Subjective Symptoms – A marked negative feature of the syphilids is the absence of pain or itching during their entire course. In fact, the patients may be unaware of their existence until they are accidentally seen. However, the lesions may rarely be sensitive and painful if the process is unusually acute or they are subjected to external irritation. Itching may be present in the warm or moist regions of the skin, especially if an eczematous condition coexists.
Concomitant Symptoms – In the primary stage a chancre may be seen or its mark or scar may be noted and a train of constitutional disturbances, varying in intensity, may appear toward the end of the primary or the onset of the secondary period. These include general adenopathy, sore throat with mucous patches or superficial ulcers in the mouth and pharynx, iritis, headache, bone pains, moderate fever reaching 100* to 101* F in the evening, lassitude, general anemia, alopecia, onychia and paronychia. It is rare, however, that all of these symptoms are observed in one case. Frequently, only one or two will be noted. In the third period, accompanying symptoms may be wholly absent although scars, the effects of iritis, together with bone pains, alopecia, leucoplakin and superficial glossitis may be present.
Syphilitic alopecia may be more or less general in the secondary period, due probably to the changed condition of the blood and consequent deficient nutrition of the hair. This early loss of hair may occur in the third month or later and usually consists of a general though irregular thinning of the hair on the head, thinning or notching of the eyebrows, eyelashes, mustache and beard, and sometimes of the pubic and axillary regions. The loss of hair may be very moderate or pronounced and, in aggravated cases, may be nearly or quite complete over the whole body. Occasionally the hair falls out in patches resembling alopecia areata or at the site of lesions involving the follicles. Early alopecia from syphilis may be aggravated by a coexisting seborrhea and tend to be more persistent but usually the loss of hair is temporary and is more restored spontaneously or by specific treatment within six months. In the tertiary period localized permanent baldness may result from destructive lesions, whether they end in absorption or ulceration. The remaining hair in case of advanced syphilis is apt to be dry and harsh. The irregular and incomplete nature of the alopecia and the notched eyebrow is always suggestive of syphilis. The more distinct patchy variety may be distinguished from the round or oval patches of alopecia areata by their irregular shape, tendency to be symmetrical and the presence of other signs of syphilis. The localized and permanent forms of alopecia due to the destructive lesions of late syphilis may be differentiated from circumscribed baldness due to lupus, favus, chronic eczema, etc., by the clinical history and the quality of the cicatrices.
Fig. 150 – Syphilitic alopecia, showing a general but irregular thinning of the hair.
Syphilitic involvement of the nails may differ little from that caused by chronic psoriasis or eczema, and may lead to similar atrophic or hypertrophic changes, for a description of which the reader is referred to the section on diseases of the nails. They occur generally in the secondary period but may appear later. One nail only may be attacked or several at the same time, or more often successively. Onychia more commonly affects the nails of the hands and runs a mild course. Perionychia attacks the fingers and toes about equally, but those exposed to injury from use or accident are more liable. It may be acute in process and chronic in course and, in the ulcerative form, may destroy more or less completely the matrix and other parts of the nails. When the ulceration is confined to the sides or the free part of the nail a regrowth of a perfect nail may be expected and even prolonged ulceration of the base may not prevent the regeneration of a fairly good nail. Considerable pain and annoyance may attend ulcerative perionychia and the outcome is always uncertain; non- ulcerative forms give little trouble and are easily cured. A history of syphilis and the presence of existing lesions should distinguish a syphilitic affection of the nails from conditions due to eczema or psoriasis.
Laboratory Diagnosis – A positive diagnosis of syphilis is established by finding the spirocheta pallida. “It is easy,” says Schaudinn, “after a certain amount of diligence, to differentiate the treponema pallidum from other types of spirochetas in fresh preparations. the fineness and feeble refractibility of this spirochete, the constant, close, deep and regular character of its spirals, which are numerous (10 to 20), render it impossible to confuse it with other microorganisms of the same type. Its chief characteristic, however, lies in the fact that it retains its spiral arrangement not only during motion but also in the state of rest while the spirals of most other spirochetes disappear when they are in a condition of repose.” There are on the market condensers, adjustable to the best makes of microscopes that converge the light obliquely on the specimen. By means of such condensers the spirochetes appear as bright refractive bodies on a dark background and are readily recognized by their regular and closely set spirals. Serum from the margin of chancres or secondary lesions is the best material in which to look for spirochetes.
