Chapter first GENERAL DIAGNOSTIC REMARKS.
1. MASKED SYPHILIS
Secale 206. – General Syphilitic Diagnostic Signs.
We have seen that syphilis, in its secondary period may manifest itself in a thousand different shapes, and in every tissue of the organism, and may even continue to exist, in a latent form after every perceptible sign of the disease has disappeared, and the organism seems to be perfectly free from it. Some extraordinary event, severe injury, and dangerous acute disease, a deeply penetrating emotion, and the like, may again rouse it into action; or, even if it should remain in its latent form, it may be transmitted to the offspring. In the former division of this work, we have shown, very fully and satisfactorily, we imagine, in what forms the syphilitic disease chiefly manifests itself, either in its primary or secondary period; all that remains for us to do on this occasion is, to add some remarks concerning latent or masked syphilis, which, in its primary period, sometimes assumes the form of gonorrhoea, and, in its secondary period, it destitute of every sign of outward manifestation. As regards the first of these two points, we have already, when speaking of the different forms of gonorrhoea (No.16), mentioned the signs by which the symptomatic syphilitic gonorrhoea is distinguished from the simple idiopathic form of this disease, but deem it necessary to revert again to this point, because, in our estimation, nothing can be more hurtful to the patient than that these two kinds of gonorrhoea with each other. With physicians who do not suppress the discharge by means of injections, but treat every case of gonorrhoea with internal remedies, the danger is, of course, much less, since, under such treatment, if the discharge is of a syphilitic nature, other diagnostic signs of the syphilitic character of the disease will not fall to make their appearance, as may have been seen in the cases related in No.174. Nevertheless, it believes every physician to be on his guard in managing a case of gonorrhoea, more particularly when no sign of inflammation seems to be perceptible, and the case belongs in the category of the so- called gonorrhoea torpida. The slighter the pain, the less considerable the discharge, the less marked the inflammatory symptoms, the more this apparent mildness of the disease should be distrusted and the more mindful we should be of the proverb, that “still waters run deep.” Nevertheless, these are not the worst cases, for here the physician will have at least one suspicious symptom that appeals to his watchfulness and care. But what about cases where, after the syphilitic disease has been apparently cured, its root is still so deeply planted in the organism, that the disease is transmitted to the offspring; that the milk of nurse thus tainted often communicates to their nurslings the germs of the most hideous and dangerous forms of the syphilitic plague?
How shall the physician, under such circumstances, proceed, in order to become cognizant of the true condition of his patients; and what answer shall he return to those who inquire of him whether they need not fear any relapses; whether it is safe from them to marry, and whether their children will not be born with any syphilitic taint? If not outward sign of disease is any longer present, it is evident that the diagnosis can no longer rest upon pathological phenomena, but has to be determined by therapeutic means. The question, therefore, will be, whether among the different modes of treatment, by means of which the primary or secondary symptoms of the disease had been removed, there is one which, the virtue of its own inherent essence and fixedness, furnishes satisfactory evidence that the root of the disease has been so completely and unmistakably eradicated from the organism, that it cannot possibly germinate anew, and produce another syphilitic monster. It is well known that the different modes of treatment employed against syphilis only secure a superficial removal of the syphilitic phenomena, and preclude the possibility of a thorough eradication of the syphilitic poison; but, supposing that all signs of syphilis have been removed by the most judicious internal treatment, how do we know that the treatment has been sufficient, and by what evidence is this to be determined? If there is any uncertainty regarding the sufficiency of treatment, by what signs can this uncertainty be cleared up? These are questions that we will now proceed to examine more in detail.
Secale 207. – Evidence of a Sure Cure.
