EARLY SYPHILIS IN THE NEGRO. BY I. EDMONDSON ATKINSON, M. D., Physician to the Baltimore Special Bispensary. ,J. H. FOSTER, STEAM BOOK AND JOB PRINTER, 2 AND 4 N. CHARLES STREET. BALTIMORE!. EARLY SYPHILIS IN THE NEGRO. I. EDMONDSON ATKINSON, M. D., Physician to the Baltimore Special Dispensary, [Bead before the Baltimore Ulinicaf Society, May 11, 1877.} Whatever may be the hygienic condition of the negro races of Africa, it is quite certain that their representatives in this country offer less resistance to the inroads of disease than almost any other class of our population. This is especially true of those individuals, whose negro blood is diluted by that of the white races, and who largely outnumber their brethren of full blooded African descent—certainly, at least, in our larger cities. That this general defect of organization exists, is proved not only by the opinions of those persons having opportunities for obser- vation, but also by the experience of the Surgeon-General’s Department of the United States Army during our late war. (See introduction to Part I, Medical and Surgical History of the War of the Rebellion.) From this latter it appears that of one thousand colored troops there was an annual death rate, from disease, of one hundred and thirty-three ; while of equal numbers of white troops, both regulars and volunteers, the annual death rate, from disease, was thirty-two for the former, and fifty-five for the latter. Without doubt, not a few different agencies were at work in producing this excessive mortality; but for the present, I only desire to call attention to that diathetic condition, which, while not frequently proving the immediate cause of death, has I. EDMONDSON ATKINSON, an immense influence, although remote, in determining the fatal issue in negroes, and complicates to a greater or less extent, the course of nearly all their maladies; namely, scrofula. The remarks that follow are principally based, then, upon the coexistence of syphilis and the scrofulous diathesis; and since the course of syphilis in scrofulous individuals has been well known and described, I can hope to bring forward but little that is new. They represent, however, the results of observations upon a num- ber of syphilitic colored persons in the early stages of the disease, (with one or two exceptions, within a year after infection) and, while deficient both in numbers and details, will, it is hoped, suffice to give a tolerable idea of the general tendencies of the malady in the race. The whole number of cases of primary or early secondary syphilis in negroes treated was one hundred ;* of these, the primary lesion was present in forty-five cases, thirty-four males and eleven females. It may be proper, at this time, to compare with these figures, the number of colored patients applying, during the same period, for treatment of simple, non-infecting chancres or chancroids. Of these there were twenty-four individuals, twelve males and twelve females. According to the summary of M. Puche, this lesion is met with four times as often as the syphilitic or infecting chancre, while other writers make more moderate estimates of its greater frequency. We have here, however, the reversed pro- portion of two to one in favor of the syphilitic chancre. The small number of my observations may be entirely misleading, and makes any reliable calculations upon this point impossible. It is likely, however, that syphilitic infecting chancres were so fre- quently encountered, in consequence of certain peculiarities of their symptoms, to be presently adverted to. The characters of infecting chancres as ordinarily met with, are too definitely known through the closely agreeing descriptions of them in text books, to make more than a brief allusion to them necessary, in order to point out the contrasting conditions as all of the cases referred to in this paper were treated at the Baltimore Special Dispensary, during- the past three years. EARLY SYPHILIS IN THE NEGRO. 3 occurring in the negro patients under consideration. The “super* ficial erosion” is, by far, the most frequent form assumed by the syphilitic chancre; thus the table of Rassereau, of chancres preceding one hundred and seventy cases of syphilitic erythema (quoted by Bumstead) show one hundred and forty-six cases of ■“superficial erosion”—Raiimler (vol. 111, Ziemmseu’s Cyclopaedia of the Practice of Medicine, page 79,) describes the superficial erosion as the typical syphilitic chancre, and says that only exceptionally more decided ulceration may take place. Fournier, (Leyons sur la Syphilis, etc: page 148) declares that in the female, at least, the chancre is of the erosive form eight times in ten. Phagedena is agreed by nearly all writers to be quite rare as a complication of the primary lesion. Fournier represents it to be so rare that in the male it is a pathological curiosity, while in the female it is almost unknown. Let us see, now, how far the primary syphilitic lesion accom- modates itself to these rules, when observed in the colored patient. Of the forty-five cases already mentioned, extensive ulceration of the chancre is noted as occurring in twenty-five cases, of which nine were women. It is noticeable that in all except two of the female patients, this condition of the chancres was