When it is impossible to diagnose syphilis by finding the spirocheta pallida or by a clear clinical history, the Wassermann reaction affords a reliable diagnostic test as well as a therapeutic index. This biologic test was introduced by Wassermann, Neisser and Bruck in May, 1906. It is based upon the well-known principle of the power of the serum of one animal to dissolve the red corpuscles in the serum of another species. This process is known as hemolysis and is dependent upon three substances: a complement, always present in any blood serum; an anti-body, resulting from the reaction of the injected animal against the injected red blood cells; and an antigen, in this instance the injected blood corpuscles. It is the union of these three elements which constitutes the hemolytic system. If the corpuscles settle at the bottom of the test tube the test is positive (hemolysis restrained), demonstrating the presence of living spirochetes. When the test is negative (hemolysis), the fluid in the tube is diffusely stained with free hemoglobin and it is presumptive, but not absolute, evidence of the absence of syphilis.
Positive reactions have been obtained in other diseases than syphilis, such as yaws, scarlet fever, malaria, leprosy and pellagra. Numerous modifications of the original test, notably that of Noguchi, have been evolved and, inasmuch as they simplify the technic and make the procedure more certain, it may be expected eventually that this test will become a more reliable diagnostic method. Some constitutions react against infections much more forcibly and quickly than others and therefore there is some variance in the time of appearance of the first positive Wassermann in cases of primary syphilis. It has been proven that the ingestion of mercury or a recent alcoholic debauch tends to the production of a negative or partially negative reaction in one that would otherwise be positive. Thus, a negative Wassermann report does not eliminate syphilis if there is a history of recent mercurial or alcoholic ingestion. Appreciating these exceptions, a positive Wassermann may be expected in nearly all cases of secondary syphilis and in a majority of the tertiary cases. Repeated negative Wassermanns indicate the cure of the disease.
Numerous classifications of the syphilids have been proposed but the simplest is, to all intents and purposes, the best and the characteristic forms of the macular, papular, vesicular, pustular, bullous, tubercular, gummatous and pigmentary types with their subdivisions will now be considered. Besides the general diagnostic points already touched upon, a differential diagnosis of these forms from diseases presenting similar lesions will be discussed under their respective headings.
Macular Syphilid (syphilitic roseola; exanthematous syphilid; erythema syphiliticum; erythematous syphilid). – This is the commonest form of the early syphilitic eruptions and occurs in the sixth to eighth week, rarely earlier or later, after the primary sore, and is usually preceded by moderate fever. The eruption occurs as round, oval or irregular, ill-defined, pea- to fingernail- sized macules. At first a bright pink or rose-red disappearing on pressure, in a few days to four weeks they appear bluish, grayish-brown or coppery-colored, little changed by tint, the color being so faint that it is hardly noticeable. Single patches develop in about two days and the whole eruption may be complete in seven to ten days. It occurs earliest and most abundantly over the chest and abdomen, less often upon the upper extremities, neck and back. Rarely, it is widely or generally distributed though it seldom invades the face or the dorsal surface of the hands and feet. The lesions may be few or many, as a rule showing no tendency to become elevated, coalescent, circular or scaly. The eruption lasts for one to four weeks, leaving behind a brownish-gray stain. Relapses sometimes occur during the first year and small circinate lesions may be present in the second or third years, or even later, and prove rebellious to treatment.
American homeopath, he directed several hospitals in New York.
Professor of dermatology.
Served as Lieut. Colonel during the 1st World War.
See his book online: American homeopathy in the world war