be readily felt through the scalp. The tunnelling and the condensation round the tunnelling are not confined to the more superficial parts, but spread through the whole thickness of the bone, obliterating the distinction between table and diploe. Gummy nodules often occupy some of the hollows excavated by the dry caries, out of which they may project above the surface, and form even large masses. When this is the case, their coverings slowly ulcerate, allow the gelatinous matter to escape, and leave rugged cavities, in which parts of the bone that have undergone condensation remain firmly adherent to the skull, without possessing sufficient vitality to form new bone for closing the cavity. In this way necrosed patches remain open for many years. Sometimes, however, the dry caries does not begin until the gummy deposits are undergoing disintegration and re-absorption. The termination of these affections is usually long deferred if left to nature; but unless far advanced, they rapidly yield to treatment. Necrosis and ulceration are not the invariable accompaniments of these slow changes in the bone; periostitis may thicken the bone for a considerable part of its length or breadth, and render it even double its natural thickness, or form prominent tumours, which nearly encompass the bone. In a young woman, suffering from long-standing syphilis, the frontal bone expanded into a mass several inches across, by gummy formation in the diploe. It was checked and diminished from time to time, but never entirely removed; eventually it caused the patient's death.2 The foregoing shows that the affections of the bones in syphilis seldom produce softening and suppuration, and their action is almost wholly confined to producing fibrous tissue 1 Virchow: Krankhafte Geschwülste, Bd. 2, S. 405. and new irregular bone; suppurative inflammation is excited only when some of the old or new bone dies, and irritates the living tissue like a foreign body. Diagnosis. The structural changes of the bones in syphilis are usually easily distinguished from those produced by other causes. They attack the superficial bones, the shaft and denser parts, rather than the articular ends or cancellous parts. They are very slow in progress, accompanied by much pain, and last a very long time. They are common in middle life, when scrofulous affections are Their processes of ulceration and induration distinguish them from malignant disease or general softening (osteo-malacia). rare. Inflammation of the Articular End of the Bones.-Richet attributes to syphilis the sharp, violent pain and swelling that was soon followed by effusion into the joint, which he noted to take place twice in the lower end of the femur, and once in the upper end, of patients suffering at the time with long existing syphilis. Lancereaux relates a case where symptoms of this kind attacked the right elbow-joint. Rest and iodide of potash given freely soon quelled the inflammation and removed the effusion. 2 The Joints are very rarely attacked by syphilis. From the rarity of the affection little is known about them. Richet and Follin describe two lesions of the joints. The first consists of gummy deposit in the fibrous capsule, but outside the synovial membrane. This change produces congestion of the synovial membrane, and effusion of serosity into the interior of the joint. According to Coulson, creeping tertiary ulcers have penetrated the synovial 3 1 Richet Mémoires de l'Académie de Médecine, xvii. 1853. 2 Follin, loc. cit., p. 714. 3 Coulson Lancet, vol. i. 1858. membrane. This affection has been observed hitherto only in the knee, during the later stages of the disease. Lancereaux1 relates at great length the post-mortem of a woman, both of whose joints were affected with firm yellowish infiltration of the capsule. The patient had also deep creeping ulcers of the skin, ulceration and stricture of the trachea and bronchi, advanced contractions and nodular formations of the liver, and enlargement of the spleen. Lancereaux also relates another case of effusion into the knee in a patient, while suffering from syphilis, which recovered perfectly by perseveringly employing antisyphilitic measures. The Symptoms are the effusion of fluid into the knee-joint, the small amount of pain, and that chiefly felt at night, the small tendency to form adhesions or anchylosis, and the slow course, for the fluid is sometimes reabsorbed and effused again two or three times during the progress of the disease. If the joint is handled, the fibroid thickening of the capsule can be felt, and its irregularity is very unlike any strumous affection. Lastly, in those cases where this disease has hitherto been observed, other evident syphilitic affections were well marked. Obstinate inflammation of the synovial lining of the larger joints is not infrequent in syphilitic persons, but except that iodide of potass and mercury are potent remedies in relieving them, these affections are not peculiar to syphilis. The Muscles and Tendons.-Two forms of syphilitic disease take place in muscles as in other organs: the gummy or nodular, and the interstitial diffused forms. The gummy form is met with as oval tumours, usually adhering closely to the muscular fibres. In a case of Mr. 1 Lancereaux, loc. cit., p. 246. 2 Virchow's Krankhafte Geschwülste, Bd. II. S. 437. 3 Pathological Transactions, vol. xi., P. 246. 3 Sydney Jones's, they even enveloped the muscular fibres in their mass. These formations have been found in most of the muscles of the body.1 Bouisson has seen them in the sterno-mastoid, vastus externus, and the laryngeal muscles. The muscles of the upper extremity are more often attacked than any others. They accommodate themselves to some extent to the contour of the muscle, and form very frequently in or near its attachment to the bones, from which, indeed, they sometimes originate. Their size varies from that of a pea to that of a pigeon's egg. They are very rarely single, but are scattered in numbers through a single muscle, or one group of muscles, and they are never observed without syphilitic disease in other tissues also; for instance, in the bones, dura mater, or viscera. On section, they are seen to be clearly circumscribed, greyish, red, yellowish-white, or dense white in colour; usually firm, sometimes gelatinous, homogeneous or fibrillated, at other times with yellow, cheesy masses scattered through their substance. Their histological structure consists in masses of round, nucleated granulation cells, springing from the cellular tissue between the fasciculi. These cells rapidly degenerate into a structureless mass of granules and fatty molecules held together by a stroma of fibres, which separates them very imperfectly from the proper muscular tissue. The Symptoms are not very distinct. Pain is not always present, but when so, it is usually increased at night, or by contracting the muscle. The tumours sometimes can be felt, being fixed, according to Nelaton, if the muscle is 4 1 Dr. Murchison found a gummy tumour in the diaphragm, with numerous syphilitic growths in the viscera. Path. Trans., vol. xiii. p. 250. 2 Gazette Médicale, pp. 543, 563. 1846. 3 Wagner: Archiv der Heilkunde, Bd. vii., S. 525. 4 Nelaton Gazette des Hôpitaux. 1861. M contracted, and moveable when it is relaxed. If left to themselves, they grow slowly larger, but if treated, commonly disappear in a short time. Interstitial Inflammation of the Muscles.-In this form the muscular fibres become welded together by adventitious cellular tissue, and the muscle grows permanently contracted and atrophid. This change takes place especially at the attachments, and in the parts near the tendons and fasciæ. These muscular nodules are sometimes situated close under the skin, and may then cause obstinate ulcers on the surface, which extend into the tissue beneath, and draw together the affected muscle. Zeissl1 relates a case where the knee was flexed to a right angle by a retracted biceps. After the failure of other treatment, a cure was obtained by the use of mercury and iodide of potash for several months. 2 The tendons, though very rarely attacked, are affected similarly to the muscles, the tendo Achillis and the long tendons of the flexors of the fingers being most frequently the seat of the gummy tumours. Bouisson saw a nodule in each tendo Achillis close to the heel in a syphilitic patient, which disappeared under the application of mercury locally, and iodide of potash internally. 3 The heart, being a muscular organ, is affected like the other muscles. The gummy nodules have been found in the substance of the auricles, ventricles, and the papillary muscles. Lancereaux gives a drawing of a heart with these nodules embedded in the substance of the ventricle, and in a papillary muscle, where it is surrounded by interstitial induration. This interstitial induration is sometimes the only change in the tissue. Wagner describes the heart of a still-born syphilitic child, where the substance was 1 Constitutionelle Syphilis, S. 276. 2 Loc. cit. |