In _man_ the disease occurs usually as the so-called _malignant

pustule_, or _woolsorters’ disease_, the latter name being given

because of the liability of those individuals who come in contact

with the carcasses and hides of diseased animals or their immediate

products. The _period of incubation is brief_--on the average two

or three days. The first lesion appears usually on the face, hands,

or arms, and is characterized by local discomfort with formation

of a small papule, which rapidly becomes a vesicle with an areola

of cellulitis about it. This is rapidly followed by induration and

infiltration, and these by local gangrene, the result being the

separation of a core-like mass, similar to that of carbuncle. The

affected area is usually discolored, often quite black. The process

is not usually accompanied by suppuration, nor is there the pain of

true carbuncle. The lesions tend to spread peripherally, but there is

more or less vesication of the surrounding skin. On account of the

local ischemia there will always be edema of the affected region,

and sometimes the swelling and local disturbance become extreme.

These peculiar lesions have given rise to the common name _malignant

pustule_, which is well deserved. At last a line of demarcation becomes

manifest, and if the disease progresses favorably the included area

is sloughed out, leaving a surface which it is hoped will soon become

covered with reasonably healthy granulations.

Absence of pain, and usually of pus, are significant features of

anthrax. Should mixed infection occur, however, we are likely to see

pus formation. When the disease partakes less of the characteristics of

malignant pustule and more of a general infection, the local symptoms

may not predominate, but, on the contrary, septic indications may

become serious and even fatal. The evidence of more or less toxemia

is usually at hand, however, and the toxin of anthrax is almost as

destructive of muscle cell integrity as is that of diphtheria.

The local lesions may be single or multiple, but will be met with

almost always upon exposed areas of the body.

=Postmortem Appearances.=--These will depend upon the clinical course

of the disease. In the sloughing tissues the bacilli are very numerous,

while around the margin more than one bacterial form will probably be

met--_i. e._, mixed infection. Should saprophytic organisms complicate

the case, they may have replaced the anthrax bacilli by the time the

examination is made. The latter abound, however, in the blood, and

may usually be found occluding the capillaries of the liver, spleen,

kidney, etc. In intestinal infection, particularly in animals, the

mesenteric nodes are involved. Inasmuch as septic features accompany

all fatal cases, putrefaction will be found to begin early, and the

changes in the blood and the gross changes in the other organs will

resemble sepsis rather than anthrax.

=Prognosis.=--Prognosis for man is not usually unfavorable, the

majority of cases recovering with more or less local destruction of

tissue. Should, however, infection become generalized, the case will

probably terminate fatally. Cases assuming the type of splenic fever

are of much more serious character, and their prognosis graver.

=Treatment.=--This should be both local and constitutional. The

former should consist of the most radical possible attack and include

complete excision of the infected area, with the use of active caustics

or the actual cautery. In fact, the latter instrument offers a most

valuable means for combating the destructive tendency of the disease.

Sloughing and separation of the cauterized mass may be hastened by

warm antiseptic poultices. Subcutaneous injections of 5 per cent.

carbolic solution have been given, with apparent benefit, in a number

of cases, but should only be relied upon in the treatment of the milder

manifestations.

Benefit will accrue from the use of the ichthyol-mercurial ointment

whose formula was given under treatment of Erysipelas. It has been

suggested to treat these cases by the employment of the bacillus

pyocyaneus, since it is known that this organism when injected with the

anthrax bacillus materially attenuates its effect.

=Prophylaxis.=--Prophylaxis is most important. The bodies of all

infected animals should be burned, not buried, since the resistant

bacilli are often brought to the surface of the soil by earth-worms.

Every discoverable source or medium of infection should be destroyed or

sterilized.

MALIGNANT EDEMA.

This disease has been recognized for some time, mainly by French

and Continental clinicians, and under such names as _gangrène

foudroyante_, _gangrène gazeuse_, _gangrenous septicemia_, and

_gangrenous emphysema_. The name _malignant edema_ was given by Koch,

who identified the infecting organism. It is one of the most dangerous

forms of gangrenous inflammation, and occurs sometimes after serious

injuries, and, again, after most trifling lesions, such as those

inflicted by the dirty pointed implements of the gardener, etc., or

even the stings of insects. Two cases are on record where the disease

followed a puncture of the hypodermic needle for the administration of

morphine. In one of these the organism was found in the solution; in

the other it probably had been deposited upon the skin.

Malignant edema is essentially a specific form of _gangrene_ (see

Chapter V), and is mentioned here rather because of its specific

character. It is characterized by rapidity of spread and the specific

nature of the exudate, as well as by the speedy destruction of the

tissue involved, and by more or less gas formation. It is not the

same as the gaseous phlegmons described by some German surgeons, yet

partakes of their general character. _Gas phlegmons_ have been rarely

noted, their peculiarity being formation not only of pus, but of more

or less offensive gases, which escape when the phlegmon is incised.

The gases are mainly due to the presence of _bacillus aërogenes

capsulatus_, and gas phlegmons, as such, are to be regarded as

instances of mixed or rarely pure infection.

Malignant edema is known by the brownish discoloration of the overlying

skin, which is streaked with blue where the overfilled veins show

through it, while the underlying tissues are sodden with fluid and

more or less inflated by the gaseous products of decomposition, so

that the finger detects a firm crepitus, as is common in subcutaneous

emphysema. From the wound, if there is one, flows a thin, foul-smelling

secretion, which may also be expressed from the deeper layers. That the

neighboring lymph spaces and nodes are actively involved is evident

from the enormous swelling of the latter, as well as from the general

condition of the patient. The rapid elevation of temperature with

but trifling remissions remains constant until shortly before death.

The tongue early becomes dry and cleaves to the palate, its surface

being covered with a thick, foul fur. Patients early become apathetic,

complaining only of pain and burning thirst. Delirium and coma usually

precede death, which may occur in fifteen to thirty hours. After death

the cadaver bloats quickly and putrefaction goes on with amazing

rapidity.

=Postmortem Appearances.=--At the seat of the lesion even muscles

and tendons will be found macerated, bone denuded and surrounded by

a putrid fluid, the entire region presenting a notable swelling and

infiltration of soft parts with reddish fluids and stinking gases. The

overlying skin will be stretched, and superficial blisters may deepen

the intensity of the process. The veins are clogged with decomposed

blood and broken-down thrombi, and in the heart and large vessels will

be found putrid liquid as well as gas, to whose presence early and

sudden death is probably due.

=Prognosis.=--This is unsatisfactory, especially when the bacillus

of malignant edema is alone at fault. Patients may escape with their

lives, but always at the expense of more or less tissue destruction.

=Treatment.=--This should consist of extensive incision to permit

escape of fluids and gases and relieve tension; of such antiseptic

applications as can be made available; of immersion of the affected

part in a hot antiseptic bath; and of such vigorous stimulation by the

most powerful measures--strychnine, alcohol, etc.--in order to support

the patient through the period of profound depression characteristic of

the disease.

[Illustration: PLATE V

Actinomycosis. Ray Fungus in Man. (Gaylord.)]

ACTINOMYCOSIS.

This also is a _subacute_ but always _destructive infection by a

specific microörganism, though not a bacterium_. Known always as

_actinomycosis_ in man, the disease, which is most common in cattle,

is called _lumpy jaw_ or _swelled head_, and years ago was usually

regarded as cancer or as a malignant affection.

Many museum specimens labelled as cancer of the tongue, jaw, etc.,

have been shown to be instances of actinomycosis of these parts. It

is occasionally met with in man, so that there are at least four

hundred cases on record in this country and in Europe. The organism

was recognized a half-century ago by Langenbeck and Lebert, but was

not scientifically described until many years later. The names of

Bollinger, Israel, and Ponfick will always be connected with these

researches.

The organism belongs among the _ray fungi_, is known as the

_actinomycis_, and occupies an uncertain place in classification.

It is large enough, when entire, to be perceived by the naked eye,

has ordinarily a yellowish tint, a tallowy consistence, and may

be seen under the microscope to consist of a cluster of branching

prolongations, club-shaped at the end, radiating from a common centre.

They give it a sunflower appearance. It is stained with difficulty,

the best stain being a combination of picrocarmine and an aniline dye.

In tissue sections the Gram stain is the best. It is cultivated with

difficulty, but can be grown upon solid media and may be inoculated.

(See Plate V.)

As met with in tissue or in pus these fungi constitute small

granulations, giving usually a gritty sensation to the finger, which

is due to the presence of calcium salts. The recognition of this

calcareous material is of importance, since it may enable a diagnosis

to be made offhand, in a case which otherwise might puzzle one.

The disease is very common among cattle in certain regions, and causes

the condemnation of many animals in every large stockyard establishment

where inspection is careful and scientific. It occurs oftener in

young than in old animals, and most frequently in those which come

from valley regions and marshes. In animals infection occurs almost

invariably through the mouth, which is easily explained by the fact

that, in grazing, the lips, tongue, and gums are likely to be irritated

and infected at any time from soil containing these fungi along with

growing grain. The path of infection is usually by the mouth, while

accident seems to determine whether the infection shall manifest itself

mainly in the intestinal canal or the respiratory tract. In animals

there is less tendency to suppuration than in man, the infection in man

being usually a mixed one. The name _lumpy jaw_, so generally given

to the affection, is indicative of the most conspicuous lesion in

cattle, for the organism, having once invaded the gum, for instance,

passes quickly to the bone, or, having involved the tongue, is not

slow to infect the lymphatics of that region. In consequence we have

tumors, often of inordinate size, which may involve the bones or the

soft parts and cause great disfigurement, along with necrosis, leading

eventually to the death of the animal. These tumors are essentially

_granulation tumors_ due to the presence of a specific irritant--the

_actinomycis_--which acts here as do the tubercle bacillus, the lepra

bacillus, etc., in other infectious granulomata.

In man the disease is generally accompanied by abscess formation,

the pus containing the distinctive yellow gritty particles which are

found in no other disease. The strong resemblance between the lymphoid

cells of this form of granuloma and the embryonal cells of sarcoma has

permitted the perpetuation of confusion between these two neoplasms.

[Illustration: FIG. 19

Actinomycosis in man. (Lexer.)]

Large abscesses form as the result of the coalescence of small ones,

and by the time the disease is recognized extensive destruction and

loss of substance may have taken place. In man it is not alone about

the mouth that the disease is noted, although primary lesion here is

by no means infrequent. It leads to affections similar to that already

spoken of in cattle, with a progressive infiltration and breaking down,

including actual necrosis of bone, etc. The pus will escape at various

points, and may give to the surface an appearance as of many craters

with a central cause. When the disease has involved the lung, either

directly or indirectly, the fungi and the calcareous particles may be

found in the sputum. Should there be suspicion of this involvement, the

sputum should always be examined. Even in the heart substance tumors of

this same character have been found. The first case noted in man had

undergone extensive vertebral caries. Intestinal infection is possible,

in which case multiple lesions will form in the intestinal walls,

which may contract adhesions to the abdominal parietes and discharge

externally through them. The appendix has been found involved in such

lesions. Infection of the skin has also been described, though this

occurs more rarely.

=Diagnosis.=--Actinomycotic lesions have been _mistaken for cancer_,

_sarcoma_, _tuberculosis_, _syphilis_, etc. In man it will always

be characterized by more or less suppuration, and in the purulent

discharge from the infected focus the yellow calcareous particles

should enable recognition of this disease at once.

=Prognosis.=--As long as the focus is accessible it is a purely local

matter, and prognosis is as favorable as in local tuberculosis; but,

inasmuch as in many cases infection has proceeded to a point where

the surgeon cannot safely follow it, prognosis must be guarded.

Actinomycosis is free from acute manifestations, for the main part free

from pain, pursues a chronic course, and is characterized, as are the

other slow infections, by progressive emaciation, prostration, etc. As

it is essentially a chronic condition, time is afforded for careful

study in doubtful cases, for microscopic examination, etc.

=Treatment.=--This must consist of extirpation of all infected tissues

and areas. If this can be done thoroughly there is a prospect of

positive cure. Free incision, wide dissection, the use of the actual

cautery, etc., are always called for in these cases. If it involves

the tongue alone, there is an excellent prospect; if but a portion of

the jaw is involved, a complete excision of one-half or more may be

followed by excellent results. If, however, the lung, liver, vertebrae,

or other vital and inaccessible parts are involved, surgical measures

may afford amelioration, but can hardly be expected to cure.

Iodine, alone or in combination, has been found efficacious in the

therapy of actinomycosis. In diluted solutions used locally, or as

potassium iodide given internally or injected into tumors, it doubtless

has a beneficial effect during the period of its administration.

Recent reports and experiences show that great value attaches to the

use, as suggested by Bevan, of copper sulphate in the treatment of

actinomycosis, its use having been suggested by the fact that copper

is used to destroy rusts (fungi) on grain. One-half grain (3 Cg.) may

be given internally three times a day, while the sinuses are irrigated

with a 1 per cent. solution. I have seen apparently complete cure of

an aggravated case follow its use. Incidentally it may be stated that

Bevan advises its use also in cases of blastomycosis.

MADURA FOOT.

While _madura foot_ is not a disease from which domestic animals

suffer, its general characteristics make it a proper subject for

brief consideration. It is essentially a disease of the tropics and

subtropics, and is often seen in some of our new possessions.

