SYPHILIS

From Big Medical Encyclopedia

SYPHILIS [syphilis (by name hero of the poem J. Frakastoro of the shepherd Sifilus (Syphilus); synonym: lues, lues venerea] — the chronic infectious venereal disease caused by a pale treponema, affecting all bodies and tissues of the person, which is characterized by the progressing current. Allocate the acquired and inborn syphilis.

The term «syphilis» for the first time appeared in the poem of the outstanding ital. scientist J. Frakastoro «About syphilis, or a Gallic disease» (1530). By name the shepherd Sifilus described in the poem gave a disease the name «syphilis». According to other version the name happens from the son Nioby Sifilus mentioned at Ovidiya.

HISTORY

On one sources, S. appeared in Europe only after discovery of America, on others — it existed in Europe since ancient times. Aretaios described cankers of a soft palate and language, to-rye can be considered as syphilitic.

At excavation of burial grounds in various districts of Europe and Asia in bones of people of the period of the Neolithic the phenomena of gummous osteomyelitis and an osteoperiostitis, syphilitic changes of bones of a skull were found in children. D. G. Rokhlin and A. E. Rubashova found at X-ray paleontologic researches of change, similar syphilitic, in bones of skeletons from the burials relating to the period from the middle of the II millennium BC up to 1 century AD.

It is possible that S. existed in ancient times both in Europe and Asia, and on the West Indian islands, and the arisen S.'s epidemic in Europe at the end of 15 and the beginning of 16 century was connected with long wars, mass movements of the population and growth of prostitution. A number of researchers considers the homeland of syphilis Africa from where owing to wars, commercial relations and evacuation of slaves the disease extended to America and Asia.

By the beginning of 16 century S. became known almost in all countries of Europe. S.'s distribution was promoted by features of an era of the arising capitalism: ruin of the peasantry, growth of the cities, development of commercial relations, long wars, mass movements of the population. Also almost unlimited freedom of sex life of men, growth of prostitution caused noticeable distribution of S. During this period of S. differed in special weight of a current. S.'s communication with the sexual intercourses gave a reason to call it «sexual plague».

In the first years after the beginning of epidemic of S. in Europe the considerable attention was paid to studying a wedge, symptoms of this disease. J. Frakastoro, F. Rabelais, A. Paré at Paratseljs> G. Fallopy in the first half of 16 century in detail described S.'s manifestations on skin, mucous membranes, in bones. A syphilitic hair loss, inborn Pages were described.

Up to 18 century the doctrine of unitarist about identity of «poisons» dominated gonorrhoeas (see), syphilis and venereal ulcer (see). Only in 19 century researches appear, in to-rykh this dogma it is rejected — S. and gonorrhea are considered as various diseases. In the 30th 19 century were proved by F. Rikor on the basis of absolutely inadmissible experiments conducted by it on healthy people that S. and gonorrhea — various diseases. In the second half 19 — the beginning of 20 century in connection with great success of microbiology became conventional that gonorrhea, a venereal ulcer and syphilis — various diseases.

The big merit in development of the doctrine about S. belongs to the outstanding syphilologist A. Fournier, to-ry in addition to the detailed description a wedge, pictures of syphilitic damages of skin and mucous membranes established connection general paralysis (see) and back tabes (see) with Page. Early defeats by syphilis of c. N of page were studied by V. M. Tarnovsky and Mauriac (Ch. M. T. of Mauriac, 1875, 1881). In 19 century R. Virkhov, S. P. Botkin, etc. researched visceral S.

An important stage in development of the doctrine about S. was the beginning of studying of experimental S., Mattsenauer's work put by I. I. Mechnikov and to E. R (R. Matze-nauer, 1903) about S.'s transfer to a fruit only through a placenta, opening in 1905 by F. Shau-dinn and E. Goffmann of the activator C. — a pale treponema, development in 1906 by A. Wasserman of S.'s serodiagnosis, introduction in 1943 by Mahoney, Arnold sh Harris (J. F. Mahoney, R.' Page of Arnold, A. Harris) together with A. Neicer and Brook (S. Bruck) penicillin in S.'s therapy, offered in 1949 by Nelsonom and Meyer (R. A. Nelson, M. M. Mauyeg) reaction of an immobilization of pale treponemas for diagnosis of the latent forms of S., etc.

S.'s distribution in Russia belongs to the end 15 and the beginning is 16 century old. In the second half of 18 century a number of the researches devoted to studying of syphilis was published. And. G. Bakherakht in 1775 published the book about venereal diseases. In 1846 Fedor Koch's guide on syphilis was published. The big role in studying of questions of syphilology was played by founders of domestic medicine M. Ya. Mudroye, N. I. Pirogov, I. E. Dyadjkovsky, G. A. Zakharyin, S. P. Botkin, etc. V. M. Tarnovsky, A. G. Polotebnov, A. I. Pospelov, M. I. Stukovenkov were founders of sifilidologichesky school in Russia. Their researches found further development in P. V. Nikolsky, I. F. Zele-nev, T. P. Pavlov's works, etc. P. V. Nikolsky made the significant contribution to development of questions of treatment of Page. He is the author of the special guide for doctors and students «Syphilis and venereal diseases».

Numerous researches on studying of the activator C. were conducted by D. K. Zabolotny, I. F. Zelenev, A. A. Bogolepov, etc. D. K. Zabolotny, except usual pale treponemas, described other forms — fine ends of the small sizes with the grains which are strongly refracting light on the ends. D. K. Zabolotny and P. P. Maslakovts's researches about a phenomenon of pasting of pale treponemas in the presence of blood serum of patients with syphilis, H are important for S.'s diagnosis. M. Ovchinnikov and V. V. Delektor-sky on ultrastructure of a pale treponema.

S. Imel a wide spread occurance in imperial Russia. From the first days of existence of the Soviet power fight with venereal diseases (see) became one of the most important tasks of bodies of health care. Progress in fight against S. was promoted by big research of the Soviet scientists in the field of experimental syphilology, immunity, a yard of superinfection, serol. diagnoses. Questions of a pathogeny, diagnosis, clinic, treatment and prevention of inborn syphilis are in details developed. In the USSR production of all modern anti-syphilitic means is organized and their action is studied in detail.

AETIOLOGY

Fig. 1. Native microdrug of a pale treponema at a research in an anoptralny microscope; X 2000.

The activator C. — a pale treponema (Treponema pallidum) — is opened in 1905 by F. Shaudshsh and E. Goffmann. According to Berdzhi's classification, it treats Spirochaetales group, the Spirochaetaceae Treponemataceae Schaudinn family, the sort Treponema Schaudinn. The treponema received the name «pale» because of weak ability to perceive coloring. A pale treponema — a microorganism of a spiral-shaped form (fig. 1) from 4 to 14 microns long and to dia. 0,2 — 0,5 microns with uniform curls, height to-rykh towards the ends of treponemas decrease. The number of curls during the movement of a pale treponema can change in this connection also its thickness changes.

Fig. 2. The diffraction pattern of a pale treponema in the course of multiple fission: 1 — fibrilla; 2 — crossing points; 3 — segments of a pale treponema; X 44 000.

At electronic microscopic examination it is established that the pale treponema is covered outside with a cover, on the ends has capitate educations, fibrilla is attached to them (superficial and deep), with the help to-rykh it moves. The pale treponema has ability to rotary motions around the longitudinal axis, forward and to undulations. Smooth progress of a pale treponema is an important differential diagnostic character. On ultrathin sections the outside wall, under it a cytoplasmic membrane is visible; both that and another consist of three layers. In cytoplasm small granules — ribosomes (see), sometimes me-zosoma and a nuclear vacuole are interspersed. It is proved that the pale treponema can be halved or on several parts (fig. 2), from to-rykh under favorable conditions usual spiral-shaped forms are formed. Along with spiral-shaped other forms of a pale treponema — in the form of cysts, granules, L-forms (see L-forms of bacteria), etc. are described. Cysts and L-forms are steady against external influences. In 1947 A. Ya. Vilen-chuk proved passability of pale treponemas through collodion membranes. S. E. Kornut (1979) established that the pale treponema can pass through filters with the size of a time 0,22 microns. P. Lepin suggested that the pale treponema represents one of phases of an evolutionary cycle of the activator C., its avirulent form; a virulent form is the ultramicroscopic phase. J. Donagh offered the scheme of development of a pale treponema, similar to the scheme of development of a malarial plasmodium. F. Krzystalowicz assumed existence at a pale treponema of a sexual cycle.

At crops of the material received directly from the patient, the pale treponema on usual mediums does not grow. Number of researchers, e.g. And. Wasserman (1922), R. R. Gelttser (1929), H. M. Ovchinnikov, achieved growth of pale treponemas, but they lost pathogenicity. The cultural pale treponema is thicker pathogenic and differs from it on the biol a little. to properties. However antigenic components of cultural and pathogenic pale treponemas are so close that the antigen prepared from cultural pale treponemas widely is applied at S. Ustanovleno's serodiagnosis three main antigens of a pale treponema: the thermolabile protein collapsing during the heating to 76 — 78 °, the thermostable polysaccharide maintaining heating to 100 ° and the lipoid antigen identical on the properties to lipoid extract of a cor bovinum. In separate researches it was succeeded to infect rabbits with a cultural pale treponema. Nek-ry researchers, e.g. Meynike (To. Mei-nicke, 1960), deny belonging of the marked-out cultures to a pale treponema, including them saprophytes. Optimum temperature for growth of a pale treponema 35 °. Temperature increase to 40 ° causes bystry destruction it, decrease lower than 35 ° limits reproduction.

Resistance of pale treponemas to external influences is small. On household goods it keeps the infectivity before drying. At t ° 40 — 42 ° activity of a pale treponema at first increases, then she perishes; at t ° 55 ° it perishes within 15 min. Low temperature has no pernicious effect on it. In Turner and Hollen-der's experiences (T. V. of Turner, D. N of Hollander) the pale treponemas stored at t ° — 70 ° within 9 years, did not lose the infectivity for rabbits. Storage of pale treponemas at t ° — 20 ° is one of methods of contents them for infection of rabbits and for reaction of an immobilization. Pale treponemas well remain in fabric of corpses. The citrated blood containing pale treponemas and stored at t ° 4 — 6 ° remains infectious for rabbits within 3 days. Out of an organism the pale treponema is very sensitive to various chemical substances. At long contact with them its stability is developed, but not so quickly and not in such degree, as at other microorganisms.

For obtaining culture of pale treponemas used the semi-turned horse serum, a beef-extract broth, added pieces of various bodies to Krom ('Kidneys, a liver, a small egg etc.), serumal water with pieces of fresh bodies, broth of cors bovinum, to Krom was added by thioglycolic sodium, cystine etc. Cultivation was made by hl. obr. in anaerobic conditions, and also at addition of mix of nitrogen with carbon dioxide gas. W. Perry grew up treponemas in the fabrics of a small egg of a rabbit placed in a blood plasma of a chicken. The pale treponemas received from sick S. of people, pathogens for rabbits, hamsters, monkeys. Pathogenicity for the person remains, despite a large number of passages on rabbits. At infection with a pale treponema of white mice and rats the disease proceeds latentno, at infection of rabbits with a suspension from bodies of mice their syphilis is developed. At Guinea pigs infection comes in 15 — 30% of cases.

It must be kept in mind that there are also other pathogenic treponemas, it needs to be considered at diagnosis. Treat them: Treponema pertenue (the activator of a yavs), Treponema carateum (the activator of pint), Treponema bejel (the activator bedzhelya), Treponema macrodentium and Treponema macrodentium occur at people in an oral cavity. Also Treponema refringens, Treponema balanitidis, Treponema bronchiale, Treponema buccale, Treponema cuniculi and some other the treponemas which do not have the special name are similar to a pale treponema. At microscopic examination they are difficult otlichima from a pale treponema. Existence of a cross immunity between them is proved. It is quite often difficult to distinguish them serological. It is easier to distinguish often meeting, especially in the contaminated ulcers of a genital tract, Treponema refringens. She is more fat, than the pale treponema, curls at it is much more rough, the movements bystry; in the depth of fabrics it meets seldom; it is easily painted with solution methylene blue, fuchsin, etc. Certain researchers found nonpathogenic treponemas in limf, nodes.

See also Spirochetes .

The ACQUIRED SYPHILIS

Epidemiology

According to WHO data, since the beginning of the 60th in 10 years sick S.' number in the world increased by 90% and made apprx. 20 million people. By 1980 in many countries of the world stabilization or even reduction of incidence of S. nakhmetitsya, however the general incidence remains still high. The statistical data provided according to WHO materials are underestimated as in the majority of the countries treatment of diseases, sexually transmitted, is made by preferential private medical practitioners. So, in the USA to 80% of sick S., according to Harris (J. W. R. Harris, 1975), receive treatment at private medical practitioners. Loukas (J. Century of Lucas, 1972) indicates that it only about 19% of all revealed patients with early forms C. is reported in departments of health care; according to Wilcox (R. R. Willcox, 1972), 7 of 10 patients with primary and secondary S. are not registered.

S.'s distribution is promoted by many factors: incomplete identification of sources of infection and contacts, self-treatment, population shift, including caused by job search in connection with unemployment growth of tourism, drug addiction, alcoholism, decrease in number of marriages, an urbanization, acceleration, prostitution, homosexuality, promiscuity, and also low level a dignity. educations, etc.

the Person catches S. from the patient. Infection, as a rule, occurs sexually, is much more rare — through various objects contaminated separated eroziro-bathing syphilitic elements of skin or mucous membranes since in the wet environment out of an organism of the patient the pale treponema keeps life activity within many hours. Infection through kisses, stings, and also through household goods is possible (spoons, glasses, cigarettes, etc.) — so-called household syphilis.

Patients with such manifestations of S. as an erosive or ulcer hard ulcer, erosive papules of skin and mucous membranes of generative organs, oral cavities, hypertrophic papules (flat condylomas) are especially infectious, in to-rykh usually find a large number of pale treponemas. In their pustular syphilides much less they are also located in deeper parts of skin. Gummas and hillocks of the tertiary period of S. (despite their infectivity proved in an experiment) are almost not infectious since pale treponemas in insignificant quantity are located only in the fringe region not - the broken-up infiltrate.

Infectivity of urine and sweat is not proved; in saliva there can be pale treponemas in that case when there are specific rashes on a mucous membrane of an oral cavity. Infection through milk of the nursing mother, sick S., and also through sperm in the absence of any changes of generative organs is possible. However in these cases it is not excluded that specific elements were located on the course of output channels of mammary glands or on the course of an urethra (cases of chancres of an urethra are known).

The medical staff can catch at sick S.' survey, carrying out to lay down. procedures, at contact with internals of sick S. (e.g., during an operative measure), during the opening of corpses (especially newborn with early inborn S.). These cases belong to professional Page.

Infection at hemotransfusion is in exceptional cases possible, taken from donors, sick S. — so-called transfusion S.

the Pathogeny

the Activator C. gets into an organism through the damaged corneous layer of skin or an epithelium of a mucous membrane. And damage can be so insignificant that remains invisible to an eye, or is located in the places unavailable to inspection. Though infection happens not in all cases of sexual and close household contact healthy to sick S. in view of the fact that there are no reliable tests of infectiousness and duration of an incubation interval is not established, to all persons which were in close contact with sick S. and not having a wedge, displays of an infection preventive treatment is carried out. Though blood is not the favorable environment for pale treponemas, however as a result a wedge, observations and by experiments on animals is proved that they are available in blood (perhaps, as in the transport environment) during the entire periods of a disease.

Experimental syphilis

experimental S.'s History begins in 19 century F. Rikor in 1860 unsuccessfully infected with the material received from sick S., dogs, cats, the Indian pigs, pigeons. Tyurenn (J. - A. Auzias-Turenne) in 1878 developed a technique of cutaneous infection of animals. Subinoculation of material from the animal infected with it to one doctor caused emergence of an erosion for the 5th day, edges a cut became dense by 10th day. N. P. Domashnev (1882, 1883) received the defeat at pigs which was not differing according to patogistologichesky data from defeats at the person.

E. F. Shperk imparted S. to 46 monkeys, 3 goats, 2 sheep, a calf, 3 rabbits and 2 pigs. Infection was made by contents of a chancre, papules, and also blood and sick S.' milk of women. Many attempts of infection of animals were done also by other researchers. The majority them was unsuccessful, and the described positive takes were not quite convincing; to confirm them with bakteriosko-pichesky researches it was not represented possible since the activator was not open yet.

Only the experiences of infection of subhuman primates executed by I. I. Mechnikov ie. Ruv 1903 on two chimpanzees, were generally recognized. In 1904. I. I. Mechnikov, having carried out a large number of experiences on monkeys, described manifestations of the secondary period of S. at a chimpanzee, and in 1905 published results of experiences on 22 chimpanzees, with the detailed description a wedge, pictures C. (chancres, the secondary phenomena, S. of a nervous system). I. I. Mechnikov's experiences on 120 macaques and baboons were not crowned with success, the real secondary phenomena of syphilis were found in one monkey. I. I. Mechnikov proved that

the activator C. does not pass through bacterial filters, made attempt of preventive vaccination, established preventive value of calomel ointment, etc. The data obtained by I. I. Mechnikov and to E. R were confirmed by Lassar (O. to Lassar, 1903) and A. Neicer. Then within a short period of time there was a large number of the researches which are also confirming these data. Finally they were confirmed when at the monkeys infected with S. the pale treponema was found.

The big contribution to the doctrine about experimental S. was made by D. K. Zabolotny. Having done in 1898 unsuccessful experiences on macaques, he the first in 1904 suggested to use baboons for S.'s infection. D. K. Zabolotny, as well as I. I. Swordsmen, conducted experiments on active immunization at Page. After repeated injections of the material containing a pale treponema, immunity at animals did not come. The preventive effect and after administration of serum of immunizirovanny monkeys was not gained. He proved that subinoculation from a monkey to a monkey works well easier, than from the person to a monkey. D. K. Zabolotny's experiences were confirmed by G. N. Gabrichevsky, M. A. Chleno-vy, E. A. F. Finger, K. Land-shteyner, A. Neicer, etc.

