tion of the second pulmonary valve sound. The earliest possible diagnosis may be made by the use of the tuberculin test. The impression that this test may be positive in syphilis is probably due to the pres- ence of tuberculosis in the syphili- tics examined. It should be remem- bered that the tuberculin test may be positive when there is tubercu- losis in any part of the body. The blood test in tuberculosis shows pronounced agglutination and lytic action upon the tubercle bacil- lus. We should not mistake for syphilis of the lung, the terminal pul- monary tuberculosis so often observed in the last chapter of syphilis. It would seem that Pelton's* case belongs to this category. Such eases are to be regarded as secondary tubercular infections of the lung. True syphilis of the lung is much more rare. *Adult syphilis of the lung, H. H. 22, 1910. Pelton, Medical Eecord, Jan. 174 Diagnosis of Syphilis. Pleura. Pleuisy may occur during the second and third stages of syphilis. During the second stage it occurs at the time of the eruption, as an expression of affection of the pleura. During the third stage it occurs most frequently because of the presence of gummata in contiguous tissues. SYPHILITIC AFFECTIONS OF THE CIRCULA- TORY ORGANS. Heart. Syphilitic affections of the heart have been recognized from time immemorial. Virchow declared that many of the cases described b} T the older writers as tubercle of the heart were probably cases of syphilis. At any rate, all parts of the heart may be affected by syphilis. The most frequently observed lesions are gumma of the muscle of the heart and fibrous syphilitic scars in the myocardium. Both the fibrous and the gummatous myocarditis are usually associated with sclerosing endocarditis and sometimes with a limited peri- carditis. Syphilis of the pericardium is rare in the absence of syphilis of the heart. Syphilitic endocarditis may be general or practically limited to the valves. The affection of the valves may lead to either insufficiency or stenosis. Syphilitic involvement of the papillary muscles may favor deficiency of the valves. Syphilis of the coronary arteries may lead to aneurysm of the heart. These arteries may be affected by a syphilitic endocarditis. How early may the heart be affected in syphilis? Fre- quently during the second stage of syphilis there are attacks of palpitation, that possibly may be due to the action of syphilitic poison upon the heart. Furthermore, during this stage of the disease there ma}' be attacks of cardiac asthma or dyspnoea. It is a question whether these symptoms, ob- Diagnosis op Syphilis. 175 served during the second stage of syphilis, are due to the action of the syphilitic virus upon the heart or to the syphilitic anemia observed in these cases. The important syphilitic lesions found in the heart, gummata and scleroses, occur in the third stage of the disease, several years after the initial lesion. Usually sudden death closes the scene before syphilis of the heart is even suspected. In other cases there are the symptoms of a chronic myocarditis. There may be general weakness, palpitation, and precordial anxiety and pain. The cardiac dullness may be normal or increased ; the heart sounds may be normal or weakened or irregular, and bruits may or may not be present. There are the evidences of a weakened circulation, notably anemia and cyanosis, oedema and dropsy, frequently albuminuria, and sometimes gangrene. Diagnosis is aided by the clinical history, and by the therapeutic test, especially in the chronic cases due to gummata. Myocarditis in a syphilitic should always be considered syphilitic until proven otherwise. The Wassermann reaction is of value in determining the presence of syphilis. Krefting * examined a number of cases postmortem. In about a dozen cases of aortic lesion, autopsy revealed syphilitic lesions. In these cases, the Was- sermann reaction was found in all but one case, in which the absence of the reaction was attributed to active anti- syphilitic treatment. In another series of eight cases of heart lesions, no Wassermann reaction was found, and there was no reason to believe that they were syphilitic. From the study of his cases, Krefting concludes that a syphilitic aortic lesion may become superimposed on an old non-syphilitic lesion of the heart. It is often essential that the diagnositician be familiar with the etiology of the diseases he studies, since the diag- nosis, at any rate the presumptive diagnosis, is often strength- ened by the exclusion of other possible causes of the disease *R. Krefting, Aortainsufficiens og Wassermann's luesreaktion, Norsk Magazin for La agevidenskaben, February, 1910. 176 Diagnosis of Syphilis. under consideration. There are many non-syphilitic causes of myocarditis, notably the infections, especially : acute artic- ular rheumatism, malaria, gout, diabetes, Bright's disease. Probably most cases are ascribed to cold, trauma, or strain. Myocarditis is frequently due to extension of inflammation from the endocardium or the pericardium. The symptoms of myocarditis may be overshadowed by endocarditis or peri- carditis. As a rule the heart is not able to do its work so well. Slight exertion causes palpitation and shortness of breath. There may be pain in the region of the heart, extending to the right arm or the epigastric region. The apex-beat, impact of the heart, and the heart sounds are weakened, indicating a weak heart. The pulse becomes weak and irregular. Frequently the respiratory passages show catarrh. Digestion is impaired. All the organs suffer from the poor blood supply. The individual is cyanotic. The veins of the neck become distended. The diagnosis rests chiefly on the evidence of a weak heart and the history or evidence of some disease that may play a role in etiology. A circumscribed m3 r ocarditis may be caused by embolism in the coronary artery or its branches, or by septicemia. The disease is often associated with : Ulcerative endocarditis, puerperal fever, malignant pus- tule, acute articular rheumatism, diphtheria, or typhoid fever, and purulent or gangrenous affection of the lungs. Acute diffuse myocarditis, whether parenchymatous or interstitial, is usually caused by the infections, especially : septicemia, typhoid fever, diphtheria, pneumonia, and gonorrhoea. The diagnosis of the syphilitic character of a myocarditis is reached chiefly through the history or evidence of other syphilitic lesions and the exclusion of other causes of myo- carditis. A gumma might respond to the therapeutic test, but there would be no such response in the cases of cardiac syphilitic scleroses. The spirochete pallida and the Wasser- mann reaction would indicate the presence of syphilis, but Diagnosis of Syphilis. 177 syphilitics are not infrequently the subjects of non-syphilitic diseases of the heart. As stated, pericarditis may be due to syphilis. Primary pericarditis may be due to trauma or causes apparently not connected with other disease, such as "taking cold." More important, because much more frequent, are the cases of secondary pericarditis, which may be caused by the infections or by extension of inflammation from contiguous organs, due to bacterial invasion or the action of toxins. Non-syphilitic pericarditis is most frequently found in association with: rheumatism (especially acute articular rheumatism), chorea, tuberculosis, pleurisy, endocarditis and myocarditis, pneumonia, influenza, scarlatina, septicemia, variola, scorbutus, nephritis, gout, cholera, dysentery, erysipelas, diphtheria, cerebrospinal- meningitis, haemophilia, hemorrhage diathesis, purpura, morbus maculosis, leukaemia, diabetes, cirrhosis of the liver, carcinoma, sarcoma, typhus, typhoid fever, intermittent fever, relapsing fever, gonorrhoea, phlebitis, osteomalacia, and aneurism (rare). The symptoms of pericarditis may be suggestive, but a diagnosis can be made only upon physical examination. The pericardial friction-sound and the evidence of effusion, espe- cially dullness in the fifth intercostal space to the right of the sternum, the precordial dullness later assuming the shape of the pericardial sac, with the base of the triangle above, are characteristic. Aspiration may be necessary to detect effusion, and at the same time will reveal the character of the effusion. Sometimes aspiration may not detect fluid in the pericardium even when present. Differentiation con- cerns especially endocarditis, pleurisy, hypertrophy of the heart, mediastinal tumors, and irritation or inflammation of the stomach. The syphilitic nature of a pericarditis is recognized through the association or history of other syphilitic lesions, the exclusion of other possible causes of pericarditis, the Wassermann reaction, possibly by finding the spirochete pal- lida, and by an appeal to the therapeutic test in doubt- ful cases. 178 Diagnosis of Syphilis. Endocarditis is a secondary process, occurring in the course of or following some infectious disease, due to the invasion of the endocardium by microorganisms, a number of which have been demonstrated, among them the micro- coccus pneumonia crouposae, streptococcus pyogenes, staphy- loccocus pyogenes aureus, bacillus diphtheria^, the gonococcus, and the tubercle bacillus. Endocarditis is especially likely to appear in the course of, or after : Rheumatism, pneumonia, influenza, septicemia (including surgical sepsis and puerperal fever) ; also osteomyelitis, peri- ostitis, erysipelas, furunculosis, and dysentery, gonorrhoea, scarlet fever; less frequently smallpox, measles, typhoid fever, syphilis, Bright's disease, and malaria. Sometimes even trivial affections (quinsy, mumps) may be accompanied or followed by endocarditis. The endocarditis may be due to the invasion by the specific microorganisms of the infectious diseases, or to secondary infection, or to the effect of toxins. In experiments upon animals it has been shown that the injection of microorganisms into the circulation is not followed by endocarditis unless the heart is first subjected to traumatic or chemical injury. This would seem to explain the role played by trauma, exposure to cold, arteriosclerosis, and atheroma. The symptoms usually of most value in diagnosis are chill, fever, pain in the region of the heart, palpitation, anxiety, headache, insomnia, and dyspnoea. Sometimes the semi-recumbent posture assumed by the patient may excite suspicion of the presence of endocarditis. Upon physical examination the heart's action may be found increased or decreased, the apex-beat displaced, the heart dullness increased, and there may be murmurs indicative of valvular disease. The history or knowledge of the existence of one of the infectious diseases may aid in an individual case. Syphilitics are especially prone to affection of the aortic valve ; affections of the mitral valve are usually rheumatic. Diagnosis op Syphilis. 179 Blood-vessels. Syphilitic arteries are probably more frequent than the literature would indicate. Syphilis is a prominent cause of arteriosclerosis. As in the heart, so in the blood vessels, syphilis seems to prefer the muscular tissue. Syphilis weakens the blood vessels and becomes one of the chief causes of aneurysm. In this way syphilis may affect any artery in the body, to cause affections so diverse as an aneurysm of the aorta or multiple aneurysms of the cerebral vessels. The rupture of these aneurysms is a frequent cause of cerebral hemorrhage. Syphilitic endarteritis may cause obliteration of the lumen of the vessel, thrombosis, aneurysm, or rupture. The veins may suffer from syphilis. A chronic phlebitis beginning several months after the primary infection, espe- cially if the pain shows distinct nocturnal exacerbations, justifies the therapeutic test for syphilis. It is a pretty good general rule to suspect syphilis in all cases of "idiopathic" disease of the blood vessels. In all such cases the advisability of making the therapeutic test should be considered. Blood. The laity have long looked upon syphilis as a disease of the blood, and , we now know that the spirochete may often be found in the blood, and the Wassermann reaction depends upon alterations in the serum. Various forms of anemia have been observed in syphilis. Syphilitic anemia, sometimes called syphilitic chlorosis, may occur early in the second stage of the disease. These cases sometimes show later leucocytosis or lymphatic anemia. Some cases of pernicious anemia have been reported in which the clinical history and the therapeutic test would indicate that syphilis was a possible etiological factor. However, the anemia found in syphilitics does not always respond readily "to anti-syphilitic treatment. 180 Diagnosis of Syphilis. Cachexia. Cachexia, like anemia, may be caused by syphilis. The diagnosis of syphilis in such cases must depend upon con- comitant symptoms. Furthermore, it should be remembered that a syphilitic may have a cachexia due to some other cause. In such cases the syphilis usually adds to the gravity of the picture. The more prominent causes of cachexia are malaria, syphilis, chronic sepsis, phthisis, lead poisoning, cancer and infantile scurvy. Cachexia strumapriva, due to destruction or removal of the thyroid gland, is easily recognized. Cachexia may be due to hemorrhage from the nose, lungs, gastrointestinal tract (in association with the ankylostoma duodenale, ulcer, cancer, hemorrhoids), the female genital tract, the bladder, and the various forms of hemorrhagic diathesis. Insufficient nourishment and bad hygienic conditions are often etiological factors. Malignant tumors, severe organic disease, poisons, and parasites may be factors in causing cachexia. Chronic sup- puration is a prominent factor. Spermatorrhoea, lactorrhoea, catarrh of the respiratory and alimentary tracts, are sup- posed to be causes. The role played by albuminuria and fever is rather to be ascribed to the diseases causing these conditions. The animal parasites probably produce cachexia through the elaboration of toxins. Among the poisons, lead and arsenic are the chief cause of cachexia. Syphilitic cachexia may be recognized by the presence of the Wassermann reaction. Other evidences of syphilis usually abound, relics of existing or preeisting stages of the disease. Amyloid Degeneration. Tuberculosis and syphilis and prominent causes of amyloid degenration. The degeneration sems to depend upon the presence of chronic suppuration. The parts most frequently Diagnosis op Syphilis. 181 showing amyloid degeneration are the liver, spleen, kidney, lymph glands, muscles and fat tissue, and in the mucous mem- brane of the gastrointestinal, respiratory, less frequently of the urinary tract. In the presence of an affection marked by chronic sup- puration, the occurence of painless swelling of the liver and spleen, albuminuria, and paleness of the skin and mucous membranes, suggests the diagnosis of amyloid degeneration. The liver, spleen and kidneys are the organs most frequently affected. But almost every part of the body may be involved. The less frequent locations of amyloid degeneration are the intestine, stomach, lymph glands, pancreas, adrenals, and rarely the muscles, ovaries, uterus and respiratory tract. Syphilis and tuberculosis are the more common causes. But amyloid disease gems to depend upon chronic suppura- tion in some part of the body. It occurs in the various cach- exias, in chronic dysentery, and in leukaemia. From what has been said, it is evident that we would not expect to find amyloid degeneration dependant upon syphilis during the first stage of the disease, nor in the second stage, except in the presence of prolonged suppuration. It is most common in the third stage of syphilis, when the history and relics of the disease usually makes clear the probable syphilitic nature of the process. In all cases of amyloid degeneration, we should look for a chronic suppuration. Syphilis is a prominent cause, both hereditary and acquired syphilis. Vieing with syphilis in frequency is chronic tuberculosis. Amyloid degeneration due to syphilis seems to affect with especial frequency the blood vessels, especially the small arteries and capillaries, less often the veins. With this there is also amyloid degeneration of the spleen, liver, kidneys and intestine. Amyloid degeneration of the spleen is marked by enlarge- ment of the organ and a feeling of fullness. Involvement of the liver in the amyloid disease causes a firm enlargement of the organ, with a feeling of fullness 182 Diagnosis op Syphilis. and pressure. Usually there is no icterus. There may be ascites, usually due to hydremia. Fatty liver may cause some confusion in diagnosis at times ; the presence of amyloid dis- ease in other organs may assist in differentiation. Amyloid disease of the kidneys usually does not cause a reduction in the quantity of urine. Albuminuria is fre- quently pronounced. As a rule the urine is clear and the specific gravity seems to depend upon the quantity passed. Casts are few or absent. Edema or ascites may be present, due to hydremia. Uramia is rare. Hypertrophy of the heart, such as is present in contracted kidney, is not caused by amyloid disease of the kidney. Amyloid disease of the intestine causes anorexia, periodical vomiting, and pale stools, containing mucus. In any case of amyloid disease, the diagnosis of syphilis must rest upon other evidence of the presence of the disease. The outlook, in cases of amyloid disease, is always grave, though possibly a cure may be secured early in these cases, when there has occurred only slight degeneration. SYPHILITIC AFFECTIONS OF THE GLANDS. Lymphatic Glands. The neighboring lymphatic glands show enlargement as the rule soon after the appearance of the initial lesion. Usually the lymphatics are enlarged, as well as the glands, in the lymphatic system leading from the region in which the chancre occurs. Occasionally the first line of lymphatics are spared and more remote glands are affected ; or the glands may appear enlarged upon the opposite side of the body, for instance, when the lesion is near the middle line. These occurrences, which must not be regarded as the rule, are explained by the anastomoses of the lymphatics. During this period, the buboes must be differentiated from those of chancroid ulcer and gonorrhoea, less frequently from the Diagnosis op Syphilis. 183 lymphatic gland enlargement of tubercle and cancer. Eczema and prurigo may also cause adenopathies. Finally, it must be remembered that simple infected sores may lead to an enlargement of the neighboring lymphatics. The spirochete pallida may be found in smears from extirpated syphilitic glands, or from the gland juice ob- tained by puncture. During the second or irritative stage of syphilis, the adenopathies assume prominence. During this stage, the enlargement of the lymphatics will usually be explained by finding syphilides in the region from which the lymph flow is derived. Occasional apparent deviations from this rule are explained by lymphatic anastomoses. Enlargement of the cervical lymphatics would suggest the probability of a secondary syphilitic lesion in the periphery from which these lymphatics are derived, such as in the ear, nose, nasopharynx, mouth, or an eruption upon the scalp. Affection of the cubital and axillary lymphatic glands should lead to an exami- nation of the hands and arms. The mediastinal, abdominal and pelvic lymphatic glands are enlarged especially in syph- ilitic affection of the intestine. Scrofula is usually syphilis or tuberculosis. It may be due to other causes, such as leprosy, glanders, etc., but they are less common with us. During the third stage of syphilis, gummata and syphilitic scars are usually marked by little or no affection of the lymphatics. However, an infected gumma may lead to en- largement of the lymphatics, the lymphadenopathy being due to the secondary infection, which is usually septic in character. Gummata of the lymphatics have been occasionally observed. Clinically, the lymphatic vessels seem to be affected more during the first than during the second stage of syphilis. 184 Diagnosis op Syphilis. DIAGNOSIS OF BUBOES. Syphilis. (First stage). Buboes show a tendency to be indolent, in the absence of secondary infection. Presence of chancre in region drained by lymphatics that empty directly or indirectly into the affected glands. Syphilitic buboes are usually multiple. Little pain or discomfort, save when there is mixed infection. Glands not greatly enlarged, in the absence of mixed infection. Cartilaginous induration. Absence of inflammatory symptoms. Glands remain freely movable. Slow course. Tendency to resolution. Occur soon after appearance of chancre. Benefited by mercury. Auto-inoculation from the pus of suppurating syphilitic buboes rarely if ever occurs, save in the presence of mixed infection. (Second stage). Syphilides may be found in the region drained by lym- phatics that empty directly or indirectly into the affected glands. (Third stage). An infected gumma may lead to adenopathy, due to the secondary infection. Lymphatic gummata are rare. In all stages of syphilis, the spirochete pallida and the Wassermann reaction are important factors in diagnosis. Diagnosis op Syphilis. 185 Inflammatory Buboes. Occur in about one-third of the cases of chancroid; less frequently in herpetic or balanitic ulceration or gonorrhoea; and may be due to infected wounds anywhere in the region drained by the lymphatic glands that empty into the affected glands. Thus an ingrowing toe-nail may cause enlargement or suppuration of the inguinal lymphatic glands. Usually single, occasionally double, rarely multiple. More prone to suppurate than syphilitic buboes. Painful. Usually cause greater enlargement of glands than syphilis. Inflammatory hardness. Inflammatory symptoms present. Periadenitis causes the gland to become fixed. Often adherent to skin; and the skin is often reddened. Course more acute than in syphilis. Tendency to suppuration. Not benefited by anti-syphilitic treatment; require local treatment. The pus from chancroidal buboes is infectious and causes auto-inoculation. The spirochete pallida and Wassermann reaction are ab- sent, except in the presence of syphilis. The venei'eal diseases, like vices, are gregarious. Mixed infections are not uncommon. The sphilitic patient enjoys no immunity from inflammatory buboes. 186 Diagnosis of Syphilis. Tuberculous Buboes. Tendency to caseation. Presence of source of infection in region drained by lymphatics that empty directly or indirectly into affected glands. Usually multiple. Usually little pain or discomfort except when there is mixed infection. Usually the glands become considerably enlarged; rarely there is little enlargement of an infected gland. Caseation and softening may be recognized by palpation. Inflammatory symptoms are usually absent, except when there is secondary infection. The affected glands may be freely movable, or they may become fixed by involvement of the peripheral parenchyma. The course may or may not be slow ; the infection may be confined to the affected glands, or it may spread to other parts of the bod} 7 through the breaking down of these glands. Usually there is no tendency to resolution. Occurs three to six weeks after infection of the region. Not benefited by anti-syphilitic treatment ; responds to the tuberculin test, and is benefited by treatment of tuber- culosis. In localized tuberculosis upon one side of the body (in- guinal region, ear, or eye) it is common to find affection of the glands upon the same side, and also upon the opposite side, though to a slighter degree. The importance of the lymphatic distribution of tuber- culosis is often underestimated. Tuberculosis of the toe may lead to caseation of the popliteal, inguinal and retroperitoneal glands, tuberculosis of the liver and spleen, and finally tuber- culosis of the lungs and caseation of the bronchial glands. Tuberculosis of the nose will cause caseation of the cervical glands, tuberculosis of the lungs and caseation of the bron- chial glands, and later tuberculosis of the liver and spleen. The skin and mucous membranes offer a barrier to infec- Diagnosis of Syphilis. 187 tion, but when the infection passes the barrier thus imposed, it is readily carried by the lymphatics to cause adenopathies. Glandular tuberculosis shows a preference for early life, most cases occurring before the tenth year. Most of the re- ported cases have occured in females. These preferences are attributed to increased susceptibility, diminished power of re- sistance, and unfavorable conditions of living. Gland tuberculosis shows a strong preference for the cervical and bronchial glands ; the preauricular and postauricular glands are less often involved, and much less frequent is tuberculosis of the axillary, cubital, inguinal, and popliteal glands. The cephalic lymph vessels convey infection from the skin of the head, the eyes, ears, nose, mouth, throat, palate, and tonsils, to the various glands of the neck, the auricular, cerv- ical, and submaxillary glands, as well as the glands of the supraclavicular and infraclavicular regions. Tuberculosis of the conjunctiva, cornea, or iris involves first the lymph glands in the region of the ear, jaw, and neck, especially or exclusively upon the diseased side. Inguinal adenopathies are rarely due to tuberculosis of the bones and joints of the foot; they are the rule in tuber- culosis of the vulva, vagina, or portio ; and of the penis or testicles. In such cases there may be an extension of the adenopathy to the retroperitoneal glands. In diagnosis, it is well to remember that a latent tuber- culosis may be made active, or the individual's immunity to tuberculosis may be lessened by the infectious diseases that are associated with catarrh of the respiratory tract, notably measles, croup, scarlet fever, diphtheria, influenza; and also by any disease that may lower the general resistance, such as typhoid fever. 188 Diagnosis of Syphilis. Cancerous Buboes. Indolent before ulceration; may be inflammatory from sec- ondary infection after ulceration. Presence of cancer in the region drained by the lymphatics. Usually multiple. At first there is little or no pain in the glands before ulceration ; later there may be pain from the pressure of the enlarged glands, or from secondary infection after ulceration. Glands become greatly enlarged. Marked induration. Inflammatory symptoms absent before ulceration ; may be present after ulceration unless prevented by treatment. Glands at first movable, later become fixed. Course usually more rapid than in syphilis. No tendency to resolution. Occur soon after appearance of cancerous nodule. Not benefited by anti-syphilitic treatment ; sometimes show temporary improvement under very large doses of the iodides. The pus is comparatively non-irritating, except in the presence of mixed infection. Prefers mature and advanced age. If the patient is not syphilitic, the spirochete pallida will be absent. Spirochetes may be found in cancer, but they are not the spirochete pallida. The Wassermann reaction is absent, except in syphilis. Syphilitics are not exempt from cancer. Diagnosis op Syphilis. 189 Buboes in Leprosy. Indolent buboes ; may be inflammatory through secondary infection of ulcers. The adenopathies of leprosy are pretty general, resembling the second rather than the first stage of syphilis. The affec- tion of the glands in the inguinal region is usually most pronounced. Usually multiple. Little pain or discomfort, in the absence of mixed infec- tion ; later they become large and painful. The size of the glands varies, probably corresponding to the amount of virus present in the body. The inguinal glands may attain the size of a goose egg, and any of the glands may become engorged ; the cervical and axillary glands are often large, and the submaxillary and sublingual glands may become so large as to interfere with mastication and deglutition. Indurated. Absence of inflammatory symptoms. Glands freely movable at first; later may become adherent. Slow course. No tendency to resolution; usually the affection of the glands increases with the progress of the disease. May be observed early in the course of leprosy. Not benefited by anti-syphilitic treatment. Softening and ulceration are rare ; late cases may show fistulas that discharge large quantities of thick matter that is comparatively non-irritating.. The spirochete pallida will not be found, and the Wasser- mann reaction is negative, save when there is a concomitant syphilis. 