Alexis Thomson and Alexander Miles - Manual of Surgery

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_Treatment._--Soft sores heal rapidly when kept clean. If concealed
under a tight prepuce, an incision should be made along the dorsum to
give access to the sores. They should be washed with eusol, and dusted
with a mixture of one part iodoform and two parts boracic or salicylic
acid, or, when the odour of iodoform is objected to, of equal parts of
boracic acid and carbonate of zinc. Immersion of the penis in a bath of
eusol for some hours daily is useful. The sore is then covered with a
piece of gauze kept in position by drawing the prepuce over it, or by a
few turns of a narrow bandage. Sublimed sulphur frequently rubbed into
the sore is recommended by C. H. Mills. If the sores spread in spite of
this, they should be painted with cocaine and then cauterised. When the
glands in the groin are infected, the patient must be confined to bed,
and a dressing impregnated with ichthyol and glycerin (10 per cent.)
applied; the repeated use of a suction bell is of great service.
Harrison recommends aspiration of a bubonic abscess, followed by
injection of 1 in 20 solution of tincture of iodine into the cavity;
this is in turn aspirated, and then 1 or 2 c.c. of the solution injected
and left in. This is repeated as often as the cavity refills. It is
sometimes necessary to let the pus out by one or more small incisions
and continue the use of the suction bell.

_Diagnosis of Primary Syphilis._--In cases in which there is a history
of an incubation period of from three to five weeks, when the sore is
indurated, persistent, and indolent, and attended with bullet-buboes in
the groin, the diagnosis of primary syphilis is not difficult. Owing,
however, to the great importance of instituting treatment at the
earliest possible stage of the infection, an effort should be made to
establish the diagnosis without delay by demonstrating the spirochaete.
Before any antiseptic is applied, the margin of the suspected sore is
rubbed with gauze, and the serum that exudes on pressure is collected
in a capillary tube and sent to a pathologist for microscopical
examination. A better specimen can sometimes be obtained by puncturing
an enlarged lymph gland with a hypodermic needle, injecting a few minims
of sterile saline solution and then aspirating the blood-stained fluid.

The Wassermann test must not be relied upon for diagnosis in the early
stage, as it does not appear until the disease has become generalised
and the secondary manifestations are about to begin. The practice of
waiting in doubtful cases before making a diagnosis until secondary
manifestations appear is to be condemned.

Extra-genital chancres, _e.g._ sores on the fingers of doctors or
nurses, are specially liable to be overlooked, if the possibility of
syphilis is not kept in mind.

It is important to bear in mind _the possibility of a patient having
acquired a mixed infection_ with the virus of soft chancre, which will
manifest itself a few days after infection, and the virus of syphilis,
which shows itself after an interval of several weeks. This occurrence
was formerly the source of much confusion in diagnosis, and it was
believed at one time that syphilis might result from soft sores, but it
is now established that syphilis does not follow upon soft sores unless
the virus of syphilis has been introduced at the same time. The
practitioner must be on his guard, therefore, when a patient asks his
advice concerning a venereal sore which has appeared within a few days
of exposure to infection. Such a patient is naturally anxious to know
whether he has contracted syphilis or not, but neither a positive nor a
negative answer can be given--unless the spirochaete can be identified.

Syphilis is also to be diagnosed from _epithelioma_, the common form of
cancer of the penis. It is especially in elderly patients with a tight
prepuce that the induration of syphilis is liable to be mistaken for
that associated with epithelioma. In difficult cases the prepuce must be
slit open.

Difficulty may occur in the diagnosis of primary syphilis from _herpes_,
as this may appear as late as ten days after connection; it commences as
a group of vesicles which soon burst and leave shallow ulcers with a
yellow floor; these disappear quickly on the use of an antiseptic
dusting powder.

Apprehensive patients who have committed sexual indiscretions are apt to
regard as syphilitic any lesion which happens to be located on the
penis--for example, acne pustules, eczema, psoriasis papules, boils,
balanitis, or venereal warts.