A. Neicer in an expedition on Zondsky islands for short term made experiments on 50 orangutans, 50 gibbons and more than on 1000 lowest monkeys. Having confirmed I. I. Mechnikov's experiences, he established that there is no basic difference in a susceptibility to S. the highest and lowest monkeys, but its current at that and others various. In laboratory practice experimental S.

was widely adopted after it was succeeded to infect rabbits. Infection was made by administration of material in an anterior chamber of an eye or its rubbing in in the scarified surface of a cornea. However results of experiences were disputable since they were not confirmed laboratory. Parodi (Ra-rodi, 1907) introduced a piece of a syphilitic papule to a rabbit under tunica vaginalis of a small egg for the first time and in 4 weeks received on this place infiltrate with a large number of pale treponemas in contents. E. Goffmann, H. Lohe and Multser (P. Mul-zer, 1908) entered a serum (the liquid received at irritation of a chancre) to a rabbit into a small egg therefore the chancre developed. Rabbits are infected in various ways: under skin of a scrotum, in a small egg, in skin of a back, in an anterior chamber of an eye, suboktsipitalno, intravenously etc. The first two ways are most widespread.

Infection of rabbits is made by the material taken directly from the person (a piece of a chancre or secondary cells, especially moist papules). Infection works well without big work, though not each rabbit. For receiving early orkhit at rabbits to them in a small egg enter a suspension of the pale treponemas received from testicles of the rabbits sick with a syphilitic orchitis. S. T. Pavlov offered an epikutanny way of infection, to-ry is closest to natural conditions of infection. P. G. Oganesyan infected rabbits vnutrikozhno, entering a suspension of pale treponemas into depilirovan-ny sites of skin of a trunk. At infection in a vein manifestations generalized S. Sifilis at rabbits, just as at people are more often noted, is the general disease, at Krom all bodies and systems are surprised.

After the incubation interval proceeding, as a rule, 2 — 3 weeks, on site administrations of material there is a small, gradually increasing consolidation reaching a consistence of a cartilage. Through a nek-swarm time in the center of consolidation arises a necrosis, the chancre becomes covered by a thin crust, edges increases gradually and surrounded with dense infiltrate. At a research find pale treponemas in a dense part of infiltrate. Gradually the chancre becomes softer, disintegration on a surface amplifies, the quantity of pale treponemas decreases, and during IV2 — 3 months it disappears. Along with development of a chancre nodes increase regional limf. During removal of a chancre on its place the second chancre (reindu-radio set) is sometimes formed. On average at 10% of rabbits after infection even the chancre is not formed by a large number of pale treponemas and there are no other manifestations S. (nul-ler). But at subinoculations to healthy rabbits subnodal limf, the nodes taken from nuller their syphilis is revealed.

Such secondary manifestations of S., e.g., as roseolas at the person, do not occur at a rabbit. The papular and papulokorochkovy rashes characteristic of generalized syphilis are more often observed. Find pale treponemas in their contents. The most characteristic places of rashes at secondary S. at rabbits are roots of ears, a muzzle, extremities, a back. Percent of detection of the secondary phenomena at rabbits depending on a number of conditions (a strain, a way of infection, breed of rabbits, etc.) it is various. Besides, the rabbit is covered with wool, and secondary manifestations of S. are often looked through. Secondary S. at rabbits lasts from several months to 2 years. Quite often their keratitis (secondary) differing in a torpid-nost of a current is noted.

Displays of tertiary syphilis and S. of a nervous system at rabbits are described a little. It is explained by the fact that did not observe rabbits so much time how many it is necessary for formation of manifestations of the tertiary period. Yu. A. Fin-kelyiteyn described 6 cases of the gummous tumors which were located on extremities of a rabbit. A wedge, manifestations of defeat of a nervous system in the form of spasms, paralyzes of back extremities, paraplegiya were described by Bertarelli, Yu. A. Fin-kelynteyn, etc. Yu. A. Finkelynteyn received a positive take at an inoculation of a brain of the animals infected with S. K. Levaditi did not observe syphilis of c. N of page at rabbits.

In an experiment also questions of immunity were studied. At S. premunition is revealed. V. Noll established that rabbits are not susceptible to superinfection the same strain, but are susceptible to infection with a heterological strain. A. Neicer and V. Kolle stated situation, according to Krom formation of a hard ulcer at repeated infection testifies to an izlechennost of the first infection. However S. T. Pavlov disproved it. He established that treatment novareeno-scrap in subtherapeutic doses when primary syphilomas are in a stage of development and premunition was not formed yet (till 24th day), leads to failure of immunity, and rabbits can be infected with S. repeatedly.

H. M. Ovchinnikov after long immunization of rabbits the vaccines prepared in various ways established that vaccination does not provide to stability them to repeated infection of S., contrary to opinion of the nek-ry foreign researchers proving existence of artificial immunity at Page.

Despite the lack of natural immunity, at S. nek-ry antibodies can be formed. So, are described and agglutinins, pretsipitina, fixators found practical application. Sick S. of rabbits have positive sedimentary reactions (cytocholic, Cana, etc.), reaction of binding complement with nonspecific organ extracts and specific treponemalny antigens. Also treponemolizina and trombotsito-barins, immobilizina are found.

There is a significant amount of strains of experimental S., the peace maintained on rabbits in various laboratories. The most widespread is Nichols's strain received by an inoculation of cerebrospinal liquid. The USSR applies strains 8 TsKVI, 1 Irkutsk, Budapest and Nichols's strain more often. Each of them has the features.

Experimental S. is good model for successful studying of a number of questions of syphilology. Experimental S.'s current at rabbits is similar to S.'s current at the person so that Yu. A. Finkelynteyn spoke about identity of these diseases.

At Guinea pigs experimental S. proceeds usually asymptomatically, approximately in 15% of cases chancres are observed. At white mice chancres develop seldom — to 0,5% of cases, but subinoculation limf, nodes or introduction of a suspension, prigo - * tovlenny of sick S.' bodies of mice, to healthy rabbits causes in them development of a chancre, in Krom find pale treponemas.

Immunity

the Congenital immunity to S. does not exist. In nek-ry works it is specified existence in a human body of substances (identical to properdin or immobilizina), at a high caption to-rykh there can be a lysis of pale treponemas. At the person of durable immunity cured of S. does not develop therefore perhaps repeated infection S. (reinfection). At diagnosis of reinfection it is necessary to adhere to such criteria as reliability of the first infection (it is confirmed with medical specialized institution), full value of treatment concerning the first infection, compliance of terms of a negativation standard serol. reactions and disappearance of syphilides in the course of therapy of the first infection to usual average values. Reinfection is confirmed by finding of pale treponemas in syphilides, positive takes serol. reactions, high caption of reagins. Also results of confrontation (identification of partners) are considered. At a wide interval of time between the first and second infection the probability of reinfection increases.

At a syphilitic infection in an organism of the patient so-called unsterile (infectious) immunity develops (see). It arises as response of an organism to a pale treponema and exists until in an organism there is an activator. The immunitas non sterilisans is followed by an infectious allergy (see). Thus, at S. reactivity of an organism changes: can both raise (allergy), and to go down (immunity). According to the Paradise apple (E. Rajka, 1966), it occurs serially during various periods, and during the nek-ry periods at the same time.

The most important factor of immunity is phagocytosis (see). At S. in response to stay in an organism of antigen (a pale treponema) antibodies (see) — immunoglobulins are formed (see). Depending on S.'s period various antibodies appear. At the beginning of S.'s disease larger antibodies of the class IgM and IgA are found; at late forms of the acquired and inborn S. — antibodies of the class IgG. Antibodies strengthen phagocytosis, performing transport function, i.e. «bringing» antigen to macrophages, and strengthening enzymatic activity of macrophages. On implementation of a pale treponema macrophages, T - and In - lymphocytes participate in an immune response of an organism (see. Immunocompetent cells). At experimental S. and at S. at the person incomplete phagocytosis is observed. However at regress of elements of early S. (e.g., primary sclerosis) in macrophages the complete phagocyte is more often observedlake.

Existence in sick S.'s organism of spiral-shaped pale treponemas and their transformation under adverse conditions for the activator in cysts, granules, polymembrane phagosomas, L-forms (a form of steady existence, a form of resistance) against the background of complete and incomplete phagocytosis cause variety of outcomes at contact of the person with the patient with an infectious form C. and distinctions during a syphilitic infection.

Superinfection call such condition of sick S., at Krom new portions of pale treponemas (repeated infection of not cured patient) come to its organism, there is as if a stratification of a new syphilitic infection on already available. Superinfection during various periods of S. is shown differently. So, in an incubation interval (usually it is shortened up to 10 — 15 days) and in the first 10 — 14 days of primary period of S. when there is no expressed premunition, repeated infection leads to consecutive development of a new chancre — a so-called consecutive chancre. It is considered that during other periods of S. at superinfection rashes of that period develop, at Krom there was repeated infection (e.g., at the secondary hidden S. there are papules, roseolas, at tertiary hidden — hillocks, gummous infiltrations).

Gistlend (Giestland, 1955) and Rock kuell (D. N of Rockwell) et al. (1964) assumed a possibility of self-healing of S. Schitayut that they apprx. 30% of the uncured patients who transferred early forms C. samoizlechivatsya, approximately 30% of uncured patients for the rest of life have only positive serological tests (perhaps, owing to education in an organism of pale treponemas in the form of cysts) and at 40% different forms of late S.

=== Pathological anatomy === develop At primary period of S. gistol. the research reveals in the field of a hard ulcer the inflammatory infiltrate in the thickness of a derma or a mucous membrane consisting from lymphoid, plasmatic, and sometimes and epithelial cells with impurity of a small amount of neutrocytes. Note characteristic changes of vessels in the form of the endarteritis which is followed by swelling of an endothelium and its proliferation that leads to narrowing, and sometimes and to closing of a gleam of vessels in this connection the small centers of a necrosis can be observed (see). During the processing of cuts by Le-vaditi method (see Levaditi a method) a large number of pale treponemas around vessels, and also in their walls comes to light. At an elektronnomikroskopichesky research (see the Submicroscopy) pale treponemas find in phagolysosomes of endotheliocytes, periendo-telialny space, macrophages, neutrocytes and plasmocytes, and also between cells of epidermis. Quite often infiltrate spreads on the course of vessels and nerves out of limits of superficial fastion, napr, to the area of cavernous tissue of penis, causing a specific endophlebitis.

Morfol. changes in limf, nodes at primary S. are not specific and correspond to changes at subacute hyperplastic lymphadenitis. They are expressed in hypostasis and a hyperplasia of the germinative (light) centers of the lymphoid follicles of bark which are indistinctly delimited from a mantle zone of a follicle. Sine are expanded, around them the expressed plazmotsitarny infiltration. In vessels are noted an endangiitis (see the Vasculitis) and a thrombovasculitis (see).

In the secondary period of S. gistol. the picture in a zone of roseolas is characterized by sharp vasodilatation of a derma, swelling of their endothelium and availability of the small perivascular infiltrates consisting from lymphoid and plasmocytes. In a zone of papular rashes the phenomena of a vasculitis with defeat of both superficial, and deep vessels are expressed. The endothelium which bulked up walls are thickened, quite often infiltrirovana by lymphocytes and plasmocytes. Infiltrate in a derma is more often than diffusion character and consists of lymphoid elements and small epithelioid granulomas (see the Granuloma); in the field of flat condylomas also considerable acanthosis with intercellular and intracellular hypostasis of epidermis, an exocytosis is observed. Gistol. the picture of pustular rashes is characterized by availability of acute inflammatory infiltrate in an upper part actually of a derma and penetration of neutrocytes into epidermis with formation of pustules in it. At secondary recurrent S. in a zone of pustules, besides, it is possible to see small granulomas from epithelial cells, sometimes with existence huge. In a derma changes of vessels, specific to the secondary period, and perivascular, preferential plazmotsitarny infiltration are found.

In limf, nodes gistol. the picture is not specific. In some cases it is possible to find proliferation of epithelial cells with impurity of colossal cells like Pirogov — Langkhansa (see. Colossal cells), therefore the picture reminds tuberculosis.

In the secondary period of S. internals (a liver, kidneys, nervous and bone systems) are surprised. So, at a research of the material received at a biopsy of a liver the pericholangitis and focal necroses of a parenchyma are found; in kidneys — proliferative changes in balls of renal little bodies, and at them-munoflyuorestsentnoy microscopy (see the Immunofluorescence) on their basal membranes — deposits of IgG.

In the tertiary period of S. nodes — gummas of various size are formed, to-rye are localized in skin, hypodermic cellulose, bones, covers of a brain, in a liver, a muscle of heart, etc. (a granuloma syphilitic), consisting of lymphocytes with impurity of plasmocytes and monocytes, epithelioid and colossal cells can meet. Borders of gummas are often indistinct; gummas pass into surrounding fabric imperceptibly in the form of gummous infiltrates. As a rule, gummas are exposed to the necrosis and disintegration reminding a tyromatosis at tuberculosis. Eventually the necrotic mass of a gumma obyzvestvlyatsya, the granulyatsionny fabric surrounding them turns in dense cicatricial with formation of the dense involved hems.

In the tertiary period of S. in a liver, a pancreas, adrenal glands, lungs, testicles the diffusion syphilitic sclerosis, or cirrhosis develops, to-ry can be an outcome of gummous infiltrates also; in a liver lobation develops. Often it is followed by development of a syphilitic vasculitis, at Krom arteries, napr, a syphilitic mesaortitis with aneurism (see the Aortic aneurysm, the Aortitis), an obliterating endarteritis of vessels of head m of an ozg are surprised generally.

In skin defeats in a type of a grumous syphilide of which existence in a derma of the granulomas consisting of a small amount of epithelial and multinucleate colossal cells like cells of the foreign bodys surrounded with a large number of plasmatic and lymphoid cells is characteristic are observed. The caseous necrosis is expressed poorly or is absent. At gummous knotty S. granulematozny changes are expressed more intensively, than at a grumous syphilide, and take not only a derma, but also hypodermic cellulose. In the center of the center of defeat there is a caseous necrosis, around to-rogo numerous lipoid and multinucleate colossal cells and on the periphery of the center — plasmocytes are located. In patol. process vessels of a derma and hypodermic cellulose are involved.

In the late period of S. processes from a nervous system develop diffusion, mainly dystrophic — back tabes (see) and a general paralysis (see). Page, as any hron. the infection, quite often is followed by the deep and progressing frustration of a metabolism, to-rye, e.g., can be expressed by an amyloidosis of internals (a spleen, kidneys, a liver, intestines).

The general patterns of a current

Reaction of an organism to implementation of the activator C. is difficult and diverse. Infection can not occur, chances of S. of a classical current, and also long asymptomatic (asimptomny) S. Priobretenny S. can lead to development of late forms of a disease (S. of a nervous system, internals, bones and joints).

Infection can not occur if the small portion of the activator gets into an organism or if in blood serum of almost healthy people the high level of thermolabile trepo-nemostatichesky and treponemotsidny substances is noted, to-rye can cause an immovability, and in some cases a lysis of pale treponemas.

At a long bessimptomnokhm S.'s current (asimptomny S.) the patient as if «slips» early active forms of a disease. At the same time it is not possible to diagnose early hidden S. since standard serological tests remain negative. In these cases probably the pale treponema is transformed to L-forms, polymembrane phagosomas, as the wedge, pictures and negative takes of serological tests defines absence. For such sick S. it is diagnosed as hidden not specified or hidden late almost always it is accidental in many years after infection on positive takes of standard serological tests, and also on reaction of an immobilization of pale treponemas — RIBT, or RIT (see Nelson — Meyer reaction), reactions of an immunofluorescence (see), or the REEF, on existence of damages of skin, a musculoskeletal system, nervous system or internals, late, characteristic of the tertiary period of S., in the absence of anamnestic data on S. Podrazdeleniye's disease of the hidden S. (lues latens) on early and late has big epidemiol. value, since. at early hidden

S. hold the same anti-epidemic events, as at infectious forms C. At impossibility of differential diagnosis between early make to late hidden S. the hidden neutoch-nenny

S. V diagnosis of epidemiology of S. special value has its classical current, at Krom distinguish four periods: an incubation interval (see) and three clinical (primary, secondary and tertiary). They consistently replace each other. The incubation interval lasts on average 3 — 4 weeks (according to a number of researchers, it was extended). The shortened incubation interval up to 8 — 15 days is noted at a bipolar arrangement of hard ulcers; lengthening of an incubation interval up to 108 — 190 days can be a consequence of reception by the patient of antibiotics concerning other diseases that leads also to a perversion of a current of Page.

The incubation interval comes to an end with emergence on site of implementation of a pale treponema of a hard ulcer. During this period the pale treponemas which got to an organism quickly extend, as a rule, lymphogenous gema-togennym in the way, and sometimes neurogenic (in Epi - peri-and endonev-riya).

Primary period of S. (lues I) begins with the moment of emergence of a hard ulcer, or primary syphiloma. It proceeds 6 — 7 weeks before emergence on skin and mucous membranes of multiple syphilitic rashes. In 5 — 7 days after emergence of a hard ulcer begin to increase nearby limf. nodes (a specific bubo, or a regional scleradenitis), the inflammation limf can develop ", vessels (specific limfangiit), and later 3 — 4 weeks increase in all limf, nodes — a specific polyadenitis is noted. A number of researchers established that the regional scleradenitis is absent in 4,4 — 6,3% of cases specific limfangiit at men is observed approximately in 40% of cases, and the specific polyadenitis often is absent.

Primary period of S. is divided into primary seronegative period (lues I seronegativa), at Krom results standard serol. reactions are negative, and primary seropositive (lues I seropositiva), when they become positive that occurs on average in 3 — 4 weeks after emergence of a hard ulcer and is explained by education in an organism of enough antibodies (reagins) in response to antigen — a pale treponema. Positive takes of reaction of Kolmer — reaction of binding complement in the cold (see Reaction of binding complement) and the REEF during this period are not the basis to diagnosis of primary seropositive syphilis since they are more sensitive, but are less specific, than standard serol. reactions.

