Mexico. MCMLIII (1953)
Donato Pérez García MD
Facing the serious and difficult unknowns of Medicine, there will always be something to clarify or to solve.
In the past there were problems that were true enigmas. But now they are easily explainable and they have fallen from their pedestal of mystery, with formulas and precise theories of mathematics, physics, or chemistry. That mystery has not been completely clarified, since we have merely described these phenomena. We have not found the causes that motivate them, and in many cases we have not even explained to ourselves how they take place. We are referring to phenomena that we experience daily, such as gravity, light, electricity, etc. But what is the intimate mechanism of each one of these events we observe daily?
Aristotle, Galileo, and Newton formulated the laws of gravity and exposed how these phenomena take place. To date no one has explained the why of them. They have only managed to describethem.
Medicine was born of empiricism. At the present time, some phenomena have been described, but there are many, innumerable, which are still in the most complete darkness.
The principle of medicine goes back almost to the beginning of humanity. It was the instinct of conservation, and sometimes chance, which forced man to look for ways to stay healthy.
Health and disease obeyed a divine mandate. This belief, for a long time, stopped the advance of all activity related to the desire of man to stay healthy. The Gods were ordering that we had to endure any ailment stoically.
Once proven, the beneficial effects of a certain substance were continued by usage in similar cases. Empirical Therapy was born. Hippocrates understood this form of application of substances, and he founded his school. It consisted of pure observation applied to the knowledge of diseases and the actions of remedies. This clinical observation was sufficient to produce results, whose value and precision we still cannot measure.
What is life? What is health? What is disease? How does medicine work? The day when man answers these questions satisfactorily, we will have obtained True Scientific Therapy.
For some, life is the result of the operation and properties of each one of the cells acting in agreement with the laws of physics and chemistry. For others it is a manifestation of spirit.
With all the medical progress of our century, we still cannot explain the phenomena of life. Physiology is more empirical than scientific. If we can say that of Physiology, what can we expect of Pathology? If we do not understand normal things, how are we going to ask for explanations of abnormal phenomena?
As much in physics as in chemistry, there have been no advances that we could call truly scientific, since to date no one has been able to explain why the so called phenomena take place.
Theories, more or less convincing, try to explain how things are made. Only a few physical and chemical phenomenons have been described. And most of the time, it has not been possible to accept that description as being true. In fact, the knowledge that we have of physics and chemistry is limited to the description of those phenomena.
Life is a balance, unknown and perfect, always at the borders of disease. And it is a complex, undetermined state, of which we cannot give a true definition that includes all its aspects.
New facts of surgery demonstrate to us that the organism has built-in maximum security: we can live without parts of our organs that perform essential functions: stomach, spleen, intestines, etc., but we are lost facing cases such as a microscopic injury to the cerebral hemispheres, whose consequences have repercussions in the nerves, muscles, and joints, almost always of irreparable character.
Concerning new discoveries in medicine, especially of speculative type, all innovations inspire distrust. Much more if they do not come from laboratories equipped with all kinds of instruments. And even more if these discoveries are personal, and have not been sanctioned by universities or institutes.
It is not conceivable, and much less in our Mexican environment, for a single person to succeed in changing the direction of medical therapeutics, which is the true aim and purpose of medicine.
Nevertheless, each discovery demonstrates to us that there is still much to investigate, and that in spite of the scientific wonders of this century, we are still in the dawn of medicine.
Therefore, more than purely scientific investigative studies, I will present a description of the practical application of discoveries verified by researchers, in general therapy, with the purpose of returning the state of health, or simply the social capacity of the patient.
For this reason, more than pathophysiological phenomena, we are going to describe physico-chemical and physico-biological phenomena observed in this therapy, in which the reader will find significant agreement with the knowledge acquired to date in pathophysiology.
This curative procedure determines only the manner of how medications must be administered: i.e. combinations, mixtures, doses, condition of the subject, etc., etc. Nothing new is added with respect to pharmaco-dynamics as shown in many books from various authors, and as practiced by all doctors.
The fundamental goal was to make certain medications effective and specific for treating some disorders, although they are not indicated, in spite of what the therapy books say. The pharmaceutic action used is probably the one that is obtained in the minority of cases, and for this reason I thought that these specific medications would give their maximum therapeutic effect if they were facilitated in some manner.
