—With the earliest possible recognition of a syphilitic chancre or sore there is need for active and prolonged constitutional treatment, in addition to whatever may be required locally. If the diagnosis can be made, constitutional treatment should commence at once; only in cases of doubt is it advisable to wait. The local treatment is a matter of ordinarily small importance; the sores tend to heal spontaneously and quickly when the system is brought under the influence of mercurials. There are few authorities who recommend excision of the primary lesion or believe it is possible to abort syphilis by anything that can be done to the chancre. It is advisable to make mild antiseptic applications only. A chancre, however, in a location which makes it difficult to keep the parts clean, should be exposed to treatment by a minor operation, as an incision of the prepuce, circumcision, or a dilatation or incision of the hymen. Aside from such operation the indication is for surgical cleanliness; soap and water followed by hydrogen peroxide, which may be continued as an application, or dusting with calomel, will usually prove sufficient. Various antiseptic solutions may be used. Dry applications, however, are the most convenient and usually the most serviceable; iodoform should be avoided on account of its penetrating odor; and pure, dry calomel will sometimes prove a mild caustic, and is best reduced with one to three parts by weight of bismuth subnitrate. The stronger applications, especially caustic, are only employed when there is unhealthy ulceration. If the sore is gangrenous it should be cocainized, then the surface thoroughly treated with some powerful caustic like nitric acid, and thereafter kept moist with aqueous antiseptic solutions. When the surface is practically healthy, dry preparations or unguents may be employed, preferably the mercurial ointments. There is greater difficulty in preserving cleanliness about the female genitalia, and here the use of antiseptic cotton or gauze will probably be necessary in addition to the other precautions. Surfaces should be kept apart by their aid, and it is well to use frequent antiseptic douches or occasionally to insert a suppository containing an antiseptic drug. Of the various preparations used those containing mercury in some form are doubly serviceable. The inguinal lymphatics should be kept anointed with a mercurial ointment, which should be thoroughly rubbed in, and the parts afterward protected with oiled silk.
While these local measures are being employed vigorous general treatment should be promptly instituted. This will be discussed when dealing with treatment of the constitutional features of the disease.
There are locations in which chancre gives rise to considerable distress, as, for instance, upon the lip and tonsils. Great improvement and relief of pain in these lesions is afforded by proper use of auxiliary drugs.
In regard to local precautions, the patient should be impressed with the virulent and infectious character of the discharge from every primary lesion, and given minute and cautious directions so that its transmission to others can be prevented. This will mean the use of separate utensils, as well as soap, towels, etc., possibly the temporary isolation of the patient.
CONSTITUTIONAL SYPHILIS.
Between the time of appearance of the primary sore and the development of widespread constitutional symptoms there intervenes a period of latency, the second period of incubation. This is more variable in duration than the first. The shortest time on record is about two weeks, and the longest about two hundred days, the average time being six or seven weeks. The secondary symptoms indicate complete generalization of the syphilitic poison, and follow the early manifestations in almost every case; nevertheless, there are instances in which they are either wanting or are so trifling as to escape observation. A careful examination during the second period will usually show, however, that the lymph nodes throughout the body are gradually becoming enlarged, especially those in the neck, along the border of the sternomastoid, the occipital nodes, those in the axilla and groin, and particularly one or two small ones above the inner condyle of the humerus, known as the supracondyloid or epitrochlear nodes. When these latter become involved without evident and local cause, syphilis is always to be suspected or even diagnosticated. This node is to be found by bending the patient’s elbow and feeling for it on the inner side, above the condyle, in the interval between the biceps and the triceps. The other lymph nodes of the body might also be found involved if they could be as easily palpated. This lymphatic involvement is quite independent of skin or other lesions, and does not yield as readily to mercurial treatment. The enlargements are usually movable, distinct in outline, and never suppurate unless locally and secondarily infected. In tuberculous patients, however, they may break down. This generalized involvement of the lymphatics is also of importance in diagnosticating old syphilitic infections.
During the second period of incubation there is generally a certain degree of malaise and progressive anemia. Examination of the blood will show diminution of hemoglobin, and a relative if not actual leukocytosis, due to reduction in the number of the red corpuscles. Occasionally the anemic features become pronounced; the patient may complain of weakness, lassitude, sleeplessness, failure of appetite, and of pain and discomfort in the bones and joints, more pronounced at night, and often regarded by patients as “rheumatic.” The painful joints may also show a slight swelling due to increase of the joint serum.
Sometimes intermittent fever accompanies these cases, especially during the early eruptive period. The rise of temperature is noted mainly in the evening, when it may reach 104° or even 105° F. It does not last long, and often precedes the appearance of a well-marked and characteristic eruption. It is a peculiar feature of the syphilitic poison that it seems to attack points of least resistance in each patient, as is the case with that of influenza. In one patient fibrous tissues will suffer most; in another, joints; in others there will be headache or expressions of perverted nerve activity, as vertigo, convulsions, disturbances of sensation, temporary paralysis; again there occur disturbances like mild pleurisy, splenic enlargement, or jaundice. Occasionally there will be a typhoidal condition, during which the kidneys are seriously compromised. Morbid conditions are intensified by an attack of syphilis. During rheumatism and the various forms of neuritis, and during almost all affections of the central nervous system, symptoms are, under these circumstances, frequently aggravated. In malarial countries it is said that latent syphilis sometimes becomes active when malaria is present. Lesions of the bones and joints are occasionally influenced, while some claim that fractures occur more readily in syphilitic subjects, and it is generally conceded that delayed union of fractures is often due to this cause. I have seen fracture, apparently spontaneous, of both tibiæ, one after the other, in a patient with syphilitic disease of the cord and bones. I have also seen exuberant callus form around a fracture in a syphilitic subject, as it never does under ordinary circumstances. Injury seems sometimes to localize the manifestations of the disease; thus chronic irritation at the site of old syphilitic lesions frequently becomes a point of development for epithelioma, or some other expression of malignant growth. This is seen particularly in cancer of the tongue, which sometimes follows the change in the epithelium known as leukoplakia.
The influence of an attack of erysipelas upon certain specific lesions is remarkable. In many instances eruptions and ulcerations have been known to subside, and gummas and exostoses to disappear, after an attack of erysipelas involving their site, but these lesions are likely to reappear after the disappearance of the acute infectious process. The temporary effect of the toxins of erysipelas upon syphilitic lesions is similar to their influence upon some malignant growths.