Syphilitic Lesions Research Articles

A case of simultaneous infection with yaws and primary syphilis

1. 1. A case is described in which framboesiform yaws preceded and outlived a typical primary syphilitic chancre. 2. 2. The fundamental nature of a syphilitic lesion as ulcerative and a yaws lesions as a hypertrophy is emphasized. 3. 3. The differences between the histology of yaws and syphilis of the skin are briefly indicated. 4. 4. The work of Schöbl taken in support of such cases as that described is considered to be conclusive proof that yaws and syphilis are two separate diseases.

To the clinical picture of silent syphilitic aortitis

An unfavourable prediction of syphilitic aortic lesion is due to its late diagnosis. The key to the success of therapy is in early diagnosis of s. a., when there are no persistent anatomical changes and the main clinical signs have not yet developed. The initial forms of s. a. have been disguised for a long time, distinguishing them from other vascular lesions which symptoms are usually quite definite.

CONGENITAL SYPHILIS

When one is dealing with an infectious disease, demonstration of the causative agent is always desirable in order to establish the diagnosis. The necessity for demonstrating the organism varies inversely with the vividness of the clinical picture presented by the patient. A new-born syphilitic child is usually free of symptoms during the first few days or weeks of life.1Hence, the demonstration of Spirochaeta pallida, were this possible, would be a valuable diagnostic aid. Obtaining material in which to demonstrate spirochetes from a living child suspected of having syphilis presents a problem which is often insurmountable. It is true that spirochetes have been shown to be present in the blood stream,2the nasal secretion,3the conjunctival secretion,4syphilitic cutaneous lesions, the urine2c and in the meconium5of syphilitic infants, but in most instances the infant in whom the causative micro-organism is found has manifest clinical

ESSENTIAL SYPHILITIC ALOPECIA

In 1925, Wile and Belote 1 called attention to the subject of alopecia in syphilis and gave an excellent summary of it, emphasizing the important contributions of Cyranka and of Gartner and discussing the two types of syphilitic alopecia: (1) essential alopecia, the type which occurs without visible accompanying syphilids in the scalp; (2) symptomatic alopecia, the type in which the loss of hair is apparently due to lesions of syphilis in the scalp. The first type, essential alopecia, is less understood. It is of interest in this discussion because the case under consideration helps to confirm the findings of Wile and Belote, who stated (1) that essential syphilitic alopecia is frequently associated with meningeal syphilis and (2) that the loss of hair is most likely due to an endocrine dysfunction resultant from a syphilitic lesion in the sympathetic ganglions. A case most striking in its clinical aspect and

XVIII. Tertiary Syphilitic Infiltrative Lesions of the Nasal Mucosa

XVIII. Tertiary Syphilitic Infiltrative Lesions of the Nasal Mucosa

Advanced Osseous Syphilis in a Four-months-old Infant

Roentgenographic examination of the skeletal system in early infancy is of paramount importance whenever there are clinical manifestations suggesting osseous involvement. The necessity of such a procedure is well illustrated in the case of a four-months-old infant in whom roentgenographic examination revealed advanced and widespread syphilitic osseous lesions in the presence of few other manifestations of the disease. An idea of the frequency of syphilitic osseous lesions in fetal life may be gained from Shipley's (1) studies. He noted advanced syphilitic osseous lesions in 15 of 100 fetuses listed as normal in the catalogue of the Carnegie Institute of Embryology. A female infant 4½ months old was admitted to the New Haven Hospital on July 8, 1931, with the diagnosis of birth injury to the left brachial plexus and paralysis of the corresponding arm. The mother was a primipara. The child was born on Feb. 18, 1931, full term, and delivered spontaneously, weighing 3.8 kilograms. During the first two months breast feedings were given; from then on she received complementary feedings along with the breast feeding. In April, 1931, the mother noted that the child cried more than usual when she was handled or fed. She was seen by a number of physicians and was finally referred to the hospital. On admission the child appeared well developed and nourished, weighing 6.1 kilograms. The infant did not appear acutely ill but was very irritable. Her temperature was 38.1° Centigrade. Tenderness was noted over all the extremities. The reflexes in the lower extremities appeared normal; no satisfactory examination could be made of the reflexes of the upper extremities. The left arm moved clumsily and not as freely as the right. The left deltoid muscle seemed weaker than the right but no difference was noted in the size. The head was well shaped. The anterior fontanelle admitted two finger tips. The eyes were normal and reacted to light promptly. The cars appeared normal. There was no discharge from the nose and no obstruction. Nothing unusual was noted about the lips or in the mouth. The chest, heart and lungs, abdomen, and external genitalia appeared normal. There were no skin lesions present and no palpable lymph nodes. The routine examination of the blood, urine, and spinal fluid revealed nothing unusual. The Kahn and Wassermann tests of the blood were both positive.

