Alexis Thomson and Alexander Miles - Manual of Surgery

A >> Alexis Thomson and Alexander Miles >> Manual of Surgery

Pages:
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43 | 44 | 45 | 46 | 47 | 48 | 49

#Treatment.#--The tuberculous abscess may recede and disappear under
general treatment. Many surgeons advise that so long as the abscess is
quiescent it should be left alone. All agree, however, that if it shows
a tendency to spread, to increase in size, or to approach the skin or a
mucous membrane, something should be done to avoid the danger of its
bursting and becoming infected with pyogenic organisms. Simple
evacuation of the abscess by a hollow needle may suffice, or bismuth or
iodoform may be introduced after withdrawal of the contents.

_Evacuation of the Abscess and Injection of Iodoform._--The iodoform is
employed in the form of a 10 per cent. solution in ether or the same
proportion suspended in glycerin. Either form becomes sterile soon after
it is prepared. Its curative effects would appear to depend upon the
liberation of iodine, which restrains the activity of the bacilli, and
upon its capacity for irritating the tissues and so inducing a
protective leucocytosis, and also of stimulating the formation of scar
tissue. An anaesthetic is rarely called for, except in children. The
abscess is first evacuated by means of a large trocar and cannula
introduced obliquely through the overlying soft parts, avoiding any part
where the skin is thin or red. If the cannula becomes blocked with
caseous material, it may be cleared with a probe, or a small quantity of
saline solution is forced in by the syringe. The iodoform is injected by
means of a glass-barrelled syringe, which is firmly screwed on to the
cannula. The amount injected varies with the size of the abscess and the
age of the patient; it may be said to range from two or three drams in
the case of children to several ounces in large abscesses in adults. The
cannula is withdrawn, the puncture is closed by a Michel's clip, and a
dressing applied so as to exert a certain amount of compression. If the
abscess fills up again, the procedure should be repeated; in doing so,
the contents show the coloration due to liberated iodine. When the
contents are semi-solid, and cannot be withdrawn even through a large
cannula, an incision must be made, and, after the cavity has been
emptied, the iodoform is introduced through a short rubber tube attached
to the syringe. Experience has shown that even large abscesses, such as
those associated with spinal disease, may be cured by iodoform
injection, and this even when rupture of the abscess on the skin surface
has appeared to be imminent.

Another method of treatment which is less popular now than it used to
be, and which is chiefly applicable in abscesses of moderate size, is by
_incision of the abscess and removal of the tuberculous tissue in its
wall_ with the sharp spoon. An incision is made which will give free
access to the interior of the abscess, so that outlying pockets or
recesses may not be overlooked. After removal of the pus, the wall of
the abscess is scraped with the Volkmann spoon or with Barker's flushing
spoon, to get rid of the tuberculous tissue with which it is lined. In
using the spoon, care must be taken that its sharp edge does not
perforate the wall of a vein or other important structure. Any debris
which may adhere to the walls is removed by rubbing with dry gauze. The
oozing of blood is arrested by packing the cavity for a few minutes with
gauze. After the packing is removed, iodoform powder is rubbed into the
raw surface. The soft parts divided by the incision are sutured in
layers so as to ensure primary union. If, on the other hand, there is
fear of a mixed infection, especially in abscesses near the rectum or
anus, it is safer to treat it by the open method, packing the cavity
with iodoform worsted or bismuth gauze, which is renewed at intervals of
a week or ten days as the cavity heals from the bottom.

Another method is to incise the abscess, cleanse the cavity with gauze,
irrigate with Carrel-Dakin solution and pack with gauze smeared with the
dilute non-toxic B.I.P.P. (bismuth and iodoform 2 parts, vaseline 12
parts, hard paraffin, sufficient to give the consistence of butter). The
wound is closed with "bipped" silk sutures; one of these--the "waiting
suture"--is left loose to permit of withdrawal of the gauze after
forty-eight hours; the waiting suture is then tied, and delayed primary
union is thus effected.

When the skin over the abscess is red, thin, and about to give way, as
is frequently the case when the abscess is situated in the subcutaneous
cellular tissue, any skin which is undermined and infected with tubercle
should be removed with the scissors at the same time that the abscess is
dealt with.

In abscesses treated by the open method, when the cavity has become
lined with healthy granulations, it may be closed by secondary suture,
or, if the granulating surface is flush with the skin, healing may be
hastened by skin-grafting.

If the tuberculous abscess has burst and left a _sinus_, this is apt to
persist because of the presence of tuberculous tissue in its wall, and
of superadded pyogenic infection, or because it serves as an avenue for
the escape of discharge from a focus of tubercle in a bone or a lymph
gland.

