suffers most in the luetic affection of these structures. It may be
met with as a diffuse process or as a gumma. In the former cases the
muscle becomes irregular in shape and size, and in the latter distinct
tumors are formed. As such growths advance and contract adhesions to
surrounding structures, there is interference with muscle play.
_Syphilitic myositis_ causes little pain, and patients with gummas in
muscles are often not seen until ulceration has begun.
The dense fibrous structure of _tendons_ and _aponeuroses_ is
frequently involved in late syphilis, causing pain and disability.
Little is discovered on physical examination, but considerable loss of
function may result. Points of tenderness sometimes are noted along
junctions with the adjoining periosteum. Such a _tendoperiostitis_ may
be painful, and even crippling.
=Bursæ.=--Bursæ are prone to be involved in syphilis, especially those
in front of the patella. A gumma frequently develops at this point,
where it constitutes a painless, somewhat tender enlargement, which
may be dense or elastic. After it has become adherent to the skin it
is usually infected, and a chronic ulcer results at this point, which
may often manifest gangrenous tendencies. This constitutes one form of
so-called _housemaid’s knee_.
=The Eye.=--Of the manifestations of syphilis in particular organs the
eye sometimes suffers severely. _Iritis_ is the most common and serious
manifestations of constitutional syphilis. It has been estimated that
nearly 60 per cent. of all cases of iritis are due to this cause. It
may occur in two months after the primary sore; it is usually acute,
and rarely begins in both eyes at the same time, but may involve one
after the other. The ciliary body is frequently associated in the
lesion, and _iridocyclitis_ occurs. It commences with congestion of
the conjunctiva, photophobia, and lacrymation. The pain is not always
severe. Inspection of the iris will show beads of lymph, a small pupil,
with loss of contractility, or the dull iris may appear infiltrated and
inflexible. The pain in some cases is extreme. Where treatment has been
only partially effective relapses are common. The greatest danger to be
feared is formation of adhesions between the anterior surface of the
lens and the margin of the pupil, _i. e._, anterior synechiæ. These are
detrimental, and serve as the cause of many irritations.
The treatment of these affections is constitutional; locally solutions
of atropine of sufficient strength to ensure dilatation of the pupil
should be used, not only to relieve the pain, but to carry the
margin of the pupil from the central portion of the lens and prevent
adhesions. The patients should be kept in the dark because of their
photophobia. Atropine may be substituted by duboisine if the former
tends to produce congestion. Leeches applied to the temples will also
give relief from pain.
The _cornea_ is often affected by a deposit on its posterior surface
of particles of debris, which give it a punctate appearance known
as keratitis punctata. It also becomes the seat of opacities which
materially interfere with vision, and prove only partially amenable to
treatment. Lesions of the cornea are frequent in hereditary syphilis.
_Retinitis_ and _choroiditis_, of either acute or chronic type, are
the most common syphilitic lesions of the fundus. They are usually
associated and involve both eyes. They come on so insidiously that they
are often far advanced when first discovered. The lesions consist of
patches of exudation and areas of atrophy, accompanied by some haziness
in the vitreous. Vision is affected in proportion to the area involved.
The _movements of the eyes_ are interfered with by lesions which
pertain, however, rather to the brain and the ocular nerves than to
the eye itself. The sixth nerve, lying on the floor of the skull, is
affected by syphilitic disease at the base of the bone. As a result of
these nerve lesions paralysis is often seen, or at least disturbances
of motility from which _diplopia_ results. _Ptosis_ occurs from
affection of the third nerve. In lesions situated below the aqueduct
of Sylvius, the paralytic condition which Hutchinson has spoken of as
_ophthalmoplegia_ is likely to appear. _Optic neuritis_ is also a late
manifestation of syphilis, and may be either chronic and mild, with a
small disturbance of vision, or acute, with rapid loss of eyesight.
=The Ear.=--The ear may suffer in various ways. The external ear may
participate in affections of the adjoining skin. The middle ear may
be affected as a result of extension of trouble from the nasopharynx,
while in the late stages of the disease patients may suffer from
labyrinthine disease, with partial or almost total deafness.
=The Nose.=--The lesions of syphilis in the nose are numerous and
offensive. Ulceration is frequent and followed by perforation through
the septum or into the mouth. When the vomer is involved the bridge of
the nose falls in. In neglected cases the whole substance of the nose
may be involved and subsequently lost. The bone is often exfoliated.
These ulcerations of the mucous membrane and periosteum give rise to
a characteristic condition known as _ozena_, with its characteristic
discharge.
=The Oropharynx.=--The tongue may be the site of intermediate and late
syphilitic lesions. Men suffer more than women, apparently because of
their use of tobacco. Mucous patches, deep ulcers, and even gummas,
single or multiple, are seen here. Gummas in the tongue are inclined to
undergo superficial ulcerative infection and become abscesses. In these
lesions there will be notable involvement of the adjoining lymphatics.
The appearance of smooth, bluish-gray patches upon the mucous membrane
of the tongue and cheeks is known as _leukoplakia_ or _leukokeratosis_.
These lesions do not respond readily to treatment; they give rise to
little or no complaint, and are often followed by malignant disease.
It is difficult to distinguish between gumma of the tongue and
epithelioma. Usually the latter is a single lesion; the former often
multiple. In epithelioma the ulcer is superficially painful, with more
elevated and indurated edges, while the pain is sometimes intense and
radiates toward the ears.
_Interstitial glossitis_ is a late manifestation of a sclerosis
beginning in the connective tissue and involving the muscle fibers,
leading to enlargement of the tongue and later to atrophy and
inflexibility.
=The Larynx.=--Syphilis of the larynx appears either as one or more
ulcers, as gumma, or as _chondritis_ or _perichondritis_, often
with necrosis of cartilage. When ulcers form they are deep and
destructive, involving even the intrinsic muscles of the larynx, and
causing harshness or loss of voice, with dyspnea. Subsequently they
lead to cicatrization, often leaving a stricture which may call for
tracheotomy. The epiglottis is also liable to ulceration and gummatous
lesions.
In these cases, aside from the general treatment, there is need also
for local applications of combined antiseptic and anodyne character.
Cocaine or one of its less toxic substitutes may be used in spray or
by insufflation, in connection with an antiseptic powder, morphine
or heroine. Edema of the glottis may be subdued by the local use of
adrenalin.