It commences as a painless swelling upon either aspect of the foot, in

which hard nodules form, which later soften, ulcerate, and discharge

puruloid material containing granules in which the microscope reveals

mycelia of the peculiar fungus that produces the disease. In some cases

these particles are black, in others colorless. The disease is of slow

progress, and the lower limbs become weak, atrophied, and finally

useless Death results from exhaustion or some terminal infection.

The principal lesion is the slowly growing gumma or granuloma, whose

presence is unmistakable. This is due to the presence of a fungus,

called by Vincent the _streptothrix maduræ_. Thus in its pathology the

disease much resembles actinomycosis. The habitually bare feet of most

of the inhabitants of the tropics and the habitat of the fungus explain

the site of the primary lesion.

=Treatment.=--The only _treatment_ is extirpation of the growth--_i.

e._, amputation.

[Illustration: PLATE VI

Tuberculosis of Testicle.

Miliary Tubercle with Caseation and Giant Cells. (Gaylord and Aschoff.)

_a_, seminal tubules; _b_, giant cells; _c_, caseated tubercles.]

CHAPTER IX.

SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC ANIMALS (CONTINUED).

TUBERCULOSIS.

The most important and frequent of the infectious diseases common to

animals and man is _tuberculosis_. This appears usually as a subacute

or chronic affection, although in a small proportion of cases it

assumes an acuteness of type which may make it fatal within as short

a time as fourteen or fifteen days, or even less, from the first

recognizable symptom. Tuberculosis is more prevalent than any other

form of disease, and is the cause of death of a proportion variously

estimated at from 20 to 30 per cent. of mankind. It is a disease which

perhaps concerns the surgeon more than the physician, inasmuch as it is

also the most common of the so-called surgical diseases. Its frequency

varies in different parts of the country. In the average surgical

clinic of the United States probably 20 to 25 per cent. of cases are

manifestations of this affection.

Surgical tuberculosis covers the entire range of diseases formerly

described as _scrofula_. The term scrofula is now expurgated from

medical terminology. All of the active manifestations formerly regarded

as scrofulous are known to be due to tuberculosis.

To the presence of tubercle bacilli in the tissues is due that

distinctive aggregation of cells which constitutes the so-called

_miliary tubercle_. Its presence and arrangement are apparently the

direct outcome of the irritation produced by these minute foreign

bodies, and its method of grouping is so characteristic that it may

be everywhere and usually easily recognized. Its centre is composed

of one, possibly several, _giant cells_, whose nuclei are generally

arranged around its margin, with perhaps degenerative changes going

on in the interior of the cell itself. In this giant cell, as well

as outside of it, may be seen one or several _tubercle bacilli_.

Around this centre are clustered a number of large cells known as

_epithelioid_, which may also contain bacilli. These cells are probably

derived from epithelium when at hand, or from the endothelium of the

vessel walls, or from the fixed tissue cells. Outside of these are

other, usually spindle-shaped, cells, contained in a connective-tissue

network and regarded mostly as _lymphoid cells_. When tubercle is

experimentally produced the bacilli seem more numerous than they do

in instances of spontaneous disease. This little aggregation of cells

constitutes a mass which may be recognized by the naked eye--a minute,

usually white point or nodule, which is known as a _miliary tubercle_.

It is subject to any one of several changes to be presently considered,

and it is usually found in large numbers. The punctate appearance

of miliary tuberculosis is perhaps best seen upon the cerebral

membranes or the peritoneum in cases of acute miliary tuberculosis. By

coalescence of a number of these nodules larger tubercles are formed,

and by combination of coalescence and caseous degeneration are produced

the large cheesy masses which were formerly called _yellow tubercle_.

(See Plate VI.)

The epithelioid cells are by some regarded as modified leukocytes; by

others as the product of division of the fixed cells. The giant cell is

probably the result of irritation in one of these cells, the stimulus

being sufficient to provoke division of the nucleus, but not of the

entire cell. As the principal cellular activity occurs in the interior

of this nodule the result is a condensation about the periphery which

furnishes eventually a sort of capsule, the tissues being hardened and

condensed as if for this special purpose. The effect of this is to

interfere with vascular supply and finally to shut it off completely.

As long as no pyogenic infection occurs, the original tubercle may

gradually shrivel down and disappear or caseous degeneration may

occur, and it may persist as a cheesy nodule for an indefinite time.

As such a tubercle grows old the cells lose their identity, refuse

to take stains, and a slow or quiet coagulation necrosis results. In

this nest sometimes calcium salts are precipitated, the result being

a _calcareous nodule_. On the other hand, during the active stage of

this tubercle formation cell resistance may be lowered, either from

general or constitutional causes; the original focus disintegrates;

tubercle bacilli are liberated, and are now carried hither and thither,

_metastatic tubercles_ being the result of their dissemination.

Spontaneous healing of tubercle is possible, and may be due to three

different causes:

(_a_) Necrosis and exfoliation of diseased tissue (_e. g._, in lupus);

(_b_) Cicatricial formation;

(_c_) Retrograde metamorphosis.

Looked at from another point of view, the possible fates awaiting the

miliary tubercle are the following:

(_a_) _Absorption_;

(_b_) _Encapsulation_;

(_c_) _Cheesy degeneration_;

(_d_) _Calcareous degeneration_;

(_e_) _Suppuration_.

=Absorption.=--Absorption of tubercle undoubtedly is possible under

favorable circumstances, but just what constitute these favoring

circumstances no one knows, since they occur in cases which do not

terminate fatally. To be able to describe them would be to detail

minutely the changes which permit of recovery after non-traumatic

tuberculous infection, which clinical fact is amply demonstrated by the

experience of the profession. Absorption is probably largely a matter

of phagocytosis.

=Encapsulation.=--Encapsulation has already been spoken of, the

capsule being formed by the condensation of the original cells of the

tuberculous agglomeration, the infectious organisms being thereby

imprisoned as long that they are practically starved and finally die.

The tubercle bacilli, however, may long lie latent in such a cellular

prison, and should anything occur to break the prison wall they may

escape and still prove actively infectious. In this way are to be

accounted for the fresh eruptions from old miliary or other deposits.

=Caseation.=--Caseation comprises a series of changes in the chemical

constitution of the cells by which an albuminoid mass much resembling

casein in composition and appearance is produced. The English

equivalent _cheesy_ well describes many of these masses, which both cut

and appear very much like domestic cheese. They have a yellowish color,

and are met with in masses in size from a pin’s head up to a robin’s

egg. These are the yellow tubercles of the older writers, and such a

cheesy tumor has been called _tyroma_.

=Calcification.=--Calcification refers to a peculiar deposition

of calcium salts within the interior of these nodules, the first

precipitation occurring usually in the centre of the giant cell, which

is itself the topographical centre of the miliary tubercle. It may

spread from this until a mass easily recognizable by the naked eye and

detectable by the finger is produced. Such calcareous particles are

frequently found in sputa, and are always an index of the tuberculous

character of the case. They differ markedly from the yellow calcareous

nodules found in the pus of actinomycosis, the circumstances under

which they are likely to be confused being met in pulmonary disease.

COLD ABSCESSES.

=Suppuration=, as indicated, is the result of a mixed or secondary

infection with pyogenic organisms. In the previous chapter tubercle

bacilli were grouped as among the facultative pyogenic bacteria, yet

pus is not formed in this disease except in consequence of coincident

activity of other bacterial organisms. Suppuration of tuberculous foci

is of importance to the surgeon, because thereby is produced a distinct

class of so-called abscesses--namely, the _cold_ or _congestion

abscesses_. These are of the chronic type, and are generally free from

the ordinary signs of abscess formation. They are invariably the result

of local infection, sometimes perhaps by the tubercle bacilli alone,

but frequently by the combined action of these with pyogenic forms. For

their formation a previous tuberculous lesion is essential. Wherever

old tuberculous lesions are encountered cold abscesses also may form.

No tissue or organ is exempt: they are found in the brain, in the

bones, viscera, joints, skin--in fact, in all parts of the body.

Cold abscesses have not only a significance of their own, but for the

most part an identity. Their distinguishing feature is a _limiting

membrane_, which forms whenever sufficient time has elapsed. Much has

been written about it, and much error has been perpetuated with regard

to it. This is the membrane formerly considered and called _pyogenic_,

under the misapprehension that by it the pus or contents of the abscess

were produced. I desire to emphasize in every possible way that this is

a mistake. This membrane does not act to produce pus, but is rather the

result of condensation of cells around the margin of the tuberculous

lesion, forming, as it were, a sanitary cordon, for the absolute and

definite purpose of protection against further ravages. I would suggest

that the term pyogenic membrane be abolished, there being no such

membrane under any circumstances, and that, this be known as that which

in effect it is--namely, a _pyophylactic membrane_. _It is a protection

against pus_, and were it not for its presence there would be no limit

to the spread of tuberculous invasion. A lesion thus surrounded is

shut off from most possibilities of harm, rarely encroaches, except

by the most gradual processes, and, on the contrary, often contracts

and reduces its dimensions, the watery portion of its contents being

gradually absorbed and the more solid and cellular portions becoming

condensed into matter which undergoes caseous degeneration, so that

eventually recovery may ensue as the consequence of a metamorphosis of

an original cold abscess into a caseous nodule surrounded by the old

pyophylactic membrane, which is now serving as a capsule.

The contents of the cold abscess are, in some instances at least, of

acute origin, and consequently may have been originally pus or its near

ally. On the other hand, in cases which have occurred very slowly this

material is not real pus, but is a semifluid debris having certain

properties which remind one of pus. It has been my effort hitherto to

devise for this material a name which should distinguish it from pus

and indicate what it really is. Inasmuch as most of it has been of a

puruloid character, at least at one time, I have suggested that it

be called _archepyon_ (_i. e._, originally pus or puruloid). As this

flows from such a cold abscess, it is more or less watery and contains

caseous, sometimes calcareous, nodules in masses of considerable

size, and not infrequently sloughs of tissue and old shreds of white

fibrous tissue which resist decomposition for a long time. This

material has been thus imprisoned, sometimes for months or even years,

and consequently has lost most of its resemblance to what it was

originally. The organisms which first produced it have long since died,

and it is practically sterile. If any organisms survive, they are the

tubercle bacilli, which are more resistant and tenacious of life than

the ordinary pyogenic organisms. This is why most culture experiments

fail, and why even inoculation with the contents of an old cold abscess

is often without effect even on most susceptible animals. _Nevertheless

the bacilli which the semifluid contents do not contain may yet linger

in the meshes of the pyophylactic membrane; and here lurks the greatest

danger in dealing with these lesions._

In old cases the pyophylactic membrane is very tough and very adherent

by its outer surface. It can sometimes be peeled off in strips of

considerable extent, at other times cannot even be separated, or

sometimes is so placed as to render it impossible to follow it to its

termination. There must be _complete extirpation of this membrane_, or

at least destruction; and when its removal is impracticable, failure to

remove it should be atoned for by some powerful caustic, such as zinc

chloride, nitric acid, caustic pyrozone or the actual cautery, which

should be made to follow it to its ultimate ramification. The membrane

and the tissues underlying, when thus cauterized, will separate as

sloughs, and these will be replaced by presumably healthy granulations,

which should be encouraged until the original cavity is filled or the

surface healed.

Acute abscesses, as indicated in the previous chapter, have no real

limiting membrane, although there is more or less condensation of

tissues about the focus of infection. A typical membrane is distinctive

of tuberculous abscesses, and is to be regarded always as their

natural protection and a barrier against their further encroachment--a

membrane whose inner surface may harbor active organisms which cannot

escape through its outer texture. Consequently, to simply incise it or

inefficiently scrape it is to do a worse than useless thing; and one

should never attack it unless he is prepared to extirpate it or destroy

its integrity, and in this way dispose of it.

Cold abscesses when near the surface cause a bluish or dusky

discoloration of the overlying skin, while the superficial and

subcutaneous veins of this region are usually enlarged. Fluctuation

is also a prominent phenomena in connection with them when they

can be palpated. Deep collections of this kind may be mistaken for

cysts or tumors, in which case the aspirator needle may be used to

facilitate diagnosis. They vary in size from the smallest possible

collection of fluid to abscesses which may contain a gallon or more of

puruloid material or archepyon. They are known often as _gravitation

abscesses_, because by the weight of the contained fluid they tend to

elongate or spread themselves in the direction in which gravity would

naturally carry a collection of fluid. Thus cold abscesses originating

from tuberculous disease of the lower spine frequently work their way

along the psoas muscle and present below Poupart’s ligament as _psoas

abscesses_, or elsewhere about the thigh, while those which come from

similar disease of the uppermost cervical vertebrae may present behind

the pharynx, as the so-called _retropharyngeal abscesses_, and those

from the dorsal spine present not infrequently as _lumbar abscesses_.

These are but two or three familiar examples of what may occur in any

part of the body.