_The local treatment_ of the primary sore consists in attempting to
destroy the organisms _in situ_. An ointment made up of calomel 33
parts, lanoline 67 parts, and vaseline 10 parts (Metchnikoff's cream) is
rubbed into the sore several times a day. If the surface is unbroken, it
may be dusted lightly with a powder composed of equal parts of calomel
and carbonate of zinc. A gauze dressing is applied, and the penis and
scrotum should be supported against the abdominal wall by a triangular
handkerchief or bathing-drawers; if there is inflammatory oedema the
patient should be confined to bed.

In _concealed chancres_ with phimosis, the sac of the prepuce should be
slit up along the dorsum to admit of the ointment being applied. If
phagedaena occurs, the prepuce must be slit open along the dorsum, or if
sloughing, cut away, and the patient should have frequent sitz baths of
weak sublimate lotion. When the chancre is within the meatus, iodoform
bougies are inserted into the urethra, and the urine should be rendered
bland by drinking large quantities of fluid.

General treatment is considered on p. 149.

#Secondary Syphilis.#--The following description of secondary syphilis
is based on the average course of the disease in untreated cases. The
onset of constitutional symptoms occurs from six to twelve weeks after
infection, and the manifestations are the result of the entrance of the
virus into the general circulation, and its being carried to all parts
of the body. The period during which the patient is liable to suffer
from secondary symptoms ranges from six months to two years.

In some cases the general health is not disturbed; in others the patient
is feverish and out of sorts, losing appetite, becoming pale and anaemic,
complaining of lassitude, incapacity for exertion, headache, and pains
of a rheumatic type referred to the bones. There is a moderate degree of
leucocytosis, but the increase is due not to the polymorpho-nuclear
leucocytes but to lymphocytes. In isolated cases the temperature rises
to 101 or 102 F. and the patient loses flesh. The lymph glands,
particularly those along the posterior border of the sterno-mastoid,
become enlarged and slightly tender. The hair comes out, eruptions
appear on the skin and mucous membranes, and the patient may suffer from
sore throat and affections of the eyes. The local lesions are to be
regarded as being of the nature of reactions against accumulations of
the parasite, lymphocytes and plasma cells being the elements chiefly
concerned in the reactive process.

_Affections of the Skin_ are among the most constant manifestations. An
evanescent macular rash, not unlike that of measles--_roseola_--is the
first to appear, usually in from six to eight weeks from the date of
infection; it is widely diffused over the trunk, and the original dull
rose-colour soon fades, leaving brownish stains, which in time
disappear. It is usually followed by a _papular eruption_, the
individual papules being raised above the surface of the skin, smooth or
scaly, and as they are due to infiltration of the skin they are more
persistent than the roseoles. They vary in size and distribution, being
sometimes small, hard, polished, and closely aggregated like lichen,
sometimes as large as a shilling-piece, with an accumulation of scales
on the surface like that seen in psoriasis. The co-existence of scaly
papules and faded roseoles is very suggestive of syphilis.

Other types of eruption are less common, and are met with from the third
month onwards. A _pustular_ eruption, not unlike that of acne, is
sometimes a prominent feature, but is not characteristic of syphilis
unless it affects the scalp and forehead and is associated with the
remains of the papular eruption. The term _ecthyma_ is applied when the
pustules are of large size, and, after breaking on the surface, give
rise to superficial ulcers; the discharge from the ulcer often dries up
and forms a scab or crust which is continually added to from below as
the ulcer extends in area and depth. The term _rupia_ is applied when
the crusts are prominent, dark in colour, and conical in shape, roughly
resembling the shell of a limpet. If the crust is detached, a sharply
defined ulcer is exposed, and when this heals it leaves a scar which is
usually circular, thin, white, shining like satin, and the surrounding
skin is darkly pigmented; in the case of deep ulcers, the scar is
depressed and adherent (Fig. 39).

[Illustration: FIG. 39.--Syphilitic Rupia, showing the limpet-shaped
crusts or scabs.]

In the later stages there may occur a form of creeping or _spreading
ulceration of the skin_ of the face, groin, or scrotum, healing at one
edge and spreading at another like tuberculous lupus, but distinguished
from this by its more rapid progress and by the pigmentation of the
scar.