=The Alimentary Tract.=--Between the mouth and the rectum the
intestinal canal is rarely involved in syphilitic disease. In the
_rectum_, however, ulcers, as well as gummatous infiltrations, are
frequently encountered. If the ulcers are low, within two inches of
the anus, they will cause great pain. Higher up the rectum is not so
well supplied with sensory nerves. Ulceration may involve the entire
circumference of the anus.
In the rectum chronic ulcers are liable to be followed by stricture,
which will call for surgical relief. (See chapter on the Rectum.)
In the _colon_ chronic ulcers have been so serious as to lead to
dysentery, followed by stricture formation. It has been suggested to
make an artificial anus at the cecum and allow the large intestine to
rest, treating it at the same time with irrigation through the opening.
=The Viscera.=--Of the solid viscera the _liver_ is more commonly
affected than the spleen or kidneys. Chronic _interstitial hepatitis_
may lead to cirrhosis, the new tissue being less distinctly distributed
than when due to alcohol, the liver consequently becoming irregular,
with a deep separation between its lobes. The pain is sometimes intense.
On the other hand isolated _gummas_, or confluent masses of smaller
gummas, may be found beneath the capsule or in the substance of the
liver. From one or both of these cases combined this viscus may attain
an enormous size, with acute pain. Under these conditions there may
occur albuminuria and evidences of amyloid disease.
Likewise in the _spleen_ there may be diffuse or localized trouble.
Here the lesions cause but slight distress.
The mercurials are of greater importance than the iodides in treatment
of these lesions. The kidneys suffer less often than the spleen.
Syphilitic patients do not lose their liability to renal disorders, but
there seems to be but small, direct connection between syphilis and the
common changes in these organs.
=The Genitalia.=--In both sexes the genitalia are subject to gummatous
involvement during the later stages; in the male more frequently in the
_corpora cavernosa_ and _testicle_. In the latter a chronic induration,
with some enlargement of the epididymis, is one of the manifestations
of constitutional disease. Most of the enlargements of the testicle
are slow and painless, and occasionally some fluid will collect.
The _prostate_ and the _seminal vesicles_ are rarely involved in
syphilis, but frequently in a tuberculous process. This is an important
diagnostic point.
In the ovaries there may occur a diffuse cirrhotic process.
=The Nervous System.=--Here the manifestations of syphilis are often
serious and widespread. They are produced by the same new tissue
to which we have so often alluded, with its tendency at first to
degeneration and later to sclerosis. They are always insidious.
Gummatous thickening may occur at any point, springing often from
the pia of the brain and cord. The arterial walls are frequently so
affected, and at many points, that multiple minute aneurysms are
produced, any one of which may give way and produce the fatal results
of a cerebral hemorrhage. In diffuse gumma of the membranes or
cortex the process is slow, and likely to involve areas which may be
recognized by cerebral localization. Many cases presenting the features
of brain tumor will yield to antisyphilitic treatment, and thus show
themselves to be syphilomas.
In the _spinal canal_ implication of the membranes is more likely to
occur than in the vessels. In the _cord_ these sclerotic changes are
also quite common and produce symptoms strongly suggestive of tabes;
in fact, there are those who hold that tabes is of specific origin.
In the motor and sensory nerves much connective tissue is present, and
consequently these nerves are not exempt from sclerotic changes with
pressure symptoms, which will give the clinical picture of a _neuritis_.
SYPHILIS IN CHILDREN.
Syphilis appears in young children under the following circumstances:
_A._ The disease may have been transmitted from the father to the ovum,
at the time of conception, by infected spermatozoa.
_B._ From the mother, who may have acquired it before impregnation
or during the early part of her pregnancy. In the latter case the
infecting influence is transmitted through the placental circulation.
_C._ From the mother at the time of its birth, from a recently infected
puerperal tract.
_D._ From some possible extrinsic source, a short time after its birth,
as, _e. g._, through the umbilicus.
The later the mother acquires the disease after conception, the less
likelihood that the child will be infected. If infection takes place
from the placenta, then it also will be found to be diseased.
=Profeta’s “Law.”=--Profeta first made the statement that the child of
an infected mother who acquired the disease late in her pregnancy may
not only be born healthy, but may be immune to subsequent infection,
as are other healthy children of syphilitic parents. But, on the other
hand, such a child may be anemic, puny, with small resisting power, or
it may develop a late hereditary syphilis. When the ovum is infected
by the father the healthy mother may escape, or she may acquire the
disease through the placenta in her own uterus, or she may suffer from
a mitigated form of syphilis whose principal features will appear as
late manifestations of the disease.
=Colles’ “Law.”=--Colles, in 1837, made the statement that such a
mother may remain healthy with an acquired immunity to subsequent
infection. The statements above made have often been alluded to as
Profeta’s and Colles’ “laws.” These should, however, be regarded simply
as statements of what usually occurs, and too much dependence should
not be placed upon them. In fact, the immunity which the mother or the
child may enjoy under conditions mentioned above is not likely to be
permanent, though it may last for a varying period of time. There is
no limit to the time when a parent may transmit syphilis to the child.
The five-year limit given for the father is often overstepped, and the
longer the man waits before marrying after acquiring the disease, and
the more thoroughly he submits to judicious treatment, the less likely
he is to convey it to offspring. This is the strongest kind of argument
that can be used to _delay marriage of syphilitics_.
_The indication of syphilis on the part of the mother_ is, in addition
to those already given above, a tendency to miscarriage or abortion.
The earlier she acquires the disease the earlier will the mishap occur.
Should she escape the child may go on to full term, or it may die and
be expelled as a dead fetus two or three months before the expiration
of term. Should a child be born alive with hereditary syphilis, the
evidences may appear at birth or within three months. Should a child
apparently escape for six months it may grow up to be puny or develop
some form of late hereditary disease, or it may possibly remain well.
These children usually show developmental defect in some direction, and
manifest a much weakened resisting power to other diseases; moreover,
the spleen will usually be found enlarged.
Among the changes which may occur are the following: The _skin_ becomes
loose and resembles that of an old person. This is partly because
it grows even faster than the tissues beneath it, so pronounced
is the emaciation. _Snuffles_, or _nasal catarrh_, is one of the
earliest features. This is due to specific swelling of portions of
the Schneiderian membrane. Snuffles _may_ occur in children without
syphilis, but syphilis will nearly always produce snuffles, which may
last for some time, and cause a widening at the root of the nose which
will persist through life. Following the snuffles there usually appears
a rash over the trunk and thighs and about the anus, accompanied by
mucous patches. This will have the same bright, coppery tint as roseola
syphilitica, already mentioned, which it much resembles. Sometimes
it assumes the mixed type of eruption, while upon the palms and soles
appears the so-called pemphigus syphiliticus. Should the child live
nodular or gummatous syphilides may develop.
