Syphilis Of The Air-Passages | Operating Microscopes

By WILLIAM C. GLASGOW, M. D.,
OF ST. LOUIS, MO.

NEXT to the skin, the respiratory tract furnishes the most frequent manifestations of syphilis. Owing to the slight disturbance caused by the initial and secondary lesions, these are often overlooked ; and the latest stage, from its greater destruction of tissue and its marked disturbances, has been placed in greater prominence as a factor in the disease. The initial lesion here has been considered by many to be only a possible contingency; and they are apt to ascribe the infection to a hidden chancre of the genitals. The observation of men of large experience has proven, however, that syphilis may be “insontia ; " that occurrence of the extra genital chancre is not rare ; and that its possibility must be considered in all cases where the initial lesion is not plainly apparent. The secondary lesions of the upper air passages are always more or less evident. To differentiate them from similar conditions due to other causes is not always easy; and in some cases a positive diagnosis can be made only through the presence of the well known lesions of the skin. Tertiary lesions are usually marked and distinctive, and in only a small percentage of cases can there be any doubt. According to anatomical classification, syphilis of the air passages may be divided into diseases of the nose, diseases of the pharynx, diseases of the larynx, diseases of the trachea, and diseases of the lungs.

SYPHILIS OF THE NOSE.

Primary syphilis of the nose is acknowledged by all authorities to be very rare. When we consider the uncleanly habits of certain people, and the frequent interchange of handkerchiefs and towels among the members of the family, by which means infection can be so readily carried, and also the frequency of abrasions at the entrance of the nostrils, we are surprised that it does not occur more frequently. Buckley, from an analysis of 9059 cases of extra genital syphilis, gives 95 cases occurring in tile, nasal cavity. In his personal experience lie has found one case occurring in 113 cases of extra genital syphilis. He thus describes the symptoms of this case: "There was great swelling of the left nostril, which stood open and was covered internally with a dry crust, and on the margin there was an ulcerated surface free from crust. The passage of the nose was red and uneven from small nodular masses." There was no history of a preceding syphilis, and the lesion was suspected to be a chancre, rather than a later manifestation of the disease. Under the mixed treatment, and calamine and zinc ointment applied to the lesion, there was great improvement with healing of the ulcer. Secondary syphilis appeared later, confirming the diagnosis. The infection in this case seems to have come from the use of an infected towel. The most frequent site of primary lesions in the nose is the cartilaginous septum, and the infection is usually carried by the finger nail. In some cases the surgeon is responsible through the use of unclean instruments. Several cases are recorded of infection by the Eustachian catheter. Bosworth describes a case of Floured “The ulcer presented a large granular mass which bled easily upon touch, and which not only produced notable stenosis, but also pressed upon the ala of the nose to such an extent as to produce a marked deformity." In a case of Watson, the base of the chancre presented the appearance of a hard cartilaginous tumor with an ulcerated surface which bled easily upon touch, and projected so far into the nostril as to produce a marked stenosis.

An indolent swelling of the submaxillary glands is constant at this stage, and the constitutional disturbances of early syphilis are often witnessed. Erythema or a subacute rhinitis is the one pronounced symptom of the secondary stage. If mucous patches occur, they must be exceedingly rare. The “snuffles “of the new born child is one of the frequent symptoms of congenital syphilis.

Syphilitic rhinitis differs in appearance in no way from an ordinary rhinitis. The diagnosis can be made with certainty only when the lesions of the skin show the recognized eruptions of syphilis. Its duration, however, is longer than a simple catarrhal rhinitis; and this chronicity and resistance to treatment add to its suspicious character.