The older French physicians, more specially Louvrier, Lafecteur and Fabre, adopted the theory that the disease must terminate in some crisis, or in critical evacuations, such as ptyalism, sweat, diarrhoea, or a copious flow of urine; they maintained that, wherever such critical evacuations had not taken place, the cure that had apparently been obtained, could not be depended upon. Hence the mercurial cures of former times, that were carried to the worst extremes of ptyalism; and the use of purgatives for the purpose of securing critical evacuations of the poisonous matter by the bowels, in case they did not occur spontaneously during the inunction cure. Other physicians sought to obtain critical eliminations by the use of sudorifics, and others again by acting upon the bladder through diuretics. In spite of such critical evacuations, experience showed that a radical cure of the disease could not more be depended upon than if such evacuations did not take place, and it is therefore questionable whether the syphilitic disease cannot be radically cured without such critical changes being secured. I can point to cases in my own practice, where the first signs of an improvement subsequent to the administration of two half-grain doses of the first centesimal trituration of Mercurius for obstinate or malignant chancres, were attended with a copious flow of urine for two or three days, or where, in other cases, the improvement was initiated with slight febrile movements about dusk, followed by tolerably profuse night-sweats. In one case, where two inflamed buboes were present at the same time, the coincidence of a critical improvement and a profuse night-sweat was so remarkable that in the very night when the sweat broke out the buboes diminished in size to a considerable extent, and the cure could be fairly dated from this change. If a crisis takes place in every cases of cure of the syphilitic disease, it is often so inconsiderable-since the body is not drenched with a barrelful of poison-that most patients, who never watch the symptoms very closely, are not aware of it; at all events, if such critical changes occur subsequently to the exhibition of our small doses, they are not the cause but the consequence of a radical; destruction, and elimination of the virus. Such changes, brought about as it were by a re-awakening of the reactive energies of the organism, do not prove anything in favor of any artificially produced critical evacuations, These so-called crises does not, therefore, furnish sufficient evidence that the disease has been really cured; if produced by the small doses of Homoeopathy, these crises are not sufficiently marked to afford adequate scope for observations; whereas evacuations consequent upon the use of massive quantities of non-specific drugs, have no critical significance whatsoever. It is well-known that in 1788, Hahnemann regarded the supervention of a mercurial fever as an indispensable proof that the virus was properly eliminated; and that even at late as 1816, he held that some perceptible mercurial effects were necessary, in order to secure the perfect reliability of a cure; afterwards, however, he abandoned this ground entirely, and taught that, to constitute a perfect cure, it was sufficient that, after the exclusively-internal use of the smallest possible doses of Mercury, the chancre gradually commenced to become cleansed and to heal spontaneously as it were, without leaving behind a single trace of discoloration of the skin. Indeed, until now, this has remained the safest and most reliable criterion of a radical cure, more particularly if such a change is accompanied by an increased appetite and heightened buoyancy of feeling and a perception of well being, as after a severe and protracted malady. If, after a pretended cure, a hard, uneven, badly colored cicatrix or a dirty, unnatural color of the skin remains behind, and if the general feeling of health is not such as it should be, and always is, after a sever sickness has been radically overcome by proper treatment, we may rest assured that the cure is not reliable, and that every imaginable kind of trouble may remain in store for the poor sufferer.
Secale 208. – Syphilitic Reagents.
But it is not always with such specific remedies that a cure of the venereal phenomena is affected in this rational manner; but, even in such a case, after using for a certain period of time more or less adequate or inadequate means of treatment, the most striking primary or secondary phenomena may disappear, and the disease, as we have seen in No.196, 197, may enter upon the stage of involution of secondary syphilis, and may assume the masked form of which we are here speaking, and where, notwithstanding that every sign of the syphilitic disease has vanished from the sphere of observation, this disease still continues to exist, as it were, in a state of slumber, While the disease exists in this condition, several physicians, in order to become sure what they might have to expect or to fear from it, have proposed the use of certain syphilitic reagents, which when introduced into a body affected with a latent syphilis, compel the disease, in a very short time, to show itself in broad daylight. With this view, Swediaur already directed attention to Iron, other physicians to the Sulphate and Phosphate of Soda. However, the facts which these authors adduce to support their assertions are not sufficient to shed light on the point in dispute, since the result obtained is confined to the well-known phenomenon that, when ulcers, concerning whose mercurial or syphilitic nature there is a doubt, are painted with solutions of the above- mentioned substances, the ulcers very soon show their true nature, the mercurial ulcers healing very soon after the syphilitic, on the contrary, becoming very much aggravated. Without entering upon a critical analysis of this statement, which has been introduced into almost every treatise on Pathology, we content ourselves with pointing out the fact, that we do not require a reagent by means of which mercurial and syphilitic ulcers can be distinguished from each other, but one that shall bring the masked syphilis to light again. The physicians of the naturalistic school have named as such reagents :(1) Sulphur, Phosphorus, and most of the Carbonates; (2) China, Angustura, Cascarilla, and other astringents, etc. As regards Sulphur, and more specially the world renowned Sulphur baths of Axilla Chapelle, we have already expressed our opinion regarding them in No.205; in the same manner we may admit that Phosphorus, the Carbonates and tannin-containing substances, will, by their continued use in excessive quantities, not only cause exanthems, but ulcers of every description; but if one would regard these effects, without any further examination of their diagnostic value and meaning, as signs of a re-awakened syphilis, he would be very much mistaken. Considering how often homoeopathic physicians employ Sulphur, Phosphorus, both kinds of Charcoal, an other similar remedies, with the best success, both for consecutive and secondary syphilitic phenomena, it must be plain to any one how little these purely theoretical conjectures of the Naturalistic School can be depended upon in practice. It is indeed questionable whether masked syphilis can be at all roused form its latent condition by any known substance. I know of but one case from my own practice, where a single dose of Arsenicum, three pellets of the thirtieth attenuation, seemed to have an effect of this kind. It was the case of a body ten years old, whose father, previous to his marriage had caught a chancre on two different occasions, which had been removed with caustics, and with large doses of the Iodide of Potassium internally. The boy’s sister had died of syphilitic pemphigus shortly after birth. In consequence of a slight injure, a sore broke out on the tibia, which soon degenerated into a suspicious, looking, but not yet distinctly-characterized tetter, for which I administered Arsenicum. Three days after exhibiting this remedy, the whole body became covered with a characteristic, syphilitic, lichenoid exanthem. I cannot say that I attach much diagnostic value to this case.