In the bone and cartilage characteristic changes are met at the
lower end of the femur and at the costochondral junctions. This
consists of an _osteochondritis syphilitica_. At the affected points
enlargements take place, which may disappear under treatment or may
go on to ulceration and necrosis. In the fingers and toes there are
manifestations already described as syphilitic _dactylitis_.
The bones of the skull are likely to be involved in thickenings,
especially about the anterior fontanelle, where they form the so-called
Parrot’s nodes. These may disappear, with or without treatment, and the
affected bone may undergo atrophy or may entirely disappear.
Among the viscera the _spleen_ generally becomes affected first and
then the liver. Syphilitic iritis may occur early, but is rather
rare; ocular changes occur more often in the choroid. In the brain
distinctive lesions may occur to such an extent as to lead to
considerable thickening of the dura, with or without hydrocephalus, and
subsequent imbecility or idiocy.
_Deafness_ is not infrequent in hereditary syphilis. It may begin
suddenly and at any age, even during infancy. It is produced by deep
lesions which do not yield readily to treatment, and sometimes leads to
deaf-mutism, especially when it occurs before the child has learned to
talk.
Among the later manifestations of hereditary syphilis are opacities
of the cornea from _interstitial keratitis_. This may occur in
children who are apparently in good health and free from other signs
of hereditary disease. The condition is rather obstinate, but it can
be made to disappear under suitable treatment. _Retinitis_ occurs
frequently in young women, and is likely to lead to atrophy or
detachment.
=The Teeth.=--The permanent teeth often show peculiar changes that
are distinctive, especially in those who have shown signs of corneal
involvement, which, having been first described by Hutchinson, are
frequently alluded to as _Hutchinson’s teeth_. When they first appear
they are smaller than natural and irregular. Later they become notched.
The crescentic notches show best upon the incisor teeth. Sometimes the
canines are also affected, being narrow, rounded, and peg-like, with
jagged edges. These teeth are usually so formed that they do not meet
properly, and so small that they scarcely touch each other. The most
characteristic changes are met with in the upper incisors, which may
be affected when all the others are fairly normal. In such cases they
will be found narrow and short, with a single broad notch at the edge,
with perhaps a furrow passing from it upward and on both anterior and
posterior aspects. Notching is usually symmetrical. No conclusions can
be drawn from the teeth if they are normal, as they may be, but when
they present the above-described features they prove a very important
indication.
The relations between syphilis and rickets have attracted much
attention, and there is little doubt but that rachitic changes are
prone to occur in subjects with inherited syphilis. The two conditions
are sometimes blended in various degrees and ways, and yet it is not
safe to say that rickets is always an expression of inherited syphilis.
TREATMENT OF SYPHILIS.
There is no question but that some of the above-described lesions
constitute as disgusting and repelling diseased conditions as the
physician or surgeon is ever called upon to treat. In spite of these
circumstances, however, it is generally believed that syphilis is a
most satisfactory disease to treat. This is because of the almost
mathematical certainty with which results can be predicted and
estimated. There is nothing more satisfactory in therapeutics than
the rapidity with which many pronounced and serious manifestations of
syphilis will disappear under the influence of proper treatment. These
statements, however, should be modified to make room for exceptional
cases, where the disease assumes a malignant type, owing probably to
some defect in the patient’s constitution, or where patients show
peculiar idiosyncrasies and susceptibilities to the influence of
mercury and iodine. Such cases happen occasionally and prove difficult
of solution, while they sorely try the surgeon’s ingenuity and
resources.
_In the majority of instances syphilis is a curable disease._ A patient
should be first impressed with the necessity of faithfully following
the directions of his physician, and continuing under treatment for
a period of at least three years after the disappearance of the last
manifestation of the disease. The disease is curable, but only by the
judicious combination of two principal remedies, _i. e._, _mercury_ and
_iodine_. Those rare instances in which cure seems to have followed
lines of treatment which do not include the use of these two drugs
are so exceptional and misleading that they should not be considered
criteria. Mercury and iodine are powerful remedies, needing to be
administered with caution and judgment. Unfortunately there is no
arbitrary limit of time for any given case. The time stated above
is that usually considered requisite. While syphilis may be curable
in some cases in less than the stated time, it is better to give it
longer treatment than is absolutely required rather than the reverse.
The treatment entails no unpleasant consequences. Warnings as to the
approach of toxic symptoms from the drugs can be easily recognized.
Of the two drugs the preparations of mercury are the more important.
The surgeon may adopt as his motto, _mercury, more mercury, and again
mercury_, and if he begins with this measure early in the disease he
may be able to conduct it to a successful termination with but little
resort to iodine. Iodine is effective rather in those cases where
treatment has been begun relatively late, and where it seems necessary
to make a double impression upon the disease.
When the nature of the primary lesion is positive treatment should
begin with the first visit of the patient to the surgeon. When there
is uncertainty regarding the character of the venereal sore, treatment
_may_ be postponed until the appearance of the first eruption. As
soon as this has appeared the treatment should be hastened. It is
necessary to begin with mercury. The patient’s mouth should be examined
by a dentist and all tartar removed from the teeth, especially from
the gingival borders, at which lines the gums are likely to become
sore when mercury is too freely used. All diseased teeth should be
extracted or filled, and the mouth and its contents should be put in
normal condition. The dentist should be informed as to the reason
for the visit. Smoking should be discontinued, especially when there
are mucous patches, since it is apt to irritate and make subsequent
lesions of the mucous membrane more likely to occur. The habits of the
patient should be regulated as to alcohol and other indulgences, and he
should be warned as to the infectious nature of the disease, _in order
that others may be protected_. In many instances tonic, even roborant
treatment may be advantageously combined with the antispecific. It will
be found that the anemia so characteristic of well-marked secondary
syphilis will improve materially under the influence of mercury alone.
Should the disease occur in a married person, or develop after
marriage, caution should be given as to the danger to offspring, and to
the other associate in the marriage relation, which might follow the
occurrence of pregnancy.
Mercury may be given by the _mouth_, by _inunction_, by _hypodermic
injection_, or by _fumigation_. The intent should be to get the
patient under its influence as rapidly as is consistent with safety.