[Illustration: FIG. 35.--Tuberculous Sinus injected through its opening
in the forearm with bismuth paste.

(Mr. Pirie Watson's case--Radiogram by Dr. Hope Fowler.)]

The treatment varies with the conditions present, and must include
measures directed to the lesion from which the sinus has originated. The
extent and direction of any given sinus may be demonstrated by the use
of the probe, or, more accurately, by injecting the sinus with a paste
consisting of white vaseline containing 10 to 30 per cent. of bismuth
subcarbonate, and following its track with the X-rays (Fig. 35).

It was found by Beck of Chicago that the injection of bismuth paste is
frequently followed by healing of the sinus, and that, if one injection
fails to bring about a cure, repeating the injection every second day
may be successful. Some caution must be observed in this treatment, as
symptoms of poisoning have been observed to follow its use. If they
manifest themselves, an injection of warm olive oil should be given; the
oil, left in for twelve hours or so, forms an emulsion with the bismuth,
which can be withdrawn by aspiration. Iodoform suspended in glycerin may
be employed in a similar manner. When these and other non-operative
measures fail, and the whole track of the sinus is accessible, it should
be laid open, scraped, and packed with bismuth or iodoform gauze until
it heals from the bottom.

The _tuberculous ulcer_ is described in the chapter on ulcers.

CHAPTER IX

SYPHILIS

Definition.--Virus.--ACQUIRED SYPHILIS--Primary period:
_Incubation, primary chancre, glandular enlargement_;
_Extra-genital chancres_--Treatment--Secondary period: _General
symptoms, skin affections, mucous patches, affections of bones,
joints, eyes_, etc.--Treatment: _Salvarsan_--_Methods of
administering mercury_--Syphilis and marriage--Intermediate
stage--_Reminders_--Tertiary period: _General symptoms_,
_gummata_, _tertiary ulcers_, _tertiary lesions of skin, mucous
membrane, bones, joints_, etc.--Second attacks.--INHERITED
SYPHILIS--Transmission--_Clinical features in infancy, in later
life_--Contagiousness--Treatment.

Syphilis is an infective disease due to the entrance into the body of a
specific virus. It is nearly always communicated from one individual to
another by contact infection, the discharge from a syphilitic lesion
being the medium through which the virus is transmitted, and the seat of
inoculation is almost invariably a surface covered by squamous
epithelium. The disease was unknown in Europe before the year 1493, when
it was introduced into Spain by Columbus' crew, who were infected in
Haiti, where the disease had been endemic from time immemorial (Bloch).

The granulation tissue which forms as a result of the reaction of the
tissues to the presence of the virus is chiefly composed of lymphocytes
and plasma cells, along with an abundant new formation of capillary
blood vessels. Giant cells are not uncommon, but the endothelioid cells,
which are so marked a feature of tuberculous granulation tissue, are
practically absent.

When syphilis is communicated from one individual to another by contact
infection, the condition is spoken of as _acquired syphilis_, and the
first visible sign of the disease appears at the site of inoculation,
and is known as _the primary lesion_. Those who have thus acquired the
disease may transmit it to their offspring, who are then said to suffer
from _inherited syphilis_.

#The Virus of Syphilis.#--The cause of syphilis, whether acquired or
inherited, is the organism, described by Schaudinn and Hoffman, in 1905,
under the name of _spirochaeta pallida_ or _spironema pallidum_. It is a
delicate, thread-like spirilla, in length averaging from 8 to 10
[micron] and in width about 0.25 [micron], and is distinguished from
other spirochaetes by its delicate shape, its dead-white appearance,
together with its closely twisted spiral form, with numerous undulations
(10 to 26), which are perfectly regular, and are characteristic in that
they remain the same during rest and in active movement (Fig. 36). In a
fresh specimen, such as a scraping from a hard chancre suspended in a
little salt solution, it shows active movements. The organism is readily
destroyed by heat, and perishes in the absence of moisture. It has been
proved experimentally that it remains infective only up to six hours
after its removal from the body. Noguchi has succeeded in obtaining pure
cultures from the infected tissues of the rabbit.

[Illustration: FIG. 36.--Spirochaeta pallida from scraping of hard
Chancre of Prepuce. x 1000 diam. Burri method.]

The spirochaete may be recognised in films made by scraping the deeper
parts of the primary lesion, from papules on the skin, or from blisters
artificially raised on lesions of the skin or on the immediately
adjacent portion of healthy skin. It is readily found in the mucous
patches and condylomata of the secondary period. It is best stained by
Giemsa's method, and its recognition is greatly aided by the use of the
ultra-microscope.

