Our own experience and examination of the literature leads us to say that the site of the primary lesion is most frequently on the lips, less frequently on the face or neck, and still less frequently on the perineum, the abdomen and the genitalia. The least frequent of all in childhood is a chancre of the tonsil or of the tongue.
Chancre of the tonsil is, however, relatively more frequent in chil dren than in adults, and is characterized by moderate enlargement of the tonsil together with ulceration of its surface accompanied by a grayish, moist coating that has often led to a diagnosis of diphtheria. The submaxillary and cervical lymph-nodes are always enlarged, always bilaterally, though the chancre is of one tonsil only.
The course of acquired syphilis in childhood is generally a mild one, even in infancy. A. Fournier has reported cases of acquired syph ilis in infancy, in which, on account of the enormous development of condylomata of the mucous membrane the nutrition was seriously im paired and a cachectic condition was produced. I myself have never seen such cases.
In older children, according to my experience, the first skin erup tion causes no constitutional disturbances. I agree with Heubner who has called attention to the infrequency of a general eruption in ac quired syphilis in children. Among 52 cases in my own material, both institutional and private, I could find a general eruption in only 13 cases, while all of the children showed at some time (luring the period they were under observation, moist condylomata in one location or another.
The exanthemata observed by me as the first in each case were invariably macular. Twice I saw an orbicular syphilide as an erup tion occurring during a recurrence. In the case of endemic syphilis, according to the observations of Glfick, somewhat different conditions prevail.
The great frequency of moist condylomata, with a predilection for the mouth and pharynx, the genitalia, the anus and the scrotum, is recognized by all (see Plate 25). Gltick has frequently seen moist papules on the nasal mucous membrane as well.
The indolent polyadenitis of syphilis is always very well marked in acquired syphilis of childhood. The submaxillary nodes usually show the greatest enlargement even if there is no induration found on the lips, probably due to the great frequency of the primary infection of the lips in the form of a papule.
Heubner has pointed out the lack of resistance of these children with acquired syphilis to other infectious diseases. There seems also, according to my observations, a peculiar predisposition to later tubercu losis, much as is the case of children with hereditary syphilis.
Severe recurrences are less frequent in the acquired than in the hereditary form of syphilis, and the reappearances of the former are nearly always mild and yield most readily to proper treatment.
It is often necessary to make a differential diagnosis between hered itary and acquired syphilis in a child. The decision is often very im portant because the source of infection must be made out and removed. If we have to do with a hereditary transmission, then the diseased par ent must he treated; if on the other hand the ease is one of contact infection, then the bearer of infection must be discovered, eliminated from the household, and treated. If a primary sclerosis can be demonstrated there is, manifestly, no doubt that the disease is of the acquired form; while diffuse infiltrations of the skin and mucous mem branes. i.e., diffuse palmar and plantar syphilide, infiltration and scars of the lips, diffuse rhinitis and nasal deformities during the first period of life, point unqualifiedly to hereditary syphilis. The differential diagnosis is generally more easily made during infancy than at a later period. The greatest difficulty arises in the case of children more than a year old with condylomata, because these can occur equally well as a recurrence of hereditary syphilis, or as a new manifestation of the ac quired form. In many cases the history of the parent will disclose the hereditary nature of the disease. In dispensary cases such evidence is very frequently not obtainable; then the general condition of the child must decide. It is wholly improbable that a child with hereditary syphilis, untreated during the first year of life, is free from specific stigmata. These are usually abnormalities of the cranium and of the nasal skeleton as already mentioned. If these are absent and the gen eral condition of the child is good, then one can diagnosticate acquired syphilis with certainty.
The presence of a syphilitic roseola on the trunk, speaks positively for the acquired type, as it never occurs there in the hereditary form. On the other hand, various disseminated exanthemata, such as the small papulte and orbicular forms, may occur during the second year of life as manifestations of a recurrence of hereditary syphilis, although this is an extremely rare occurrence, and is never unaccompanied by other stigmata of the hereditary form of the disease, especially in the nervous system.
The differential diagnosis between late hereditary syphilis and the tertiary stage of acquired syphilis in children is much more diffi cult. I know of but one pathognomonic symptom: the presence of radial scars on the lips. This occurs only in hereditary syphilis. Hutchinson's triad is found also in tertiary acquired syphilis.