Syphilis

syphilis. An infectious disease spread by inoculation thru sexual intercourse; also possible by contamination thru table utensils, towel, pipes, etc.

Syphilis of Bone. The lesions produced in bones by syphilitic infection may be congenital or acquired, and, as in other syphilitic lesions, the manifestations may be protean.

Most children with congenital syphilis, show an irregularity of the epiphyseal line, which results in the latter becoming markedly toothed, instead of constituting a straight line across the bone, at right angles to the long axis of the shaft.

Besides the irregularity of the epiphyseal line, three other changes are seen in the bones of syphilitic infection. The most common lesion is one which affects the periosteum and leads to the formation of periosteal bone. This periosteal formation may occur either in congenital or in acquired syphilis, and it may affect one or many bones. In some cases there is an enormous thickening of the epiphysis of the bones, and as a result of the epiphyseal thickening, secondary changes in the joints occur, so that the thickening of bones and the changes in the facets of the joints, suggest fracture or dislocation. In other cases, the thickening affects only the shafts of the long bones, generally of the leg or arm, although no bones are exempt. In some cases, both in the congenital and acquired forms, there may be marked proliferation of the endosteum of the bone, with or without thickening of the periosteum, although thickening of the periosteum usually is present. This process, as a rule, affects one bone in its entirety, and most commonly affects the bones of the lower leg, notably the tibia. As a result of these changes the bones are enlarged and thickened, and in some cases, from endosteal thickening, the marrow canal is very largely or entirely obliterated. In some cases true gummata of the bone are formed. These gummata may appear in the spongy portion of the bone, sometimes in the shaft, or in the epiphysis. They also appear to be formed in the lower layers of the periosteum and lead to circumscribed nodular thickenings on the surface of the bone.

Symptoms. These vary with the different pathologic conditions present. The periosteal thickening may occur at any time of life over any bone of the body.

The presence of circumscribed periosteal thickening of bone in itself should always lead to the suspicion of the presence of syphilis.

Pain, as a rule, is only very slight, and the diagnosis depends upon the history and the detection of other syphilitic lesions.

The cases in which there is both endosteal and periosteal thickening, occur chiefly in children and are of a congenital nature.

The physical symptoms are very characteristic. The bone usually affected is the tibia, which is enlarged to a most marked degree, and often shows a pronounced bowing forward, similar to the bowing and thickening of the tibia seen in osteitis deformans. The bone is extremely dense and obviously heavier than normal. The bones are moderately tender to pressure, but have nothing like the extreme tenderness noted on pressure in osteomyelitic bones.

In cases of gummata of bones the symptoms vary. In some cases the gummata are on the surface of the bone, especially the sternum, and at times on the long bones. In such cases there appear a softening and reddening of the skin about the affected area, which remains indolent for a long time.

If such an area opens spontaneously, or is opened by incision, the contents are seen to be composed of a yellow, rather gelatinous material, quite like the caseous material from a tuberculous abscess.

Treatment. In most cases the regular anti-syphilitic treatment is indicated. In cases of periosteal thickening, the results vary with the time at which the treatment is begun. In the early cases, a thorough anti-syphilitic treatment may lead, after a varying length of time, to complete disappearance of the newly formed periosteal bone. On the other hand, if the periosteal process has lasted for a long time and the bone has become densely cortical, although anti-syphilitic treatment may lead to a diminution of the localized pain, the dense bone does not disappear. In cases of combined endosteal and periosteal thickening, the pain usually disappears under anti-syphilitic treatment but the changes in the bone persist.

Syphilis  is a chronic, infectious, and sometimes hereditary, constitutional disease. Its first lesion is an infecting area or chancre, which is followed by lymphatic enlargements; eruptions upon the skin and mucous membranes; affections of the appendages of the skin, (hair and nails); chronic inflammation and infiltration of the cellulo-vascular tissue, bones and periosteum, and later, often by gummata. This disease is caused by a microorganism known as the spirochaeta pallida  or treponema pallidum  of Schaudinn and Hoffmann.

Transmission of Syphilis. This disease can be transmitted (a ), by contact with the tissue-elements or virus acquired syphilis, and (b ), by hereditary transmission, hereditary syphilis.

The poison cannot enter through an intact epidermis or epithelial layer; an abrasion or solution of continuity is requisite for infection.

Syphilis is usually, but not always, a venereal disease. It may be caught by infection of the genitals during coition; by infection of the tongue or lips in kissing; by the use of an infected towel on an abraded surface; by smoking poisoned pipes, and by drinking out of infected vessels.