These opinions are very personal and could be, or rather will be, attached to the exact knowledge of science based on physiology, chemistry, and physical biology. This is a new system for application of all medications. I will call it: CELLULAR THERAPY.
The reasons exposed in the text will justify its name.
ORIGINS OF THIS THERAPY
Gastrointestinal disorders in our country (Mexico), bring to their death more than half of all children, within the first and second years of infancy. Ignorance of the most elementary rules of hygiene generates a great number of diseases. One of these disorders, a regional dysenteric form of enteritis, was the reason for these studies: The green diarrhea of nursing children, that affected me as an adult, in the form of a simple nutritional disorder. I was physically malnourished, something compensated for by the same discipline that guided me in all my actions, even those that had nothing to do with the disease.
Submitted as I was, during my medical student life to all the therapies known at the time and to all my teachers, who showed great persistence in returning me to a healthy state, I felt a great disappointment toward medicine when I did not obtain at least an improvement compatible with my activities, which had been reduced to a minimum.
The fashionable new treatment for Diabetes Mellitus was INSULIN. The laboratory producing this medication was also recommending it as the best treatment for emaciation.
Without any hopes of obtaining some improvement of my disorders, resigned to my condition, desiring only to not have the appearance of being sick, and to inspire a relative confidence to my patients, I followed the instructions of the laboratory producing the insulin. I began to apply 10 units of this hormone daily, by intramuscular injection, half an hour before the main meal. I followed all the strict instructions of the manufacturer, because it said that any negligence in this application could cause death.
I continued increasing the dose and injecting myself before the main meal, and occasionally before the three meals customary in this country. I did not have to wait long for results. A few months later, the anorexia had disappeared and the taste of all types of food was most pleasant. Indeed I began to gain weight. In addition, I had a pleasant feeling of euphoria, and the main reason for my condition, diarrhea, had almost disappeared.
The Insulin produced, independently of its recognized specific function, an extraordinary and rapid cellular assimilation of substances ingested at the appropriate moment after its application.
Anxious to speed-up my recovery, on many occasions without the least precaution about dosage, I injected myself with up to 80 units of insulin. This caused me to experience true hypoglycemic shocks (1926).
The duties of my profession, which are the most hazardous, prevented me from continuing the application of this hormone for an indefinite period of time. Since the symptoms sometimes appeared outside the predicted time, it was necessary to contain them with the ingestion of some food or sugar. If I did not do this, the action of the insulin would give the impression of lack of consciousness, similar to that produced by narcotics.
I heard that many people considered me a cocaine addict.
These circumstances brought in me a firm resolution: to determine with precision at what time the symptoms of hypoglycemia would appear.
I took advantage of the desperation of a good friend, who had one of those many incurable ailments, to propose to him a cow’s milk injection intravenously — which at the time was usually applied intramuscularly. The hope was to cause in him the well-known reaction, but more abrupt and more intense, and at a precise time. I did all the preparations for the case, warning him that when he began to feel the choking sensation, palpitations, anxiety, lack of air, etc., to immediately warn me to halt the application and to inject what would be suitable.
In 10cc of bidistilled water and with all the rules of asepsis, I added one tenth of a cubic centimeter of cow’s milk sterilized by boiling, in a hypodermic syringe. After shaking it, I inserted in the vein the needle of the syringe that contained this solution. More than one tenth of a cubic centimeter was injected. At the end of it, the patient yelled, indicating to me the choking sensation, with his face turning red. The application of caffeine-strychnine was enough to stop the present symptoms and to return the patient to his previous state.
I learned a lot with this dangerous experiment. Milk proteins can be injected intravenously, although in a very small dose. This experiment allowed me to inject the amino acids that comprise insulin intravenously. According to the discoverers of this hormone, this was fraught with danger. In fact, I prepared 10 units of insulin that were injected in me intravenously, not experiencing, as expected, any immediate serious symptoms. Twenty minutes after the application, however, I began to feel: blurred vision, asthenia, hunger, thirst, and all the accompanying symptoms of the action of the pancreatic hormone. Therefore, I had obtained what I wanted: to know with precision the time of occurrence of the symptoms of hypoglycemia.
This experience, acquired at my own risk, made me begin to see great possibilities for this therapy. If by the action of this hormone, food is digested and assimilated, we have weight gain, euphoria, and the biggest mental and physical capacity for all activities, I thought: “Will the same thing happen with medications?”
