Manual of Surgery Volume I Part 18

The administration is controlled by the systematic examination of the urine for a.r.s.enic.

_The Administration of Mercury._--The success of the a.r.s.enical preparations has diminished the importance of mercury in the treatment of syphilis, but it is still used to supplement the effect of the injections. The amount of mercury to be given in any case must be proportioned to the idiosyncrasies of the patient, and it is advisable, before commencing the treatment, to test his urine and record his body-weight. The small amount of mercury given at the outset is gradually increased. If the body-weight falls, or if the gums become sore and the breath foul, the mercury should be stopped for a time. If salivation occurs, the drinking of hot water and the taking of hot baths should be insisted upon, and half-dram doses of the alkaline sulphates prescribed.

_Methods of Administering Mercury._--(1) _By the Mouth._--This was for long the most popular method in this country, the preparation usually employed being grey powder, in pills or tablets, each of which contains one grain of the powder. Three of these are given daily in the first instance, and the daily dose is increased to five or even seven grains till the standard for the individual patient is arrived at. As the grey powder alone sometimes causes irritation of the bowels, it should be combined with iron, as in the following formula: Hydrarg. c. cret. gr. 1; ferri sulph. exsiccat. gr. 1 or 2.

(2) _By Inunction._--Inunction consists in rubbing into the pores of the skin an ointment composed of equal parts of 20 per cent. oleate of mercury and lanolin. Every night after a hot bath, a dram of the ointment (made up by the chemist in paper packets) is rubbed for fifteen minutes into the skin where it is soft and comparatively free from hairs. When the patient has been brought under the influence of the mercury, inunction may be replaced by one of the other methods, of administering the drug.

(3) _By Intra-muscular Injection._--This consists in introducing the drug by means of a hypodermic syringe into the substance of the gluteal muscles. The syringe is made of gla.s.s, and has a solid gla.s.s piston; the needle of platino-iridium should be 5 cm. long and of a larger calibre than the ordinary hypodermic needle. The preparation usually employed consists of: metallic mercury or calomel 1 dram, lanolin and olive oil each 2 drams; it must be warmed to allow of its pa.s.sage through the needle. Five minims--containing one grain of metallic mercury--represent a dose, and this is injected into the muscles above and behind the great trochanter once a week. The contents of the syringe are slowly expressed, and, after withdrawing the needle, gentle ma.s.sage of the b.u.t.tock should be employed. Four courses each of ten injections are given the first year, three courses of the same number during the second and third years, and two courses during the fourth year (Lambkin).

_The General Health._--The patient must lead a regular life and cultivate the fresh-air habit, which is as beneficial in syphilis as in tuberculosis. Anaemia, malaria, and other sources of debility must receive appropriate treatment. The diet should be simple and easily digested, and should include a full supply of milk. Alcohol is prohibited. The excretory organs are encouraged to act by the liberal drinking of hot water between meals, say five or six tumblerfuls in the twenty-four hours. The functions of the skin are further aided by frequent hot baths, and by the wearing of warm underclothing. While the patient should avoid exposure to cold, and taxing his energies by undue exertion, he should be advised to take exercise in the open air. On account of the liability to lesions of the mouth and throat, he should use tobacco in moderation, his teeth should be thoroughly overhauled by the dentist, and he should brush them after every meal, using an antiseptic tooth powder or wash. The mouth and throat should be rinsed out night and morning with a solution of chlorate of potash and alum, or with peroxide of hydrogen.

_Treatment of the Local Manifestations._--_The skin lesions_ are treated on the same lines as similar eruptions of other origin. As local applications, preparations of mercury are usually selected, notably the ointments of the red oxide of mercury, ammoniated mercury, or oleate of mercury (5 per cent.), or the mercurial plaster introduced by Unna. In the treatment of condylomata the greatest attention must be paid to cleanliness and dryness. After was.h.i.+ng and drying the affected patches, they are dusted with a powder consisting of equal parts of calomel and carbonate of zinc; and apposed skin surfaces, such as the nates or l.a.b.i.a, are separated by sublimate wool. In the ulcers of later secondary syphilis, crusts are got rid of in the first instance by means of a boracic poultice, after which a piece of lint or gauze cut to the size of the ulcer and soaked in black wash is applied and covered with oil-silk. If the ulcer tends to spread in area or in depth, it should be sc.r.a.ped with a sharp spoon, and painted over with acid nitrate of mercury, or a local hyperaemia may be induced by Klapp's suction apparatus.