PRODUCTIVE-CICATRICIAL SYPHILITIC DISEASE OF THE PULMONARY ARTERY

Syphilis may affect the pulmonary artery as a productive-cicatricial lesion like that form common in the aorta, the so-called Dohle-Heller type; it may occur as a gummatous arteritis, or it may be manifested simply by the formation of gummas. Warthin further accepted as syphilitic a form of diffuse arteritis which affects principally the smaller vessels. Neither he nor Bruning, Thorel, Henschen or Rogers, all of whom he quoted in support of this view, offered definite or convincing proof. The conclusions of these investigators were arrived at by probability, exclusion or belief, based occasionally on the finding of syphilitic lesions elsewhere in the body. In spite of Peck's excellent critique of the matter, the recent report of a case by Hare and Ross is based on the presence only of suspicious lesions in the systemic aorta. These authors quoted Thomas in support of their conclusion, but many of Thomas' cases did

STUDIES ON THE PHYSIOLOGICAL EFFECTS OF FEVER TEMPERATURES

1. Multiple, unsustained fevers (41-42 degrees C.) produced by irradiation in a high frequency electrostatic field (10,000 kilocycles) destroyed T. pallidum in rabbits with active syphilitic lesions as determined by the injection into normal rabbits of extracts prepared from their testes and popliteal lymph nodes. 2. One febrile period of 6 hours at a temperature of 41.5-42 degrees C. was likewise found to be sufficient to destroy T. pallidum. 3. Infection with T. pallidum persisted in a control series of untreated rabbits for as long as 395 days after inoculation, but clinical healing occurred in from 3 to 4 months after injection. 4. The time interval between inoculation and fever treatment, or between the end of the fever treatment and reinoculation, did not affect the results. 5. The fever treatment was effective at any stage of experimental syphilis in rabbits.

STAINING OF SPIROCHAETA PALLIDA IN SMEARS BY ALCOHOLIC SILVER NITRATE

It is generally recognized that a method of staining Spirochaeta pallida applicable to smears made from primary syphilitic lesions would be useful. Methods that depend on silver nitrate for staining the organism in tissues have been developed by Levaditi, 1 Jahnel, 1 Warthin and Starry 2 and Dieterle. 3 Warthin 4 developed a method applicable to spinal fluid also. With all of these methods, silver nitrate is used in aqueous solution, and in that respect they differ from the method we reported in a preliminary paper. 5 With this method, which is a simplified form of the procedure used for nerve fibers, 6 alcoholic solutions of both silver nitrate and reducing agent are used. The use of alcohol instead of water as a solvent for the reagents greatly lessens their ionization, and by slowing the rate of reduction of the silver nitrate by pyrogallol, U. S. P., makes the

Sensitization of Rabbits with Neoarsphenamin

Although it has been demonstrated, , that guinea pigs can be readily sensitized to neoarsphenamin, Frei reported that he could achieve no hypersensitiveness to this drug in rabbits. In view of the findings of Sulzberger and Mayer that guinea pigs bred in different countries reacted differently to the same brand of neoarsphenamin, experiments have been carried out to determine whether the rabbits bred in Peiping could be sensitized by this compound. The brand of neoarsphenamin used throughout the work was that prepared by Hoechst Company, Germany, The ampules used for each experiment were from the same batch. 0.15 gm. of the drug was dissolved in 10 cc. of doubly distilled water and the solution diluted to 100 cc. with sterile normal saline. Only freshly prepared solutions were employed. Observations have been made on 50 native bred adult male rabbits; individual body weights varied from 1350 to 2320 gm. All animals were albinos and the majority were of a delicate build with a slender head and moderately short ears. Thirty rabbits had been inoculated with Treponema pallidum from 4.5 to 34 months previously. At the time of the present experiments, only 4 showed active syphilitic lesions, the remainder being in the latent stage of the infection. Twenty-four hours before each experiment, the skin over both flanks was shaved; only ordinary soap was used. In each instance, the right flank was used for the first, and the left for the second injection, both being administered intradermally. The second or “testing” injection was made 4 weeks after the administration of the sensitizing injection. In the case of 8 normal and 12 syphilitic rabbits, 0.1 cc. was used for both the sensitizing and the testing doses.