The third stage of syphilis shows the most marked manifestations in the nose, causing ulcerations, superficial and deep, and gummata. Gummatous deposit may occur in any portion of the nose. The most frequent site is the septum and the floor of the cavity. It is most commonly limited in extent, forming a tumor as large as, or larger than, a pea. In some cases, however, the infiltration is more extended. It commences most frequently in the submucous tissues, extending both to the surface and the deeper tissues. It may continue for months with an unbroken surface; but sooner or later degeneration occurs, and ulcerations, either superficial or deep, result. The periosteum or perichondrium becomes involved, and later there is necrosis of the bony structures. The septum is a frequent site of ulceration, especially the junction of the cartilaginous with the bony septum. Perforation of the septum is a common result. Many consider a perforation of the septum to be an evidence of syphilis; but experience shows that the perforation may be due to the breaking down of a tubercular infiltration or may be the result of any constant and repeated irritation of the septum. Where the bony septum is involved, the existence of syphilis is unquestionable. Next to the septum, gummata are seen most frequently in the floor of the nasal cavity. The mucous membrane and the submucous tissues, with the underlying bone, are involved, and perforation of the hard palate occurs. Frequently gummata are found in other portions of the nasal cavity, producing, necrosis of the bones and great development of fibroid tissue. The deformity resulting from the destruction of the bony frame work of the nose and the shrinking of the fibroid tissue produces the typical saddle nose which is characteristic of syphilis.

The Symptom of the early stage of nasal syphilis is a profuse secretion. It can hardly be distinguished from that of a catarrhal rhinitis, except that it is more obstinate and resists ordinary treatment. When it occurs in the new born it is probably syphilitic. In the later stage there is a great tendency to the formation of crust with a muco purulent secretion; the peculiar fetor of dry or syphilitic caries is unmistakable. With the formation of the gummata there is more or less obstruction of the nostrils through edematous swelling. When degeneration takes place beneath the mucous membrane, or when perichondritis exists, there is always more or less pain until the pus reaches the surface.

SYPHILITIC LESIONS OF THE PHARYNX.

Lesions of the pharynx occur in some form in the majority of cases of syphilis. The chancre or primary infiltration is more common than is ordinarily believed, and it is often overlooked owing to the insufficient illumination of the pharynx during examination. Excluding primary lesions of the lips and tongue, we find the tonsils to be the most frequent site, and, next to this, the soft palate. Contrary to the usual belief, infection in these cases has taken place most frequently through the use of pipes, eatingutensils, and public drinking cups. The use of the last seems to be the most common source of infection. We can well imagine that the use of a cup by one having mucous patches on the lips would carry the infective material to the next one who used it. Unclean practices are responsible for only a limited number of cases. Referring to Table 3, published by Buckley, we find 307 cases of chancre of the tonsil among 9058 eases of syphilis. Schadek, among 68 cases of extra genital chancres found in the fauces, locates 34 on the tonsil.

Chancre of the tonsil presents the appearance of an indurated ulcer of the organ, which may be limited in extent or involve a large surface (compare Fig. 575). The ulceration is superficial, but may be small, with its base covered with dirty gray secretion. The indurated condition of the periphery declares the diagnosis, which will soon be confirmed by the glandular swellings and the lesions of the skin. In some cases the symptoms of the chancre are so slight as to escape notice; in others they are marked. Pain may be very prominent, either confined to the pharynx or radiating to the ear. The submaxillary glands become swollen, but their suppuration is rare.

Erythema of the fauces is frequent. We find a circumscribed redness of the mucous membrane involving the soft palate, the pillars of the fauces, or the tonsil. The color is a coppery red, and it is sharply limited to certain areas. Frequently it is confined to one side, with a well marked line of demarcation in the median line and in the line between the bard and soft palates. Occasionally we find patches of congestion on the two sides, with the median line free the so called "Dutch garden symmetry” (Hutchinson). This condition usually coincides with the early skin lesions of syphilis, and is often overlooked, as it rarely gives any special symptoms. Erythematous patches may be present in the naso pharynx giving rise to catarrhal symptoms. We occasionally see in those who have passed through the secondary stage, perhaps years afterward, the occurrence of a subacute angina, which will yield only to the specific treatment. In a case of the writer, an angina which had been under treatment for a long time by several physicians yielded at once to a mixed treatment, and the redness entirely disappeared. With the cessation of treatment owing to an attack of grippe, the angina returned, and permanently disappeared only after a prolonged specific course.