=Treatment.=--Aside from the treatment of cold abscesses, already

indicated by radical measures, other means have been suggested, and

particularly for the treatment of those in which such extreme measures

are impracticable or impossible. It is sometimes efficacious to simply

tap or remove by aspiration the contents of such a cavity. It may never

refill, or but slowly, and after repeated tapping alone a very small

percentage of such cases will subside into inactivity and the lesion be

subdued, if not absolutely cured. Treatment by injection of emulsions

of iodoform has found favor with many surgeons. I have never been able

to secure the good results reported by others, and consequently have

abandoned it; yet it deserves mention here because of the repute it has

enjoyed.

This is based upon the alleged specific properties of iodoform as

being peculiarly fatal to tubercle bacilli, presumably by liberation

of free iodine. A cavity to be thus treated should be first emptied as

completely as possible, after which may be thrown into it a glycerin

emulsion or an ethereal solution, or a suspension in sterilized oil

of 5 to 10 per cent. of iodoform. From 25 to 200 Cc. of some such

preparation is introduced, while the walls of the abscess are more or

less manipulated in the endeavor to completely disseminate the mixture.

The cannula through which it has been introduced is then withdrawn; and

this can usually be done with but little unpleasant iodoform effect.

This is due to the pyophylactic membrane, which limits the activity of

the drug as it has done that of the previous contents of the abscess.

Such cavities have also been treated by washing out through a trocar

with an injection of various antiseptic or stimulating solutions, among

which may be mentioned hydrogen peroxide, weak iodine solutions, etc.

My own advice is to treat all tuberculous lesions radically when such

measures are not contra-indicated by their multiplicity or by too great

depression of the patient, and so long as lesions are accessible to

ordinary operative procedures. This same advice pertains also to those

which have already spontaneously evacuated themselves, or where the

overlying skin is threatening to break and permit escape of contents.

Almost any case where this is imminent is one in which the surgeon, as

such, ought to interfere. On the other hand, in deep collections and in

debilitated individuals the treatment by injection may be tried.

The best way to treat accessible tuberculous lesions is by extirpation,

as this hastens convalescence and leads to more permanent results.

THE GUMMAS OF TUBERCULOSIS.

The other and essential characteristic of tuberculous disease is the

_infectious granuloma_ to which it gives rise. This is a term first

applied by Virchow to new formations of granulation tissue which are

the result of the presence of invading and specific irritants. This

tissue varies little in type from that already described under Ulcers,

and is common to the neoplasms which are found in tuberculosis,

syphilis, leprosy, glanders, and other local infections. So little does

the tissue type vary in these different instances that it is difficult

to distinguish by microscopic sections of the unstained tissues, or

at least those unstained for bacteria, to which class of lesions they

belong.

[Illustration: PLATE VII

Lupus of Skin. (Gaylord.)

_a_, fresh tubercles containing numerous plasma cells; _b_, mature

tubercle with giant cells. Below are accumulations of plasma cells

about the vessels. Low power.

Unna’s polychrome methylene blue.]

This tissue may be met with in any of the tissues of the body, but

is less seen upon the serous membranes of the cranial and peritoneal

cavities, whereas in the joint cavities it is common. It is provoked,

as just stated, by the presence of tubercle, and has the power of

penetration into and substitution for almost all the other tissues

of the body. Thus in a primary tuberculous focus within the bone a

granuloma will form and extend its limits, while the surrounding bony

tissue melts away before it; and it is by the growth of this tissue

in a particular direction that tuberculous products from within the

bone cavity are finally carried to the surface. When this material

has escaped from bone, or from tissues without the bone, toward the

surface its presence is marked by induration, by livid discoloration of

a limited area of skin, with elevation of the surface, which finally

breaks down and shows discolored, bleeding, and pouting granulations,

which in the absence of restraint now proliferate more rapidly, and

often to the point where they loose their former blood supply, and

consequently necrose upon the surface. This is the _fungous granulation

tissue_, especially of the German writers, and may be met with upon

the surface, or is frequently seen in opening into joint cavities and

other tissues infected by tubercle. The appearances of this fungous

tissue are modified somewhat by environment and pressure: in joints

flat and radiating masses of it will be found, extending along the

synovial surfaces and into the articular crevices. This fungous tissue

may grow in any direction, but apparently advances in the direction of

least resistance. It leads to complete perforations of the flat bones,

like those of the skull, while tuberculous masses from the dura may

cause multiple perforations, the granulation tissue finally escaping

through the overlying skin. In tuberculosis of synovial sheaths and

bursæ it extends along and may completely fill and even distend them.

It will separate tissues which were united together, and it may lead

to disintegration and disorganization of the firmest textures in

the body. So long as it is not exposed to the air nor to pyogenic

infection, it will preserve its characteristics for a considerable

length of time. Immediately upon exposure it is likely to break down,

and infection will travel speedily along it into the deeper cavity

whence it has sprung. A mass of this tissue contained within the normal

tissues, condensed more or less by pressure, uninfected, and not freely

supplied with blood, is entitled to the name of _tuberculous gumma_,

whose tendency, however, is too often to break down and suppurate.

Such gummas may be found in any part of the body, and differ only in

unessential respects from the diffuse and more or less infiltrated

masses of granulation tissue which occupy serous cavities or which

extend in various directions.

The lesions of surgical tuberculosis, except those already spoken of

as constituting cold abscess, are so essentially connected with the

presence of granulation tissue, just described, or of this form of

the infectious granulomas, that no student can appreciate the subject

until he is familiar with this tissue in its various phases and in

various locations. Of such great importance is it that this be realized

that some of the local manifestations of this new tissue must here be

considered, although they may be rehearsed in other form in succeeding

chapters.

_In the skin and subcutaneous tissues_ and _in and under mucous

membranes_ this granulation tissue may be studied at places where

it is free from most mechanical restraints to growth, and where, in

other respects, its appearances are typical. The most characteristic

manifestations in the skin occur as _lupus_, a disease considered

cancerous or of uncertain etiology. Lupus is always a cutaneous

manifestation of this protean disease. (See Plate VII.)

In its incipient stages lupus consists of multiple minute nodules

of granulation tissue just beneath the surface, containing all the

elements of true miliary tubercle, with infiltration of the surrounding

skin, even into the subcutaneous fat. The most common location of these

lesions is on exposed surfaces. Bacilli are not numerous in them, yet

may be demonstrated. The tendency is more or less rapidly to break

down, the result being a tuberculous ulcer, which, as it extends,

manifests usually a disposition to cicatrize in the centre while

enlarging around its periphery. The dermatologists describe several

different forms of lupus under the names _hypertrophicus_, _vulgaris_,

_maculosus_, etc., all of which are essentially the same in character,

the differences being largely constituted by the rapidity or slowness

with which the granuloma of the skin breaks down. From the surface

these growths may extend and involve parts at considerable depth, even

the periosteum. This name should also include the lesions described as

_scrofuloderma_ or scrofulous ulcers of the skin, they being all of the

same character.

A variety known as _anatomical tubercle_ has been described by some

writers, found especially upon the hands of those who frequent

dissecting-rooms or handle dead bodies, and is supposed to be the

result of local inoculation. It appears usually as a warty growth,

which ulcerates and becomes covered with a scab--is usually indolent

in character, but is followed by lymphatic involvement, and in rare

instances by death from tuberculous disease.

[Illustration: FIG. 20

Tuberculosis of cervical lymph nodes.]

_In the lymphatic structures and lymph nodes_ tuberculosis is a most

frequent affection. In these localities it may occasionally be primary,

but is almost always a secondary lesion. It is in separating from the

lymph stream the tubercle bacilli, which would otherwise be passed

into the general circulation, that the lymph nodes, acting as filters,

render us the greatest possible service. These filters themselves,

however, almost always become infected, and, enlarging, they assume

the appearances known to the laity as _scrofula_, which have been

generally referred to as _scrofulous glands_. These lesions abound

rather about the axilla and the cervical and bronchial nodes than about

the lower extremities. Nevertheless, the retroperitoneal, mesenteric,

and inguinal nodes are occasionally infected. In these nodes will be

found giant cells surrounded with epithelioid cells, containing bacilli

and undergoing cheesy degeneration or suppuration. Infection often

proceeds from centre to periphery, and then to the surrounding tissues,

the filter, as such, having become so choked that nothing seems to pass

it. By virtue of this surrounding infiltration (which used to be known

as _peri-adenitis_, when lymph nodes were spoken of as _lymph glands_)

generalized infection is in some measure prevented, while the natural

barriers are altered and natural distinctions between tissues are

lost. This makes complete extirpation of these tuberculous foci often

very difficult, while the adhesions which they contract, for instance

in the neck, are often to the large vessels and nerve sheaths, by all

of which their operative treatment is naturally complicated. When

infection from the superficial nodes extends toward the surface it is

easily recognized by the dusky hue of the overlying skin, the hardness,

infiltration, and, later, the fixation, of these masses, accompanied

usually by evidences of suppuration.

_In and on the serous membranes_ we find tuberculous lesions, either

primary or metastatic, usually miliary in type. In the _pleural cavity_

they produce effusion (hydrothorax), which may necessitate repeated

paracentesis, or by a mixed or secondary infection may cause empyema,

for which much more radical and even extensive operations are demanded.

(See Thoracoplasty.)

In the case of the _peritoneum_ we find (_a_) miliary tuberculosis,

(_b_) a slower non-exudative form with firm, sometimes pigmented

nodules, and (_c_) a form characterized by small gummas which become

caseous, coalesce, and ulcerate, binding together intestinal coils

and producing extensive and irregular adhesions, with seropurulent

exudation, often enclosed in walled-off sacs. In all of these cases

surgical intervention should be considered, while in the more acute

miliary forms abdominal section, with flushing, has in many instances

afforded relief.

Tuberculous _meningitis_, cerebral or spinal, is in surgical cases

practically always of miliary type, accompanied by the inevitable

increase of fluid, and, in the cerebrospinal canal, of consequent

tension. Inasmuch as the latter constitutes the most formidable feature

of these cases, its possible relief by puncture may be considered.

And so lumbar puncture (_q. v._) may be practised, and even tapping

the cerebral ventricles after making the small trephine opening has

been done a few times, though not with encouraging success. (See

Hydrocephalus.) Too often tuberculous meningitis is the terminal

infection which ends many a case of local tuberculous disease in other

parts of the body.

In general the more acute and miliary the lesions presented in

tuberculous disease of serous membranes the greater the tendency to

profuse watery (serous) exudate, whose volume may demand operative

measures for relief.

_In the bones_ we often find indications of tuberculous disease. It

is not much more than sixty years since Nélaton called attention to

the frequency of these intra-osseous lesions, and demonstrated the

essentially tuberculous character of much that had hitherto been

overlooked or considered under that vague term scrofula. All those

forms of bone disease comprehended under the names _Pott’s disease_,

_spina ventosa_, _tumor albus_, etc., are now known to be distinctly

tuberculous lesions. In many instances these follow the slight

circulatory disturbances brought about by contusions sprains, etc. This

is especially the case in those who are predisposed to this disease.

[Illustration: FIG. 21

Tuberculous spondylitis (caries): _a_, osteogenesis and osteosclerosis;

_c_, cavity formed by degeneration of tuberculous focus. (Krause.)]

Tuberculosis of bone always assumes the phase of miliary lesions,

followed by the formation of a granuloma, which may gradually encroach

upon surrounding tissues or may assume a more fulminating type and

spread rapidly. Apparently because of the circulatory conditions

these lesions generally occur near the epiphyseal lines of the long

bones, apparently seeking the ends of the bones, as pulmonary lesions

seek the terminations of the lungs. These lesions may be solitary or

multiple. Beginning always minutely, they spread so as to produce foci

perhaps two inches in diameter. As the result of the formation of

granulation tissue, the surrounding bone melts away and disappears,

the result being a great weakening of its structure and expansion of

its dimensions in order to make room for the growing mass within.

The tendency of this granulation tissue thus imprisoned is always

to escape in the direction of least resistance. This carries it

sometimes into the joint, sometimes out through epiphyseal junctions,

and sometimes through channels in the bone made by its own pressure,

with external escape and appearance of the dusky distinctive tissue,

felt beneath and then upon the skin. Where bone is so weakened in

one direction it is usually strengthened by compensatory deposition

of calcium salts at other points, and the result frequently is a

striking _combination of osteoporosis_ in the immediate presence of

the disease, with _osteosclerosis_, sometimes to a remarkable degree,

even to _eburnation_, of an adjoining portion. When this mass undergoes

caseous degeneration the progress of the disease is much slower and

the pain less. When it undergoes suppuration there are more evidences

of inflammation, with more pain and systemic disturbance, as well as

local swelling, tenderness, etc. The surrounding musculature is rarely

involved, although the periosteum is nearly always so. In fact, it

is stated that in an inflamed and suppurating bone lesion, if the

muscles are extensively invaded, it may be regarded as of syphilitic

rather than of tuberculous origin. The _pyophylactic_ membrane already

alluded to is seen in almost every instance of tuberculous disease.

The spina ventosa of some writers refers to the expansion of the shaft

and medullary cavity of a long bone whose interior is occupied by

a mass of tuberculous gumma, which is perforated at one point, and

through which opening it escapes as does lava from a crater, to involve

the structures on the outer side. The appearance of this granulation

tissue in joints as _fungous tissue_ has already been mentioned. In a

general way it preserves its fungoid characteristics until attacked by

pyogenic or saprogenic organisms, when it quickly breaks down, forming

an ulcer if upon the surface, or a cold abscess if not externally open.