The most effective of these methods to which patients will ordinarily
submit is that by _inunction_. This consists essentially in the use
of _mercurial ointment_ (blue ointment), of which 15 Gm. may be used
daily or nightly, which should be thoroughly rubbed into some area
of the body; the areas selected being changed at perhaps three-day
intervals, in order that irritation, which its prolonged use produces,
may be avoided. It takes considerable effort to so completely rub this
in as to make most of it disappear, and it can be done more easily
upon those parts of the body which are free from hair. It can be best
done by employing someone for the purpose, but patients can be easily
taught to use it themselves. There are upon the market, ointments
containing mercury made with other excipients than lard, which are less
uncomfortable to the skin and seem to be absorbed better; among these
is a preparation made with a petroleum compound called vasogen, which
may be procured in different strengths; that containing 33 per cent. or
50 per cent. is the best.
Inunction should be practised at least once every twenty-four hours,
until either the gums become tender or swollen, with an offensive odor
of the breath, or until the skin is irritated. The mouth should be
protected by use of an astringent antiseptic mouth-wash, such as the
following: Carbolic acid 10 parts, oil of wintergreen 1 part, tincture
of myrrh 50 parts. A little of this solution in a tablespoonful or more
of water makes a serviceable wash, which should be used several times
a day. There are sanitaria and springs, or health resorts, in this
country where a specialty is made of this manner of treatment. At these
resorts inunction is practised freely and thoroughly, but the benefit
which is obtained comes rather from the attention which patients give
to the treatment, and their abstention from business or dissipation,
than from any inherent medicinal features either in the mineral water
or climate.
Under the influence of mercurial ointment alone, if a patient is
willing to persist in its use, many cases of syphilis may be conducted
to a successful termination; but its use is disagreeable to some
people, and it may be impossible to resort to it for any great length
of time. It has its inconveniences and disadvantages, but it should be
applied in at least the first stages of the disease.
When mercurial ointment is seen to have made a distinctive impression
upon the constitution of the patient it may be discarded and the
treatment changed to the internal administration of the drug.
Mercurials may be given internally in any one of several different
preparations. Hutchinson has recommended _gray powder_, in doses of
¹⁄₄ to ¹⁄₃ Gm. three or four times a day. _Corrosive sublimate_ is a
reliable form in which to administer mercury in doses which can be
tolerated, from 1 to 2 Mg., three or four times a day. The red iodide
may be given in similar doses, or the green iodide may be administered
in doses of 0.15 to 2 Cg. These preparations sometimes irritate the
intestinal tract and produce a certain amount of colic or looseness
of the bowel. For the latter some astringent may be combined with the
mercury, while intestinal pain may be checked by the use of extract of
conium.
The _hypodermic use of mercury_ can be made effective, but there are
but few preparations which can be used that do not cause pain and
subsequent irritation. Perhaps that which gives least pain is the
sozoiodolate of mercury. This is sparingly soluble in water, dissolving
in about 500 parts by weight. As the dose is 9 or 10 Cg., the amount
of water necessary for this solution is so bulky that the dose should
be injected into the gluteal region. Corrosive sublimate is also
used in 1 per cent. solution, made up in common salt solution of the
usual strength of 9 to 1000. Of this 10 minims represent a suitable
dose to commence with, which may be increased to 30 or 40 minims when
necessary. This should be given in the same region, the needle being
driven in its full length perpendicularly to the surface. When this is
done an injection is made into the muscle, where it seems to be more
effective than in the subcutaneous fat. When the dose is increased to
more than 20 minims a 2 per cent. solution may be used and the amount
of fluid correspondingly reduced.
_Fumigation_ is a method now not often adopted, calomel being used for
the purpose, an ordinary cabinet hot-air bath confining the vapor about
the patient. One treatment a day by either of these methods is usually
sufficient.
About the _initial sore_ dry calomel, pure or reduced with bismuth
subnitrate, may be used. The condylomas met with about the
perineum will often shrink and disappear under the influence of
this application. _Mucous patches_ should be treated with absolute
cleanliness; in the mouth a wash of diluted hydrogen dioxide may be
used, and the patches touched with a strong nitrate of silver solution,
pure carbolic acid, or camphophenol. This will not prevent contagion
from such a source, but will reduce it to a minimum beneficial in every
respect.
The various eruptions of syphilis will disappear gradually under the
influence of a local application of one of the mercurial preparations,
either the ordinary mercurial ointment or ammoniated mercury.
In cases of _inherited syphilis_, especially in young children, a
reduced mercurial ointment, or the use of gray powder (mercury with
chalk) will give the best results. The dose should be regulated by
the age of the patient; for instance, of the latter 1 to 2 Cg. for an
infant. The iodides have also proved successful.
_Iodine_ and its preparations have by many authorities been held to
be useful in the later and especially in the gummatous lesions of
syphilis. There are patients who cannot take iodine to any extent
without suffering from such disturbance of mucous membranes, especially
in the nose and intestines, as to make it an exceedingly unpleasant
remedy.
The iodides have not proved as successful as the mercurials;
nevertheless, the combination is a popular one and sometimes of
peculiar value. The potassium salt is the one generally used, as it
is cheaper than the sodium compound. The latter, however, is less
irritating and often more available. The lithium compound is ideal
in some respects, but very expensive. The iodides may be given in
large doses, to the extent of 30 Gm. or more (an ounce or more) in
twenty-four hours. Large doses are sometimes necessary in the treatment
of late syphilis of the nervous system. When it is necessary to put
the patient rapidly under the influence of antispecific medication the
combined use of these two drugs, as for example by mercurial inunction
and the use of one of the iodides internally, will most speedily
bring about the desired result. This result may be overreached, and
sore mouth or other toxic manifestations may appear suddenly and
unexpectedly.
The mercuric salts are soluble in solutions of the iodides, and what is
known as _mixed treatment_ is often employed. The salts may be combined
in any desired preparation. Donovan’s solution is exceedingly valuable,
the arsenic which it contains seeming to reinforce both the mercury and
the iodine.
The iodides produce eruptions or rashes which strongly simulate both
syphilitic and non-syphilitic skin diseases, and confusion may arise
from their use. In those who are sensitive to the iodides, and in whom
catarrh of the mucous membranes is easily produced, it is best to begin
with small doses, increasing them as circumstances may warrant. Some
patients cannot take iodine in any form. When iodides irritate the
stomach they should be given in essence of pepsin.
Of the various vegetable remedies some are unreliable and of little
value. Certain combinations can, however, be effected in some cases by
which the value of the effective agents may be enhanced. _Zittmann’s
decoction_ or _McDade’s formula_ will occasionally prove of service. In
aggravated cases the former is believed to be the most effective of all
methods of administering mercury. Tonics or any other medicines which
may be called for in particular cases should be given judiciously.