Staining Treponema Pallidum With Alcoholic Silver Nitrate

An alcoholic solution of silver nitrate has been found to be an efficient stain for nerve fibers in celloidin sections (Davenport). The results obtained on nerves suggested the possibility of staining Treponema pallidum, since the methods of Jahnel and of Levaditi employed aqueous silver solutions. Lymph taken from primary and secondary syphilitic lesions was the material chosen for experimentation. With the exception of one instance in which the lesion occurred on the lower lip, all material was obtained from lesions on the external genitalia. The lesion was cleaned with gauze and cotton. The exuding lymph was placed on a slide by means of a sterile wire loop and allowed to dry in air at room temperature. The staining procedure was essentially that previously reported (Davenport). The slides were coated with a 2% solution of celloidin, dried for about 2 minutes, and put into a 10% solution of silver nitrate in 85% alcohol for 5 1/2 hours at 37°C. The preparations were reduced in an alcoholic solution containing 3% pyrogallic acid and 5% formalin, and were subsequently gold toned. Of 10 cases examined, preparations from 4 showed many deeply stained spiral forms having the morphology characteristic of Treponema pallidum. These also showed Treponema pallidum upon dark field examination and blood taken from the 4 patients gave positive Wasserman and Kahn reactions. No such characteristic forms could be found in smears from the 6 remaining cases, nor could Treponema pallidum be observed in dark field examinations. Our results lead us to believe that alcoholic silver nitrate is an efficient, rapid and simple method of staining Treponema pallidun in smears.

The diagnosis of cardiovascular syphilis; analysis of clinical and post-mortem findings

The symptoms and signs of cardiovascular syphilis are discussed. An analysis was made of 61 clinical cases and 78 necropsies; statistics limited to the cases proved post-mortem are presented. The average age at death was 47.9 years. There were but 3 cases under thirty years of age, and only 2 above seventy years. Males outnumbered the females in the ratio of 5.5 to 1. The syphilitic lesions were associated with lesions of nonsyphilitic disease of the heart in 43 per cent of the necropsies. Symptoms of the disease were absent in about one-quarter of the patients in whom the disease was disclosed at necropsy. Pain was present in 28 per cent. It conformed to the syndrome of angina pectoris in but 4 per cent. The mouths of the coronary arteries were partially occluded in 10 patients; none of these had angina pectoris, and 8 were without pain of any sort. Neither the presence nor the character of the pain could be related to the condition of the coronary arteries or of the aorta. The coronary arteries were normal in 58.3 per cent of the series of 24 necropsies. Shortness of breath was common after the onset of congestive failure of the heart. The symptoms of weakness, hoarseness, dysphagia, and fever were absent or were present in a negligible number of these patients. Hoarseness of the voice was noted in but one of seven cases of aneurysm involving the transverse portion of the aortic arch. The duration of the symptoms rarely exceeded a few months in the necropsy cases; it was somewhat longer in the clinical series treated as out-patients. From these latter there is presumptive evidence that adequate therapy may relieve symptoms and prolong life. The manner of death was that of progressive failure of the heart in 79 per cent of the series of 24 necropsies. In 4 of these the actual death was sudden. The heart was enlarged in 22 cases, or 91.6 per cent, of the 24 necropsies. This enlargement was present in the absence of aortic insufficiency in 7, or about one-third of the group. The average weight of the heart was 555 gm. Increase in the supracardiac dulness and other findings above the heart are common, but too often not recorded in the physical examination. A systolic murmur over the precordia or more localized at the apex or base is common. That at the base is not due to roughening of the The diastolic murmur of aortic insufficiency was noted in 47.4 per cent. In 50 per cent of the 16 aortic regurgitant cases in the series of 24 necropsies the diastolic murmur was transmitted to the apex. aortic valve. This diastolic murmur may be inconstant in its presence in its earlier stages. Its detection sometimes requires painstaking auscultation. Aortic insufficiency was recognizable in half again as many cases as were evident at post-mortem, and in at least three-fourths of the cases (murmur present in life) the regurgitation could not be attributed to lesions of the valve. The insufficiency of the valve is best explained as due to yielding of the muscular ring round the aortic orifice. The apical findings, known as those of Austin Flint, are occasionally present. The aortic second sound may be masked by the murmur of aortic insufficiency, or it may be accentuated in the absence of the murmur and even if the latter is present. A change in the quality (i.e., a tympanic note) may take place in the aortic second sound, but it is difficult to differentiate from that found in arteriosclerosis of nonsyphilitic causation. The Corrigan type of pulse was absent in 5 of 16 cases of aortic insufficiency. That such is possible does not appear to be generally recognized. There is nothing characteristic of the blood pressure save in the presence of aortic insufficiency. Careful physical examination may detect evidence suggestive of syphilis elsewhere in the body. The Wassermann reaction was negative in 10, or 23.87 per cent, of the 42 cases in which it was recorded. The roentgen ray findings are very important aids in the diagnosis. It is unreasonable, however, to expect that the slight lesions in early cases of cardiovascular syphilis can be detected by the roentgen ray. In advanced cases the differential diagnosis from nonsyphilitic conditions may be difficult or impossible solely from the roentgen ray findings. The presence of cardiovascular syphilis was not diagnosed in 44 per cent of this series, although the subsequent necropsy disclosed advanced lesions in one-third of these failures. About one in five of the cases in which the syphilitic lesions were of advanced degree remained undiagnosed in life.