Mass reproduction of pale treponemas and their distribution on an organism happens at the end of primary and the beginning of the secondary period of S. Nastupayet the peculiar so-called treponemny sepsis which is followed quite often by weakness, an indisposition, sleeplessness, headaches, loss of appetite, an acrimony, sometimes ostealgias and joints at night, temperature increase to 38 — 39 ° and also development of a polyadenitis.

In the secondary period of S. (lues II) on skin and mucous membranes there are rozeolezny, papular and pustular rashes, also internals (a liver, kidneys, etc.), nervous and bone systems are surprised. The secondary period of S. with the first (bright and plentiful) an enanthesis and mucous membranes in the presence of primary sclerosis or its remains is named secondary fresh S. (lues II recens). Existence in an organism of a large amount of antigen (pale treponema) brings to expressed immunol. to reactions owing to what a part of pale treponemas perishes, and rashes of the secondary period, having existed several weeks, spontaneously pass, without leaving any marks. There comes hidden, or latent, secondary S.'s (lues II latens) period. Then the wavy, phasic course of an infection follows: the wedge, a recurrence of a disease (lues II recidiva), to-rye arise in the absence of treatment or its insufficient efficiency, are replaced by the eclipse periods of a disease. At secondary recurrent S. the quantity of rashes with each subsequent recurrence decreases, rashes become larger and are characterized by tendency to group in the form of rings, arches, ovals, garlands etc. Without treatment the secondary period of S. proceeds on average 3 — 4 years and can be followed by several recurrence. In 60 — the 80th 20 century at sick S. decrease in frequency of pustular syphilides (earlier they were observed in 10,7% of cases, in a crust, time — in 1%), especially syphilitic ecthymas, rupees is noted; more often the papular syphilide of palms and soles (it is frequent only soles) — to 14 — 20% in relation to other localizations of a papular syphilide is registered.

In the absence of treatment or at insufficient treatment 3 — 4 later and more there comes the tertiary period of S. (lues III), at Krom in an organism hardly it is possible to find single pale treponemas. During this period an organism, being sensibilized to pale treponemas and their toxins, reacts even to their small number a peculiar anaphylactic reaction — formation of tertiary syphilides (hillocks and gummas), development to-rykh comes to the end with characteristic disintegration, a necrosis and the subsequent scarring. Hillocks are formed on skin, mucous membranes, gummas — in hypodermic cellulose, on mucous membranes, in bones, internals and nervous tissue. Being located in vitals, they can pose hazard to life of the patient. Alternation of the active and hidden (lues III latens) periods is possible. Tertiary S. can last decades. In this period the great value is attached to injuries, napr, physical, mental, and also to other factors weakening protective forces of an organism (hron. infections, intoxications, in particular alcohol). Irrespective of tertiary S.'s manifestations at insufficiently treated or uncured patients late defeats of a nervous system (back tabes, a general paralysis, diffusion meningovaskulyarny S., etc.) and internals are possible (cardiovascular S., a syphilitic aortitis, etc.).

One of options of a current of S. is malignant S., to-ry is characterized by an acute and heavy current. Damage of skin and mucous membranes is especially expressed. Primary period is shortened; the heavy general phenomena, deep pustular syphilides, an ulceration of mucous membranes, damage of bones, periosteums, a nervous system and internals, and also an orchitis in the absence of reaction limf, nodes and, as a rule, negative takes of serological tests are observed. This form of syphilis almost does not meet now.

Clinical manifestations and differential diagnosis

In a wedge, a current of the acquired S. allocate primary, secondary and tertiary periods, and also visceral S., syphilis of a nervous system and syphilis of bones and joints.

Primary period of syphilis, or primary syphilis, begins with emergence of a small reddish spot or a papule on site of implementation in an organism of pale treponemas. Within several days this element increases to the size of a pea, at the same time in its basis dense sclerous infiltrate (primary sclerosis) comes to light. In the central part of an element there is a superficial necrosis and depending on its depth primary erosion or an ulcer carrying the name of primary syphiloma («primary affect») or a hard ulcer is formed (see Affect primary). The hard ulcer is accompanied by changes regional limf, nodes and vessels (see. Primary complex ).

Fig. 9 — 26. External displays of syphilis. Fig. 9. A hard ulcer on a penis. Fig. 10. A huge hard ulcer on skin of the bottom of a front abdominal wall. Fig. 11. Indurative hypostasis (an atypical hard ulcer) in the field of the left big vulvar lips. Fig. 12. A hard ulcer on an upper lip. Fig. 13. The hard ulcer of a prepuce complicated by a sphacelism. Fig. 14. A phagedenic hard ulcer on a penis. Fig. 15. The Rozeolezny syphilide (the multiple not merging pink spots) on skin of a trunk and a shoulder at the patient with secondary fresh syphilis. Fig. 16 — 18. A papular lentikulyarny syphilide (a roundish papule of red color) at secondary recurrent syphilis on skin of a trunk and hands (fig. 16), soles (fig. 17) and the person (fig. 18).

Characteristic signs of a hard ulcer are the surface erosion or an ulcer of a round or oval form from 0,5 to 1 cm in size in dia. with the flat sharply limited and slightly towering over healthy skin regions (tsvetn. fig. 9). In the basis infiltrate in the form of a thin (pergament) plate or the massive consolidation reminding a cartilage of an auricle on density is probed; the inflammatory phenomena on peripheries and subjective feelings are absent. The surface of an erosion or ulcer smooth, saturated red color, shines thanks to existence serous separated, in Krom at a research many pale treponemas are found. In some cases on a surface of a hard ulcer the dense plaque gray vato - yellow color (color of the spoiled fat) or dot hemorrhages of dark red color (a petekhialny hard ulcer) is formed. The hard ulcer located on open sites of skin is quite often covered with a thick layered dark-brown crust. The size of a hard ulcer can be less usual (a dwarfish chancre) or to considerably exceed it (a huge chancre). Huge chancres most often develop on skin of a pubis (tsvetn. fig. 10), the bottom of a stomach, on an inner surface of hips, on a chin (at extra sexual infection) at the weakened patients.

The hard ulcer located, e.g., in a proctal fold can take a form of a linear crack or a slit-like erosion; at localization in a zone of a preputial bag the extensive surface erosion of dark red color reminding an erosive balanitis can develop., a balanoposthitis (see), with a gentle lamellar sclerosis in the basis (a kombustiformny chancre, a syphilitic balanitis of Follman-na).

The hard ulcer more often happens single, there are at the same time 2 — 3 and more chancres less often. Multiple hard ulcers are approximately in an identical stage of development. Consecutive development of several hard ulcers in the persons which underwent repeated infections during an incubation interval or in the first 10 — 12 days of existence of a hard ulcer when still there is no so-called shankerny immunity is in rare instances observed. Simultaneous development of hard ulcers on skin of external genitals and on the sites remote from them — bays, a breast, etc. is occasionally noted (bipolar chancres).

At infection sexually the hard ulcer is usually localized on generative organs: at men — most often on an internal leaf of a prepuce (a preputial fold), in the field of a wreath of a balanus, on a dorsum penis and on a balanus, is more rare — on skin of a scrotum and pubis, is even more rare — in the field of an outside opening of an urethra and in a navicula; at women — on big and small vulvar lips, at a clitoris and a bridle of vulvar lips, on hips, is more rare — in a zone of a uterine pharynx (in the form of sharply outlined erosion of a ring-shaped or semi-lunar form with the surface shining red color), it is extremely rare — on a mucous membrane of a vagina. Sometimes in a circle of a hard ulcer at its arrangement on big vulvar lips the massive painless indurative hypostasis of fabric caused by specific defeat small limf, vessels of skin and podkbzhny cellulose is formed. In rare instances indurative hypostasis hides the place of penetration of an infection, representing as if independent manifestation of primary S. — an atypical hard ulcer (tsvetn. fig. 11).

At extra sexual infection the hard ulcer is most often localized on lips, language, almonds, gingivas, in the sky; much more rare — on a chin, a conjunctiva a century and an eyeglobe, in the field of a papilla of the breast. The most unusual cases of infection and consequently, and localizations of a hard ulcer can be observed. The hard ulcer of almonds usually happens single, unilateral, at the same time there can be moderate inflammatory phenomena with sharp increase in an almond (chancre-amigdalit). Erosion and ulcers have dark red or opal color the bottom covered with a gryaznosery plaque; in the basis of ulcers or erosion — dense infiltration (indurative hypostasis), than speak insignificant morbidity and a nek-swarm difficulty during the swallowing. The general phenomena (fever, a headache, etc.) are absent; the accompanying sign is unilateral increase submaxillary (submandibular, T.) and cervical (sometimes and parotid) limf, nodes, slightly painful at a palpation.

The hard ulcer can be located on fingers of hands, is more often at medical staff, in particular at gynecologists and obstetricians. The infection gets through small injuries and agnails and causes quite often, in addition to a typical hard ulcer, a picture of a deep felon (chancre felon). At the same time the distal phalanx of a finger becomes cyanotic color, is club-shaped diffuse indurative hypostasis is thickened, noted. Around a nail the deep deckle-edged ulcer of a semi-lunar (horseshoe) form is found; its bottom is covered with purulent disintegration. Chancres felons are sharply painful. Without specific treatment they can exist a long time.

The hard ulcer in the field of a papilla of the breast at women usually has an appearance of narrow, quite deep semi-lunar crack with lamellar consolidation at the basis. The hard ulcer of a mucous membrane of a mouth and a red border of lips represents a limited erosion of a saucer-shaped form with lamellar consolidation at the basis (tsvetn. fig. 12). Unlike an afta (see) it maloboleznen it is also not surrounded with a zone of a hyperemia. The hard ulcer on lips quite often is followed by considerable hypostasis. In corners of a mouth, on gingivas, in skin folds the hard ulcer takes a form of cracks. On a back of the tongue he usually sharply acts over surrounding healthy fabric.

Consecutive infection can join primary S. Acute inflammatory reaction leads to hypostasis of surrounding fabric, the discharge of a hard ulcer becomes serous and purulent, in it hardly it is possible to find pale treponemas. At localization of a hard ulcer on an internal leaf of a prepuce or in a wreath of a balanus there can be a phymosis (see), at Krom it is not always possible to probe primary sclerosis; in separated from a preputial bag hardly pale treponemas can be found. At the same time specific is observed limfangiit (see) and typical consolidation inguinal limf, nodes (see Lymphadenitis), in punctate to-rykh is found by pale treponemas. More rare complication of a hard ulcer at men is the paraphimosis (see). At the weakened patients, especially at having alcoholism, the hard ulcer can be complicated by a sphacelism, quite often owing to accession fuzospirillez-ache infections. At the same time the necrosis of fabric develops, and on a surface of a hard ulcer the dirty-gray or dark scab surrounded with a wide zone of an inflammation is formed (tsvetn. fig. 13). At distribution of a necrosis of fabric on the periphery and in depth of a hard ulcer there is a so-called phagedenic (corroding) chancre (tsvetn. fig. 14).

At infection at the same time syphilis and a venereal ulcer (see) there is a mixed chancre. At the same time at first the wedge, a picture of a venereal ulcer develops, and after the expiration of an incubation interval of S. signs of a hard ulcer — characteristic consolidation of the basis of an ulcer and gradual smoothing of its bottom join. In separated ulcers it is possible to find pale treponemas.

The syphilitic scleradenitis arises on 5 — the 7th day after emergence of a hard ulcer. Limf, nodes at the same time are not soldered among themselves and to surrounding fabrics, have a plotnoelastichesky consistence, reach the size of large haricot or plum, are easily displaced and are painless at a palpation. Quite often they are located in the form of a chain, and a node, the next to a hard ulcer, it is more than others. At localization of a hard ulcer on a penis, sometimes on a dorsum penis specific is observed limfangiit in the form of the painless dense tyazh which is not soldered to surrounding fabrics. The scleradenitis is allowed slowly and can remain in the presence of symptoms of fresh secondary Page.

At the end of primary period increase in all limf, nodes is observed (polyadenitis), especially accurately increase cervical, elbow, occipital, axillary; and axillary have a plotnoelastichesky consistence, are not soldered to people around of a tkanyakhma, are painless at palpation. The polyadenitis can be observed several months, being slowly resolved.

S.'s diagnosis in primary period is confirmed with a research serous separated from a surface of an ulcer (erosion) on existence of a pale treponema. When it is difficult to receive a discharge (a phymosis, a hard ulcer of an urethra, etc.), investigate punctate from regional limf, nodes. Without fail carry out serol. blood analysis. Also confrontation, i.e. survey of the partner who is a possible source of infection that is important for diagnosis and for organizational measures for fight against distribution of Page is recommended.

Differential diagnosis carry out with a venereal ulcer by the form of ulcers, to a state limf, nodes, to-rye at a venereal ulcer represent the ostrovospalitelny buboes soldered in the general package and further can suppurate, be softened and be opened; with a herpes simplex (see) at localization of rashes on generative organs (in favor of herpes sharpness of a current, existence of burning or an itch, lack of a regional adenitis and consolidation in the basis of the erosion having usually scalloped outlines testifies). Besides, the hard ulcer needs to be differentiated with a sha-nkriformny ecthyma (see) piogenic or scabby origin, localized on skin of generative organs, for a cut negative takes of repeated researches on a pale treponema and serological tests are characteristic; with the erosive balanitis which is characterized by extensive surface erosions of red color with twisting edges, at Krom there is no consolidation in the basis of erosion (see the Balanitis, a balanoposthitis), cancer ulcers, to-rye a thicket occur at elderly people, differ in a long current, slow development in the periphery and in depth, have the wrong outlines, quite often vyvorochenny edges, the pitted bleeding bottom, are painful at palpation, in scraping from a cancer ulcer find atypical cells.

The syphilitic scleradenitis should be distinguished from the lymphadenitis at a pyoderma (see) which is characterized by painful increase limf, nodes (in acute cases at the same time there can be phenomena of a limfangiit and the general reaction in the form of a feverish state); from lymphadenitis at tubercular defeat limf, nodes (see Tuberculosis extra pulmonary, peripheral lymph nodes) when their slow pastose increase and involvement in process of surrounding fabric with development of a periadenitis is observed, quite often skin over inflamed limf, nodes is also involved in process, at the same time it gradually becomes thinner, fistulas and sluggish ulcers with the hanging edges are formed; from an inguinal lymphogranulomatosis (see the Lymphogranulomatosis pakhovy).

Secondary period of syphilis, or secondary syphilis, comes later 6 — 7 weeks after emergence of a hard ulcer. Between primary and secondary periods of sharp border does not exist; usually at emergence of fresh secondary rashes the hard ulcer and lymphadenitis still remains. Approximately in 15 — 20% of cases, it is preferential at the weakened patients, is more often at women, in 7 — 10 days prior to emergence of rash the prodromal phenomena in the form of the subfebrile temperature, weakness, headaches, and also ostealgias, the joints and muscles amplifying at night can be observed, etc. On skin and visible mucous membranes various rashes (secondary syphilides) — the most often rozeolezny (a rozeolezny syphilide), papular are found (a papular syphilide), is more rare — pustular (a pustular syphilide), and also a pigmental syphilide, or a necklace of Venus (see); the hair loss (syphilitic baldness) is observed. The type of syphilides depends on reactivity of an organism, their localization and influence of the irritating external factors. The abundance and symmetry of the first rash of the secondary period and more limited, usually grouped nature of recurrent rashes are natural.

Rashes have characteristic signs: rozeolezny rashes — faded color (light pink), papular and pustular — stagnant and cyanotic and brownish-brownish (ham, copper-colored); usually they do not merge among themselves, remain accurately delimited from each other (an exception rashes pleated make skin and on the sites which are exposed to maceration and friction); rashes, as a rule, are not followed by subjective feelings therefore quite often in the beginning the patient does not notice them; rashes often polimorfna: at the patient it is possible to observe at the same time existence of rozeolezny and papular, papular and pustular rashes (true polymorphism). Homogeneous elements of rash usually appear not at once, and attacks therefore they are in various stage of development (evolutionary, or false, polymorphism). Secondary rashes (except for deep pustular) have high-quality character and do not leave behind an atrophy or hems. They differ in high infectivity (especially erosive papules pleated of skin and on mucous membranes) as contain a large number of pale treponemas.

The Rozeolezny syphilide (a syphilitic roseola, or a spotty syphilide) — a light pink spot, from 0,5 to 1 cm in size in the diameter. Spots pour out plentifully and symmetrically on skin of a trunk and extremities, do not merge with each other (tsvetn. fig. 15). Subjective feelings, and also peeling during the entire period of existence of spots are absent. In the beginning spots have pink color, then gradually turn pale and get the scarcely noticeable brownish-yellowish shade which especially clearly is coming to light at a dermoskopiya (see). Having existed on average 15 — 20 days, rozeolezny rashes disappear, without leaving a mark.

Isolated cases of the shelled rozeolezny elements, Ur-tikaropodobnykh, slightly edematous roseolas and roseolas with punctulate granularity on a surface are described. Sometimes at secondary recurrent S. rozeolezny rashes are observed, to-rye in comparison with fresh are less plentiful, are grouped on limited sites of skin, often forming ring-shaped or arc-shaped figures, but to the sizes is slightly larger, have cyanochroic-pink coloring.

At differential diagnosis syphilitic roseolas should be distinguished from a chromophytosis (see a chromophytosis), at Krom the symptom of a peeling at a poskabli-vaniye of spots is found, as a rule; from pink depriving (see. Deprive pink), for to-rogo are characteristic brighter pink coloring, spots of an oval form with a clear peeling in the central part, a spot are larger than roseolas, and rashes often are followed by an itch, existence of primary large spot — a «maternal» plaque is characteristic. The syphilitic roseola needs to be differentiated also with the rashes arising at other diseases. So, at toxidermias (see) menocelis differs in more acute current, abundance, bright coloring, tendency to merge, emergence of an itch, sometimes burnings of skin. Several days later the peeling at first in the center, then on the periphery of rashes comes to light. At belly and a sapropyra (see the Typhoid, the Sapropyra epidemic) emergence of roseolas is followed by a serious general condition; spots are less plentiful and quite often gain hemorrhagic character. Spots from stings of crab-louses (see the Louse) have the grayish-violet shade which is not disappearing at a dermoskopiya, hl are located. obr. on a lower surface of a front abdominal wall, side parts of a trunk, on an inner surface of hips, is more rare on buttocks and a waist. Detection of crab-louses confirms the diagnosis.