Secale 209. – Suspicious Symptoms.
Strictly speaking, a few suspicious signs might perhaps be pointed out. This was likewise the opinion of the older physicians. Although these signs are not definitely characteristic, and do not even occur in every case of masked syphilis, yet they do manifest themselves in some cases and afterwards confirm their syphilitic character by the fact that, through the operation of certain extra-ordinary causes, they very frequently assume an evident and unmistakable character of constitutional syphilis. Among these signs we number: A certain pale, faintish-white, or dirty-yellow complexion, with an unclean forehead; occasional breaking out of isolated pimples on the hairy scalp or in the whiskers, not itching, but scurfy; emaciation of the features, with dry coryza and crusty nostrils, or discharge of fetid, purulent nasal mucus, without and distinct sign of a regular ozaena syphilitica; moreover, frequent attacks of a slight angina with evening hoarseness, ill-defined redness, and a varicose condition of the vessels; frequent appearance of erosions on the inner surface of the prepuce, without any definite character, soon disappearing again, never itching, and resembling herpes praeputialis; isolated attacks, of bone-pains; scattered appearance of isolated pustules or indurated pimples which are scarcely noticed, and disappear again in a short-time; rhagades on the inside of the joints of the hands or fingers; slight swellings of single bones, scarcely perceptible; lowness of spirits, sadness. These symptoms do not occur simultaneously, but singly, and are generally so mild that they are overlooked by the patient, and that even the physician, unless he should have his suspicion, is disposed, on account of their ill-defined and imperfect development, to regard them as ordinary symptoms of an arthritic, scrofulous, rheumatic, or catarrhal disposition or diathesis, until they finally become more marked, and their true nature can no longer be misapprehended. Many sudden outbreaks of a syphilis that had been forgotten for years, and undoubtedly foreshadowed by such apparently trifling symptoms in the course of years; their true nature remains unknown; but, whenever several of them exist together, the physician will do well to keep his eyes wide open, and to institute careful and cautious inquiries into the past history of the patient’s ailments. However, such inquiries should not be conducted with an anxious mind, nor should such symptoms lead the physician at once to jump at the conclusion that there is a latent syphilitic taint, except the character of each symptom reveals some undoubted analogy with corresponding syphilitic manifestations. In this respect, grave mistakes are committed by many pathological manuals, which present to their credulous readers even haemorrhages, dropsies, gastric ailments, chest and nervous affections, haemorrhages, paralysis of the feet, statement on the neck and chest, occasional glandular swellings, etc., as symptoms of a latent syphilis. Of course, it is possible that all these affections may develop themselves as consensual affections, during the course of very violent venereal diseases where special organs have become involved, of themselves, they cannot be regarded as symptoms of a latent syphilis, for the reason that they do not constitute idiopathic phenomena, either of the primary or secondary period of this disease; on the contrary, belong to an entirely different range of diseases, and, if they occur in the syphilitic disease at all, constitute purely accidental disturbances. A symptoms which, of itself, cannot take upon itself the characteristic appearance of a syphilitic phenomenon, cannot be regarded as a suspicious symptom; a suspicion of this kind can only be properly entertained when several of these symptoms are present, and there is no other disease to which they could be traced as characteristic manifestations. Of far great importance to a correct diagnosis are the symptoms occurring in children including a correct discriminative distinction between mercurial and syphilitic symptoms, on which account we shall consider infantile and mercurial syphilis in two separate articles.
II. INFANTILE SYPHILIS.
Secale 210. – General Symptoms.