The spirochaete has been demonstrated in every form of syphilitic lesion,
and has been isolated from the blood--with difficulty--and from lymph
withdrawn by a hollow needle from enlarged lymph glands. The saliva of
persons suffering from syphilitic lesions of the mouth also contains the
organism.

[Illustration: FIG. 37.--Spirochaeta refrigerans from scraping of Vagina.
x 1000 diam. Burri method.]

In tertiary lesions there is greater difficulty in demonstrating the
spirochaete, but small numbers have been found in the peripheral parts of
gummata and in the thickened patches in syphilitic disease of the aorta.
Noguchi and Moore have discovered the spirochaete in the brain in a
number of cases of general paralysis of the insane. The spirochaete may
persist in the body for a long time after infection; its presence has
been demonstrated as long as sixteen years after the original
acquisition of the disease.

In inherited syphilis the spirochaete is present in enormous numbers
throughout all the organs and fluids of the body.

Considerable interest attaches to the observations of Metchnikoff, Roux,
and Neisser, who have succeeded in conveying syphilis to the chimpanzee
and other members of the ape tribe, obtaining primary and secondary
lesions similar to those observed in man, and also containing the
spirochaete. In animals the disease has been transmitted by material from
all kinds of syphilitic lesions, including even the blood in the
secondary and tertiary stages of the disease. The primary lesion is in
the form of an indurated papule, in every respect resembling the
corresponding lesion in man, and associated with enlargement and
induration of the lymph glands. The primary lesion usually appears about
thirty days after inoculation, to be followed, in about half the cases,
by secondary manifestations, which are usually of a mild character; in
no instance has any tertiary lesion been observed. The severity of the
affection amongst apes would appear to be in proportion to the nearness
of the relationship of the animal to the human subject. The eye of the
rabbit is also susceptible to inoculation from syphilitic lesions; the
material in a finely divided state is introduced into the anterior
chamber of the eye.

Attempts to immunise against the disease have so far proved negative,
but Metchnikoff has shown that the inunction of the part inoculated with
an ointment containing 33 per cent. of calomel, within one hour of
infection, suffices to neutralise the virus in man, and up to eighteen
hours in monkeys. He recommends the adoption of this procedure in the
prophylaxis of syphilis.

Noguchi has made an emulsion of dead spirochaetes which he calls
_luetin_, and which gives a specific reaction resembling that of
tuberculin in tuberculosis, a papule or a pustule forming at the site of
the intra-dermal injection. It is said to be most efficacious in the
tertiary and latent forms of syphilis, which are precisely those forms
in which the diagnosis is surrounded with difficulties.

ACQUIRED SYPHILIS

In the vast majority of cases, infection takes place during the congress
of the sexes. Delicate, easily abraded surfaces are then brought into
contact, and the discharge from lesions containing the virus is placed
under favourable conditions for conveying the disease from one person to
the other. In the male the possibility of infection taking place is
increased if the virus is retained under cover of a long and tight
prepuce, and if there are abrasions on the surface with which it comes
in contact. The frequency with which infection takes place on the
genitals during sexual intercourse warrants syphilis being considered a
venereal disease, although there are other ways in which it may be
contracted.

Some of these imply direct contact--such, for example, as kissing, the
digital examination of syphilitic patients by doctors or nurses, or
infection of the surgeon's fingers while operating upon a syphilitic
patient. In suckling, a syphilitic wet nurse may infect a healthy
infant, or a syphilitic infant may infect a healthy wet nurse. In other
cases the infection is by indirect contact, the virus being conveyed
through the medium of articles contaminated by a syphilitic
patient--such, for example, as surgical instruments, tobacco pipes, wind
instruments, table utensils, towels, or underclothing. Physiological
secretions, such as saliva, milk, or tears, are not capable of
communicating the disease unless contaminated by discharge from a
syphilitic sore. While the saliva itself is innocuous, it can be, and
often is, contaminated by the discharge from mucous patches or other
syphilitic lesions in the mouth and throat, and is then a dangerous
medium of infection. Unless these extra-genital sources of infection are
borne in mind, there is a danger of failing to recognise the primary
lesion of syphilis in unusual positions, such as the lip, finger, or
nipple. When the disease is thus acquired by innocent transfer, it is
known as _syphilis insontium_.

#Stages or Periods of Syphilis.#--Following the teaching of Ricord, it
is customary to divide the life-history of syphilis into three periods
or stages, referred to, for convenience, as primary, secondary, and
tertiary. This division is to some extent arbitrary and artificial, as
the different stages overlap one another, and the lesions of one stage
merge insensibly into those of another. Wide variations are met with in
the manifestations of the secondary stage, and histologically there is
no valid distinction to be drawn between secondary and tertiary lesions.