The papular syphilide in the form of fresh rash of the secondary period meets less than rozeolezny; especially often it is observed at secondary recurrent Page. In size of elements distinguish miliary (melkopapulezny, lichenoid), lenti-kulyarny (krupnopapulezny) and monetovidny (nummulyarny) syphilides. The most often found lentikulyarny papular syphilide is characterized by rashes of dense sharply limited roundish papules to dia. 3 — 5 mm. Color their dark red with a cyanotic or yellowish and brownish shade, reminds dim color of red copper or ham (tsvetn. fig. 16). A surface of papules in the first days smooth, further papules begin to be shelled. The peeling appears in the center and comes to an end earlier, than on the periphery thanks to what it is possible to see a regional peeling in the form of a nimbus («Biyett's collar»). Pressure upon the center of a papule the stupid probe causes sharp morbidity (Yadasson's symptom). Papular elements appear on skin gradually therefore it is possible to see papules in various stages of development. At fresh secondary S. papules are disseminated symmetrically through skin. At a recurrence papular rash is less plentiful and tends to group with formation of rings, semi-arches or garlands. After their permission on site of papules it is long there is a noticeable pigmentation.

Distinguish the following a wedge, kinds of a lentikulyarny syphilide: seborrheal, psoriasiform, ring-shaped, kokardopodobny, papular syphilide of palms and soles (tsvetn. fig. 17), and also erosive, or becoming wet, and a vegetans syphilide.

External displays of syphilis. Rice 18. A papular lentikulyarny syphilide (a roundish papule of red color) at secondary recurrent syphilis on face skin. Fig. 19. A papular keratosic syphilide (the massive merged shelled papules) on skin of a sole of the patient with secondary recurrent syphilis. Fig. 20. A papular erosive syphilide (papules of bright red color with an erosive surface) on a penis of the patient with secondary recurrent syphilis. Fig. 21. Flat condylomas (hypertrophic papules with the wide basis) in the field of an anal orifice at the patient with secondary recurrent syphilis. Fig. 22. Ektimatozny syphilide (large roundish deep ulcers, crusty) on skin of a back, buttocks and hands at the patient with secondary recurrent syphilis. Fig. 23. A pustular rupioidny syphilide (pustules with multilayer cone-shaped crusts) at the patient with secondary recurrent syphilis. Fig. 24. Melkoochagovy baldness at the patient with secondary recurrent syphilis. Fig. 25. Diffusion baldness and single lentikulyarny papules on skin of temporoparietal area at the patient with secondary recurrent syphilis. Fig. 26. A grumous syphilide in the form of the drain ulcerated centers on skin of a shin at the patient with tertiary syphilis.

At a seborrheal syphilide of a papule are covered with fat massive scales — crusts of yellowish or gray-yellow color. Papules are localized on the sites of skin rich with sebaceous glands — in a forehead (tsvetn. fig. 18), pleated skin, on a pilar part golovy.

The psoriasiform syphilide is characterized by emergence of a plentiful silvery peeling on a surface of papules. Lack of a terminal film, dot bleeding and peripheral growth of papules with formation of large plaques distinguishes this form of syphilis from scaly depriving (see Psoriasis).

Ring-shaped (tsirtsinarny, or circular) the syphilide with a ring-shaped arrangement of recurrent papules most often, yvat on skin of a penis, a scrotum.

The Kokardopodobny syphilide and a korimbiformny syphilide, close to it, are characterized by a peculiar arrangement of papules: in the center one large papule, and on a circle or small papules are randomly scattered.

At a papular syphilide of palms and soles of a papule at first tower over the level of skin a little and appear through in the form of sharply limited reddish-violet or yellowish spots, century the basis to-rykh dense infiltration is probed. Further papules become covered dense difficult by the deleted scales. Sometimes, merging, form the rings and massive plaques similar to the centers of palmar and bottom psoriasis (tsvetn. fig. 19). Detection of typical plaques of psoriasis on other places, symmetry of defeats, characteristic changes of nails, a psoriasis triad and lack of clear dense infiltrate around the centers exclude Page. The considerable thickening of a corneous layer of epidermis over papules is in rare instances observed, a cut leads to formation of syphilitic callosities, warty educations.

Erosive, or becoming wet, the syphilide is characterized by emergence of the becoming wet or erosive papules most often in large folds of skin, on generative organs (tsvetn. fig. 20). They result from maceration and exfoliating of a rogov.y layer and tend to the peripheral growth and merge in plaques to krupnofestonchaty edges. From their surface the serous exudate containing a large number of pale treponemas therefore they differ in the greatest infectivity constantly separates. Under the influence of long irritation moist papules can vegetirovat (a vegetans syphilide): their surface becomes the hilly, uneven, covered serous scales or the grayish sticky plaque containing a significant amount of pale treponemas. Papules vegitans, or flat condylomas (condylomas syphilitic), reach sometimes the big sizes. They are especially often formed in a mezhjyagodichny fold, on vulvar lips, at a root of a penis, in the field of a scrotum, an anus (tsvetn. fig. 21) and, more rare, a navel, under mammary glands, in axillary hollows and in interdigital folds of legs.

Syphilitic condylomas need to be distinguished from sharp-pointed condylomas (see the Wart), to-rye are located on soft and narrow, in the form of a leg, the basis; from the centers of a vegetans pemphigus (see) which are characterized by friability and juiciness of growths, lack of dense infiltrate and existence of fresh bubbles on the periphery; from hemorrhoidal nodes (see Hemorrhoids), to-rye are painful, smooth, inclined to bleedings, have character of soft ektazirovanny venous nodes; from the lozhnosifilitichesky papules of Lipshyutts observed, as a rule, at women in the uniform of dense dry papules of light pink color, hemispherical, size from lentil to a pea, quite often pruritic, as a rule, neero-ziruyushchikhsya, located linearly at the edges of big vulvar lips, is more rare in the field of inguinal and genital folds, on a crotch and in the field of an anus (see Psevdosifilis papular.)

The miliary syphilide is characterized by an enanthesis of a trunk and extremities of conic papules size about poppy or prosyany grain, the brownish and reddish or copper-colored color, a dense consistence inclined to group with formation of circles, rings, plaques with gear edges and a fine-grained surface. At a rassasyvaniye of papules the pressed pigmented scars can come to light. The miliary syphilide is more often observed at patients with secondary recurrent S., is frequent at the weakened, exhausted patients, at TB patients and hron. alcoholism. Differs hron. a current will also badly respond to specific treatment.

The miliary syphilide is differentiated with lichenoid tuberculosis, to-ry it is observed preferential at children's and youthful age, characterized by an extra pulmonary tuberculous focus (see Tuberculosis extra pulmonary) and positive skin test on tuberculine (see the Tuberculinodiagnosis); with a White's disease (see); by red hair it is deprived (see Deverzhi a disease), the expressed keratinization differing markedly in mouths of follicles of hair, localization on extensor surfaces of extremities, hron. current, absence of group of elements; with the lichenoid trikhofitid arising against the background of the centers of a deep t.rikhofitiya (see) as a toxidermia.

The Monetovidny syphilide differs from a lentikulyarny syphilide in emergence of large papules (with 10 — a 20-kopeck coin) and massiveness of infiltrate. Single papules are usually grouped, at their rassasyvaniye there is expressed nevus pigmentosus. Quite often they are combined with other secondary syphilides. Are observed usually at patients with secondary recurrent Page. In rare instances large papular elements merge in plaques size about a children's palm more (blyashkovidny, or continuous, a syphilide).

Rare form of secondary S. is the herpetiform syphilide consisting of small papules on a top to-rykh the bubble is formed. Contents of a bubble quickly dry up, the crust is formed, after falling away the cut is bared the shelled surface of papules. Sometimes papules are grouped, forming plaques of copper-colored color of the size of a nail more. After a rassasyvaniye there is a pigmented spot with the smallest scars on a surface which are gradually smoothing out.

The pustular syphilide arises, as a rule, at a heavy (malignant) current of Page. Emergence of pustular rash quite often is followed by a feverish state. Distinguish the following kinds of a pustular syphilide: acneform, ospennovidny, impe-tiginozyy, ektimatozny, rupioid-ny.

The acneform syphilide more often is a symptom of fresh secondary Page. The pustules of the size of hempy grain of a cone-shaped form having the small papular infiltrate localized in a circle of follicles of hair or a sebaceous gland in the basis are characteristic of it. They appear more often on skin of a back, a breast, extremities. Purulent exudate dries up in a brownish crust, after falling away the cut and permissions of infiltrate remains the scarcely noticeable pigmented scar. It is necessary to differentiate it with vulgar eels (see), as a rule, the iodide and bromic rashes developing against the background of seborrhea, both more sharply arising, to-rye are easily distinguished on the basis of the anamnesis (administration of drugs of bromine and iodine).

The Ospennovidny syphilide more often is manifestation of fresh secondary Page. Evolution of the ospennovidny elements reaching the size of lentil, which are not connected with hair follicles, almost same as at an acneform syphilide. It needs to be differentiated with natural smallpox (see Smallpox natural) and in chicken pox (see), to-rye differ in more acute current and (quite often) serious general condition. At smallpox the prodromal rash located usually on an inner surface of hips, side sites of the person and neck on forearms is observed; smallpox pustules have no limited dense infiltrate of copper-colored color in the basis, characteristic of S.

The impetiginous syphilide is observed more often in combination with papular rash of fresh secondary Page. It is localized by hl. obr. on skin of a pilar part of the head and on a face. There are papules of dark red color of the size of a small coin, in their center in several days there are pustules, to-rye quickly dry up, forming a massive friable impetiginous crust. The nevus pigmentosus on site of this syphilide completely disappears. Along with superficial the deep form of an impetiginous syphilide (is observed usually at late recurrent secondary S.). (See Impetigo) the impetiginous syphilide differs in lack of signs of rapid peripheral growth of elements of rash and bent to merge from piokokkovy impetiginous rashes, existence around crusts of the typical roller of sharply limited dense infiltrate of cyanotic-red color and other symptoms S.

Ektimatozny a syphilide — a severe malignant form of a pustular syphilide, arises at the weakened people not earlier than 5 —-go month after infection, is asymmetric on skin of shins, persons and trunks are more rare (quantity of elements — ecthymas — 5 — 10). There is dark red slightly infiltrirovanny limited spot, against the background of to-rogo in the center there is a deep pustule which is gradually drying up with education by dense grayish-borax, almost black crust bordered with the roller of dense specific infiltrate. Due to the peripheral growth of an ecthyma can reach the size of metal ruble and more. Under a thick crust the ulcer of a round or oval form with abruptly going down edges and the bottom covered with yellowish-gray disintegration is found. Infiltrirovanny edges of an ulcer in the form of the narrow roller of copper-colored color slightly tower over the level of surrounding skin (tsvetn. fig. 22). After permission of ecthymas on their place there are profound strongly pigmented hems afterwards gaining nacreous-white color. Syphilitic ecthymas should be differentiated with vulgar ecthymas (see), to-rye develop directly from streptogenny phlyctenas; in their circle there is a diffuse inflammatory reaction of skin and there is no peripheral papular roller typical for syphilitic ecthymas.

The Rupioidny syphilide (or syphilitic rupees) is a kind of hard proceeding syphilitic ecthymas, with sharply expressed tendency of inflammatory process to extend both on the periphery, and in depth. As a result of the eccentric growth of infiltrate and its consecutive disintegration the crusts having an appearance of a multilayer, cone-shaped oyster sink are in breadth and deep into formed (tsvetn. fig. 23). In syphilitic rupee it is possible to observe three zones: in the center the rupioidny crust, on the periphery — the roller of papular infiltrate of violet-red color, and between them a ring-shaped zone of an ulceration is located. In separated and infiltrates of syphilitic ecthymas and rupees few pale treponemas, and Wassermann reaction contain (see Wasserman reaction) in some cases can be negative.

The pigmental syphilide, or a necklace of Venus, arises on 5 — the 6th month after infection, is more rare in the second half of the first year, usually on a back and side surface of a neck (a necklace of Venus), is more rare in other places. Against the background of a little pigmented skin whitish spots of roundish outlines appear. In some cases at a necklace of Venus are found in patients patol. changes of cerebrospinal liquid (see).

Education around a nail of sharply limited inflammatory infiltrate is characteristic of syphilitic paronychias (see) at secondary S., to-ry further resolves or ulcerates. The ulceration, especially at a pustular syphilide, is followed by sharp morbidity, obilnsh release of pus, rejection of nail plates. The ulceration which took a matrix and a bed of a nail leads to his death.

Damages of mucous membranes of an oral cavity, a pharynx, a throat, upper respiratory tracts, generative organs arise in the secondary period of S. along with skin rashes or separately (at a recurrence). Often they are not followed by subjective feelings therefore are quite often looked through and can be a source of infection. Distinguish spotty, papular and pustular syphilides of mucous membranes. The spotty syphilide of mucous membranes of a mouth, a thicket on almonds, a uvula, a soft palate, on palatoglossal (lobbies) and palatopharyngeal (back) handles in the form of sharply outlined drain erythematic centers of sinyushnokrasny color is observed along with skin rashes (rozeolezny and papular) fresh secondary S. Subjektivno the feeling of insignificant dryness in a throat, pain during the swallowing is possible.

The papular syphilide of mucous membranes often accompanies skin rashes. In the beginning 0,5 cm in size in the diameter or it is more papule, dense, cyanotic-red color, about 1 — 2 cm in the diameter can expand or merge in large plaques with sharply outlined scalloped edges. The central part of papules owing to maceration of an epithelium quickly gets a grayish-whitish (opal) shade, on the periphery the narrow border of infiltrate of sinyushnokrasny color remains. Education erozirovanny and even the izjyaz-curling papules delimited from a healthy mucous membrane by the roller of not broken up infiltrate of cyanotic-red color is possible. Most often papular elements are found on almonds, a hard and soft palate, on mucous membranes of lips and gums, in language. Being at the places which are exposed to constant irritation (e.g., on edge of language or in corners of a mouth), they can hypertrophy, vegetirovat. Such papules considerably act over urovnekhm surrounding healthy skin, are covered with a reinforced epithelium of grayish-white color, are dense to the touch. At the remained epithelial cover of a papule, even located on palatine tonsils and a soft palate, cause only a feeling of small difficulty during the swallowing: eroziro-bathing and ulcerated papules, especially in corners of a mouth, as a rule, cause considerable pain. Papular rashes in the field of voice folds (see the Throat) cause an osiplost and occasionally full aphonia.

The papular syphilide of mucous membranes should be distinguished from infectious quinsy, including Vincent's quinsy (see Quinsy) and diphtherias of a pharynx (see Diphtheria), to-rye proceed more violently, are followed by sharp morbidity and the acute general phenomena; from aphthous stomatitis (see), at Krom the acute beginning is also observed, there are inflammatory reactions in a circle aft and sharp morbidity. Carry out differential diagnosis with red flat it is deprived, the characterized rash on mucous membranes of a mouth of the small painless white papules forming defeat in a type of the drawing (e.g., a fern); at attentive survey of all integument sometimes find typical elements red flat depriving (see. Deprive red flat); with the centers of a leukoplakia (see), to-rye are stabler, have white or grayish-white color, hl are localized. obr. on a mucous membrane of lips, along the line of a smykaniye of teeth, in corners of a mouth and on cheeks, differ in the wrong outlines and have no inflammatory infiltrirovanny nimbus on the periphery.

The pustular syphilide of mucous membranes meets extremely seldom, usually at a pustular enanthesis. Tires of pustules, quickly bursting, bare erethistic ulcers from 0,5 to 1 in size — 2 cm in the diameter. The bottom of ulcers is covered with se-rovato-purulent disintegration.

Syphilitic baldness, or syphilitic baldness, is observed preferential at secondary recurrent, is more rare — at secondary fresh S. Razlichayut the melkoochagovy, diffusion and mixed syphilitic baldness. Melkoochagovy baldness is characterized small, up to 1,5 cm in the diameter by ochazhka of incomplete baldness (tsvetn. fig. 24), it is preferential in occipital and temporal areas, and also eyebrows («omnibusny», or «tram», a syphilide), eyelashes (Pinkus's symptom). Diffusion baldness (tsvetn. fig. 25) is shown by a poredeniye of hair on all pilar part of the head and has no characteristic signs (its diagnosis is established on the basis of other manifestations of secondary S. and positive serological tests). The mixed baldness — a combination diffusion and melkoochagovy (see the Alopecia).

Syphilitic onychia and paronychia are more often observed along with a papular syphilide of palms and soles. The syphilitic papules located under a nail at first appear through in the form of burokrasny spots, then the nail over spots becomes whitish, fragile and easily crumbles. The damages of nails observed occasionally at a pustular syphilide differ in sharp morbidity. The infiltrate located under a nail plate or at a matrix is exposed purulent a raspadu, as a result nail plates are torn away from a nail bed to a greater or lesser extent, become brittle, fragile, with the crateriform deepenings at a root of a nail. In some cases the thickening of nails exceeding normal thickness by 3 — 4 times can be observed.

Tertiary period of syphilis, or tertiary syphilis, it is characterized by the changes of destructive character which are coming to an end with formation of a hem and disturbance of functions of the struck body. Tertiary S.'s manifestations have usually localized character, and not only skin and mucous membranes, but also internals, a musculoskeletal system, c can be surprised. N of page.