Tuberculous disease of the bone is most common in the young, and in

them the majority of tuberculous joints are those whose bony structures

have been first involved. In other words, the majority of cases of

tuberculous pyarthrosis are due to primary bone disease. As the result

of the tuberculous infection the bones become distorted, which is best

illustrated in Pott’s disease of the spine; while, as the result of

the constant irritation, joint ends become displaced by chronic muscle

spasm, and joint contours entirely altered by expansion of the affected

bone and thickening and infiltration of the overlying soft parts.

I have often, for the sake of illustration to medical students,

drawn a certain analogy (following Savory) of the gross resemblances

between lungs and bones in their behavior when involved in tuberculous

disease. In either case the structure is in a measure spongy and

contains cavities and networks of tissue; in each case the structures

are invested by a resisting membrane--in the one instance pleura,

in the other periosteum. Again, each is closely related to a serous

cavity--the lungs to the pleural cavity, the bones to the serous

cavities of the joints. Tuberculous disease manifests a predilection

for the extremities of both organs. Perforation into the adjoining

serous cavity is frequent, and previous to perforation collections

of serous fluid are frequently noted--in one instance pleurisy, in

the other hydrarthrosis. Moreover, these fluids may frequently become

contaminated, and then become purulent, constituting empyema or

pyarthrosis as the condition may be. One sees, too, in each place the

same striking combinations of weakening of tissue and strengthening in

order to atone for the undermining of the disease. These are not all of

the similarities that might be adduced, but are perhaps sufficient for

the purpose of showing that tuberculous disease is essentially one and

the same thing, no matter what tissue is invaded.

_In the tendon sheaths and bursæ_ we frequently find manifestations

of tuberculosis. When seen early these are always in the direction

either of miliary affection, or, most commonly, of tuberculous gumma,

while when seen late the disease has usually advanced to the point of

suppuration, and we now have cold abscess of the affected part.

In many joints and tendon sheaths, particularly the latter, we find

certain detached, usually colorless, firmly resistant masses, of

smooth and polished surface, lying in a collection of fluid, in size

from a minute particle up to that of a melon-seed. These have been

known at various times as _rice grains_, _melon-seed bodies_, _corpora

oryzoidea_, etc., and for a long time their explanation was a mystery.

It is now well established that in the majority of instances these

are the result of fungous granulations which have become detached in

small pieces, which then, in the absence of infection, have shrunken

and become rounded and polished by attrition. The bursal enlargement

and distention with fluid in which they are usually found is commonly

spoken of as _hygroma_ of that particular bursa. Tuberculosis of these

bursæ, however, does not always result so harmlessly as the formation

of these bodies, but, on the contrary, tuberculous infiltration may

extend beyond the serous limits to the surrounding soft parts, with

a tendency finally to external escape, just as in the case of bone

lesions. These constitute affections of the soft parts which are more

or less destructive, and are difficult, often impossible, to deal with,

because of the mutilation which a thorough extirpation of the disease

would necessitate.

_In the testicles and ovaries_, particularly in the former, tuberculous

disease is frequently met with. In the testicles it begins usually in

the _epididymis_, forming a somewhat dense nodule and a distinct tumor,

easily observed from the outside, although its minute character may be

still concealed. The tendency here is almost invariably to progressive

infiltration and breaking down, either into a caseous mass or, more

commonly, into puruloid material, while sometimes acute infection

supervenes.

It is not always easy to distinguish between syphilis and tuberculosis

of the testicle, though the latter is usually characterized by the same

tendency to effusion into the adjoining serous cavity, _i. e._, that

of the tunica vaginalis, as is manifested in disease of the lungs or

bones. When the disease is extensive the overlying skin is involved,

and frequently the surgeon is called to deal with cases of perforation

and escape of fungoid tissue on the outside.

_In the kidneys, in the ureters, as also in the bladder_, tuberculous

lesions are noted, the miliary form being particularly frequent in

the former. Tuberculous disease of the kidney leads sooner or later

to caseation and a condition of pyonephrosis or its equivalent, which

calls practically always for extirpation of the affected organ.

Tubercle bacilli are sometimes recognized in the urine, but only when

the lesion has an opportunity of discharging into one of the urinary

passages.

_In the peritoneum_ tubercle appears usually in the miliary form,

leading sometimes to such extensive involvement of and interference

with visceral functions as to produce anasarca or more general

disturbance prior to death. Acute miliary disease here is as rapid

and as essentially fatal as the same affection of the dura or pia,

while the more chronic forms are followed by degenerations that may

involve the intestines either in agglutinated masses or in ulcerations

and possible perforations. The indication in all tuberculous lesions

of serous membranes is for exposure by operation, disinfection of the

surface, and evacuation of retained fluids. Recovery from tuberculous

peritonitis, even of acute type, after abdominal section, is now

definitely established as a possibility. The same would probably

be true of tuberculous meningitis were we permitted to expose the

membranes and attack them or drain them in the same way.

Although a few distinct organs or tissues have here been specifically

considered in their relations to tuberculous disease, there is no organ

or tissue in the body which is exempt from its ravages and in which

evidences of tuberculous disease may not be found. Even the _mammary

gland_ occasionally presents tumors composed of tuberculous granuloma

which more or less simulate malignant disease, while calling for the

same radical treatment (Fig. 22).

[Illustration: FIG. 22

Gross appearance in tuberculosis of the mamma. (Dubar.)]

=Paths of Infection.=--The tuberculous virus may enter the body

through various channels. Probably in the majority of instances it

gains entrance through the _respiratory tract_, less often by the

_alimentary canal_, and _occasionally by air contact of open wounds or

direct infection by local agencies_. It is now well established that

tuberculous disease is easily inherited, although a predisposition to

its ravages is transmitted from parent to children.

In what this predisposition consists is not always easy to say. As

the tubercle bacillus grows in the tissues, it is by preference an

anaërobe, and it seems to be lowered in activity or banished by access

of oxygen. It has been shown that in those individuals in whose pallid

skin, long bones, flabby muscles, and pale conjunctivæ we recognize

a predisposition to this disease, the heart is disproportionately

small as compared with the weight and size of the lungs. This means a

relatively feeble pumping power, and is perhaps the best explanation

for what is accepted as a fact. The _mucous membranes of the nose_ and

_throat_ are usually the first lodging places for germs carried by the

air, they finding here the warmth and moisture necessary for their

detention, development, and growth. As long as these membranes are

unbroken and healthy, infection is rarely possible; but let tubercle

bacilli become caught in the crypts of the tonsils or in adenoid tissue

in the nasopharynx, and the other disturbance, set up by irritant

organisms of various species, will usually bring about conditions

favoring their growth and incorporation into the living tissues. This

lymphadenoid tissue is often the port of entry for these organisms.

The explanation for local and surgical tuberculosis in bones and other

accessible tissues probably is connected with causes determining at

these points an area of least resistance, in which the germs find

tissues more susceptible than elsewhere, and in which they may live and

thrive.

Not the least interesting and important of the considerations

regarding tuberculous disease is the possibility of an _acute outbreak

of tuberculosis after long latent or chronic manifestations of the

disease_. This means, in effect, the onset of _general miliary

tuberculosis_ which soon terminates fatally, and death is not the

infrequent result of such extremely rapid outbreaks from tuberculous

disease of joints, bones, ovaries, etc. For the disease when it has

assumed this extremely rapid type there is, so far as known, no relief.

=Diagnosis.=--So far as the general recognition of tuberculous

disease is concerned, it is not often difficult. It is accompanied

usually by more or less marked cachexia (at least this is the case

when infection is serious and widespread), one of whose principal

characteristics is the so-called _hectic_ (habitual) fever of old

writers. This was a fever of a remittent type, accompanied also by more

or less colliquative night sweats, with dryness of the skin during

the daytime, and flushing of the face. Hectic fever, as a matter of

fact, often accompanies tuberculous disease, but is seldom encountered

until pyogenic infection has occurred and suppuration is taking or

has taken place. There is now much reason to consider hectic fever as

an auto-intoxication from absorption of morbid products. In advanced

cases we may find evidence of _amyloid_ changes, although these are

seldom recognized prior to autopsy. It is seldom difficult to recognize

tuberculous disease except when at a considerable depth. Here, as long

as there is no suppuration, there is little tendency to _leukocytosis_,

by which diagnosis as between _sarcoma_ and _tuberculous_ infection

may perhaps be made. Sometimes when in doubt the exploring trocar or

an exploratory incision may be resorted to, it being always best to be

prepared at the same time to proceed with whatever further operative

procedure the findings may indicate.

=Treatment.=--It is well to emphasize, first of all, that _tuberculous

disease when circumscribed and accessible is a distinctly curable

affection_. If this is accepted, it puts a much more hopeful aspect

upon the condition than it formerly bore. It moreover justifies

operations of a more radical nature than were formerly practised.

Treatment should be divided into the hygienic and constitutional and

the local and operative.

Of all the natural remedies, _oxygen_ undoubtedly ranks first. This

means the best of _ventilation_, an outdoor life if possible, and

preferably in localities and at altitudes free from dust and well

supplied with ozone. When this is impossible inhalations of dilute

oxygen are capable of doing much good. The two canons of successful

treatment of pulmonary tuberculosis are equally of value in surgical

tuberculosis, viz., _abundance of oxygen and hypernutrition_. The diet

should be rich and nutritious, at the same time capable of complete

digestion. The emunctories should be stimulated and elimination favored

in every possible way. Undoubtedly the old standard remedies--cod-liver

oil, compound syrup of hypophosphites, etc.--are beneficial, and much

good may be accomplished by their proper use.

Certain remedies have been at various times supposed to be endowed with

specific properties, and for many years clinicians have endeavored to

find that substance with which the system could be safely saturated

and prove inimical to the parasite causing this disease. Such agent

has not yet been discovered; nevertheless, much has been done in

this direction. Of the remedies highly spoken of for this purpose,

_creosote_ and _guaiacol_ are considered the best. These are somewhat

difficult of administration, but if the latter is given in the form of

the carbonate, generally known as _benzosol_, it comes the nearest to

the ideal for which we are striving. _Benzosol_ should be given to the

adult in doses of at least a gram a day, perhaps more. It is better

tolerated and less offensive than the guaiacol from which it is made. I

have never seen anything but benefit result from its use, and yet would

not extol it as a positive cure. Nevertheless in conjunction with other

local and constitutional measures its administration may be followed by

complete recovery.

Of the various _local measures_, _physiological rest_ should be placed

first, and can be achieved in some places better than in others. The

various forms of apparatus resorted to by orthopedists are simply

mechanical measures in furtherance of this purpose. Some surgeons have

faith in _iodoform_, used locally in solution or suspension in some

menstruum like glycerin, oil, etc. The benefit which has been claimed

in some cases is not duplicated in the experience of all surgeons;

nevertheless, it has undoubtedly been of service. A recent and most

promising method of treating tuberculous disease of the extremities

has been suggested by Bier, and consists in the establishment of a

_permanent hyperemia_ by the application of a rubber tourniquet on the

proximal side of the lesion. (See chapter on the Joints.)

It would appear that the access of more blood which is thus permitted

is inimical, presumably by the presence of the oxygen which it brings,

to the development of the disease germ. The method depends for its

rationale upon the fact that the congested lung does not become

tuberculous. Lannelongue has suggested what he calls the _sclerogenic

treatment_ of tuberculous lesions, by injection of a very dilute

solution of zinc chloride, which serves as an irritant and produces a

tissue sclerosis that serves the purpose of a prophylactic membrane,

while at the same time the solution is fatal to those germs with which

it comes in contact. This treatment is painful and has not proved

acceptable.

The astute surgeon, who gains the confidence of his patients and

retains it, will not hesitate to remove by a suitable operation the

tuberculous focus which he feels confident that he can reach and

extirpate. The resulting tissue defects may be in many instances

atoned for by plastic operations. At other times this procedure

means _excision of some joint_, which leaves usually a much better

functionating member than would the disease if permitted to go on

to spontaneous recovery--_i. e._, ankylosis--and at the same time

removes a focus of disease which is a menace if left to the future

welfare of the patient. It may mean at other times _amputation_, but

the artificial limbmaker now supplies a member vastly more useful than

a natural one crippled by this infectious disease. In a general way,

then, time may be saved and recovery ensured by early and judicious

operation, while later in the course of this protean malady it may be

absolutely necessitated in the endeavor to save life.

After operations where clean extirpation and reunion of the parts

with primary healing is impossible a local dressing of balsam of Peru

containing 10 per cent. of guaiacol is recommended. Gauze saturated

with this dressing and packed into the cavity best accomplishes the

purposes of a surgical dressing for such cases.

The superficial and ulcerative (skin) lesions due to tuberculosis often

yield very readily to exposure to the Röntgen rays and the ultraviolet

rays. Recrudescences appear not infrequently, and the treatment should

be administered at intervals long after the apparent subsidence of the

lesion.

Deep pain of tuberculous lesions, especially in bone, is often relieved

by _ignipuncture_, meaning thereby a perforation into the depth even of

the bone-marrow by the actual cautery (Paquelin’s), which may be thrust

directly through the skin or which may be used after exposing the bone

by incision. The use of the actual cautery is indicated in eradicating

and destroying tuberculous tissue when a neat dissection or extirpation

is impossible.