THE ASSOCIATION OF CARCINOMA OF THE TONGUE AND SYPHILIS

Recent literature contains many references to the frequent association of carcinoma of the tongue and syphilis of the tongue. In discussing this subject in 1929, Parounagian 1 made the following statement: The majority of cases I have seen of cancer of the tongue usually begin on a syphilitic base, i. e., gumma turning to cancer. Eller and Anderson 2 state their belief that cancer of the tongue and tertiary syphilis of this organ are associated in 60 per cent of the cases. These two statements substantially confirm earlier German figures relating to the occurrence of cancer of the oral cavity on preexisting syphilitic lesions or their residua. Clinical experience at the University Hospital in Ann Arbor, where both cancer and syphilis are seen in large numbers, has generally confirmed our opinion as to the frequency of the association of the two conditions in the tongue. Many cases of cancer arising

To the question of pathological and anatomical changes in the kidneys with their syphilitic lesion

Despite the fact that an extensive literature is devoted to kidney syphilis, this question still cannot be considered finally resolved. The kidneys can be exposed to the action of syphilitic infection in any period of syphilis, but specific morphological changes in them are found only in the gummy period of the disease. Gumma diseases observed in this period are among the very rare finds during the section. When looking through the extensive literature, we did not come across definite statistical indications of the frequency of kidney damage by the gummy process and found only random information about the amount of renal gummy syphilis. So in Wagner (1881) on 9000 sections of the kidney gum were found in 3 cases; Spiess (1877) had 7 cases of gummy interstitial nephritis in 220 autopsies of syphilitics. Lancereaux (1866) noted one case of kidney gum in 24 syphilitic sections. The rarity of gummy kidney damage can be judged to a certain extent because among the vast museum of the Pathological and Anatomical Institute of Kazan University for a long period of its existence there has not been a single case of such a change in the kidneys.

To the thyroid syphilis clinic

Syphilitic lesions of the endocrine glands are relatively common. Being a common blood disease, syphilis, affecting various organs and systems, should also affect the endocrine system, which is richly supplied with blood vessels; when infected with syphilis, some of the endocrine glands increase in volume and swell simultaneously with the lymph glands, and they often contain a large number of spirochetes.

To the clinic of pituitary syphilis

Syphilis affection of the cerebral appendage is observed quite often. Virchow first described the gum of the cerebral appendage in 1858. Further observations showed that the defeat of the cerebral epididymis with syphilis is a fairly common disease and, according to some authors, syphilis of the cerebral epididymis occurs in 42%, according to others in 57%. How often syphilitic lesions of the epididymis are observed, comparatively, can be seen from the statistical data of Buschke and Jost'a, who collected from the literature 246 cases of syphilis of the cerebral epididymis, of which 162 cases had acquired syphilis.

On the incubation period in neurolues

Speaking about syphilis lesions of the central nervous system, it is impossible not to note that these lesions are among the most severe diseases of the latter. But, on the other hand, their severity is redeemed to some extent by the specific means of combating them which we have in our hands. In this case, the fight against neurolues is reduced not so much to its treatment as to its prevention. Hence the interest with which the question of the influence of various conditions on the occurrence of syphilitic lesions of the central nervous system has recently begun to be comprehensively discussed and the exact causes which, from the general number of syphilitics, distinguish the group subsequently condemned to neurolues have been sought to be elucidated.

