Page:EB1911 - Volume 27.djvu/1012

Rh always with the same result. But in the case of the Hunterian sore, inoculation of the individual from the primary sore gives no result, because, as explained below, the constitutional disease has rendered the individual proof against further infection. The soft sore is often multiple. It makes its appearance about three days after the exposure, and as it increases in size free suppuration takes place. It is often of about the size of a silver threepence. Its base remains soft. In individuals broken down in health, the ulceration is apt to extend with great rapidity, and is then spoken of as phagedaenic.

Just as an individual may contract syphilis and gonorrhoea at the same connexion, so also he may be inoculated simultaneously with the bacilli of the soft chancre and the spirochaete of syphilis. In this case the soft chancres may make their appearance, as usual, within the first three or four days, but though passing through the customary stages they may refuse quite to heal, or, having healed, they may become indurated in the second month, constitutional symptoms following in due course.

The virulence of soft sores being due to the presence of harmful germs, the surface of the sores should be touched with pure carbolic acid, which has the effect of destroying the germs and converting the sores into healthy ulcers. Or the chancres may be treated by the application of lint soaked in weak carbolic lotion. If the sore happens to be under a tight prepuce, and the germs are of great activity—as is apt to happen in such a case—ulceration may extend with extreme rapidity. It is advisable, therefore, to remove or to lay open the prepuce, in order that the sores may be effectively dealt with.

Bubo.—The bacilli from the soft sore are apt to find their way into the lymphatic vessels, and so to reach the glands in the groin, when they set up destructive inflammation. Under the influence of rest the inflammation may subside, but if it continues and suppuration threatens, the gland had better be laid open and scraped out. If a speck of the contents of the abscess be inoculated on to the skin, a soft chancre is again produced.

The cause of syphilis, whether inherited or acquired, is the presence in the blood and tissues of the same organism, which can be demonstrated in the various secondary lesions, in the blood and in the internal organs. The name of the germ is Spirochaeta, pallida; it is a protozoon of spiral form, from 4 to 20 in length and  in diameter, with a flagellum at either extremity. It possesses motility of three kinds—a lashing, a corkscrew and a to-and-fro movement. It stains pale pink with Giemsa’s fluid. At the time of writing (1910) it has not been found practicable to make an artificial cultivation of the spirochaete. But it may generally be found in primary and secondary syphilitic lesions by the aid of a in. oil-immersion lens—and abundant patience. The pale, spiral, hair-like germ is also found in children who inherit syphilis. Inoculations of the spirochaete in monkeys have produced the characteristic primary (Hunterian) sores, which have proved infective to other monkeys. And in the reproduced primary sores, as also in the secondary lesions following them, the same specific micro-organism has been demonstrated.

Syphilis is an infective fever, and its life-history may well be compared with that of vaccinia. A child is vaccinated on the arm with vaccine lymph—for two or three days nothing is observed; but on the fourth day redness appears, and by the eighth day a characteristic vaccine vesicle is formed, which bursts and sets free a discharge which dries into a scab. If on the eighth day the clear lymph in the vesicle is introduced at another point in the child’s skin, no characteristic local effect follows. The system is " protected " by the previous inoculation; this protection will last for some years, and perhaps for life. There is, then, exposure to a poison; its introduction locally; a period of incubation; a characteristic appearance at the seat of inoculation; a change in the constitution of the individual, and protection for a variable period. So with syphilis. The syphilitic poison is introduced at the seat of an abrasion either on the genital organs or on some other: part of the surface of the body. The poison lies quiescent for a variable period. The average period is four weeks. A cartilaginous, button-like hardness appears at the seat of inoculation. If this is irritated in any way, an ulceration takes place; but ulceration is an accident, not an essential. From the primary seat the system becomes infected. The virus, passing along the lymphatic vessels, attacks the nearest chain of lymphatic glands. If the original sore is in the genital organs, the glands in the groin are first attacked; if in the hand, the glands of the elbow or armpit; if on the lip, the glands below the jaw. The affected glands are indurated and painless; they may become inflamed, just as the primary lesion may, but the inflammation is an accident, not an essential. In due course the poison may affect the whole glandular system. The body generally is so altered that various skin eruptions, often symmetrical, break out. Any irritation of the mucous membrane is followed by superficial ulcerations, and in the later stages of the disease skin-eruptions, scaly, pimply, pustular or tuberculous in type, appear. These eruptions do not itch. The individual is as a general rule protected against a second attack of syphilis, although there have been rare cases recorded in which individuals have been attacked a second time. In weakly people, in severe cases, or in cases that have not been properly treated by the surgeon, syphilitic deposits termed gummata are formed, which are very apt to break down and give rise to deep ulcerations. Gummata may attack any part; the skin, muscles, liver and brain are the favourite, sites.