190 Diagnosis of Syphilis. Buboes in Glanders. Tendency to suppuration. Point of inoculation in the region drained by the lym- phatics. Usually multiple. Marked pain and discomfort. Comparatively slight enlargement of the glands. Inflammatory induration, soon followed by softening. At first movable, before suppuration and breaking down. Usually rapid course, two weeks ; the chronic form of glanders, which may last for months or years, does not show much involvement of the lymphatics. Tendency to suppuration. Occur soon after infection. Not benefited by anti-syphilitic treatment. Mallein test of value. Spirochete pallida absent. Wassermann reaction negative. There is often a history of exposure to the infection. Bacteriological examination reveals the bacillus mallei, to make the diagnosis absolute. X Diagnosis of Syphilis. 191 Syphilitic Lymphangitis. 1. The affected lymphatic vessels feel harder than in cases of in- flammatory lymphangitis. 2. The lymphatic vessels are not especially tender, and show a gen- eral absence of inflammatory symp- toms. 3. Penile erections are not pain- ful, and the skin overlying the af- fected lymphatic vessels remains apparently normal. 4. Syphilitic lymphangitis al- most always terminates in resolu- tion. 5. Syphilitic lymphangitis does not require local treatment, and disappears under the usual mercu- rial treatment. 6. Spirochete pallida and the Wassermann reaction are present. 7. There may be the history or other evidence of syphilis. Inflammatory Lymphangitis. . 1. Lymphatic vessels tender, but not so hard as in syphilitic lym- phangitis. 2. Inflammatory lymphangitis is marked by tenderness of the af- fected vessels, and inflammatory symptoms. 3. Erections are painful, and the skin is reddened over inflamed lymphatic vessels. 4. Inflammatory lymphangitis frequently undergoes resolution, but may terminate in suppuration. 5. Inflammatory lymphangitis is greatly benefited by local treat- ment, and does not require the anti-syphilitics. 6. Absent in inflammatory lym- phangitis, except in syphilitics. 7. Absent, unless there is a con- comitant syphilis. 192 Diagnosis of Syphilis. Spleen. Syphilis ranks with malaria and tuberculosis among the chronic infections that may affect the spleen. Acute enlarge- ment of the spleen may occur in the second stage of syphilis. Chronic enlargement of the spleen is common in hereditary syphilis, in which the involvement of the spleen is next to that of the bones in frequency. The hyperplastic enlargements of the spleen may be soft or indurated. These are the two forms distinguished by Virchow. Further, the spleen may be en- larged by amyloid change. Gummata of the spleen are comparatively rare, and usually are associated with syphilis of the liver. The spleen may be enlarged while the patient is still suf- fering from the initial lesion. Furthermore, the spleen may be enlarged from non-luetic causes, such as malaria, any time during the course of syphilis. An enlarged spleen sometimes undergoes reduction in size under the therapeutic test for syphilis. In such cases a presumptive diagnosis of syphilitic enlargement of the spleen may be made, though such a reduc- tion may at times occur in non-syphilitic cases. The clinical history is of value as a side light in the diagnosis of obscure cases. The presence of the Wassermann reaction indicates syphilis, but does not exclude the other causes of enlargement or affection of the spleen. Thymus Gland. Cases of syphilitic affection of the thymus gland have been reported from time to time, but the affection is so rare that the diagnosis must rest largely upon the clinical history of the case, and the result of the therapeutic test in suspected cases. The most marked changes have been hyperplasia and induration. The presence of syphilis may be recognized by the Wassermann test, and by the evidences of the disease in other parts of the body. Diagnosis op Syphilis. 193 Simmonds declares that macroscopic cyst formation together with an increase in the epithelioid structure of the thymus, may be taken as a sign of congenital syphilis. Congenital syphilis is manifested in the thymus gland by an increase of the epithelioid cells, which are found either in columns, or canals, or surrounding microscopic spaces, vacuoles. In a few instances the epithelioid cells have been found in such abundance and the lymphoid structure has been so scarce and Hassal's corpuscles have shown such paucity that the entire structure of the gland has been altered. In these cases macro- scopic cysts may form, which contain a serous fluid, lymphoid cells, or purulent material. In these cases, the spirochete pal- lida may be demonstrated in the contents as well as in the cyst wall. THYMUS GLAND. Chiari, Zeitschrift fiir Heilkunde, xv, 403, 1894. Eberle, Ueber kongenitale Lues der Thymus. Kaufmanns, Lehrbuch der pathologischen Anatomie, iv. Aufl. 1907, s. 316. Schlesinger, Arehiv fiir Kinderheilkunde, xxvi, 205. *Simmonds, M., Die Thymus bei kogenithaler Syphilis, Arch. Path. Anatomy, Band 194, p. 213, 1908. Tuve, Ueber die sogenannten Duboisschen Thymusabszesse, Disserta- tion, Leipzig, 1904. Thyroid Gland. Syphilitic patients not infrequently show enlargement of the thyroid gland. But the enlargement is not always due to syphilis. Syphilitic patients are as liable as the non-syphilitic to non-luetic enlargement of the thyroid. Furthermore, the positive therapeutic test for syphilis is not always to be relied upon in these cases, since non-syphilitic enlargement of the thyroid will frequently respond to this test. In congenital syphilis, gummata of the thyroid has been observed, in association with syphilitic lesions in the viscera and other parts of the body, especially the thymus, lung, liver and pancreas. Gumma of the thyroid has also been observed later in life, usually in association with visceral involvement. Clinically these cases present a tumor of varying size, not 194 Diagnosis of Syphilis. adherent to the skin, but possibly firmly adherent to the trachea and larynx, and without metastases. Ulceration may occur, and pressure on the trachea may lead to edema of the larynx and difficulty in deglutition. Hoarseness is a common symptom. Interference with the function of the thyroid may lead to myxedema. There may be the symptoms of exophthalmic goitre. Enlargement of the thyroid is often observed during the second stage of syphilis, frequently as an early symptom. Such syphilitic goitres, which respond favorably to anti- syphilitic treatment, should be distinguished from the swelling of the thyroid in syphilitics, due to the anti-syphilitics and made worse by these remedies. THYROID. Barth and Gombault, Progres Med., 1884, xii, 834. Birch-Hirsclifeld, Lehrlmch der speciellen pathologischen Anatomie, Berlin, 18S7, i, 578. Clarke, Lancet, 1897. ii. 389. Davis, B. F., Syphilis of the thyroid. Archives of Internal Medicine, xxxix, vol. v. No. 1, January 15, 1910. Demme, Krankheiten der Schilddriisen. Bern, 1897 ; Gerhardt's Hand- buch der Kinderkrankheiten, iii, part 2, p. 413. Engel-Reimers, Jahrb. d. Hamburg, Statskrankenanst., 1891-92, ii. 430-436. Fraenkel, Deutische med. Wochenschrift, 1887, xiii, 1035. Fiirst, Moritz, Berlin klin. woch., 1898, xxv, 1016. Julien, Traite pratique des maladies veneriennes, 1899, p. 642. Kohler, Berlin klin, Wochenschrift, 1892, xix, 125. Lancereaux, Traite historique et pratique de la syphilis, 1868. i, 377. Lang, F., Jahresbuch d. Gesellsch. f. Natur. und Heilk., in Dresden, 1851-52. Lockwood. St. Bartholomew's Hosp. Reports, 1895, xxi. 232. Mauriac, Syphilis primitive and svphilis secondaire, 1890, p. 474. Mendel. Me'd. Klin., Berlin, 1906, ii. 833. Navratil, Chir. Beitr.. Stuttgart, 1882, pp. 21, 22. Power and Murphy. A system of syphilis, 1908, ii. 169. Richardson, The thvroid and parathvroid glands. 1905. Thursfield. Brit. Med. Jour., 1908, i,* 147. Wagner, Arch. d. Heilk.. iv. Wermann, Berlin, klin. Wochenschrift. 1900. xxxvii, 122. Ziegler, Text-book of Special Pathological Anatomy. Davis has recently reported a case of syphilis of the thyroid, in which the diagnosis was confirmed by the histo- logical findings. He gives a resume of twenty cases from the literature, eight, of these were diagnosticated clinically with- - Diagnosis of Syphilis. 195 out any recorded anatomic proof of the correctness of the diagnosis. Three cases were diagnosticated both clinically and histologically. Eight cases were diagnosticated histo- logically. One other case was probably diagnosticated only clinically. Davis claims that the case he reports is the first case of gumma of the thryoid in which the diagnosis was confirmed by the anatomical findings, to be reported in American litera- ture, the third in the English language, and the eleventh in the entire medical literature. Supraneal Bodies. Gummata or gummatous degeneration have been observed in the adrenals in some cases of Addison's disease. The pos- sibility of such an occurrence would be suggested by the association of syphilis and Addison's disease, especially if the former antedated the latter. The Wassermann reaction and the therapeutic test would make the diagnosis. Syphilis of the Breast. Chancre of the breast occurs almost exclusively as the result of nursing an infected infant, the nipple or areola being infected usually by a child with mucous patches in the mouth. Often a fissure or abrasion of the nipple exists, favor- ing infection. The examination of the child's mouth will often suggest the diagnosis. Though the mother may be protected from infection by her own syphilitic child, a nurse, who is not the mother of the child, enjoys no such immunity. Infection may also be received from other sources. When due to nursing a syphilitic child, multiple chancres, sometimes in- volving both breasts, are not uncommon. The chancre presents the general appearance of that lesion, indurated base, with axillary or cervical adenopathy. The lymph glands in the axilla and above the divide are enlarged, and often the inflamed lymphatics may be traced with the finger, or even with the eye, the perilymphangitis causing a 196 Diagnosis of Syphilis. distinct cord or possibly color lines. Induration remains at the site of the inoculation long after the chancre has healed and the adenopathies have disappeared. Chancroid is not so common in this localitj', and is marked by its auto-inoculability. The second stage of syphilis is manifested in the breast chiefly in the form of mucous patches and moist papules. The secretions from these lesions are infections, so that not infre- quently there is presented a picture much resembling that of chancroid. This is especially true in obese women with large, pendulous breasts, the region beneath the breast being espe- cially liable to affection. The other syphilides, such as the pigmentary syphilide, may be found upon the skin of the breast as elsewhere. Evidences of the disease in other parts of the body affords an aid to diagnosis. In the third stage of syphilis, the breast may be affected by gummata, either circumscribed or diffuse, the so-called syphilitic mastitis. The circumscribed gumma presents an indolent swelling, without change in the color of the skin, marked by the ab- sence of pain and the presence of axillary adenopathy. Usually both breasts are affected. Diffuse gummata in this region are subcutaneous or in the tissue of the gland. They are of slow growth, indolent, and often discovered only upon palpation. Later the mass breaks down in its center, becomes adherent to the skin, which shows a change in color. Ulceration ensues, with the discharge of the broken-down tissue, and healing takes place with de- formity. Such growths bear a marked resemblance to cancer of the breast. All stages of syphilis show the Wassermann reaction, ex- cept where it is obscured by anti-syphilitic treatment. The spi- rochete may be found, and is of special diagnostic value in the first and second stages of the disease. But a syphilitic may be affected by cancer of the breast, so that when in doubt, the therapeutic test is often of value. Diagnosis of Syphilis. 197 SYPHILITIC AFFECTIONS OF THE URINARY ORGANS. Kidneys. Acute, subacute, or chronic nephritis, granular kidney, gummatous infiltration, and amyloid kidney may occur in the course of syphilis. Perinephritis and paranephritis have also been observed. Various combinations of these affections may exist. Thus amyloid disease and contracted kidney are held by some observers to be characteristic of syphilis. Statistics would indicate that amyloid disease is from seven to ten or more times more frequent than gummata of the kidney. Gum- mata are apparently comparatively rare in the kidneys in hereditary syphilis. All of these affections of the kidneys, save gummata, may be found in the absence of syphilis. The kidney may be affected during the second and third stages of syphilis. The Bright's disease of syphilis may be infectious or syphilotoxic in character. Improvement under anti-syphilitic treatment would speak for the syphilitic nature of a nephritis. Further than this, the clinical history of the case may be of value in diagnosis. It must be remembered, however, that a syphilitic patient may have a nephritis from other causes. Sometimes albuminuria and cylindruria occur during mercurial treatment, to disappear after the remedy is stopped. Amyloid kidney may be caused by other diseases than syphilis, such as tuberculosis. There is usually albuminuria, and frequently amyloid disease may be present in other organs, especially the spleen and liver. The syphilitic origin of the amyloid disease may be inferred from the clinical history. Gumma is the only characteristic syphilitic lesion of the kidney. One or both kidneys may be affected. A unilateral affection, especially in the presence of gummata in obher parts of the body, is most characteristic. However, in such a 198 Diagnosis op Syphilis. case Lang made a false diagnosis of gumma of the kidney in a case of echinococcus cysts, the peresites being later voided in the urine. Haematuria, marked by the passage of bright blood, has been observed in syphilis. The disappearance of the bleeding under the use of the iodides would seem to speak for the syphilitic nature of the hemorrhage. However, pain without haematuria is probably more characteristic of renal syphiloma. Obscure cases of renal disease may occasionally be cleared up absolutely by the microscopic examination of the urine, which may reveal pieces of a gumma or of amyloid material. Haemoglobinuria has occasionally been observed in syphilis. Sometimes the affection is periodical. It is possible that the haemoglobinuria may be caused by syphilis. Incidentally it may be mentioned that the affection has been attributed by some to the use of mercury. Ureter. Gumma of the ureter has been reported. There was dila- tation of the kidney and ureter above the obstruction ; and gummata were found in the liver and spleen. Bladder. Ulcers have been observed in the bladder, which were ap- parently due to syphilis. Such syphilitic ulcers have been described by Virchow, Tarnowsky, Proksch, etc. In the re- ported cases, in which the diagnosis was made ante-mortem, the patients have shown other symptoms and evidences of syphilis with the symptoms of vesical ulceration. The patients have ranged in age from childhood to Virchow's case, a woman eighty-four years old. With the modern cystoscope, there is no reason why such cases should not be recognized. Diagnosis of Syphilis. 199 Uretha. The primary sore is the most frequent syphilitic affection of the urethra. In this location, the chancre not infrequently assumes the slate-pencil shape. The condition is to be dif- ferentiated chiefly from gonorrhoea, chancroid ulcer, and sim- ple stricture of the urethra. The second stage of syphilis is probably not infrequently represented by an eruption of syphilides in the urethra, which have been observed occasionally through the endoscope. In such cases the mucous membrane of the urethra is found inflamed in circumscribed spots, sometimes circular in form, marked by increased redness, swelling, and a greater secretion of mucus. There may be found a papular syphilide or a circumscribed erosion. There is often not much increased secre- tion of mucus, which seems to depend largely upon the degree of infiltration. The possibility of urethral herpes must be borne in mind. The third stage is more frequently reported than the second stage, though not so frequent as the first stage of syphilis of the urethra. During this stage there may be gummata of the urethra, which may break down to form ulcers, and lead later to cicatrization. The presence of nodules or ulcers or scar tissue may be observed through the endo- scope. The gummata and gummatous ulcers respond to the therapeutic test. The syphilitic nature of the scars may be inferred from the history of the case. Sometimes the gummata break down and lead to the formation of fistulas. Any part of the urethra may be affected by syphilis. Pain varies in severity, and may be absent altogether. Differential diagnosis calls for the separation of syphilis from cancer and tuber- culosis of the urethra. The history, Wassermann reaction, therapeutic tests, examinations of the secretion, and possibly the microscopic examinations of particles of the tissue make the diagnosis. 200 Diagnosis op Syphilis. Urethral Chancre. 1. Incubation from ten to forty days, usually two or three weeks. 2. Located at or near the mea- tus. 3. Absence of chordee; ardor urinae felt only at meatus. 4. Scanty discharge, serou9 or sero-sanguinolent ; may become purulent only as result of second- ary infection. 5. Induration usually involving one lip of meatus; sometimes in- volving the entire meatus, when the induration may be pencil shaped. 6. As a rule the inguinal lym- phatics present multiple indolent buboes. 7. Visual examination reveals an ulcer. 8. Microscopic examination reveals the spirichsete pallida. The Was- sermann reaction is present. It is, of course, possible for urethral chancre and gonorrhoea to co-exist. 9. The use of the penile syringe causes pain at the meatus. 10. Subsequent constitutinal symp- toms. Gonorrhoea. 1. Incubation from one day to one week, rarely longer. 2. Extends from meatus back- ward, and may involve any part of urethra. 3. Chordee common ; ardor urinse may be felt along the entire urethra. 4. Copious discharge, purulent and irritating, comparatively rare- ly stained with blood. May become laudable when ulcer is healing. 5. No induration, save such as may be due to inflammation, irri- tation, or caustics, and it is then more temporary and not so hard, firm and elastic as the induration of chancre. G. Buboes are usually absent; when present they are usually single and tend to suppurate. 7. No ulcer; visual examination reveals only an inflammation. 8. Microscopic examination reveals gonococci, especially in early cases. So-called chronic gonorrhoea is often a septic urethritis, due to the ordinary pyogenic micro-organisms. 9. As a rule the use of the syringe is not accompanied by pain. 10. Gonorrhoea remains a local disease. Diagnosis op Syphilis. 201 Chancroid. 1. Short incubation, usually a number of hours, rarely longer than two days. 2. Located at or near the mea- tus; rarely extends beyond the fossa navicularis. 3. Chordee usually absent; there may be ardor urinae at the meatus. 4. Discharge abundant, purulent, irritating. 5. Little or no induration. i*i. The lymphatic glands are af- fected in about one-third of cases; the affected glands usually sup- purate, and the pus from them is infectious, causing autoinoculation. 7. Visual examination will reveal the characteristic clean cut irregu- lar ulcer. 8. Microscopic examination may reveal the bacillus of Ducrey or the ordinary pyogenic micro-organ- isms, especially the streptococcus. It is not uncommon for the various genital infections to co-exist. 9. The use of the penile syringe is painful at the meatus. 10. Chancroid remains a local disease. Stbictueb. 1. Occurs after some injury or disease of the urethra; rarely con- genital. 2. Possibly may occur anywhere; most frequent in the region of the bulb, in the region of the peno- scrotal angle, and posterior to the fossa navicularis. 3. No chordee; there may be ob- struction to flow of urine but no ardor urinse. 4. There may be a gleety dis- charge and shreds in the urine. 5. Little or no induration. 6. No affection of lymphatics, save such as may be due to coin- cident or preceding disease. 7. No ulcer; examination will re- veal the stricture. 8. There is no characteristic microscopic evidence of stricture; there may be evidence (gonococci, streptococci, etc.) of a co-existing disease, that possibly may have played a role in the etiology of the stricture. 9. Usually the use of the penile syringe is not painful. The stric- ture may be recognized by the obstruction offered to the passage of a sound or catheter. 10. Stricture is a local condi- tion; the obstruction offered to the outflow of urine may lead to changes higher up the urinary tract, especially cystitis. 202 Diagnosis op Syphilis Urethral Syphilides — Urethral Herpes. Herpes progenitalis may occur in the meatus or urethra, hut it is more frequently found in males in the sulcus behind the corona, and sometimes on the glans ; in females, upon the labia, the hood of the clitoris, the vagina, and the cervix uteri. The patient complains of itching and burning, and there may be some edema of the affected parts, especially when the prepuce or labia is affected. Upon mucous mem- branes, the vesicles soon rupture, leaving small superficial ulcers. In differential diagnosis, it is well to remember that herpes is at first announced by an eruption of accuminate vesicles, and the subsequent ulcers are covered with a serous exudate. On the other hand, mucous patches are flat, and are covered with macerated epithelium. The herpetic eruption consists of a vesicle or group of vesicles altogether different from the eruption of syphilis. Herpes is marked by little inflammation, slight discharge, rarely bj T transitory enlargement of the neighboring glands, and does not present a history and course such as we observe in syphilis. In urethral syphilides, the spirochete pallida is present, and the Wassermann reaction may be obtained. These are absent in urethral herpes. There may be the history or evidence of the primary sore, in urethral syphilides. Absent in herpes. Diagnosis op Syphilis. 203 Urethral Gumma — Tuberculosis — Cancer. These will receive further consideration when discussing the third stage of syphilis of the penis. Tuberculosis of the urethra has been produced experiment- ally in animals by injecting tubercle bacilli into the uninjured urethra of rabbits (Baumgarten) and guinea pigs (Cornet). A number of cases have been reported in which the urethra was apparently primarily affected by tuberculosis in both men and women. In searching the literature upon this sub- ject, it is well to bear in mind the fact that many writers report tubercles as primary infections, when they are the first extra-pulmonary lesions observed. Undoubtedly most of the cases may be attributed to infection with tuberculous sputum carried by soiled fingers. The infection may be car- ried directly to the urethra by instruments, catheters, bougies, sounds, coitus or masturbation. More rarely the infection pos- sibly comes from above, from a preceding tuberculosis of the kidney, bladder or prostate. The infection by the tubercle bacilli seems to be favored by gonorrhoea, stricture, phimosis, nephritis, trauma, and possibly also by alcoholism. Tuber- culosis of the urethra has been reported less frequently in women than in men. In the female, pregnancy seems to favor the infection. So that the diagnosis of tuberculosis of the urethra would be aided by finding tuberculosis of the lungs, tubercle bacilli in the sputum, or a tuberculous lesion higher up in the urinary tract; and the diagnosis would be made plainer by finding tubercle bacilli in the urethral secretion, or by a local reaction following the test injection of tuberculin. The endoscopic ap- pearance will often suffice to make the diagnosis, or a positive diagnosis could be made by finding the tubercle bacillus in scrapings from the affected tissue. Both cancer and tuberculosis do not necessarily give the history of syphilis, though they may occur in syphilitics. Both these affections are much more painful than gummata. Cancer 204 Diagnosis op Syphilis. is especially prone to lead to adenopathies in the neighboring lymphatic glands. In early cases the diagnosis of cancer of the urethra may be facilitated by endoscopic examination, and the diagnosis may be made absolute by the microscopic examination of a portion of the growth. Later the nature of the disease will be declared emphatically by the course of the affection. Neither cancer nor tuberculosis are materially benefited by anti-syphil- itic treatment. Finally, cancer of the urethra usually begins at the meatus, or is secondary to cancer of the penis or of the vulva. The spirochete pallida speaks positively for syphilis. A spirochete may be present in cancer, but it differs in appear- ance from the spirochete pallida. The Wassermann reaction is of even more practical value at this stage of syphilis, because of the difficulty experienced in finding the spirochete pallida in the third stage of the disease. Diagnosis of Syphilis. 205 MALE GENERATIVE ORGANS. Penis. The most frequent syphilitic lesion of the penis is the chancre, which has received sufficient description. The second stage of syphilis is often early represented upon the penis by the roseola and papular syphilides. The third stage of the disease also seems to show a predilec- tion for the penis, the gummata sometimes developing upon the scar of the initial lesion. In such cases the physician may be somewhat confused at times, since the lymphatic glands may still be enlarged. Frequently it is necessary to differentiate between gummata and papular syphilides of the penis. The ulcers may be formed by the breaking down of syphilitic pustules or gummata, and must in either case be differentiated from chancroid ulcers. Tubercular ulcers are comparatively rare, but must receive consideration in diagnosis. Cancer, espe- cially carcinoma, must be differentiated from gumma. Finally, it must be remembered that not all nodules in the penis are syphilitic. In making a diagnosis of syphilis, the history of the case, which is often misleading, is sometimes of value. The course of the disease and the presence or history of other syphilitic manifestations may shed valuable side lights. Most illuminating are the spirochete pallida and the Wassermann reaction, which may render clear the most obscure case. Penis. Syphilis : 1. Chancre. 5. Chancroid. 2. Roseola. 6. Tubercle. 3. Papular syphilides. 7. Cancer. 4. Gumma. 8. Simple tumors. 206 Diagnosis of Syphilis. In making these differentiations, the spirochete pallida and the Wassermann reaction speak for syphilis, but do not exclude other affections. Mixed infection is not uncommon. The first stage of syphilis is frequently found upon the penis. Some authorities state that this is the most common syphilitic lesion of the penis. Next in frequency, if not as common, is the manifestation of the second stage. The gen- eral eruption of syphilis frequently involves the skin of the penis, including the thin skin covering the glans and the inner layer of the prepuce. During this stage the urethral mucous membrane may show various eruptions. These have received sufficient description under the discussion of the syphilitic affec- tions of the skin and mucous membranes. The third stage, marked by gummata, is less frequently found in the penis, but is far from infrequent. From these considerations, it is not strange that the penis is frequently the site of syphilitic scars. Chancre. The initial lesion upon the penis involves most frequently the prepuce, glans, or urethra. (See page 38.) Indolent buboes may be present in the groin at the time of the appearance of the primary sore, and usually are present within two weeks after the beginning of the chancre. The spirochete pallida may be readily found in the secretion from the chancre, and also in the serum aspirated from the buboes. The Wassermann reaction is not present before the sixth week after infection. The syphilitic lesions may encroach upon the lumen of the urethra, causing more or less occlusion. This usually disappears later, in the case of chancre. Gummata and the pustular syphilides may destroy tissue, and the cicatericial tis- sue that is formed, may contract and cause a stricture that is more permanent. Diagnosis of Syphilis. 