Manual of Surgery Volume I Part 17

#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 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 l.a.b.i.a 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.

_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 p.e.n.i.s 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 inst.i.tuting 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 Wa.s.sermann 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 pract.i.tioner 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 p.e.n.i.s. It is especially in elderly patients with a tight prepuce that the induration of syphilis is liable to be mistaken for that a.s.sociated 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 s.e.xual indiscretions are apt to regard as syphilitic any lesion which happens to be located on the p.e.n.i.s--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 p.e.n.i.s and s.c.r.o.t.u.m should be supported against the abdominal wall by a triangular handkerchief or bathing-drawers; if there is inflammatory dema 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 quant.i.ties 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 const.i.tutional 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 appet.i.te, becoming pale and anaemic, complaining of la.s.situde, 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 acc.u.mulations 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 acc.u.mulation 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 a.s.sociated 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 sh.e.l.l 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).

[Ill.u.s.tration: 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 s.c.r.o.t.u.m, 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 a.n.u.s, 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 a.n.u.s 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 alopcia_). 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 a.s.sumes 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, dema, and mucous patches may be the cause of persistent hoa.r.s.eness. 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 a.s.sume the clinical features of an evanescent periost.i.tis, 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 acc.u.mulations 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.

Const.i.tutional 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 a.s.sumes 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 pa.s.s off spontaneously; and they disappear rapidly under treatment.

#Serum Diagnosis--Wa.s.sermann Reaction.#--Wa.s.sermann 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 gla.s.s tube. There is abundant evidence that the Wa.s.sermann 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-a.r.s.eno-benzol, popularly known as salvarsan or "606." Other preparations, such as kharsivan, a.r.s.eno-billon, and dia.r.s.enol, are chemically equivalent to salvarsan, containing from 27 to 31 per cent. of a.r.s.enic, 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 a.r.s.enic. Neo-kharsivan, novo-a.r.s.eno-billon, and neo-dia.r.s.enol 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 pa.s.sed 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 b.u.t.tock or into the substance of the gluteus muscle. The part is then ma.s.saged for a few minutes, and the ma.s.sage is repeated daily for a few days.

No hard-and-fast rules can be laid down as to what const.i.tutes 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 Wa.s.sermann reaction_ is present before treatment is commenced, the above course is prolonged as follows: for three weeks is given a course of pota.s.sium 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 pa.s.s 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. Wa.s.sermann's reaction usually yields a negative result in from three weeks to two months, but later may again become positive. Subsequent doses of the a.r.s.enical 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 pota.s.sium 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 alb.u.men in the urine contra-indicates a.r.s.enical 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 a.r.s.enic. 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 aort.i.tis 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 a.s.sociated with diabetes and Bright's disease. Its use is not contra-indicated in any lesion of active syphilis.