encountered. I can only account for this fact by the well known liability of the less severe forms of ulceration of the female genitals to escape attention ; indeed, I have frequently been amazed to discover ex- tensive disease, wdiere its existence had never been suspected by the patient. This is probably due to uncleanly and careless habits. The superficial erosion was but seldom encountered. In nearly all of my cases, free secretion of pus, accompanied the lesion, even where much ulceration was not present. This ten- dency to free pus formation, as may be supposed, altered consid- erably the physical characters of the sores. These were in striking contrast with those usually observed in otherwise healthy subjects. The chancres, instead of the dull gray or reddish coloration; instead of smooth, glazed, inactive bases; instead of flattened, or even elevated surfaces with insignificant or slanting walls; had generally a yellowish or yellowish-gray, color and precipitous or excavated borders, actively secreted a creamy or 4 I. EDMONDSON ATKINSON, thick sanious pus, and were very tender. Instead of being' sur- rounded only by the typical syphilitic induration, they were not seldom so inflamed that this induration was masked by that of simple inflammatory infiltration. In twenty-seven cases, specific induration, of various degrees of intensity, clearly and definitely existed; in ten cases the presence of simple inflammatory infiltration made it impossible of recog- nition ; and in eight cases it was absent. Two of the last mentioned patients were males, in one of whom the lesion was diagnosed as syphilitic, from accompanying painless multiple inguinal adeno- pathy, attendance having ceased before further verification of the diagnosis. Unmistakable constitutional symptoms subsequently justified the diagnosis in the second case. In a third patient, a young mulatto man, two chancres, one upon the skin of the prepuce the other upon its mucous portion, while presenting convex surfaces and serous discharge, remained absolutely unindurated until fifty-five days after they were first observed, when, co'incidently with the first appearance of general symp- toms, viz: general adenopathy, roseola, etc., induration to the size of small chestnuts suddenly occupied the seats of the chan- cres. The sores in the other two patients were single and situated, one upon the skin of the prepuce, the other upon the prepuce near the frsenum. The other six patients whose chancres were not indurated were females. These sores were situated upon the four- chette in four cases, upon the posterior commissure in one case, and upon the labium minus in one case. The absence of induration in vulval syphilitic chancres has not been at all un- common in my experience, and I am confident that the doctrime of its necessary presence ia a common source of error. The diagnosis in the cases above mentioned, rested, in two patients upon painless multiple enlargement of the inguinal glands; one woman had been the subject of inherited syphilis and bore upon her person scars from ulcerations during childhood, and whose central upper incisors were deeply notched. Her chancre was accompanied by indolent, but greatly enlarged inguinal glands and followed by faucial mucous patches and rheumatoid EARLY SYPHILIS IN THE NEGRO. 5 pains with nocturnal headache. The three remaining cases continued under observation until unquestionable syphilitic secondary manifestations supervened. Induration of the chancres varied in all degrees of intensity and differed from that usually met with, only in its frequent com- bination with an inflammatory condition. This complication, besides obscuring the diagnosis, most probably by the discomfort occasioned, compelled that application for relief, which absence of personal cleanliness and solicitude would otherwise fail to effect; and thus, we have, perhaps, a reasonable explanation of the greater frequency of the infecting chancre in these cases. The same combination, undoubtedly, encouraged the occurrence of traumatic phymosis, of which seven cases were treated. In six cases there was phagedena. 7'he term is here used in its mildest sense. Serpiginous or sloughing phagedena were not encountered. Indeed, in none of these persons (three males and three females,) did the process pass beyond extensive and deep ulceration, not always to the destruction of induration, in two cases burrowing far along the urethra, destroying the vestibule, while a third patient lost a considerable part of his glans penis. The chancres, which were situated upon the external genital organs, with the exception of one upon the groin, were single in twenty-eight cases, while in seventeen cases there were two or more sores. Passing now from the consideration of the primary lesion to that of the glands in proximate connection with it, a decided evidence of the influence of the scrofulous diathesis becomes manifest, in their tendency to very pronounced inflammatory action and to the production of pus. Early inguinal adenopathy occurred in forty-eight cases including four, in which, although in the earliest stages of syphilitic infection, the chancres were not detected. (The adenopathy was absent in one case, wdiile the chancre and general symptoms were present.) In twenty two cases