Quite imperceptibly at times, relapses of congenital syphilis extend into the second and third year of life, localizing themselves especially in the skin, in the visible mucous membranes, and in the osseous system.
The most important skin lesion of hereditary syphilis of the second to the fourth year of life are condylomata lata of the genito-anal region; these differ in no way from those of acquired syphilis.
The visible mucous membranes frequently show, even up to the sixth year of life, syphilitic recurrences in the form of mucous patches, the favorite location of which is the mucous membrane of the mouth and pharynx including the tonsils, but especially the upper surface of the tongue. On the latter, extensive manifold condylomata with a ten dency to repeated recurrences are not infrequent (Plate 27).
Recurrent exanthemata occur, but rarely, up to the middle of the second year of life, either in the form of an extensive eruption of prom inent papules at the hairy margin of the forehead or on the flexor sur face of the extremities, or in the form of inconspicuous, tender, half lentil to bean sized spots on the forehead and the lower part of the body; these are at first salmon colored, later yellowish, shining, and somewhat scaly. The trunk is nearly always entirely free.
Exanthemata of this latter variety usually occur only after in sufficient treatment of the first symptoms of syphilis; they very closely resemble the eruptions of herpes tonsurans maculosus and are fre quently overlooked or misinterpreted. Occasionally there are found, even during the second year, on the skin of the extremities and of the hack, small, disc-shaped, lightly pigmented spots, not raised above the surface. which take on a bluish violet tint and become clearly marked when the child cries.
Toward the end of the first and during the second year there fre quently develops the clinical picture of pseudoleuka2mic anemia with marked splenomegaly, so that the spleen occupies, as a hard body, the whole left. half of the abdomen and may reach down into the pelvis.
The liver is always considerably enlarged at the same time. In many cases of hereditary syphilis with hepatic and splenic enlargement the liver is much larger than the spleen. Here there is a real syphilitic ment of the liver with an indurative hyperplasia of the spleen, while the type first described is a manifestation of pseudoleukTmic anemia, an affection that may occur without preceding syphilis, especially in severe rickets.
After the period of infancy, con genitally syphilitic disease of the visceral organs often takes on a true gummatous character in the form of solitary syphi lomata, which may occur both in the parenchymatous and lymphatic organs and the mucous membranes. A nodular appearance of the liver is very frequent. Contracted kidney as a result of syph iloma likewise occurs during childhood.
The skin and subcutaneous tissues occasionally show solitary gummata in the years following infancy.
These appear as fluctuating, dome-shaped projections, in size from that of a bean to a hazel-nut, with or without. slight reddening, and unaccompanied by fever. If recognized early and treated with mercury these rapidly disappear. If not, they burst and empty out a tough, sticky, light yellow mass and arc converted into cup-shaped, thick-walled ulcers that are painless and without reaction and heal with great difficulty even under the most approved treatment.
A rare form of recurrence is to be found in a diffuse, sclerotic glossitis, which von During has observed repeatedly in endemic syphilis and which I have seen three times. The tongue is either enlarged in toto, projecting from the mouth, much as in inyxcedema, the whole muscular portion being uniformly thickened but the tongue not being oedematous or painful; or there may be large circumscribed nodules that occupy from one-third to three-fourths of the whole parenchyma of the tongue. Such indurations of the tongue occur (luring childhood only with syphilis.
Laryngeal involvement is an important manifestation of recurrence of hereditary syphilis. According to Ripault there are usually present nodular, papular growths on the epiglottis and the mucous membrane of the vocal cords, that break down into ulcers, and later form sear tissue. We ourselves have seen the surface of the vocal cords and epi glottis thickly covered with condylomata in a child of 15 months with hereditary syphilis (see Fig. 133).
Laryngeal syphilis of earliest childhood often presents the picture of croup and is often mistaken for croup; in some cases intubation and tracheotomy have been performed to prevent suffocation. Hereditary laryngeal syphilis is comparatively rare during the third and fourth years, but becomes more frequent again during the period of late syphilis. The essential symptom is hoarseness, even complete aphonia, without a demonstrable catarrhal condition of the deeper air-passages.