CARDIOVASCULAR SYPHILIS

THE importanceof syphilis as acauseof vascular diseaseneeds no stressing,for preeminently it is itself a vascular disease. Thepathologist is able to demonstratecharacteristiclesions in the blood vessels,and to point to the various end resultsthat may be expected. Some of theseresults are easily distinguished in the living subject, for example, aortic valvular disease,though it may not always be simple to besurethat this particularanatomical change is due to the ravages of the Treponema pallidtzim'z, and not to those of rheumatic.infection. When the question of cardiac muscular damage comes up, however, its recognitionis not so straightforward, owing to the impossibility of knowing the exactstateof the coronaryarteriesduring life, and also of the exactdegreeof pathologicalchangethat may have crept, as it were, almost unawaresinto the musclefibres themselves. セ N Noble Chamberlain,in discussingthis problem begmsby statingthe criteria necessaryfor a 、ゥ。ァセ nosis of syphilitic aortitis.' He remarkstruly that early recognition of a lesion of the aorta is very important,for it may be possibleto forestall further seriousconsequences by instituting early treatment. The nature of the sounds heard in: the so-called aortic areaare not conclusive. The ringing second cardiac sound, especially in persons over fifty yearsof age, evenin' the absenceof arterial hypertension,is not certainproof. Neitheris thepresence of murmursheardin this region. But when either of these signs is noted, when the patient suffers pain and breathlessness, and.when there is perhaps somedemonstrabledulnessin the greatvesselarea, the diagnosisof aortitis is stronglysuggested.Even then it is not certainthat syphilis is the cause. To feel reasonablysure on this point it is necessary to have serologicalevidence, given by theWassermann reaction (though this may be difficult or impossible to elicit, even after a provocative dose of arsenic),or other stigmataof a syphilitic infection, such as characteristicchangesin the nervous system. Aortic dilatation is most probably due to syphilis, and it should always be looked for. In regardto thosepatientswho show signs of a frank aortic regurgitation, the distinction betweenrheumatic and 'syphilitic diseasehas to be made, for syphilis and rheumatismare the most likely causes. Chamberlain remarks that subacute endocarditis must also be excluded; this is sound advice, for infection, that is, active infection, is not infrequently overlookedin the survey of a patient who has a cardiacvalvular lesion. The history, though this is often misleading, the coincidenceof mitral disease,the radiological evidenceand the electrocardiographic findings, when taken together, will generallyenablea correctopinion to be formed. On the subject of syphilitic myocarditis there is less generalagreement.Various authorsarequoted in support of the frequency of syphilitic disease of the cardiac muscle, and others against it. Chamberlainsums up by saying that in spite of conflicting statementsmost workers admit that involvement of the myocardium is by no means rare. The symptomslikely to leadto suspicionthat 'a patient is suffering from syphilitic myocarditis are in part those of other myocardial lesions, breathlessness, palpitation, pain in the precordial region, and nocturnal distress,and in part those suggesting other visceral forms of syphilis. In otherwords,therecannotbe saidto be anabsolutely characteristic picture. Attacks of the so-called cardiac asthma, for example, occurring at night, are common, but by no means pathognomonic. Some workers have claimed a distinctive picture in the electrocardiogram,but, though the evidence yielded by this method strongly supports a diagnosis of cardiac,vascular01' nutritionaldisturbance, it does not point to a definite :.etiological factor. It will be seen,therefore, that when the pathologists are not in entire agreement,the clinician is set a task that is apt to prove difficult. Perhaps the bestway to put the matter is to point out that