There is nothing in antisyphilitic treatment which precludes other
treatment when needed.
CHAPTER XI.
CHANCROID OR VENEREAL ULCER.
Since the time of John Hunter and his pupils, who confused the three
totally different and so-called venereal diseases, pathologists have
drawn a distinct line between _chancre_, which is simply the initial
sore of syphilis, and _chancroid_ or _venereal ulcer_, which is a
distinctly local lesion, often destructive, but never followed by
constitutional disease, except of septicemic or pyemic type. It is
usually found upon the _genitals_, about the foreskin, glans, and
vulva, but may be met anywhere upon the body where infection has
occurred. It is distinctly _auto-inoculable_, in which respect it
differs from chancre.
Varying views have been held as to the minute agency concerned in
the production of this lesion. The bacillus discovered and studied
by Ducrey, in 1889, is now accepted as the exciting cause. This
is 1.5 μ long and 1 μ thick, with rounded deep-staining ends and
fainter-staining central portion, occurring with great constancy in
chancroidal pus, less often in buboes than in ulcers, in and outside of
the cells, and in chains. It is cultivated with difficulty, grows best
on human blood, takes basic aniline stains, but is easily decolorized
by alcohol or by Gram’s method. Characteristic ulcers can be produced
by inoculating it, even in monkeys.
Chancroid begins, in twenty-four hours, as a red point or papule,
which is quickly converted into a pustule and then into an _ulcer_.
The borders of this ulcer enlarge, its depth increases, until after a
few days it forms a more or less deep, often undermined excavation,
irregular in contour, discharging grayish purulent material. In this
respect it differs also from chancre, whose natural discharge is more
like serum. In other words, _chancroid is essentially destructive,
chancre constructive_, since the latter forms a new-growth which
ordinarily has little or no discharge. When the necrosis of chancroid
becomes extensive and tends to spread rapidly the ulcer is spoken
of as _phagedenic_. This tendency to rapid local gangrene is the
combined result, probably, of virulence of virus and lowered local or
constitutional tissue resistance. It is consequently most often seen
in alcoholics and prostitutes. In rare instances a surface larger than
the hand may be rapidly destroyed, every particle of material sloughed
being infectious.
In chancroids of the mild variety the discharge may dry upon their
surfaces and scabs or crusts result, beneath which, when detached, the
characteristic ulcer is present.
Under proper treatment this foul ulcer is soon converted into an
ordinary granulating surface, which heals by cicatrization.
CHANCROIDAL BUBO.
Infection, by propagation along the lymphatics, of the inguinal nodes
is frequent, and, since the infection is almost always a mixed one,
suppuration is frequent.
The pus of a suppurating chancroidal bubo is as infectious as the
discharge from the original sore; hence the need of great caution. The
edges of the local incision should be promptly cauterized so that they
may not become linear chancroids. Phagedena shows itself here as well
as about the genitals proper, and differs only in that it makes the
case more serious. A chancroidal bubo may, however, subside without
abscess formation. The signs of suppuration are those incident to pus
formation anywhere near the surface. When pus is present its early
evacuation is demanded.
=Diagnosis.=--Chancroid is likely to be confounded with _chancre_ and
_herpes preputialis_. It has no period of incubation. Destruction
commences after infection, so that within twenty-four hours macroscopic
evidence may be observed, and within two or three days the sore has
attained distinct size and shape.
_Chancroid._ _Chancre._ _Herpes._
Local ulcer. First local sign of a Local neurosis.
constitutional
disease.
A distinctly venereal Usually a venereal May be non-venereal,
infection. infection. from friction, irri-
tation, uncleanliness,
etc.
No incubation; lesion Incubation from ten to No incubation.
noticed within a few seventy days before
days. first lymphatic in-
duration.
Commences and remains Commences as a papule, Commences as a crop
as an ulcer. or occasionally as an of vesicles.
erosion. This _may_
ulcerate later.
Usually multiple. Usually single. Multiple and occurring
in crops or series.
Secretion purulent Secretion slight and Little or no secretion.
and abundant. serous or bloody.
May occur again and As a rule, it only Patients who once have
again. occurs once in the it are frequently
same patient. subject to it.
Auto-inoculable. Not auto-inoculable. Not inoculable.
Phagedena frequent. Phagedenic action very Never.
rare.
Buboes in about 65 Bubonic enlargement Lymphatics rarely
per cent. of cases. nearly always. involved.
Buboes usually Buboes as a rule do
suppurate. not suppurate.
=Prognosis.=--Except in the most debilitated and dissipated, in whom
phagedena may prove fatal, recovery always occurs, but often with the
loss of tissue and disfiguring scars.
=Treatment.=--In mild cases--_i. e._, those showing but little
destructive tendency--cleanliness and the use of hydrogen peroxide,
followed by local use of any of the ordinary antiseptic powders, or
even of calomel, will usually prove sufficient. Sodium sozoiodolate
makes an excellent application. It is odorless and non-toxic. At first
its use may be preceded by morphine or cocaine, but after a few days it
will prove a painless application. If the ulcer manifest any tendency
to spread, it should be cleansed, cocainized, and then cauterized with
nitric acid or the actual cautery, after which it should be so treated
as to encourage granulation. This plan should be followed in phagedenic
cases, which may call for general anesthesia, with the use of scissors
and a sharp spoon, followed by cauterization of every particle of raw
or diseased surface.
Widespread phagedena is more rare now than formerly. Cases which are
extensive do best when submitted to continuous immersion of the hips
in a sitz-bath as hot as can be tolerated. All aggravated cases call
for invigorating and tonic measures, laxatives, improved nutrition, and
stimulants.
_Suppurating buboes_ should be incised, usually curetted, and
thoroughly swabbed with pure carbolic acid, followed by pure alcohol
to neutralize the acid, then packed lightly with antiseptic gauze, and
allowed to close by granulation. Virulent cases will be accompanied by
sloughing of so much tissue that it is best to remove all sloughs with
scissors. Here even stronger caustics will be called for. _Phimosis_
often complicates chancroid, and will necessitate circumcision or
incision along the dorsum of the prepuce, with such attention to the
parts thus exposed as their condition may require.
=Mixed Chancre.=--Mixed chancre, or the combination of the two lesions,
has been already discussed.
=Extragenital Chancroid.=--Extragenital chancroid may occur upon any
portion of the body, but is more rare than extragenital chancre. It
is characterized by the same peculiarities as pertain to the venereal
sores already described, and is amenable to similar treatment.
CHAPTER XII.