207 Subpreputial Ulceration in Cases of Phimosis. Chancre. 1. Incubation ten to forty days, usually two to three weeks. 2. The ulcers are usually single. May be felt. 3. Comparatively slight inflam- mation. 4. The swelling is hard, dry, and indurated. 5. Scanty discharge, serous or sero-sanguinolent ; may become purulent as the result of secondary infection. 6. There is no marked inflam- mation and ulceration of the pre- putial orifice, save such as may be caused by secondary infection. 7. Palpation may reveal the cartilaginous induration at the base of the ulcer. 8. Multiple indolent buboes are the rule. Suppuration of buboes in eases of chancre is usually due to mixed infection. 9. Spirochete pallida and Was- sermann reaction. The latter is not present before the sixth week. Non-syphilitic Ulceration. (Chancroid, herpetic, balanitic. ) 1. Incubation less than a week, as a rule to be measured by hours, rarely more than two days. 2. Multiple ulcers are the rule. At times these can be felt. 3. Marked inflammatory reac- tion-heat, pain, redness and swell- ing. 4. The swelling is more edema- tous in character. 5. Profuse discharge, purulent, rarely streaked with blood, and in- fectious. Autoinoculation is com- mon, especially in chancroid. 6. The margins of the preputial orifice are usually ulcerated, espe- cially in chancroid. 7. There is no such induration, save such as may be caused by in- flammation, irritation, or caustics, or by a previous chancre. 8. Buboes are usually absent, and when present are single or double, rather than multiple, and tend to suppurate. 9. Spirochete pallida and Was- sermann reaction absent, except in the presence of a concomitant syphilis. Roseola and papular syphilides are the two most common eruptions upon the penis during the second stage of syphilis. (See pages 48, 54, and 58.) The eruption upon the penis is but a part of the general eruption, and has already been described in studying syphilitic affections of the skin. Gumma is not so frequently found as the secondary lesions, but is not rare. (See page 52.) 208 Diagnosis of Syphilis. Chancre of Penis. Incubation : About two weeks, with limits extending from one week to two months. Confrontation : Derived from a preceding case of syph- ilis, directly or indirectly. Often attempts to deceive. Auto-inoculation does not occur; may infect others. Occurs at point of inoculation ; may be genital or extra- genital. Begins as an indurated infiltration or nodule. Shape: Usually round or oval. Location : Usually superficial. Cartilaginous induration of base. May be elevated; margins usually not markedly abrupt. Usually single ; multiple chancres are rare. Secretion : Scanty and serous. Pain and discomfort comparatively slight. Adenopathy : Indolent buboes usually appear within two weeks after the appearance of the chancre. Duration : A few weeks under anti-syphilitic treatment. Later appearance of second and third stages of syphilis, when not cured. Undergoes resolution, leaving a scar or loss of pigment when located on the skin ; these may not be visible when located upon mucous membrane. Spirochete pallida present, best found in scrapings from the deeper part of the chancre. Wassermann reaction present ; may be obscured by anti- syphilitic treatment. Immunity : Second attacks are rare. General health may be good. Diagnosis of Syphilis. 209 Chancroid of Penis. Incubation : A number of hours ; usually the symptoms come on within a day or two after exposure. Confrontation : Due to inoculation from chancroid ( pus from ulcer of bubo). Often co-exists with syphilis. Auto-inoculation common; infects others to produce chan- croid. Usually confined to genitals ; extragenital chancroid is rare. Begins as a nodule and forms a pustule that breaks down to form a deep, painful ulcer with an unclean base. Induration may be caused by caustics or inflammation, but differs from the cartilaginous induration of chancre. Shape: Usually less symmetrical in outline than chancre. Edges clean cut, irregular, sometimes undermined. May be single ; often are multiple. Secretion: Abundant and purulent. Pain and discomfort greater than in chancre. Adenopathies in about one-third of cases. The buboes usually suppurate, and the pus from them is infections — may cause chancroid. Disappears promptly under local treatment ; not influenced by anti-syphilitic treatment. Chancroid is not followed by general symptoms. The local lesion is marked by greater persistence and more destruction of the tissue, when not treated, than occurs in chancre. Spirochete pallida absent. Wassermann reaction absent, except in syphilitics. No immunity; second attacks common. General health may be good. 210 Diagnosis of Syphilis. Epithelioma of Penis. Usually requires months to develop, but may develop rapidly. Frequently history of exposure to cancer, or family history of cancer. Offensive odor; less marked under treatment. Occurs most frequently after forty. Impairment of general health occurs sooner than in syphilis. Pain is usually a prominent symptom. Shape : Irregular. Bleeds more readily than chancre. Absence of the cartilaginous induration of the base ; the base is less circumscribed and more extensive. Adenopathies : Enlargement of the lymphatics usually does not begin until after the first three months. Mercury is deleterious rather than beneficial. Microscopic examination: Endocytes, ingrowing epithelial cells, cancer nests. Spirochete pallida absent. A spirochete may be present, but it is not the spirochete pallida. Wassermann reaction: Absent, except in syphilitics. Usually induration is greater after ulceration. Cachexia comes on comparatively early. Absence of the history and evidence (lesions or relics) of syphilis. A syphilitic patient is not exempt from epithelioma, but the co-existence of the diseases is far from the rule. Diagnosis of Syphilis. 211 Tubercular Ulcer of Penis. Slow in development. In the reported cases there has often been a history of unclean circumcision. Later in life the patients often have pulmonary tuberculosis, or there is a history of conjugal tuberculosis. The ulcers are usually multiple ; may be single. Most frequent under forty; often occurs in youth. Habitus phthisicus may be present in advanced tuberculosis. The ulcer is painful. Shape: Usually round, rather than ovoid. Absence of cartilaginous induration of the base. Usually small in size compared with the syphilitic lesions. Adenopathies: Usually absent; may be caused by secondary septic infection. Anti-syphilitic treatment valueless. Microscopic examination: Tubercle. Tubercle bacillus is present, but may be difficult to find in the tissue. Tuberculin test positive. Little or no induration. Cachexia is usually absent; may be present in cases of ad- vanced tuberculosis.* *Tuberculosis of the penis has been observed in a large number of cases. In almost every ease the infection has been ascribed to unclean circumcision. Such cases have been reported by Lindemann, Lehmann, Elsenberg, Hofmokl, v. Bergmann, W. Mayer, Eve, Loewenstein, Kolizow, Gescheit, Pasternatzki, Chwolsow, Janowitsch, Tschainski. Occasionally cases occur that may not be attributed to circumcision. Such cases are due in a great majority of cases, to infection carried by the fingers. It is remarkable that extra-pulmonary infection is not more common in cases of pulmonary tuberculosis. Occasionally tuberculosis of the penis occurs in patients that are not affected with pulmonary tuber- culosis. Cornil refers to a case described by Ssalitscheff, in which a primary tuberculosis of the glans penis was observed in a man of forty- seven, whose wife was apparently tubercular. In tuberculosis of the penis, the infection is derived from the sputum. This holds true in eases ascribed to unclean circumcision, in which it has been demonstrated that the infection came from oral haemostasis per- formed by a tubercular operator. The cases ascribed to coitus with a tubercular patient, are more likely cases of sputum infection. The tubercle bacilli may be conveyed from the sputum by unclean fingers, masturbation, or by contamination of the genitals with saliva. Ill 212 Diagnosis of Syphilis. Ulcer of Penis Due to Pustules. Syphilitic pustules occur during the second stage of the disease. Cause rapid destruction of tissue. History or evidence of preceding chancre. Preceding pustular syphilide. Syphilitic pustules occur as large and small pustules. The small pustules, which may be miliary (about the size of a pin- head), are arranged in groups. Resemble lichen scrofulosorum. The large pustules are found early in the second stage of syphilis, often in association with papules. They run a pro- tracted course and differ from the eruption of smallpox in the absence of the vesicular stage. In the eruption that occurs later in syphilis, the pustules are circumscribed and are grouped like the papular eruption. The syphilitic pustules occur without previous vesiculation. After ulceration, the margin is infiltrated and sharply defined. Complicating inflammation may cause chronic edema and elephantiasic hypertrophy. The spirochete pallida is present, and the Wassermann reaction may be obtained. Other secondary lesions are usually present, especialy eruptions upon the skin and mucous membranes. Diagnosis of Syphilis. 213 Gumma of the Penis. Usually occurs before forty. History or evidence of the preceding stages of syphilis. Gummatous ulcer : Does not bleed so readily as epithelioma ; the secretion is comparatively slight and not so offensive nor irritating as that of epithelioma. Induration precedes ulceration. Pain : Comparatively slight or absent. Cachexia is usually absent. Adenopathy: Comparatively slight; due especially to mixed septic infection. Microscopic examination: Granulation tissue. The spi- rochete pallida is difficult to find. Wassermann reaction, except when obscured by energetic anti-syphilitic treatment. Papular Syphilide of the Penis. The large papules are the only ones that need be con- sidered in this connection. Firm, sharply denned, brownish red papules. The size of a lentil or larger. Project somewhat above the surface. Enlarge from the center towards the periphery. After the formation of scales and crusts they disappear, leaving a slightly pigmented depression that later becomes white and shining. Usually there are present all stages of development and involution of the eruption, to aid in diagnosis. Often occurs as the first eruption during the second stage of syphilis, frequently associated with roseola. Constitutes the most frequent form of relapse of syphilis during the first decade. Central atrophy is a prominent diagnostic feature. Large papules, with central atrophy and peripheral growth, may attain the size of a dollar — syphilis papulesa orbicularis. I 214 Diagnosis of Syphilis. Tumors of the Penis. Circumscribed fibrosis in the corpora cavernosa is so com- mon after forty as to merit a place among the natural changes in the body. Fibromata and enchondromata are not uncommon in this locality. Calcification is rare, and ossification is still more uncommon, only five cases having been reported. Soft warts are not uncommon on the glans or prepuce. Sometimes these become cornified, constituting the so-called horns. Epi- thelioma and sarcoma occur upon the penis, the involvement - being primary much more often than secondary. The most common malignant picture is that of a wart serving as the base of an epithelioma. Tumors of the penis may bear some resemblance to gum- mata, but there is an absence of the history and relics of the preceding stages of the disease, nor do we find gummata in other parts of the body. In non-syphilitic tumors, the spirochete pallida and the Wassermann reaction are lacking. The latter is of most prac- tical value in differential diagnosis in these cases. Cases of doubt may be decided by the therapeutic test or the removal of a section for microscopic examination, the method preferred usually depending upon the urgency of the case. Diagnosis of Syphilis. 215 TESTICLES. The second and third stages of syphilis affect the testicles much more frequently than the penis, which is so frequently the seat of the primary sore. Syphilis may cause a simple orchitis, which is due to the development of smaller nodules that later cause sclerosis and atrophy (Malassez and Reclus). This is the orchitis syphilitica simplex of Virchow. The same investigators claim that the orchitis gummosa of Virchow is due to necrosis of the gumma and the sclerosed part. The orchitis may extend to the albuginea, to constitute a peri- orchitis, the albuginitis syphilitica of Ricord. A simple orchitis may occur early, within a few months after the primary inoculation. In such cases the epididymis is swollen, usually uneven, and, as a rule, painless. A simple orchitis, probably due to small gummata, is one of the prominent symptoms of the third stage of syphilis. This is the period when we may find the orchitis gummosa of Virchow. In tertiary orchitis the swelling of the testicle comes on slowly, with a feeling of dullness and weight in the scrotum, rarely with real pain. Digital examination will often reveal distinct nodules and depressions. Later the gummata disappear largely through absorption and contraction of the deposited cicatricial tissue, rarely with suppuration. Gradually the tes- ticles decrease in size, to show absolute atrophy in the course of a number of months. There may be but a rudiment of the testicle left. The epididymis is rarely primarily affected, and it usually does not show so great alterations, though it may present thickenings and cicatricial contractions. Sometimes confusion in diagnosis may be caused by the comparatively rare cases of fungus testiculi syphiliticus. These are cases in which a large gummatous mass of the testicle in- volves all the coverings of the testicle and perforates these, to appear as a soft, necrotic, fungus-like, granular mass, that discharges pus and necrotic tissue. Such cases are compara- tively rare. At first there is pain, which later decreases and 216 Diagnosis of Syphilis. may disappear. Necrosis in time leads to greater or less de- struction of the growth and testicle. All this takes weeks or months, and is accompanied by more or less marked septic symptoms. Syphilitic orchitis is to be differentiated especially from traumatic orchitis, gonorrhoeal orchitis, epidemic orchitis, and tuberculosis and cancer of the testicle. Gonorrhoea affects especially the epididymis ; syphilis more frequently and most markedly affects the testicle. In lues the onset of orchitis is more gradual, the testicle is usually less tender, and the swelling is usually not so marked as in gonor- rhoea epididymitis. The syphilitic induration is usually found in the head of the epididymis. Epidemic orchitis may occur in the course of mumps. It is rare after thirty. The diagnosis is made by the affection of the parotid gland, parotitis epidemica ; the intense early symptoms, high fever and acute course ; the short course, usually but a few days ; and the exemption of the epididymis. Traumatic orchitis is marked by an acute inflammation following trauma. There is usually a history of the trauma- tism, which may, however, serve to localize an infection, such as tuberculosis. There is a more acute course, marked by pain, swelling, fever, and possibly abscess formation. Tuberculosis of the testicle runs a chronic course, like syphilis, but shows as a rule a distinct preference for the epi- didymis. Fistula? are more common in tuberculosis than in syphilis of the testicle. Ulceration and breaking down of the nodules is much more common in tuberculosis, which also much more frequently extends to the vas deferens, seminal vesicles and the prostate. In tuberculosis of the testicle there is almost always pulmonary tuberculosis. Tubercle bacilli may be found in the discharge. The tuberculin test will give a general reaction, and frequently also a local reaction. Furthermore, tuberculosis of the testicle does not show the same response to the therapeutic for syphilis as is found in syphilitic orchitis, especially early in the course of the disease. Carcinoma of the testicle does not undergo the same con- X Diagnosis of Syphilis. 217 traction as is evidenced by the atrophy following syphilis. Cancer shows more of a tendency to grow towards the surface and break down, forming a fungous ulcer, fungus testiculi malignus. Cancer frequently originates in the testicle, but pro- duces a more continuous and progressive affection of the lymphatic glands. 1. Syphilitic orchitis. 4. Epidemic orchitis (mumps). 2. Traumatic orchitis. 5. Tuberculosis. 3. Gonorrhceal orchitis. 6. Cancer. A careful search may disclose the spirochete pallida in the blood. Of more practical value is the Wassermann test, which is present in syphilis, though it may be observed or rendered negative by anti-syphilitic treatment. The spirochete pallida and the Wassermann reaction indi- cate the presence of syphilis, but not necessarily that the orchitis is syphilitic. Syphilitic patients are affected with non- syphilitic orchitis more frequently than with syphilitic orchitis. 218 Diagnosis of Syphilis. Syphilitic Epididymitis and Orchitis. Syphilis, inherited or acquired, presents a history or other symptoms of the disease. During the second stage of syphilis, there may be a slight painless enlargement of the epididymitis. In the third stage of syphilis, the testicle shows a painless enlargement, when affected, being nodular when the disease is manifested by circumscribed gummata, and remaining smooth when there is a diffuse infiltration. Begins in the connective tissue of the testicle. The cord usually remains free from affection, and the seminal vesicles are uninfluenced by the disease. The process tends to run a chronic course. Tendency to fibrous overgrowth. Suppuration rare. Fistulae uncommon. Enlargement of testicle moderate, rarely more than twice the normal diameter. The opposite testicle remains free, and the prostate is not affected. Not much pain ; rather a feeling of weight. Potency is somewhat impaired. Atrophy of the testicle is common. Skin of scrotum often purplish, but is seldom involved. There is nearly always hydrocele. Abscess is rare. The urine remains clear. Wassermann reaction present. Little or no tenderness on pressure, and absence of dis- charge or bleeding, and fungous appearance rare. Curable, though chronic, and responds to anti-syphilitic treatment. Inguinal glands usually not involved. Diagnosis op Syphilis. 219 Gonorrhoea! Epididymitis and Orchitis. History: Occurs in the course of gonorrhoea, usually in the second or third week, frequently late in the disease, sometimes after the patient believes himself to be free from infection. Affection of the testicle is favored by stricture, hypertrophied prostate, sexual or alcoholic excess, over-exertion, and instru- mentation. Most frequently occurs in gonorrhoea of the prostatic por- tion of the urethra. The onset is acute, as a rule, and recurrent attacks are far from uncommon. Involvement of the opposite testicle not uncommon. Po- tency is unimpaired, save in double orchitis. The posterior urethra is usually congested or inflamed. The testicle is sensitive. Hydrocele and abscess are rare. The urine is cloudy. Shows a preference for the left testicle. Usually the epididymis is the part affected, causing tender- ness upon palpation posterior and external to the body of the testicle. Exceptionally the epididymis may be anterior or internal or superior to the testicle, or in some abnormal relation to the body of the testicle. The involvement of the unde- cended testicle may vary the picture. 220 Diagnosis of Syphilis. Tubercular Epididymitis and Orchitis. Prefers youth; has been found in the fetus. History : Association with tuberculous patients ; the patient may suffer from pulmonary tuberculosis, or there may be a family history of the disease. Conjugal tuberculosis. A preference is shown for the epididymis, which becomes nodular ; hard, irregular tumor, the substance of the testicle and the vesiculs seminales are less frequently involved. The tumor is of moderate size. The prostate is congested and may be tuberculous. Rectal examination reveals enlargement of the seminal vesicles. The affection runs a chronic course. The disease is marked by recurrent acute attacks. Potency is somewhat impaired. Atrophy of the testicle is rare. The testicle is sensitive. There is often hydrocele, and abscess is common. The urine is cloudy and may contain tubercle bacilli (which should be carefully differentiated from the smegma bacillus). Tuberculin test is positive. There is some pain. Development is slow. Often the cases do not come under observation for a number of months. The tuberculous nodule is harder than the malignant tumor of the testicle, and shows earlier tendency to become adherent to the skin. Frequently ends in ulceration and fistulae. Tendency to fatty, caseous or purulent degeneration. The skin is congested, but is involved only in the process of abscess formation. Often marked tenderness. Discharge is not especially offensive. Fungus appearance is common. Lasts for several years, and some cases are cured. Inguinal glands usually not involved. Diagnosis of Syphilis. 221 Cancer of the Testicle. Carcinoma of the testicle is most frequent between thirty- five and forty ; sarcoma is observed most frequently in early life, up to ten years, and in adults between thirty and forty. Spindle-celled sarcoma nearly always occurs under ten ; the round-celled sarcoma is most frequent between thirty and forty. Adenopathies occur. Enlargement of the lymphatic glands is rare early in carcinoma — during the first three weeks. Sar- coma of the testicle shows involvement of the lymphatic glands, especially the retroperitoneal glands. The lymphatic involve- ment in this region seems an exception to the general rule in sarcoma. There is often a history of trauma preceding the affection of the testicle. The growth first appears, as a rule, in the region of the hilum, between the testicle and the epididymis. Growth is at first slow, so that often it is several weeks or even months before the patient comes under observation. Sarcoma presents a solid, smooth, symmetrical growth. Hydrocele is usually absent. The scrotal veins are dilated. Pain is usually, but not invariably, present. Malignant disease often shows a marked temporary response to the therapeutic test with the iodides. Wassermann reaction: Absent, except in syphilitics. In cases of doubt, the removal of a section for microscopic examination is justifiable. 222 Diagnosis op Syphilis. Encephaloid Carcinoma of Testicle. There may be a family history of cancer, or the history of association with cancer cases. Encephaloid carcinoma begins in the testicle, affecting pri- marily the seminiferous tubules. The course is rapid. Tend- ency to disintegration of tissue in multiple patches. Ulceration and fungus appearance common. Fistula? common. There is severe lancinating pain, especially late. The tumor is soft, often fluctuating. The skin presents a network of large veins over the surface of the tumor, and is finally involved. The testicle is greatly enlarged. There is little or no tenderness on pressure. The discharge is offensive, and bleeding is inclined to be free. Fungus appearance is characteristic in advanced cases. A cure is rare ; most cases terminate fatally within two years. The inguinal glands are usually involved, and also the iliac and lumbar glands. Cancer does not present the history nor other evidences of existing or preeisting syphilitic lesions. The Wassermann reaction is negative. There may be some response to the energetic use of anti- syphilitic treatment, but the improvement is not so markd nor permanent as in syphilis. Usually it is unsafe to delay diagnosis, so that the therapeutic test for syphilis is of less practical value in these cases than the serum reaction. Diagnosis op Syphilis. 223 Benign Tumors of the Testicle. The more common benign tumors are: fibromata, enchon- dromata, osteomata, and myomata. Lipomata and fibromata may occur in the tunica vaginalis, usually to be unrecognized during life, unless they become large, when they may resemble the malignant growths. Teratomata, bengin and malignant cysts may occur here. Among the malignant tumors, carci- nama especially the medullary form, is more common than sarcoma. Tumor may give the history of trauma. The testicle be- comes more or less enlarged, depending upon the size of the tumor, which may vary greatly. The cord is not affected ; the veins may become dilated. The seminal vesicles are not affected. Tumors are essentially chronic in their mode of onset, and run a fairly rapid course in this region. Potency is unim- paired. The urine remains clear. Hydrocele is unusual, and there is no tendency to the formation of abscess. Atrophy of the testicle does not occur, and the opposite testicle remains free from affection. Absence of the history or evidence of existing or pre- existing lesions of syphilis. Wassermann reaction absent. Therapeutic test for syphilis negative, though there may be some response to energetic anti-syphilitic medication. 224 Diagnosis of Syphilis. Traumatic Orchitis. Caused by trauma: Blow, kick, missile, fall. Runs a course much similar to epididymitis. Traumatic orchitis, even though severe, is usually not fol- lowed by sterility. Atrophy of the testicle is more common than in gonorrhceal inflammation. Epidemic Orchitis (Mumps). Other sjmptoms of mumps, especially parotitis; history of exposure to mumps. Presence of an epidemic of mumps. Incubation : Often occurs during the course of mumps. The incubation of mumps is about two weeks, varying from three days to six weeks. During this period prodromal symp- toms are present in about one-third of cases. Mumps is announced by chill or chilly sensations. The fever is slight, 101° or less, reaching later in the course of the disease 102°, exceptionally 104°. Swelling of one or both parotid glands, accompanied by pain and tenderness, is one of the most characteristic features of the disease. Orchitis occurs in about two-thirds of the cases. Atrophy of the testicle results seven times out of ten. Double orchitis is comparatively rare; when it does occur, impotence may follow. Orchitis occurs in many of the infections : 1. Typhoid fever. 4. Tonsilitis. 2. Influenza. 5. Rheumatism and 3. Smallpox. 6. Mumps. Diagnosis op Syphilis. 225 The Semen. Syphilis of the testicle is prone to affect the secreting part, so that later there is diminution of the semen, sometimes abso- lute aspermia. The possibility of paternal transmission of syphilis is well recognized. It is not known whether this occurs through dis- ease of the spermatazoa or through the excretion of the syph- ilitic poison in the semen without affection of the living sper- matazoa. It is the writer's opinion that paternal transmission of syphilis can occur only through inoculation with infected hands or by semen from syphilis of the male generative organs, especially the testicle. The spirochete pallida has been ob- served in the semen of syphilitics. Unfortunately, syphilis of the male generative organs may not always be detected during life. Syphilitic impotence usually does not occur until late in the disease. Oligospermia, azoospermia or impotentia may result from gummatous orchitis, though great deformity and destruction of tissue may occur without rendering the patient impotent. The diffuse interstitial gumma, orchitis fibrosa syphilitica, may cause impotence through compression of the canals due to contraction of the connective tissue. As a rule impotence is not caused by syphilis. 