_Senior Medical Student._
The bony manifestations of syphilis occur as secondary and tertiary
lesions, and as Keyes, of New York, has pointed out, these so-called
“nodes” are simply local periosteal congestions, accompanied by serious
effusions without cell hyperplesia. Any bone in the body may be affected
by syphilis, but certain of them suffer by preference, such as the thin
bones of the nose and pharynx—that is, those exposed to climatic changes
and injuries, such as the bones of the skull, ulna, tibia, etc.
We must call special attention to injury as a powerful pre-disposing
cause of bone syphilis, for, when we consider that bone lesions may be
the only manifestations of existing syphilis, with the presence of a
bone lesion before us, with an antecedent history of an injury, we must
not forget that we may overlook the true nature of the disease, and
hence must be constantly on the alert for the syphilitic taint.
Lancereaux classified the bone lesions under three heads, viz.:
(a) Inflammatory osteo-periostitis.
(b) Gummy tumor of bone.
(c) Dry caries, atrophic form.
(1) Inflammatory osteo-periostitis is the most frequent form, and is
characterized by inflammatory phenomena, vascularization and exudation
of a serio-glutinous material. It may be either diffuse or
circumscribed, and located, as its name implies, in the area of contact
with the osseous and periosteal surfaces. The pain is aching, acute,
throbbing or boring in character, while tenderness upon pressure and
percussion is most exquisitely excruciating. The diagnosis of
inflammatory osteo-periostitis is comparatively easy, if we remember the
characteristics, viz., an oval, painful, boggy or even hard bony lesion,
accompanied by nocturnal exacerbations of pain, with a concomitant or
antecedent history of syphilis. Ostitis with parenchymatous thickening
is somewhat less positive in its character, but with nocturnal pains
which are usually constant.
(2) Gummy tumor of bone develops either under the periostum, in the
substance of bone, or in the medullary canal. It is simply an
intensification of the process found in the inflammatory form just
described, the difference being that the cell hyperplasia is more
abundant. Much of the new material collects in a circumscribed space,
and being more rapidly formed and less capable of organization, it
entails more profound lesions by its retrograde metamorphosis. Generally
tumor of the bone is, therefore, a much more serious form of disease
than osteo-periostitis.
In the long bones the medullary canal is the usual seat of deposit. The
bone becomes hypertrophied in a porous manner, the Haversian canals and
canaliculi become enlarged and filled with a gummy material which
resembles a solution of gum arabic. In the flat bones, especially the
cranial bones, the cancellar tissue is attacked, and may cause a
separation of the two tables, and often necrosis of one or the other
plates results. If it happens to be the inner one which undergoes
carious degeneration, brain symptoms will develop.
(3) Dry Caries.—According to Virchow, dry caries is always due to
syphilis. This affection is a miniature gummy ostitis. Around one of the
vascular canals the gummy material is deposited, this gummy material
being later absorbed, leaving a stellate induration. This goes on
leaving a funnel-shaped depression, its point leading into the diploe,
which may be plainly appreciated by palpation. The essential features of
this caries is the fact that no sequestra are formed, no pus extruded,
nor is the skin but rarely involved.
The following is a case of syphilis in which osteo-periostitis
developed:
On January 22nd, 1909, R. B., age 35, white, a housewife, applied to the
Medical Department of the University Hospital Dispensary for treatment,
complaining of rheumatism in her back and a sore shin. The patient has
been married 14 years and has had four children; the two eldest are the
only ones now living. Three years ago she gave birth to a full-term
child which only lived a few minutes after expulsion.
One year later she gave birth to another child, which was not at full
term, but about six months advanced. She says two days previous to this
birth she fell down stairs and struck on her abdomen. When the child was
born its thigh was fractured, and the physician who attended her said
the fracture was caused by the fall.
Her father died nine years ago, at the age of 68 years, of apoplexy; her
mother was killed a few years ago in an accident. She has two brothers
and three sisters, all living and in good health, as far as she knows.
She is at present living with her husband, and says he is apparently
well and sound, but drinks heavily, and when under the influence of
liquor abuses her a great deal. Patient denies ever having had
tuberculosis, syphilis, diphtheria, typhoid, scarlet fever, malaria,
grippe, gonorrhoea, or any of the nervous or malignant diseases. She
sometimes has a sore throat when she takes cold, but it only lasts a few
days. She has complained of rheumatism in her back and limbs for the
past three or four years, and thinks it is worse at night.