Mucous patches are of frequent occurrence in secondary syphilis. They are found on the pillars of the palate, the tonsil, and other parts of the buccal cavity. They are usuall circumscribed in extent, presenting small patches of a mother of pearl color. As a rule, they are level with the surface of the mucous membrane, and are brought into greater prominence through the congestion of the surrounding tissues. They present somewhat the appearance of the mucous membrane after the surface has been touched with nitrate of silver. In a certain number of cases we find the patch thickened and somewhat raised above the surface, resembling in a certain degree the patches of diphtheria. They have a tendency to remain unchanged over long periods, unless modified by treatment. Occasionally we see the infiltrated patches presenting ulcerations and erosions. These are superficial in character and have a tendency to extend at the periphery. Secondary lesions appear from six months to two years after infection.

Tertiary syphilis of the pharynx is strictly the result of a gummatous infiltration of the tissues, the mucous membrane, the submucous tissues, or the bones. Manifold in its pictures, modern medicine ascribes all these conditions to degeneration of the gummatous infiltration. More or less rapid ulceration, with great destruction of tissue and the development of a cirrhotic contractile tissue, is the usual sequel. Gummatous tumors may be confined to limited areas, or the deposit may be extensive. Unless checked by treatment they may break down rapidly, giving rise to ulceration, which in the beginning may be small and may occur at several points. If unchecked, it is prone to extend, producing great destruction of tissue. The ulcer may be round or irregular, and is surrounded by a red areola. It has sharply defined edges, and its base shows feeble granulation tissue exuding secretions composed largely of pus and broken down epithelium. The posterior pharyngeal Wall is a frequent site of the gummatous infiltration and extensive ulceration. Superficial ulcers frequently occur in the tipper part of the pharynx, and are hidden from view unless discovered through a rhinoscopic examination. When the ulcers extend deeply into the tissue, they may involve the periostemn with a subsequent caries of the bone.

The posterior surface of the palate is a common site of a softening gumma. The destructive process may be very rapid, and perforation of the palate is .quickly established; unless cliecked, the eroding process may continue until more or less of the palate is destroyed. The dependence of the ulceration upon the gummatous deposit is strikingly shown in some of these perforations of the soft palate, where we see large areas destroyed, with normal strings of tissue remaining between the perforations. Ulcers of the tonsil are not usually as large as those of the palate; they are more longitudinal, and show less tendency to extend. Several ulcers may be seen at the same time on the tonsil with sound intermediate tissue. The deep perforating ulcer has occasionally produced erosion of a blood vessel with hemorrhage. Gummatous tumors occur on the posterior pharyngeal wall and the hard palate, where they show little tendency to soften. They appear as hard, firm, rounded tumors covered with mucous membrane. They may be quite large and present the appearance of a fibroma or a sarcoma. A case of the writer presented a gummatous tumor of the tonsil, as large as a small hen's egg, largely blocking up the fauces. In some of these cases the diagnosis is difficult, and can only be affirmed after a microscopical examination or the test of treatment.

Another result of gummatous infiltration is seen in the development of contraction and scar tissue. A great and varied distortion of the pharynx is the result, and membranous folds are formed which cause great inconvenience and distress. Adhesion of the soft palate to the posterior pharyngeal wall, often complete, or with a small opening, is not uncommon. A membranous adhesion between the lower pharynx and the root of the tongue, largely closing the larynx and esophagus, has several times been observed. Such it case came under my observation a few years ago. The opening was large enough to allow free respiration, but great difficulty was experienced in swallowing. Adhesions between the soft palate and the palatine folds are of frequent occurrence. They are usually unilateral.

Symptoms of secondary syphilis of the pharynx may differ but slightly from those of an ordinary catarrhal pharyngitis. There may be a sensation of' dryness of the membrane, and more or less pain oil swallowing. The secretions are usually increased. The glands of the neck are swollen; but this may also result from other causes. The occurrence of the tertiary stage gives rise to more prominent symptoms. The pain of swallowing may become so intense as almost to preclude the taking of food. It may radiate to the ears and assume the form of neuralgia. The secretions are greatly increased, and become purulent and ropy. When the palate is involved either through infiltration or ulceration, we find a disturbance of' the speech, .and fluids are often regurgitated into the nasal cavities.