226 Diagnosis op Syphilis. SYPHILITIC AFFECTIONS OF THE FEMALE GENERATIVE ORGANS. Vulva. In women, the primary sore of syphilis is found most fre- quently upon the vulva. This fact should only emphasize the importance of differentiating between chancre and other lesions that may occur upon the vulva. The chief of these are simple ulcer, chancroid ulcer, cancer, and tuberculosis, both the tuber- cular ulcer and lupus. The spirochete pallida is present in chancre, and its recognition makes the diagnosis of syphilis absolute. The Wassirmann reaction is not present before the sixth week. During the second stage of syphilis, syphilides, especially mucous patches, frequently occur upon the vulva. The Was- sermann reaction is present, and the spirochete pallida may be found in the secretion from the patches. It is better to secure the specimen of serum from the deeper part of a patch, by scraping. The third stage of syphilis is rarely represented by gum- mata of the female genitalia. When gummata do occur in this region, they are most frequently located in the vulva. The tertiary lesions often appear in parts affected by the preceding stage of the disease, apparently developing from remnants of the secondarv lesions. Diagnosis of Syphilis. 227 Chancre of the Vulva. Confrontation. — Due to inocula- tion from a ease of syphilis. De- ception is common. Furthermore, because of false modesty and the comparatively slight discomfort these patients often experience, the physician is frequently not con- sulted until late, at which time other lesions are present. Incubation. — Usually two or three weeks, sometimes as short as a week' and possibly as long as two months. Location. — Most frequent on the labia majora (about one-third of cases) ; frequently situated at the introitus of the vagina, in the re- gion of the meatus, and the nym- phse; less frequently upon the four- ehette, the prepuce of the clitoris. Autoinoculation does not occur ; but multiple chancre is more fre- quent in this region than elsewhere. Begins as infiltrated induration or nodule, that usually has undergone central necrosis to form an ulcer be- fore the patient comes under obser- vation. Shape. — Symmetrical ; usually round or oval. Ulcer. — Usually superficial, may be elevated, rarely deep; sloping edges. Floor of View. — Smooth, red, livid, often covered with a scab or membrane. Secretion. — Scanty and serous, in the absence of irritation or second- ary infection — which is not uncom- mon in this region. Induration. — Cartilaginous. Sensibility. — Little or no pain, so that it often passes unnoticed. Course. — Regular; phagadena rare; confers marked immunity. Adenopathy. — Indolent buboes are the rule, though suppuration may occur, due to mixed infection. Usu- ally the glands are first found en- larged upon one side, then upon both sides, from one to four or more upon either side, in the region of Poupart's ligament. Termination. — Usually undergoes resolution, to be followed later by the general symptoms of syphilis, unless the disease is cured. Mercury is specific. Spirochete pallida. — Present. The recognition of this organism, en- ables the diagnosis to be made posi- tively much earlier than was for- merly possible — before the charac- teristic induration appears. Wassermann reaction. — Present later, after the body has had time to reaet against the syphilitic virus. 228 Diagnosis op Syphilis. Chancboid of the Vulva. Due to inoculation from chancroid (ulcer, bubo, or lymphitis). Ofter associated with the other venereal diseases. Incubation is short, a number of hours, so that the ulcer is present a day or two after exposure. The most frequent locations are the labia majora, especially the pos- terior commissure, the vaginal ori- fice, the fimbria 1 marking the re- mains of the hymen, the urethral orifice. More than one-third of the eases occur on the fourchette or fossa navicularis. Extra-genital chancroid is rare. Autoinoculation is common; mul- tiple ulcers are the rule. Begins as a nodule, that soon be- comes pustular and ulcerates. Usu- ally the ulcer is present when the patient is first seen, and the other stages of new lesions may be ob- served. Less symmetrical than chancre; the borders often describe segments of circles. Involves the whole thickness of the integument: sharp, abrupt edges, often undermined. The floor is rough, grayish, pul- taceous, covered with secretion. The secretion of the ulcer is abundant and purulent. Induration is absent, except when caused by caustics or inflammation, when it does not resemble the cir- cumscribed cartilaginous induration of chancre. Chancroid is painful. Runs an irregular course, with tendency to spread; phagedena com- mon; little or no immunity, so that second attacks are common. Affection of the lymphatic glands is not so common as in chancre. When present, the buboes are in- flammatory in character and usually suppurate. Pus from them is in- fectious. The local lesion is marked by greater persistence and more destruc- tion of tissue than is observed in chancre. Not followed by general symptoms. Local treatment is curative. Spirochete pallida absent, except in syphilis. Wassermann reaction indicates syphilis. Diagnosis of Syphilis. 229 Cancer of Vulva. Carcinoma and sarcoma are rarely primary in the vulva, usually ap- pearing secondary to lesions in the vagina or uterus. However, primary involvement of the vulva is a pos- sibility that must be remembered by the diagnostician. Carcinoma usually begins as small, round, irregular nodules, usu- ally located upon the inner surface of the labia majora or between the labia majora and minora. The nod- ules are covered with scaly epi- thelium, that soon disappears with ulceration. Before ulceration, the nodules cause little or no discom- fort, and they are usually of slow growth, so that they may give rise to no symptoms for some time, ex- cept possibly a slight pruritus. Of- ten they remain for some time un- noticed. Ulceration is followed by pain and a serous or bloody dis- charge, and further infiltration and hardening of the tissue. The mar- gins of the ulcers are irregular and raised, and the discharge becomes seropurulent and offensive. The process is usually unilateral. Ade- nopathy appears in the inguinal glands. The disease shows a ten- dency to develop more rapidly and involve the deeper tissues. Thus, there may be great destruction, in- volving the nymph*, clitoris and the vaginal walls. Pruritus is a prom- inent sypmtom; pain varies greatly in intensity in different case3. Sarcoma of the vulva is much more rare than carcinoma. The most common types of sarcoma in this re- gion are the melano-sareoma and myosarcoma Sarcoma prefers youth. The labia majora is the site of pref- erence, though sarcoma may begin in other parts of the vulva. The symptoms are not marked until ex- coriation or ulceration takes place. Epithelioma may resemble syph- ilis and lupus, at first, but the his- tory and symptoms soon make the diagnosis. In chancre, the inguinal glands are more quickly involved, and the constitutional symptoms soon appear. Chancroid shows marked ulceration with little or no induration, and edges that are more sharply cut and perpendicular. Lupus is marked by concomitant ulceration and cicatrization, and less pain than is present in carci- noma. The odor soon becomes more offensive in carcinoma than in syph- ilis or lupus. When the diagnosis is in doubt, especially if the spirochete pallida and the Wassermann reaction are not found, we should resort to the microscopic examination of a sec- tion of the affected tissue. The specimen should be taken so as to include both the diseased and the healthy tissue. 230 Diagnosis of Syphilis. Tuberculosis of Vulva. In the female genital tract, tu- berculosis seems to prefer the tubes. Primary tuberculosis of the vulva is very rare, but probably not so unique as the statistics would seem to indicate. Cases have been de- scribed by numerous observers — C'hiari, Cayla, Maedonald, Peckham and Lewers, Haberlin, Viatte. In this connection, it is well to take only the cases reported by com- petent observers, since the smegma bacillus may be mistaken for the tubercle bacillus by those not fa- milnr with the technique of stain- ing this organism. Tuberculosis of the vulva prefers the labia majora and the labia mi- nora. The lesion is sometimes found in the region of the anus. Usually the secretion of the ulcers and the tissues of the papules contain nu- merous tubercle bacilli, but some- times these can not be found. 'J he tubercular lesions appear as flat, assured, painful ulcerations, with irregular serrated borders. The color of the ulcer is pale red or grayish. There is a thin, purulent secretion. The ulcer tends to en- large at the periphery, while in the center a Hat cicatrix forms. Com- plete spontaneous recovery of the entire lesion is rare. Tuberculosis of the female geni- tals is more frequent than is gen- erally believed. In the examina- tion of women dying of phthisis, Kiwisch found genital tuberculosis in the proportion of 1.40; Cornil in 1.50-60 cases. Lupus of tiie Vulva. The recent lupus nodules are em- bedded in the true skin and do not disappear upon pressure. The lupus ulcers are marked by their indo- lence. There is little tenderness. The base and edges of the ulcer are flabby and vascular, and there is an abundant development of granula- tions. The tendency to spread from center to periphery is not so marked as in syphilis. The diagnosis is sometimes aided by the appearance of new lupus nodules in from two to four weeks. The course of lupus is slower than that of syphilis; lupus will often cause less destruc- tion in years than syphilis causes in a few weeks. Finally, lupus is due to the tubercle bacillus, and syphilis to the spirochete pallida. The tuberculin reaction speaks for lupus; the Wassermann reaction in- dicates syphilis. Diagnosis op Syphilis. 231 Condylomata of the Vulva. Venereal warts occur especially in the presence of uncleanliness, and are frequently found in syph- ilitic and gonorrheal cases. These are sometimes known as pointed condylomata. They present the general characteristics of warts, are provided with a pedicle, and vary in size from a pinhead to a pea. Because of their vascular structure, they have a tendency to bleed out of proportion to the size of the growth, when injured. Condyloma lata is of more in- terest to us, since it is a syphilitic lesion. The heat and moisture in this region favor the maceration of the papular syphilide, which be- comes denuded of its epithelial cov- ering, and also grows in circumfer- ence at the base. Thus, there is de- veloped a lesion varying in size from a pea to a quarter, or even larger, slightly elevated above the surrounding tissue, with abrupt margins and a broad flat surface. Condylomata lata are often found when the patients first come under observation, associated with remains of the chancre and various syphil- ides. Condyloma lata is very infectious. Causes little or no pain or dis- comfort. Responds to anti-syphilitic treat- ment. Spirochete pallida present. Wassermann reaction present. Elephantiasis of the Vulva. Elephantiasis arabum is rare in this country. The labia majors be- comes enormously swollen. The tissues are thickened and the lym- phatic vessels are dilated. Punc- ture or incision reveals a clear or milky fluid. The disease is due to the filaria sanguinis hominis. 'Syphilitic elephantiasis of the vulva is much more common in this country. Both the labia majora and minora hecome enlarged, and may be covered with warty growths. Old cases often show ulceration, due to maceration and chafing. Usually both sides are affected, but not in- variably. The disease is marked by lymph stasis. Wassermann reaction is present. Therapeutic Test. — Anti-syphilitic medication is usually not sufficient to remove the hypertrophy; an ap- peal must often be made to surgery. 232 Diagnosis of Syphilis. Vagina. The initial lesion of syphilis may occur in the vagina, but it is rare in this location. The papules and other syphilides have been observed in the vagina, but they seem to be comparatively rare in this part of the genital tract. Usually they occur in association with vul- var lesions. Gummata have been reported in the vagina, but are rare. Gummata of the rectum may affect the vagina and cause fistulae. Uterus. The first stage of syphilis is frequently announced by a chancre upon the cervix, most frequently upon the posterior lip. This is not so common a location of the primary sore as the vulva, but it is sufficiently common to warrant the physician being very careful in the examination of these cases. Fortunately, the hands may be protected by rubber gloves when called upon to make a digital examination in a suspicious case. It is a pretty good general rule to use the gloves unless there is a reasonable certainty that the case is not syphilitic. It seems probable that the semen may carry the syphilitic infection. If this is true, we must admit the possibility of a chancre in the body of the uterus or the tubes, though I know of no authentic case. The apparent rarity of such cases argues against the frequency of this mode of infection. The positive diagnosis of cervical chancre is made by finding the spirochete pallida. The differentiation from cancer may be settled, in case of doubt, by submitting a section to microscopic examination. Chancroid and tuberculosis must at times be considered. A simple ulcer or gonorrhoea may enter into the question of differential diagnosis. During the second stage, syphilides, especially papules, are found upon the cervix somewhat more frequently than in the lumen of the vagina. An endometritis may occur during this Diagnosis op Syphilis. 233 stage, which some observers believe may be due to an eruption of syphiloderms upon the mucous membrance of the uterus. Gummata have occasionally been reported in the cervix. There are no authentic cases of gummata of the body of the uterus, in the literature examined by the writer. Fallopian Tubes. There are no cases of primary sore of the tubes reported. This fact would seem an argument against infection being car- ried to the mother by the semen. Catarrhal salpingitis may occur during the second stage of syphilis, which the writer believes may be due to tubal syphilides. Gummata have been observed in the tubes, in association with gummata of the liver and brain. Ovaries. The most important lesions occur during the third stage of syphilis. Gummatous oophoritis may or may not be diffuse. The disease may lead to the conversion of the ovaries into a cicatricial mass, without Graafian follicles. Such patients, of course, are sterile. Tumors in the region of the ovaries, have been observed to diminish or disappear under the therapeutic test for syphilis. The Wassermann reaction is positive, and there may be found the history and other evidences of syphilitic affections of other parts of the body. 234 Diagnosis of Syphilis. SYPHILITIC AFFECTIONS OF THE ORGANS OF LOCOMOTION. Periosteum. Here we will consider only the second and third stages of syphilis. Two affections of the periosteum occur frequently in syphilis, namely, the simple periostitis and the gummatous periostitis. Simple periostitis may occur in other diseases than syphilis ; gummatous periostitis, on the other hand, occurs only in syphilis. Second Stage. — Simple periostitis may result in circum- scribed, less often diffuse, thickenings of the periosteum. The thickening is due to a growth beneath the periosteum and firmly adherent to it. Later the growth undergoes ossification and becomes intimately attached to the bone. This is the ossifying periostitis syphilitica, that causes (1) circumscribed deposits of bone, tophi, or (2) a diffuse thickening of the bone over larger surfaces. At first these deposits are not attached to the bone. Later, after they become intimately blended with the bone, there is usually more or less constriction at the base, indicating that the new formation did not originate from the bone. In diagnosis, it is often important to recognize the possi- bility of absorption of the growths caused by simple syphilitic periostitis. As a rule, the probability of absorption under treatment depends upon the degree of ossification. Before ossification, proper treatment may cause the growth to dis- appear entirely. The possibilit} 7 of the growth breaking down, undergoing purulent disintegration, is not great, save in tuber- culous patients, when trauma not infrequently leads to caries and necrosis. The Wassermann reaction is of value in determining the presence of syphilis. The test may be negative in quiescent cases, or where there has been energetic anti-syphilitic treatment. Diagnosis of Syphilis. 235 The spirochete pallida may be detected in the blood, but the examination is difficult and tedious. In the more superficial bones, palpation may reveal a pain- ful swelling, usually flat and more or less diffuse, depending upon the extent of the region involved in the inflammation. Usually the general symptoms are not so marked as in the non-syphilitic inflammations of the periosteum, so that the patient may not be kept from his work even where there is extensive involvement of the periosteum. The periostitis in- volves especially the portion of the periosteum next the bone, but frequently the external surface of the periosteum is also inflamed, and at times the superficial inflammation is the more prominent. The cessation of the growth of the swelling with at the same time a decrease of the pain, in cases that have existed for a short time, usually indicates that absorption will take place. If the swelling does not decrease, but rather con- tinues to increase after the pain becomes less, ossification will probably result. Ossification of the nodules or diffuse swell- ings may be detected by palpation only after a number of weeks or months. Even after ossification, absorption some- times occurs. When the periostitis occurs near the insertion of muscles, the process of ossification may extend to the muscles, myositis ossificans. A similar ossification of the muscles may occur in diseases of the central nervous system, and after great exertion. It has been known to disappear after the use of iodide of potassium — both the ossification and the tendency to ossification of the muscles. Suppurative periostitis shows pain during the acute course of the inflammation. The part is painful and tender. The skin becomes edematous, reddened and possiblj' thinned. When the pus bursts through the periosteum, the pain decreases, to disappear later with the discharge of the pus through the skin. The introduction of a probe through the sinus thus formed, will reveal the presence of roughened bone. With proper drainage, the loosened periosteum again will become adherent 236 Diagnosis of Syphilis. to the bone through granulation. When a portion of the periosteum has been entirely destroyed by the process, the overlying tissues and skin become united to the bone in a cicatrix, which may assume the form of a cicatricial band. Chronic suppurative periostitis does not run such an acute course, the pain is less, and frequently the pus does not find exit through a fistula, but collects to form an abscess. Under treatment, the so-called "cold" abscesses of syphilitic periostitis are more frequently absorbed than the "cold" abscesses of tuberculosis. Third Stage. — Gummatous periostitis also develops espe- cially upon the under side of the periosteum, but much more frequently causes erosion of the bone, the gummata frequently passing into the Haversian canals. Around the gumma there is more or less extensive sclerosis and hyperostosis. The gumma is usually more soft and elastic to the touch than the deposits of simple periostitis. Perforation of flat bones may be caused by the erosion above referred to, especially if periosteal gummata occur in corresponding places on both sides of the bone. This is the caries sicca of Virchow. Gummatous periostitis does not go on to ossification, but terminates in absorption or ulceration. Absorption is followed by more or less depression over the affected surface. Around this depression there remains for a long time the wall of bone caused by the hyperostosis around the gumma. Later this, also, may be absorbed. Ulceration following gummatous periostitis may lead to superficial caries and necrosis, or to the formation of more or less extensive fistula? leading from the carious or necrotic bone. After the affected bone is thrown off, the soft tissues become intimately attached to the osseous cicatrix. The nodules of gummatous periostitis, which are at first firm to the touch, later show fluctuation, as the gummata undergo softening and liquefaction. The overlying skin re- mains normal in color for a long time, and may show only slight discoloration in the cases that terminate in absorption, Diagnosis op Syphilis. 237 which is the rule under proper treatment. When the gumma breaks down, the overlying skin becomes discolored and thinned and finally perforated, to give exit to the necrotic gummatous tissue. The gummatous mass breaks down first in the center, and the ulceration proceeds gradually towards the circum- ference of the gumma. So at first the nodule will not col- lapse, and later, with the destruction of the periphery of the growth, the nodule seems to disappear rapidly. Usually the gumma involves the bone to a greater or less extent, so that after the termination of the ulcerative process there is a de- pression, frequently surrounded by the ring formed by the sclerosing ostitis. Later this also may be absorbed. Bones. It is not always possible to differentiate between gummatous periostitis and gummatous ostitis, since so frequently the gum- mata affect both the periosteum and the bone. Second Stage. — Simple ostitis may be caused by syphilis as well as by a number of other affections. In simple syphilitic ostitis, the bone is usually thickened. Later, as a rule, the thickened portion of bone becomes absorbed, and the process of absorption may extend to the healthy bone. This form of ostitis, and more often syphilitic osteomyelitis, may terminate in caries and necrosis. Third Stage. — Gummata may occur either in the bony tissue or in the medullary cavity. Gummata, of course, are found only in syphilis. The part of the bone invaded by the gumma becomes osteoporotic, and surrounding this there is a zone of sclerosis. Such is the usual course when the gummata are small and undergo absorption, which is the rule in such cases. More especially in the larger gummata, absorption is more or less incomplete, and there remains more or less of the gumma, which undergoes caseation. Usually the sequestra from necrotic gummatous bone, are rougher and appear as if they had been channeled or eaten by the disease, whereas the necrotic bone from cases of simple ostitis is usually more 238 Diagnosis of Syphilis. smooth. Gummatous infiltrations of the bone probably do not undergo ossification. Syphilitic cachexia may lead to fragilitas ossium, osteop- sathyrosis. This affection involves usually a large number of bones, especially the long bones, and is characterized by fra- gility of the bones. Occasionally the syphilitics show a pecul- iar thinning or perforation of the flat bones, especially the parietal bones, less often the occipital. The early diagnosis of syphilitic ostitis or osteomyelitis is often difficult. Usually the affection runs a slow course, with at first dull pains. The pains are described as being deep in the bones, and show nocturnal exacerbations. The general symptoms are not marked. There is little or no fever. As the inflammation slowly progresses, the pain gradually in- creases in severity. A sclerosing ostitis leads to a sensation of heaviness of the affected bone. There may be pressure symp- toms, when foramina, canals or cavities are encroached upon. Asorption may lead to osteoporosis or actual fragilitas ossium. A simple syphilitic ostitis rarely undergoes suppuration. Gummatous ostitis and osteomyelitis may show no symptoms and end in absorption. Usually there is pain. Palpation may reveal tender spots, and percussion of the affected bone may disclose the location of the diseased focus. Usually the pain is severe, especially at night, and, as a rule, the pain is dis- tinctly referred to the affected part. The gummata frequently extend to the periosteum and the surrounding tissue, forming a prominent tumor. When central, the gummata often cause thinning of the bone, so that palpation may reveal crepitation, or slight trauma may cause fracture. If the gumma under- goes absorption, the bone may be left osteoporotic, so that fracture readily occurs. Shortening or absolute destruction of the bone may result. Gummatous ostitis may terminate in necrosis. The separa- tion of the bone is accompanied by more or less pain, depend- ing upon the tension produced by the suppuration attending the process. There may be an accompanying erysipelas or inflammation of the deeper structures, especially when there Diagnosis op Syphilis. 239 is not free exit for the pus. When there is an ample fistula leading to the surface, the free discharge of the pus is accom- panied by less general disturbance, and there is not so much danger of erysipelas or inflammation of the deeper structures. The pus has a foul odor and continues to escape until all of the dead bone has been removed. After the dead bone is en- tirely removed, the fistula may close permanently, often with the formation of a cicatrix that binds the soft parts to the bone. Necrosis of bone may lead to the absorption of small bones, the perforation of flat bones, and such mutilation of the long bones that fracture may readily occur. The Wassermann reaction will reveal syphilis, but does not necessarily indicate that the bone affection is syphilitic. It will often be found of great value in diagnosis. The literature contains reports of syphilis of almost every bone in the body, so that we are justified in believing that the disease may affect any bone. Dittrich observed a case of syphilitic necrosis of the hyoid. Here we will consider only the bones more commonly affected. The skull seems a favorite site for syphilis, especially the frontal bone, the parietal bones, and the bones of the nose and the hard palate. The occipital and temporal bones are not so often affected. When the syphilitic process extends deep in the bones of the skull, there may be symptoms of cere- bral compression. The prognosis in such cases is grave, but not necessarily fatal, since the process may undergo absorption, especially when the patient is under specific treatment for syphilis. When the process terminates in necrosis, the outlook is worse. Often there may be extensive gummatous affection of the bones of the skull without suggestive symptoms, as has been evidenced by finding these growths at autopsy in the absence of symptoms during life. But usually syphilis of the bones of the skull produces marked symptoms. The soft parts are frequently destroyed, to reveal the necrotic bone. The skull may be perforated. In such alarming cases, the prog- nosis is not necessarily fatal, for even large perforations may be closed. Great care must be exercised when tempted to 240 Diagnosis of Syphilis. remove a large sequestrum, since nature sometimes seems to be able to do this operation more safely than the surgeon. The defects are usually filled with a cicatrix, that binds the me- ninges to the bone and soft parts. The formation of new bone is more rare. Syphilitic necrosis of the skull may lead to meningitis; and syphilitic tumors may cause brain pressure symptoms, paralysis, epilepsy, and mental disturbance. In all these cases the prog- nosis is grave. An infected necrosis, that causes meningitis, is best treated surgically. Pus here, as elsewhere, should be discharged. Syphilitic affection of the orbital bones is not very com- mon, but should always be thought of when called upon to make a diagnosis in a case presenting the symptoms of a tumor in this region. There is often an accompanying gum- matous infiltration of the periosteum and the cellular tissue. The more superficial tumors may be felt. The deeper tumors are recognized chiefly by the protrusion and rigidity of the eyeball. Pain varies in intensity, and is sometimes excessive. The infiltration may cause rigidity of the eyelid. The syph- ilitic process may extend to the eye itself. The danger of loss of the eye or meninigitis must be recognized. However, anti-syphilitic treatment is usually followed by good results, though the course is often protracted. Syphilis of the nose or pharynx may extend to involve the base of the skull. Of the facial bones, those of the nose and the upper jaw are most frequently affected. The spinal column. The cervical spine are most frequently affected. The symptoms vary with the extent and location of the disease. There may be only tenderness and limited motion, or there may be great deformity and pressure symptoms. Syphilis of the vertebral arches may affect the nerve roots, the meninges and the medulla ; affection of the transverse process may lead to erosion of the vertebral artery and hem- orrhage. Extensive cervical spondylitis that leads to the de- struction of large portions of the cervical vertebras, will cause a kyphosis in this region, the head being bent forward and often inclined toward one of the shoulders. Diagnosis op Syphilis. 