GONORRHEA.
Gonorrhea is an acute infectious process, involving especially
the mucous membranes of the genito-urinary organs, but met with
elsewhere about the body, in both superficial and deep tissues. The
name itself is a misnomer, since it implies a flow of semen, whereas
the discharge which issues from the male urethra is simply mucopus,
and is the product of a severe inflammation of the mucous membrane.
A less inaccurate name for it is _blennorrhea_, although this is
usually limited rather to a discharge from the vagina, and indicates
a whitish and copious fluid exudate, mingled with pus corpuscles and
bacteria. It is stated that probably 80 per cent. of men have at some
time contracted this disease. Neisser claims that it is a more common
affection than measles.
True gonorrhea is the result of an infection by a specific organism
universally recognized as the _gonococcus_ of Neisser, though the
discharge, when studied in the clinical laboratory, may give evidence
of being the product of a mixed infection and contain the ordinary
pyogenic or other organisms. The common name for the disease is _clap_.
The gonococcus is a diplococcus which seems to be injurious only to the
tissues of the human being, as inoculations in animals have produced
no definite or reliable result. Like syphilis, it is spread by direct
or indirect contagion, and usually in the same way. It is generally
found in the genito-urinary mucosa of both sexes, but it has been
accidentally and even innocently conveyed by immediate and mediate
transfer to the mucous membranes of the _eye_, the _rectum_, and even
to the _mouth_, although here, as in the nose, the mucous membrane is
but little susceptible to its activity. It is generally stated that 20
per cent. of the blindness occurring in the young is due to gonorrheal
conjunctivitis. Those membranes covered with cylindrical epithelium
are more liable to succumb to infection by this parasite than are
those covered with squamous epithelium. The more the epithelial cells
conform to the former type, the more difficult it is to get rid of the
infection; hence the disease lingers in the cervical canal longer than
in the vagina.
The disease always commences as a contagious catarrhal discharge from
the mucous membrane. It may spread much farther than this, invading
deeper tissues by continuity, or tissues at a distance by the lymph
stream, or producing even metastatic expressions of infection in
distant tissues and organs. Under these circumstances the serous
membranes are likely to suffer, and the peritoneum, the endocardium,
the pericardium, the pleuræ, the meninges, and particularly the serous
linings of some of the joints, as the elbow and knee, show unmistakable
evidences of infection; while through the medium of the venous and
then the arterial systems typical representations of pyemia following
gonorrhea may occur.
The disease as it usually appears is seriously and often obstinately
complicated by the structure of the membranes which it involves.
The mucous membranes throughout the body are more than mere mucous
surfaces; they are dotted with openings for the escape of glandular
secretions, and nowhere is this more conspicuous than in the urethra,
where many minute follicles, so called, empty tiny drops of secretion
into the mucous canal. Infection may easily travel along these routes
and lurk within such minute recesses long after it has apparently
disappeared from the surface; and so it often happens that in the male
not only the urethral follicles but the ducts leading to Cowper’s
glands and prostate become involved, while in the female the follicles
around the meatus, the urethra, and the vulva rarely escape. The
clinical importance of this statement is of interest, as by it may be
explained many of those cases where an old infection seems to have been
lighted up, or where the contagion has been conveyed to another after
an attack which was supposed to have been entirely cured. Nothing seems
to favor outbreaks of this kind as do alcoholic and sexual excesses.
The gonococcus may be scarcely regarded as an obligate pyogenic
organism by itself, but the parts most often involved in this disease
may be regarded as never free from the presence of other germs
of greater or less activity, and by association, if not by actual
symbiosis, such an intense reaction is provoked that the resulting
products do not differ from true pus, save by the added presence of the
specific organism most at fault. Under these circumstances abscesses
may form in any tissue infected. Another expression of this fact would
be the establishment of a pyarthrosis after involvement of one or
more joints. Gonococci may be found in almost every abscess of truly
gonorrheal origin; on the other hand, in some of the serous cavities it
is possible, at least for a time, that gonococci may be present in the
serous fluid without producing in it more than a disturbing effect, the
fluid now appearing turbid rather than puruloid.
The amount of toxemia which may be produced by gonococci without
reference to formation of pus has not yet been established. It is,
moreover, a difficult thing to estimate in cases of mixed infection.
Occasionally there are cases of metastasis and gonorrheal invasion
which are free from evidences of suppuration, and yet there may be
anemia and cachexia of profound type; these can only be explained on
the theory of an intoxication.
Besides the serous tissues of the body the _fibrous_ structures may
suffer seriously, not only in an acute manner, but also in a chronic
and obstinate form.
It has been the custom to speak of _urethritis_ as a synonym for
gonorrhea, and to divide it into the specific and non-specific forms,
including under the former expression cases where the gonococcus can
be demonstrated, and under the latter term those which do not seem
to show it. There is no doubt but that urethritis may be set up by
the introduction of a foreign body, such as a sound or catheter, as
well as by some irritating discharge from the vagina, and also as the
result of excess of uric acid in the system, perhaps even of alcohol.
These, if occurring in a previously uninfected urethra, may be regarded
as distinctly non-specific lesions. It is also supposed that under
certain circumstances inflammation may be set up by other organisms
than the gonococcus; nevertheless almost all cases of so-called clap
are positively gonococcus infections, simple or mixed, and have but one
origin.
=Diagnosis.=--_Diagnosis can be made positive only with the
microscope._ A recognition of the gonococci by staining them and then
watching the effect of iodine in their decolorization will be of
great importance and reliable. The affinity of these germs for basic
aniline dyes, and the fact that they do not take the iodine stain
of Gram, will serve to differentiate them from the numerous other
organisms with which they may be found mixed. By staining a cover-glass
preparation first with methyl blue or other basic color, then placing
it in Gram’s solution, and finally in a solution of Bismarck brown,
the true gonococci which have been made visible by the methyl blue
will have disappeared under the influence of the iodine, while other
bacteria will be stained by it. It has been mentioned that the germ
is a diplococcus of rather ovoid form, met in clusters but not in
chains, and in groups of four or multiples of four; it may be attached
to epithelium and pus corpuscles, or found within them, and is rarely
found free in fluid except when present in large numbers. These
organisms are capable of cultivation, growing best upon a mixture of
human serum and neutral agar, at a temperature of 36° C.