Later, I had the idea of taking advantage of the action of this hormone in neurosyphilis. Neurosyphilis was perhaps the most rebellious disease to all known therapies. This would be a definitive test, and would demonstrate the results very well. It was known, in the incipient states or acute stages of neurosyphilis, that induced malaria, with all its objections, can achieve a notable partial recovery in some cases, but in the majority it will only stop for some time. Then it evolves towards dementia or other more serious forms of this disease. This is how I began the application of this hormone in patients with neurosyphilis. Later, I will relate all the necessary and associated details.
When I had completely demonstrated the beneficial results in neurosyphilis through the change of serologic reactions, mental symptoms, and neurologic signs, I tried to apply this curative method in diseases caused by viruses. Measles was the first one, and I observed excellent results. I did the application on children in full eruptive stage. This is when, as we all know, the symptoms are exacerbated. And I remained amazed that within 1 to 2 hours, all the symptoms and signs had disappeared. This new therapeutic advance opened a new road to perform the application of this therapy in all the illnesses caused by pathogenic germs. The great metabolic modifications observed also allowed me to take advantage of it in non-classic diseases. This is how I covered almost all pathologic disorders.
SYNONYMY — Syphilis from Greek, synonymous with Phileo, I love; from Arab, safala; from Hebrew, schafal; from Latin, lues: infection, damage; Gallic disease, Neapolitan disease,With these and more names given to the disease, it was perhaps the most serious threat, devastating humanity. And it could not be dominated, in spite of all the research known in the modern classic medical world.
It is a contagious and hereditary disease; chronic; of diverse, numerous, continuous, or intermittent manifestations; specific; the most polymorphic of all the well-known diseases, attacking all organs; treacherous, sly, evolving during almost the whole life of the individual; and before which, only prophylactic measures have been effective to date.
The oldest writings of Chinese origin, 2,000 years before Jesus Christ, already spoke of a disease. Comparing this literature with writings of Rome, Greece, and India demonstrates that, due to the lack of studies and basic knowledge, it was confused with skin disorders such as leprosy, lupus, psoriasis, etc., but that in fact it was syphilis.
Surely it is a prehistoric disease, as old as man, since in the fossil findings studied up to now, it has been verified that bony deformations correspond to lesions of this origin in the bones. And possibly the syphilitic fossils found in Europe are older than in America. The fact that corroborates this appreciation, the troops of Alexander The Great, King of Macedonia, during the campaigns of India, in the year 327 BC, were decimated by a rare disease, and he also was probably a victim of the same disease, succumbing at the age of 33. By the end of the year 1400, Europe was devastated by an epidemic that began during the War of Naples. Near perfect descriptions of the time identify it as syphilis, which they called Neapolitan disease. The Roman emperor Julius Caesar, who crossed the Rubicon river in 49 BC, returned to Rome after the conquest of the Gauls, and brought a disease that the Romans named Gallic disease. In 1530, Girolamo Fracastorius makes a true description of this disease in his Sphilo poem, a character of “Morbus Gallicus”. These data of historical interest demonstrate that it was in Europe where syphilis made its appearance, for the first time, in the history of humanity.
PATHOGENIC GERM. — The discovery of the flagellated protozoan of the family of the Trypanosome, Treponema Pallidium or Pale Spirochete of Schaudin and Hoffmann, took place in 1905 and takes the name of its discoverers. It is a germ that has the form of spiral, from 6 to 12 turns, with specks one quarter of a micron in diameter, of 6 to 14 microns in length. It is generally found in chancres, syphilitic papules, in the gummas, the nervous system when in the tertiary neurosyphilitic stage, and sometimes in the blood in the secondary stage.
Levaditi was the first who tried to cultivate it. But it was Noguchi who obtained the first cultures, as well as the first who respectively demonstrated its presence in the medulla and the brain of patients with Progressive Locomotor Ataxia and General Progressive Paralysis. It can be confused with the spirochete of Vincent (existing normally in the mouth), the spirochete perfringens, and the spirochete of ulcerated cancer. By the particular character of each one of these spirochetes, bacteriologists can make perfect distinction between them.