_Condylomata_ are more characteristic of syphilis than any other type of
skin lesion. They are papules occurring on those parts of the body where
the skin is habitually moist, and especially where two skin surfaces are
in contact. They are chiefly met with on the external genitals,
especially in women, around the anus, beneath large pendulous mammae,
between the toes, and at the angles of the mouth, and in these
situations their development is greatly favoured by neglect of
cleanliness. They present the appearance of well-defined circular or
ovoid areas in which the skin is thickened and raised above the surface;
they are covered with a white sodden epidermis, and furnish a scanty but
very infective discharge. Under the influence of irritation and want of
rest, as at the anus or at the angle of the mouth, they are apt to
become fissured and superficially ulcerated, and the discharge then
becomes abundant and may crust on the surface, forming yellow scabs. At
the angle of the mouth the condylomatous patches may spread to the
cheek, and when they ulcerate may leave fissure-like scars radiating
from the mouth--an appearance best seen in inherited syphilis (Fig. 44).

_The Appendages of the Skin._--The _hair_ loses its gloss, becomes dry
and brittle, and readily falls out, either as an exaggeration of the
normal shedding of the hair, or in scattered areas over the scalp
(_syphilitic alopoecia_). The hair is not re-formed in the scars which
result from ulcerated lesions of the scalp. The _nail-folds_
occasionally present a pustular eruption and superficial ulceration, to
which the name _syphilitic onychia_ has been applied; more commonly the
nails become brittle and ragged, and they may even be shed.

_The Mucous Membranes_, and especially those of the _mouth_ and
_throat_, suffer from lesions similar to those met with on the skin. On
a mucous surface the papular eruption assumes the form of _mucous
patches_, which are areas with a congested base covered with a thin
white film of sodden epithelium like wet tissue-paper. They are best
seen on the inner aspect of the cheeks, the soft palate, uvula, pillars
of the fauces, and tonsils. In addition to mucous patches, there may be
a number of small, _superficial, kidney-shaped ulcers_, especially along
the margins of the tongue and on the tonsils. In the absence of mucous
patches and ulcers, the sore throat may be characterised by a bluish
tinge of the inflamed mucous membrane and a thin film of shed epithelium
on the surface. Sometimes there is an elongated sinuous film which has
been likened to the track of a snail. In the _larynx_ the presence of
congestion, oedema, and mucous patches may be the cause of persistent
hoarseness. The _tongue_ often presents a combination of lesions,
including ulcers, patches where the papillae are absent, fissures, and
raised white papules resembling warts, especially towards the centre of
the dorsum. These lesions are specially apt to occur in those who smoke,
drink undiluted alcohol or spirits, or eat hot condiments to excess, or
who have irregular, sharp-cornered teeth. At a later period, and in
those who are broken down in health from intemperance or other cause,
the sore throat may take the form of rapidly spreading, penetrating
ulcers in the soft palate and pillars of the fauces, which may lead to
extensive destruction of tissue, with subsequent scars and deformity
highly characteristic of previous syphilis.

In the _Bones_, lesions occur which assume the clinical features of an
evanescent periostitis, the patient complaining of nocturnal pains over
the frontal bone, sternum, tibiae, and ulnae, and localised tenderness on
tapping over these bones.

In the _Joints_, a serous synovitis or hydrops may occur, chiefly in the
knee, on one or on both sides.

_The Affections of the Eyes_, although fortunately rare, are of great
importance because of the serious results which may follow if they are
not recognised and treated. _Iritis_ is the commonest of these, and may
occur in one or in both eyes, one after the other, from three to eight
months after infection. The patient complains of impairment of sight and
of frontal or supraorbital pain. The eye waters and is hypersensitive,
the iris is discoloured and reacts sluggishly to light, and there is a
zone of ciliary congestion around the cornea. The appearance of minute
white nodules or flakes of lymph at the margin of the pupil is
especially characteristic of syphilitic iritis. When adhesions have
formed between the iris and the structures in relation to it, the pupil
dilates irregularly under atropin. Although complete recovery is to be
expected under early and energetic treatment, if neglected, _iritis_ may
result in occlusion of the pupil and permanent impairment or loss of
sight.