SYPHILITIC LESIONS OF THE LARYNX.

The larynx becomes involved in a large number of cases of syphilis. The disease may be in the milder forms, and be overlooked, or in the most destructive which cannot escape notice. Authorities are greatly at variance as to its frequency, laryngologists meeting a larger percentage of cases than the dermatologists. In a large number of cases laryngeal syphilis appears secondary to syphilis of the pharynx. It has, however, been frequently observed independently, often occurring many years after the initial lesions. it may occur in varied forms from two months to fifteen years after infection. Primary syphilis of the larynx is almost unknown, although it has been reported. Secondary syphilis has been observed as early as the second month the usual time is from six months to three years after the infection. It assumes the forms of an erythema, mucous patches, and erosions.

Erythema or syphilitic catarrh is an early and most constant lesion. It resembles so closely an ordinary catarrhal laryngitis that in many cases it is impossible to make a differential diagnosis unless it is accompanied by the skin lesions. Even in such cases the occurrence of laryngeal hyperemia may be an accidental condition of ordinary catarrhal laryngitis in a syphilitic subject. The true nature of the lesion call be determined only by the result of treatment. In certain typical cases the color of the membrane is of a deeper red than that of an ordinary catarrhal hyperemia. It is more persistent, and there is usually a greater swelling of the membrane. In other cases it is found confined to limited areas. Mucous patches are not frequent. They have been reported as occurring on the under surface of the epiglottidean folds, the true and the false cords. They are similar in appearance to the mucous patches of the pharynx. They seem to be the origin of the erosions which are often seen in the larynx. Occasionally they present the appearance of condylomata.

Symptoms of the second stage are obscure, and will depend upon the area affected. When the vocal cords are concerned, the symptoms resemble those of a catarrhal laryngitis; the voice may become rough and hoarse. If the arytenoid cartilages or the interarytenoid fold are involved, the patient may have all irritative or tickling cough and clearing of the throat. The tertiary lesions of the larynx appear from the third year of infection on to an indefinite period. Cases are on record in which the laryngeal affection has arisen twenty years after the primary lesion. It assumes the form of a gummatous infiltration or tumor; and when softening occurs there is ulceration and the gummatous infiltration will present the appearance of a thickened, infiltrated area. This may extend through the submucous tissue, involving the perichondrium, while the mucous membrane of the affected area may be normal or reddened. The epiglottis is the most frequent site of the infiltration (Fig. 620), but it is also seen on the true cords, false cords, and the ary epi glotti (lean folds. The epiglottis may be changed into a swollen, deformed organ, and the ary epiglottidean folds become large and prominent: the swollen false cords may largely fill the glottic opening. Gummatous tumors are simply circumscribed areas of infiltration which develop into the form of a tumor (Fig. 621). They occur in all parts of the larynx, and may be single or multiple. The tendency of the gummatous formation is to soften, and when this occurs the destructive process is very rapid. It burrows deeply in the tissues, producing a deep, excavated ulcer, with destruction of the underlying cartilage. The epiglottis may be partially eroded or completely destroyed through the necrotic process. The crico arytenoid Joint and both the true and false cords may be involved in the same process. The collateral edema and swelling may be so great as to occlude the glottis. The deep ulcer of syphilis has a certain characteristic appearance : the edges are sharply defined, and the base is covered with gray secretion. In form it is irregular and it is surrounded by infiltrated tissue. The superficial ulceration is not so characteristic. It may have an extensive surface, and has a great resemblance to a tubercular ulceration.

The differential diagnosis between a syphilitic ulcer of the late stage and the tubercular will often be difficult and at times impossible, without the consideration of other signs and symptoms of the disease; this will especially be the case where a mixed infection is present (Fig.622). The syphilitic ulcer has sharp, better defined edges; it is apt to be single, and presents the appearance of an excavated area with a reddened, thickened surrounding. The tissue about a tubercular ulcer shows an anemic color. A common sequence of the ulceration will be found in the development of the contractile sear tissue, which produces great distortion of the laryngeal structures and which remains permanently, giving in after years positive evidence of the disease. Adventitious membranes may be formed between the cords, largely closing the glottis.

