Manual of Surgery Volume I Part 16

_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 quant.i.ty of saline solution is forced in by the syringe. The iodoform is injected by means of a gla.s.s-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 The cannula is withdrawn, the puncture is closed by a Michel's clip, and a dressing applied so as to exert a certain amount of compression.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 When the contents are semi-solid, and cannot be withdrawn even through a large cannula, an incision must be made, and, after the cavity has been emptied, the iodoform is introduced through a short rubber tube attached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 a.s.sociated 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 sc.r.a.ped 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 r.e.c.t.u.m or a.n.u.s, it is safer to treat it by the open method, packing the cavity with iodoform worsted or bis.m.u.th 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. (bis.m.u.th and iodoform 2 parts, vaseline 12 parts, hard paraffin, sufficient to give the consistence of b.u.t.ter). 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.

[Ill.u.s.tration: FIG. 35.--Tuberculous Sinus injected through its opening in the forearm with bis.m.u.th 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 bis.m.u.th subcarbonate, and following its track with the X-rays (Fig. 35).

It was found by Beck of Chicago that the injection of bis.m.u.th 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 bis.m.u.th, 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, sc.r.a.ped, and packed with bis.m.u.th 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 and in width about 0.25 , 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 sc.r.a.ping 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.

[Ill.u.s.tration: FIG. 36.--Spirochaeta pallida from sc.r.a.ping of hard Chancre of Prepuce. 1000 diam. Burri method.]

The spirochaete may be recognised in films made by sc.r.a.ping 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.

[Ill.u.s.tration: FIG. 37.--Spirochaeta refrigerans from sc.r.a.ping of v.a.g.i.n.a.

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 a.s.sociated 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 s.e.xes. 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 s.e.xual 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 const.i.tutional 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 circ.u.mscribed 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 b.u.t.ton 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 s.p.a.ces 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 a.s.sumes 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 p.e.n.i.s the infiltration may be so superficial that it resembles a layer of parchment, but if it invades the cavernous tissue there is a dense ma.s.s of induration. (4) On the external aspect of the prepuce or on the skin of the p.e.n.i.s 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 ca.n.a.l of the urethra, in either of which situations the swelling and induration may lead to narrowing of the urethra, so that the urine is pa.s.sed 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 l.a.b.i.a; the induration is rarely characteristic and does not last so long. The primary lesion may take the form of condylomata. Indurated dema, with brownish-red or livid discoloration of one or both l.a.b.i.a, 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 p.e.n.i.s 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 dematous and inflamed, and there is an abundant discharge of pus from its orifice. It occasionally happens that the infection a.s.sumes 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 p.e.n.i.s; 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 const.i.tutional 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 a.s.sociated with induration and enlargement of the adjacent glands, is most likely to be the primary lesion of syphilis.

[Ill.u.s.tration: 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.