_The primary period_ embraces the interval that elapses between the
initial infection and the first constitutional manifestations,--roughly,
from four to eight weeks,--and includes the period of incubation, the
development of the primary sore, and the enlargement of the nearest
lymph glands.

_The secondary period_ varies in duration from one to two years, during
which time the patient is liable to suffer from manifestations which are
for the most part superficial in character, affecting the skin and its
appendages, the mucous membranes, and the lymph glands.

_The tertiary period_ has no time-limit except that it follows upon the
secondary, so that during the remainder of his life the patient is
liable to suffer from manifestations which may affect the deeper tissues
and internal organs as well as the skin and mucous membranes.

#Primary Syphilis.#--_The period of incubation_ represents the interval
that elapses between the occurrence of infection and the appearance of
the primary lesion at the site of inoculation. Its limits may be stated
as varying from two to six weeks, with an average of from twenty-one to
twenty-eight days. While the disease is incubating, there is nothing to
show that infection has occurred.

_The Primary Lesion._--The incubation period having elapsed, there
appears at the site of inoculation a circumscribed area of infiltration
which represents the reaction of the tissues to the entrance of the
virus. The first appearance is that of a sharply defined papule, rarely
larger than a split pea. Its surface is at first smooth and shiny, but
as necrosis of the tissue elements takes place in the centre, it becomes
concave, and in many cases the epithelium is shed, and an ulcer is
formed. Such an ulcer has an elevated border, sharply cut edges, an
indurated base, and exudes a scanty serous discharge; its surface is at
first occupied by yellow necrosed tissue, but in time this is replaced
by smooth, pale-pink granulation tissue; finally, epithelium may spread
over the surface, and the ulcer heals. As a rule, the patient suffers
little discomfort, and may even be ignorant of the existence of the
lesion, unless, as a result of exposure to mechanical or septic
irritation, ulceration ensues, and the sore becomes painful and tender,
and yields a purulent discharge. The primary lesion may persist until
the secondary manifestations make their appearance, that is, for several
weeks.

It cannot be emphasised too strongly that the induration of the primary
lesion, which has obtained for it the name of "hard chancre," is its
most important characteristic. It is best appreciated when the sore is
grasped from side to side between the finger and thumb. The sensation on
grasping it has been aptly compared to that imparted by a nodule of
cartilage, or by a button felt through a layer of cloth. The evidence
obtained by touch is more valuable than that obtained by inspection, a
fact which is made use of in the recognition of _concealed
chancres_--that is, those which are hidden by a tight prepuce. The
induration is due not only to the dense packing of the connective-tissue
spaces with lymphocytes and plasma cells, but also to the formation of
new connective-tissue elements. It is most marked in chancres situated
in the furrow between the glans and the prepuce.

_In the male_, the primary lesion specially affects certain
_situations_, and the appearances vary with these: (1) On the inner
aspect of the prepuce, and in the fold between the prepuce and the
glans; in the latter situation the induration imparts a "collar-like"
rigidity to the prepuce, which is most apparent when it is rolled back
over the corona. (2) At the orifice of the prepuce the primary lesion
assumes the form of multiple linear ulcers or fissures, and as each of
these is attended with infiltration, the prepuce cannot be pulled
back--a condition known as _syphilitic phimosis_. (3) On the glans penis
the infiltration may be so superficial that it resembles a layer of
parchment, but if it invades the cavernous tissue there is a dense mass
of induration. (4) On the external aspect of the prepuce or on the skin
of the penis itself. (5) At either end of the torn fraenum, in the form
of a diamond-shaped ulcer raised above the surroundings. (6) In relation
to the meatus and canal of the urethra, in either of which situations
the swelling and induration may lead to narrowing of the urethra, so
that the urine is passed with pain and difficulty and in a minute
stream; stricture results only in the exceptional cases in which the
chancre has ulcerated and caused destruction of tissue. A chancre within
the orifice of the urethra is rare, and, being concealed from view, it
can only be recognised by the discharge from the meatus and by the
induration felt between the finger and thumb on palpating the urethra.

_In the female_, the primary lesion is not so typical or so easily
recognised as in men; it is usually met with on the labia; the
induration is rarely characteristic and does not last so long. The
primary lesion may take the form of condylomata. Indurated oedema, with
brownish-red or livid discoloration of one or both labia, is diagnostic
of syphilis.

The hard chancre is usually solitary, but sometimes there are two or
more; when there are several, they are individually smaller than the
solitary chancre.