STUDIES IN EXPERIMENTAL SYPHILIS

Syphilitic rabbits, whether untreated or treated after the 90th day of infection, were found to be more refractory to subsequent inoculation with the homologous strain of Treponema pallidum than to inoculation with heterologous strains of the same organism, when clinical criteria alone were employed in judging the outcome of reinoculation. The incidence of second infection with homologous strains was 5.4 per cent, as against 50 per cent with heterologous strains.(2) The resistance which develops in rabbits during the course of a syphilitic infection appears therefore to be strain-specific rather than species-specific. The protection afforded against homologous strains was found to persist for at least as long as 6 months after treatment was discontinued. A given strain may afford a higher degree of protection against some strains than against others, but whether this is to be explained upon the basis of biologic relationship or of differences in virulence, or possibly as the result of both of these factors was not disclosed by the experiments. Rabbits infected with a strain (Nichols) which had been adapted to this species for over a decade could be infected with strains which had been recovered recently from the human body. The previous existence of a syphilitic lesion in the testis which was used as the site for reinoculation did not seem to exert any influence upon the incidence of successful second infections obtained with heterologous strains of Treponema pallidum. Sometimes the course of the second infection produced by inoculation with heterologous strains was less pronounced than that observed in the controls, but in most instances no significant alteration was observed. In syphilitic rabbits treated late in the course of the disease and reinoculated with heterologous strains of Treponema pallidum no lesion may develop at the site of reinoculation but nevertheless the Wassermann reaction may become positive and remain so for weeks thereafter. It is suggested that such animals may be examples of asymptomatic reinfection.

METHOD FOR DEMONSTRATION OF SPIROCHAETA PALLIDA IN SINGLE MICROSCOPIC SECTIONS

In the study of the pathology of infectious diseases, no known organism has offered more resistance to the possibilities of constant demonstration than Spirochaeta pallida . In the laboratory of general pathology, the histologic diagnosis of syphilitic lesions could not always be supplemented with the staining of the organism. Furthermore, in lesions regarded as suspicious of a positive differential diagnosis could not be made on the basis of a negative result with the staining methods that have appeared from time to time. Even with the old Levaditi method for total blocks, the clinical and anatomicohistologic diagnosis of syphilis was often more significant than the absence of spirochetes by doubtful staining methods. Manouelian's modification of the Levaditi procedure made the technic more reliable, but such methods utilized the total blocks, often leaving no tissue available for ordinary histologic stains in cases of biopsy. When Noguchi showed that spirochetes were present in

THE RÔLE OF SYPHILIS IN THE PARKINSONIAN SYNDROME

icity made the largest number of patients fall definitely in the later decades of life. Some of the early writers were struggling to probe further into the problem of its etiology, and in the pre-Wassermann days its concurrence with syphilis was noted. Eshner 2 concluded that there is little connection etiologically between paralysis agitans and locomotor ataxia. Wassermann tests and examinations of the spinal fluid were not made in his cases, but he cites a case of tabes in which six months later a parkinsonian syndrome developed, the patient dying two years later of a cerebral hemorrhage. He cites eleven patients between the ages of 52 and 65 in whom this coincidence was found. In the light of present knowledge, however, the facts are unreliable. Oettinger 3 noted five patients, with an average age of 55, with syphilis and an associated parkinsonian syndrome. The diagnoses in these cases were made on indefinite grounds, such as a history of syphilitic infection, scars of a syphilitic lesion of the skin, etc. In three of these cases a negative blood Wassermann reaction was found, and in four other cases cited with pigmented scars a positive diagnosis of syphilis was not made, nor were any associated neurosyphilitic signs mentioned. Oppenheim,4 in 1912, stated that in seven of his cases there had been syphilitic infec¬ tion, and in three the disease had appeared at an early age ; however, antisyphilitic treatment had no effect on the patients' progress. The literature, as quoted by Camp,5 in 1888, contains, according to Placzek, a case report by Heineman in which tabes dorsalis and paralysis agitans occurred in the same patient. He reported a second case in 1892, with the typical syndrome and tabes. In 1898. Weil, and in 1900, Hess and *Read at the Fifty-Second Annual Meeting of the American Neurological