the glandular hyperplasia was quite indolent; there were inflammation and tenderness but no suppu- ration in fifteen cases; while in twelve cases there was suppuration in one or both groins. I. EDMONDSON ATKINSON. Suppuration of the glands communicating with infecting -chancres in otherwise healthy individuals is practically of such rare occurrence, that the indolent multiple adenopathy is proba- bly the most valuable symptom by which we recognize syphilitic infection. It is well known, however, that scrofulous persons are much more liable to suppurative adenitis accompanying infecting chancres, but I am not aware of its ever having been described as of a frequency comparable to that abovementioned. Naturally, then, the course of these adenopathies merits some description. The only noteworthly peculiarity of the indolent glandular enlargements was the extreme degree to which the parts were often hypertrophied, in several instances occupying the whole inguinal region as huge, nodulated masses in which the glandular outlines could be obscurely felt, and thrusting themselves upon the attention with startling prominence. The fifteen persons whose groins were inflamed and tender without suppurating, offered interesting symptoms, both as regards themselves and as foreshadowing the more advanced degree of inflammation observed in the third series. Several had buboes like those usually accom- panying non-infecting chancres ; that is, buboes of irritation, with, however, the superaddition of other glands painlessly enlarged. The great majority had diffused and very large tumors, occu- pying the surface usually covered by the inguinal glands and forming matted, inflammatory masses in which it was impossible to distinguish any indications of the individual glands. In these cases it was evident that the tumors projecting far beyond the normal level, were chiefly due to the inflammation of peri-glandular cellular tissue. These swellings were exceeding painful for the most part, and incommoded the bearers to such a degree that locomotion became almost impossible, and occasionally compelled confinement to the bed. Of the twelve remaining cases of primary adenopathy, the smaller number were instances of suppuration of single glands and their surrounding connective tissue, the other glands of the part, while enlarged, remaining for the most part indolent and painless. In the other cases, however, the points of suppuration EARLY SYPHILIS IN THE NEGRO. 7 appeared, as it were, imbedded in and slightly projecting beyond the mass of matted inflammation, involving the greater part or all of the inguinal area, occasionally of both groins—it being quite impossible to define any glandular outlines. It never happened that the whole mass broke down into pus, but rather that one or two fluctuating points revealed themselves, and when these were incised and their contents evacuated, the surrounding inflammation slowly and gradually subsided. The nature of the pus discharged from these buboes was usually creamy, by no means so serous as that which I have seen from suppurating glands of later stages of the disease. The course of these sup- purations was not so tractable as that of simple irritative buboes, but was milder and more amenable to treatment than ordinary scrofulous adenitis, responding with tolerable alacrity to the combined influence of suitable tonic and mercurial remedies. The orifices of the abscesses gradually forming the exuberant everted lips of scrofulous fistulous openings, and contracting finally healed leaving hypertrophic cicatrices. The number of patients in whom secondary symptoms were manifested was eighty-two. In forty-nine of these infection had taken place six months or less previously; in sixteen cases more than six months and less than one year previously; in six cases more than one year previously ; and eleven persons could give no definite information, but were most likely but a few months syphilitic. An enumeration of all the various symptoms displayed by these people, could be of no profit equivalent to its tediousness. I consequently propose to limit my remarks to those of them possessing peculiar interest and especially as showing the influ- ence of the scrofulous diathesis upon them. During the early stages of constitutional infection, the lymphatic glands, or, at least, those situated in superficial portions of the body, are prone to the same kind of inflammation as are the glands in connection with the primary lesion. Adenopathy other than- inguinal and occurring during the early secondary period, was noted in nearly all of my patients, frequently occasioning pain and tenderness. Positive suppuration, however, took place in eight cases. In every instance the cervical or submaxillary 8 I. EDMONDSON ATKINSON. glands were the ones involved, the cervical (principally anterior) glands in four cases and the submaxillary glands in four cases. These glands became greatly swollen and closely resembled ordi- nary scrofulous inflammation of the same parts, from which they differed in greater amenability to treatment. In healing however, the enlarged, hardened glands remained very persistently. Roseola was, as might be anticipated, but rarely seen, the normal color of the skin and the insignificance of the symptom usually preventing its detection. When seen it was simply as macules of deeper pigmentation than that of the surrounding integument, not fading upon pressure. The papular syphiloderm was encountered in twenty-five cases, fifteen males and ten females. The ordinary lenticular papules were most frequently observed, but the small papular syphiloderm also occurred. In two cases the latter form of eruption appeared to be confined to the papillae surrounding the orifices of the hair follicles of the general surface (not of the scalp); and in these patients the epidermal accumulations at the apices of the papules were unusually abundant and strongly suggested lichen pilaris. Ihe danger of such an error has previously been pointed out as more apt to occur in the negro subject.