[HF0443, Diagnosis of late syphilis. 1943, Length: 00:14:15, Color, Sound. This Betacam SP tape was duplicated from a U-matic videotape by Bono Film & Video, Inc. for the National Library of Medicine, February 2008.] [Syphilis] [Music] [The United States Public Health Service] [The Diagnosis of Syphilis by the General Practitioner] [The Diagnosis of Late Syphilis] ["Know syphilis and the whole of medicine is open to you." - Sir William Osler] [Narrator:] These words of Sir William Osler are especially true of late syphilis. Each case presents a complicated problem of diagnosis and treatment. One of the most common late skin lesions is the nodular ulcerative syphilid. This lesion consists of nodules which progress to ulceration. They often arrange themselves in circles or arcs. Such lesions result in scars characterized by the fact that they do not contract. The serpiginous syphilid is characterized by its snake-like border with slight atrophy and scaling within the arcs. Osteochondritis of the nasal structures may result only in perforation of the septum in collapse of the bridge of the nose producing the well-known saddle nose. This is more frequent in congenital than in acquired syphilis. Perforation of the palette is not frequent but should be looked for. Most cases of otosyphilis come to treatment before the condition is this far advanced. X-ray examination helps to establish the diagnosis. In the absence of clinical signs and symptoms, involvement of the central nervous system can be detected only by examination of the spinal fluid. Even if clinical signs are present, the diagnosis cannot be certain without confirmation by a spinal fluid examination. Every patient receiving antisyphilitic treatment should be subjected to this examination before being discharged, since involvement of the central nervous system is the most frequent cause of resistance to treatment. The technique of spinal puncture can be learned only by supervised experience. Examination of the spinal fluid should include serologic tests, cell counts, globulin and colloidal tests. The serologic test and cell count are the most important. Spinal fluid examination should be used to confirm such clinical diagnoses as general paresis, tabes and meningovascular syphilis. General paresis, however, is a psychiatric diagnosis. The signs include change in personality, neurosthenic symptoms such as depression or elation, lack of judgment, confusion of ideas, impaired memory, and slurred speech. [Man:] Yeah, yeah. [Interviewer:] Tell me, how is your memory? [Man:] Memory, a hundred percent. [Interviewer:] Memory is a hundred percent. How are your spirits? [Man:] Spirits, a hundred percent. [Interviewer:] Are you happy? [Inaudible Remark] You're happy? [Inaudible Remark] I wonder if you'd say this after me. Lovely Lily Leman. [Man:] Lovely Lily lemon. [Interviewer:] Lovely Lily Leman. [Man:] Hundred percent. [Interviewer:] Truly rural. [Man:] Truly [inaudible]. [Interviewer:] Truly rural. [Man:] Truly, lulal [phonetic]. [Interviewer:] Liquid electricity. [Man:] Liquid electricity. [Narrator:] The paretic patient may exhibit hyperactive reflexes unless tabes is superimposed. When tabes dorsalis is present, however, the patellar reflexes are diminished or absent. And the pupils usually do not react to light. In advanced cases of tabes, the gait is characteristic of that resulting from degeneration of the posterior columns of the spinal cord. The Romberg test is positive. Sphincter control may be lost. Optic atrophy may be associated with tabes or it may be the only clinical sign of central nervous system involvement. Paralysis of the extraocular muscles may occur in meningovascular syphilis or the paralysis may strike other parts of the body. Involvement of the extraocular muscles is common. In cardiovascular syphilis, the disease most often strikes the aorta and the aortic valve. Aneurysm as here illustrated develops from simple aortitis. Syphilitic involvement of the aortic valve is characterized by an early diastolic murmur in the aortic area. Such a murmur when not accompanied by mitral disease usually indicates syphilitic involvement of the heart. Many symptoms of a syphilitic involvement of the cardiovascular system such as dyspnea on exertion are identical with symptoms produced by other cardiac conditions. Most characteristic of this condition, however, is paroxysmal dyspnea without exertion and associated with a sense of constriction across the chest. Uncomplicated syphilitic aortitis is very difficult to diagnose. Many cases passed rigid physical examinations without detection. Look for history of circulatory embarrassment, progressive cardiac failure, substernal pain and paroxysmal dyspnea. Look for x-ray evidence of aortic dilatation. Look for increased width of the area of dulness to percussion at the base of the heart. Listen for a tambour accentuation of the second aortic sound. It sounds like this. [ Noise ] Such a tune quality of the second aortic sound in the presence of late syphilis suggests aortitis. Arsenical drugs are dangerous in cardiovascular syphilis. Prepare such patients with bismuth for three or four months before giving arsenic. Since many cases of uncomplicated syphilitic aortitis passed unrecognized, it is best to start treatment with bismuth in all cases where the duration of the infection is more than five years. [The Diagnosis of Latent, Prenatal, and Congenital Syphilis, Latent Syphilis] Congenital syphilis frequently causes an osteochondritis of the nasal bones which later produces a profile like this. Also, the teeth of the second dentition are frequently deformed in the manner described by Hutchinson. Interstitial keratitis is more common in congenital syphilis than in acquired syphilis. It may appear anytime from childhood to adult life and if not properly treated continues to recur and may eventually lead to blindness. Deafness is a frequent manifestation of late congenital syphilis and is quite resistant to treatment. Spinal fluid examination is just as