The other lesions of the eye are much rarer, and can only be discovered
on ophthalmoscopic examination.

The virus of syphilis exerts a special influence upon the _Blood
Vessels_, exciting a proliferation of the endothelial lining which
results in narrowing of their lumen, _endarteritis_, and a perivascular
infiltration in the form of accumulations of plasma cells around the
vessels and in the lymphatics that accompany them.

In the _Brain_, in the later periods of secondary and in tertiary
syphilis, changes occur as a result of the narrowing of the lumen of the
arteries, or of their complete obliteration by thrombosis. By
interfering with the nutrition of those parts of the brain supplied by
the affected arteries, these lesions give rise to clinical features of
which severe headache and paralysis are the most prominent.

Affections of the _Spinal Cord_ are extremely rare, but paraplegia from
myelitis has been observed.

Lastly, attention must be directed to the remarkable variations observed
in different patients. Sometimes the virulent character of the disease
can only be accounted for by an idiosyncrasy of the patient.
Constitutional symptoms, particularly pyrexia and anaemia, are most often
met with in young women. Patients over forty years of age have greater
difficulty in overcoming the infection than younger adults. Malarial and
other infections, and the conditions attending life in tropical
countries, from the debility which they cause, tend to aggravate and
prolong the disease, which then assumes the characters of what has been
called _malignant syphilis_. All chronic ailments have a similar
influence, and alcoholic intemperance is universally regarded as a
serious aggravating factor.

_Diagnosis of Secondary Syphilis._--A routine examination should be made
of the parts of the body which are most often affected in this
disease--the scalp, mouth, throat, posterior cervical glands, and the
trunk, the patient being stripped and examined by daylight. Among the
_diagnostic features of the skin affections_ the following may be
mentioned: They are frequently, and sometimes to a marked degree,
symmetrical; more than one type of eruption--papules and pustules, for
example--are present at the same time; there is little itching; they are
at first a dull-red colour, but later present a brown pigmentation which
has been likened to the colour of raw ham; they exhibit a predilection
for those parts of the forehead and neck which are close to the roots of
the hair; they tend to pass off spontaneously; and they disappear
rapidly under treatment.

#Serum Diagnosis--Wassermann Reaction.#--Wassermann found that if an
extract of syphilitic liver rich in spirochaetes is mixed with the serum
from a syphilitic patient, a large amount of complement is fixed. The
application of the test is highly complicated and can only be carried
out by an expert pathologist. For the purpose he is supplied with from 5
c.c. to 10 c.c. of the patient's blood, withdrawn under aseptic
conditions from the median basilic vein by means of a serum syringe, and
transferred to a clean and dry glass tube. There is abundant evidence
that the Wassermann test is a reliable means of establishing a diagnosis
of syphilis.

A definitely positive reaction can usually be obtained between the
fifteenth and thirtieth day after the appearance of the primary lesion,
and as time goes on it becomes more marked. During the secondary period
the reaction is practically always positive. In the tertiary stage also
it is positive except in so far as it is modified by the results of
treatment. In para-syphilitic lesions such as general paralysis and
tabes a positive reaction is almost always present. In inherited
syphilis the reaction is positive in every case. A positive reaction may
be present in other diseases, for example, frambesia, trypanosomiasis,
and leprosy.

As the presence of the reaction is an evidence of the activity of the
spirochaetes, repeated applications of the test furnish a valuable means
of estimating the efficacy of treatment. The object aimed at is to
change a persistently positive reaction to a permanently negative one.

#Treatment of Syphilis.#--In the treatment of syphilis the two main
objects are to maintain the general health at the highest possible
standard, and to introduce into the system therapeutic agents which will
inhibit or destroy the invading parasite.