The initial lesion of syphilis may be found on the finger, penis, eyelid, lip, tongue, cheek, palate, nipple, etc. Syphilis can be transmitted by vaccination with human lymph which contains the pus of a syphilitic eruption or the blood of a syphilitic person. Syphilis is divided into three stages (1) the primary stage—chancre and indolent bubo; (2) the secondary stage—disease of the upper layer of the skin and mucous membranes, and (3) the tertiary stage—affections of connective tissues, bones, fibrous and serous membranes, and parenchymatous organs.

Syphilitic Periods. (1) period of primary incubation—the time between exposure and the appearance of the chancre, from ten to ninety days, the average time being three weeks; (2) period of primary symptoms—chancre and bubo of adjacent lymph glands; (3) period of secondary incubation—the time between the appearance of the chancre and the advent of secondary symptoms,—about six weeks as a rule; (4) period of secondary symptoms—lasting from one to three years; (5) intermediate period—there may be no symptoms or there may be light symptoms which are less symmetrical and more general than those of the secondary period; it lasts from two to four years, and ends in recovery or tertiary syphilis; and (6) period of tertiary symptoms—indefinite in duration; the fifth and sixth may never occur, the disease being cured.

Primary Syphilis. The primary stage comprises the chancre or infecting sore or bubo. A chancre or initial lesion is an infective granuloma resulting from the poison of syphilis. The chancre appears at the point of inoculation, and is the first lesion of the disease. During the three weeks or more requisite to develop a chancre the poison is continuously entering the system, and when the chancre develops, the system already contains a large amount of poison.

A chancre is not a local lesion from which syphilis springs, but is a local manifestation of an existing constitutional disease, hence excision is entirely useless. The hard chancre, or initial lesion, never appears before the tenth day after exposure, it may not appear for weeks, but it usually arises in about twenty-one days. The lesion commonly appears as a round, indurated, cartilaginous area with an elevated edge, which ulcerates, exposing a velvety surface looking like raw ham; it bleeds easily, rarely suppurates, does not spread, and the discharge is thin and watery.

The bubo of syphilis is multiple, consisting of a chain of glands, freely movable, indurated, painless, small and slow in growth, and the skin over the bubo is normal.

A positive diagnosis of syphilis can be made when an indurated sore is followed by multiple indolent glands or buboes in the groin and by the enlargement of distant glands.

Secondary Glands. The symptoms are noticed from four to six weeks after the stage of the induration of the chancre, and may continue to appear at any time, up to twelve months. The most constant are certain eruptions on the skin, faucial inflammation, and enlargement or induration of the lymphatic glands; others are febrile reaction, pains in the back or limbs, swelling of the joints, iritis and falling out of the hair.

Tertiary Syphilis. These symptoms appear from one to two years after contagion and may continue to break out from ten to fifteen years, or more. The characteristic lesions are certain late eruptions on the skin, periostitis and nodes on the bones, and growths in the subcutaneous tissue, muscle, and viscera, especially the liver and spleen. These growths, in the viscera and other parts, which are so characteristic of syphilis in its later stages, are known as gummata. They consist of a substance like granulation tissue, with a varying proportion of cells. In early stages they are grayish, gelatinous, and transparent, but the cells undergo fatty change and caseation takes place, so that the centre becomes yellow, and the circumference develops into fibrous tissue, which contracts like a scar tissue. Sometimes gummata break down completely, and suppuration, with destruction of the tissues in which they are situated, takes place; thus caries and necrosis not infrequently follow nodes on the bones.

Treatment. Mercury is the drug of great benefit in syphilis. This can be administered either internally, by inunction, or by injection. Of all the preparations to be given internally, protiodide of mercury, in one quarter grain doses, three times a day, is to be preferred.

Inunction  represents the most efficient way of administering the mercurial treatment, when the stomach is intolerant of drugs, or when administered by the mouth in full doses, they do not favorably modify the symptoms. The patient is instructed to take a warm bath, and the mercury is then well rubbed in over the inner surface of the forearm and arm and alongside of the chest for fifteen minutes. Either the oleate of mercury, 10 per cent., or the ordinary mercury ointment is commonly employed; the former is more clean, but less efficient. The rubbings should be done by the patient, should be made over a large surface of the body, and should be performed thoroughly; one dram (4.0) of blue ointment is rubbed in daily. For the injections, a 10 per cent. salicylate of mercury in olive oil is to be preferred; 10 to 15 minums of this solution is to be injected into the buttocks, three times a week. The dose is gradually to be increased until 30 drops are employed. Recently salvarsan (606) in 0.6, or 10 grain doses is given either intravenously or intraspinally. Neosalvarsan (914) is to be similarly given. The latter has the advantage in that sterile water is used, and that, as a rule, there is no reaction from its injection. Iodide of potassium in large doses (60 to 90 grains) three times a day, is also to be given.