Tertiary syphilides of skin have character of grumous or gummous educations (a difference between a hillock and a gumma quantitative, depending on size and depth of an element). At a grumous syphilide in the thickness of a derma accurately konturirovanny roundish dense educations towering over surrounding fabrics with a semi-spherical surface, from 0,3 to 1 cm in the diameter are probed (skin over them gains reddish and cyanotic color). Hillocks, appearing at different times, find a tendency to be grouped in rings, arches, garlands or closely. The so-called fokusnost of rash is characteristic, at a cut a peculiar character of each hillock separately accurately is defined. Permission of hillocks can be various. Usually in the center of hillocks there is a necrotic disintegration that leads to formation of small sores of the correct rounded shape with abrupt almost steep edges and the bottom covered with dense fabric disintegration. Edges of such ulcers dense, valikoobrazny form. After healing of ulcers there are small grouped scars surrounded with a pigmental border. In rare instances hillocks resolve and after several weeks or 2 — 3 months disappear, leaving behind the site of the gentle atrofichny skin surrounded with the pigmented border. In a stage of a peeling the grumous syphilide a little in what differs from the grouped papular syphilide; the atrophic changes only remaining allow to establish the true nature of rashes.

Non-simultaneous emergence of hillocks, various duration of their existence and various character of permission explain observed in some cases motley picture of a grumous syphilide. At fading in of the new isolated centers of defeat process can occupy extensive sites of skin in the form of the widespread superficial grouped grumous syphilide. The centers of the grouped syphilide take a peculiar form when there is a progressing growth of infiltrate due to emergence of new hillocks on the periphery of the center. The ulceration of older hillocks which is consistently turning into scarring is at the same time observed (tsvetn. fig. 26). Such drain grumous infiltrate, breaking up, begins to increase in a certain direction in the form of an arch or a garland, as if crawling over sites of healthy skin and leaving behind a zone of the cicatricial changed skin — a superficial serpiginozny grumous syphilide. Hems after such syphilide have mosaic character because of uneven pigmentation, unequal depth and a form of separate scars, to-rye, in turn, depend on various size and depth of formation of separate hillocks.

In rare instances there is a merge of group of hillocks in one continuous dense infiltrate in the form of sharply limited extensive plaque (platform) of cyanotic-red color size about a palm more. On its certain sites it is possible to notice a peeling, on others — an ulceration.

The grumous syphilide should be distinguished from a tubercular lupus (see Tuberculosis extra pulmonary, skin), at a cut hillocks have a soft consistence, are easily pressed through by the stupid probe, at a diaskopiya accept characteristic coloring of apple jelly, leave behind continuous atrophic hems, on to-rykh fresh hillocks can appear. Beginning preferential at children's age, the tubercular lupus without treatment gets hron. current.

The gummous syphilide (syphiloma) represents the painless node of a plotnoelastichesky consistence located in deep layers of a derma and a hypoderma, in the beginning not soldered to surrounding fabric. Later 2 — 4 weeks the gumma is accustomed to drinking with skin, turning into the tumorous formation of dark red color up to 1,5 cm in size towering over the surface of healthy skin in the diameter. Further the central part of a gumma begins to be softened, flyuktuirovat, skin over it becomes thinner, nekro-tizirutsya. The gumma is opened with allocation from a perforation opening of the sticky viscous liquid similar to arabic gum. The created gummous ulcer deep, has the correct roundish outlines, dense valikoobrazny steep edges and the bottom covered with yellowish and purulent fabric disintegration (a gummous core). Without treatment it can exist a long time. At the same time increases in sizes, quite often affects healthy skin in one direction in the form of an arch, a garland; at the same time on old sites there is a scarring (the gummous syphilide is gray-piginiruyushchy).

Gummas more often happen single; quite often meet on a face, on skin near joints, on a front surface of shins. At a close arrangement of several gummas the drain massive gummous infiltrate (gummas the platform) which afterwards is opened in several places with formation of the ulcers merging then in an extensive ulcer with the dense sharply outlined scalloped edges can be formed. Under unfavorable conditions of a gumma can expand also in depth, causing a disfiguration and even loss of nek-ry bodies — a nose, an eye, a small egg etc. (the irradiating, mutiliruyushchy gummas). Regressing, the gummous ulcer is cleared of necrotic masses and filled with granulations. After healing on its place the dense hem involved in the center bordered with a belt of the gentle atrofichny pigmented skin is formed. The gradual rassasyvaniye of gummous infiltrate with substitution by connecting fabric is much less often observed.

A special kind of gummas is circumarticular nodosity of Zhanselm — Lyuttsa, developing near large joints (see Nodosity circumarticular). They can exist for years, without causing subjective feelings; will difficult respond to treatment.

The syphiloma should be distinguished from a scrofuloderma (see Tuberculosis extra pulmonary, skin), edges arises usually in the area limf, nodes, differs in a soft consistence and breaks up in all the weight with the subsequent fusion of skin and formation usually of several fistular courses, from to-rykh liquid is allocated it is purulent - a bloody discharge. The developed ulcer has the soft hanging uneven edges, its bottom is covered with sluggish zhelepodobny granulations. Healing happens slowly to formation of «shaggy» hems, to nipples and * skin bridges. The gummous syphilide is differentiated with an indurative erythema to Base-on (see Tuberculosis extra pulmonary, skin), edges develops symmetrically in the lower third of shins in the form of several nodes of an indistinct form more often. The disintegration of nodes observed in nek-ry cases leads to formation of ulcers with the soft basis, with uneven cyanotic and reddish edges, with sluggish and drift. It is necessary to distinguish a gummous ulcer from cancer which is often painful, has the basis of a ligneous and dense consistence, vyvorochenny edges, its bottom bleeds.

Rare manifestation of tertiary S. — - a tertiary erythema, or a tertiary roseola of Fournier, edge is observed by hl. obr. during from 2 to 5 years from the beginning of a disease. It is characterized by scarcity and limitation of erythematic elements, their large sizes and a peculiar configuration in the form of rings, arches and garlands, and also drift and resistance to specific treatment. In nek-ry cases the centers of a tertiary erythema slightly infiltrirovana, sometimes at the same time are available rashes of brownish and reddish papulobugorkovy elements.

In the tertiary period of S. of damage of mucous membranes are more often shown by the low-painful gummous infiltrates of stagnant-red color located in a soft and hard palate in a bone part of a nasal partition, is more rare on a back wall of a throat and in fabrics of language. At disintegration of gummous infiltrate there is an ulcer. It is deep, its bottom is covered with pus and fabric disintegration, edges crateriform, surrounded with the roller of dense infiltrate. It can extend to a bone tissue, edges is exposed to destruction with sequestration. So, at an arrangement of an ulcer on a mucous membrane of a nose there is a perforation of a partition of a nose, and during the involvement in process of upper parts of a bone partition of a nose the nose (a saddle, lornetoobrazny nose) is deformed. The ulcers located in front department of a soft palate (see) on border with a hard palate, usually are followed by perforation of a soft palate therefore the message between an oral cavity and a nasal cavity is formed. At development of gummous process on border of a soft palate, palatal handles and a uvula the ulceration leads to their destruction; rough radiant hems with an increment of a palatine velum to a back wall of a throat and cicatricial narrowing of a pharynx with the corresponding functional frustration are formed. Gummous ulcers of a hard palate can be limited to superficial disintegration of a bone tissue. In more hard cases the bone is perforated and the message between an oral cavity and a nasal cavity is formed that leads to disturbance of phonation (twang) and hit of food in a nose. Gummous defeat of a back wall of a throat (see) leads to ulceration, sharply delimited from healthy fabric by the roller of dense infiltrate. The bottom of an ulcer is covered is purulent - a necrotic plaque. After healing the peculiar radiant involved hem is formed.

Gummous defeats of language are shown in the form of a gummous or diffusion sclerous, or intersticial glossitis (see).

Tertiary damages of a soft and hard palate can be shown in the form of a grumous syphilide. At the same time on a mucous membrane there are grouped hillocks, dense to the touch, saturated-red color with a cyanotic shade. Further hillocks resolve or break up with formation of the isolated deep sores which are leaving behind the involved focal scars of white color more often. Groups of scars it is characteristic of a grumous syphilide.

Visceral syphilis. Damage of internals can meet at primary seropositive, secondary and tertiary S., sometimes together with defeat of a nervous system, bones and joints. Damages of internals at the secondary, early eclipse period of S. and in some cases in primary period, as a rule, proceed favorably and will successfully respond to antisyphilitic treatment that quite often is one of confirmations of the specific nature of these defeats. Most often they have functional character, do not disturb patients and are distinguished only at special, purposeful methods of a research.

At early S., by data And. V. Davydova (1950), at 15% of patients fever, at 35% of patients — change of activity of cardiovascular system is noted, at 50% of patients — functional frustration went. - kish. path, renal failure, changes in urine; as a rule, the liver, sometimes a spleen is involved in process, permeability of capillaries is broken, the picture of blood changes, functional disturbances of closed glands appear.

Damages of a liver (see the Liver, syphilis) are possible in the period of seropositive primary ending or the beginning of the secondary period of S. (is more often in 6 — 8 months after infection). At the same time the liver increases in sizes, is painful, is broken its pigmental, anti-toxic, carbohydrate and other functions. At the same time the spleen (a syphilitic hepatosplenitis) can increase in sizes. It is more, than at a viral hepatitis, the amount of bilirubin, globulins, in urine increases in blood — bilious pigments and urobilin, temperature often increases, headaches are noted, i.e. the symptomatology is identical to displays of a viral hepatitis, but differs in lack of preicteric dispepsichesky frustration or they are poorly expressed. Very seldom specific hepatitis without jaundice develops. Diagnosis is facilitated by a wedge, secondary S.'s symptoms and, as a rule, sharply positive serological tests. Specific therapy gives a favorable effect, but it is not recommended to apply biyo-hinol.

Damage of kidneys (see Kidneys, syphilis) at early S. can be shown by a high-quality proteinuria (see) or a syphilitic lipoid nephrosis. At the same time the patient is pale, it has hypostases and changes in urine (urine muddy); density of urine to 1,040 and above, in draft — cylinders, leukocytes, an epithelium, lipoblasts, it is rare — erythrocytes, protein — 20 — 30 °/o0, the general diuresis is reduced, changes of an eyeground and the ABP are not observed. Extremely seldom acute or subacute syphilitic nephrite, existence to-rogo 'is registered at early forms C. nek-ry researchers it is denied.

Defeat of cardiovascular system meets in the form of the diffusion interstitial myocarditis (see) having an autoallergichesky origin owing to toxi-infectious dystrophy of the myocardium diagnosed, as a rule, at an electrocardiographic research. Sometimes patients complain of bystry fatigue, weakness, an asthma, dizziness. In some cases temperature increases, cardiac sounds become deafs, arrhythmia develops. Against the background of a small leukopenia, thrombocytopenia, a monocytosis ROE almost always raises. The tool and functional research of cardiovascular system (arterial and venous pressure, speed of a blood-groove in a big and small circle of blood circulation, electro-, a vector - ballisto-, phono-and an arteriopyezografiya) reveals involvement it in patol. process at all stages early S. Sifiliticheskiye endo-and perivasculites, disturbances of permeability and firmness of capillaries are noted in the secondary period of S., syphilitic phlebitis — in the secondary and tertiary periods of a disease. Early cardiovascular changes well give in to specific therapy.

Syphilitic gastritis, or early gastrosifilis (see the Stomach, syphilis), has no signs, characteristic of S., is followed by nausea, an eructation, loss of appetite, decrease in gastric acidity. Sometimes there is an expressed symptomatology (pains of different intensity, dispeptic frustration, a lose of weight of a body, weakness, an akhiliya, positive reaction to the occult blood in Calais, impurity is fresher than blood in emetic masses), edges are led originally to the wrong diagnosis of cancer or stomach ulcer (or the gatekeeper), the gastroduodenita or a gepatokholetsistita and only positive serological tests, especially the REEF and RIBT, active manifestations of S. on skin and mucous membranes, sometimes the anamnesis allow to diagnose damage of a stomach etiologically correctly. The penicillin therapy leads to bystry regress of symptomatology.

From endocrine system it is most often involved in patol. process a thyroid gland (see). Extremely seldom chances of not sugar mocheiznureniye of a syphilitic etiology, orkhita (see) and epididymites (see). Syphilitic endocrinopathies are steadier against specific therapy, than early syphilitic damages of internals (they are treated antibiotics in combination with nonspecific means).

Damages of internals in the tertiary period of S. proceed most hard and carry the name of late visceral Page. From them S. of cardiovascular system are most frequent, to-ry makes 90 — 94% of all late syphilitic visceral pathology, S. of a liver — 4 — 6%, S. went. - kish. a path, kidneys, lungs, hemadens — 1 — 2%.

Fig. 3. Roentgenograms of a thorax of patients with tertiary syphilis (direct projection): shooters specified a gumma of the right auricle (a), an aneurysm of the ascending part of an aorta (b), a gumma of the left lung.

Late syphilitic defeats of cardiovascular system (cardiovascular S.) come to light at 0,25 — 0,96% of therapeutic patients, from them in 93,4% of cases, by data Myuntanya (M. of Munteanu, 1973), the mesaortitis is registered. However its intravital diagnosis as Blumgart notes (H. L. Blum-gart, 1940), makes only 10% of cases since at most of these patients serological tests negative, and RIBT and REEF are put seldom. Late syphilitic myocardites are shown by formation of gummas or hron. the interstitial myocarditis which is often called by gummous myocarditis. Gummas of heart meet extremely seldom (fig. 3, a) and in connection with small size can proceed asymptomatically. An asthma, the general weakness, bystry fatigue, pains in heart are sometimes noted. After substitution of a gumma the carrying-out system of heart can be broken by fibrous fabric (more often in the field of ventricles) that leads to disturbance of a cordial rhythm. Gummous myocarditis can be also followed by cyanosis of skin (especially extremities), expansion of borders of heart, dullness of the I tone, a systolic apex murmur, disturbance of a rhythm. It differs from other forms of cardiovascular S., as a rule, in positive results of serological tests. At late begun treatment its outcome — a diffusion or focal cardiosclerosis (see).

An uncomplicated syphilitic aortitis — the most frequent manifestation of visceral S. (see the Aortitis). It is more often observed at men, than at women. At a disease there is a consolidation of walls of an aorta and expansion of its ascending part to 5 — 6 cm (3 — 3,5 cm are normal). Less often the aortic arch or its descending part is involved in process and it is extremely rare — its belly part. Quite often the disease is diagnosed at rentgenol. inspection on a characteristic limited aortectasia and existence of the sites of calcification which are located longwise in walls of the ascending part in the form of linear spots. The soft, blowing, unsharply expressed systolic noise on an aorta, emphasis of the II tone on an aorta with a metal shade (the ringing tone), in blood a lymphocytosis, an eosinophilia, moderate increase in ROE is objectively noted. Patients can complain of an asthma, the general weakness, heartbeat, pains in heart, behind a breast (aortalgiya) and feeling of a prelum. Arteriosclerotic changes quite often join a syphilitic aortitis, complicating its recognition. According to various researchers, in 22 — 26% of cases it is combined with symptoms of neurosyphilis and in 56% — with late asimptomny syphilitic meningitis; at 84% of patients serological tests happen negative, RIBT is positive in 100% of cases. The syphilitic aortitis can be complicated by a stenosis of mouths (more often than right) coronary (coronal, T.) arteries, aortic incompetence, an aortic aneurysm (see). Unlike atherosclerosis (see) syphilitic changes do not extend on the course of coronary vessels, and are limited to their initial sites, leading to a stenosis that can (owing to coronary spasms) to result in acute or chronic coronary insufficiency (see) and to serve as the reason of a transmural myocardial infarction (see). Clinically the picture of the stenocardia (see) proceeding heavier develops than at atherosclerosis. Heart failure can develop progressing (more often than left ventricular type) (see). Aortic incompetence arises owing to wrinkling and shortening of its shutters or gates (organic valve insufficiency) or because of an aortectasia (relative valve insufficiency). Peripheral hypostases, attacks of cardiac asthma (see), diastolic noise (short and silent or hoarse), systolic noise on an aorta (sharp) and accent of the II tone with a metal shade join the symptoms of a simple aortitis specified earlier. For the last decades the number of aneurisms in relation to total number of syphilitic aortites increased (at men of aneurism occur by 4 — 5 times more often than at women). Syphilitic aneurism, according to Yurye (S. of Ni-riez) et al. (1957), in 2/3 cases is localized in the ascending part of an aorta (fig. 3, b), in 20% — in the field of an arch and only in 10% — in a belly part of an aorta. It has the meshotchaty form more often, than spindle-shaped. If there are a wedge, symptoms, then they depend on the size and localization of aneurism. Syphilitic aneurisms differentiate with tumors of a thorax, at the same time help RIBT and REEF since serological tests, as a rule, negative.

Fig. 4. Macrodrug of a liver at tertiary syphilis (a lobular liver).

In a crust, time late syphilitic damages of a liver meet seldom, though S. Razvivayutsya they in 10 — 30 years after infection at not treated or badly treated patients with syphilis take the second place after late cardiovascular. A. JI. Butchers (1949) distinguished several forms of late syphilitic hepatitises. At focal gummous hepatitis in interstitial tissue of a liver gummous nodes size to egg develop. There are pains in right hypochondrium, fever of remittiruyushchy type, vomiting, loss of appetite, jaundice; in blood moderate anemia, a small leukocytosis is observed. The liver is increased, hilly, dense. As a result of a necrosis and scarring the lobular liver (fig. 4) develops, the involved (star-shaped) hems are formed. The spleen, as a rule, does not increase. Specific treatment in an initial stage yields satisfactory results. Cases of an asymptomatic course of gummous hepatitis are described. Differential diagnosis is carried out with an echinococcosis (see), abscess and a tumor of a liver (see).

At diffuse miliary gummous hepatitis in a liver there are in a large number small gummous ochazhka or there is a growth of diffusion gummous infiltrate (in case of a combination to intersticial process). Then infiltrate is replaced with cicatricial fabric and cirrhosis develops. At the same time note consolidation and morbidity of a liver, and also increase in a spleen, in the subsequent there is a reduction of the sizes of a liver, it becomes hilly. Specific treatment can give effect only at the beginning of a disease.