The second of these objects has been achieved by the researches of
Ehrlich, who, in conjunction with his pupil, Hata, has built up a
compound, the dihydrochloride of dioxydiamido-arseno-benzol, popularly
known as salvarsan or "606." Other preparations, such as kharsivan,
arseno-billon, and diarsenol, are chemically equivalent to salvarsan,
containing from 27 to 31 per cent. of arsenic, and are equally
efficient. The full dose is 0.6 grm. All these members of the "606"
group form an acid solution when dissolved in water, and must be
rendered alkaline before being injected. As subcutaneous and
intra-muscular injections cause considerable pain, and may cause
sloughing of the tissues, "606" preparations must be injected
intravenously. Ehrlich has devised a preparation--neo-salvarsan, or
"914," which is more easily prepared and forms a neutral solution. It
contains from 18 to 20 per cent. of arsenic. Neo-kharsivan,
novo-arseno-billon, and neo-diarsenol belong to the "914" group, the
full dosage of which is 0.9 grm. As subcutaneous and intra-muscular
injections of the "914" group are not painful, and even more efficient
than intravenous injections, the administration is simpler.

Galyl, luargol, and other preparations act in the same way as the "606"
and "914" groups.

The "606" preparations may be introduced into the veins by injection or
by means of an apparatus which allows the solution to flow in by
gravity. The left median basilic vein is selected, and a platino-iridium
needle with a short point and a bore larger than that of the ordinary
hypodermic syringe is used. The needle is passed for a few millimetres
along the vein, and the solution is then slowly introduced; before
withdrawing the needle some saline is run in to diminish the risk of
thrombosis.

The "914" preparations may be injected either into the subcutaneous
tissue of the buttock or into the substance of the gluteus muscle. The
part is then massaged for a few minutes, and the massage is repeated
daily for a few days.

No hard-and-fast rules can be laid down as to what constitutes a
complete course of treatment. Harrison recommends as a _minimum_ course
of one of the "914" preparations in _early primary cases_ an initial
dose of 0.45 grm. given intra-muscularly or into the deep subcutaneous
tissue; the same dose a week later; 0.6 grm. the following week; then
miss a week and give 9.6 grms. on two successive weeks; then miss two
weeks and give 0.6 grm. on two more successive weeks.

When a _positive Wassermann reaction_ is present before treatment is
commenced, the above course is prolonged as follows: for three weeks is
given a course of potassium iodide, after which four more weekly
injections of 0.6 grm. of "914" are given.

With each injection of "914" after the first, throughout the whole
course 1 grain of mercury is injected intra-muscularly.

In the course of a few hours, there is usually some indisposition, with
a feeling of chilliness and slight rise of temperature; these symptoms
pass off within twenty-four hours, and in a few days there is a decided
improvement of health. Three or four days after an intra-muscular
injection there may be pain and stiffness in the gluteal region.

These preparations are the most efficient therapeutic agents that have
yet been employed in the treatment of syphilis.

The manifestations of the disease disappear with remarkable rapidity.
Observations show that the spirochaetes lose their capacity for movement
within an hour or two of the administration, and usually disappear
altogether in from twenty-four to thirty-six hours. Wassermann's
reaction usually yields a negative result in from three weeks to two
months, but later may again become positive. Subsequent doses of the
arsenical preparation are therefore usually indicated, and should be
given in from 7 to 21 days according to the dose.

When syphilis occurs in a _pregnant woman_, she should be given in the
early months an ordinary course of "914," followed by 10-grain doses of
potassium iodide twice daily. The injections may be repeated two months
later, and during the remainder of the pregnancy 2-grain mercury pills
are given twice daily (A. Campbell). The presence of albumen in the
urine contra-indicates arsenical treatment.

It need scarcely be pointed out that the use of powerful drugs like
"606" and "914" is not free from risk; it may be mentioned that each
dose contains nearly three grains of arsenic. Before the administration
the patient must be overhauled; its administration is contra-indicated
in the presence of disease of the heart and blood vessels, especially a
combination of syphilitic aortitis and sclerosis of the coronary
arteries, with degeneration of the heart muscle; in affections of the
central nervous system, especially advanced paralysis, and in such
disturbances of metabolism as are associated with diabetes and Bright's
disease. Its use is not contra-indicated in any lesion of active
syphilis.

The administration is controlled by the systematic examination of the
urine for arsenic.

_The Administration of Mercury._--The success of the arsenical
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.