_In lesions of the mouth and throat_, the teeth should be attended to; the best local application is a solution of chromic acid--10 grains to the ounce--painted on with a brush once daily. If this fails, the lesions may be dusted with calomel the last thing at night. For deep ulcers of the throat the patient should gargle frequently with chlorine water or with perchloride of mercury (1 in 2000); if the ulcer continues to spread it should be painted with acid nitrate of mercury.

In the treatment of _iritis_ the eyes are shaded from the light and completely rested, and the pupil is well dilated by atropin to prevent adhesions. If there is much pain, a blister may be applied to the temple.

_The Relations of Syphilis to Marriage._--Before the introduction of the Ehrlich-Hata treatment no patient was allowed to marry until three years had elapsed after the disappearance of the last manifestation. While marriage might be entered upon under these conditions without risk of the husband infecting the wife, the possibility of his conveying the disease to the offspring cannot be absolutely excluded. It is recommended, as a precautionary measure, to give a further mercurial course of two or three months' duration before marriage, and an intravenous injection of an a.r.s.enical preparation.

#Intermediate Stage.#--After the dying away of the secondary manifestations and before the appearance of tertiary lesions, the patient may present certain symptoms which Hutchinson called _reminders_. These usually consist of relapses of certain of the affections of the skin, mouth, or throat, already described. In the skin, they may a.s.sume the form of peeling patches in the palms, or may appear as spreading and confluent circles of a scaly papular eruption, which if neglected may lead to the formation of fissures and superficial ulcers. Less frequently there is a relapse of the eye affections, or of paralytic symptoms from disease of the cerebral arteries.

#Tertiary Syphilis.#--While the manifestations of primary and secondary syphilis are common, those of the tertiary period are by comparison rare, and are observed chiefly in those who have either neglected treatment or who have had their powers of resistance lowered by privation, by alcoholic indulgence, or by tropical disease.

It is to be borne in mind that in a certain proportion of men and in a larger proportion of women, the patient has no knowledge of having suffered from syphilis. Certain slight but important signs may give the clue in a number of cases, such as irregularity of the pupils or failure to react to light, abnormality of the reflexes, and the discovery of patches of leucoplakia on the tongue, cheek, or palate.

The _general character of tertiary manifestations_ may be stated as follows: They attack by preference the tissues derived from the mesoblastic layer of the embryo--the cellular tissue, bones, muscles, and viscera. They are often localised to one particular tissue or organ, such, for example, as the subcutaneous cellular tissue, the bones, or the liver, and they are rarely symmetrical. They are usually aggressive and persistent, with little tendency to natural cure, and they may be dangerous to life, because of the destructive changes produced in such organs as the brain or the larynx. They are remarkably amenable to treatment if inst.i.tuted before the stage which is attended with destruction of tissue is reached. Early tertiary lesions may be infective, and the disease may be transmitted by the discharges from them; but the later the lesions the less is the risk of their containing an infective virus.

The most prominent feature of tertiary syphilis consists in the formation of granulation tissue, and this takes place on a scale considerably larger than that observed in lesions of the secondary period. The granulation tissue frequently forms a definite swelling or tumour-like ma.s.s (syphiloma), which, from its peculiar elastic consistence, is known as a _gumma_. In its early stages a gumma is a firm, semi-translucent greyish or greyish-red ma.s.s of tissue; later it becomes opaque, yellow, and caseous, with a tendency to soften and liquefy. The gumma does harm by displacing and replacing the normal tissue elements of the part affected, and by involving these in the degenerative changes, of the nature of caseation and necrosis, which produce the destructive lesions of the skin, mucous membranes, and internal organs. This is true not only of the circ.u.mscribed gumma, but of the condition known as _gummatous infiltration_ or _syphilitic cirrhosis_, in which the granulation tissue is diffused throughout the connective-tissue framework of such organs as the tongue or liver. Both the gummatous lesions and the fibrosis of tertiary syphilis are directly excited by the spirochaetes.

The life-history of an untreated gumma varies with its environment. When protected from injury and irritation in the substance of an internal organ such as the liver, it may become encapsulated by fibrous tissue, and persist in this condition for an indefinite period, or it may be absorbed and leave in its place a fibrous cicatrix. In the interior of a long bone it may replace the rigid framework of the shaft to such an extent as to lead to pathological fracture. If it is near the surface of the body--as, for example, in the subcutaneous or submucous cellular tissue, or in the periosteum of a superficial bone, such as the palate, the skull, or the tibia--the tissue of which it is composed is apt to undergo necrosis, in which the overlying skin or mucous membrane frequently partic.i.p.ates, the result being an ulcer--the tertiary syphilitic ulcer (Figs. 40 and 41).