It by no means follows that because the infecting sore is small, unimportant or quickly healed, the attack, of which the sore is the first (primary) symptom, will be mild. The most serious train of symptoms may follow the healing of a primary sore which has been so unimportant as scarcely to have attracted the attention of the individual, or actually to have escaped notice. Indeed, it not infrequently happens that the most serious forms of secondary or tertiary symptoms succeed a sore which was regarded as of such trivial nature that the individual declined to submit himself to treatment, or quickly withdrew himself from it to enter a fool’s paradise. The advisability of ceasing from treatment should always be determined by the surgeon, never by the patient; mercurial treatment must be continued long after the disappearance of the secondary eruptions. It is the disease which the surgeon has to cure, not the symptoms. The patient is apt to think only of the symptoms.

“Is the disease curable?” This is the question constantly put by the patient on his coming for treatment. The answer is: “Yes; beyond doubt.” But the individual must be made to understand the necessity of his submitting himself trustfully and patiently to a prolonged course of treatment. A second question is as to whether, in the course of the disease, his hair will fall out, his body will be covered with sores and his face with blotches, and if his bones will be attacked. , Here, again, the answer will be that prompt submission to treatment will render all such calamities extremely improbable. Another question often put is as to whether the disease is contagious or infectious. Obviously, if a man has a primary sore or a secondary eruption upon the lip or tongue he should use his own glass, cup or spoon, and should refrain from kissing any one. If due care thus be taken no danger is likely to ensue.

The diagnosis of syphilis is often difficult. The first appearance of the: sore about four weeks after exposure to the risk of infectiqn, its hardness, the indolent enlargement of the associated lymphatic glands, and the occurrence of rash or of sore throat, are all helpful. But when the primary sore occurs on the finger, the face or, indeed, in any extra-genital region, it is apt to be lacking in the usual characteristics, and so the diagnosis may for a while be missed. In the case of doubt, the blood of the patient should be submitted tp the delicate test known as the Wassermann reaction.

The General Treatment of Syphilis.—It is impracticable to lay down a hard and fast line for the treatment of the disease, for no two individuals are exactly alike, neither does the disease follow a strict path in all cases. But experience has amply shown that in the early stages of the disease, mercury, at least for the present, is the only drug on which reliance can be placed. Guaiacum was at one time extensively used, and somehow or another sarsaparilla acquired a bubble reputation; but the practical surgeon of to-day ignores these drugs in the treatment of syphilis. Still, mercury must be prescribed with great judgment. For a man worn out by alcoholic or other excesses, or with health broken down by tuberculosis or other exhausting disease, mercury must be given with great caution. In times past, its feckless administration until profuse salivation was set up, or until the teeth fell out and the very jawbones became diseased, deservedly brought the mercurial treatment into disrepute. “Better the disease than the remedy,” said public opinion, and not without reason. But this miscarriage of treatment is absolutely a thing of the past. Before placing a patient under mercurial treatment it ought to be seen that there is no unwholesome condition of his gums, and that his teeth are put in a satisfactory state; unless this is done, the administration of small doses of mercury may have the effect of producing salivation, and, in consequence, a temporary cessation of the treatment. In any case the glims must be watched, and the treatment stopped if tenderness occurs.

There are several ways of giving mercury: (a) by the mouth; (b) by rubbing a mercurial ointment into the skin; (c) by injection into the muscles; (d) by inhalation of mercurial vapour. Inunction is especially suited for those whom mercury given by the mouth causes diarrhoea or other disturbance; in a private; house, however, it is found “dirty” and objectionable.

The fumigation-treatment is carried out by seating the naked man on a cane-bottomed chair and covering him over with a blanket; calomel being volatilized, its fumes are. carried under the blanket along with steam.

Treatment by intra-muscular injections is increasing in popularity, but in carrying it out, great care must be taken that no septic germs are introduced. The preparation of mercury is given in solution or mixed with oil, and is usually injected about once a week into the muscles of the buttock or loin. The “grey oil,” which is much used for injections, consists of finely divided metallic mercury in