Hron. epithelial hepatitis is followed by a febricula, small appetite, weakness, a skin itch, jaundice. The liver is increased, in the beginning is painless, smooth. In blood anemia, a leukopenia and a hyperchromia is noted. Functional trials reveal disturbance of activity of a liver. Then it becomes dense, decreases in sizes, ascites develops (see). Death comes from a liver failure (see).

Damage of a stomach at late S. is characterized by formation of limited nodes or diffuse gummous infiltration and is followed by the same symptoms, as at new growths of a stomach (see). Disintegration of a gumma is similar to disintegration of a cancer tumor of a stomach and can cause bleedings or perforation of a wall with the subsequent peritonitokhm. Gummous infiltrate can be replaced with cicatricial fabric that leads to deformations of a stomach (two-way, multiband a stomach) or to its diffusion fibrous wrinkling. Results serol help with diagnosis. reactions, especially RIBT and REEF (see the Immunofluorescence), and also specific treatment, a cut is effective in initial stages of a disease (before formation of cicatricial changes). Damages of a gullet (see) and intestines (see the Rectum) meet seldom. Both diffusion, and limited gummous processes develop. At disintegration of gummas ulcers with the subsequent scarring leading to stenoses of a gullet or intestines are formed. Damages of a spleen are usually combined with damages of a liver — a hepatolienal syndrome (see). The isolated gummous splenites or diffusion intersticial syphilitic splenitis are exclusively seldom observed.

Damages of kidneys (see) can be shown in the form of a lipoid nephrosis (more often at early S.), the amyloidosis of a kidney (see the Amyloidosis) proceeding as an amyloid nephrosis, the nephrosclerosis leading to development of a contracted kidney. In some cases the isolated gummas can be formed (in cortical substance) or there is a diffuse gummous infiltration. At these processes there are hypostases, in urine — protein, blood, the cylinder, and at the isolated gummas — pristupoobrazny pains in a waist. Sclerous process in a kidney leads to increase in the ABP, a hypertrophy of a left ventricle of heart, emergence of emphasis of the II tone on an aorta, disturbance of water exchange and increase in amount of residual nitrogen. The earlier specific therapy is begun, the results are more favorable.

Extremely seldom meet at late S. of damage of lungs, to-rye are shown gummous (fig. 3, c) and sclerous by forms (see Lungs, syphilis). Process develops slowly and imperceptibly without subjective and objective signs in initial stages. An early symptom is the cough amplifying at night with lack of a phlegm (at the beginning of a disease). It is possible to suspect a disease on negative takes of researches on tuberculosis and cancer of a lung (in the presence of a single large gumma), to a long current, rather good overall health, lack of elevated temperature (or to its discrepancy to extent of damage of lungs) and a blood spitting, sharply expressed asthma (not the corresponding extent of damage of lungs), an unilaterality of defeat (despite duration of existence of process), preferential localization in average shares, is more often than the right lung, to data of radiological and serological inspection (especially RIBT and REEF), sometimes according to the anamnesis, and also on other syphilitic damages of internals, a nervous system, musculoskeletal system and by results of trial antisyphilitic treatment (use drugs of iodine, to-rye give improvement at S. and deterioration at tuberculosis). The gumma of a trachea or bifurcation of bronchial tubes can lead to development of a stenosis with a lethal outcome.

Cases of syphilitic pancreatitis and an angiosclerosis of a pancreas (see), a gummous thyroiditis, a gumma of testicles belong to casuistic observations.

Syphilis of a nervous system (neurosyphilis) is subdivided into early forms, or early neurosyphilis (up to 5 years from the moment of infection, generally in the first 2 — 3 years), and late, or late neurosyphilis (not earlier than 6 — 8 years after infection). Early neurosyphilis call mezenkhimny since at it a meninx and vessels of a brain are surprised, mezenkhimny reaction prevails; parenchymatous elements can sometimes be involved in process, but for the second time. Late neurosyphilis call parenchymatous since at it nervous cells and fibers, and also a glia are surprised. Changes have inflammatory and dystrophic character; mezenkhimny reaction is not expressed. Such division of neurosyphilis is conditional since in the last decades considerable lengthening of stage of latency, and S. of vessels of a brain as well as the myungin-govaskulyarny S., are registered in 10 — 15 years and more after infection is observed.

In development of neurosyphilis, especially parenchymatous, the main role is played by absence or the insufficient previous treatment, injuries (especially craniocereberal), intoxications (as a rule, alcoholic) and long hron. infections.

The pathomorphism of modern neurosyphilis consists in growth of number of the erased, malosimgggomny, atypical forms. The expressed forms back tabes meet extremely seldom, the symptomatology of a general paralysis changed, the gumma of a head and spinal cord, and also a syphilitic cervical pachymeningitis became casuistry.

Early neurosyphilis is shown by defeat of a meninx of different degree of manifestation: from the latent (latent) forms to acute generalized meningitis (see). Allocate the latent (latent) syphilitic meningitis, a me-ningonevrotichesky form of syphilitic meningitis (basal meningitis), syphilitic hydrocephaly, acute generalized (manifest) syphilitic meningitis, a syphilitic meningomyelitis, early meningo vascular to Page. The latent (latent) syphilitic meningitis occurs at 10 — 15% of patients of primary both 20 — 25% of patients with the secondary and early hidden Page. At the same time, as a rule, the wedge, symptoms are absent. The headache, a sonitus, dizziness, decrease in hearing, morbidity at the movement of eyeglobes is sometimes noted. Even less often the hyperemia of an optic disk, a papillitis come to light. The diagnosis at patients with early S. is established on changes in cerebrospinal liquid (as a rule, a large amount of protein and a cytosis).

The Meningonevrotichesky form of syphilitic meningitis (basal meningitis) meets in 10 — 20% of all cases of early neurosyphilis. Proceeds subacutely. Slight meningeal symptoms are noted: slight headache, dizziness, sometimes nausea, vomiting. As a result of defeat III, VI, VIII couples of cranial nerves are observed an easy ptosis, asymmetry of the person, a smoothness of nasolabial folds, deviation of language, omission of a soft palate, decrease in bone conductivity. Minor changes in cerebrospinal liquid are found. During the involvement in process of an optic nerve (as a rule, bilateral) the central sight goes down, fields of vision are narrowed, the optic disk is hyperemic, borders its indistinct, fabrics of a disk slightly bulk up, veins extend (arteries change a little).

Syphilitic hydrocephaly (see) meets in 7 — 15% of all cases of early neurosyphilis and is caused by a local inflammation of covers of a brain. Acute syphilitic hydrocephaly is characterized by the accruing headache, dizziness, pernicious vomiting, confusion of consciousness. In nek-ry cases there can be epileptiform attacks (see. Epileptiform syndrome), alalias. At the latent syphilitic hydrocephaly listed a wedge, manifestations are less expressed. At Ophthalmolum. a research define congestive disks of optic nerves. The spinal puncture (see) improves a state. In cerebrospinal liquid (see) proteinaceous and cellular dissociation is noted.

Acute generalized (manifest) syphilitic meningitis meets seldom. The disease begins with temperature increase, is followed by a sharp headache, dizziness, vomiting. Meningeal symptoms, patol are expressed. reflexes, napr, a Babinski's reflex (see Babinsko-go a reflex), Oppengeym's reflex, Rossolimo a reflex (see), and also a hyperemia of optic disks, a papillitis. The vascular frustration which are followed by epileptiform attacks, paresis of extremities are sometimes noted (see Paralyses, paresis). In cerebrospinal liquid define a large amount of protein and a cytosis. This form of early neurosyphilis develops on 5 — the 6th month from the moment of infection during existence of rashes of recurrent S. or without them. Differential diagnosis is carried out with bacterial meningitis. The anamnesis, early active S.'s symptoms (help with statement of the correct diagnosis at their existence), positive Wassermann reaction, RIBT and REEF in blood and cerebrospinal liquid.

The syphilitic meningomyelitis in a crust, time meets seldom (to 0,5% of all cases of early neurosyphilis). The disease arises in 1 — 3 years after infection. Can sharply proceed. At the same time paralyzes of the lower extremities with deep disturbance of a trophicity, decrease or an anesthesia, disorder of function of pelvic bodies develop. A syphilitic meningomyelitis rezistenten to specific therapy. It is differentiated with a tumor of a spinal cord (see), fibrinferments of spinal arteries, myelites of other etiology, and also with multiple sclerosis (see), to-ry begins, as a rule, at youthful age.

At early meningovaskulyarny S. a meninx is gradually involved in process. Klien, a picture at the same time is various: the headache, defeat of cranial nerves, disturbance of sensitivity, a hemiparesis alternating paralyzes (see. Alternating syndromes), epileptiform attacks. This form meets seldom. Early meningovaskulyarny S. is differentiated with diseases, at to-rykh defeat of vessels of a brain — atherosclerosis (see), is noted by rheumatism (see).

Allocate the following forms of late neurosyphilis: the late latent (latent) syphilitic meningitis, late diffusion me-ningovaskulyarny syphilis, syphilis of vessels of a brain (vascular syphilis), back tabes, a general paralysis (see), a gumma of a brain.

The late latent (latent) syphilitic meningitis arises not earlier than in 2 years after infection, more often much later. It appears at not treated or not enough treated sick S. or resistant to specific therapy. The disease is characterized by Lange and Wasserman's positive reactions in cerebrospinal liquid, and also absence at most of patients of the expressed effect of specific therapy. On the basis of this form of late neurosyphilis form late diffusion meningo vascular syphilis, back tabes, a general paralysis.

Late diffusion meningovas-kulyarny syphilis in a crust, time meets quite often. It develops in 10 — 25 years after infection. At the beginning the disease proceeds, as a rule, is benign; recurrence with spontaneous remissions is characteristic. A hemiparesis (see the Hemiplegia), the epileptiform attacks, disorders of sensitivity (see) alternating paralyzes, alalias (see) and memories (see), astenisation of the personality, etc. is noted a persistent, but unsharp headache (see), dizziness (see). At gemiplegiya, to-rye a thicket are caused by specific arteritis of one of branches of carotid or vertebral arteries, carry out the differential diagnosis with an idiopathic hypertensia (see). Reovazografichesky researches (see Geography) reveal not same changes of vessels of various areas of hands and legs; at elekt-roentsefalografichesky researches (see Elektroentsefalografiya) dominance of irritable process on the general background of low bioelectric activity is noted. Changes in cerebrospinal liquid are insignificant, reactions of RIBT and REEF positive in blood and cerebrospinal liquid while serol. reactions in blood can be negative.,

Syphilis of vessels of a brain (vascular syphilis) together with late diffusion meningo vascular syphilis in a crust, time are the main forms of late neurosyphilis. At S. of vessels of a brain of a cover and substance of a brain are not involved in process therefore composition of cerebrospinal liquid normal. The disease meets in 30 more often — 50-year age. It is characterized by development of specific infiltrate in vessels of a brain that leads to thrombosis (see) or to a stroke. Complexity of diagnosis is that in 60 — 70% of cases standard serol. reactions (Wassermann reactions, Kan and Legislative Assembly — Vitebsk) are negative.

Depending on localization of the struck vessels nevrol. the symptomatology is various. So, there can be mental disturbances, epileptiform attacks, aphasias, disturbances of sensitivity. The acute course of a disease reminding a stroke (see) is occasionally observed. The page of vessels of a brain can be combined with other forms of neurosyphilis, napr, with back tabes, visceral S. that facilitates diagnosis; the combination to atherosclerosis (it is observed that more often than advanced age of patients) is often possible that does diagnosis difficult. Sometimes only trial antisyphilitic treatment resolves an issue of the diagnosis.

Back softness, a smoothness nevrol is inherent to tabes in connection with use of new methods of treatment of syphilis. symptoms (see. Back tabes). In 60 — 80% of cases there are no data of the anamnesis on early S. V transferring to diagnosis existence at 12 — 15% of patients of cardiovascular S. and patol helps. the stabilogramma (see Sta-bilografiya) appearing in an initial stage back tabes.

The gumma of a head or spinal cord in a crust, time meets seldom. Usually it is localized on a convex surface of hemispheres or in the field of the basis of hemicerebrums (see the Brain). Nevrol. the picture is characterized by focal symptomatology in combination with headaches and increase in intracranial pressure. At a gumma of a spinal cord symptoms, full cross damage of a spinal cord can develop (see. Vertebral and spinal injury). Differential diagnosis is carried out with a tumor of a brain. Lack of effect of antisyphilitic therapy during 3 — 4 weeks or increase nevrol. symptoms, despite therapy, confirms a tumor of a brain.

In diagnosis of neurosyphilis the important role belongs to changes in cerebrospinal liquid, and also results of specific reactions — RIBT, RIF.

Mental disorders at syphilis of a brain are subdivided into a general paralysis and syphilitic psychoses (syphilis of a brain).

In a wedge, a picture of a general paralysis (see) the cement form with pr prevailsogrediyentny weak-mindedness (see), frustration of criticism, apathy, complacency. Syphilitic psychoses are shown various on symptomatology and weight a wedge, a picture: psychopatholike, neurosis-like, endoformny, paroxysmal, exogenous oozes of reactions (see Bongeffer exogenous types of reactions, t. 10, additional materials), the various manifestations of a psychoorganic syndrome arising in connection with intoxication, defeat of a meninx, brain vessels and also with development of gummas. Syphilitic psychoses develop at all stages of a syphilitic infection at 2 — 15% of patients with the acquired S., as a rule, within the first decade after infection. The greatest number of the diseased occurs among persons with not treated or insufficiently treated S.; their age from 30 to 50 years; the ratio of men and women is approximately identical.

A uniform systematics of shapes C. of a brain is absent. Mental disturbances "are classified preferential on a basis morfol. changes and clinic. Nek-rye from the allocated shapes C. of a brain correspond to the periods of a syphilitic infection. Separate forms of mental disorders are connected by transitional cases; throughout a disease one form can replace another.

In primary period of a syphilitic infection psychogenic reactions can meet (see Psychogenias.), it is preferential in the form of a superficial depression with alarm and the seerkhtsenny ideas (see).

The syphilitic neurasthenia (A. Fournier, 1879) arises more often in the secondary period of a syphilitic infection, is more rare in primary. Among observed at the same time asthenic frustration (see. The asthenic syndrome) prevails irritability, excitability, the expressed hyperesthesia and, as a rule, with firmness lowered, quite often accompanied with alarm, mood. Often there are reaching big intensity headaches amplifying at night. Among nevrol. symptoms are noted an anisocoria (I eat.), sluggish reaction of pupils to light, increase and irregularity of tendon and periosteal jerks, difficulties at selection of words. Symptoms of a meningism can meet (see Meningitis).

Against the background of a syphilitic neurasthenia can sharply arise or rather gradually syphilitic meningitis and meningoentse-falita. They are shown by a combination of various forms of stupefaction — devocalization (see), twilight stupefaction (see), a delirium (see. Delirious syndrome) — with neurologic (epileptiform attacks, disturbances from III, VI, VII couples of cranial nerves, paresis and paralyzes of extremities, meningeal symptoms) and all-brain (a headache, dizziness, vomiting) symptoms.

Syphilis of vessels of a brain is observed in the secondary and tertiary periods of S. and shown by a syphilitic endarteritis. Most often apoplekti-formny and epileptiform syndromes meet, to-rye are quite often combined. There are they against the background of the cerebral and organic phenomena, an adynamy, disturbances of memory. Strokes in the beginning lungs, are made heavier over time. Attacks proceed as jacksonian (see. Jacksonian epilepsy), but can be transformed to generalized, single and serial attacks up to development of the epileptic status are possible (see Epilepsy). Strokes and paroxysms sometimes are followed by the subsequent stupefaction (devocalization, a delirium, a twilight state). For both forms, especially for apoplektiformny, are characteristic nevrol. frustration (paresis, paralyzes, aphasias etc.).

In nek-ry cases of S. of vessels of a brain, at one patients gradually, at others sharply, after a stroke clear decrease in intelligence with euphoria, carelessness or with alarm, tearfulness and morbid depression, the expressed decrease in criticism, reminding a simple form of a general paralysis (see) — a Parrot's disease develops. At a number of patients organic decrease is shown by development korsakovsko-go a syndrome (see).

Occasionally S. of vessels of a brain is followed by endoformny frustration — nonsense (see) and hallucinations (see). Their development is preceded by poorly expressed and not numerous manifestations of a psychoorganic syndrome (see) and separate nevrol. symptoms. In one cases into the forefront the wedge, pictures acts a malosistemati-zirovanny persecution complex, poisonings, physical destruction — syphilitic paranoid according to E. Krepelin (1912). In other cases verbal polyvocal hallucinosis of the menacing or imperative contents — syphilitic hallucinosis P Louth (1913) prevails. «Pure» forms, i.e. forms with one nonsense or hallucinations, meet seldom. The mixed pictures are usually observed. The course of syphilitic psychoses chronic and acute — in the form of attacks, lasting several weeks or months. Chronically current psychoses are not exposed to transformation over time. Acute forms can be followed by episodes of the dulled consciousness. Organic decrease at hallucinatory-dilision syphilitic psychoses develops slowly and does not reach a deep water.

At all syphilitic psychoses the progreduated course of a disease which is shown a psychoorganic syndrome (see) is observed. However rate of its development and degree of manifestation differ in a big variety. In the most hard cases weak-mindedness develops, a cut almost always happens lacunary and quite often accepts stationary character. In mild cases this process is slowed down and can proceed with stops lasting several years. There are many cases of S. of a brain, at Krom change of mentality is shown by decrease in level of the personality or a psikhopatization. Mental disturbances at S. of a brain often have the following characterologic features: viscous affect with irritability, discontent, feeling of hostility, sensitivity, malignancy, an explosibility, a dysphoria prevails (see). They are shown in the form of episodes or exist is long. Many patients are inclined to formation of the supervaluable ideas of hypochiondrial or litigious character. Asthenic frustration pale into insignificance.

At single gummas of the considerable sizes there is pseudo-that-frosty syndrome (slackness, apathy, low-mobility in combination with the increased drowsiness turning into devocalization of consciousness). At small gummas the psychoorganic syndrome of various depth develops (see. Psychoorganic syndrome).