=Tuberculin.=--Finally the treatment of tuberculosis cannot be

dismissed without a reference to the glycerin extract made from a

filtered culture of the tubercle bacillus, containing the peculiar

toxalbumin first prepared by Koch, forever associated with his name,

and first given to the world in 1890, when its announcement created

a furore and aroused hopes that have never been completely realized.

Yet in spite of disappointments which have often followed its use, it

is a remedy of great value when judiciously used in selected cases.

The diagnostic value of the material should also not be forgotten,

as by its use one may possibly decide in doubtful cases as between

tuberculous or some other disease. The best preparation for use

today is that made by Koch’s new process, by which the possibility

of the presence of microörganisms is eliminated. It contains those

constituents of the bacilli which are insoluble in glycerin, and

which have distinct immunizing power. On the market it is known as

_tuberculin rest_, indicated simply as T. R. The initial dose is ¹⁄₅₀₀

Mg., to be increased with each injection. Its effect, _e. g._, on

lupus, is very marked.

CHAPTER X.

SYPHILIS.

The younger generation, when studying the subject of syphilis,

should be referred back one hundred years or more to the time when

the opinions held by John Hunter generally prevailed--when venereal

diseases were grouped under one heading, and considered to be but three

manifestations of the same morbid condition. It took years for the

profession to break away from this mistaken teaching, and a generation

had passed before gonorrhea was separated from the others. This left

chancroid and syphilis still more or less confused in the minds of

many, and until the middle of the previous century they were considered

as different types of the same disease by some of the most experienced

observers. Thus it happened that those who made a special study of

this subject were grouped into two classes, the _unicists_ and the

_dualists_, according as they held to the unity or duality of syphilis

and chancroid. It was a question of importance, and differences of

opinions led to bitter antagonisms. Its importance inhered in this:

either all venereal sores were to be subjected to constitutional

treatment, or else differences in treatment were to be made according

to the local or constitutional nature of the malady. Men sacrificed

their own health, even their own lives, in their willingness to make

experiments upon themselves, and auto-inoculability was proved by one

observer through some 1700 inoculations produced upon his own body.

Such devotion to medical science has been rarely eclipsed. In the

latter half of the eighteenth century came clearer distinctions, and

toward its close there were none who ranked as authorities who held to

the old view of the unity of these diseases.

Syphilis is a disease of ancient if not of respectable origin. We read

much of the possibility of so-called pre-Columbian syphilis, implying

by that term that the Spaniards who came over to this country found

it here and carried it with them back to Europe. This is probably

the case, and yet the disease antedates the Christian era, as may be

established by familiarity with ancient literature, whether Arabian,

Egyptian, or Hebraic. No one can read the Psalms of David, for

instance, without finding therein intrinsic evidence that the writer

thereof, whoever he may have been, suffered from this disease. Of

its antiquity, however, as well as of its universal distribution, we

need not speak. History has shown that whenever it has appeared in

a community previously unaffected by it, it has assumed malignant

and epidemic features, and has spread rapidly while claiming many

victims; on the other hand, in those communities where it has long been

domesticated, it assumes usually a milder type, as though a racial

immunity were being gradually established.

_Syphilis is an infectious chronic disease, acquired either by

inheritance or by contagion, mediate or immediate_, with a certain

period of incubation, characterized by an initial lesion at the site

of infection, which is followed in time by a series of systemic

disturbances, usually quite characteristic, in a commonly determinate

order. A large proportion of these consist of neoplastic lesions of

the general type of the infectious granulomas. In the majority of

instances it is of distinctly venereal origin, although not always. It

is known among the common people as _pox_, while a frequent synonym for

it in foreign literature is _lues venerea_, or often _lues_ alone, the

adjective being _luetic_.

_Syphilis is always transmitted as such_ and is not interchangeable

with leprosy, tuberculosis, or anything else, although it is not

unfrequently complicated with them as well as with cancer. It has

certain resemblances to the exanthemas in its periods of incubation,

and in the fact that one attack is supposed to confer immunity, as well

as that many of the typical symptoms of syphilis pertain to the skin

and mucous membrane; further resemblances may also be found in each

case.

Within certain limits the specific infection of syphilis, or, as it is

frequently spoken of, the specific disease, passes through a somewhat

regular program in which periods of activity and latency seem to

alternate. The first visible lesion is at the point of entrance of the

virus, in acquired cases, after a certain period of incubation, and

is known always as the _chancre_. Of course, in inherited syphilis

no chancre or primary sore is found. Then occurs a second period of

incubation, during which there is a still more widespread general

infection of the body, in which at first the lymphatic system seems

to suffer most. This is characterized by a certain degree of fever,

progressive anemia, malaise, tenderness and pain in bones and joints,

all of which indicate a _progressive toxemia_.

=Manner of Contagion.=--The manner of contagion in acquired cases is

naturally most often that of the sexual act, although contagion may

come from many sources, including unclean utensils, pipes, etc., as

well as the instruments of the dentist or the surgeon. Some abrasion

of the infected surface is almost invariably presupposed, since it

is not established that the virus of syphilis will enter an unbroken

surface, though it may lurk thereon; but the abrasion may be trifling

and occur in such situation, especially on the female genitalia, as to

be undiscoverable or unnoticed. It is then possible that patients may

speak truthfully when denying the existence in the past of any venereal

sores. The transmission of infection from parent to offspring in the

uterus will be discussed later.

=Nature of the Virus.=--That syphilis is a disease of parasitic

character, _i. e._, _contagious_, there can, of course, be no question.

The nature of the _contagium vivum_ which produces these changes, long

unknown, is now believed to be revealed in the _spirochæta pallida_

recently described by Schaudinn and others; an organism 4 to 10 μ in

length, ¹⁄₂ μ in width, possessing several curves like those of a

corkscrew, with sharpened poles, mobile, its motions consisting of

rotations and bendings. It has been demonstrated that primary lesions

contain the organism, either constantly or in the majority of cases,

while in skin and nearly all other lesions it can be also shown (Fig.

23).

[Illustration: FIG. 23

Spirochæta pallida (syphilis) in adrenal of child with congenital

syphilis. (Gaylord.)]

=Evolution of the Disease.=--Ever since the days of Ricord’s writings

on the subject it has been customary to group the manifestations of

syphilis into three groups or stages: _the primary_, _the secondary_,

_and the tertiary_. Less stress is laid upon these stages than

previously, yet it is convenient to retain them for descriptive

purposes. It should be emphasized, however, that between them there are

no arbitrary limits of time or tissue. _Primary_ syphilis under this

classification includes the first period of incubation and the symptoms

and appearances of the initial lesions. _Secondary_ syphilis may be

made to include the earlier constitutional symptoms which involve or

at least become apparent upon the more superficial portions of the

body, _i. e._, skin, mucous membrane, lymphatics, etc. Later comes

the so-called _tertiary_ period, in which the body surfaces are not

necessarily spared, but in which also deep lesions of the viscera, the

bones, the brain, etc., are noted. Between the first and the second

stages comes the so-called second period of incubation. The second and

third stages are characterized by frequent neoplastic formations, which

assume the type of the infectious granulomas and are commonly spoken of

as gummas; these lesions are destructive in their tendency, and will so

prove unless dissipated or aborted by suitable treatment.

_In the first and second stages of the disease it can be conveyed by

inheritance and inoculation_; in the later stage such an occurrence is

exceptional.

That syphilis is, _per se_, an infection is proved by the

constitutional symptoms which accompany its earlier manifestations; the

fever, usually mild, though sometimes well marked, which comes early

in the course of the disease, the general lymphatic involvement, the

malaise and depression, all indicate the systemic disturbances of a

true toxemia.

The periods of quiescence between successive outbreaks of the disease

are, moreover, characteristic, although they sometimes lull the patient

and his physician into an inactive state, during which medication is

too often suspended, so that when fresh disturbance arises vigorous

treatment must be renewed.

_The infection of syphilis occurs on the instant of inoculation_, as in

the case of tetanus. This is important, as upon it depends the question

of early local treatment. While excision of the primary sore, or even

of an area which might have become infected during exposure, and before

the actual formation of the chancre, has been often practised and urged

by some, experience has shown that it has little to commend it, since

the general experience is that it does not prevent the development of

the disease.

In its tendency syphilis is constantly progressive and destructive,

although it often behaves in a capricious manner, sometimes when under

efficient treatment and generally when treatment is inefficient. It

is usually more virulent in the dissipated and those who are weakened

by inheritance or poor constitutions, or by other disease. One reads

in literature on the subject about the malignancy of some cases and

the benignancy of others. Some cases seem to have a malignant aspect,

while others run an unusually mild course, so much so as to raise the

question whether the patient had syphilis. As far as the nature of the

parasitic cause is understood, this would depend on differences in the

make-up of the individual rather than in the actual virulence of the

germ. In the extremes of life individuals are more susceptible. When

implanted upon a tuberculous constitution it sometimes renders the

tuberculous lesions more active; whether it acts as a mixed infection

is not definitely known. Tuberculous lymph nodes frequently break down

during the course of secondary syphilis, and consumptive patients grow

rapidly worse. Syphilis, like alcohol, tends to play havoc with the

bloodvessel walls, and their combined effects in this direction are

greatly to be deprecated and should be prevented.

=The Lesions and Secretions which Convey Infection.=--As far as

acquired syphilis is concerned _absolute contact_ is necessary between

the infecting material and the infected area, while upon the latter

must exist some abrasion of the surface. Chancres and the early

eruptions or mixed lesions have been proved to be absolutely virulent.

The genitalia of both sexes are frequently the site of wart-like

lesions referred to as condylomas, which are usually kept more or less

moistened by the secretion of the parts, and are fruitful sources of

contagion. _The discharging lesion of those suffering from syphilitic

disease should be regarded as capable of transmitting it_, while during

the primary and secondary stages the blood and lymph should be regarded

as probable sources of danger.

Inoculation with the blood of patients during these stages has been

known to be successful. How long the blood retains its power of

infection is uncertain; it is usually regarded as free from it when the

disease is latent.

The _natural and physiological secretions of various organs_, _e.

g._, saliva, milk, perspiration, tears, and urine, are not generally

believed to _be capable of transmitting the disease_. The semen of

syphilitic men may reproduce the disease by heredity but not by direct

inoculation. It is possible under these circumstances for the father

to transmit the disease to the ovum without previously infecting the

mother; such infection of the ovum by diseased spermatozoa is quite

different from the infection of the ovum by the mother who has acquired

the disease, the father having escaped it.

In a general way it may be held that secretions of organs, or even of

lesions, which are non-specific, are not contagious except as they

happen to be mixed with blood or with disintegrated portions of actual

syphilitic lesions; thus, for instance, vaccinal lymph might be safely

taken from a syphilitic subject if there were absolutely no admixture

of blood. _But the difficulty of securing pure lymph is such as to

make its use inadvisable because of its danger._

_Suppuration frequently complicates syphilitic_ lesions. This is to be

regarded as in the nature of a secondary and pyogenic infection. It has

not been established that the germ of syphilis is by itself a pyogenic

organism.

_Gonorrhea or chancroid is often simultaneously contracted with

syphilis_, with resulting clinical complications that are perplexing as

well as difficult to treat. The contagion of chancroid acts promptly,

as will be stated in the chapter on Chancroid; and so it may happen

that the sore which begins as a chancroid is gradually converted

into a true chancre, the change taking place so gradually that it is

difficult to state when it begins or is completed. In this way result

the so-called _mixed sores_, which may give rise to so much doubt that

the surgeon feels it wise to wait for some secondary manifestations

before deciding that syphilis has been acquired. Confusion is often

created by preliminary treatment which the local lesion has received

previous to its examination by the surgeon. Patients, especially in the

lower walks of life, frequently go to a druggist or to someone who will

cauterize the sore and thus mask its characteristics to a degree which

makes prompt diagnosis impossible. Again, patients are often uncertain

regarding the matter of time, which is of great importance; thus the

sore which appears within a few days after exposure may be chancroidal,

while one which comes on twenty or thirty days afterward may be

syphilitic. These periods, however, afford little help when there have

been repeated exposures, by which confusion may be caused; but an

accurate and complete personal history will be helpful toward a correct

diagnosis.

=Location of Primary Lesions.=--Owing to the greater delicacy of the

mucous membranes they are more frequently the site of primary lesions

than the skin: 85 to 90 per cent. of all primary sores occur about

the genitalia; in men, especially on the inner side of the prepuce,

the glands, and the sulcus behind it; externally, chancre may occur

upon any part of the surrounding skin; in women, the tissues about the

vulva are most frequently its seat. Occasionally it is found within the

vagina, but rarely upon the os. The so-called extragenital chancres

are met with anywhere, especially on the most exposed parts, as the

lips, tongue, tonsils, eyelids, and nipples. Syphilis is occasionally

conveyed to a wet-nurse by the infected mouth of an infant suffering

from hereditary disease; even multiple chancres sometimes occurring.