241 Syphilis frequently affects the long bones. Thes disease seems to show a preference for the bones of the leg and fore- arm, the clavicle and the ribs. It may be stated as a general rule that the diaphysis is more frequently affected than the epiphysis. However, the joint is not always exempt. The long bones are usually affected in one or more places, rather in their entirety. This fact, together with the observa- tion that the more exposed bones (frontal bone, parietal bone, bone of the nose and upper jaw, the bones of the fore- arm and leg, the clavicle and the ribs) are most frequently affected, would seem to indicate that trauma is an important factor in localizing the syphilitic process. There is a close analogy to tuberculosis, for it is a well known fact that trauma will predispose to the development of tubercle. This recalls the old experiment of injecting tubercle bacilli into an animal and then breaking the bones. The tubercle bacilli become localized at the point of fracture, to form tubercles. So in syphilis, the patient often attributes affection of the bone to some trauma. The value of anti-syphilitic treatment in many cases of fracture or wounds, probably depends upon the specific address to a syphilitic process that had become local- ized in the fracture or wound. Swelling or enlargement of the bone, and pain, that is usually worse at night or whenever the patient retires, are prominent symptoms of syphilis of the bones. However, there may be great swelling without pain, or pain without apparent enlargement of the bone. It should be remembered that non- syphilitic exudations may cause pain in the bones that may show distinct nocturnal exacerbations. Of the syphilitic affections of the small bones, dactylitis syphilitica deserves special attention. This affection may begin in the bone, periosteum, fascia, tendons or tendon sheaths. One or more fingers may be involved. The affected bone soon be- comes greatly swollen. Necrosis is frequent, the necrotic bone being cast off gradually through a sinus or sinuses, or thrown off as a sequestrum. In this way part or all of a phalanx may be destroyed. With the termination of the process, the finger is left shorter than normal, as a rule. Rarely there is an 242 Diagnosis of Syphilis. excessive formation of new bone, so that the finger may actually be left longer than normal. Syphilitic dactylitis causes little or no pain and is not ac- companied by acute inflammatory symptoms. These two diag- nostic points usually suffice to differentiate the affection from paronychia, whitlow and gout. Rheumatoid arthritis begins in the joints, involves the tendon sheaths, causes early deformity of the fingers, is painful, and is associated with other symp- toms of the disease in lieu of the symptoms of syphilis. En- chondroma is a more chronic affection, forms hard, well-defined tumors, and does not give the history of syphilis. Tubercular dactylitis presents a different history, usually occurs in indi- viduals having pulmonary tuberculosis, responds to the tuber- culin test and not to the therapeutic test for syphilis. Chronic syphilis, like chronic heart and lung diseases, may lead to the formation of drumstick fingers, with the character- istic enlargement of the terminal phalanges. The toes may be affected like the fingers, though less fre- quently. Upon the sole of the foot, syphilis may produce an ulcer resembling the perforating ulcer of the foot, that is ac- companied by great destruction of the soft parts, and may lead to necrosis of the bones of the foot. In making a diagnosis, syphilis must at times be differ- entiated from trauma, tuberculosis, sarcoma, rickets, osteo- malacia, necrosis following mercurial ulceration, phosphorus necrosis, actinomycosis, and a number of rare affections, such as the necrosis sometimes observed about the time of puberty in workers with mother-of-pearl, and the necrosis disseminata of Blasius, that may occur from concussion. Bones. (a) Syphilis. (e) Rickets. 1. Gummatous osteitis. (0 Osteomalacia. 2. Simple syphilitic osteitis. (g) Necrosis following 3. Gummatous periostitis. mercurial ulceration (b) Trauma. (h) Phosphorus necrosis. (c) Tuberculosis. (i) Actinomycosis. (d) Sarcoma. (J) Other necroses. Diagnosis of Syphilis. 243 1. That observed about the time of puberty in workers with mother-of-pearl. 2. Necrosis disseminata of Blasius, that may occur from concussion. Syphilis op Bone. 1. History or evidence of syph- ilis in patient or parents. No age is exempt. 2. The diaphyso-epiphyseal swell- ings of the long bones usually oc- cur at or soon after birth. Some- times unilateral. 3. The affection of the bones is usually preceded or accompanied by snuffles, coryza, eruptions upon che skin and mucous membranes. There may be hoarseness, nocturnal peev- ishness and irritability, and the senile appearance. Cachexia is ab- sent or only moderate. Pain is often greater at night. 4. Circumscribed tumors on fron- tal and parietal bones, rarely on the occiput. 5. The ribs are not often affected, and then usually not coincident with the other bones. 6. Closure of fontanelles usually not delayed. 7. Resolution occurs without leav- ing deformity, save such as may be caused by destructive changes. 8. Synovitis is often present, es- pecially in the elbow and knee. In general, syphilis tends to spare the articulations. 9. There are often sinuses and abscesses. 10. Anti-syphilitic treatment is useful. 11. Irregular abnormal deposition of lime salts. There may be sep- aration of the epiphyses. 12. Mortality high, especially when many bones are involved. 13. Spirochete pallida and Was- sermann reaction. Rickets. 1. There may or may not be a syphilitic history. Prefers child- hood. 2. The osseous deformities of rick- ets usually appear later, rarely be- fore six months. Bilateral. 3. The deformity of the bones is usually accompanied or preceded by gastro-intestinal disturbances, marked by anorexia, and diarrhoea or constipation; bronchial catarrh and cough; nocturnal restlessness; sweating often without apparent cause; pallor; general sensitiveness of the body, and at times spasm, especially laryngo-spasm. Marked cachexia. 4. The cranial bones are thick- ened in spots, especially in the oc- cipital region. 5. The affection of the ribs, the so-calley rickety rosary, is usually coincident with the affection of the other bones. 6. The closure of the fontanelles is delayed. 7. There is usually some deform- ity, due to bending of the affected bones and distortion of the joints. 8. Synovitis is rare. 9. Sinuses and abscesses are com- paratively rare in rickets. 10. Phosphorus treatment is use- ful. 11. Deposition of a soft non-calci- fied osteoid tissue. 12. Mortality not so high, espe- cially under proper treatment. 13. Spirochete pallida and Was- sermann reaction absent, except in concomitant syphilis. Syphilitics are apt to be rachitic. 244 Diagnosis op Syphilis. Tuberculosis of Bone. 1. Presence of pulmonary tuber- culosis: history of exposure to tu- berculosis; family history of tuber- culosis. Frequently there is a his- tory of trauma. Prefers adolescence. 1. Usually begins in the medulla and tends to cause destruction of bone, usually terminating in suppu- ration, possibly as the result of mixed infection. 3. Frequently there is emaciation and the evidence of tuberculosis elsewhere, especially in the lungs - and glands. 4. Probably no bone is exempt. In the order of frequency, the fol- lowing bones are most frequently attacked: vertebra', hip joint, small joints of hand and foot, knee, the long bones, ankle joint, tarsus, el- bow, shoulders, and wrist. The cranial bones are not often affected, if we except the mastoid. 5. Does not present the rickety rosary. 6. Closure of the fontanelles is visually not delayed. Usually occurs after closure. 7. Deformity due to destruction of bone and suppuration. General symptoms of tuberculosis assume prominence. 8. Frequently involves the articu- lations. 9. Sinuses and abscesses are com- mon. 10. General treatment of tubercu- losis beneficial. Anti-syphilitic treat- ment useless. 11. Formation of tubercle. 12. Mortality high. 13. Tubercle bacillus. Tuberculin test. Sarcoma of Bone. 1. Absence of the history or evi- dence of antecedent syphilis, except when the diseases co-exist. Fre- quently there is a history of trauma. No age is exempt; prefers the period from twenty to fifty. 2. May be central or periosteal in origin, the latter being of the more malignant type. Causes absorption of the normal bony tissue. For this reason, though the bone is appa- rently enlarged, it readily suffers fracture. 3. The patients often appear in perfect health early in sarcoma; later the health is greatly impaired. 4. Possibly no bone is exempt. A distinct preference is shown for the long bones, especially the femur, tibia, humerus, fibula, ulna, radius, in the order of frequency. 5. Rickety rosary absent. 0. Closure of fontanelles not de- layed. Usually occurs after the fon- tanelles have closed. 7. Enlargement and destruction of affected bones. In the later course of the disease, the general health is greatly impaired. 8. The central sarcomata are more prone to involve the extremi- ties of the bone, affecting the joints. 0. Less tendency to form sinuses and abscesses. 10. Anti-syphilitic treatment is often followed by temporary im- provement that may tend to obscure the diagnosis. 11. General symmetrical enlarge- ment, due to growth of sarcoma. 12. Mortality high. 13. Microscopic examination re- veals the characteristic appearance of sarcoma. Diagnosis op Syphilis. 245 Osteomalacia. 1. Recurrent attacks in succeed- ing pregnancies. May be family his- tory of osteomalacia. Often history of traumatism. Occurs at a later age than rickets. 2. The disease is general in char- acter, affecting a number of bones. 3. The pain in pregnancy occurs especially in the latter part of gesta- tion. The general health, at first good, later becomes impaired. 4. The bones of the pelvis, spine and thighs are most frequently af- fected. 5. Rickety rosary usually absent. 6. Occurs after closure of the fon- tanelles. 7. Deformity due to softening of the bones. 8. Sinovitis is rare. 9. Sinuses and abscesses absent. 10. Anti-syphilitic treatment use- less, as is also the treatment for rickets. 11. Softening of the bones due to lessening of the lime salts. 12. Improvement or arrest usually occurs under treatment. 13. Softening of the bones due to lessening of the lime salts, depend- ant upon decreased alkalinity of the blood, apparently caused by an in- fection (usually genital) with acid intoxication. The blood contains myelocytes, and an increase of eosin- ophiles. Actinomycosis. 1. Often history of exposure to the disease in animals. Occurs most frequently in those brought in close contact with animals. Most fre- quently found in adults. 2. A local affection, affecting espe- cially the jaw bone. 3. Actinomycosis is characterized by an insiduous onset and chronic course. 4. The jaw bone is most fre- quently affected — lumpy jaw. The general health, previously good, be- comes greatly impaired. 5. Does not resemble rickets. Ro- sary absent. 6. Usually occurs long after clos- ure of the fontanelles. 7. Deformity due to expansion and erosion of bone, the formation of granulation tissue, and the presence of abscesses and fistulas. 8. Sinovitis absent. 9. Sinuses and abscesses common. 10. Anti-syphilitic treatment use- less. The affection remains local in character. 11. Lumps or nodules form, due to the growth of the aetinomyees. 12. Chronic course. Mortality high; much depends on the location of the process. 13. The pus discharged is granu- lar, and contains the ray fungus, recognition of which makes the diag- nosis absolute. Syphilitic osteitis affects individuals in all grades of health ; usually begins in periosteum; tends to formation of new bone, or to necrosis ; suppuration is often absent ; does not tend to involve neighboring articulations ; frequently affects cranium ; characterized histologically by a rather large mass of granula- tion tissue ; usually can be arrested or cured by anti-syphilitic treatment. Tuberculous osteitis is usually accompanied by other symp- toms of tuberculosis ; begins in the medulla ; tends to disin- tegration of the affected tissue; termination in suppuration the 246 Diagnosis of Syphilis. rule ; tends to involve neighboring articulations ; rarely in- volves the cranium ; characterized histologically by tubercle ; not affected markedly by anti-syphilitic treatment. Rickets may sometimes resemble the bone lesions of heredi- tary syphilis. Epiphyseal swellings that occur during the first six months of life are usually syphilitic. Syphilitic epiphyseal swelling may be unilateral ; the rachitic affection is symmetrical. The enlargement of the costo-chondral articulations, commonly known as the rosary of rickets, is absent in syphilis. Rickets thins the bones ; syphilis enlarges them, but does not produce the nodes characteristic of rickets. Rickets causes tardy closure of the f ontanelles ; syphilis may cause abnormal closure of the various cranial openings, through osteophyte growths. Syph- ilitic bone lesions are usually accompanied by other sj'mptoms of syphilis, and they respond to anti-syphilitic treatment ; rickets causes other symptoms than those on the part of the bones, is not markedly benefited by anti-syphilitic treatment, but responds readily to the treatment of rickets. Trauma, when severe enough to cause necrosis, will usually be prominent in the history of the case. Syphilis is the most common cause of necrosis of bone. A less frequent cause is tuberculosis, and typhoid fever is a rare factor in the causa- tion of necrosis of bone. These need but be mentioned. Often there is a history of trauma in cases of syphilis, tu- berculosis, and sarcoma. But the trauma is usually not the overshadowing element in these cases. Furthermore, simple trauma does not present the Wassermann reaction, except in syphilitics. Actinomycosis is found most frequently in the head (jaw, tongue), neck, air passages (lungs), alimentary tract (small intestine), and skin. Actinomycosis occurs in man through direct transmission from infected animals ; and from foreign bodies, especially cereal grains with sharp extremities, more rarely isinglass, splinters, etc., which are contaminated by the parasite. Infection may occur through carious teeth, and the spreading of infection from barber's utensils has been noted. Diagnosis of Syphilis. 247 Joints. Syphilis shows a preference for the knee and elbow, though the disease has been reported to have attacked practically every joint in the body. Arthralgias are often observed early in the course of syphilis, when they should be regarded as belonging to the second or irritative stage of the disease. The later cases are usually due to gummata. In either case, the disease may be monarticular or polyarticular. The simple cases, belonging to the second stage of syphilis, frequently undergo involution in the course of a week or two. The gummatous cases usually are more chronic, though spontaneous involution may occur even in these cases. At any rate, we occasionally observe the spontaneous cure of chronic cases that have begun late in the course of syphilis. The symptoms vary in intensity and character, depending largely upon the severity and extent of the process. At first there may be only pain, observed upon extreme flexion or extension of a joint. Palpation may reveal tender points in the joint. There is usually more or less swelling of the joint. Frequently there is fever, and in some cases the temperature is high. The pain usually shows nocturnal exacerbations, and the fever observes morning remissions. In more severe cases the movement of the affected joint becomes impeded, and there may be produced more or less deformity of the joint. In all cases, anti-syphilitic treatment may result in an arrest or cure of the disease. The cases that occur early in the course of the dis- ease, especially those that belong to the second stage, give the best prognosis. The later cases, especially those due to gumma, are more chronic and more frequently leave a stiff, ankylosed or deformed joint. Especially in the cases accompanied by an ostitis or periostitis of the bones entering into the joint, with more or less destruction of the cartilage, capsule and ligaments of the joint, there may be left a loose joint. Such a joint, for instance, at the elbow or knee, is comparatively useless. In the cases in which ankylosis occurs, the union is usually not bony. 248 Diagnosis of Syphilis. Differential diagnosis calls for the recognition of joint tuberculosis, the exclusion of trauma, and the separation from rheumatism. Indeed, these cases were formerly included among the rheumatisms. In the separation from trauma, it must be remembered that trauma may serve as an etiological factor in the localization of the syphilitic process in a joint. Trauma may also serve to localize a tuberculosis or a rheumatism in a joint or joints. The same is true in rickets and osteomalacia, which may involve the joints. The rheumatisms frequently show affections of the heart, which are not so common in syphilis of the joints. When the heart is affected, rheumatism shows a preference for the mitral valve, whereas syphilis is more often accompanied by affection of the aortic valve. The therapeutic tests are often of value. Rheumatism responds to the salicylates, syphilis to the preparations of iodine and mer- cury. However, syphilis of the joints is often benefited by the salicylates, and rheumatism, especially chronic rheumatism, is frequently best treated by the iodides. The fact can not be emphasized too strongly that not every case that responds to mercury or the iodides is syphilis. Tuberculosis responds to the tuberculin test, and usually causes more rapid destruction of the joint than syphilis. The spirochete pallida and the Wassermann reaction speak for syphilis. The serum reaction is of most practical value in these cases. It may be absent in cases that receive anti- syphilitic treatment. In the differentiation between the affection of the joints during the second and third stages of syphilis, aid in diag- nosis may be afforded by the occurrence of the former com- paratively early in the course of the disease, often as one of the early symptoms of the second stage, whereas the gum- matous cases usually occur late in the course of syphilis. The irritative cases are often accompanied by pain and fever, whereas the gummatous cases are comparatively free from these symptoms and usually show more swelling than is observed in the early cases. In making a prognosis, it must be remembered that anti- Diagnosis of Syphilis. 249 syphilitic treatment may cause the syphilitic process to dis- appear, but can not replace destroyed tissue or cicatrices. Villous hyperplasia of the synovial membrane, accompanied by grating and friction sound upon movement of the joint, usually does not undergo complete cure. Syphilis of Joints. Syphilis most frequently affects the knee and elbow, but no joint is exempt. The diagnosis is based upon other symptoms of syphilis. Disease of the joints in syphilis range in severity from arthralgias to arthritis; there may be a chronic hydrarthrosis, villous hyperplasia of the synovial membrane, and in- volvement of the cartilages of the joints. The syphilitic affection may be monarticular or polyarticular. The affection of the joints may appear in the second or third stages of syphilis. Thus, Lang saw a case of disease of the hip-joint during the second stage of syphilis, in the presence of a recent exanthem. If the swelling is localized, in a part of the capsule or ligaments of a joint, it is probably gumma- tous. Syphilitic polyarthritis rarely shows cardiac complications, thus differing markedly from rheuma- tism. Syphilis of the joints may show great pain and marked fever, but in general the subjective symptoms are less obtrusive than the objective symptoms. The patients are often well nourished. A history of trauma is not un- common. The spirochete pallida and the Wassermann reaction indicate syph- ilis. Antiluetic treatment is often of value as a therapeutic test; but de- structive changes in the joints may be irreparable. The salicylates act promptly in acute articular rheu- matism, but have little or no effect in syphilis. In secondary syphilis, both inher- ited and acquired there is a lia- bility to general periostitis, usually slight and transitory. Though the periostitis may be severe, it is usu- ally transitory. Early in the second stage of syph- ilis, the most common affection of the joints is a simple serous syno- vitis, which may later become a chronic hydrops. The third stage of syphilis may present a chronic serous synovitis, accompanied by a thickening of the joint capsule, contraction and fib- rous ankylosis. This may be due to perisynovial gummata, or to gummata of the bone with second- ary involvement of the joint. There may be more or less destruction of the cartilage. Hereditary syphilis is peculiarly liable to bone complications. Chronic serous synovitis is often present, appearing especially as a symmetrical swelling of the knees. There is considerable thickening, but effusion is comparatively slight. Osteochondritis is common in hered- itary syphilis. This may be present at the time of birth or come on later. The bone is thickened and tender in the region of the epi- physes. The epiphyses may become separated. There may be greater or less deformity of the joint, the de- formity being especially prominent in cases that show suppuration. 250 Diagnosis op Syphilis. TUBEBCULOSIS OF JOINTS. Joint tuberculosis and tubercu- losis of the bones is most common in childhood. Acute osteomyelitis or epiphysitis presents a more sud- den onset, pain is more prominent and permanent, and necrosis and suppuration are more rapid. Radiography is often of value in the recognition of joint or bone tuberculosis, use being made of the plates rather than of the prints (Kiliani). In this way tuberculous foci may be discovered that would otherwise remain obscure. Thus, we may be able to recognize tuber- culosis in the vertebra? before the symptoms become prominent, and the rice bodies in the knee may be recognized upon the radiographic plate. In joint and bone tuberculosis, the tuberculin test may clear up the diagnosis. Traumatic Affections of Joints. A history of trauma is often pres- ent in the history of syphilis of the joints, and is not uncommon in rheumatism and joint tuberculosis. The trauma in these affections is often comparatively slight, so that we will be led to suspect some other cause of the joint lesion. Trau- matic affections of the joints occur in all degrees of severity. There is a tendency toward the development of syphilitic lesions in the injured joint, in syphilis, just as there is a tendency to the development of rheumatic affection of such a joint in the presence of rheumatism, or of tuberculosis in tuberculous pa- tients. The Wassermann reaction and concomitant symptoms of syph- ilis or the relics or history of the disease, may aid in diagnosis. Rheumatisms. The rheumatisms should be sep- arated especially from gout, arth- ritis, trichinosis, syphilis, tubercu- losis, and rickets. Acute Articular Rheumatism. — The affection of medium-sized joints and especially the flitting from joint to joint, are characteristic points. Atypical cases and cases that do not respond readily to treat- ment should arouse the suspicion that they are not cases of rheu- matism. Acute articular rheu- matism must be separated especially from other forms of rheumatism, involvement of the joints in septi- cemia, and gout and sarcoma. Chronic Articular Rheumatism. — The age of the individual, the num- ber of joints affected, longer dura- tion despite medication, and the ab- sence of sweating, high fever, or complications on the part of the heart, are important points in diag- nosis, and serve to differentiate chronic from acute rheumatism. Gonorrhoeal Rheumatism. — A preference is shown for the period of adolescence, the male sex, and the knee joint. There may be in- volvement of the ankle and joints of the foot. Usually the affection of the joints is observed within three months after the gonorrhoeal infection. The joints are greatly swollen. The disease runs a chronic course, as a rule, does not show sweating nor involvement of the heart, and when cured does not re- turn nor leave deformity. Muscular Rheumatism. — The char- acteristic symptom is pain, which may vary in all degrees of severity and character, and is confined to the voluntary muscles. The pain is usu- ally relieved by pressure. Myalgia must be differentiated from the in- fections, especially smallpox, tuber- culosis, syphilis, and septicemia; and aneurysm, caries of bone, and tumors must be excluded. The sep- aration from neuralgia is sometimes difficult. Diagnosis op Syphilis. 