Syphilis of bones and joints. In the secondary period of S. the osteoperiostites and periostites which are followed by night pains can be observed (see Os.Teoperios-tit, the Periostitis). Their preferential localization — tibial bones and bones of a skull. In places of defeat small swellings of a dense consistence, painful are palpated at a palpation.

As the main manifestations of S. of bones in the tertiary period serve gummous infiltrations, to-rye can have diffusion or, more rare, limited character. At gummous processes in a bone granulyatsionny fabric causes a destructive (ra-refitsiruyushchy) osteitis (see) with the subsequent reactive changes. Dominance of processes of an osteogenesis over destruction distinguishes S. from tuberculosis of bones (see Tuberculosis extra pulmonary, a tuberculosis of bones and joints). The isolated periostites at S. meet extremely seldom. They are, as a rule, combined with deeper damages of a bone therefore it is more correct to speak about osteoperiostites or about osteomiyelitichesky gummous process if the marrowy cavity and spongy substance is involved in process (see Osteomyelitis).

Fig. 5. Roentgenogram of a shin of the patient with tertiary syphilis (side projection): the arrow specified a gumma in an upper third tibial - bones.

At late S. osteoperiostites usually arise at the same time in several bones and differ in duration of a current. They are characterized by extensive dense periosteal stratifications, roughness of edges and have an appearance of a crest or lace in this connection them call pectineal or lacy. The periosteal gumma extends on the plane at edge of a bone and leads to destruction of a bone, an uzuration. Around the formed uzura there is a sklerozirovaniye of bone structure, ossification of a periosteum (periosteum). The gummous process which arose in the inner layer of a periosteum can get on vessels into compact substance of a bone, into spongy substance that leads to destructive changes of these layers with the subsequent reactive changes. Destructive changes depend on localization of process. So, at localization of a gumma in spongy substance of a bone destructive changes are extensive, inflammatory reaction of a bone is small (the same changes are noted at S. of short bones, napr, vertebrae, bones of a tarsus, a wrist); at its localization in compact substance — destruction is insignificant, but reactive changes are expressed. From bones of a skeleton at S. a diaphysis of long tubular bones, as a rule, of a tibial bone (fig. 5) most often is surprised. However at the same time productive changes with plentiful periosteal stratifications, a hyperostosis (see) complicate rentgenol. recognition of destructive gummous manifestations. Quite often radiological the limited periostitis in the form of an osteophyte, skintight to a bone, is defined, to-ry extends around a bone that is natognomonichny for Page.

Flat bones of a skull, a breast are involved in process in 5% of cases of all bone syphilitic defeats. Most often frontal and parietal bones of a skull are surprised. At the same time preferential destructive gummous processes are observed. Cases are characteristic, at to-rykh process it is limited to destruction only of an outside plate of a bone. Quickly enough defect of a bone is replaced reaktivno with the formed bone masses and periosteal stratifications, less powerful and dense, than in long tubular bones. Gummous destructions of bones of a skull can be followed by defeat of soft tissues in some cases. At the same time they are softened, ulcerate, in them are formed, unlike tubercular osteomyelitis, wide superficial fistulas. Damage of bones of a nose and hard palate happens usually owing to transition of process from mucous membranes, i.e. secondary bone process takes place.

Syphilitic spondylites meet seldom, in 2 — 6% of cases. Preferential the body of one is surprised, is more rare than two-three vertebrae, as a rule, in cervical department of a backbone. At the same time the immovability of the struck department develops, and also the non-constant spontaneously arising pains are observed. The given a wedge, pictures (relative ease of a current), a X-ray pattern (lack of a shadow of a natechnik, an accurate ocherchennost of the centers of destruction, preservation of intervertebral disks), serological blood analyses and results of trial antisyphilitic treatment help with diagnosis.

Differential diagnosis carry out with nonspecific osteomyelitis, tuberculosis of bones, including a tubercular spondylitis (see), bone sarcoma (see the Osteosarcoma), the deforming osteitis (see Pedzhet a disease), metastatic defeats at malignant tumors (see the Backbone).

Damages of joints at late S. meet less than damages of bones. On N. A. Velyaminov's classification, distinguish primary and synovial and primary and bone arthritises (see the Osteoarthritis). Primary and synovial arthritises happen acute and chronic. The so-called reactive arthritises (see) arising under the influence of the gummous process which is close located to a joint belong to acute forms (in an epiphysis, a metaphysis). However are more often observed hron. synovial arthritises (Kleton's synovites), emergence to-rykh connect with activation latentno of the proceeding infection. They are shown by pains, a spherical swelling of a joint and an intra joint exudate with insignificant dysfunction of a joint. Twosideness of defeat is noted. Radiological changes in a joint are not found. Gummous synovites meet seldom.

Primary and bone arthritises (osteoarthrites) arise owing to gummous defeats of an epiphysis of bones (a gummous epiphysitis). Radiological in an epiphysis round sotovidny defects decide on the low-expressed sclerous reaction in a circle. Discrepancy between the extensive destructions of bones of a joint revealed on the roentgenogram and a top general condition of the patient is characteristic. Most often knee, shoulder, elbow and ankle joints are surprised, to-rye are gradually deformed.

The diagnosis is established on the basis of the anamnesis, a clinical picture, data of laboratory and radiological researches. Laboratory diagnosis of S. includes microscopic examination of syphilides on a pale treponema and serological tests on Page. The pale treponema is found at a research of scrapings from a chancre, papules, pustules. In case of impossibility to take material from a chancre (e.g., at a phymosis) make a puncture limf, nodes. The research is conducted in native drug under a microscope in a dark field (see. Dark field method). In some cases reveal a pale treponema at a research of the drugs painted by Romanovsky's method — Gimza (see Romanovsky — Gimza a method, at Krom the pale treponema is painted in pink color, and other treponemas gain intensive-blue color) or impregnirovanny caustic silver (see Levaditi a method), and also processed by ink across Burri (see Burri a method). From methods of silvering (see Silverings methods) the most bystry and simple is Morozov's method (see Morozov a method).

The main serological tests on S. (so-called standard serological tests) are Wassermann reaction (see Wasserman reaction), sedimentary reactions — Kan's reaction (see Kan reaction) and cytocholic reaction (see Legislative Assembly — Vitebsk reaction), and also selection reactions, or microreactions on glass with a drop of blood, plasma, the active or inactivated blood serum and special cardiolipin antigen (are applied to mass serological inspections on S. as express diagnosis). At impossibility of statement of these reactions their active modifications — Grigoriev's reaction — Rapoport (see Grigoriev — Rapoport reaction) and Weinstein's reaction — Reznikova, based on use of a natural complement of active ispytuyemy blood serum are allowed. For recognition of false positive results of standard reactions, at doubts in correctness of results apply reaction of an immobilization of pale treponemas — RIT, or RIBT (see Nelson — Meyer reaction) in an original technique, or its melanzherny option, at Krom ispytuyemy blood serum, a complement and antigen place not in test tubes, and in mixing pipettes for calculation of a leukocytic blood count; reaction of an immunofluorescence (see) — the REEF, in several modifications (e.g., RIF10, RIF200); reaction of passive hemagglutination — RPGA (see I eat agglutination); reaction of immune sticking (see) — RIP. At RIF10, RIF200 ispytuyemy blood serum is dissolved respectively in 10 and 200 times. Positive takes of RIF200, Rifabs (reaction of an immunofluorescence with absorption) demonstrate existence active S. Metodika RIP is more available, than at RIT and REEF, and yields the results close to results of RIT and REEF. RIT is most specific, but positive takes come to light later, than at the REEF and standard serological tests.

At establishment of the diagnosis of S. of a nervous system, and also during the definition of an izlechennost investigate cerebrospinal liquid — define total quantity of protein, quantity of uniform elements, put globulinovy reactions (reaction to Nonna — Apelta and Pandi's reaction), Wassermann reaction with three cultivations of cerebrospinal liquid and colloid reaction with chloric gold (Lange's reaction), RIT and RIFts (reaction of an immunofluorescence with is not divorced-ache liquid).

Treatment

S.'s Treatment is carried out to the USSR according to the special instructions approved by M3 of the USSR (1976, 1981) and additions to them (1983). It is begun only after establishment of the diagnosis on the basis of clinical and datas of laboratory. An exception of this rule are the following cases: the persons which had sexual or close household contact with the sick infectious or early hidden S. need to carry out preventive treatment; preventive treatment appoint to the children (in the absence of S.'s manifestations) born by sick S. mothers (uncured or insufficiently treated), and also the women who did not receive the put preventive treatment during pregnancy (if it came before their removal from the account after the end of therapy concerning S., and also at the first pregnancy after removal from the account on end of dispensary observation); trial treatment is carried out to persons with negative takes of standard serological tests to blood, and also RIBT and REEF at suspicion on late (tertiary S.) syphilitic damages of internals, nervous system, bones, joints.

Despite the accurate strictly regulated schemes, in to-rykh doses of antisyphilitic means are defined (see), plans of their introduction, methods of the nonspecific stimulating impact on an organism, treatment carry out individually, taking into account features of disease, portability of drugs. It should be begun as soon as possible, it is better in primary seronegative period of a disease when the good therapeutic result is easier and quicker achieved. There are two main methods of treatment — chronically alternating (several bucketed courses) and continuous, or permanent. Only the systematic intensive care using the single, daily and course doses of drugs recommended by the instruction, with observance of optimum intervals between their introduction and courses of treatment is effective. In the course of treatment carefully watch health of the patient, portability to them pharmaceuticals, a condition of his internals and a nervous system, do bulk analyses of urine (weekly), blood (time in 10 — 15 days). Serological blood analyses are conducted at preventive treatment and at primary seronegative syphilis of 1 times in 5 days throughout all first course of treatment, and at other stages of a disease — in an initiation of treatment, then each 2 weeks during and before the termination of a course.

Therapy is carried out in a complex, i.e. apply the antisyphilitic means and drugs stimulating body resistance to an infection; appoint polyvitamins; associated diseases treat. At the same time alcohol intake is forbidden, smoking is sharply limited, good nutrition with enough proteins, carbohydrates, vitamins, with restriction of hardly assimilable fats is recommended. The physical tension, mental injuries, and also sleep disorders negatively influence results of treatment.

Patients with the infectious and early hidden S. surely receive the first course of treatment in a hospital, other courses — is out-patient. The minimum terms of stay in a hospital for socially adapted faces with primary seronegative S. — 14 days, with seropositive and secondary fresh S. — 20 days, with recurrent and early hidden S. — 25 days. The extract from a hospital is allowed after full regress of active manifestations

of S. V a crust, time at S.'s treatment usually do not use drugs of mercury and arsenic (Novarsenolum, Myarsenolum, Osarsolum), to-rye were widely used earlier since they often cause by-effects.

The most effective and well transferable drugs for S.'s treatment are antibiotics (drugs of penicillin — Benzylium-penicillin sodium or potassium salt, ekmonovotsillin, Bicillinum-1,-3,-5, fenoksimetilpe-nitsillin; erythromycin, tetracycline, Oletetrinum). Use also drugs of bismuth (biyokhinol, Bismoverolum, Pentabismolum), iodine (potassium iodide or sodium iodide, spirit solution of iodine, kaltsiyodin). Compounds of cobalt (cyanocobalamine, 1% solution of Coamidum) promote strengthening of treponemotsidny effect of penicillin, increase in its concentration in blood serum. In the absence of effect of full treatment (according to schemes) (delay or lack of a negativation of serological tests — relative or true serological resistance, seroretsidiv), and also at treatment by one antibiotics by the patient at the same time with specific (antisyphilitic) the nonspecific therapy directed to increase in body resistance to an infection — an injection of pyrogenal, Prodigiosanum, 2% of solution of sublimed sulfur in peach-kernel oil, fresh prokipyachenny skim milk, an electropyrexia is appointed the specified drugs (see the Pyrotherapy); segmented UF-radiation; hypodermic administration of oxygen; autohemotherapy; biogenic stimulators — an aloe, FIBS, peloidodis-tillit, a vitreous, extract of a placenta; methyluracil, pentoxyl; polyvitamins; fortifying means — phytin, neurosin. Nonspecific therapy is appointed taking into account the general condition of the patient and alternated at the subsequent courses of treatment. At the late forms of a disease which are not giving in to therapy at serorezistentny S. the resort therapy (in the absence of the general nro-tivopokazaniye) — sulphidic, iodine-bromine, carbonic bathtubs in a complex with administration of drugs of bismuth is shown.

Single doses of penicillin are defined with the weight of the patient, course — with a stage of a disease. At a permanent method (the scheme approved in 1976) treatment by penicillin lasts at primary seronegative Page 40 — 68 days, at seropositive — 76 — 125 days, at secondary fresh S. — 100 — 157 days.

Considering need of ensuring high concentration of penicillin for bodies and fabrics, and also for cerebrospinal liquid, its good tolerance, the possibility of increase in single and course doses of an antibiotic and reduction of duration of treatment was studied. On the basis of these researches effective schemes of permanent intensive treatment of Page are developed and approved (the instruction of 1981). Course treatment is carried out according to indications by several methods: drugs of penicillin and bismuth (consistently or at the same time); drugs of penicillin or Bicillinum in combination with nonspecific therapy; erythromycin or phenoxymethyl-lenitsillinom either tetracycline or Oletetrinum along with drugs of bismuth. The quantity of courses depends on the period of a disease. At pregnancy treatment is carried out by penicillin without drugs of salts of heavy metals. Preventive treatment is carried out by one rate of penicillin (if from the moment of contact with the patient there passed no more than 14 days) or according to the scheme of treatment of primary seronegative S. (from 14 days to 4 months). In the presence of changes in cerebrospinal liquid the course dose of penicillin increases by 20%. If from the moment of contact there passed more than 4 months, sick preventive treatment is not appointed, but it remains under dispensary observation up to 6 months.

Treatment of patients with late neurosyphilis according to the existing instruction of M3 of the USSR of 1981 is begun with administration of drugs of iodine, and then bismuth. At a gumma of a brain and late vascular S. preference is also given to iodide and bismuthic drugs; treatment is finished with purpose of 1 — 2 massive rates of penicillin.

Criteria of an izlechennost of syphilis

Most of syphilologists consider that the full therapy which is especially begun in the early periods of a disease provides treatment of patients. It is confirmed by long-term overseeing by patients after its termination, lack of displays of a disease at them, existence of healthy posterity, cases of reinfection.

At the solution of a question of an izlechennost from S. of each specific patient the period of process prior to treatment, full value of therapy, the loudspeaker serol is considered. reactions in blood (resistant negative takes), data complex a wedge, the examination conducted with participation of the neuropathologist, therapist, ophthalmologist, a research of cerebrospinal liquid (in a year after the end of treatment and before removal from the account), roentgenoscopies of bodies of a thorax, dispensary observation in current of 1 year after treatment concerning primary seronegative S., 3 years — after primary seropositive and secondary fresh S.'s treatment; 5 years — after secondary recurrent, hidden, tertiary, early visceral S., syphilis of a nervous system and 10 years — after late visceral S.'s treatment and syphilis of a nervous system, and also serorezistentny Page. Faces without manifestations S., but being ill in the past are subject to comprehensive examination and if symptoms of a disease are not found in them, and from the moment of infection there passed more than 10 years, they are not registered.

Great difficulties arise during the definition of tactics in relation to patients with the phenomena of serological resistance after full treatment, at to-rykh, except positive serological tests in blood, other symptoms of a disease is not revealed. According to «The instruction for treatment and prevention of syphilis» (M3 of the USSR, 1976) these persons should conduct in addition three courses (specific and nonspecific) treatments. At assessment of results of a serological research it is necessary to resolve an issue whether resistant positive serological tests, despite treatment are, a sign of not cured S. or immu-nol. trace reaction of the postponed disease, or result of nonspecific serological changes. In this case negative indicators of RIBT and REEF at positive standard serological tests allow to exclude Page. Trace serological tests usually have a small antiserum capacity, and at neiz-treated S. the caption tends to increase.

The forecast

the Forecast at full treatment favorable. Results of therapy by that it is better, than earlier it is begun. The current and the forecast of a disease in many respects are defined by the general condition of an organism. At the children and old men having the lowered resilience to an infection,

S. usually proceeds heavier. Associated diseases (tuberculosis, defeats of cardiovascular, endocrine and nervous systems) burden S.'s current, complicate its treatment, worsen the forecast. Abuse of alcoholic drinks, mental injuries, non-compliance with the mode recommended by the doctor, defective treatment, complications at it reflect adversely on the forecast of a disease that can be shown by serological resistance, a serological and clinical recurrence, syphilitic damage of internals, a nervous system, bones and joints.

Marriage is allowed to the had S. if he received full treatment and is struck off the register after the put term of dispensary observation and the corresponding comprehensive examination. After removal from the account the woman is allowed to have posterity on condition of preventive treatment during the first pregnancy; the issue of need of preventive treatment at the subsequent pregnancies is resolved individually taking into account the anamnesis of the patient.

Prevention

S.'s Prevention is performed in a complex. The great value is attached to actions of the public plan: moral hygienic to education, dignity. to education, an explanation of danger of illegitimate sexual bonds and a role of alcoholism in their emergence (see. Sex education). Bystry elimination of focuses of the disease by early identification, hospitalization and treatment of patients, inspections of estimated sources of infection, and also the persons which had sexual or close household contact with patients and attraction them to treatment are carried out; preventive kliniko-serological inspections of employees of child care facilities, food and utility enterprises, drivers of motor transport (groups of the increased risk of infection with venereal diseases). According to the law the sick S. evading from treatment, having sexual bonds after the prevention that they have no right to have them are brought to judicial responsibility (see Venereology). This work is performed on the special plan by dermatovenerologists, obstetricians-gineko-logs, a dignity. doctors, all all-medical network, it is coordinated by special headquarters at public health departments and the interdepartmental commissions at executive committees of People's Deputies.

