The various manifestations of syphilis on the skin, or syphilides, as they are commonly called, present different types and degrees of severity, and involve the skin either superficially or deeply. We may, however, classify them to a certain extent, and in doing so will find that they partake of one or the other of the following characters, namely : macular, papular, tubercular, pustular, squamous, bullous, and gummatous, together with ulceration, occurring with, or following, any of the five types last mentioned.
The appearance of the first cutaneous eruption ushers in what is termed the secondary period of the disease.
As a rule, the first eruption is macular, and consists of small, rosy points or spots usually called syphilitic roseola. These present little or no elevation, and disappear under pressure, showing that they are little mote than points of congestion. They usually pass away within a few weeks, with or without treatment. They are chiefly met with on the trunk and extremities.
Another and much rarer macular lesion is the pigmentary syphilide, which appears as dark-colored spots on the neck, and almost wholly confined to young females. After a time a portion of the pigmentary deposit fades away, producing a somewhat characteristic appearance some what resembling vitiligo.
After the macules of syphilis have disappeared, or even before they are quite gone, a generalized eruption of papules may appear. These are solid elevations, and not unfrequently present minutes scales at their apices. Should the patient be broken in health, a tendency to pustulation and ulceration may be developed; and we may have the papules becoming purulent at their summits, or we may have a frankly pustular eruption from the outset. As the disease progresses there is a tendency to deeper involvement of the integument and larger size of the lesions, so the papules are not uncommonly followed by tubercles, not perhaps as numerous as the papules, but still freely distributed over the entire surface. These not infrequently undergo ulceration and become covered with greenish-black crust.
In addition to the foregoing, we may have the appearance of reddish and not greatly elevated patches, covered with white scabs, constituting the so-called squamous syphilide. These various manifestations may occupy a year or more in their evolution, l and embrace the secondary period of the disease. After the disappearance of these various eruptions, there is not infrequently a decided halt in the progress of the disease, and the patient may go on for a considerable period, for years even, without a fresh outbreak. When it does come, however, it ushers in what is known as the tertiary stage of the disease.
In the tertiary period of syphilis the eruption are usually of a tubercular or ulcerative character, and, instead of being generally and somewhat evenly distributed over the surface, they are usually collected into groups; for instance, half a doze or more tubercles may form a group or patch, and there may be one or several such patches. As a rule, the number of patches is limited. The individual lesions sometimes disappear by absorption, but very frequently undergo ulceration, and in either case leave indelible scars. In this stage of syphilis we meet with the lesions known as the gumma. It consists of a small tumor, which usually undergoes softening throughout its entire substance, and terminates by ulceration. This lesion is not confined to the skin, but may involve almost any organ of the body.
Concomitants of Syphilis.- The disease we are describing does not vent its entire energy upon the skin, but early in its history it exhibits its presence on the mucous membranes by the development of rather large, flattish tubercles in the mouth and about the genital organs and around the anus. It is in females especially that the mucous patch or condyloma reaches its highest development.
Early in the disease, too, the hair may fall out, so that an almost complete alopecia of the scalp may occur before it is checked by treatment. This early alopecia, however, is not permanent, as the hair begins to grow again as soon as the patient is brought under the influence of proper constitutional treatment. During this period, also, inflammation of the iris is a not infrequent complication.
Ulcerations, more or less extensive, of the soft palate and tonsils, may supervene among the early or late symptoms of the disease.
In the tertiary period painful swellings are met with along the course of the long bones, especially the tibia and in the flat bones of the skull. These nodes, as they are called, are due to an inflammatory deposit beneath the periosteum, which is usually accompanied with considerable pain, worse at night. The gummy deposit, separates the periosteum from the bone, and, by depriving the bone-tissue of its proper nourishment, produces necrosis.
An interesting case is reported of ulcerating gummata of the scalp scalp forty-four years after infection, as occurring in a man aged 63, who contracted syphilis when between eighteen and twenty years of age. Typical syphilides followed, relapsed a number of times and finally disappeared without treatment. When he was twenty-four years (about five years after infection) he married. His wife miscarried once, but remained healthy, dying at sixty. His eldest son developed psoriasis palmaris when seven years old again when eighteen, which was caused by anti- syphilitic treatment; in other respects, as well as his younger sister, remained well. The patient himself was affected by herpes zoster in 1878. In 1886 a gumma appeared on the left parietal bone, which ulcerated and exposed the bone and caused necrosis. Gradually the bone was cast off, and necrosis of the diploe appeared. As, however, demarcation proceeded slowly and symptoms of pressure on the brain set in, trephining was decided upon, which exposed a collection of pus under the necrosed bone. Improvement set in on anti-syphilitic remedies. Soon, however, an attack occurred during which he lost consciousness; then the functions of the brain became disturbed, intelligence gradually waned, oedema of the extremities set in, new gummata appeared on the scalp, and the patient died. Post-mortem there were found thrombosis of the iliacs, caries and necrosis of the left parietal bone, thickening of the meninges, beneath it, but no pathological changes in the brain.
The ulcerations of syphilis are somewhat peculiar, and, once seen, can hardly be mistaken afterward. They are usually round, and with clean-cut margins, as if punched out, differing in this respect from the overhanging walls of scrofulous ulcers, or the sloping margins of the simple variety.
Late in the disease, and among the tertiary group of symptoms, we meet with a peculiar deformity of the phalanges, commonly known as dactylitis syphilitica, the appearance of which is so peculiar and characteristic that is should not be mistaken for anything else. This lesion is rare, however, and perhaps unknown to many physicians and the illustration best shows its characteristic features.
Necrosis of the nasal and palatal bones may occur late in the disease.
Syphilis is an all-pervading disease, and may involve the viscera as well as the more superficial organs. The liver, kidneys, lungs, brain. spinal cord, etc., may become the seat of gummy tumors, which, according to their location and size, may do more or less damage, even to the extinction of life.
Dr. Marchiafava thus describes the lesions found by him in the kidney in two cases of hereditary syphilis. “The organs were of normal size, but the cortical substances was of a grayish color, and dotted with minute whitish nodules, corresponding to the glomeruli. Under the microscope, the lesions were seen to proceed from a diffuse arteritis of the glomerular and afferent vessels. The arteries were contracted, and finally obliterated, and became converted into a hyaline mass. The vascular loops of the glomeruli were thus destroyed, as was also, at a later period, the epithelium of the convoluted tubules which derives its nourishment from the afferent vessels.”
Dr. Ingram has observed, in twelve cases of congenital syphilis, concentric enlargement of the wrists. This enlargement has more the appearance as if two fine sil ligatures had been tied around the wrist immediately above the joint, the strands being placed about half an inch apart and tied tight enough to hide themselves in the flesh. To the touch they have all the dense hard feeling that callus does when thrown about a fracture.
Etiology.- The original first cause of syphilis is unknown. We know, however, that at the present time it is propagated from one to the other by contact. The blood and the secretions from early syphilitic lesions are the medium of contagion, and the contact of these with an abrasion of the skin or with an even unabraded mucous surface is sufficient to transfer the disease. Whether a bacillus is an accidental or an essential feature of the process may as yet be considered unsettled.