Conversely, children have been infected by wet-nurses with syphilitic

lesions about the nipple. The disease has been conveyed by bites, as

upon the face and fingers. Surgeons and obstetricians are peculiarly

exposed, as are also nurses, to this disease, especially occurring

upon the fingers and hands. Infants have been known to be inoculated

during parturition. These are all examples of _direct_ or _immediate_

contagion. On the other hand, the disease may be positively conveyed

by utensils in common use between different individuals, as table-ware

or tobacco-pipes; by tools of trade which are passed from one person

to another, as, for instance, the blowpipe in glass factories; and by

cigars as they are made in some places, the wrapper being moistened

from the mouth of the cigarmaker. These are examples of its _indirect_

transmission. Physicians are familiar as well with instances where the

disease has been conveyed by instruments, either surgical or those of

the dentist. So possible is this last form of contagion that dentists

are trained to sterilize their instruments as carefully as does the

surgeon.

Possibility of conveying syphilis by vaccinal lymph has been alluded to

as occurring only in those instances where the blood of the syphilitic

patient is mingled with the lymph. The production of vaccinal virus

is now, however, so well regulated that it is rare that the surgeon

employs humanized lymph. Some cases considered vaccinal have been due

to the _use of infected instruments_; hence the necessity for extreme

caution in this regard. When the disease is acquired in a non-venereal

manner it is called _syphilis insontium_, or syphilis of the innocent;

this, however, is an unfortunate expression, as it tends to cast

reflections upon other cases which may be, in effect, just as innocent.

=Symptoms of the Ulcer.=--In all probability the initial sore and the

ensuing lymphatic involvement are due to the parasite and to its toxic

products. These latter are quickly taken into the general circulation

and are held to confer the immunity which syphilitics enjoy before

the outbreak of the general eruption. Anemia, malaise, and other like

symptoms are evidences of a progressive intoxication or toxemia, while

the earlier eruptions, which tend to evince the contagious element in

a rather virulent form, may be due to the germs alone, or combined

with their toxins. On this hypothesis can be explained the partial or

complete immunity evinced by mothers who bear syphilitic children, the

infection coming from the father.

From the first evidence of infection the whole syphilitic process gives

evidence of its infectious character. The bloodvessel walls undergo a

thickening of their coats and more or less obliteration of their lumen,

and this, of course, causes a disturbance in the nutrition of the parts

supplied by them. This vascular change can be recognized even in the

minute vessels of the initial lesion, and thereafter pertains to most

if not all specific manifestations of the disease.

Our knowledge of the nature of this disease would be more complete were

it possible to convey it to animals, but these are practically exempt

from it, for the few and rare instances where, it is said, the disease

has been inoculated upon the higher quadrumana furnish insufficient

data. In this respect the disease is like the exanthemas, of whose

parasitic origin there can be no question.

_The First Period of Incubation and the Chancre._--The time which

elapses between the exposure and the first appearance of the initial

lesion is known as the _first period of incubation_. _This varies,

within wide limits, from ten days to forty or fifty_; some writers have

made it even seventy days. The average period varies from three to four

weeks. There is often uncertainty as to when the induration began, and

patients, women especially, may easily make a mistake of several days

in fixing this date.

_Every case of acquired syphilis begins with an initial sore_, though

this may be so located or so complicated with some other lesion as to

be overlooked. The character of the induration varies somewhat with the

location, _i. e._, whether upon the skin or mucous membrane. The amount

of moisture or maceration to which it is exposed will also influence

its appearance. It may be minute, so as to almost elude observation

even on visible parts, or it may spread and involve an area 1 Cm. in

diameter. The lesion is _usually solitary_, but when several abraded

spots are infected at the same time there may be multiple sores. When

a surgeon sees a lesion of this character it has usually changed its

original appearance--perhaps by some previous treatment, perhaps by

maceration. There is one invariable feature upon varying expressions

of which diagnosis is based, and that is _induration_. The instances

in which this fails are very rare; on the other hand, it is possible

that it may be the result of treatment already undergone, and for this

reason the recent history of the case should be obtained; in other

words, _the typical chancroid is always indurated_, but an indurated

sore does not of itself necessarily indicate syphilis if it can be

satisfactorily accounted for in other ways. The presence of an active

primary lesion seems to confer immunity to subsequent infection for a

period co-equal with the active manifestations of the disease, although

even in this respect exceptions are occasionally to be noted.

The induration of syphilis develops beyond and beneath the limits of

the superficial lesion, and gives the sensation, when grasped between

the fingers, of a piece of firm material embedded in the skin or

membrane. It is firm, slightly elastic, with usually well-defined

boundaries, which accounts for the expression, _parchment induration_.

Ordinarily no pain or other sensations accompany its formation

or attract attention; hence the frequency with which it escapes

observation for some time and the uncertainty which the patient feels

regarding the dates. The surface of the induration usually becomes

moist or abraded and frequently ulcerated; but these surface lesions

tend eventually to heal, even if let alone, except in those parts, _e.

g._, the lips, where they are constantly bathed by discharge.

The characteristic induration disappears slowly in a few weeks or

months, leaving ordinarily no trace of its existence, although

sometimes a small scar, occasionally pigmented, is left to mark its

site.

There are two or three classical varieties of chancre which deserve

more minute description. As ordinarily seen upon the genitalia, a

chancre may assume the following types:

A. Dry, scaly papule.

B. Superficial erosion.

C. Hunterian, or ulcerating chancre.

A. =Dry Papule.=--The _dry papule_ commences as a small rounded area of

redness, becoming infiltrated and rising above the surface, gradually

developing into a nodule the size of a pea or larger, over which the

superficial skin seems to be thickened. Should the summit of this

nodule become abraded there will escape a serous fluid, which dries

and forms a thin scab. This papule may disappear more slowly than it

came, or may become more infiltrated, while its surface breaks down

into an ulcer, whose area will be dropped a little below that of the

surrounding tissue. In this case the induration is produced almost

entirely by new round-cell infiltration, as in the other varieties;

when it ulcerates these cells are the ones mainly to suffer, so that

there is not much destruction of the original elements, and but little

scar remains.

B. =Superficial Erosion.=--The superficial erosion is the most common

of the primitive sores, but is not often seen so early as to have its

first appearance noted. It begins as a well-defined, dark-red area,

which loses its epithelium and exposes a raw surface, with a trifling

depression whose edges are usually on a level with the surrounding

skin, while in the previous case the edges are generally characterized

by an elevated margin. The base of this sore is also indurated, and

partakes usually of the parchment-like character already described.

C. =Hunterian Chancre.=--The Hunterian chancre, so named after John

Hunter’s description of it, is the most distinct and typical of these

primary lesions. It begins as a papule, with some erosion, increasing

slowly in size, sharply outlined, with a somewhat flat top. As it grows

larger it increases in firmness until its base is extremely dense.

In color it is greenish or bluish red, and this color appearance is

more distinctive than in the other forms. In from one to three weeks

its surface epithelium is usually loosened by maceration, and serous

discharge is the consequence, or else it becomes covered with a grayish

exudate, which, by its location, is rarely allowed to form a scab. The

centre of the ulcer becomes deeper, its edges more elevated, and in

typical cases a minute crater is formed by a characteristic destructive

process. While the Hunterian chancre tends in ordinary cases to slowly

disappear of itself, this involution can be materially hastened by

local and constitutional treatment, and usually heals, when properly

treated, with but slight local evidence of its previous existence.

=The Mixed Chancre.=--Chancroid will now be described, and its

consideration will include the statement that it may be followed by

true syphilitic chancre. Such a lesion is known as _mixed chancre_ or

_mixed sore_, and indicates a simultaneous infection by two distinct

infecting agencies; it may easily cause confusion, for if seen early

it will lack the characteristic induration of syphilis. This latter

will only appear about the time that the chancroidal ulcers should be

healed, if promptly and properly treated. Supposing this treatment

to consist at least in part of caustics, the surgeon may be in doubt

as to whether the induration is due to this agency or to developing

syphilis. It seems justifiable to imagine causes of this kind while

awaiting the further developments of the case, and to postpone vigorous

antisyphilitic remedies until the diagnosis is established. It is a

serious thing to condemn to a long course of mercurials a patient who

perhaps does not need such drastic drugs. Instances arise where the

situation is to be carefully considered in view of these possibilities.

Should the healing and apparently healthy ulcer, however, take on an

indurated base and develop the typical scleroses of chancre, it may be

supposed that all doubt has been removed. The possibility of syphilitic

infection being implanted upon a chancroidal base by subsequent

exposure should also be taken into consideration. This will require an

accurate history and a faithful narration of the same by the patient.

There are, also, the _extragenital chancres_, which may be met with

upon the hands, upon the breasts, in the oropharynx, as well as about

the eyelids. Chancres on those surfaces of the body where tissues are

loose may attain considerable size and ulcerate early, the discharge

drying into scabs or crusts, which mask the underlying ulcer. Around

the margins of the nails these lesions show but slight induration.

Sometimes suppuration and granulation are profuse. When appearing

upon the tonsils there is nearly always ulceration, with considerable

swelling and often a false membrane. A patient with this lesion will

complain of sore throat, and involvement of the surrounding lymphatics

is usually extensive.

When _chancre appears upon the lips_ there is usually extensive

induration; the lesion attains considerable size, with protrusion,

unless recognized and treated, and ulceration takes place early and

deeply. It may be confused here with _epithelioma_. The latter occurs

during the later period of life, is slower in its evolution, and its

involvement of the neighboring lymph nodes. The local changes which

often precede cancer, _e. g._, hyperkeratosis and papilloma, will be

lacking in chancre of the lip.

Sometimes at the site of the original chancre, which may have healed,

there will be found one of the later lesions of the disease, which may

be mistaken for another primary sore occupying the site of the first

one. It may be distinguished by its central ulceration, its tendency to

extend, and by the absence of the lymphatic involvement which is met

with in the early stages of the disease.

=Pathology of the Chancre.=--The chancre should be regarded as

the first neoplastic evidence of a disease which is throughout

characterized by its tendency toward new-cell formation. In the

developed chancre there is a well-defined cell proliferation in the

skin or mucous membrane, whose bloodvessels show the same character

of change already mentioned, since in the walls, both of the minute

arteries and veins, are found many new cells, some of which were

originally leukocytes, but most of which are products of cell division,

as shown by their numerous mitoses. All the coats of the vessels are

involved and even the perivascular spaces are involved and obliterated.

Essentially, then, the chancre consists of a local infiltration of the

superficial tissues by cells, most of which are of the round type;

the whole constitutes what may be spoken of as the initial sclerosis,

which remains or disappears as such unless infected secondarily. This

sclerosis should be carefully sought in every suspected region when

the patient is first examined. It may range in bulk from a millet-seed

to that of a good-sized grape; it is usually movable upon the tissues

beneath; it may ulcerate deeply, and, should it persist for a long

time, it may seem unusually active just before the outbreak of the

so-called secondary symptoms.

But little can be predicted with regard to the future course of the

disease from the size, number, or appearance of the primary sores. The

nature of the tissues upon which the virus has been implanted is a

more important feature in the evolution of the disease than anything

pertaining to its primary lesions, so far as appearances go. In

patients of depraved habits or vitiated constitutions the chancre may

often become gangrenous or phagedenic.

=Lymphatic Involvement.=--Soon after the appearance of the primary

sore, or coincident with it, the enlargement of the adjoining

lymphvessels and nodes begins. This is noted first in those which

are in closest communication with the site of the chancre, usually

in the groin. Occasionally thickened lymphvessels may be felt as

cords extending along the dorsum of the penis. There may be enough

involvement of the perivascular spaces to produce this appearance and

sensation even around the bloodvessels. This lymphatic involvement is

exceedingly significant, and yet may be found to some degree after

chancroid and even after herpes of the genitals. It is, of course, an

expression of a travelling infection--in the first case produced by the

syphilitic virus; in the second, by the chancroidal virus; and in the

third, by ordinary pyogenic organisms which enter through the pathway

afforded by the herpes.

The involved lymph nodes of syphilis suppurate much less often than

do those of chancroid, and suppurating bubo is, therefore, not common

in syphilis. The term _bubo_ generally means an involvement of the

lymphatics in the groin, although, strictly speaking, it implies

a similar condition in any part of the body. _Syphilitic bubo_,

therefore, is to be distinguished from chancroidal as well as from

non-specific bubo. These lymphatic lesions are sometimes spoken of as

constituting the characteristic _adenopathy_ of the disease, but this

is an unfortunate expression, as it implies _glandular_ involvement,

and the term lymph gland should never be used, since the structures are

not glandular in any respect. The enlargement and persistence of these

lymph nodes constitute peculiar features of the disease, and may be

noted long after the subsidence of active manifestations.

=Treatment.=--With the earliest possible recognition of a syphilitic

chancre or sore there is need for active and prolonged constitutional

treatment, in addition to whatever may be required locally. If the

diagnosis can be made, _constitutional treatment should commence at

once_; only in cases of doubt is it advisable to wait. The local

treatment is a matter of ordinarily small importance; the sores tend

to heal spontaneously and quickly when the system is brought under

the influence of mercurials. There are few authorities who recommend

excision of the primary lesion or believe it is possible to abort

syphilis by anything that can be done to the chancre. It is advisable

to make mild antiseptic applications only. A chancre, however, in a

location which makes it difficult to keep the parts clean, should

be exposed to treatment by a minor operation, as an incision of the

prepuce, circumcision, or a dilatation or incision of the hymen.