Patient never complained of any trouble other than those mentioned until
three years ago, when her third child was born. She says that at that
time her hair fell out, and an eruption, which itched slightly, broke
out all over her body, including her face, but only extended down her
arms as far as her wrists. This lasted a few weeks, then seemed to
subside, but never entirely disappeared, and when she gave birth to the
still-born child, one year later, it broke out again worse than before.
She went to Dr. McElfresh, who treated her for about three weeks, giving
her some medicine to take internally, also some sulphur ointment. She
for a time got some better, but owing to her circumstances was unable to
continue treatment with Dr. McElfresh, and has done nothing for her
condition until the present time. For the past four months she has been
suffering with a pain in her right shin; this has been gradually getting
worse, and one week ago began to swell and cause her considerable pain,
being worse at night, and sometimes hurting her so much that she is
unable to sleep, hence her reason for coming to the dispensary.
Upon questioning her in regard to her general health, she says she feels
as well as she ever did, with the exception of the previously mentioned
pain.
Her appetite and digestion are good, and her bowels are regular, and she
has no lung, heart or kidney trouble. She has had no headaches, nausea,
or vomiting, and her menstrual periods have always been regular and
painless.
Upon examining patient I found her to be well nourished and well
developed, weighing 142 pounds. Her color was good and her pupils about
normal in size, reacting to light and accommodation. Both patella
reflexes were absent, also Romberg's sign, and there was no enlargement
of the mastoid, epitrochlear, post-cervical or inguinal glands. Her
pulse was 84 to the minute, regular in rate and force. The tension and
volume was good; her temperature was 98.6°. Her heart was normal in
size, and on auscultation the sounds were clear and no murmurs were
heard. The expansion of both lungs was good, the respirations being 20
to the minute.
Percussion and auscultation were negative; all the abdominal organs
seemed to be normal. There was an ecchymotic area under her left eye,
which she says was caused by her husband striking her two years ago when
intoxicated.
There was a circular reddish macular papular, non-itching eruption which
does not disappear on pressure, varying from the size of a bird shot to
that of a nickel, and is confined to her back, chest, shoulders and
arms, most profuse on the left side, and is not seen on the lower limbs
at all. On her left shoulder some of these lesions have developed into
pustules, which have become infected and slightly ulcerated; these give
her slight pain.
In the corner of her mouth is a scar which looks like the initial sign
of lues, but she claims it appeared a few weeks after the breaking out
on her body. On examining her mouth no mucus patches or scars were
found.
She now has an osteo-periostitis on the anterior aspect of her right
tibia. It is moderately swollen, slightly reddened, and is very painful
(the pain is aching, acute and boring in character) on pressure, and on
tapping the bone with my finger above and below this point it caused her
intense pain. (Patient claims she has never received any injury in this
location.)
Upon consulting Dr. McElfresh, he remembered the case and said that he
had treated her for a short time about two years ago for the initial
symptoms of syphilis, but since then has never seen her.
She is now receiving the mixed treatment of protiodid of mercury, gr. ¼,
with a saturated solution of potassium iodid three times a day, starting
her on ten drops, then increasing it one drop each time taken. I
requested her to return when the medicine is finished.
DISCUSSION BY DR. WARNER HOLT, OF WASHINGTON, OF THE PAPER ON THE
CHEMICAL CO-RELATION BETWEEN THE SALIVARY GLANDS AND THE STOMACH,
BY JOHN C. HEMMETER, OF BALTIMORE.
_Read Before the Society for Experimental Biology and Medicine, of
New York, Meeting in the Rockefeller Institute for Medical
Research, on December 16, 1908._
Dr. Holt said in part: “This experimental study by Dr. Hemmeter is not,
as it might appear to be, only an inquiry into the physiology of a
limited part of the digestive apparatus, but it is an attempt to solve a
biologic problem and to get at the broad basic principles that underlie
the chemical co-relation of the organs.
“When a worker occupies himself with the effect of the extirpation of
one organ of digestion upon the organs in the next segment of the
digestive apparatus, he naturally thinks of phenomena of exclusion or
loss of function in one or the other of the segments following the one
extirpated, but instead of phenomena of exclusion it is conceivable that
those of exaggerated activity in the other segments of the digestive
tube might result.
