Manual of Surgery by Alexis Thomson (golden son ebook .TXT) 📕

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, tibiæ, and ulnæ, 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 anæmia, 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 spirochætes 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 spirochætes, 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 spirochætes 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