Aside from such operation the indication is for surgical cleanliness;

soap and water followed by hydrogen peroxide, which may be continued

as an application, or dusting with calomel, will usually prove

sufficient. Various antiseptic solutions may be used. Dry applications,

however, are the most convenient and usually the most serviceable;

iodoform should be avoided on account of its penetrating odor; and

pure, dry calomel will sometimes prove a mild caustic, and is best

reduced with one to three parts by weight of bismuth subnitrate. The

stronger applications, especially caustic, are only employed when

there is unhealthy ulceration. If the sore is gangrenous it should be

cocainized, then the surface thoroughly treated with some powerful

caustic like nitric acid, and thereafter kept moist with aqueous

antiseptic solutions. When the surface is practically healthy, dry

preparations or unguents may be employed, preferably the mercurial

ointments. There is greater difficulty in preserving cleanliness about

the female genitalia, and here the use of antiseptic cotton or gauze

will probably be necessary in addition to the other precautions.

Surfaces should be kept apart by their aid, and it is well to use

frequent antiseptic douches or occasionally to insert a suppository

containing an antiseptic drug. Of the various preparations used those

containing mercury in some form are doubly serviceable. The inguinal

lymphatics should be kept anointed with a mercurial ointment, which

should be thoroughly rubbed in, and the parts afterward protected with

oiled silk.

While these local measures are being employed vigorous general

treatment should be promptly instituted. This will be discussed when

dealing with treatment of the constitutional features of the disease.

There are locations in which chancre gives rise to considerable

distress, as, for instance, upon the lip and tonsils. Great improvement

and relief of pain in these lesions is afforded by proper use of

auxiliary drugs.

In regard to local precautions, the patient should be impressed with

the virulent and infectious character of the discharge from every

primary lesion, and given minute and cautious directions so that

its transmission to others can be prevented. This will mean the use

of separate utensils, as well as soap, towels, etc., possibly the

temporary isolation of the patient.

CONSTITUTIONAL SYPHILIS.

Between the time of appearance of the primary sore and the development

of widespread constitutional symptoms there intervenes a period of

latency, the _second period of incubation_. This is more variable

in duration than the first. The shortest time on record is about

two weeks, and the longest about two hundred days, the average

time being six or seven weeks. The _secondary symptoms_ indicate

complete generalization of the syphilitic poison, and follow the

early manifestations in almost every case; nevertheless, there are

instances in which they are either wanting or are so trifling as to

escape observation. A careful examination during the second period will

usually show, however, that the lymph nodes throughout the body are

gradually becoming enlarged, especially those in the neck, along the

border of the sternomastoid, the occipital nodes, those in the axilla

and groin, and particularly one or two small ones above the inner

condyle of the humerus, known as the _supracondyloid_ or _epitrochlear_

nodes. When these latter become involved without evident and local

cause, syphilis is always to be suspected or even diagnosticated. This

node is to be found by bending the patient’s elbow and feeling for

it on the inner side, above the condyle, in the interval between the

biceps and the triceps. The other lymph nodes of the body might also

be found involved if they could be as easily palpated. This lymphatic

involvement is quite independent of skin or other lesions, and does not

yield as readily to mercurial treatment. The enlargements are usually

movable, distinct in outline, and never suppurate unless locally and

secondarily infected. In tuberculous patients, however, they may

break down. This generalized involvement of the lymphatics is also of

importance in diagnosticating old syphilitic infections.

During the second period of incubation there is generally a certain

degree of malaise and progressive anemia. Examination of the blood

will show diminution of hemoglobin, and a relative if not actual

leukocytosis, due to reduction in the number of the red corpuscles.

Occasionally the anemic features become pronounced; the patient may

complain of weakness, lassitude, sleeplessness, failure of appetite,

and of pain and discomfort in the bones and joints, more pronounced

at night, and often regarded by patients as “rheumatic.” The painful

joints may also show a slight swelling due to increase of the joint

serum.

Sometimes intermittent fever accompanies these cases, especially

during the early eruptive period. The rise of temperature is noted

mainly in the evening, when it may reach 104° or even 105° F. It does

not last long, and often precedes the appearance of a well-marked and

characteristic eruption. It is a peculiar feature of the syphilitic

poison that it seems to attack points of least resistance in each

patient, as is the case with that of influenza. In one patient fibrous

tissues will suffer most; in another, joints; in others there will

be headache or expressions of perverted nerve activity, as vertigo,

convulsions, disturbances of sensation, temporary paralysis; again

there occur disturbances like mild pleurisy, splenic enlargement, or

jaundice. Occasionally there will be a typhoidal condition, during

which the kidneys are seriously compromised. Morbid conditions are

intensified by an attack of syphilis. During rheumatism and the various

forms of neuritis, and during almost all affections of the central

nervous system, symptoms are, under these circumstances, frequently

aggravated. In malarial countries it is said that latent syphilis

sometimes becomes active when malaria is present. Lesions of the bones

and joints are occasionally influenced, while some claim that fractures

occur more readily in syphilitic subjects, and it is generally conceded

that delayed union of fractures is often due to this cause. I have seen

fracture, apparently spontaneous, of both tibiæ, one after the other,

in a patient with syphilitic disease of the cord and bones. I have also

seen exuberant callus form around a fracture in a syphilitic subject,

as it never does under ordinary circumstances. Injury seems sometimes

to localize the manifestations of the disease; thus chronic irritation

at the site of old syphilitic lesions frequently becomes a point of

development for epithelioma, or some other expression of malignant

growth. This is seen particularly in cancer of the tongue, which

sometimes follows the change in the epithelium known as _leukoplakia_.

The _influence of an attack of erysipelas_ upon certain specific

lesions is remarkable. In many instances eruptions and ulcerations have

been known to subside, and gummas and exostoses to disappear, after an

attack of erysipelas involving their site, but these lesions are likely

to reappear after the disappearance of the acute infectious process.

The temporary effect of the toxins of erysipelas upon syphilitic

lesions is similar to their influence upon some malignant growths.

=Syphilis of the Skin.=--Passing now to the lesions of early

constitutional syphilis as manifested in particular regions or organs

of the body, we take, first, the skin. When syphilis seems to have

ended its existence during the primary stage (Fordyce) no further

disturbances are expected, and only by waiting can the termination of

the disease be determined.

The malignancy of the disease may be estimated by noting the rapidity

with which the destructive lesions appear; thus gummas which appear

early in the skin or mucous membranes, or elsewhere, indicate a serious

type of the disease. So also does profound cachexia, including in this

term more than mere anemia. The devastations of the disease in Europe

during the fifteenth century show that it presented at that time a

severe type.

The eruptions of syphilis have been grouped under distinctive terms,

and are usually referred to as _syphilides_ or _syphilodermas_. It has

been already stated that among the new formations of syphilis are those

known as syphilodermas; any of the former which are distinctly due to

syphilis may be syphilomas. Thus, we may have syphiloma in the skin,

in the bones, in the viscera, etc. It has been customary to speak of

the syphilides as simulating the non-specific eruptions and identify

them by placing before them the adjective syphilitic. Thus writers

formerly described syphilitic psoriasis, syphilitic erythema, etc.;

but these terms have been abandoned, because it is recognized that the

skin lesions of syphilis while imitating most of the features of the

non-specific diseases are yet distinctly different from them. We speak,

therefore, now of a macular, vesicular, papular, squamous syphilide,

etc., implying thereby that it is vesicular, scaly, or otherwise, as

the case may be, and at the same time that it is a cutaneous expression

of syphilis.

[Illustration: PLATE VIII

Grouped Miliary Papular Syphilide.]

[Illustration: PLATE IX

Mixed Papular and Papulopustular Syphilide.]

[Illustration: PLATE X

Tuberculous Ulcerating Syphilide, showing Lesions in Different

Stages.]

The _syphilodermas have certain peculiarities_ which are striking

and distinctive; they are symmetrically distributed; their color is

characteristic, and is due to the disease of the bloodvessel walls,

which has been referred to, by which stasis is favored and exudation

encouraged. The pigmentation is often striking, and, whatever it

may be at first, it assumes a tint described by the terms “raw ham”

or “coppery.” Dark pigmentation may take the place of the lighter

colored, as the sole evidence of the existence of the previous lesion.

Occasionally, however, the normal pigment of the skin disappears and a

bleached-out area marks the site of the previous lesion. This is often

irregular in shape and considerable in size. Such a spot is spoken of

as _leukoderma_. Again, the syphilodermas are generally _polymorphous_,

and seem to be capable of imitating almost every known non-specific

skin affection; so close is the resemblance that it often requires

careful study of the case to permit of diagnosis. The absence of

itching is also a feature of most of these cases.

The early syphilides are superficial, distributed generally and

symmetrically, and disappear spontaneously.

When skin lesions are clustered, as in the macular and papular forms,

they usually group themselves symmetrically and in more or less

circular outline. When, however, they are too regularly arranged, it

may be taken as evidence of their older and more relapsing character.

The later skin lesions of syphilis differ in several respects from the

earlier. They are less regularly grouped; they involve a greater depth

of tissue; they tend to ulcerate and to leave permanent scars; and they

have around them a more infiltrated area, probably because they are

deeper. They are, however, not so infectious as the earlier lesions,

and it is rare that they are of serious menace to others. (See Plates

VIII, IX, X.)

Fordyce and others have pointed out that the prompt and specific

influence of mercury and even of iodine upon these eruptions is an

instance of the selective action of certain drugs, and nothing could be

more conspicuous in demonstrating it.

Certain types of syphilide are common in the earlier stages and others

in the later; there may be a well-defined limit between the two, since

in not a few instances all types seem to be combined.

The first eruption of so-called secondary syphilis assumes the

erythematous or macular type, and has been referred to as _roseola

syphilitica_. It appears as a generalized eruption, in spots varying

from 0.5 to 1 Cm. in size, which are of a vivid color and scarcely

elevated above the surface. It commences usually upon the abdomen,

proceeds to the chest, and then to the extremities. It does not often

appear upon the face. Two or three weeks may be consumed in its

generalization over the entire body. If let alone it has a duration of

a few days to several weeks, and may then fade away, leaving nothing to

indicate its presence save a slight pigmentation.

Of more pronounced character is the _papular_ eruption, which commences

as a small papule, and is described as _lenticulopapular_ and _miliary

papular_. At first these are generalized, then become circumscribed,

and exhibit transition forms from the early to the later type of

lesions. The papules vary in size from that of a millet-seed to that

of a split pea; even this type may disappear without ulceration or

suppuration.

Lichen planus may be mistaken for papular syphilide, but may be

distinguished from it by intense itching and by lack of the pigment

changes which characterize the syphilide.

The _squamous syphilide_ is sometimes a continuance of the papular,

and sometimes it begins as such. It is characterized by a variety of

scaly macules and papules, which strikingly resemble the lesions of

psoriasis. The latter are seldom seen on the palms and soles, while

the squamous syphilide is very frequently seen in these locations.

Moreover, along with the squamous lesions are frequently associated

other skin lesions, which give the case a complex type, resembling

at one point one of the non-specific affections, and others at other

points. Such changes are mainly expressions of various stages in the

involution or degeneration of the papule, but they may give the case a

variegated appearance, in which pigmentation may be prominent.

Some years ago Biett described a form of syphilide which he claimed

was unmistakable and indicative. Since he described the lesion it has

been known as _Biett’s collarette_. It appears in from ten to twenty

weeks after the secondary symptoms are fully declared, is superficial,

usually situated upon the trunk and extremities, but never upon the

palms or soles. It consists of a flat papule almost level with the

skin, 1 to 2 Cm. in diameter, rounded in contour, while around it there

is seen a zone of white epidermal scales pretty sharply defined and

giving it the name of collarette. The area within is dry and painless,

and the ring itself narrow. There is little or no itching. It may be

followed by some other skin lesion. The lesion is often so mild as to

pass unnoticed.

At other times _pustulocrustaceous syphilides_ will appear above the

level of the skin, surrounded by a series of narrow concentric rings,

not scaly, but composed of a number of small pustules, the first ring

being perhaps an inch from the centre of the inner lesion. This is seen

more often in males than in females, and it seems as though the smaller

pustules were the result of an auto-infection of ordinary pyogenic

character. In the presence of either of these lesions a positive

diagnosis of syphilis can be made.

The _pustular syphilide_ may give rise to large or small pustules,

which soon become superficial ulcers, often irregular in shape, with

an unhealthy floor which may be livid or gangrenous, or may resemble a

diphtheritic lesion, while from its surface exudes a mixture of blood,

debris, and pus, which dries into dark-colored crusts and constitutes

the lesion known as _ecthyma_. These lesions are often deceptive, since

while scabbing seems to be occurring over the surface the ulceration

may be extending beneath. This is an intermediate or earlier tertiary

rather than a secondary lesion.