251 Muscles. Rheumatic pains are present in the muscles during the second stage of syphilis, often as early symptoms of the irri- tative stage, probably due to a myositis. Now and then there is a marked myositis early in the course of syphilis. The muscle is tender, and the portion of muscle affected is usually contracted. These pains, that occur during the second stage of syphilis, may persist for weeks. The outlook, as to perfect recovery, is absolutely good. The third stage of syphilis is represented in the muscles by the gumma. This begins as a painful infiltration, some- times in the belly of the muscle, more often near a tendon. The muscle is rigid, usually contracted. The growth of the gumma is slow. When the process terminates in absorption, the destroyed muscular fibres are replaced by connective tissue. More frequently the gumma grows, to later involve the over- lying parts, including the skin, to which the tumor often becomes adherent. When the mass softens and discharges through the skin, there is formed a more or less sinous ulcer. Such a process runs a course of weeks or months. After heal- ing, the cicatricial contractions lead to more or less deformity. Motion is impaired, and the muscle is bound by the scar to the overlying structures and skin, and sometimes also to the periosteum. An interstitial infiltration may accompany gummata of the muscles or appear as an independent affection. The processes are usually associated. The muscular fibres become replaced by connective tissue. Thus, the muscles lose their contractility, but there is not left the great deformity that follows the sloughing of a gumma of the muscle. Syphilitic myositis ossificans has already been studied. Atrophy of muscles, either singly or in groups, may be caused by syphilitic affection of the nerves, which we will consider later. Of these various syphilitic affections of the muscles, the gumma is most frequently of diagnostic importance. Usually 252 Diagnosis op Syphilis. gummata are multiple, but single gummata are occasionally en- countered. Such growths should be differentiated from neo- plasms, especially sarcoviata. The specific test for syphilis usually suffices to make this differentiation. Sometimes it is advisable to remove a piece of the suspicious growth for micro- scopic examination. In this connection, it must be remem- bered that the microscopic differentiation between gumma and sarcoma is often one of the most difficult to make. Actinomy- cosis has been mistaken for gummata. This is more liable to occur when there are multiple nodules, which is more char- acteristic of syphilis than of actinomycosis. In suspected cases the microscope will reveal the presence of the actinomyces. Enlargement of the spleen would speak for actinomycosis rather than syphilis. Such a case was reported by R. Koehler, in which Israel found post-mortem actinomycosis of the spleen, heart and lungs, and also cicatrices in the liver. Trichinosis often presents the picture of muscular rheumatism, with the history of meat poisoning. In aucte polymyositis, the symptoms are pain, tenderness, and loss of function in the affected muscles. The resemblance to trichinosis is indicated by Hipp's suggestion, that this affec- tion of the muscles be termed pseudo-trichinosis. Sometimes a differential diagnosis is impossible without examination of a section of the affected muscle. There is of ten a simultaneous involvement of the skin and muscles, derma- tomyositis. Acute parnchymatous myositis occurs after slight injuries, disturbances of the circulation, in the neighborhood of new growths, and in typhoid fever. Tendons. Reference has already been made to the fact that the gum- mata of muscles seem to show a distinct preference for the region of the tendons. Syphilitic affections of the tendon sheaths have been re- ported by a number of observers. Hygromata have been observed quite early in the course of syphilis. These are only Diagnosis of Syphilis. 253 slightly painful. There may also be a true synovitis, marked by painfullness that is increased by motion. Bursae. Hygroma occasionally occurs early in the course of syphilis. The diagnosis is usually made by the concomitant symptoms of syphilis, and the Wassermann reaction, together with the disappearance of the hygroma under anti-syphilitic treatment. The fluctuating tumor may be somewhat tender, but is usually comparatively or absolutely painless. Gummatous bursitis is comparatively rare. Palpation may detect alternating points of fluctuation and the hard points formed by the gummata. Usually there is only slight tender- ness. Again, there may be great tenderness, and the mass may be either hard or soft. Usually the disease shows a tendency to break down. The growths respond to the therapeutic test when long continued. Fasciae. Nodular infiltrations may appear in the fasciae early in syphilis. Gumma of the fascia usually involves the muscles, though there are exceptions to this rule. The diagnosis is made by the Wassermann reaction, the presence of other evi- dences of syphilis, and the disappearance of the affection of the fascia under anti-syphilitic treatment. 254 Diagnosis of Syphilis. SYPHILITIC AFFECTIONS OF THE NERVOUS SYSTEM. Brain and Meninges. During the second stage of syphilis there may be symp- toms of brain irritation or of irritation of the meninges. Among these symptoms, the more common are headache, ver- tigo, and general irritability ; less often there is nausea. There is rarely fever or acceleration of the pulse. These symptoms last for but a few days, with a return to the normal as the rule. The headache may be general ; over the entire head, or frontal or occipital. Bands of pain extending over the head from ear to ear have been described, as have also pains encircling the head horizontally. Rarely there is irreg- ularity of the pupils or slowing of the pulse. Ophthalmoscopic examination will reveal often irritation of the choroid and at times of the retina. The irritation of the retina may be marked, though there is little or no disturbance of vision. The spirochete pallida may be found, especially in the blood and cerebrospinal fluid, to make the diagnosis of syphilis absolute. Often the diagnosis may be cleared up by the Wassermann reaction. The search for the spirochete pallida is of most value during the second stage of syphilis ; during the third stage, it is more difficult to make. The Wassermann reaction is present in all stages of syphilis, when the disease process is active. It may sometimes not be found if the patient has received anti-syphilitic treatment. True meningitis is usually due to caries or necrosis of the bones of the skull. Frequently syphilitica show symptoms of pachymeningitis, especially a constant pain in the head, that is frequently localized, and may be increased by percussion. Pachymeningitis hemorrhagica is comparatively rare. Hydro- cephalus internus, ependymitis with hydrops, has been observed in syphilis. The softening of the brain, observed in some cases of syphilis, is due as a rule to a syphilitic endarteritis. The endarteritis seems to prefer the carotids and their branches, the Diagnosis op Syphilis. 255 arteriae fossae Sylvii et corporis callosi, especially in their first portions. This is the source of the terminal arteries of the lenticular nucleus and the caudate nucleus, where softening most frequently occurs. Hemorrhages in the brain are rather frequent in syphilis, being due as a rule to aneurysms, which are frequently found in the diseased vessels of syphilitics. Gummata of the dura mater develop between the folds of the dura, and show a preference for the duplications of the membrane, such as the falx cerebri. The gummata may be extensive or circumscribed, frequently the size of a walnut or larger. These growths sometimes cause erosion of the con- tiguous portion of the skull. Gummata of the pia mater lead to adhesion with the dura and also with the contiguous portion of the brain. When located upon the upper and lateral portions, the white sub- stance is not infrequently involved, often without softening of the brain. Gummata of the pia, when located at the base of the brain, are not so likely to involve the dura. Meningeal gummata may be diffuse, at first appearing as a jelly-like infil- tration, that later becomes converted into a cicatricial mem- brane. Meningitis gummosa basilaris diffusa has the unenviable reputation of being the most frequent syphilitic affection of the brain. It seems to prefer the region of the chiasm, fre- quently involving the oculomotor, optic and other cerebral nerves. The convexity is less frequently involved. Gummata of the brain, in the absence of affection of the meninges, must be regarded as rare. In such cases, the arteries in the region involved, will be affected as a rule by an oblit- erating endarteritis, that leads to softening of the brain. Syphilis frequently seems to play an etiological role in the production of a number of diseases that can not always be said definitely to be syphilitic, such as ophthalmoplegia, immobility of the pupils, atrophy of the optic nerve, dementia paralytica, and locomotor ataxia. Headache is one of the most common symptoms of syphilis of the brain and meninges. The headache may be general or 256 Diagnosis of Syphilis. localized, and occurs in all grades of severity. Usually the headache is more or less continuous, rarely showing distinct intermissions, though exacerbations are the rule. The exacer- bations are often nocturnal, though this characteristic is not peculiar to syphilis, as is sometimes taught. The duration of syphilitic headache varies greatly. Thus, the headache due to meningeal irritation, which occurs especially as a symptom of the second stage of syphilis, usually does not last longer than a week or two, when the case is under proper treatment, and several weeks possibly in cases not treated. Sometimes the patients complain of headache of a recurrent type, with intervals of a number of weeks or months, in which cases there are probably multiple causes and the location of the pain often changes. Long continued localized headache may be due to neuralgia, which may involve either superficial or deep nerves, for instance in the dura. With tlic headache there is often vomiting, less often vertigo. Frequently neuralgia is accom- panied by insomnia, irritability and various parasthesis. Irri- tability (motor, sensory or mental), various paralyses and degradation of the intelligence and power of thought, as well as various psychoses, are frequently observed in syphilis, though they may be due to other diseases. Brain syphilis of long dura- tion is frequently accompanied by obstruction to the power of thinking, lessened concentration or loss of memory, together with unconsciousness and convulsions. In brain syphilis, the pulse may show various changes. Fre- quently the pulse is slow, like in tumor of the brain ; again the pulse may be fast or irregular. Cases ma}' show polyuria and polydipsia. Optic neuritis or choked disk, with the vision normal or dis- turbed in various ways, may be found in brain syphilis. But a chronic optic neuritis would rather argue against syphilitic brain tumor (Gowers). Functional or focal symptoms may enable us to locate the region in the brain involved in the syphilitic process. In all brain affections of an obscure nature, it is well to think of syphilis. Such cases justify the therapeutic test. Diagnosis of Syphilis. 257 Hydrocephalus internus syphiliticus, ependymitis syph- ilitica, shows violent headache as a prominent symptom. The headache is continuous, often with marked exacerbations, and is frequently accompanied by nausea and vomiting. The latter symptoms may sometimes be caused by movements of the head or change of position. Cerebral syphilis may produce a monoplegia, hemoplegia, an epilepsy, a pseudo-chorea, aphasia, alexia, disturbances of hearing due to affection of the auditory center in the temporal lobe. Affections of the eye may be due to syphilitic affection of any part of the optic tract from the cortex to the eye. This gives an idea of the variety of affections that may be caused by cerebral syphilis. Space forbids entering into the details of cerebral localization. All suspicious cases should be sub- jected to the therapeutic test, when this is practicable. The base of the brain is frequently the seat of diffuse or circumscribed gummata. Here, again, the gummata often begin in the meninges. A useful point in diagnosis is the fact that syphilis of the convexity of the cerebrum is marked by cortical symptoms, whereas syphilis of the base of the brain is prone to involve the cerebral nerves of this region. Basilar meningitis is frequently accompanied by affection of the spinal meninges and by syphilis of the spinal cord. Furthermore, affection of the cerebral arteries at the base of the brain often leads to hemorrhages and softening. It is remarkable how extensive lesions are sometimes found post-mortem with the history of little disturbance during life. We have referred to involvement of the cerebral nerves. It is possible for syphilis to affect a single cerebral nerve, but frequently there is affection of a number of these nerves. Thus, when the olfactory and optic nerves are affected, the process may extend back to affect also the trochlears, trige- minus and abducens, and possibly the facial and auditory nerves. Posteriorly, the process may involve the hypoglossus and vagus. The optic chiasm seems to be a favorite location in basilar syphilis, and in these cases the ocular muscles are affected. 258 Diagnosis of Syphilis. H. Oppenheim regards oscillating hemianopsia bitemporalis as characteristic of syphilis of the base of the brain. He ascribes the appearance and disappearance of the symptoms in these cases to the presence or absence of swelling of the tissue in this region. Crossed paralysis is referred by Nothnagel to affection of the cerebral peduncles. In these cases the cerebral nerves, especially the oculomotor, will be affected on the side of the lesion, and the extremities of the opposite side. This is the so-called hemiplegia alternans superior. Similar symptoms may be caused by syphilitic basilar meningitis. Nothnagel believes that an alternating paralysis appearing at the same time points to a lesion in the cerebral peduncles. Hemiplegia alternans inferior, in which the crossed hemi- plegia affects the facial on the side of the affected peduncles and the opposite side of the body, is explained by the cross- ing of the motor fibres passing from the cerebral cortex to the spinal cord, which takes place lower down in the pyramids. Affection of the pons affects the facial more frequently than when the process is located in the peduncles. In addition there is usually disturbance of speech and deglutition. Soft- ening of the pons, due to syphilitic arteritis, may cause the symptoms of acute bulbar paralysis. Lesions in the region of the corpora quadrigemina usually cause bilateral affection of the oculomotors, and also disturb- ance of equilibrium and co-ordination, similar to affection of the cerebellum. Lesions in the cerebellum cause disturbance of equilibrium and a peculiar gait. There are comparatively few cases of syphilis in this region reported. Affection of the medulla oblongata is always grave. These cases frequently run the course of an acute bulbar paralysis. In some cases a cure has followed anti-syphilitic treatment. So much for syphilitic affection of the meninges and the cerebral cortex. We will now turn to syphilis of the deeper portions of the brain. In the deeper portions of the brain syphilis most frequently Diagnosis op Syphilis. 259 causes softening and hemorrhages. Gummata, both circum- scribed and diffuse, are comparatively rare. Most of the trouble in this region is due to syphilis of the cerebral vessels. Affections in the neighborhood of the central ganglia pro- duce symptoms chiefly through involvement or pressure upon the motor tracts, especially the internal capsule. If these tracts are not involved, lesions of the cerebral ganglia may be present without symptoms. Syphilitic affection of the cerebral vessels may lead to oc- clusion of these vessels gradually through ah obliterating en- darteritis, or suddenly through thrombosis. Furthermore, weakening of the vessel walls may lead to the formation of aneurysms, either sacculated or dissecting. These are well described in Schmaus' Pathology. Affection of the endar- teries, at the base of the brain, occluding these vessels, almost invariably leads rapidly to softening of the area supplied by the endartery. On the other hand, the vessels of the cortex more frequently anastomose, so that there is a possibility of a collateral circulation being established when a vessel in this region is occluded. It is evident that affection of the cerebral vessels may lead to a number of cerebral symptoms. Thus, there may be head- ache and vertigo, insomnia, mental irritability, and paresthesia?, especially formication, a day or two preceding the paralysis of a part. Hemiplegia or hemiparesis may appear suddenly without loss of consciousness, or be preceded by an apoplecti- form attack. Paralysis may disappear suddenhy or gradually. H. Oppenheim has observed that occasionally a central lesion may cause hemianesthesia, aphasia, and hemianopsia. The cases of partial occlusion of a vessel are prone to render prom- inent the vacillating character of cerebral symptoms, often regarded as characteristic of syphilis. Aneurysm, before burst- ing, may cause much the same symptoms as tumor. Later the vessel may be occluded by thrombi or emboli, when there will be added the symptoms of more or less complete occlusion of the artery, with consequent ischaemia or softening of the brain area supplied. Usually the aneurysms burst, with the symp- 260 Diagnosis of Syphilis. toms of cerebral hemorrhage. In the diagnosis of the cause of affection of the cerebral arteries, early age speaks for syphilis as against arteriosclerosis. Syphilis of the brain usually produces multiple lesions. Both the circumscribed and diffuse gummata are usually ac- companied by syphilitic arteritis. Syphilitic basilar menin- gitis is often accompanied by an extension of the process to the spinal meninges. In such cases the spinal symptoms are added to the cerebral symptoms, though the latter often over- shadow the former. Often marked cerebral changes, especially the psychoses, are observed clinically in syphilitics, in cases that show no recognizable lesion post-mortem. Furthermore, marked anatom- ical lesions, such as extensive gummata, may be found post- mortem without the clinical evidence of brain affection during life. In many cases the general cerebral symptoms are fol- lowed by focal lesions only after the lapse of a long time, or not at all. Epilepsy and hysteria and mania have been observed early in the second stage of syphilis, and sometimes late in the dis- ease. Delirium and disturbances of the intelligence have also been observed. In such cases, the absence of other etiological factors will often point to syphilis as a possible cause. The therapeutic test is often suggestive. Cerebral syphilis usually runs a chronic course, though extreme chronicity would speak against cerebral syphilis ; some cases run an acute course. Syphilis often plays an important role in diseases of the nervous system, sucli as epilepsy and hysteria. Thus, in individuals predisposed to these affections, the occurrence of syphilis may be sufficient to cause the appearance of the cere- bral disturbance. Furthermore, syphilitics seem more prone to development of lesions of the nervous system. It is possible that mental exertion may predispose to the localization of syphilis in the nervous system. Worry and excessive devotion at the shrine of Bacchus and of Venus, are also prominent causes of affection of the brain in syphilitics. Diagnosis op Syphilis. 261 The matter is put very succintly by Gray* when he says that we should suspect intra-cranial syphilis if there are present : 1. Quasi-periodical headache that returns at a certain time in the twenty-four hours, most frequently at or toward night, less frequently in the afternoon or morning. 2. Paralytic or convulsive symptoms that have been preceded by this characteristic headache and insomnia, when the headache and insomnia will have suddenly ceased upon the supervention of the paralysis or convulsion. 3. Symptoms indicative of a lesion at the base of the brain, preceded or not by the characteristic headache and insomnia. 4. Convulsions in the adult which have not been preceded by con- vulsions in infancy, and are not of traumatic or nephritic origin, or due to pregnancy, or in an individual subject to migraine. 5. Hemiplegia in an adult under forty years of age, even when there has been no preceding headache and insomnia. 6. A comatose condition extending over days or weeks, not traumatic, meningitic, diabetic, nephritic, or from typhoid fever. Often great stress is laid upon the value of the test for syphilis with iodide of potassium, in cerebral syphilis. In this connection it must not be forgotten that iodide of potassium often seems to cause marked improvement in non-syphilitic brain tumors. As a rule, the syphilitic tumors of the brain, under proper treatment, give a better prognosis than non- syphilitic brain tumor. The outlook depends largely upon the severity, duration and repetition of the paralyses and other symptoms. We must consider the possibility of death or re- covery, decrease and increase of the paralyses and other symp- toms, and also the termination in idiocy, delirium that passes into general paralysis, and fatal coma. At the same time we must remember the possibility of complications, such as hypo- static pneumonia, and bedsores with consequent sepsis. Spinal Cord and Meninges. Spinal syphilis is not so common as cerebral syphilis. Early in the course of syphilis there may be symptoms of spinal meningeal irritation. Thus, early in the second stage the patient may experience pain and paresthesias in the lower extremities, together with a feeling of debility. Lang ascribes these symptoms to hyperemias or slight infiltrations of the spinal cord or meninges, and believes that it may possibly *A treatise on nervous and mental diseases, by Landon Carter Gray 262 Diagnosis of Syphilis. change from an irritation to a distinct meningitis or menin- gomyelitis spinalis. An increase of the skin and tendon reflexes has been re- ported early in the second stage of syphilis, the irritability of these reflexes at first increasing and later decreasing below the normal, to later gradually again return to the normal. The change begins about the time the eruption appears, and the normal condition is not reached until several weeks after the eruption disappears. True spinal meningitis may, though rarely, be caused by syphilitic vertebral periostitis. Gummata of the spinal me- ninges or of the spinal cord are rare. Affection of either the spinal meninges or of the cord usually involves the spinal nerves. Syphilitic affection of the blood vessels may affect the cord. As stated, syphilis of the cord often occurs in associa- tion with syphilis of the brain, when it is frequently over- shadowed by the latter. Spinal syphilis usually presents, in addition to the symptoms of syphilis in other parts of the body, symptoms on the part of the spinal meninges, and also symptoms due to the affection of the spinal cord. Sometimes the physician ma}' not be able to find evidences of syphilis in other parts of the body, and rarely the meninges may lie affected without involvement of the cord. Among the early symptoms of spinal syphilis are stiffness of the spinal column, neuralgia, and girdle pains or pares- thesia;. The patient complains of heaviness of the extremities. There may be alterations of sensibility, especially minor altera- tions, as for heat and cold, etc. When the process attacks the cord and involves the various spinal tracts, the resulting paralyses and pareses may enable us to locate the seat of the morbid process. The higher the lesion in the cord, the more extensive will be the resulting paralyses and pareses. Thus, lesions in the dorsal or lumbar portion of the spinal cord may cause more or less complete paralysis of the abdominal and intercostal muscles, and para- phlegias of the lower extremities, and paralvsis of the sphinc- ters. Lesions in the cervical portion of the cord are marked Diagnosis of Syphilis. 263 by pain, paresthesias and stiffness of the neck, and affection of the lower portion of the body as a rule appears later. Affec- tion of the thoracic muscles and the diaphragm is marked by dyspnoea and attacks of asphyxia. Affection of only one side of the cord in any of these regions will cause a corresponding affection of half of the body. At times the involvement of the cervical portion of the cord is marked by an ascending paralysis, affecting successively the lower extremities, the sphinc- ters, the lower part of the trunk, and later the upper extremities and the muscles of respiration. All cases of spinal syphilis offer a grave prognosis. Even when only the lower extremities and sphincters are affected, cystitis and decubitus may lead to a fatal termination. Paralysis of the respiratory muscles may lead to a fatal pneumonia or gangrene of the lung. Sudden asphyxia may be caused by paralysis of the phrenic nerve. But in all cases, even those that appear the most grave, improvement or cure may follow the proper treatment of the disease. When improvement occurs, the paralyses usually disappear in the reverse order of their appearance. Thus, improvement is noted first in the muscles of respiration, possibly, and later in the paralysis of the trunk, of the upper extremities, and later of the sphincters and of the lower extremities. Often there remains for a long time weakness of the muscles that have been affected, pains and paresthesias and abnormalities of sensation. Any degenerative changes that may have been caused by the process in the cord will remain, of course, to cause permanent affection of the area involved. Many observers have noted that syphilis of the cord usually develops gradually and frequently accompanies brain syphilis, and the process tends to descend. But in many cases the affec- tion of the cord seems to come on suddenly, and at times the lesion seems to extend from below upwards. Great diagnostic aid may be secured by an examination of the cerebrospinal fluid for the spirochete pallida. The spiro- chete may also be found in the blood, in S3>philis. The Wasser- mann reaction will often render valuable aid in clearing up obscure cases. 264 Diagnosis of Syphilis. In meningomyelitis syphilitica there is not infrequently marked fluctuation of the symptoms, especially disappearance and reappearance of the patellar reflex. Occasionally spinal syphilis runs its course as an acute, subacute or chronic myelitis. Rarely paraplegia occurs suddenly, when it is usually due to an endarteritis causing thrombosis or hemorrhage. A pseudotabes syphilitica is occasionally encountered, marked by loss of the knee-jerk, the presence of lancinating pains, ataxia, immobility of the pupil, vesical disturbance, gastric crises, etc. The condition is due to meningitis spinalis syphilitica that affects especially the posterior columns and the posterior roots. Spinal syphilis sometimes shows successive exacerbations, resembling somewhat the clinical picture presented by multiple sclerosis. Multiple sclerosis, however, presents other symptoms, such as tremor of the muscles when in motion and not when at rest, hesitating speech, and nystagmus, that usually suffice to make the diagnosis. Symptoms of meningeal irritation would speak for spinal syphilis and against multiple sclerosis. Cases of syphilitic progressive muscular atrophy have been reported. A point of differentiation from the non-syphilitic progressive atrophy is the presence of pain and paresis before the atrophy of the muscles. The syphilitic spinal paralysis of Erb is due to the gradual development of meninglomyelitis. There is a weakness of the lower extremities, rarely an actual paraplegia. The gait be- comes spastic. The legs are stiffened and locomotion is diffi- cult. However, muscular rigidity and contracture are usually only slight. The knee-jerk is increased. Vesical weakness and impotence are present. Muscular atrophy is absent ; electrical irritability is present. The disease does not involve the nerves of the arms or head. The disease occurs usually from one to three years after infection, rarely from five to twenty years. Usually the affection responds to anti-syphilitic treatment. Grave cases may be incurable or fatal. The spasmodic tabes dorsalis of Charcot, or the spastic Diagnosis of Syphilis. 