It is the exception for a hard chancre to leave a visible scar, hence,
in examining patients with a doubtful history of syphilis, little
reliance can be placed on the presence or absence of a scar on the
genitals. When the primary lesion has taken the form of an open ulcer
with purulent discharge, or has sloughed, there is a permanent scar.

_Infection of the adjacent lymph glands_ is usually found to have taken
place by the time the primary lesion has acquired its characteristic
induration. Several of the glands along Poupart's ligament, on one or on
both sides, become enlarged, rounded, and indurated; they are usually
freely movable, and are rarely sensitive unless there is superadded
septic infection. The term _bullet-bubo_ has been applied to them, and
their presence is of great value in diagnosis. In a certain number of
cases, one of the main _lymph vessels_ on the dorsum of the penis is
transformed into a fibrous cord easily recognisable on palpation, and
when grasped between the fingers appears to be in size and consistence
not unlike the vas deferens.

_Concealed chancre_ is the term applied when one or more chancres are
situated within the sac of a prepuce which cannot be retracted. If the
induration is well marked, the chancre can be palpated through the
prepuce, and is tender on pressure. As under these conditions it is
impossible for the patient to keep the parts clean, septic infection
becomes a prominent feature, the prepuce is oedematous and inflamed, and
there is an abundant discharge of pus from its orifice. It occasionally
happens that the infection assumes a virulent character and causes
sloughing of the prepuce--a condition known as _phagedaena_. The
discharge is then foul and blood-stained, and the prepuce becomes of a
dusky red or purple colour, and may finally slough, exposing the glans.

_Extra-genital or Erratic Chancres_ (Fig. 38).--Erratic chancre is the
term applied by Jonathan Hutchinson to the primary lesion of syphilis
when it appears on parts of the body other than the genitals. It differs
in some respects from the hard chancre as met with on the penis; it is
usually larger, the induration is more diffused, and the enlarged glands
are softer and more sensitive. The glands in nearest relation to the
sore are those first affected, for example, the epitrochlear or axillary
glands in chancre of the finger; the submaxillary glands in chancre of
the lip or mouth; or the pre-auricular gland in chancre of the eyelid or
forehead. In consequence of their divergence from the typical chancre,
and of their being often met with in persons who, from age,
surroundings, or moral character, are unlikely subjects of venereal
disease, the true nature of erratic chancres is often overlooked until
the persistence of the lesion, its want of resemblance to anything else,
or the onset of constitutional symptoms, determines the diagnosis of
syphilis. A solitary, indolent sore occurring on the lip, eyelid,
finger, or nipple, which does not heal but tends to increase in size,
and is associated with induration and enlargement of the adjacent
glands, is most likely to be the primary lesion of syphilis.

[Illustration: FIG. 38.--Primary Lesion on Thumb, with Secondary
Eruption on Forearm.[1]]

[1] From _A System of Syphilis_, vol. ii., edited by D'Arcy Power and
J. Keogh Murphy, Oxford Medical Publications.

#The Soft Sore, Soft Chancre, or Chancroid.#--The differential diagnosis
of syphilis necessitates the consideration of the _soft sore_, _soft
chancre_, or _chancroid_, which is also a common form of venereal
disease, and is due to infection with a virulent pus-forming bacillus,
first described by Ducrey in 1889. Ducrey's bacillus occurs in the form
of minute oval rods measuring about 1.5 [micron] in length, which stain
readily with any basic aniline dye, but are quickly decolorised by
Gram's method. They are found mixed with other organisms in the purulent
discharge from the sore, and are chiefly arranged in small groups or in
short chains. Soft sores are always contracted by direct contact from
another individual, and the incubation period is a short one of from two
to five days. They are usually situated in the vicinity of the fraenum,
and, in women, about the labia minora or fourchette; they probably
originate in abrasions in these situations. They appear as pustules,
which are rapidly converted into small, acutely inflamed ulcers with
sharply cut, irregular margins, which bleed easily and yield an abundant
yellow purulent discharge. They are devoid of the induration of
syphilis, are painful, and nearly always multiple, reproducing
themselves in successive crops by auto-inoculation. Soft sores are often
complicated by phimosis and balanitis, and they frequently lead to
infection of the glands in the groin. The resulting bubo is ill-defined,
painful, and tender, and suppuration occurs in about one-fourth of the
cases. The overlying skin becomes adherent and red, and suppuration
takes place either in the form of separate foci in the interior of the
individual glands, or around them; in the latter case, on incision, the
glands are found lying bathed in pus. Ducrey's bacillus is found in pure
culture in the pus. Sometimes other pyogenic organisms are superadded.
After the bubo has been opened the wound may take on the characters of a
soft sore.