Another type of pustular syphilide is that known as _rupia_, where

the ulcers are larger and are covered with concentric layers of crust

resembling an oyster-shell. These lesions begin as papules and undergo

changes which make them bullæ or pustules and then open ulcers. The

peculiar scabs are somewhat conical in shape when not disturbed, and

are greenish or brownish in color. If they are dislodged, irregular,

indolent, and often sensitive ulcerated areas will be found beneath

them. Even when these ulcers heal they are irregular in outline and

show a white scar often surrounded by an areola of pigment. This rupia

is the most visible lesion of syphilis, as no other skin disease

assumes any such type.

In the last-described and ulcerative forms of syphilide there is a

possibility of septic infection, or at least of septic intoxication by

absorption; hence the need for care in this direction. In fact, into

the treatment of every pustular indication of syphilis the elements of

local protection and local antisepsis should enter.

=The Mucous Membranes.=--Here the manifestations of syphilis are of

great importance because of their extreme infectiousness. The earlier

manifestations are seen mainly about the mouth. When an eruption

appears upon the skin a condition corresponding to it may often be

recognized in the pharynx and upon the uvula and soft palate. This will

be accompanied by discomfort, and the patient complains of “soreness

of the throat.” These throat lesions are chronic, liable to recur,

and disappear slowly, unless the patient is vigorously treated; they

sometimes cause dryness of the fauces, followed by a free flow of

mucus. The dusky discoloration of the rash is quite distinctive.

The congested areas have a dusky hue on the skin and are spoken of as

“coppery” or “raw-ham” in tint. They are usually well outlined; should

the disease progress they become eroded. “Syphilitic sore throat,” as

this condition is often called, may be aggravated by the use of tobacco

and by unclean mouths. The involvement of the cervical lymphatics will

be proportionate to the vividness of the lesion.

TERTIARY OR CONSTITUTIONAL SYPHILIS.

There is no distinctive time limit between the so-called secondary and

the tertiary symptoms of syphilis. Generally the lesions disappear with

but little treatment; in many instances they will fade away without

any. In most cases, however, the patient, even under poor management,

takes enough medicine to disperse the lesions more quickly than they

would spontaneously subside. If he discontinues medicine for several

weeks, sometimes many months will elapse before there are any active

manifestations of the disease. During this period, however, the

lymphatic enlargements will not decrease perceptibly, and there may be

evidence of advance in this direction. The so-called tertiary symptoms

appear usually without fever or other symptoms, and not often in less

than five or six months after the commencement of the disease. On the

other hand, their advent may be delayed for years, even when the early

treatment of the case has been but partially effective.

No organ or tissue in the body is exempt from the ravages of tertiary

syphilis. Even the finger-nails and the hair may suffer, while the

teeth are affected in the hereditary manifestations. Affections of the

skin occur, according to Haslund, in about 12 per cent. of the cases.

The _mucous membranes_ are liable to exhibit those lesions above

described, known as _mucous patches_, usually regarded as late

secondary symptoms. The description applies equally well to the

tertiary lesions. They occur about the oropharynx, upon the tongue,

the lips, the nostrils, and the eyelids. They are frequently found

also about the rectum, anus, and genitalia of either sex. In general

they present about the same appearance. They commence usually with

a slight elevation of the surface and at several points, sometimes

simultaneously and successively. These surfaces ulcerate superficially,

and thus are produced irregular but rounded patches, with uneven edges,

of grayish-yellow surface, which ordinarily are not sensitive, but

occasionally extremely so. They may disappear under local treatment,

but in that case tend to recur at frequent intervals. If unnoticed

or not properly cared for the ulcers may become deeper and assume

an unhealthy appearance. In the mucus-lined cavities affected the

condition of these ulcers will depend upon the personal habits of the

patient. In mouths where tartar has accumulated upon the teeth, or

where the toothbrush is seldom used, the patches may become large and

foul.

_These lesions are extremely infectious_ and the disease may be

conveyed by kissing, by the common use of small domestic utensils,

by the pipe, by dentists’ instruments, etc. Patches occurring at the

junction of the skin and mucous membrane may extend over onto the

latter and become deep, specific ulcers. Lesions of this character

need judicious local as well as constitutional treatment. They will

often disappear under the latter alone, but it should be combined

with local measures. These consist in cleanliness and the use of

various antiseptic solutions or applications. An antiseptic mouth

wash, as diluted hydrogen dioxide, or of water given a mahogany color

by tincture of iodine, should be frequently used. There should be an

application of a 5 per cent. solution of silver nitrate, or some other

astringent, stimulating, or mild caustic.

[Illustration: FIG. 24

Grouped papulopustular syphilide and numerous pigmented spots from

former lesions. (Fordyce.)]

=The Skin.=--The late syphilides of syphilis belong to the _gummatous_

or _tuberculous_ types (_i. e._, tuberculous in the anatomical sense,

or nodular). The latter may occupy the entire thickness of the skin or

lie even deeper. Such lesions may begin as papules and develop into

distinct and circumscribed nodules, while these may coalesce into

considerable masses. These tend to break down and leave scars after

they have disappeared. There is little difference, microscopically,

between the nodule and the gumma. Clinically, the tuberculous lesions

spread usually in a serpiginous manner, producing a more or less

curvilinear outline. (See Figs. 24 to 27.) These ulcerations undermine

the tissues to a greater or less extent, and pus and debris will be

formed in consequence. In this way they imitate considerably the

lesions of lupus, and it may require a careful study of the case and of

its history to make a diagnosis. Some of these lesions are extremely

slow in their course and long in duration. When scars form they are

usually white and smooth, with irregular borders, but sometimes are

surrounded by pigment that makes them characteristic. The extent of

the scar is no criterion as to the size of the originating lesion, the

former being always smaller than the latter.

[Illustration: FIG. 25

Ulcers resulting from deep ecthymatous syphilide. (Fordyce.)]

=The Gumma of Syphilis.=--This is as characteristic of late syphilis

as is the _condyloma_ of the earlier stage. By this term is meant a

new formation which may vary in size from a millet-seed to a large

mass. Sometimes it is diffuse, or it may be circumscribed. It seems

to originate from connective tissue, and may be met in all parts of

the body. Microscopically it consists of a delicate stroma filled with

small, round cells, the mass being furnished usually with bloodvessels,

also of new formation. Such a gumma may pass through various stages

of integration and disintegration. The cells sometimes undergo fatty

changes by which the entire mass is softened, and its interior contains

a puruloid material resembling pus. The gumma, as it increases, will

replace other tissues and cause them to disappear, and thus it happens

that when it disappears the region previously occupied by it seems

to have diminished in size. Sometimes, however, cicatricial tissue

takes its place and not only distorts an organ or part but impairs its

function. Thus softening and melting may occur at one time and a dense

scar or mass at another.

The degree of infectiousness of gummatous and other late syphilitic

ulcerations is uncertain. The later they occur, the less infectious. It

would be safe, however, to assume that they are all dangerous.

=The Gummatous Syphilide.=--This begins, as a rule, as a subcutaneous

gumma which quickly proceeds to and involves the skin. At first it

appears as an induration, developing into a distinct tumor, becoming

more indurated and firmly implanted as it grows, the overlying skin

becoming reddened and swollen. After a time there occurs softening in

the interior of the mass, and upon incision there will escape not pus

but viscid, puruloid fluid, yellowish gray in color, which may contain

corpuscles resembling those of pus. It is the content of such a tumor

as this which has given it its peculiar name, _gumma_. Should proper

treatment be rapidly pushed, it is possible for a softened gumma to

disappear by absorption, but if ulceration or evacuation has taken

place, there remains usually a permanent disfigurement at the site of

the mass; like tuberculous gummas these growths may undergo caseous or

even calcareous degeneration.

A gumma of the skin will open at one or several points, and, becoming

thus secondarily infected, may give exit to sloughing tissue and foul

discharge. If the skin directly overlies the bone, then the tumor may

involve the latter as well; and when it ulcerates, the bone will be

exposed. In the healing process, however brought about, deformity from

cicatricial contraction may cause much disfigurement. When a gumma

appears beneath the true skin and then disappears it may leave areas

of depression, with more or less adherent, bleached-out scars, perhaps

with a pigmented margin. The appearance of such scars is suggestive of

the disease even without a definite history.

The gummas form the most important features of syphilis, at least from

a surgical standpoint, since they frequently appear in the depths

as well as on the surface of the body, without any other symptoms,

and they often cause no little perplexity in diagnosis. Syphilomas,

tuberculous gummas, phlegmons, innocent and benign tumors, as

occurring especially in and upon the bone, in the muscles, tongue, the

breast, the testicle, and elsewhere, may be difficult of diagnosis.

Of course, a history of syphilis is a great help. Doubt frequently

arises when such a history cannot be obtained. Scarcely any other

disease will produce multiple lesions such as are seen in syphilis,

and when multiple they are usually distributed, with some appearance

of symmetry. Ulcers formed by their breaking down are often extremely

sensitive, but do not bleed easily, nor show a tendency to exuberant

granulation. In cases of doubt the most successful test is perhaps the

therapeutic, and consists in giving mercurial or mixed treatment to the

point of toleration and noting its effect.

[Illustration: FIG. 26

Tuberculous serpiginous syphilide resembling lupus vulgaris. (Fordyce.)]

[Illustration: FIG. 27

An ulcerating gumma of the leg. (Fordyce.)]

In many patients, especially of the hospital class, scars, which

are strongly suggestive, will be visible upon the legs. It does not

follow, however, that an old scar upon the legs, even if surrounded

by a pigmented area, is necessarily of syphilitic origin. Old ulcers

of the limbs are frequently seen in connection with varicose veins,

and may show exceedingly chronic tendencies; moreover, it is possible

for chronic and non-specific ulcers to occur in old syphilitic

subjects when the course of the local lesions may be influenced by

the old affection, although they are not specific ulcers. Benefit,

however, will in such cases accrue by the reasonable administration of

antispecific treatment, but it should be combined with suitable local

measures.

=The Vascular System.=--The lesions which are encountered in the

bloodvessel walls in chancre and early syphilis have been described.

The heart and vessels are liable to suffer, as they contain connective

tissue. Gummas have been noted in the heart, while the poison also may

produce thickening of the valves, and disease of the coronary arteries,

the endocardium and the myocardial structure.

The arteries often suffer from _arteriosclerosis_, which is either

diffuse or nodular. Endarteritis is a common manifestation of syphilis

and leads frequently to the formation of aneurysm. Sometimes this

appears as a single and large lesion; at other times hundreds of small

aneurysms will form in the arterial system of the brain, so that the

arteries are studded with them. The explanation of aneurysm under these

circumstances is that the arterial walls, being weakened, dilate under

the influence of blood pressure. Thus the arteries, from the largest

to the smallest, also may suffer. The veins likewise are subject to

syphilitic phlebitis, which is frequent in the superficial veins of the

extremities.

=Bones and Joints.=--Syphilitic manifestations in bones are frequent,

but are not so common in the joints. While early syphilitic periostitis

is not infrequent the actual lesions of the bone are mostly expressions

of late syphilis. Nearly all of them are painful. The pain is worse

at night, and is called the osteocopic pain of syphilis. At first

these bone lesions are hyperplastic, because of the connective tissue

in the bone. Periostitis is a common manifestation, and here, again,

the neoplastic tendency of the disease is manifested, in that the

periosteum is thickened as well as the bone beneath, and swellings

called _nodes_ are thus formed. Nodes are met with more often on the

tibia and the sternum than elsewhere, but are frequent upon the skull

and clavicles. No bone is exempt from these lesions. They often form

at points where there has been previous injury. These swellings are

ill-defined, and usually quite tender, while the skin over them is

easily movable unless secondary infection has occurred and suppuration

is present. The nocturnal pains in these lesions, of which patients

often complain, are sometimes excruciating. Should suppuration occur,

with subsequent formation of ulcer, there may be necrosis of the

exposed bone. Another bone lesion of syphilis assumes the type of

_ostitis_. Physiologically this consists essentially of gummatous

involvement of the connective tissue, which may be either localized or

diffuse. When this undergoes retrocession there occurs a rarefaction of

the bone, by which it is weakened and easily broken, so easily in fact

that we have to deal sometimes with what is referred to as _spontaneous

fracture_. There is frequently a thickening and condensation of

the entire bone, with some distortion, so that the actual weight

of the bone may be nearly doubled. _Dactylitis_ is the name given

to syphilitic ostitis of the phalanges, which increase in size and

become tender and useless, while the skin becomes glazed. Occasionally

the disturbance appears to involve the extra-osseous tissues rather

than the bones themselves. Bones which are spongy are liable to this

disease. Some of the bones in the face are peculiarly susceptible;

hence the loss of the bridge of the nose, or of a portion of the hard

palate, by the ulcerative processes so common in this disease.

The joints are subject to changes somewhat similar to those occurring

in tuberculous disease. There may be either a gummatous synovitis

or an arthritis, or else destruction of articular surfaces. These

joint lesions of syphilis are all slow in their course, and sometimes

difficult of distinction from tuberculous and other lesions. They have

so much in common with the joint expressions of tabes that some writers

believe that tabes is necessarily an expression of syphilis of the cord.

As long as no active destruction has occurred within a bone or joint

these cases are usually amenable to treatment, but for the actual

destructions caused here or elsewhere by syphilis there is no repair

possible, and the harm once done cannot be undone. Plastic operations

and injections of paraffin may have to be practised for cosmetic

purposes and relief of disfigurement.