We have already stated, in No.186-189, in what manner children may become affected with syphilis: (1) according to some authors, at birth (which we feel disposed to doubt, see No.213), while passing through the vagina and vulva where syphilitic ulcers are seated (syphilis adnata); or, (2) in consequence of one of the parents or both having syphilitic symptoms on the sexual parts at the moment of conception (syphilis congenita); or (3) in consequence of father or mother, although apparently in perfect health, being tainted with latent syphilis (syphilis hereditaria). On this occasion we have directed the reader’s attention to the general symptoms by which hereditary syphilis distinguished form congenital syphilis, as well as from that which is acquired at birth; nevertheless, we deem it advisable to once more present a cursory view of the symptoms which characterize infantile syphilis in either of the above-mentioned forms. In general, these symptoms are no other than the various symptoms that have been described in the preceding chapter as belonging to the primary and secondary forms of the venereal diseases; in the first place, however, some of these symptoms are particularly proper to children, and others assume a somewhat altered form when manifesting themselves on children, be this owing to the greater tenderness of their skins, or to other causes. Usually the mucous membranes are attacked first, next the outer integuments, afterwards the lymphatic glands, and, lastly, the bones; sometimes, however, all these different tissues simultaneously. If the mucous membranes are attacked, we see at their openings on the surface of the body either protopathic or consecutive discharges, ulcers, even true chancres, mucous tubercles, fig-warts, and fungoid growths; in the glandular system we have buboes, enlargements, or swellings of various kinds; and in the osseous system we discover exostoses and caries, which, however, occur less frequently than other derangements. According to the results which Diday and Bertin have obtained through observations continued for a long series of years, there have appeared: (1) chancres and other ulcers about the mouth, on the palate, tongue, shoulder-blades, umbilicus, labia majora, glans and extremities; (2) fig-warts and other vegetations, on the tongue, at the inferior commissure, in the vagina; (2) syphilitic pustules and tubercles on the head, chin, shoulders, chest, abdomen, labia majora, nates, thighs, and legs, arms, fingers, and toes; (4) vesicular eruptions on the neck and legs; (5) swellings and buboes on the head, neck, shoulders; discharge from the nose and vagina.
What deserves special notice in this kind of syphilis is the peculiar expression of all these children form the moment when these syphilitic phenomena first make their appearance. The skin, specially in the face, loses its transparency looks dusky as if painted: the more this tint spreads the more marked it becomes. It is specially striking on the lower half of the forehead, on the nose, eyelids, cheeks; it occurs much less frequently on the more depressed portions of the face, for instance, in the inner canthi, the folds in the cheeks, etc. Even if this peculiar tint does not seem to extend over a large surface, yet the whole skin partakes of it more or less; the child becomes pale, of a yellowish hue, and the skin has a peculiar lack-lustre appearance, by which the syphilitic affection of such children, when seen at the breast, at once betrays itself. Sometimes this yellowish tint is so distinct that the skin seems coverted with liver spots; most generally, however, the tint is not very striking, so that it would scarcely be noticed but for the fact, that it is almost always accompanied by the peculiar lack-lustre appearance of the skin. Usually this tint is preceded by a general pallor, and requires form eight to ten days for its full development.
Secale 211. – Cutaneous Affections.
In the case of syphilitic children, the skin symptoms show themselves first and foremost. Among them we distinguish:
(1) The pemphigus of new-born infants, which we have described in the second division, and which usually breaks out in the palms of the hands, and on the soles of the feet, and consists of vesicles which, surrounded by a violent-red areola, reveal, after bursting, ulceration of the subjacent integuments.
(2) The various pustules and tubercles, appearing either flattened, salient, tubercular, scurfy, ulcerated, or chancrous, the first named of which, the so-called flat or mucous tubercles, mostly break out on the scalp, in the face, on the chin, scrotum, at the margin of the anus, on the thighs, hands, and feet; whereas the ulcerous, phagedaenic tubercles sometimes covers both extremities.
(3) Chancres. These are partly protopathic, partly consecutive, and, in their form, deviate but little from the known kinds; for here, too, they either occur as simple or as indurated, elevated, and phagedaenic chancres. They occur most frequently at the fraenulum of the tongue, on the velum palati, and in the fauces, in the shape of small, round, somewhat prominent vesicles that soon bursts; whereas, if they occur on the inner surface of the cheeks, they appear in the shape of small cracks, and on the hands and feet in the shape of true rhagades; those that break out on the scalp and in the face are phagedaenic, and soon terminate in fatal gangrene.