265 paralysis of Erb, is believed by some to be due to syphilis. The spastic paralysis is the characteristic feature. These cases usu- ally do not show sensory disturbances nor affection of the bladder or rectum. Among the comparatively rare affections is a multiple syph- ilitic root neuritis due to gummatous meningitis. Of the cerebral nerves, the oculomotors and the facials are most fre- quently affected. In the spinal cord, the cervical and dorsal portions are most frequently involved, to affect either the anterior or posterior roots upon one or both sides. There is a gradual development of progressive paralysis. There may or may not be symptoms of cerebral or spinal syphilis. There are gradu- ally increasing neuralgias of the spinal nerves and hyperesthesias of the skin or girdle pains. Affection of the anterior nerve roots leads gradually to motor palsies. There is usually little response to anti-syphilitic treatment. Tabes dorsalis is usually found in individuals who present the evidence or history of a previous syphilitic infection. But he would be a bold man, indeed, who would presume to declare that tabes is always due to syphilis. The fact remains, how- ever, that syphilis seems to play an important role in the etiology of tabes. To such a degree is this true, that the pres- ence of tabes dorsalis justifies the presumptive diagnosis of syphilis, though a positive diagnosis of syphilis in these cases could only be made in the presence of other symptoms or evi- dence of that disease. Anti-syphilitic treatment is usually of no value, so that the therapeutic test fails us in these cases. Of most diagnostic value is the Wassermann reaction. Peripheral Nerves. Aside from affection of the peripheral nerves by brain or spinal syphilis, these nerves may be affected by the pressure of gummatous infiltrations in the bones, periosteum, muscle and fascia through which the nerves pass. In most cases the lesion causing affection of these nerves, manifested by neuralgia and paralysis, escapes detection. Frequently neuralgia is due to syphilis. A painful ring 266 Diagnosis op Syphilis. extending over the skull from ear to ear and two or three fingers wide, sometimes observed in syphilis, is believed to be due to meningeal irritation. Peripheral neuralgia may appear early in the second stage of syphilis, or later in the course of the disease, even years after the primary infection. The early cases may be due to a simple syphilitic irritation that does not leave permanent anatomic alterations. Gummata are comparatively rare in the nerves, though neuralgia not infrequently is caused by the pressure of gummata in other tissues. Such a gumma may extend to the nerve, to destroy the nerve or to cause a neuritis or a perineuritis. Trigeminal neuralgia is most frequent. Any of the branches may be involved, or all of them. Occasionally a single branch, such as the supraorbital or the lingual, may alone be involved. The neuralgia usually disappears under anti-syphilitic treat- ment. Peripheral neuralgias of the spinal nerves are not so com- mon. Thus, neuralgia of the occipitalis major and of the nervus auricularis inagnus have been observed to disappear under anti- syphilitic treatment. Neuralgia of the brachial plexus is not common, but such a neuralgia has been observed, apparently due to the pressure of enlarged lymph nodes. Intercostal neuralgia may be found early in the second stage, as an irritative symptom of syphilis. Occasionally inter- costal neuralgia is caused by syphilitic periostitis of the ribs. Syphilis is frequently a cause of sciatica. The sciatica is frequently due to syphilitic perineuritis. The etiologic role played by syphilis is revealed by the response of the sciatica to the anti-syphilitic treatment. Visceral neuralgias arc frequently observed in syphilis. These are usually duo to affection of the internal organs, such as the heart, intestine, etc., or of the arteries (coronary arteries) or lymphatics, and possibly at times affection of the correspond- ing nerves. Paralysis is a prominent symptom of syphilis. Reference has already been made to the paralysis due to brain and spinal Diagnosis of Syphilis. 267 syphilis. Syphilitic peripheral paralysis is far more frequently observed in the cranial nerves. The peripheral paralyses at times appear and disappear suddenly. Perhaps the most frequent paralysis is that of the oculo- motor, which in fully half the cases is due to syphilis. The paralysis may affect the oculomotor in its entirely, or only a single branch may be involved. Facial paralysis is frequent in the second stage of syphilis, often appearing within a year after infection. The paralysis disappears as a rule completely under anti-syphilitic treatment. Syphilitic facial paralysis is sometimes recurrent, and the affec- tion may be bilateral. A bilateral facial paralysis, accompanied by paralysis of other cerebral nerves (auditory, oculomotor, abducens, trigeminus, and hypoglossal) speaks for syphilis at the base of the brain. Peripheral paralysis of the other cerebral nerves is rare. They are more often affected by brain syphilis. BASAL GUMMATOUS MENINGITIS. Headache is present in about three-fourths of cases, and frequently occurs as one of the most important early symptoms. It is usually worse at night. The pain may be sharp, boring or dull, superficial or deep seated, rarely circumscribed. Other important symptoms are: Nauralgias. Cerebral vomiting and vertigo. Alterations of mentality, such as somnolence, semi-intoxication, or im- pulsive, motiveless activity, and losse of the aesthetic sense. Coma, with the possibility of spontaneous recovery. Persistent sleep is ominous. Alterations in brain activity, which may be tardy or excited. There may be nocturnal automatism or dementia, alternating with delirium, epileptic attacks, or paralytic seizures. The brain symptoms rarely re- semble those of uremia, meningitis, or typhoid fever. Epilepsy may be typical or unilateral, frequent or violent: and tetanic or cataleptic seizures may occur. Polyuria, polydipsia, diabetes insipidus, and diabetes mellitus occur. Fever may be irregular. Affection of cerebral nerves, especially the third nerve, which is affected in more than half of the eases, and the optic nerve, which is affected in over half of the cases. Choked disk, usually bilateral, occurs in ten per cent, of cases-, neuritis, unilateral, in about five per cent, of cases; simple atrophy with blindness, amaurosis, hemianopsis. The fourth, sixth, and fifth nerves are affected less frequently, in the order given. The olfactory nerve is rarely involved. The facial may be affected unilaterally, peripherally. The eighth nerve is sometimes involved. The vagus or hypoglossus may be affected. 268 Diagnosis of Syphilis. Localization of the Functions. SEGMENT. Second and third cervical. Fourth cervical. Fifth cervical. Sixth cervical. Seventh cervical. Eighth cervical. First dorsal. Second to twelfth dorsal. First lumbar. Second lumbar. Third lumbar. MUSCLES. Sternomastoid, trapezius, Scaleni and neck, Diaphragm. Diaphragm, Deltoid, Biceps, coracobrachialis, Supinator longus, Rhomboid, Supra — and infra spinatus. Levator angnla scapula?. Deltoid. Biceps, coracobrachialis, Supinator longus, Supinator brevis, Deep muscles and shoulder blade, Rhomboid, teres minor, Pectorali8 (clavicular part), Serratus magnus. Biceps, brachialis anticus, Pectoralis (clavicular part), Sena I us magnus, Triceps, Extensors of wrist and fingers, Pronators. Triceps (longhead), Extensors of wrist and fingers, Pronators of wrist, Flexors of wrist, Subscapular, Pectoralis (costal part), Lai issimus dorsi, Teres major. Flexors of wrist and fingers, Intrinsic muscles of hand. Extensors of thumb, Intrinsic hand muscles, Thenar and hypothenar eminences. Muscles of back and abdomen, Erectores spina?. Quadratus lumborum, Transversalis obliqui, Ilio-psoas, Sartorius. Ilio-psoas, sartorius, Flexors of knee ( Remak ) , Quadriceps femoris. Quadriceps femoris, Inner rotators of thigh. Obturator, Adductors of thigh. Diagnosis op Syphilis. 269 The Segments of the Spinal Cord (M. Allen Starr). REFLEX. Hypoehondrium ( ?) Sudden inspiration, produced by- sudden pressure beneath the lower border of the ribs. Pupil, fourth to seventh cervical. Dilation of the pupil produced by irritation of the neck. Scapular, Fifth cervical to first dorsal. Irritation of skin over the scapula produces contraction of the scapular muscles. Supinator longus. Tapping its tendon in wrist produces flexion of forearm. Triceps. Fifth to sixth cervical. Tapping elbow tendon produces ex- tension of forearm. Posterior wrist. Sixth to eighth cervical. Tapping tendons causes extension of hand. Anterior wrist. Seventh to eighth cervical. Tapping anterior tendon causes flex- ion of wrist. Palmar, seventh cervical to first dorsal. Stroking palm causes closure of fin- SENSATION. Back of head to vertex. Neck. Outer part of shoulder. Back of shoulder and arm. Outer side of arm and forearm. Outer side of arm and forearm. Outer half of hand. Front, back of arm and forearm. Middle and ring fingers. Epigastric, fourth to seventh dorsal. Tickling mammary region causes re- traction of the epigastrium. Abdominal, seventh to eleventh dor- sal. Stroking side of abdomen causes re- traction of belly. Cremasteric, first to third lumbar. Stroking inner thigh causes retrac- tion of scrotum. Patella tendon. Striking tendon causes extension of leg. Bladder center. Second to fourth lumbar. Forearm and hand; ulnar area. Inner side of forearm. Skin of chest and abdomen, in bands running around and downward, corresponding to spinal nerves. Skin over groin and in front of scro- tum. Outer side of hip. Front of thigh. Front of thigh. Inner side of leg. 270 Diagnosis of Syphilis. Fourth lumbar. Fifth lumbar. First and second sacral. Third sacral. Fourth and fifth sacral. Adductors of thigh, Abductors of thigh, Flexors of knee (Ferrier). Glutei, Biceps femoris, Sc;nitendinosus, Popliteus, Outward rotators of thigh, Flexors of knee (Ferrier). Biceps femoris, Semimembranosus, Extensor longus digitorum, t.astric, ; ibiclia posticus Tibialis anticus. Peronei, Intrinsic muscles of foot. Sphincter ani et vesicae, Perineal muscles. Gummata in the pons, eras or medulla, may cause hemiplegia and crossed paralysis — hemiplegia and (1) Oculo-motor paralysis, "i (2) Facial paralysis, oi (3) Abducens and trigeminus paralysis. Arterial phenomena: (1) In cortical region — syncope or apoplectiform attack from variation in blood pressure. (2) In central ganglia — encephalomalacia. hemiplegia, hemianes- thesia, and hemianopsia. These usually occur later than meningitis and neuritis. Duration — With remissions and exacerbations, a few months, rarely more than six. in the absence of treatment. Diagnosis of Syphilis. 271 Rectal center. Fourth lumbar to second saeral. Gluteal. Fourth to flfth lumbar. Stroking buttock causes dimpling in fold of buttock. Achilles tendon. Over-extension causes rapid flexion of ankle, called ankle clonus. Babinski reflex. Scratching sole of foot causes exten- sion of great toe. Fifth lumbar to first saeral. Outer and back side of thigh and front of leg to ankle. Dorsum of foot. Leg and foot, outer part. Plantar. Tickling of sole of foot causes flex- ion of toes and retraction of leg. Back of thigh and leg in saddle- shaped area. Inner side of foot. Back of buttock, seat. Perineum, anus. Back of scrotum. From M. Allen Starr — Localization of the functions of the segments of the spinal cord. Cancer at the Base of the Brain. Course more continuous and progressive. Intermittent or remittent in syphilis. Definite localization. Localization varies in syphilis. Few changes in the vessels. Changes in vessels may be marked in syphilis. Tubercuxous Meningitis. Less development of connective tissue. Vascular changes are rarer. Nerves less frequently involved. Course more acute, febrile, and progressive. Remissions less frequent and less marked. 272 Diagnosis op Syphilis. Stiff neck and general muscular rigidity occur — rare in the congenital type of syphilis. Mental obscurity more marked and sudden, and not marked by the intermissions observed in syphilis. Early irritation, followed by paralysis; paralysis occurs at once in syphilis. Age: Tuberculous meningitis is more frequent under twenty-five; syphilitic meningitis usually occurs after twenty-five. Other evidences of tuberculosis are present as a rule. Syphilis of the Convexity. May occur as circumscribed or diffuse meningitis or meningo-ence- phalitis, with symptoms like those of cortical tumor or with diffuse manifestations. Headache is one of the early symptoms. Convulsions, may occur as the first evidence of the disease. After thirty, convulsions indicate syphilis, in ninety per cent, of cases, in the absence of uremia and alcohol as causes. — (Fournier.) Focal symptoms, Jacksonian epilepsy with monoplegia or hemiplegia. Pain and paresthesia occur; anesthesia is rare. Aphasia is frequent, of the transitory motor type, due to vascular disease more frequently than to gumma. Acute psychoses may occur, most frequently as dementia, when the process is diffuse. Syphilitic Abtebial Disease. May occur alone or with other varieties of brain syphilis. Most frequent form. Next to affection of the nerves, this is the most frequent cause of paralysis. Prodromal distubraiwes: Headache is the rule, but less constant than in meningeal syphilis. Vomiting, vertigo, dullness, psychic changes, dementia, convulsions, intermittent hemianopsia, and aphasia are prominent symptoms. Choked disk is rare. Thrombosis and obliteration of the vessels is gradual in onset and is intermittent — may involve the leg and in a few hours or days the arm. These changes are due to obliteration of the vessels and multiple softening, which occurs in ninety-five per cent, of the cases in the region of the artery of sylvius pseudobulbar paralysis and may result from involvement of the bulbar vessels. The attacks, at first mild and short, increase in severity. Arteriosclerosis usually occurs later in life, is slower in progress, and the changes are more disseminated. Average duration, without treatment, one to three months. Basal gummatous meningitis rarely lasts over six months. Gummata. May occur in any part of the brain or meninges. Cortical pummafa— cortical epilepsy and monoplegia. Should be dif- ferentiated from other tumors, especially tubercle and glioma. Cortical tumor: Headache duller and deeper; pressure symptoms, mental depression, and slow pulse more marked; disk changes follow focal symptoms; the process advances less by epochs. In syphilis: Headache is frequently local, pressure symptoms more diffuse, due to more rapid and extensive involvement ; disk involved usu- ally only in the presence of basal meningitis: cortical paralysis, often associated with Jacksonian epilepsy; improvement under anti-syphilitica is permanent. Diagnosis of Syphilis. 273 Cebebrospinai, Syphilis. The symptoms are asymmetrical and less pronounced. The disease responds tomercury and the iodides. The symptoms are variable. The symptoms are variable. Meningeal and nerve root symptoms as- sume prominence. Syphilis of the cord is less frequent than syphilis of the brain. Varieties of cerebrospinal syphilis: ( 1 ) Gummata of bones — exceptional, as are also exostoses and caries. (2) Gummatous meningitis — most frequent. (3) Meningomyelitis — the myelitis occurring secondary to meningitis. (Myelomalacia is sometimes called syphilitic myelitis.) (4) Gummata of the cord — relatively infrequent. (5) Vascular disease. Softening is rare and involves small areas only. (6) Perineuritis gummosa of the sensory or motor nerve roots. Sarcomatosis. Multiple sarcomatosis of the brain and cord shows more steady pro- gression and greater constancy of symptoms than is usually observed in syphilis. In cerebrospinal syphilis, tabes, and dementia, lymphocytes are found increased in the cerebrospinal fluid, withdrawn by lumbar puncture. The presence of the spirochete pallida in the fluid makes the diagnosis of syphilis absolute. The Wassermann reaction is of very great value in the recognition of the syphilitic character of obscure cases. Albumosuria present in cerebrospinal meningitis, absent in tubercular meningitis. Acute meningitis should be differentiated from other affections of the meninges, etc., and from — Cerebritis, acute softening, intracranial tumor, ear disease, and head symptoms of continued fevers, acute rheumatism, acute ulcerative en- docarditis, pneumonia, pericarditis, tubercular meningitis, cerebrospinal meningitis, delirium tremens, acute mania. Cerebrospinal meningitis is differentiated by the more prominent dis- turbances of sensation, by herpes, and by the occurrence of other cases. Basilar meningitis occurs more especially in children affected with tuber- culosis elsewhere, or who come of tuberculous stock. It has long pro- dromes, and a longer duration. Its symptoms are less acute and intense. It more frequently implicates the membranes of the spinal cord. Pachy- meningitis is a disease of age. It occurs in drunkards, and in cases of dementia paralytica, chronic insanity, etc. It shows a more fluctuating course. It must be repeated again and again that the various forms of meningitis are to be separated and decognized more by the etiological relations of the disease than bby any difference of symptomatology. Tuberculosis and typhoid fever show typical temperature curves, with lung symptoms in tuberculosis, and abdominal symptoms in typhoid fever. In scarlatina, variola, and erysipelas it is rather a question of detecting a complication, as each disease shows characteristic eruptions upon the surface. Here, too, the persistence of cerebral signs after subsidence of the high temperature is of value. Septic and pyemic diseases follow wounds, are attended with chills, and show joint affections and internal metastases. Ulcerative endocarditis, a septic process, has the same history. Uremia is recognized by the dropsy, the condition of the urine, and, so far as the nervous symptoms are concerned, by the predominance of convulsions. y 274 Diagnosis of Syphilis. ORGANS OF SPECIAL SENSE. Organs of Sight. Reference has already been made to the deep seated affec- tions of sight, such as cerebral disease and affection of the optic nerves. Here we will discuss only the affections of the eyes. All three stages have been observed in the eyebrows. The initial lesion is rare. The lids, also, may be affected in all stages of syphilis. Ini- tial scleroses and papules have been occasionally observed. In such cases there is ulceration, the surrounding skin is swollen, the conjunctiva is often chemotic, and there is swelling of the preauricular or submaxillary lymphatic glands, or of both groups. There is the characteristic induration, and an absence of the history of trauma. The second stage may be represented on the lids by macules, papules or pustules, as a part of the general eruption, especially in neglected or malignant cases. The papules are usually cov- ered with crusts. As a rule they are situated on the free border of the lid, and tend to ulcerate and cause loss of the eyelashes, madarosis. The loss of the eyelashes may occur also as an ex- pression of alopecia, independent of previous affection of the lids. The lids may be the seat of gummatous infiltrations and ulcerations, often associated with similar affection of the fore- head, temple, cheek and nose. Gummata may occur as hordeola and chalazion, or as flat superficial infiltrations, or as tumors, which may reach the size of an almond or of the normal eye or even larger. Often there is affection of the skin, and also of the cartilage, tarsitis syphilitica. Pain may be severe or absent altogether. Ulceration is common. The prognosis is better when the infiltrations do not go on to ulceration. But in either case there is often considerable subsequent deformity, because of the loss of substance and the subsequent contraction of the skin and cartilage. Destruction of the hair follicles may lead to a loss of the lashes. Diagnosis op Syphilis. 275 In diagnosis we must differentiate between the rare cases of chancre and those of gummata of the lids, and also between the syphilitic and the non-syphilitic chalazion or hordeolum. There is usually not much difficulty differentiating syphilis of the lid from lupus, which usually first affects the cheek or nose. However, in exceptional cases lupus may be confined to the lids. At times it is necessary to differentiate between syphilitic and cancerous ulcer. Syphilis is one of the general causes of blepharitis. In suspicious cases, we must remember that there are many other general causes of blepharitis, e. g., tuberculosis, the exanthe- mata, anemia, and malnutrition from any cause. Among the important local causes are external irritation, such as may be caused by vitiated air or smoke; injuries, chronic conjunctivitis, inflammation of the lachry mo-nasal passages, disease of the rhino-pharynx, and possibly also abnormal shortness of the lids. At times a stubborn blepharitis depends upon eczema, eczema seborrhoeicum, seborrhoea, or acne. The oculists seem to stretch a point in declaring that blepharitis may be due to refractive errors. Dacryoadenitis, inflammation of the lachrymal gland, has at times been ascribed to syphilis. Among the other causes are traumatism, "catching cold," rheumatism, mumps, gout, sep- ticemia, and the extension of inflammations from the conjunctiva and cornea. Dacryocystitis, inflammation of the lachrymal sac, may occur as an extension of inflammation from chronic nasal affections in cases of inherited or acquired syphilis. Indeed, chronic nasal syphilis is especially liable to involve the lachrymal apparatus. Stricture of the nasal duct may be due to this cause. Conjunctiva. The chief syphilitic lesions are : 1. Chancre. 5. Nodular syphilides. 2. Papular syphilides. 6. Syphilitic ulcer, and 3. Copper-colored spots. 7. Gummata. 4. Mucous patches. 276 Diagnosis op Syphilis. The search for the spirochete pallida and the Wassermann reaction may afford valuable aid in diagnosis. The conjunctiva may be affected in all stages of syphilis, though less often than the lids. The initial scleroses usually are found on the transition fold of the lower lid, rarely on the con- junctiva tarsi or the conjunctiva bulbi. The primary sore is frequently accompanied by conjunctivitis and photophobia. The preauricular and submaxillary lymphatics are the seat of indolent buboes. Recovery usually occurs without permanent injury, save possibly a scar. During the second stage of syphilis there is sometimes a stubborn conjunctivitis. A similar condition, marked by red- dening of the conjunctiva, is sometimes observed in hereditary syphilis. The conjunctiva may be the seat of slightly elevated papules during the second stage of syphilis, accompanying a similar eruption on the lids or over the body. Gummata of the conjunctiva generally involve also the sclera, and may extend to the limbus cornea;. When ulceration takes place, there is left a cicatrix or pterygium-like thickening of the conjunctiva. Gummata must be at times differentiated from carcinoma and sarcoma. Gumma of the caruncula; has also been mistaken for cancer, the differentiation being made by the therapeutic test . The tear ducts may be affected by syphilis of the conjunc- tiva or lids or of the mucous membrane of the nose. Dacryocys- titis may occur in either acquired or hereditary syphilis. Os- titis or periostitis of the bony lachrymal canal may affect the lachrymal sac and duct. Stricture of the nasal duct may be due to syphilis, either inherited or acquired. Thus, of two hundred cases of stricture of the nasal duct, in Galezowski's clinic, seventeen were of syphilitic origin. Other causes are nasal tuberculosis extend- ing to the lachrymal passages : polypi of the lachrymal sac : and occlusion resulting from rhinitis attending the exanthemata, especially measles, scarlet fever and smallpox. Diagnosis of Syphilis. 277 Cornea. We have already referred to affection of the cornea in syphilis. Considerable diagnostic importance is attached to keratitis parenchymatosa as a symptom of syphilis. This may be present in acquired or in hereditary syphilis. This, to- gether with deafness and the changes in the incisors, consti- tutes the triad recognized by Hutchinson as characteristic of hereditary syphilis. Syphilitic keratitis, various known as interstitial or par- enchymatous keratitis, inherited, specific, and diffuse intersti- tial keratitis, is marked by the absence of destructive change in the cornea. The diagnosis is often aided by the presence of other symptoms or evidence of syphilis, such as the notched teeth described by Hutchinson. Deafness is less common. Parenchymatous keratitis is usually due to syphilis in pa- tients under thirty ; after that age it is more frequently due to other causes, notably rheumatism, gout and tuberculosis. A few cases have been reported in which the gummatous infiltra- tion extended to the cornea from the conjunctiva or sclera. Sclera. Gummata of the sclera are rare. Because of their rarety, they must be differentiated from malignant neoplasms. The Wassermann reaction and the therapeutic test suffice to make the differentiation. Iris. There are many causes of iritis. Thus, among the local causes are foreign bodies in the cornea, penetrating wounds of the eyeball, careless and continued use of caustic agents, and smollen masses of lens-matter. Inflammation may extend to the iris by continuity from the cornea, sclera, ciliary body, or choroid. Or iritis may be an expression of sympathetic oph- thalmitis, arising from trouble in the other eye. 278 Diagnosis of Syphilis. Among the general causes of iritis, syphilis easily takes first place. Other causes of iritis, that must at times receive con- sideration in making a diagnosis, are rheumatism, tuberculosis, gonorrhoea, and trauma. Rarely cases are due to relapsing fever, typhoid fever, typhus, smallpox, septicemia, cerebro- spinal meningitis, malaria, and influenza. The irregularities of menstruation have at times been accused of playing a role in etiology, iritis catamenalis. So that syphilis is far from being the only cause of iritis. Iritis is a prominent symptom of syphilis, which causes over half the cases. Papules have been occasionally observed, iritis papulosa, especially on the edge of the cilia or the pupil. Syph- ilitic iritis heals, frequently with injury to sight through the formation of posterior synechia; or occlusion of the pupil. Re- lapses are frequent, and the disease often extends to other parts of the eye, especially the ciliary bodies and the choroid. Rarely there is the formation of a secondary glaucoma. During the third stage of syphilis, gummata may occur in the iris. Diagnosis op Syphilis. 279 Syphilitic Iritis. Syphilitic iritis is generally plastic ; may be parenchymatous. Most frequent in second stage of syphilis. Syphilitic parenchymatous iritis often presents small nod- ules at the margin of the pupil or at the ciliary border of the iris ; later these disappear to leave atrophic areas. The recognition of the nodules aids in the diagnosis of syphilis, but often there are no nodules present in syphilitic iritis. The nodules vary in size, sometimes being so large as to fill the anterior chamber and even burst through the envelopes of the eye. Simple Iritis. Non-syphilitic iritis may be due to rheumatism, gonorrhoea, tuberculosis, traumatism. Less frequent causes are diabetes, typhoid fever, typhus, relapsing fever, smallpox, cerebrospinal meningitis, septicemia, influenza, and malaria. Inflammation of the ciliary body is usually secondary to affection of the iris, constituting an iridocyclitis. Gummata of the iris and ciliary body may extend to cause perforation and destruction of the eye. Inflammation of the iris may also extend to the choroid, as an iridochoroiditis. The choroid may also be inflamed without affection of the iris. Syphilis is a prominent cause of diffuse exudative choroid- itis and choroiditis centralis. Choroiditis becomes dangerous when it causes cloudiness of the crystalline lens, or when it in- volves the retina or optic nerve* 280 Diagnosis of Syphilis. Retina. The retina often shows hyperemia or irritation in syphilis, during the second stage of the disease ; and grave retinitis, also, is not uncommon. The optic nerve is often hyperemic early in syphilis, during the second stage. Affection of the intracranial portion of the optic nerve, or gummata of the brain or meninges, may cause optic neuritis or neuroretinitis. Independent syph- ilitic optic neuritis or neuroretinitis is apparently more rare. A number of observers have reported affections of the retina due to disease of the retinal blood veseels. Amblyopia and amaurosis, either permanent or tempoi'ary, often occur in tlie course of syphilis in the absence of demonstrable lesions, so far as ophthalmoscopic examination goes. We do not know whether there is a primary syphilitic ret- initis. Some observers declare that all cases of syphilitic retinitis are due to an extension of inflammation from the choroid. However this may be, a serous inflammation of the retina often results from syphilis. In syphilitic retinitis, the inflammation shows a tendency to be circumscribed instead of general, described by Galezowski as retinitis with exudative 6pots. These may be present when there is also considerable general edema of the retina. A positive diagnosis of syphilis can be made only in the presence of concomitant evidence of the disease. The ophthalmoscopic picture is that of simple serous retinitis, the edema of the retina causing it to appear as if seen through a mist. The patient complains of a gradually increasing mist before the eyes, without decided pain in the eyes, sometimes with photophobia. Photopsies and .scintillations are common and are regarded by some as important symptoms of syphilitic retinitis. Irregularities of the field of vision and scotomas are common. Syphilitic retinitis may occur in heredi- tarv syphilis or in congenital cases from six months to two years after infection. Usually there is involvement of both eyes. Syphilitic chorio-retinitis usually begins in the uvea and involves the retina later. The inflammation may begin simul- taneouslv in the retina and choroid. Like syphilitic retinitis, Diagnosis op Syphilis. 