The big role belongs to personal prevention — use of the means protecting skin and mucous membranes from penetration of a pale treponema at the sexual intercourse (condoms or chemical drugs destroying a pale treponema in the place of its implementation in skin). However condom (see) does not exclude a possibility of hit of pale treponemas on skin of para-genital sites. Therefore after sexual intercourse with the accidental partner it is necessary to wash generative organs and adjacent sites of skin warm water with soap, and then to process leather of generative organs, a pubis, a crotch, an upper third of an inner surface of hips Mechnikov's ointment (33% of calomel) or 0,05% solution of a gibitan. These events are held on points about-ti in the venereal help. When there is a danger of infection as a result of sexual or close household contact with the patient infectious (active or early hidden) S., carries out preventive treatment.

S.'s prevention internals and a nervous system is provided by comprehensive inspection of the patient (a research of an eyeground, cerebrospinal liquid, a chest fluoroscopy) and treatments of early displays of a disease.

Transfusion S.'s prevention is carried out by dermatovenerologists, doctors of blood transfusion stations and the general medical network. It is based on the accounting of the following provisions. In blood pale treponemas can be in all stages of S., including the hidden stage and an incubation interval. In limf, nodes, in cerebrospinal liquid, watery moisture of an eyeglobe even pale treponemas, their cysts and L-forms are found in the patients with early and late S. who received full treatment. In stored blood pale treponemas a long time keep the properties therefore donor blood, plasma, marrow of patients even and the persons who received full treatment concerning S. cannot be applied by the hidden S. to transfusions.

Thanks to growth of cultural level and dignity. literacy of the population in the last decades in the USSR cases of household infection of S. meet extremely seldom.

INBORN SYPHILIS

the fact that S. is transferred to posterity is known since the end of 15 century — since emergence of epidemic of this disease in Europe. Mattse-nauer's (R. Matzenauer) works proved a placental way of transfer of Page. The father usually infects with sick S. mother, edges the reb-enka vnutriutrobno infects. The most dangerous to posterity is the secondary period of S. at mother. Also transfer of a disease of mother suffering from tertiary and late inborn Page is possible. Penetration of pale treponemas into an organism of a fruit is carried out in the form of an embolus on an umbilical vein, through limf, cracks of umbilical vessels, and also with a blood flow of mother through the placenta changed by toxins of pale treponemas (see). The specific septicaemia develops, pale treponemas at the same time are found in various bodies of a fruit.

Changes of a placenta are characterized by puffiness, decrease in resistance of fabric and the expressed hypertrophy with increase in weight it in relation to the mass of a fruit. Normal this ratio makes 1:5 — 1:7, and at S. — 1: 3 — 1: 4. At gistol. a research involvement in patol is noted. process of preferential fetal part of a placenta in the form of defeat of vessels (endoarteritis, mesoarteritis, periarterites and phlebitis), is lovely to an obliteration of their gleam, plentiful growth of granulyatsionny fabric, emergence pair abscesses.

Allocate early inborn S. (at a fruit, children of chest age, at children aged from 1 year up to 4 years) and late inborn Page.

Early inborn syphilis of a fruit. Owing to defeat by a syphilitic infection of a placenta food of a fruit is at a loss, the metabolism is broken and there comes his pre-natal death. It occurs between VI and VII months of pregnancy, is more rare — between V and VI months. Death which came till V month of pregnancy is connected with the poisoning influence on a fruit of toxins of pale treponemas. The page of a fruit is characterized by specific changes of internals in the form of the diffusion and inflammatory infiltration of fabrics consisting of lymphocytes, plasmocytes with the subsequent growth of connecting fabric, education is lovely pair or solitary gummas. The liver, a spleen, kidneys, easy, closed glands, bones are surprised, the arrest of development of a fruit is observed. It is more, than other bodies, the liver suffers. The spleen is sharply increased and condensed. In lungs especially severe defeats in the form of plentiful desquamation of an alveolar epithelium and growth of connecting fabric in hmezhalveolyarny partitions are observed. Affected areas of lungs are airless, have grayish-white color, and on a section yellow-white — white pneumonia (see). In kidneys cellular infiltrates are determined by the course of vessels, balls of renal little bodies and tubules are not developed. Specific changes of heart (the centers of cellular infiltration, swelling of cells around vessels, necroses) meet seldom. In went. - kish. a path the flat infiltrates ulcerating with places in a mucous membrane and a submucosal layer of a stomach and intestines come to light, is more often than a small bowel. From closed glands adrenal glands most often suffer, the pancreas, a hypophysis, gonads is less. By VI—VII-му month of an antenatal life the bone system of a fruit is surprised (the syphilitic osteochondritis, is more rare an osteoperiostitis).

When specific gistol. changes of internals are sharply not expressed or their certain sites are surprised, the child can be born live, but usually with poorly expressed immunity easily susceptible to various intercurrent diseases.

Syphilis of children of chest age is direct continuation of S. of a fruit. The disease is shown since the birth, and is more often in the first 8 weeks of life. It is characterized by various, quite often multiple damages of skin, mucous membranes, internals, a nervous system, sense bodys, bones, especially when children are born from not treated mothers suffering from active manifestations of secondary Page. The general condition of such newborns is broken: the expressed concern, causeless crying day and night, sometimes a shriek (Sisto's symptom) which is followed by spasms in connection with increase in intracranial pressure are noted. Hydrocephaly (see), the phlebectasia of a skull, periostites of bones of a skull can be observed. Despite breastfeeding and absence went. - kish. frustration, there is anorexia (see), the child does not put on weight, badly develops, its dystrophy is observed (see). Skin is flabby, wrinkled, with a grayish and earthy shade, a mask-like face, the child has «a senile appearance».

The most frequent and early manifestations of inborn S. at children of chest age — damages of skin, among to-rykh first of all the syphilitic pemphigus (syphilitic pemphigoid) comes to light. She is visible already at the birth or arises in the first days or weeks of life. It is symmetrized on soles and palms, sometimes on shins and forearms, is more rare on a face and a trunk. The dense infiltrirovanny basis, their size from a pea to cherry have bubbles, they are not surrounded with a hyperemic inflammatory nimbus, have serous contents, a cut soon becomes purulent, and then hemorrhagic. After opening of bubbles the erosion which are becoming covered by crusts are formed, after their falling away pigmentation is noticeable. In contents of bubbles and in separated erosion many pale treponemas are found.

At the end of the first month of life, and a thicket on 8 — the 10th week, there is a diffusion syphilide (diffusion papular infiltration) which is characterized by consolidation of skin against the background of the previous erythema around lips, a nose, an anus and also on palms, soles, buttocks. Skin becomes reinforced, intense, brilliant, as if varnished, there are bleeding cracks and erosion, in to-rykh pale treponemas come to light. After healing of deep cracks and erosion there are typical scars having an appearance of thin white strips and furrows (Robinson's symptom — Fournier).

Papular rash — frequent manifestation of inborn Page. It is observed - usually in 4 — 8 weeks after the birth, and sometimes later. It is localized on extremities, a face and buttocks in the beginning. Papules (see) can extend on all skin, they are resolved by the peeling beginning in the center. At children with subnutrition of a papule on a face can abscess, turning into pustules (see), after opening to-rykh there are erosion which are becoming covered by crusts. The papules located in the field of natural folds of skin on the adjoining surfaces, are easily macerated, become wet, f are eroded and ulcerate allocating a large number of pale treponemas. Spotty (ro-zeolezny) rash at babies is observed exclusively seldom. Changes of nails and periungual rollers are possible (onychias and paronychias).

Among damages of mucous membranes the most frequent and early symptom is the rhinitis (see) arising owing to specific infiltration of a mucous membrane of the nasal courses. Rhinitis complicates nasal breath, and the child cannot suck a breast. In separated from a nose pale treponemas contain. The defeat of a mucous .obolochka of a throat which is shown by an osiply voice, an aphonia (see), and sometimes l are ingo a stenosis (see) is possible.

From specific changes of internals approximately at 80% of patients the gepatospleno-megaliya (see the Gepato-liyenalbny syndrome) which is combined usually with a specific enanthesis and mucous membranes, especially in the first 3 months of life comes to light. Specific damage of kidneys is shown by a glomerulonephritis (see), a nephrosonephritis (see. Nephrotic syndrome), characterized by the increased urine protein content (12 — 20 ‰) in the absence of uniform elements, sometimes existence of hyaline and granular cylinders. At 94% of patients vessels in the form of an obliterating endarteritis (see the Endarteritis obliterating), inflammatory change of venous walls are surprised. Early and often the small egg is surprised, painless increase to-rogo is followed by an edema (see Gidrotsele). Changes of closed glands quite often have multiglandular character with involvement in process of adrenal glands, thyroid, goitrous, gonads, is more rare than a hypophysis. These changes clinically at chest age are not distinguished because of poorly expressed symptomatology. Defeats of c. N of page are characterized by meningitis, an encephalomeningitis, gummas of a brain (see the Brain). At the same time spasms, causeless shout, an edema of a brain, paralyzes, different size of pupils, changes in cerebrospinal liquid (increase in a cytosis and amount of protein, positive glo-bulinovy and serological tests) are observed. At an oftalmoskopichesky research, according to various researchers, the specific chorioretinitis, or a choroiditis is found in 16 — 22% of patients (see). Almost at 70% of children increase in peripheral, especially elbow, lymph nodes is defined. Changes of blood (hypochromia anemia, a leukocytosis, thrombocytopenia, the slowed-down blood coagulation, the increased ROE) are often observed.

Defeats of bone system, most often an osteochondritis (see), quite often system character occur at 85% of patients, according to M. M. Rayts (1948), generally in the first 3 months of life. At the same time long tubular bones of top and bottom extremities (a syphilitic osteochondritis of Vegner — Korzuna), and also flat bones of a skull, a basin, a shovel at the same time can be surprised. Vegner's osteochondritis — Korzuna can be the only manifestation of inborn S., a cut comes to light at rentgenol. research. At this osteochondritis process of preliminary calcification of an epiphyseal cartilage and a new growth of a bone tissue in combination with the accruing inflammatory changes in adjacent departments of a bone is broken. At the expressed changes of a bone tissue the phenomena of a pseudoparalysis of Paro are observed, at Krom owing to a vnutrimetafizarny change there is a false paralichepodobny state. The affected hands or legs are not mobile, have forced situation — legs are tightened to a stomach, and hands are extended along a trunk or taken away back (see fig. to St. Osteochondritis, t. 18, Art. 21 j. Hiting at of the affected extremity causes strong shout of the child because of sharp боли® Sensitivity and electroexcitability of muscles unlike true paralysis are kept. In chest age also osteoperiostites, an osteosclerosis (see), gummas, changes are possible (see).

Syphilis of early children's age (aged from 1 year up to 4 years) is characterized by the same manifestations, as at chest age, but they are less expressed. The nature of rashes, their localization and evolution are similar to rashes of the secondary period of the acquired Page. On skin and mucous membranes papular and pustular elements are observed. Papules most often are located in the field of an anus, pleated necks, in axillary, inguinal areas, behind auricles, in corners of a mouth. They quickly become becoming wet, ero-zirovanny, vegetans. On a face and on a pilar part of the head there are papules pustules. Quite often papules arise in language, almonds, gums and lips. Papules of a throat result in hoarseness and an aphonia. Rozeolezny rash meets seldom. The polyadenitis, and also a gepatosplenomegaliya, occasionally a nephrosonephritis is noted. Changes of c. N of page are shown in the form of specific meningitis, meningoentsefa-litas, epileptiform attacks, mental retardation in various degree (see the Oligophrenia). Chorioretinites and an atrophy of an optic nerve are sometimes diagnosed (see). Defeat of bone system, according to B. M. Pashkov (1955), is noted at 60% of sick children in the form of periostites of tibial bones and an osteosclerosis.

Late inborn syphilis is usually shown aged from 4 up to 17 years, sometimes in 20 — 30 years and more after the birth. On a current it is similar to S. Osobennostyami acquired tertiary of late inborn S. unconditional and probable signs, including dystrophies, or stigmas are. To unconditional, or reliable, to signs the so-called triad of Getchinson (a parenchymatous keratitis, Getchinson's teeth, labyrinth deafness) belongs, edges completely meets seldom. More often than other signs the parenchymatous keratitis (at 50% of patients) which is shown a photophobia (see), dacryagogue, a nictitating spasm (see), uniform opacification of a cornea (see), sometimes deeper and intensive in the center, an injection of vessels of a conjunctiva and especially around a cornea, decrease or loss of sight is observed. More often both eyes, though not always at the same time are surprised. Getchinson's teeth occur at 15 — 20% of patients. Both upper medial cutters are narrowed and rounded slightly off, screw-drivers with a wide neck and a narrow cutting edge have the form, it is frequent with semi-lunar dredging. At the labyrinth deafness (see) which is found at 3,5% of patients is more often at girls aged from 8 up to 15 years, damages of acoustical nerves are noted. There is deafness suddenly, keeps with firmness, the rezistentna to specific therapy and which appeared at early age when the child learns to pronounce words brings to a surdomutism (see).

Fig. 6. Roentgenogram of a shin of the patient with inborn syphilis (side projection): the curvature of a tibial bone is visible forward (an acinaciform shin).

To the probable signs allowing to make late inborn S.'s diagnosis only in the presence of confirmatory data (the anamnesis; results of clinical and serological inspection of the child and mother, change in cerebrospinal liquid), belong Robinson's symptom — Fournier, acinaciform shins — a curvature of tibial bones (fig. 6), deformation of a nose (a saddle, lornetovidny, «goat» nose), a yagodi-deobrazny skull forward! kisetoob, different and reniform teeth. Robinson's symptom — Fournier results from the diffusion syphilide postponed at chest age and is shown by whitish thin hems in the form of a grid or linear strips, radtsarpo the lips located around, corners of a mouth, on a chin. They should be differentiated with rubchikamy after burns, pyodermas, candidiasis, herpetiform eczema of Kaposha (see. Vaccinal rashes). Acinaciform shins arise after the osteochondritis postponed at chest age. False acinaciform shins are possible at the acquired S. after the postponed osteoperiostitis and at Ped-zhet's disease.

Avsitidiysky's symptom described by it in 1891 (a thickening of the sternal end of a clavicle, a thicket right, arising because of a diffusion hyperostosis), dystrophy of bones of a skull in the form of increase in parietal and frontal hillocks, high («Gothic», or «lancet») a hard palate, an aksifoidiya (lack of a xiphoidal shoot of a breast), Karabelli's hillocks (existence of the fifth additional hillock on a chewing surface of the 1st painter of an upper jaw), a diastem to Gosha (widely placed upper cutters) belongs to stigmas (dystrophies); infantile ‘a little finger, a hypertrichosis (overgrowing honor with hair of a forehead to eyebrows and the strengthened growth of hair); asymmetry of auricles.

Inborn S.'s diagnosis is established on the basis of kliniko-serological inspection taking into account age features. In diagnosis of the latent (latent) forms or at poorly вырая^енной to symptomatology, especially at children of chest age, an essential role is played by data of the anamnesis (the analysis of prescription of a disease of mother, quality of her treatment to and during pregnancy), results of serological tests at the child, including RIBT and REEF and a radiographic research of bones, and also survey of an eyeground. At active early inborn S. serological tests are positive at 95 — 100% of patients. At inborn S. of early children's age serological tests of blood are usually positive. Late inborn S.'s diagnosis is established on the basis of existence of unconditional signs, by comparisons of probable signs and a stigma about a wedge, by S.'s manifestations (damage of internals, a nervous system, skin and mucous membranes), and also with the anamnesis, positive serol. reactions of blood. Classical serological tests are positive at 70 — 92% of patients, and RIBT and REEF — almost at 100%.

The anamnesis (syphilis at mother) and existence of positive serological tests of blood, including RIBT and REEF is important for the hidden late inborn S.'s diagnosis.

For differential diagnosis of the latent forms of inborn S. at newborns with false positive serological tests the great value has the REEF with IgM, and also RIBT, to-rye are, as a rule, positive at the children sick with inborn Page.

Treatment. To children with early inborn S. appoint 6 courses of specific treatment penicillin (ek-monovotsilliny). The dose on a course is calculated depending on age and the weight of the child: up to 6 months — 500 000 PIECES, from 6 months to 1 year — 400 000 PIECES, after 1 year up to 5 years — 300 000 PIECES on 1 kg of weight of the child. At late inborn S. 8 courses of treatment by penicillin in a dose are conducted of a course from 300 000 to 200 000 PIECES on 1 kg of weight of the child in combination with drugs of bismuth (on the 2, 4, 6, 8 courses). At a slow negativation of serological tests the pyrogenic drugs (10 — 15 injections of pyrogenal), vitamin therapy, the general UF-radiation are used.

The children who were born without clinical and serological manifestations of S., from patients or mothers who were ill S. not receiving specific treatment during pregnancy or receiving it only in recent months pregnancies (the negativation of serological tests did not occur), it is necessary to treat preventively according to schemes of therapy of early inborn syphilis.

The forecast at inborn S. favorable with the good long-term results on condition of timely appointment and full carrying out specific y nonspecific therapy, a balanced diet and leaving.

Prevention consists in identification and sick S.' treatment of women to and during pregnancy. Along with a wedge, inspection of all pregnant women carries out obligatory double (in the first and second half of pregnancy) a serological blood analysis. At identification at pregnant any form C. specific treatment is necessary (antibiotics). At double (with a break in 7 — 10 days) sharply positive serological tests, RIBT and REEF the diagnosis of the latent seropositive syphilis is made and therapy according to the scheme of treatment of secondary recurrent syphilis is appointed. To newborns, mother to-rykh were insufficiently treated before pregnancy and did not receive preventive treatment during pregnancy, preventive treatment according to the schemes approved by M3 of the USSR is carried out.




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M of H. Bukharovich (treatment, the forecast, prevention of the acquired syphilis), I. V. Davydovsky, G. M. Tsvetkova (a stalemate. An.), V. N. Dobronravov (a wedge, displays of primary, secondary and tertiary acquired syphilis), F. A. Zverkova (inborn syphilis), M. V. Milich (epid., a pathogeny, of, the general patterns of a course of the acquired syphilis, visceral syphilis, syphilis of a nervous system, bones and joints), H. M. Ovchinnikov (etiol., experimental syphilis, lab. diagn.), N. G. Shumsky (mental disorders), L. A. Shteynlukht (history).

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