The inoculation of syphilis into laboratory animals led to the discovery of serum diagnosis by Wassermann in the year of 1906. The knowledge of the disturbances of the cerebrospinal fluid was obtained by Widal, Sicard, and Ravaut. The active chemotherapeutic and arsenic agents were discovered by Ehrlich in 1910. These three events were true pedestals in the progress of the treatment of this disease.
MODES OF CONTAGION — Sexual contact predominates in the contagion of Syphilis. Contagion is less frequent by kissing, and by breast-feeding healthy children. Outside of these, other means of infection are extraordinarily rare. What has been observed frequently, is the infection of surgeons when they have touched some active lesions, if previously an erosion of their skin had taken place. The infection is acquired from syphilitic individuals when they have primary or secondary lesions, or chancres. Almost no risk of contagion exists in the tertiary stage. The blood of secondary syphilitics is contagious, as has been demonstrated by inoculations to man and to monkeys. We suppose that sperm does not have any risks of contagion, because otherwise all the children of syphilitics would inherit the disease, and it has been clarified, throughout many years of demonstrations, that sperm does not transmit the disease. Milk, saliva, nasal or bronchial mucus, if there is no secondary lesion in evolution, are not contagious. Suppurating non-syphilitic lesions, as for example: acne, furuncles, gonorrhea, etc., are not generally contagious. Vaccination from arm to arm, fortunately not practiced in these times, was a constant source of contagion. For contagion to occur, it is necessary to have an entrance door, a means of continuity through the skin or the mucous membranes such as a scratch, scrape, erosion, or injury. It is extremely rare for the infection to go through intact skin or healthy mucous membrane.
Every country, every race, and every age are afflicted by syphilis, but certain conditions favor the contagion, such as lack of hygiene, weakness, or the parent’s hereditary predisposition to syphilis. This last one gives some immunity in certain individuals, but most frequently it does not. In penitentiary environments, the proportion of infected individuals is up to 80%. One of the factors that has always facilitated the propagation of the disease has been war. After wars, the invaded towns have experienced true epidemics. In this last war, we had no reason to complain in proportion to all the previous wars, because almost all the armies imposed extreme prophylactic measures. Nevertheless, due to lack of controls after demobilization, there has been a slight increase in cases of syphilis. At all times, this has been the disease brought by the conquerors to their conquered.
The exact knowledge of the way to prevent the disease is what stopped its expansion.
According to a well accepted theory, congenital syphilis is acquired by the fetus when it is in the placenta. Nevertheless there have been demonstrations that the infection in the newborn may take place during childbirth. The disease is contracted in two ways: congenitally and through parturition; but congenitally is the most frequent.
There are five types of syphilis recognized to be congenital:
1. Embryonic syphilis, contracted during the first three months of pregnancy.
2. Fetal syphilis, which develops before birth, is the cause of the great majority of abortions, premature childbirth, and deaths of the fetus. Normally, it has as its only symptom one of these manifestations, since testing the parents always comes out negative. This is the reason for confusion for doctors with little experience, because the parents do not have any manifestations of the disease.
3. Syphilis hereditaria tarda, appears in the first years of life of the child, with cutaneous manifestations, mucous or nervous, the latter being most frequent. On this subject, treatises and more treatises have been written to demonstrate that almost all the physical or mental abnormalities in children or in young people are of syphilitic origin, or because they have inherited syphilis from their parents, or simply because they have stigmas.
4. The nearer the contagion is to the conception, the more probability of syphilis for the descendants. In general old syphilitic parents do not conceive syphilitic children.
5. Abnormal implantation of the placenta, its weight, or size larger than normal, hydramniotic, rare presentations of the fetus, pregnancies of twins or more... All these anomalies in pregnancy always suggest hereditary syphilis.
MANIFESTATIONS OF SYPHILIS
PRIMARY STAGE — CHANCRE — Chancre, from French, chancre, deriving from Latin Cancro which means Cancer, is the name of the first manifestation of syphilis.
The first lesion appears in the genital organs about fifteen days after sexual relations, whether it is in a man or a woman. But to be clearer, in this exposé, we are going to speak first of the man, since there are sharp differences in its appearance.