SYPHILIS OF THE TRACHEA.

Syphilis of the trachea assumes the form of erythema in the early, and gummatous infiltration in the later stage ; it is frequently consecutive to the disease in the larynx. Erythema of the trachea can be discovered only through the use of the laryngeal mirror. There are no symptoms, unless there be irritating cough. The gummatous ulcer can occasionally be seen in the mirror, if it occurs on the portion of the trachea which can be illuminated. It is more frequently entirely overlooked, and is suspected only when the development of stenotic symptoms shows the presence of contractile scar tissue. It may be multiple, and invade large areas of' the trachea, and it may be superficial or deep. The deep ulcer may break down the cartilage and form a connection with the adjacent organs. Contractile adhesions may result, largely occluding the lumen of the trachea. In a case of' the writer the upper portion of the trachea was almost entirely closed by adhesions; the patient survived fourteen years after a low tracheotomi.

SYPHILITIC LESIONS OF THE LUNGS.

That syphilitic lesions of the bronchi and lungs occur has been proven by post mortem examinations, but the diagnosis in most cases is extremely difficult, if not impossible, during life. Post mortem Specimens bave shown the presence of the gummatous infiltration, and this has been found broken down, forming cavities. Syphilitic phthisis can only be suspected when it occurs in a person subject to syphilis, and even then a' possibility of a mixed infection must be considered. The physical signs and symptoms are similar to those occurring in many cases of ordinary phthisis, and it resembles those cases which have been justly termed local tuberculosis of the lungs. The general symptoms are slight, and emaciation is not so marked as in tubercular phthisis. The physical signs will show a local infiltration confined to single portions of the lungs. We may have the moist rales and bronchial breathing with dullness, if a perceptible area has been infiltrated: the cavity signs will be present where an abscess has emptied into a bronchus. The iodid of potash test will be the leading element in the diagnosis.

TREATMENT.

The treatment of syphilis of the respiratory tract follows the rules of the treatment of general syphilis, with the addition of such local treatment as may be needed in individual cases. The accepted rule of giving the mercurial in the early stage and the iodids in the later will be generally followed. The experience of the writer has shown, however, the greater value of the so called "mixed treatment" in almost all stages of the disease. The fresh solution of a combination of corrosive sublimate, gr.12, and iodid of potassium, gr. x, has given quicker and better results than the use of the same drugs in pill form, as biniodid or protiodid of mercury. In addition, when it is necessary to check ulcerative action or to promote the absorption of gummatous infiltration, the iodids must be given in larger and increasing doses. Occasionally a course of mercurial inunction will develop the power of the iodids when the response to treatment is not satisfactory. In all cases where there has been a development of syphilitic anemia a course of tonics will be indicated; and we should have decided benefit from the use of iron, manganese, strychnia, and cod liver oil.

The local treatment, although secondary, will be essential in most cases of nasal and throat syphilis. The thorough cleansing of the surface by means of the spray or syringe, using an antiseptic and alkaline solution, will favor resolution and will prepare the way for the proper application of such local remedies as may be indicated. In nasal syphilis such local treatment is all important. The dead bone should be removed, if this can be done without violence, and the ulceration touched with nitrate of silver. In the pharynx and larynx the application of compound solution of iodin will hasten the resolution of the gummatous infiltration; and acid nitrate of mercury or nitrate of silver will tend to bring about the healing of the ulceration. In ulcers of the larynx the insufflations of aristol or iodoform with morphia will be grateful and useful. The cicatricial contractions, with the resulting stenosis in both the pharynx and the larynx, will be troublesome and obstinate. The results of surgical treatment of these conditions have been most unsatisfactory division of the adhesions and membranous formations by either the knife or the cautery being almost always followed by a re growth of the divided structures. Gradual dilatation has given the best results. No surgical interference is justifiable until the disease has become quiescent.

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