* In other respects the papular syphiloderm in negroes differs from the same lesion in the white subject only in coloration and in its very pronounced tendency to pass into pustular eruptions. In the early stage of its existence the papule is simply of a darker hue than the sur- rounding skin; later, this increase of pigmentation is supple- mented by a peculiar whitish appearance, which close examination reveals to be the result of a fine desquamation occurring irregularly upon the surface of the papule. This condition has been described by Dr. R. W. Taylor. Still later, from the rapid and continuous shedding of epidermis, the papules may acquire a lighter hue than the rest of the skin, having at the same time a shining, polished aspect. Dr. Taylor has reported a condition observed by him in two negroes, where, in striking contrast with the black surface, was the surface of many of the papules which *Duhring, Diseases of tho Skin, page 453. EARLY SYPHILIS IN THE NEGRO. 9 were quite white, “in fact nearly of a snow white in spots where the skin was kept clean and of a dirty white elsewhere, f This description has no reference to the fine white desquamation already referred to, but is attributed by Dr. Taylor to an alteration in the pigment cells of the rete Malpighii together with increased cell proliferation. I have never observed a loss of pigment to any" thing like this extent. The following figures indicate the above mentioned tendency of papular lesions to become pustular: In twenty-two cases, four- teen females and eight males, pustules were present either without papular accompaniments or as the prevailing symptom; in ten cases the eruption was papulo-pustular, that is, while the original eruption was apparently papular, the summits of the papules had become pustular; in six cases the same condition existed supple- mented by pure vesicles and pustules ; pure pustules occurred alone in six cases. |lt was manifest that the papulo-pustular eruptions would most frequently have been examples of the small papular syphiloderm had it not been for the pus forming diatheses of the bearers. Two of these cases were of distinctly follicular eruptions, advanced stages of the follicular papular syphiloderm already mentioned. Occasionally, upon the cheeks and forehead, little dome-shaped pinhead-sized elevations were noticed, of a color resembling that of a slight admixture of lampblack with white wax and of a very deceptive solid appearance ; upon punc- turing them however a drop of deep-seated thickened pus could be expressed. They differed from simple acne in speedily disappearing under specific treatment. There was one case of ecthyma and one of impetiginous eruption upon the scalp ; the latter was associated with broad flat papules (Syphilide en nappe) and covered the entire scalp with a thick, yellow scab. Smaller patches of impetiginous syphiloderm were several times encoun- tered. There were many cases, where, while papules formed the prevailing eruption, pustules to a limited extent were present. The course of these pustular eruptions was unilormly benign; + American Journal, Syphil. and Dermatol., April, 1873. +Dr. Duhring has met the “large acuminated pustular syphiloderm” more frequently in negroes than in whites.—Diseases of the Skin, page 161. I. EDMONDSON ATKINSON. the scabs, which formed at an early period were for the most part simple dessications of the pustules, imparting a harsh, raspy feeling to the touch, and falling off, left a thin cuticle already formed or a trifling superficial ulceration which healed immedi- ately, Thus the presence of pustulation was no evidence of special severity of the disease, and generally, no unusual refrac- toriness to treatment was encountered. Rheumatoid pains were very often present. Of thirty persons whose joints were principally complained of, the shoulder was affected in thirteen. In some cases where there were swelling and pain with fever, acute rheumatism was simulated. In addition to these cases, however, there were six examples of decided joint effusion, (five males and one female), the knees being the only joints implicated; the left knee three times, both knees three times. The subjects of this lesion were all, except one, in the earlier months of the disease, the one exception being that of a young negro man who had had primary symptoms eighteen months previously. Pain and difficult locomotion were prominent symp- toms in every case, causing decided lameness. The effusions were -quite extensive and were felt to be