For many years the prevailing idea was that the chancre had the following characteristics: singular, hard, with painless bubo, venereal tumor, tumor in the groin, or adenitis without many symptoms, that did not get to suppuration. This is to say that it resolved by itself. To speak with so much precision of medical subjects not well studied, gave rise to very many medical, personal, and familial disasters. In these last years it has become clear that when there has no longer been a remedy for many patients, it is not possible to make a diagnosis only by simple sight or touch. The classic descriptions say clearly: well defined erosion with rounded off contours, without edges, smooth surface, grayish or red in color, flesh with little secretion, very hard base, painless, and without inflammatory phenomenon, of very small size. It can be so small that sometimes it remains undetected by the patient, being almost microscopic in size. There are many varieties such as flat chancre, with ridges, scrofulous, ulcerous, etc.
The chancre of women appears almost always in the genital mucous. It very frequently remains undetected by the patient. For this reason, she denies having ever had an infection. It is a superficial erosion, like a desquamation of the epithelium. It leaves a bright red surface, irregular, barely limited by the coloration to the rest of the mucous. We will be able to observe by these descriptions that it is very difficult, even for the doctor to make the diagnosis of syphilitic chancre, with the simple means of exploration that we have in the clinic. For this reason, if we want to make a precise diagnosis of the chancre type, it must always be based on laboratory data. How many losses of life and how many disasters have come from chancre diagnosis taken lightly?
The rule in each case, whenever the patient has some lesions in the genital area, although this patient says that there is no reason to suspect the woman or the man, is to investigate by means of the microscope. That is to say, let the laboratory make the diagnosis, taking directly many biopsies from the lesion, especially scraping the surface of the chancre. We must also look for satellite lymphatic ganglia. Generally these ganglia are painless, multiple, and they almost never arrive at suppuration. The lymphatic ganglion nearest to the lesion is where it enters the circulatory current. Almost always before the chancre has reached its complete development, it has already invaded the whole organism by these channels. For this reason local lymphocytis and lymphadenitisare precocious lesions. It has been perfectly demonstrated that the fundamental lesions of syphilis are always in the vasa; attacking first the vasa irrigating the vasa called “vasa vasorum”, they must be present for all the subsequent studies of the site of the lesion.
We must give great emphasis to the exact classification of the kind of chancre, because most of the time, neither the patient nor the doctor gives importance to the primary lesion. And this, later, always gives unfortunate results for the patient and all those surrounding him. No treatment must be instituted before making the correct diagnosis. Because, if it is syphilis, the treatment always remains incomplete and often, most frequently, the individual becomes resistant to all therapies. Later, serious lesions appear, which the patient never relates to the primary manifestation.
The doctor must never take into account the desire of the patient to be healed more or less quickly, as the patient always demands it. In the doctor’s and the patient’s mind will remain, all their life, the doubt about whether or not the lesion that healed spontaneously had been syphilis. Therefore, we repeat, the primary lesion is never serious and most of the time will heal on its own.
The genital organs of the man and the woman are the most frequent places where the chancre will appear; the anus, the tongue, the mucous of the lips, the sinuses, etc., are also propitious places for the occurrence of the first syphilitic manifestation.
At the appearance of a chancre, the lymphatic gland is immediately observed. In only three cases out of 5,000, the adenitis (by inflammation of the ganglia receiving the lymph of the infected region), did not occur, because as we will see later, it is a constant manifestation of the chancre. If the chancre takes place in the genital regions, the adenitis will appear in the left or right inguinal region (groin), according to the side where the lesions are located, or on both sides. They appear on the same side, if the primary infection is observed in the paragenital or anal regions; in the axillary region if the infection is in the sinuses or an upper limb. But if it is in the hand, the first infection can appear either in the epitrochlear ganglion or the armpit. Submaxillary adenitis comes when the primary infection is on the tongue or on the lips. Uterine neck adenitis appears in the pelvic ganglia, more reason that the patient does not realize the onset of the disease, since the primary infection took place in the uterine neck. Too frequently, it is ulcerations of another origin — almost always gonococcic — that facilitate the onset of the syphilitic infection. As a rule, the onset of syphilis in the woman is made through the uterine neck, a site impossible to reach by the doctor’s eye, and almost no symptoms are given to reveal its presence. Besides, if even in very apparent places it is difficult to do, because of the limited means at the disposal of the doctor, the diagnosis of syphilitic chancre in these areas in the woman can never be done during the diagnosis of the first syphilitic manifestation. This is the main reason that when asked about the primary manifestation, they always deny having had any. The general rule in adenitis is that it never suppurates and presents few or no symptoms of inflammation.