281 this affection begins from six months to two years after the primary infection. The etiology of retinitis proliferans is not clear, but syph- ilis and traumatism are regarded as prominent factors in causation. Crystalline Lens. Cloudiness of the crystalline lens has been referred to in connection with choroiditis. An independent hyalitis syphilitica is regarded as a possibility. This opinion seems to be based upon reasoning rather than upon actual observation. Thus, cataract is caused by atheroma of the blood vessels, and syph- ilis is known to be a prominent cause of atheroma. However, the literature is remarkably free from instances of independent syphilis of the crystalline lens. Gumma has been reported to affect the lens secondarily. Gummata of the orbit occasionally perforate the skull. Vitreous. Opacities in the vitreous have been ascribed to syphilis, and also to a number of other conditions, such as general exhaus- tion from long-continued fevers, gout, constipation, anaemia, congestion of the liver, irregular menstruation, and the action of certain drugs, especially arsenic. Injuries, through causing choroidal hemorrhage, may also cause opacities of the vitreous. Optic Nerve. Optic neuritis may be due to intracranial tumor — neoplasma of the brain or meninges ; gummata, tubercle, cysts, abscesses, tumors- — that increase intracranial pressure. Possibly active inflammation is a factor in etiology. Some observers lay great stress upon this class of causes. Others attribute an important role to interstitial edema of the brain tissue extending through the optic nerve to the papilla. At any rate, optic neuritis is one 282 Diagnosis of Syphilis. of the most important diagnostic points in the recognition of intracranial growths and inflammations. Optic neuritis has also been observed in a number of infec- tious diseases: Measles, typhoid fever, influenza, scarlet fever, smallpox, malaria, whooping-cough, beri-beri, pelagra, typhus, typhoid fever, pneumonia, rheumatism, diphtheria, myxedema, and acromegaly. In many of these cases the optic neuritis may have been due to nephritis, meningitis, or syphilis. Syphilis is one of many causes of optic neuritis. It may cause optic neuritis by attacking the nerve directly or by pro- ducing a gumma in the cranial cavity. Optic neuritis may be divided into (1) intraocular optic neuritis, papillitis, and (2) retrobulbar neuritis, characterized by inflammation of the nerve between the eye and the chiasm. Intraocular optic neuritis has been subdivided by v. Graefe into (a) choked disk, papillitis from stasis, and (b) simple optic neuritis, or descending optic neuritis, in which the inflam- mation spreads down the nerve trunk from an intracranial lesion. Choked disk causes disturbances of vision of varying degree up to complete blindness. There is generally a gradual reduc- tion of the central acuity of vision, sometimes with a central scotoma, more often with contraction of the field of vision at the periphery, frequently more marked at the nasal side. But the interference with the field of vision is subject to all sorts of variations. The color-sense may be little or greatly affected. The field of vision for the various colors do not always corre- spond. A pronounced choked disk is characterized ophthalmo- scopically bj T obliteration of the outlines of the papilla, its place being marked by an elevated mass marked on the surface by radiating stria? that fade gradually into the surrounding tissue. Near the center are the larger retinal vessels, the veins large and tortuous, the arteries often reduced in size. Rarely pulsation of the arteries may be noted. The capillary vessels on and close beneath the surface of the elevation are numerous and enlarged. On the borders of the elevated mass and in the sur- rounding retina small patches of whitish exudate and hemor- Diagnosis of Syphilis. 283 rhages are not uncommon, and when large and numerous would indicate a neuro-retinitis. In such cases opacities may develop in the posterior portion of the vitreous, sometimes with newly formed blood vessels leading out to them. The height of the elevation may be an aid in diagnosis. Thus, in choked disk the height of the elevation measured with the ophthalmoscope va- ries from 1 D to 6 D. When less than this, the condition verges into that of simple papillitis. Simple papillitis, as stated, is marked by less elevation of the mass at the site of the papilla. There is also less complete obliteration of the borders of the papilli; the striae are not so prominent. However, hemorrhage and exudation may be even more extensive than in cases of pronounced choked disk. Usually it is easy to recognize an intraocular optic neuritis with the ophthalmoscope, when the media are clear. The con- dition must not be mistaken for hyaline bodies in the papilla nor an obscuration of the borders of the disk by opaque nerve fibres. Cases described as false or spurious optic neuritis have probably been due to the latter condition, the margin of the disk being more or less completely obscured by a grayish stria- tion, resembling a mild case of choked disk. Such cases show an absence of the other signs of stasis, that we would expect to find in choked disk, such as enlarged capillaries. Having made a diagnosis of choked disk, we must next con- sider the cause of the condition. The most frequent cause is an intracranial tumor. Indeed, choked disk is a prominent symp- tom of such tumors, some observers declaring that it occurs in 95 per cent, of all cases. It is interesting to note that some observers declare that optic neuritis in these cases is not due to simple stasis, but is rather an active inflammation caused by the passage of irritating substances, produced directly or indi- rectly by the tumor. The other theory, supported by v. Graefe and many other prominent ophthalmologists, is that the con- dition depends upon the increased intracranial pressure caused by the tumor. Others have attributed choked disk to the exten- sion of an edema of the brain tissue through the optic nerve to the papilla ; or to the edema of the nerve trunk causing com- 284 Diagnosis of Syphilis. pression of the central retinal vein. However, the presence of a double choked disk points strongly to the presence of an intracranial tumor. Exceptions have been noted. Thus, in a case reported by Krohn, metastases from a carcinoma of the ovary caused a double choked disk through the development of metastases in the optic nerve behind each globe. Unilateral choked disk may be due to brain tumor, which is explained by the pressure-theorists upon the ground of a localized meningitis or hemorrhage. All sorts of brain tumors may cause choked disk. Thus it has been observed in neoplasms of the brain, meninges or skull ; in gunimata, tubercles, cysts, abscesses, and aneurysms. Great diagnostic aid is often afforded by the Wassermann reaction. Optic neuritis may be caused by a great number of general diseases, besides the local causes, such as tumors or inflamma- tions in the cranial or orbital cavities, meningitis, infectious thrombosis of the brain sinuses, etc. Among such general causes are measles, typhoid fever, and influenza ; less frequently scar- latina, variola, malaria, whooping-cough, beri-beri, pelagra, typhus, pneumonia, rheumatism, diphtheria, and myxedema. Albuminuria may cause a neuritis, which may explain the oc- currence of that condition in so many of the general diseases. In other cases it may be due to infection of the trunk or inter- vaginal space of the nerve, or to a general toxemia. Other causes of optic neuritis are disorders of menstruation, especially those marked by a sudden stopping of the flow, and cases of premature menopause and atrophy of the uterus ; hydrocephalus internus ; deformities of the skull ("Thurmschadel") ; cerebral softening : puerperium : lactation : chlorosis ; severe hemorrhages ; gonorrhoea ;nephritis ; lead poisoning, either directly or through lead-nephritis : intranasal cauterization: acromegaly: sunstroke; violent physical exertion ; carious teeth, etc. At any rate, optic neuritis has been found in all these conditions. Retrobulbar neuritis may be divided clinically into (1) acute or fulminant retrobulbar neuritis, and (2) chronic retro- bulbar neuritis. Diagnosis op Syphilis. 285 (1) Acute or fulminant retrobulbar neuritis is character- ized by pain back of the eye, that may be spontaneous, present upon movement of the eye or upon pressure upon the eyeball ; obscuration of vision, that progresses to complete or nearly complete blindness in from one to eight days. With these not infrequently there are associated the symptoms of acute myelitis, more rarely of multiple neuritis. The ophthalmoscope reveals a normal disk or a hyperemic nerve-head with or without slight haziness of the surrounding retina, and rarely minute retinal hemorrhages and small grayish or yellowish spots in the neigh- borhood of the macula. Syphilis can not be regarded as a prom- inent cause of this disease, the condition most frequently being referred to rheumatism and influenza. Other infectious diseases seem sometimes to play a role in etiology. (2) Chronic retrobulbar neuritis. In this class should be placed the cases of recurrent attacks of acute retrobulbar neu- ritis and also those that run a slow course, the loss of vision progressing for several months as a central scotoma, the loss of vision at first being only relative in that some or all colors are mistaken within its borders. The ophthalmoscope may reveal nothing abnormal, or there may be congestion of the disk and slight haziness of the surrounding retina. Later, in long continued cases, there is atrophy of the outer quadrant or half of the optic disk, and occasionally atrophy of the entire disk even where the defect of vision is limited to a central scotoma. Syphilis is not a prominent cause, the disease usually being due to rheumatism or exposure ; chronic meningitis or periostitis in the optic canal ; and most frequently the condition is a toxic amblyopia, due to systemic poisoning with alcohol, tobacco, lead, carbon disulphid, iodoform, quinin, mydriatic al- kaloids, male-fern, and ptomains; less frequently the salicylates and salicylic acid, cocain, snake venom, carbolic acid, aconite, chloral, santonin, picric acid, digitalis, tea, coffee, chocolate, gelsemium, ergot, the coal tar products, arsenic, naphthalin, potassium bromid, ergot, amyl nitrite, nitrobenzol, mercurial compounds, silver nitrate, antipyrin, curare, etc. UhthofF gives the following points of differentiation between 286 Diagnosis of Syphilis. the toxic retrobulbar neuritis, such as is due to alcohol and tobacco, and the cases of retrobulbar neuritis due to syphilis, rheumatism, disorders of menstruation, cold, diabetes, etc.: (a) In true toxic amblyopia the central scotomata are almost in- variably confined to red and green, (b) The scotomata and visual disturbances are bilateral, and the former are confined to the center of the field, (c) Vision does not fall below 6/200. (d) The form of the scotoma is that of an oval, including both blind spot and fixation-point, with its long axis lying above the horizontal meridian, (e) The vision becomes gradually less, (f) The disease affects men above forty years of age. (g) Pain is noticed on extreme ocular movements in essential retro- bulbar neuritis, but is invariably absent in the toxic form. Atrophy of the optic nerve may be due to sclerotic changes following retinitis, or be associated with sclerotic changes in the spinal cord. Thus, atrophj 7 of the optic nerve is one of the early symptoms in some cases of tabes. Many cases are due to multiple sclerosis, exophthalmic goiter, cerebral syphilis, pro- gressive paralysis, syringomyelia, amyotrophic lateral sclerosis, degenerative changes, and various mental diseases. Ocular Muscles. Affections of the ocular muscles may be due to many causes. Thus, there may be over-development or under-development of the muscle itself, so-called structural squint or heterophoria ; or there may be faulty insertion of the tendon of the muscle, so-called insertional squint or heterophoria. Finally, there may be paresis or spasm of a muscle due to an affection of its nerve or nerve nucleus, so-called innervational anomalies, paretic and spastic squint or heterophoria. Syphilis, especially tertiary syphilis, plays a prominent role in the etiology of the cases due to paresis of muscle. Many cases are due to tabes. Other causes are meningitis, tuberculous meningitis, pachymeningitis, tumors of the brain and skull, abscess of the brain, hemorrhages in the brain, exposure to cold ("rheumatic" paralysis), trauma- tism, and hysteria. More rarely cases are due to diphtheria, Diagnosis op Syphilis. 287 diabetes, influenza, whooping-cough, various poisons, and slight impairment is sometimes observed in neurasthenia. Among the causes of muscular spasm are irritative lesions, such as are caused by meningitis ; chorea, epilepsy, and hysteria. Spasm is less frequent than paresis. Sometimes the cause may not be apparent, when the cases are classed as idiopathic. The antagonist of a paralyzed muscle is prone to show spasm sooner or later. The symptoms of muscular over-action and under-action are: 1. Limitation or excess of movement of affected eye in some direction. 2. Diplopia. 3. False projection of objects seen with the affected eye. 4. Apparent movement of objects when patient approaches them. 5. Vertigo. 6. Altered position of head in attempt to overcome diplopia. 7. Mydriasis and 8. Paralysis of accommodation, in ophthalmoplegia interna. 9. Ptosis (with 7 and 8) in complete oculomotor paralysis. Organs of Hearing. We have already referred to the central changes that may cause alterations in hearing, so that we will consider here chiefly the changes in the ears. The ears are rarely affected by chancre, though isolated cases of primary infection of the ears have been reported, the infection being carried by a towel, a bite, a kiss, or by the Eustachian catheter. The second, or irritative, stage of syphilis is represented on the external ear by macules, papules and pustules, as is true of the skin in general. Such affection of the ear usually indicates a neglected case. Exceptionally papules may occur in the external auditory canal in cases with only moderate develop- ment of syphilides over the body. Such papules may greatly 288 Diagnosis op Syphilis. interfere with hearing when they obstruct the canal ; a wide canal is not so likely to be occluded. Papules may also occur upon the drum membrane ; in such cases roaring in the ear is a prominent symptom. Under proper treatment all of these cases usually result in recovery without loss of hearing. Ulcerative papules in the canal may lead to loss of the little hairs and the formation of flat or depressed cicatrices, but their course is usually favorable. Gummata of the external ear are comparatively rare, though gummatous ulcerations and gummatous infiltrations with subse- quent atrophy and contraction of the cartilages have been observed. A gummatous ulceration of the external canal that led to circular contraction, has been reported. Syphilis may involve the middle ear. usually in cases show- ing a syphilitic pharyngitis and rhinitis. Syphilides or gum- mata may occlude the Eustachian tube at the ostium pharyngeum, and subsequent cicatricial contraction often causes permanent loss of hearing. Otitis media may occur independently or through tubal transmission of the inflammation. The inflam- mation is often purulent, the membrana tympani becomes cloudy and possibly is perforated. During this process there is ring- ing in the ear. but often there is no special pain. There is lowered bone conduction in complicating diseases of the laby- rinth. Syphilis of the ear may lead to caries and necrosis of the tympanic cavity, the mastoid process and the petrous por- tion of the temporal bone. Such cases ma} - result fatally. Syphilis of the internal ear (the auditory nerve and the labyrinth) occurs during the first two years and sometimes later. In these cases deafness develops either suddenly or grad- ually, and as a rule is permanent. However, in some cases im- provement of the deafness occurs, though the improvement is usually only temporary. Affection of the labyrinth in syphilitics sometimes seems to follow "catching cold." There is diminution of bone conduc- tion, and there is lessened perception of the high tones. The hearing is suddenly destroyed permanently. Inflammation of the interna] ear causes noises in the ear, attacks of vertigo, and Diagnosis of Syphilis. 289 disturbances of equilibrium. Though one ear seems most af- fected, the process usually involves both ears. All in all, affection of the labyrinth is rare compared with the frequency of syphilis. Most of the cases present catarrhal or purulent otitis that probably act as predisposing factors, though these, too, may be due to syphilis. Affection of the internal ear has been observed in hereditary syphilis from the eighth to the twentieth year, most frequently in the female (three to five times). Such cases usually show interstitial keratitis, though cases of keratitis are often observed that show no affection of the ear. Thus, of Hutchinson's one hundred and two cases of syphilitic keratitis, only fifteen showed deafness. In the disturbances of hearing due to basilar meningitis, there is usually also paresis of other cerebral nerves. Such cases may show hallucinations of hearing. In a case reported by Lang, there was a weak memory, diabetes insipidus, and a lowered hearing power on one side, sometimes amounting to absolute deafness, due to a nodular syphilide. In making a diagnosis of syphilis of the ear, it must be remembered that various parts of the ear may be affected by syphilis in the same individual. Thus, syphilis of the external ear may be associated with syphilis of the middle ear, and syph- ilis of the middle ear may complicate syphilis of the internal ear, and occasionally disturbance of hearing may be due to central affection. Organs of Smell. We have already referred to the alterations of the sense of smell due to central disease, especially basal meningitis. The sense of smell may be altered also through affection of the olfac- tory nerves. Rhinitis syphilitica also causes changes in the sense of smell. This has already been discussed. 290 Diagnosis of Syphilis. Organs of Taste. There are many causes of alterations of taste. Syphilis of the tongue or palate may disturb especially the finer distinctions of taste. Intensely interesting, from a diagnostic standpoint, are those cases in which alterations of taste have apparently depended upon central disease. Syphilitic involvement of the glossopharyngeal or the fibres of the chorda ma} 7 affect the taste. Loss of taste has been observed in neuralgia of the third branch of the trigeminus twenty years after syphilitic infection, in which a cure was effected with iodide of potassium. Diagnosis op Syphilis. 291 Conclusions. 1. The diagnosis of syphilis is not always easy. 2. There are numerous combinations of signs and symp- toms that are characteristic of syphilis. 3. The therapeutic test for syphilis is not always reliable, (a) Other diseases sometimes respond to the use of anti-syphil- itic remedies in the absence of syphilis, (b) Some of the mani- festations of syphilis respond very slowly or not at all to the use of the anti-syphilitics. 4. A syphilitic is not exempt from other diseases. 5. Syphilis presents so many and such varied manifesta- tions that it is well to think of this disease when making a diag- nosis in obscure cases. 6. We should not be unduly influenced by the social status of our patient. Syphilis and virtue are not incompatible. 7. The old saying "once a syphilitic always a syphilitic," should not be taken too seriously. There is probably no chronic disease more genuinely amenable to treatment than syphilis. But the fact of its curability does not abrogate our dread of this most infamous disease. 8. The spirochete pallida and the Wassermann reaction are positive evidences of syphilis. In this connection we must bear in mind that syphilitics do not enjoy any immunity from non- syphilitic affections. Furthermore, the spirochete pallida is often difficult to find, especially late in the course of syphilis. And the Wassermann reaction may be absent, especially when the patient has been subjected to vigorous anti-syphilitic treat- ment. 9. Parasyphilis is a term that should never be used, at least in its old significance. Cases are either syphilitic or non- syphilitic. Later researches may possibly reveal a use of the term analogous to the use of paratyphoid in relation to true typhoid infection. But the old use of parasyphilis should be discontinued, since the recognition of the spirochete and the development of the serum reaction enable the diagnosis to be made with greater accuracy than formerly: RECENT BIBLIOGRAPHY BEARING ON THE DIAGNOSIS OF SYPHILIS. Aboulker, C. — Gommea syphilitiques de la langue et de la face, avee osteo-arthropathie specifique des deux genoux — Bull. med. de l'Algiere, Alger, 1905, xvi, 371. Abt, I. A. — Congenital syphilis in infants — Interstate M. J., St. Louis, 1909, xvi, 259. Abt, I. A. — Congenital syphilis (Abstr) — Illinois M. J., Spring- field, 1909, xv, 405-406. Aeliard— Syphilis viscerale, avec ophtalmoplegie double — Bull, med., Paris, 1906, xx, 323-326. Adamson, H. G. — Inherited syphilis —Rep. Soc. Study Dis. Child, Lond., 1908, viii, 93-107. Adamson, H. G. — On eruptions of the napkin region in infants, with especial reference to the diagnosis of the eruptions of congenital syphilis from cer- tain non-specific napkin-area eruptions of common occur- rence^ — -Brit. J. Child. Dis., Lond., 1908, v, 13-24. Aitkin, C. J. H. — Late manifesta- tions of congenital syphilis — Transvaal, M. J., Johannesburg, 1907-8, iii, 310. Albanns, G. A. — Fever following syphilis — Vrach., S. Petersb., 1908, vii, 12-14. Albarel — Le testicule pathologique dans Rabelais — Chron. med., Paris, 1905, xii, 593. Alessandrello, G. — Sifilosclerosi in- iziale del labbro inferiors od epitelioma u 1 c e r a t o — Gior. med. d. r. esercito, Roma, 1907, lv, 511-515. 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Antonelli, A. — Frequence et me- canisme pathogenique du stra- bisme chez les heredo-syph- ilitiques — Ann. d. mal ven., Paris, 1907. ii. 81-92. Antonelli et Bonnard — Stigmates oculaires et stigmates dentaires d'hercdo-syphilis: a forme com- plexe et rare — Ann. d. mal. ven., Paris, 1908, iii. 343-351, incl. 2 pi. Antonelli — Pathologie naso-lacry- male dans la syphilis heredi- taire — Arch, d'ophth., Paris, 1909, xxiv, 599-608. Apert, E. — Syphilis pulmonaire chez une fillette de 13 ans; gomme volumineuse ramoille occupant tout le lobe inferieur du pou- mon droit et s'accompagnant de pleurisie sero-fibrineuse syphilis du rein et de la rate — Bull. Soc. de pediat.. Paris, 1905, vii, 128-135. Apert — Heredosyphilis du poumon droit — Bull. Soc. de pediat de Paris, 1908, xi, 254-262. Apert E., Levy-Fraenkel et Menard — Tabes et paralysie generale ju- veniles par paralysie acquise tabes de la mere; tabes et paralysie generale du pere — Bull. Soc. de pediat., Paris, 19(17, ix, 331-338. ApostololT, V. L. — Gangrenous syph- ilitic ulcer in a tubercular pa- tient — Kharkov M. J., 1906, i, 131-1HS. Aianjo, G. — Chancre sifilitico de la una de origen professional — Rev. sanmil. v med. mil. espan., Madrid, 111117'. i. 234. Archer e Silva — Sobre a spirochete pallida dc Schaudinn in syph- ilis experimental — Med. con- temp., Lisb.. 1906, xxiv, 20. Ardin-Delteil — Coma syphilitique recidivant — Bull. med. de l'Al- gerie, Alger, 1908, xix, 649-652. Aristoff — Hard chancre of the right tonsil; diphtheroid and vario- loid course of syphilis — Med. pribav. k. morsk. sborniku, St. Petersb., 1905, 138-143. Arloing, F. — Ophthalmoreaction ft la tuberculine dans qualques cas de Byphilis — Bull. Soc. de med. d. hop. de Lyon, 1907. vi, 364- 368. Arloing. F. — Ophthalmoreaction ft la tuberculine dans quelqueg cas de syphilis — Lyon med., 1908, ex.. 117-100. Armand-Delille. P. et Blechamnn — Volumineuse splenomegalie avec reaction lymphoide et anemie metaplastique chez un nour- risson probablement syphilitique — Ann. de med. et chir. inf., Paris. 1907, xi. 480. Armand-Delille. P. F. — Heredo- syphilis niungolisme et malfor- mation^ eardiaques congenitales ehez un nourrisons — Bull. Soc. de pediat. de Paris. 1908, x. 144-148. Recent Bibliography. 295 Armand-Delille, P. F. — Heredo-syph- ilis monogisme et malforma- tions cardiaques congenitales chez un nourrisson — Ann. de med. et chir. inf., Paris, 1908, xii, 474-476. Armstrong, J. M. — The etiology of syphilis— St. Paul M. J., St. Paul, Minn., 1906, viii, 439-456. Arnheim, G. — Kulturversuche der spirochaeta pallida — Dermat. Centralbl., Leipz, 1909, xii, 290- 294. Arning, E. — Farbung der spirochsete pallida — Deutsche med. Woch., Leipz. u. Berl., 1907, xxxiii, 1027. Arning, E. u. Klein, C. — Die prak- tische durchfiihrung des naeh- weises der spirochaeta pallida im grossen krankenhausbetrieb — Deutsche med. Wchnschr., Leipz. u. Berl., 1907, 1482-1487. Aronstan, N. E. — The diagnosis of syphilis — Centr. States M. Monit., Indianap., 1905, viii, 257. Aronstan, !N. E. — A contribution to the study of the prognosis of syphilis — Am. J. Dermat and Genito-Urin. Dis., St. Louis, 1905, ix, 51. Arthur, R. — The mimicry of syphilis — Australas. M. Gaz., Sydney, 1908, xxvii, 132. Arquellada. A. M. — Estudio de la heredo-sifilis del rechen nacido y de las formas hereditaris precoz y tardia — An. de la Acad, de obst., Madrid, 1909, ii, 350-364. Arquellada, A. M. — Estudio de la heredosifilis del recien nacido y de las formas hereditaria pre- coz y tardia — Rev. espan. de dermat. y sif., 1909, xi, 336-351. Arruga, H. — El problema de la sifilis — Gae. med. catal., Barcel., 1909, xxxv, 201, 245. Ashhurst, A. P. C. — A case of syph- ilitic dactylitis of the toe — J. Am. M. Ass., Chicago, 1906, xlvi, 584. Ashi, K. — A rare case of hereditary syphilis — Hifukwa kin Hinjo- k'ikwa Zasshi, Tokyo, 1907, vii, 450-452. Ashmead, A. S. — Relation of syph- ilis with Japanese racial pecu- liarities and customs — Am. J. Dermat. and Genito-Urin. Dis., St. Louis, 1906, x, 279-285. Ashmead, A. S. — Syphilis in rela- tion to crime — J. Cutan. Dis. incl. Syph., N. Y., 1906, xxiv, 571. Ashmead, A. S. — On the supposi- tious relationship of crime with syphilis — Am. J. Dermat. and Genito-Urin. Dis., St. Louis, 1908, xii, 384-387. Ashmead, A. S. — Some observations on certain pathological ques- tions concerning the mutilation represented on the anthropo- morphous Huacos pottery of old Peru— N. York M. J., 1909, xe, 857-861. Ashmead, A. S. — The question of a relationship between "syphili- tic" llamas of the department of Puno, Peru, and pre-Colum- bian syphilis in man — Am. Med., Burlington, Vt., and N. Y., 1909, ns. iv, 35-37. Ashmead, A. 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