_Tertiary Lesions of the Skin and Subcutaneous Cellular Tissue._--The clinical features of a _subcutaneous gumma_ are those of an indolent, painless, elastic swelling, varying in size from a pea to an almond or walnut. After a variable period it usually softens in the centre, the skin over it becomes livid and dusky, and finally separates as a slough, exposing the tissue of the gumma, which sometimes appears as a mucoid, yellowish, honey-like substance, more frequently as a sodden, caseated tissue resembling wash-leather. The caseated tissue of a gumma differs from that of a tuberculous lesion in being tough and firm, of a buff colour like wash-leather, or whitish, like boiled fish. The degenerated tissue separates slowly and gradually, and in untreated cases may be visible for weeks in the floor of the ulcer.

[Ill.u.s.tration: FIG. 40.--Ulcerating Gumma of Lips.

(From a photograph lent by Dr. Stopford Taylor and Dr. R. W. Mackenna.)]

_The tertiary ulcer_ may be situated anywhere, but is most frequently met with on the leg, especially in the region of the knee (Fig. 42) and over the calf. There may be one or more ulcers, and also scars of antecedent ulcers. The edges are sharply cut, as if punched out; the margins are rounded in outline, firm, and congested; the base is occupied by gummatous tissue, or, if this has already separated and sloughed out, by unhealthy granulations and a thick purulent discharge.

When the ulcer has healed it leaves a scar which is depressed, and if over a bone, is adherent to it. The features of the tertiary ulcer, however, are not always so characteristic as the above description would imply. It is to be diagnosed from the "leg ulcer," which occurs almost exclusively on the lower third of the leg; from Bazin's disease (p. 74); from the ulcers that result from certain forms of malignant disease, such as rodent cancer, and from those met with in chronic glanders.

_Gummatous Infiltration of the Skin_ ("Syphilitic Lupus").--This is a lesion, met with chiefly on the face and in the region of the external genitals, in which the skin becomes infiltrated with granulation tissue so that it is thickened, raised above the surface, and of a brownish-red colour. It appears as isolated nodules, which may fuse together; the epidermis becomes scaly and is shed, giving rise to superficial ulcers which are usually covered by crusted discharge. The disease tends to spread, creeping over the skin with a serpiginous, crescentic, or horse-shoe margin, while the central portion may heal and leave a scar.

From the fact of its healing in the centre while it spreads at the margin, it may resemble tuberculous disease of the skin. It can usually be differentiated by observing that the infiltration is on a larger scale; the progress is much more rapid, involving in the course of months an area which in the case of tuberculosis would require as many years; the scars are sounder and are less liable to break down again; and the disease rapidly yields to anti-syphilitic treatment.

[Ill.u.s.tration: FIG. 41.--Ulceration of nineteen year's duration in a woman aet. 24, the subject of inherited syphilis, showing active ulceration, cicatricial contraction, and sabre-blade deformity of tibiae.]

_Tertiary lesions of mucous membrane and of the submucous cellular tissue_ are met with chiefly in the tongue, nose, throat, larynx, and r.e.c.t.u.m. They originate as gummata or as gummatous infiltrations, which are liable to break down and lead to the formation of ulcers which may prove locally destructive, and, in such situations as the larynx, even dangerous to life. In the tongue the tertiary ulcer may prove the starting-point of cancer; and in the larynx or r.e.c.t.u.m the healing of the ulcer may lead to cicatricial stenosis.

Tertiary lesions of the _bones and joints_, of the _muscles_, and of the _internal organs_, will be described under these heads. The part played by syphilis in the production of disease of arteries and of aneurysm will be referred to along with diseases of blood vessels.

[Ill.u.s.tration: FIG. 42.--Tertiary Syphilitic Ulceration in region of Knee and on both Thumbs of woman aet. 37.]

_Treatment._--The most valuable drugs for the treatment of the manifestations of the tertiary period are the a.r.s.enical preparations and the iodides of sodium and pota.s.sium. On account of their depressing effects, the latter are frequently prescribed along with carbonate of ammonium. The dose is usually a matter of experiment in each individual case; 5 grains three times a day may suffice, or it may be necessary to increase each dose to 20 or 25 grains. The symptoms of iodism which may follow from the smaller doses usually disappear on giving a larger amount of the drug. It should be taken after meals, with abundant water or other fluid, especially if given in tablet form. It is advisable to continue the iodides for from one to three months after the lesions for which they are given have cleared up. If the pota.s.sium salt is not tolerated, it may be replaced by the ammonium or sodium iodide.