A phagedenic chancre, called red or ulcerous phagedenic, has a red wine coloration, and grows discreetly and quickly, despite all treatments (in extent and depth). It can last in all its evolution from three weeks to three months. Only a mixed energetic treatment can stop these manifestations.
It has been established at the present time that almost all chancres are simple lesions vulgarly called “redness.” The more serious types of phagedenism are always mixed and for this reason, the first step for the conscious doctor, is to send the patient to the laboratory, so that all known means can be used for the search for the bacillus of Ducrey and Treponema. If after these tests, the result has been negative, insist after some time to search for Treponema. If weeks or months have passed, look for the infection in the blood of the patient, by means of reactions, of precipitation, and others.
It is not possible to make a true description of a typical syphilitic chancre. These symptoms are valid only to give us an idea: in an interim of 10 up to 60 days after the infectious contact, appears a slightly greasy rising skin, then its crest erodes giving rise to a small reddish ulcer, covered with light grayish-yellow exudate, sharply defined with discreet inflammation around it; and after a few days it becomes hard. This is the reason why the chancre is called hard. It is simply a rosy erosion in the beginning, rarely painful, healing within a period of four to five weeks without medical treatment.
When the bacillus of Ducrey is associated with the treponeme, then it is frequent to find phagedenic chancres. They always give a show, truly spectacular and stubborn to the treatments in use. The adenitis of mixed chancres always suppurates and is open spontaneously to the outside or by the intervention of the surgeon. In surgery it is imperative to perform the evacuation of all the inflamed ganglia of the region. The real chancre adenitis never suppurates and is very discreet in all its symptoms.
SECONDARY STAGE — About six weeks following the appearance of a chancre, the secondary eruptions appear. They appear without apparent cause and generally when the individual does not even suspect having this disease. Very slyly, without noise, without symptoms or fever, without inflammatory reaction, with slow evolution, of local character, with little or nothing obvious, irregular in its size, without itching or local subjective symptoms, and with all these peculiarities, appears the ROSEOLA. Most of the time, this is what starts, the secondary stage. It is characterized by rosy, circular spots (from where the name comes), without elevation of the surface of the skin, without ridges; first on the sides and soon on the lateral parts of the thorax and on the back; finally, on the chest and the internal part of the limbs. If no other symptoms exist accompanying or preceding those of Roseola, we can be sure that it is the secondary manifestation of syphilis.
More frequently, coinciding with the appearance of the Roseola skin lesion, is alopecia, on the hairy part of the scalp. It is distinguished from other alopecias by not showing any symptoms with the fall of hair of the head, the eyebrows, beard, armpits, or any of the other parts of the body. It lasts a few weeks, never lasting a year. Whenever the patient gets alarmed, he immediately consults with the doctor and, with the usual treatment, improves quickly.
We observe other forms more or less similar to the skin lesions described; but in addition to being the most frequent, they are the clearest of the secondary manifestations.
Almost with the same certainty, lesions of the mucous membrane (mucosa) are also classified as secondary manifestations. Formerly called mucous plates, these syphilitic manifestations are the most contagious. Other lesions range from the roseola of the mucous membrane which are simply pink spots in the mouth, the throat, the vagina, to the ulcerous forms passing through a well classified series of erosive syphilomas (these are properly called mucous plaque), erosive papilloma syphilomas, hypertrophic papilloma syphilomas, papillo-ulcerous syphilomas, and ulcerous syphilomas.
They are all benign, insignificant manifestations, without proper character that allow them to be classified with ease. But the most important aspect of these is that they are extremely contagious. Heavy drinkers and smokers seem to have a certain propensity to present these symptoms, and as a result of the irritant ingested it is common to find them in these individuals at the isthmus of the throat, on the lips and on the tongue. Sometimes they are also on the roof of the palate, on the internal part of the cheeks, in the gums, and on the floor of the mouth. The most important of all these lesions is the one appearing in the isthmus, being also the site of presentation of many other diseases and for this reason lending itself to confusion. We will make a brief description to help determine an accurate diagnosis:
Mucous plaques are observed in the front part of the sides of the palate, never in the back. The swollen tonsils, the appearance of banal tonsillitis, with reddish erosions, sometimes with light ulcerations giving a certain diphtherian aspect, usually are confused with true diphtheria, because they also have grayish-white exudate. They show in short, characteristics common to those shown by diphtherian plaques. Diagnosis in both cases is necessary — especially if it is diphtheria, because that quickly evolves towards the patient’s death. Examination of the exudate is done, investigating the bacillus of Klebs Loffler.