uncomplicated by grave in- flammation; indeed, there seemed to be no tendency towards destructive changes, and under suitable treatment the effusion, pain and lameness disappeared after somewhat protracted intervals. While I am satisfied that this synovitis is of more frequent occurrence than is usually believed, I think the proportion here reported is much in excess of what will be found in white patients. It is worthy of note, that although conforming to the rule as to the especial joint affected, these cases developed more severe subjective symptoms, as pain and lameness. (These symptoms were not especially nocturnal in character.) Recovery was per- fect in all but one case, still under treatment, where the joint remains somewhat stiffened and doughy to pressure. It may not be amiss, at this time, to refer to the two cases in more ad- vanced stages of the disease, where permanent injury to the joints had taken place. Here, however, the elbows were the joints affected. In one case where syphilis had existed for more than one year, the elbow joint (left) remained stiff in a half flexed EARLY SYPHILIS IN THE NEGRO. position, while in the second case, after three years of syphilis, both elbow joints were anchylosed, after suppuration and fistulous openings. Iritis was, likewise, very frequently treated. Eleven cases of this affection were noted. Of these, four were of males and seven of females, all in the first year of syphilis. The right eye was alone involved in three cases, the left eye alone in two cases, both eyes in five cases; in one case I neglected to note the eye affected. The inflammation was speedily followed by resolution in all ex- cept two cases. These latter came under treatment, each with great alterations about the eyes. There was double iritis, with much conjunctival and corneal disturbance and with ulceration resulting in staphyloma. Both patients had been very careless and negligent. It is to be regretted that accurate and detailed examinations of the eyes of these patients were not obtained. I am not aware of any reports upon the comparative frequency of iritis in syphilitic patients, but am sure that my own experience gives no such frequency of the affection in white persons. As is evident, the symptoms here described are mostly such variations as the presence of the scrofulous diatheses would induce. At the same time it is true that these processes do not, as a rule, betray anything like the intractability of purely scofulous affec- tions. Under the influence of appropriate treatment, they heal without much delay, leaving behind, however, so far as concerns the glands, indolent enlargements which linger for indefinite periods, and are liable to renewed suppurative action. This be- havior we have a right to expect, for, while the active manifestations of scrofula are chiefly observed in childhood and early youth, syphilis is usually a malady of adult life. Moreover, it must be remembered that lesions generated solely by the scrofulous influ- ence, indicate, of course, an exceedingly pronounced and active tendency of the diathesis. Now, in the cases under consideration, the lesions were evoked by the virus of syphilis, and were to a certain minor extent, influenced by the feebly active scrofulous diathesis. Certainly, syphilis in an individual in whom scrofula is actively manifesting itself, can have only a very unhappy and obstinate course; as, indeed the simple presence of the diathesis 12 I. EDMONDSON" ATKINSON, cannot fail to exert itself, to some extent, in combatting treatment and in prolonging and intensifying symptoms. While these patients did not improve under treatment with the same alacrity as persons more vigorously constituted, they were, nevertheless, generally brought under the healing influence of remedies without much delay. I have never hesitated to employ mercurial preparations and am in the habit of giving them for lengthy periods, with short remissions and intermissions depen- dent upon the intervention of buccal or digestive symptoms, and I think I have never observed untoward results from the practice. A mild degree of salivation has been produced upon one or two occasions, but gave only little inconvenience and quickly subsided. The administration of the drug was instituted during the primary stage when practicable, but I am unable to form definite conclu- sions as to the value of this plan. A treatment by mercurials would, however, be far from complete were the assiduous administration of tonic remedies neglected- These were indeed, essential adjuvants to the specific medicines. During the stage of initial lesion and primary adenopathy, bark and iron, sometimes in very large doses, were of great benefit. After the appearance of secondary symptoms, and, in markedly scrofulous cases during the primary stage, cod liver oil was inval- uable. Under such combined treatment, it was not uncommon to see patients rapidly regain vigor and strength ; and indeed, the popular theory of the debilitating tendencies of a mercurial treat- ment found no realization. Treatment of the primary lesion and of special symptoms was instituted according to requirement. There is, however, in these cases a marked predisposition towards the return of symptoms and constant vigilance in meeting them must be exercised.