“For '_a priori_' we cannot know whether the influence that one segment
of the digestive tract exerts upon the succeeding segment is that of
stimulation or of inhibition, or of both, viz., of stimulation under one
set of conditions and inhibition under another set of conditions. In the
investigation of the problem of a chemical co-relation between the
salivary glands and the stomach, Dr. Hemmeter has done meritorious work,
a great part of which it has been my good fortune to observe and assist
in personally; though I am a physician in the employment of the
government at Washington, I consider myself a post-graduate student of
Professor Hemmeter. I have seen personally four of his animals that had
successfully been nursed through the Pawlow operation and extirpation of
the salivary glands after months of the most trying work. It required a
great deal of perseverance to persist in this kind of work, especially
when some of the best animals that had emerged safely from the
vicissitudes of the operation for an accessory stomach and from the
removal of all the salivary glands on one side of the head succumbed to
the third operation in the attempt to remove the remaining salivary
glands on the other side.
“The history of these operative failures, though they will never be
told, constitute a large part of the merit of those who have worked with
Dr. Hemmeter in this research. No matter what the final outcome of the
future investigation of this problem will be, whether affirmative or
negative, the intrinsic value of such work will be appreciated by all
who are to the least degree conversant with the history of physiology.
Nowadays we are too liable to forget the hard plodders in experimental
work who have started the solution of a problem, and when the last word
has been said the worker of the beginning is generally forgotten.
“In this connection I desire to quote an expression of Prof. William H.
Welch concerning the merit of the work of ex-Surgeon General Sternberg,
done since the first Yellow Fever Commission was appointed, in 1879 (see
Medical News. June 21, 1902. p. 1198). Dr. Welch said 'that Sternberg's
work with yellow fever would stand forever; that it was a common thing
in these busy days to forget the steps which led up to an important
discovery. All that Dr. Sternberg had done in the study of yellow fever
was necessary work, and it had to be done just in the way that he did
it. The ground had first to be cleared. If it were not so, the discovery
had not been possible; and later discoverers themselves would have had
to hunt out the large host of microorganisms which Dr. Sternberg had
described and laid aside.'
“And similarly I can say of Dr. Hemmeter's efforts that, no matter what
the eventual outcome of this problem will be, all that he has done was
necessary work, and it had to be done just in the way that he did it.
“Just one more idea and I shall have finished. It concerns the
demonstration of such research work in places at a distance from the
experimentor's laboratory. Such demonstrations are always attended with
great difficulty. They usually require four animals, two or three
janitors to transport them, and as many laboratory assistants as the
director of the laboratory can manage to take with him. The technique of
these operations, the high-grade sensitiveness of operated animals, the
refinement with which chemical tests should be made, all require for
their safe conduct that the experimentor should work only with those men
who are used to his system. The animals themselves are always influenced
in one way or other by the presence of strangers. I remember in one
animal which was demonstrated on March 17th, at the University Hospital,
the demonstration at which Dr. Satterthwaite was present, a most
unexpected change in the quality of the gastric secretions took place.
This was a control animal which had undergone no operation whatever. He
was simply taken along to show the proteolytic power of a normal dog and
compare it with the operated dogs. His gastric juice had been previously
tested on several occasions, and always found to be of regular standard,
but on the night of the demonstration before the Medical Society this
animal's gastric juice was practically inactive, containing no HCL nor
pepsin.
“Dr. Hemmeter has already informed you that in some animals the loss of
gastric juice after extirpation of the salivary glands is only
temporary, and that in varying time—in some cases three weeks, in other
animals three to four months—there is a gradual resumption of gastric
secretion. This resumed secretion, however, never becomes as effective
as it was in the same dog before an operation. The question when to
begin to make observations on an operated animal depends entirely upon
the state of this animal; if the dog eats his food with appetite, he has
no fever, and his digestion appears to be satisfactory; then the
observations may be begun, even if it is only one week or ten days after
the last operation. One of the most valuable animals that was used in
this series of experiments was so injured in the effort to transport him
to another laboratory that he could not be used for further
experimentation. The dog struggled so in his holder while he was being
transported in a wagon that the partition of true mucosa which separates
the accessory from the plain stomach was broken through. This had
happened once before in transporting a dog from the laboratory to Dr.
Hemmeter's country place, and his associates in the Medical Faculty,
becoming aware of the great labor and cost involved in such operations,
and the rarity with which they succeed, advised that no further Pawlow
dogs be sent to other laboratories.”