The importance of these lesions is that they are all extraordinarily contagious. Contagiousness increases to an extreme degree when they appear in the genital organs of the woman, because this is the true vector of most of the contagions. —These manifestations have the characteristic of being silent, and the woman almost does not attach any importance to them, or rather, often does not even know that she is experiencing them.
They have different forms, almost always associated. They are observed at the level of the vulva and are more frequent in ulcerous forms. In order of presentation they are found primarily on the labia major, the labia minor, and the clitoris, the fourchette, and the whole vulvo-vaginal-anal region, the neck of the uterus, and the vagina. We must take notice that in the meretrix (prostitute) the secondary infection is frequent in both labia, including also the perivulvar region, favored by the moisture, the thinness of the skin and mucous, the heat, and the friction. The mucosal contact of secretions, which generally are pathological, almost always added to the syphilitic infection a gonococcal infection. This constantly produces a secretion that sometimes becomes caustic, favoring in the end the presentation of the secondary manifestations in this area. Being a symbiosis of several germs, the suppression of these manifestations will not be rapid in general, because to make them disappear, it is necessary to use mixed treatments, and none of the classic treatments in use for these diseases, give favorable results. In general terms, we can say that the syphilitic infection as well as the gonococcic, lapse from the acute state to the chronic state, in spite of the intervention of the doctor, because most of the time, with caustic antiseptics, other lesions take place, or the same ones extend and take many months to cure.
Among the great symptoms as frequent as the manifestations afore described, we found the ALGIAS (pains). Besides appearing often, they are easily mistakable because so many algias are brought about by various causes. Because doctors seldom know how to interpret them and much less how to cure them, it is more convenient to give symptomatic relief medicines and never look for the cause of pain.
The main algias are in the order they appear: cephalgia, sternodynia, pleurodynia, myalgias, arthralgias, and miscellaneous non localized pains.
Cephalgia (headache) is the most constant of the syphilitic pains. It is a deep pain. It seems that it originates in the encephalon and meninges, spreading to the whole encephalic mass. It is generally more intense in the frontal region, giving the sensation of constriction, heaviness, pulsating, increasing intensity in each pulsation. The main characteristic is that it is exacerbated at night, disappearing slowly in a few weeks. Cephalgia in the secondary stage does not have serious prognosis. The persistent migraines of the tertiary stage, however, which are the omen of the attack of syphilis to the nervous centers, are very resistant to the antiluetic (antisyphilitic) treatments and are always of serious prognosis.
The arthralgias (joint pains) and myalgias are easily confused with the various forms of rheumatism. The characteristics distinguishing them from rheumatism are: they do not increase with changes of temperature, nor with nutrition; however they have nocturnal exacerbation. Apparently they do not obey to any cause.
The secondary lesions of syphilis, appear in all organs. We will only list those which are more frequently affected. The adenopathies and all the lesions of the external parts of the eye: keratitis, iritis, conjunctivitis, and blepharitis.
TERTIARY STAGE — Systematically, we have reviewed the main manifestations of the secondary stage. This stage is characterized because it is easy to diagnose, because of its visible lesions. But we never know when the third stage is going to begin. In general terms, we can say that in the whole evolution of syphilis, it may appear after a few months, even years, up to forty or more, during which syphilis is latent. It never gives manifestations in any organ, and further more, the blood in several tests can be negative. Because of that, it is impossible to say whether or not the patient is cured, having had some, or no manifestations of the second stage. All signs or symptoms — appearing after a few years of the primary infection, with or without treatments, well done or badly carried out, and sometimes without reason — display the following characteristics: without fever, of slow evolution, without inflammatory reactions, without deep lesions, without disorganised lesions, they attack the individual in old age or near old age, rarely during youth. Included are lesions from the skin to the central nervous system.
We will only give a small list of the most important manifestations because almost all pathology books a chapter on syphilis. We will explain the most serious and frequent manifestations of this disorder.