_Local Treatment._--The absorption of a subcutaneous gumma is often hastened by the application of a fly-blister. When a gumma has broken on the surface and caused an ulcer, this is treated on general principles, with a preference, however, for applications containing mercury or iodine, or both. If a wet dressing is required to cleanse the ulcer, black wash may be used; if a powder to promote dryness, one containing iodoform; if an ointment is indicated, the choice lies between the red oxide of mercury or the dilute nitrate of mercury ointment, and one consisting of equal parts of lanolin and vaselin with 2 per cent. of iodine. Deep ulcers, and obstinate lesions of the bones, larynx, and other parts may be treated by excision or sc.r.a.ping with the sharp spoon.

#Second Attacks of Syphilis.#--Instances of re-infection of syphilis have been recorded with greater frequency since the more general introduction of a.r.s.enical treatment. A remarkable feature in such cases is the shortness of the interval between the original infection and the alleged re-infection; in a recent series of twenty-eight cases, this interval was less than a year. Another feature of interest is that when patients in the tertiary stage of syphilis are inoculated with the virus from lesions from these in the primary and secondary stage lesions of the tertiary type are produced.

Reference may be made to the #relapsing false indurated chancre#, described by Hutchinson and by Fournier, as it may be the source of difficulty in diagnosis. A patient who has had an infecting chancre one or more years before, may present a slightly raised induration on the p.e.n.i.s at or close to the site of his original sore. This relapsed induration is often so like that of a primary chancre that it is impossible to distinguish between them, except by the history. If there has been a recent exposure to venereal infection, it is liable to be regarded as the primary lesion of a second attack of syphilis, but the further progress shows that neither bullet-buboes nor secondary manifestations develop. These facts, together with the disappearance of the induration under treatment, make it very likely that the lesion is really gummatous in character.

INHERITED SYPHILIS

One of the most striking features of syphilis is that it may be transmitted from infected parents to their offspring, the children exhibiting the manifestations that characterise the acquired form of the disease.

The more recent the syphilis in the parent, the greater is the risk of the disease being communicated to the offspring; so that if either parent suffers from secondary syphilis the infection is almost inevitably transmitted.

While it is certain that either parent may be responsible for transmitting the disease to the next generation, the method of transmission is not known. In the case of a syphilitic mother it is most probable that the infection is conveyed to the ftus by the placental circulation. In the case of a syphilitic father, it is commonly believed that the infection is conveyed to the ovum through the seminal fluid at the moment of conception. If a series of children, one after the other, suffer from inherited syphilis, it is almost invariably the case that the mother has been infected.

In contrast to the acquired form, inherited syphilis is remarkable for the absence of any primary stage, the infection being a general one from the outset. The spirochaete is demonstrated in incredible numbers in the liver, spleen, lung, and other organs, and in the nasal secretion, and, from any of these, successful inoculations in monkeys can readily be made. The manifestations differ in degree rather than in kind from those of the acquired disease; the difference is partly due to the fact that the virus is attacking developing instead of fully formed tissues.

The virus exercises an injurious influence on the ftus, which in many cases dies during the early months of intra-uterine life, so that miscarriage results, and this may take place in repeated pregnancies, the date at which the miscarriage occurs becoming later as the virus in the mother becomes attenuated. Eventually a child is carried to full term, and it may be still-born, or, if born alive, may suffer from syphilitic manifestations. It is difficult to explain such vagaries of syphilitic inheritance as the infection of one twin and the escape of the other.

_Clinical Features._--We are not here concerned with the severe forms of the disease which prove fatal, but with the milder forms in which the infant is apparently healthy when born, but after from two to six weeks begins to show evidence of the syphilitic taint.

The usual phenomena are that the child ceases to thrive, becomes thin and sallow, and suffers from eruptions on the skin and mucous membranes.

There is frequently a condition known as _snuffles_, in which the nasal pa.s.sages are obstructed by an acc.u.mulation of thin muco-purulent discharge which causes the breathing to be noisy. It usually begins within a month after birth and before the eruptions on the skin appear.

When long continued it is liable to interfere with the development of the nasal bones, so that when the child grows up there results a condition known as the "saddle-nose" deformity (Figs. 43 and 44).

