Chronic ulceration of the stomach due to syphilis is most common in men between twenty-five and forty years of age, in many of whom secondary symptoms of the infective disorder either have been very slight or were rapidly removed by treatment. The gastric complaint usually develops slowly, and for several months may be mistaken for some form of simple or inflammatory dyspepsia; but sooner or later the characteristic symptoms of ulcer show themselves and soon become severe. So far as our own experience goes, these cases chiefly differ from the simple variety of the disease in three particulars, the first of which is the extreme severity of the pain and vomiting, the second the infrequency of haemorrhage, and the third their obstinacy to ordinary treatment and their great tendency to relapse.
Pain is invariably present, and, as is usual in gastric ulcer, is principally experienced in the epigastrium within half an hour after a meal containing solid food. In many instances, however, the suffering is almost constant, and even a diet of milk gives rise to oppression at the chest with distension and troublesome flatulence. When the disease has existed for some months the pain is often most intense during the night, when the stomach is devoid of food, and it may then extend all over the abdomen and chest and radiate clown the extremities or up into the neck. Under these conditions the epigastrium is usually very tender, and the cranium, the tibiae, and the heels may also be unduly sensitive to pressure. The attacks last for several hours, and are frequently accompanied by flatulent and acid eructations, burning in the throat, intense thirst, and vomiting. They are temporarily relieved by a draught of milk or a dose of bicarbonate of sodium, and more effectually by vomiting. Rosanow diagnosed a syphilitic ulcer in one patient on account of the nocturnal pain, and successfully treated it, while Bartumeus appears to lay stress upon attacks of emesis during the night ; but since both these phenomena are met with in simple ulcer when complicated with hypersecretion, they cannot be regarded as pathognomonic of the specific form of the complaint. Vomiting is another conspicuous feature of the disease. At first the patient may be sick only during the painful crisis, which the act of emesis tends to curtail; but as soon as secondary gastritis develops vomiting may occur after every meal, while from time to time attacks come on which last for many days and prevent the administration of nourishment by the mouth. The constant pain and vomiting soon induce a serious deterioration of the general health. The patient becomes very thin and feeble, and presents the pinched and careworn look of one who is always suffering. The appetite may remain good, or even be excessive, but he is afraid to gratify the desire for food on account of the punishment which is sure to follow; while at intervals he is tormented by a thirst which no amount of water will subdue. The bowels are confined and the tongue is often covered with a white fur. The urine is diminished in amount and its reaction is often neutral or slightly alkaline, while in many cases it contains an excess of phosphates but is deficient in chlorides. Anaemia is invariably present, and the peculiar sallow complexion of many of the patients is very suggestive of a specific cachexia. Although nearly 70 per cent, of the cases of simple ulcer suffer from haematemesis, this symptom appears to be comparatively rare in the syphilitic disease, possibly on account of the gradual obliteration of the gastric vessels, which, as has already been pointed out, occurs in the vicinity of the sore. When, however, the portal circulation is embarrassed by coexisting disease of the liver or spleen, vomiting of blood may be an early and recurrent symptom.
As a rule the complaint fails to respond to the ordinary methods of treatment, and even when anti-syphilitic remedies are employed it may exhibit a great tendency to relapse. This latter peculiarity was very marked in the case of a woman who came under our care four or five times within two years for severe pain and vomiting after meals, accompanied by rapid emaciation. On each occasion the administration of mercury and iodides afforded almost immediate relief, and the disease appeared to be cured at the end of two months ; but as soon as she discontinued the medicine, though persevering with a liquid diet, the pain recurred and she again lost flesh and vomited her food.
With regard to the chemistry of digestion there is very little evidence to offer. In the early stages of the complaint free hydrochloric acid may usually be detected after a test meal, and in those cases where nocturnal attacks of pain are present the vomit usually contains an excess of the mineral acid. But when the disease has given rise to great loss of flesh and to debility we have never observed hyperchloracidity, but, on the contrary, have often found evidence of lactic acid fermentation. When vomiting is excessive the ejecta consist almost entirely of alkaline and bile-stained mucus. The usual cause of death is exhaustion from inanition, but an intercurrent affection like tuberculosis or some syphilitic complication often hastens the fatal termination. Haematemesis and perforation appear to be rare. Among the sequelae of the disease, pyloric stenosis is the most important, and has been recorded by Cornil, Wagner, and Klebs.
Gastritis occurs both in hereditary and acquired syphilis, and is chiefly characterised by its chronicity and intractability to ordinary treatment. In infancy and early childhood the intestine usually suffers along with the stomach, so that in addition to the vomiting there is either diarrhoea or obstinate constipation. In all cases the loss of flesh, anaemia, and debility are out of proportion to the severity of the local symptoms, owing to the consecutive atrophy of the gastric and intestinal glands, which can be demonstrated in almost every case of so-called ' syphilitic marasmus.' During the period of childhood intercurrent attacks of acute gastritis, characterised by incessant nausea and vomiting, and occasionally by severe gastralgia, are apt to occur from time to time. The bowels are confined, the tongue is thickly coated, and slight delirium may appear at night. If no food can be retained in the stomach the disease may prove fatal; but as a rule the acute disease passes off in a few days, and is again replaced by the chronic form. In almost every instance the child presents evidences of syphilis in the face, teeth, and eyes, while not infrequently the development of a gumma heralds the onset of an acute attack. In one case which came under our care a large mass could be felt for several months in the liver, and subsequently a gummatous swelling appeared upon the forehead; while in one reported by Hemmeter the child presented an enormous gumma of the lower jaw.