important in congenital syphilis as in acquired syphilis. Juvenile paresis starts at about the age of puberty. It can be prevented. Examine the spinal fluid at four years of age or as soon thereafter as congenital syphilis is discovered. All syphilitic infections are latent at some time during their course. All syphilitic infections are latent most of the time from the disappearance of the primary and secondary manifestations until the ultimate breakdown of the patient. To prevent the tragedies of late syphilis, take routine blood test on all patients. When a routine blood test is reported positive, a complete history and physical examination are indicated. The physician should inquire into history of genital lesions, skin eruptions, and other indications of primary and secondary syphilis. A history of prolonged sore throat especially in the absence of rhinitis is suggested. Inquire whether there is a history of previous blood test or injections in the arm or hip. If there is no history indicative of acquired syphilis, ask about symptoms of congenital syphilis in the patient and in his brothers and sisters. Ask about symptoms of syphilis in the patient's father and mother. Note the causes of death of deceased parents. For the physical examination, natural daylight is preferable to artificial light. Inspect all portions of the skin carefully in good light. Note particularly the palms of hands and the soles of the feet. Palpate the lymph nodes to detect enlargements. Inspect the hair for patchy alopecia. Look for iritis and muscular pulses and test the pupillary reflexes. Inspect the eyegrounds for pallor of the optic discs and for corneal retinitis. Look for split papules at angles of the nose and mucus patches within. Is the septum perforated? Look for split papules at the angles of the lips and mucus patches in the mouth and pharynx. Perform an otoscopic examination routinely. Pulsation in the suprasternal notch would suggest an aortic aneurysm. In an asymptomatic case, look carefully for signs of cardiovascular syphilis. Examine the lungs as a routine procedure. Test the deep reflexes and perform a Romberg test. In the abdominal examination, look for enlargement of liver and spleen, masses or other pathology. Look for moist papules and mucus patches, and for evidence of gonorrhea. Remember that cervical chancres may be manifested only by diffuse induration of the cervix. A syphilitic infection may be considered latent if a thorough physical examination and the spinal fluid examination both yield negative results. Late syphilis results from untreated latent syphilis, thus, latent syphilis presents a challenge to which the logical answer is mass blood testing. To prevent the tragedy of late syphilis, we cannot sit back and wait for patients to report to treatment sources. Perform blood tests on industrial, youth, military, and other population groups at every opportunity. Examine the families of patients who are discovered to have syphilis. Examine extramarital sexual contacts of known cases. Perform blood tests on all hospital and office patients routinely. [Doctor:] And now, we're ready for the blood test, Mrs. Hamilton. This is a routine procedure which I perform on all of my patients. I have found from my experience that syphilis is no respector of persons and it often strikes without one's knowing it. But I feel certain that the report we receive will be reassuring to both of us. [Narrator:] What if the report is positive? Does a single positive laboratory report prove the presence of syphilis? No. One should first rule out the possibility of technical error or biologically false reaction. Three procedures are essential to the establishment or exclusion of syphilis in the patient on whom a positive blood test has been obtained by routine examination. The first of these is a thorough and careful family history and history of past illnesses and complaints. The second is a careful and detailed physical examination. The third is a check of the original positive blood report with additional tests performed in reliable laboratories. If the blood test reports on the history and physical examination are not definite and consistent, perform a spinal fluid examination before discharging the patient as nonsyphilitic. Treatment for syphilis should not be started until the presence of syphilis has been definitely established. Antisyphilitic treatment is not without danger. Its hazard should not be accepted lightly. If the physician with all available information at hand is still in doubt as to whether the patient does or does not have syphilis, he should request consultation with a specialist. In many parts of the country, such consultation service is available through the county, city, or state health department. To keep abreast of current developments in the diagnosis, treatment, and public health aspects of syphilis, read Venereal Disease Information, one of the medical journals published by the United States Public Health Service. [ Music ] [This film is in three parts: I. Diagnosis of Early Syphilis. II. Diagnosis of Late and Latent Syphilis. III. The Management of Syphilis.] [A United States Public Health Service Production. Clinical Photography...Carroll T. Bowen, Passed Assistant Surgeon (R), Medical Direction...Glenn S. Usher, Passed Assistant Surgeon, General Direction...W. Allen Luey, Production...Howard Ennes, Medical Consultants Harold N. Cole, M. D., Cleveland, Ohio, Joseph E. Moore, M. D., Baltimore, Maryland, Paul A. O'Leary, M. D., Rochester, Minnesota, Thomas Parran, Surgeon General, U. S. Public Health Service, Washington, D. C., Francis E. Senear, M. D., Chicago, Illinois, John H. Stokes, M. D., Philadelphia, Pa., Lida J. Usilton, M. A., U. S. Public Health Service, Washington, D. C., Raymond A. Vonderlehr, Assistant Surgeon General, U. S. Public Health Service, Washington, D. C.] [Federal Security Agency Paul V. McNutt, Administrator. U. S. Public Health Service Thomas Parran, Surgeon General] [U. S. Public Health Service, 1798] [The End]