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

(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 glass, and has a solid glass 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 passage 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 massage of the
buttock 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 washing 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
labia, 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
scraped 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 arsenical 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 assume 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 instituted 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 mass (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 mass 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 circumscribed 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 participates, 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.

[Illustration: 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.

[Illustration: 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
rectum. 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 rectum 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.

[Illustration: 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 arsenical preparations and
the iodides of sodium and potassium. 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 potassium 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 scraping 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 arsenical 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
penis 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 foetus 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 foetus, 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
passages are obstructed by an accumulation 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).

[Illustration: 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 shining top and
of a reddish-brown colour. It affects chiefly the buttocks 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 anus 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 stomatitis 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
hoarse.

_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.

[Illustration: 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 associated 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 assume 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.

Occasionally a syphilitic child suffers from a succession of these
gummatous lesions with resulting ill-health, and, it may be, waxy
disease of the internal organs; on the other hand, it may recover and
present no further manifestations of the inherited taint.

_Affections of the Eyes._--At or near puberty there is frequently
observed an affection of the eyes, known as _chronic interstitial
keratitis_, the relationship of which to inherited syphilis was first
established by Hutchinson. It occurs between the ages of six and sixteen
years, and usually affects one eye before the other. It commences as a
diffuse haziness or steaminess near the centre of the cornea, and as it
spreads the entire cornea assumes the appearance of ground glass. The
chief complaint is of dimness of sight, which may almost amount to
blindness, but there is little pain or photophobia; a certain amount of
conjunctival and ciliary congestion is usually present, and there may be
_iritis_ in addition. The cornea, or parts of it, may become of a deep
pink or salmon colour from the formation in it of new blood vessels. The
affection may last for from eighteen months to two years. Complete
recovery usually takes place, but slight opacities, especially in the
site of former salmon patches, may persist, and the disease occasionally
relapses. _Choroiditis_ and _retinitis_ may also occur, and leave
permanent changes easily recognised on examination with the
ophthalmoscope.