[Ill.u.s.tration: FIG. 43.--Facies of Inherited Syphilis.

(From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_.)]

_Affections of the Skin._--Although all types of skin affection are met with in the inherited disease, the most important is a _papular_ eruption, the papules being of large size, with a smooth s.h.i.+ning top and of a reddish-brown colour. It affects chiefly the b.u.t.tocks and thighs, the genitals, and other parts which are constantly moist. It is necessary to distinguish this specific eruption from a form of eczema which occurs in these situations in non-syphilitic children, the points that characterise the syphilitic condition being the infiltration of the skin and the coppery colour of the eruption. At the a.n.u.s the papules acquire the characters of _condylomata_, also at the angles of the mouth, where they often ulcerate and leave radiating scars.

_Affections of the Mucous Membranes._--The inflammation of the nasal mucous membrane that causes snuffles has already been referred to. There may be mucous patches in the mouth, or a stomat.i.tis which is of importance, because it results in interference with the development of the permanent teeth. The mucous membrane of the larynx may be the seat of mucous patches or of catarrh, and as a result the child's cry is hoa.r.s.e.

_Affections of the Bones._--Swellings at the ends of the long bones, due to inflammation at the epiphysial junctions, are most often observed at the upper end of the humerus and in the bones in the region of the elbow. Partial displacement and mobility at the ossifying junction may be observed. The infant cries when the part is touched; and as it does not move the limb voluntarily, the condition is spoken of as _the pseudo-paralysis of syphilis_. Recovery takes place under anti-syphilitic treatment and immobilisation of the limb.

Diffuse thickening of the shafts of the long bones, due to a deposit of new bone by the periosteum, is sometimes met with.

[Ill.u.s.tration: FIG. 44.--Facies of Inherited Syphilis.]

The conditions of the skull known as Parrot's nodes or bosses, and craniotabes, were formerly believed to be characteristic of inherited syphilis, but they are now known to occur, particularly in rickety children, from other causes. The _bosses_ result from the heaping up of new spongy bone beneath the pericranium, and they may be grouped symmetrically around the anterior fontanelle, or may extend along either side of the sagittal suture, which appears as a deep groove--the "natiform skull." The bosses disappear in time, but the skull may remain permanently altered in shape, the frontal and parietal eminences appearing unduly prominent. The term _craniotabes_ is applied when the bone becomes thin and soft, reverting to its original membranous condition, so that the affected areas dimple under the finger like parchment or thin cardboard; its localisation in the posterior parts of the skull suggests that the disappearance of the osseous tissue is influenced by the pressure of the head on the pillow. Craniotabes is recovered from as the child improves in health.

Between the ages of three and six months, certain other phenomena may be met with, such as _effusion into the joints_, especially the knees; _iritis_, in one or in both eyes, and enlargement of the spleen and liver.

In the majority of cases the child recovers from these early manifestations, especially when efficiently treated, and may enjoy an indefinite period of good health. On the other hand, when it attains the age of from two to four years, it may begin to manifest lesions which correspond to those of the tertiary period of acquired syphilis.

#Later Lesions.#--In the skin and subcutaneous tissue, the later manifestations may take the form of localised gummata, which tend to break down and form ulcers, on the leg for example, or of a spreading gummatous infiltration which is also liable to ulcerate, leaving disfiguring scars, especially on the face. The palate and fauces may be destroyed by ulceration. In the nose, especially when the ulcerative process is a.s.sociated with a putrid discharge--ozaena--the destruction of tissue may be considerable and result in unsightly deformity. The entire palatal portions of the upper jaws, the vomer, turbinate, and other bones bounding the nasal and oral cavities, may disappear, so that on looking into the mouth the base of the skull is readily seen. Gummatous disease is frequently observed also in the flat bones of the skull, in the bones of the hand, as syphilitic dactylitis, and in the bones of the forearm and leg. When the tibia is affected the disease is frequently bilateral, and may a.s.sume the form of gummatous ulcers and sinuses. In later years the tibia may present alterations in shape resulting from antecedent gummatous disease--for example, nodular thickenings of the shaft, flattening of the crest, or a more uniform increase in thickness and length of the shaft of the bone, which, when it is curved in addition, is described as the "sabre-blade" deformity. Among lesions of the viscera, mention should be made of gumma of the testis, which causes the organ to become enlarged, uneven, and indurated. This has even been observed in infants a few months old.