In the skin they are: the dry syphilitic, the ulcerous, the erythematous, and the gummatous lesions which from the histopathologic point of view are defined as syphilitic neoplasms of the tertiary stage.
The various regions of the digestive tract are not equally affected. There is preference for certain organs. The regions of transition between the skin and the mucosa are the favorites. The buccopharyngeal cavity and the anorectal region, the liver, esophagus, stomach, and intestines follow.
The nasal cavities, the larynx, and finally the lungs are the organs of the respiratory apparatus affected by tertiary syphilis. The differential diagnosis has importance mainly with tuberculosis.
In syphilis we find: absence of the tubercle bacillus in the saliva, absence of sanguinolent sputum, conservation of good general health (before the development of very old syphilis), and immediate response to antiluetic treatment. In contrast to the condition of certain affections of the lung, we generally find unilateral lesions (at the beginning) and frequently lesions of the same character in the larynx or pharynx, as in tuberculosis.
Osteoperiostitis in the bones is a frequent manifestation of the tertiary stage. Its preferred sites are the tibia, the ulna, the radius, and the bones of the head. In the long bones, in the union of the epiphysis with the diaphysis, is where extraordinary development appears along with the pain, as predominant symptoms. Once past the acute period in that tumoral process it finishes with the formation of an exostosis, that is to say, a definitive bony tumor that attaches to the bone mass. For example, in the tibia, all the characteristics are often shown. These exostosis have the following form: at the crest of the tibia, instead of describing a curve of anterior convexity, is observed and felt a voluminous bony projection, rounded and rough.
In the flat bones, as those of the head, we observe gummatous osteomyelitis, that besides producing a secretion similar to rubber, causes necroses to the bone. And often — when neither the patient nor the doctor are aware of this process taking place — spontaneous fractures occur. As we shall see, there is no such thing, because it is syphilis that produced them. When osteomyelitis originates in the internal lamina of the bones of the skull, it causes intense migraine, convulsions, paralysis, and variable meningitic attacks.
We must not pass unnoticed one of the frequent cerebral phenomena of tertiary syphilis: convulsions. All the epileptic forms are observed. Only a conscientious examination of the patient can give us an exact diagnosis of the etiology of convulsions. It is said by great authors of treatises that epilepsy has these characteristics: it has AURA, (sounds or sights expressed by the patient before convulsions), often tonic and then clonic, the thumb flexes within the other fingers, and after all the convulsions there is a period of stertors, which means that the patient is sleeping deeply with heavy snoring.
Ocular paralysis, hemiplegia, aphasia, face paralysis, bulbar paralysis, and all the motor paralyses often originate from advanced syphilis, that almost never left impressions in the patient, and for this reason their appearance is disconcerting for the patient.
Because of the great frequency, the violence, the absence of any prodromes, and because it appears in people with apparent good health, it is important to speak a little about this phase.
An apoplectic seizure, after an abundant supper or some other excess, triggers the terrible crisis. Suddenly the patient faints, falls as if struck down by a thunderbolt, with slight generalized convulsions, or localized in the part of the body that is going to stay paralyzed, state of complete or semi-complete unconsciousness, and immediately afterward, one side is paralyzed. It can include the face and be of the same or opposite side. When it has been serious, the state of unconsciousness lasts several days and the patient recovers by himself. Or also it usually happens that he succumbs after the apoplectic attack. After some months or years, the attack recurs and paralyzes other parts of the body.
Hemiplegia or hemiparesis also settles in, sometimes slowly. It begins with numbness, cramps, formication, and little by little the strength is lost in one side, until reaching its maximum in a few days. Sometimes before being well established, there are intermittent attacks; almost always, there is contracture and an exaggerated increase of all the reflexes, especially the tendinous ones.
Classic therapy does nothing to help this class of patients.
Aphasia is one of the most frequent symptoms of syphilis of the third stage. Its beginning is abrupt and sudden; but it can also be slow and progressive in a few days. The patient begins to feel certain difficulty articulating some words, mainly when he is articulating a difficult word, substituting one letter by another, accentuating progressively this disorder while the aphasia is settling in.
In the majority of cases there is blindness and verbal deafness. Along with these serious symptoms coexist intellectual, moral, and sensorial disorders; symptoms that almost always are part of the cortege of the different forms of cerebral syphilis.
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