TERTIARY OR CONSTITUTIONAL SYPHILIS.
There is no distinctive time limit between the so-called secondary and the tertiary symptoms of syphilis. Generally the lesions disappear with but little treatment; in many instances they will fade away without any. In most cases, however, the patient, even under poor management, takes enough medicine to disperse the lesions more quickly than they would spontaneously subside. If he discontinues medicine for several weeks, sometimes many months will elapse before there are any active manifestations of the disease. During this period, however, the lymphatic enlargements will not decrease perceptibly, and there may be evidence of advance in this direction. The so-called tertiary symptoms appear usually without fever or other symptoms, and not often in less than five or six months after the commencement of the disease. On the other hand, their advent may be delayed for years, even when the early treatment of the case has been but partially effective.
No organ or tissue in the body is exempt from the ravages of tertiary syphilis. Even the finger-nails and the hair may suffer, while the teeth are affected in the hereditary manifestations. Affections of the skin occur, according to Haslund, in about 12 per cent. of the cases.
The mucous membranes are liable to exhibit those lesions above described, known as mucous patches, usually regarded as late secondary symptoms. The description applies equally well to the tertiary lesions. They occur about the oropharynx, upon the tongue, the lips, the nostrils, and the eyelids. They are frequently found also about the rectum, anus, and genitalia of either sex. In general they present about the same appearance. They commence usually with a slight elevation of the surface and at several points, sometimes simultaneously and successively. These surfaces ulcerate superficially, and thus are produced irregular but rounded patches, with uneven edges, of grayish-yellow surface, which ordinarily are not sensitive, but occasionally extremely so. They may disappear under local treatment, but in that case tend to recur at frequent intervals. If unnoticed or not properly cared for the ulcers may become deeper and assume an unhealthy appearance. In the mucus-lined cavities affected the condition of these ulcers will depend upon the personal habits of the patient. In mouths where tartar has accumulated upon the teeth, or where the toothbrush is seldom used, the patches may become large and foul.
These lesions are extremely infectious and the disease may be conveyed by kissing, by the common use of small domestic utensils, by the pipe, by dentists’ instruments, etc. Patches occurring at the junction of the skin and mucous membrane may extend over onto the latter and become deep, specific ulcers. Lesions of this character need judicious local as well as constitutional treatment. They will often disappear under the latter alone, but it should be combined with local measures. These consist in cleanliness and the use of various antiseptic solutions or applications. An antiseptic mouth wash, as diluted hydrogen dioxide, or of water given a mahogany color by tincture of iodine, should be frequently used. There should be an application of a 5 per cent. solution of silver nitrate, or some other astringent, stimulating, or mild caustic.
Fig. 24
Grouped papulopustular syphilide and numerous pigmented spots from former lesions. (Fordyce.)
The Skin.
—The late syphilides of syphilis belong to the gummatous or tuberculous types (i. e., tuberculous in the anatomical sense, or nodular). The latter may occupy the entire thickness of the skin or lie even deeper. Such lesions may begin as papules and develop into distinct and circumscribed nodules, while these may coalesce into considerable masses. These tend to break down and leave scars after they have disappeared. There is little difference, microscopically, between the nodule and the gumma. Clinically, the tuberculous lesions spread usually in a serpiginous manner, producing a more or less curvilinear outline. (See [Figs. 24] to [27].) These ulcerations undermine the tissues to a greater or less extent, and pus and debris will be formed in consequence. In this way they imitate considerably the lesions of lupus, and it may require a careful study of the case and of its history to make a diagnosis. Some of these lesions are extremely slow in their course and long in duration. When scars form they are usually white and smooth, with irregular borders, but sometimes are surrounded by pigment that makes them characteristic. The extent of the scar is no criterion as to the size of the originating lesion, the former being always smaller than the latter.