_The urethra may be infected from without and from within_, and this
infection may be either of a truly specific type (gonococcus) or of the
pyogenic type; as between these forms information may be gained by the
history and the clinical course, but the minute diagnosis is only to
be made with the microscope. This is of more than theoretical value,
inasmuch as it substitutes a certainty for a working hypothesis. It is,
moreover, sometimes of great value, as when the question of infection
of one of the opposite sex comes up, or it may have at times even an
important medicolegal value, as in cases of rape.
_Infection from without_, so far as the male urethra is concerned,
is a question of the venereal origin of the disease. _Infection from
within_, in the specific form, is a matter of recrudescence of a
formerly active lesion supposed to have disappeared. Infection of
_non-specific type from without_ affects the introduction of germs
either by venereal contact or by the medium of an unclean catheter,
sound, or some other instrument, or _from within_ by the extension
forward of an inflammation higher up in the genito-urinary tract, such
as may be due to stone in the bladder, cystitis, enlarged prostate, or
uric acid or oxalic acid crystals. Urethritis, usually of mild type,
is not infrequent in old men from either of these causes. It may also
be produced by the infection of a too strong or irritant injection,
whether used either for prophylaxis or for ordinary treatment.
Classifying them we may then have urethritis of the following four
types:
_A._ Gonorrheal of extrinsic origin.
_B._ Gonorrheal of intrinsic origin (originally extrinsic).
_C._ Non-specific urethritis of extrinsic origin.
_D._ Non-specific urethritis of intrinsic origin.
_A._ The period of incubation is short, usually two to six days, and
the resulting inflammation is severe; the consequences are often remote
and sometimes disastrous. Gonococci will be found in the pus and
epithelial debris.
_B._ This has been described as “_bastard clap_.” It is really an
auto-infection, with an incubation period of a few hours, and is
practically the reawakening of a quiescent stage of _A_. It is
characterized by abundant purulent discharge; this latter is thin and
mucilaginous, more like that of so-called gleet, with an abundance of
pus threads, or “clap threads,” in the urine. In this form gonococci
are also found, but less frequently.
_C._ Much like _A_ in its clinical course, but less violent, and with
less widespread reaction. Its period of incubation is rarely over
thirty-six hours. This type is most common after alcoholic and sexual
excesses; the latter especially with one already suffering from vaginal
discharge, particularly so when near the time of menstruation. Here
the microscope will show few if any true gonococci, but a profusion of
pyogenic organisms.
_D._ This form of disease is of non-venereal origin, and is susceptible
of easy explanation and of satisfactory treatment if the cause be
properly treated. No case of urethral discharge which does not seem to
fall easily into one of the above categories should be treated without
a search of the anterior urethra, especially the fossa navicularis, for
possible _chancre_ or _chancroid_, as well as for stricture.
Among the laity the idea is prevalent that gonorrhea is a disease of
more or less trifling import, while many of the profession regard it as
rarely worthy of serious consideration. This is an unfortunate notion
regarding this disease, and those who have had largest experience
unite in expressing the opinion that gonorrhea reckons more victims
in the death list than does syphilis--not because it is more common,
but because of its complications and the ravages, especially in the
kidneys, resulting therefrom. It has been shown that the specific
organism producing it may linger for years in the follicles of the
urethra, whence it may issue forth, unexpectedly, to produce vaginitis,
perhaps in the most innocent of women, and thus bring on a train of
pelvic disorders which may involve the ovaries, the tubes, and the
peritoneum. Doubtless _gonorrhea has made_ in this indirect way _many
more victims than syphilis_.
Regarding gonorrhea thus seriously, it is well to treat it cautiously
and to inculcate vigilance in the daily life and habits of the patient.
There are no arbitrary limits during which danger exists and then
passes; peril lurks about such a case for an almost indefinite time.
There is danger not alone to the individual, but to all with whom he
may have sexual or even other relations. This advice pertains not alone
to the urethral discharge and the care of the urethra, but especially
to the avoidance of all possible contamination of the conjunctiva.
One of the saddest spectacles in the domain of medicine is to see one
or both eyes of an innocent victim injured or ruined by gonorrheal
infection.
There is no denying the clinical fact that individuals vary
considerably in their susceptibility to this disease; moreover,
individual susceptibility varies at different times. Alcoholic and
sexual indulgence seem to materially lower this susceptibility. Thus
from the same individual, and within twenty-four hours, one may acquire
the disease while others escape. In some instances immunity seems to
be afforded by repeated attacks; in other individuals repeated attacks
seem only to enhance the liability to the disease. The gonococcus
grows best in alkaline media. Prolonged sexual excitement diminishes
the acidity of the urethral fluids, and this favors the growth and
development of the germ. No credence should be given to popular notions
concerning the possible avoidance of infection after exposure. Even a
careful _toilet_ is usually inefficient for this purpose, while the use
of prophylactic injections is to be reprehended. They do more harm than
good. If strong enough to be bactericidal, they should be extremely
irritant; if weak enough to be tolerated, they will prove useless.
The patient should also be warned concerning possible transfer of the
disease without sexual contact, and all toilet utensils, towels, etc.,
should be kept by themselves, and all syringes and instruments used in
the treatment of the case should be carefully sterilized.
=Course.=--The period of incubation generally varies within wide
limits, as mentioned above under classification of the various
types; it may be as short as a few hours or may extend to ten days,
or possibly even longer. Usually it is from two to five days. The
early symptoms consist of discomfort along the course of the urethra,
chemosis or edema, and swelling of the meatus. Within a short time
after these symptoms the characteristic discharge appears. It may at
first be viscid, but soon becomes purulent, and then more or less
profuse, while urination gives rise to great discomfort. By the end
of the first week the discharge is usually grayish in color, thick,
continuous, and so profuse as to equal in volume 20 to 50 Cc. in
twenty-four hours. The lesion is not confined to the urethra, and soon
spreads to the peri-urethral tissues and thence to the lymphatics. A
peri-urethritis with venous engorgement is added to the urethritis, and
there is such an obstruction of the return circulation as to produce
swelling and edema of the prepuce; this not only makes access to the
urethra difficult, but conceals any excoriation and ulceration which
may be going on beneath it. Sometimes this tumefaction proceeds to a
degree where gangrene results.
All these local disturbances will be accompanied by more or less
lymphatic involvement in the groins and in the perineum, with great
soreness and tenderness throughout the entire genital tract. _Chordee_
(painful erection) is a common and painful complication of this stage
of the disease. Finally a well-marked degree of _auto-intoxication_,
with its ordinary febrile and septic manifestations, may ensue. As
the disease spreads farther back into the deep urethra there is
irritability of the bladder, while in severe cases the frequent
attempts at urination thus excited, with the accompanying pain during
the act of expelling a few drops of urine, are distressing features
of the disease. The pains are not limited to the organs involved, but
are often referred to the back, to the perineum, and down the thighs.
The symptoms above referred to belong to a well-marked case of acute
specific type. There may be milder manifestations of each kind, and
occasionally a case will run its course with but a minimum of the
difficulties and discomforts above mentioned. Sometimes by the end
of the third week, usually before, the disease will show a tendency
to subside, even if inadequately treated. The inflammatory symptoms
become less marked, the discharge thinner and less voluminous, until
perhaps by the end of the seventh week there is noticed only a small
amount when the patient rises in the morning. With all this apparent
and spontaneous improvement there may be present, nevertheless, a
serious and distressing amount of peri-urethral infiltration, which
will soon be followed by cicatricial contraction and the formation of a
_stricture_, the most frequent sequel of gonorrhea.
=Complications.=--Complications may occur along any portion of the
genito-urinary tract. These will be considered in their anatomical
order.
=Balanitis.=--Balanitis signifies an inflammation of the mucosa
covering the glans. When the mucous surface of the prepuce is also
involved, as it usually is when the orifice is contracted, then the
condition is known as _balanoposthitis_. In the absence of ordinary
cleanliness of the parts this may go on to erosion or extensive
ulceration. It is sometimes complicated with chancroid or chancre. When
such a condition exists, and the glans cannot be sufficiently exposed
for purposes of cleanliness, the dorsum of the prepuce should be slit
up sufficiently to permit of complete exposure, while in some cases the
edema and the infiltration will be such as to justify circumcision.
When needed these operations should be practised even if raw surfaces
are thereby left exposed to infection. Such possibility may be usually
obviated by cauterizing a fresh surface, as soon as exposed, with pure
carbolic acid or one of the stronger caustics, or operation may be made
with the thermocautery.
=Folliculitis.=--Folliculitis implies the extension of the infection
to the follicles and lacunæ which abound within the urethral canal. As
long as their orifices do not become occluded they easily discharge
their contents into the urethra, but when so swollen as to become
occluded they lead to the formation of abscesses, which, beginning in a
minute way, may sometimes give relatively extensive disturbance. These
discharge internally; sometimes they so present that they may be opened
externally, as they should be under these circumstances. They form a
communication between the urethra and the exterior, and in this manner
the majority of the ordinary urinary fistulæ are produced. These often
occur in the perineum, but sometimes even in the pendulous portion.
=Peri-urethritis.=--Inflammation frequently extends beyond the
anatomical confines of the urethra, and produces a degree of
infiltration which is often well marked and disastrous. The site of
such a lesion is marked by a nodule, more or less tender, which may
subsequently break down into an abscess. The pus from these abscesses
will usually escape into the urethra. Sometimes it burrows into
the tissues of the corpus spongiosum, or travels even farther, and
produces locally extensive destruction of tissue, with its possibility
of urinary infiltration as a sequel, and all the septic disturbances
which can be imagined as resulting therefrom. Thus fistulas often
follow abscess formation, and these may be succeeded by phlebitis of
the peri-urethral and prostatic plexuses, extensive destruction or
multiple abscesses, or even gangrene and pyemia. Peri-urethritis is the
essential factor in the production of strictures of the urethra, which
constitute an exceedingly common condition.
While urethral stricture is a common result of gonorrhea it constitutes
by itself a special lesion. (See chapter on the Genito-urinary Tract.)
These peri-urethral infiltrations may occur in irregular patches, so
variously placed as to encroach upon the urethra at different points
without completely surrounding it, or they may form tubular lesions
by which very serious annular constriction is produced. The degree
of infiltration is, to some extent, a measure of the violence of the
inflammation and of the virulence of the infection. This is true,
however, only up to a certain point. One object of properly directed
treatment should be to guard against the deep extension of a gonorrheal
infection, in order to limit the tendency to the formation of stricture.
Between the folds of the triangular ligament are situated two racemose
follicles known as Cowper’s glands. These occasionally become infected
in the same way as the anterior follicles of the urethra and give rise
to a painful swelling in the perineum, which gives most discomfort
to the patient in the sitting posture. This condition is known as
_Cowperitis_. It may proceed to abscess formation, in which case
incision in the perineum should be made for its relief.
=Prostatitis.=--The prostate consists of a collection of follicles
embedded in a mass of involuntary muscle fiber. The largest of these
follicles is known as the _utricle_, or, under the old anatomical
name, _uterus masculinus_. These are liable to invasion when the
infection has reached the deep urethra. The reaction which follows in
this tissue after such invasion gives rise to _prostatitis_ and causes
much pain and general reaction. The prostate, being embedded within a
fibrous capsule, cannot expand easily when it becomes inflamed, and the
pressure thus made not only causes intense pain, but will also obstruct
the urethra and occasion great difficulty in urination, sometimes
retention of urine. In proportion to the other disturbance will be
the general reaction, and fever may run high, with early expressions
of septic intoxication or of septicemia. The prostate becomes tender,
and pain is felt not only in the pelvic region, but in the back and
in the thighs, as well as along the urethra. Prostatic abscess is a
frequent sequel to this condition; it sometimes evacuates spontaneously
into the urethra, or bursts through the capsule and burrows along the
structures in the perineum and lower pelvis; occasionally it empties
into the rectum. Intensity of symptoms should give rise to a suspicion
of prostatic abscess, and a perineal incision should be made early and
the abscess evacuated. Occasionally these abscesses present toward the
rectum, when they should be tapped or incised through the bowel.
From the prostatic urethra inflammation may extend on one side or both
along the vas deferens to the seminal vesicles. The production in
this way of a _vesiculitis_ is made known by the reference of pain to
the rectum and by the appearance of blood, sometimes with pus, in the
seminal discharge. By a digital examination of the rectum the enlarged
and tender vesicles can be recognized above the prostate.
When the deep urethra has become seriously involved the condition
of the patient is unpromising. Belfield calls attention to the
triple function of the deep urethra, in that the impulse to urinate
originates therein, that it is a sphincter for the bladder, and that
it is intimately concerned with the sexual act. When it is disturbed
by gonorrheal infection all of these functions are disturbed, the
most serious symptoms being increased desire to urinate, amounting to
almost constant vesical tenesmus; marked difficulty in expulsion of
urine, which may increase to complete retention, and frequent bloody
emissions, with chordee. The pain, the heat, and the sense of tension
in the perineum and in the parts around it are distressing, as well as
pain during and after urination, which is usually referred to the end
of the urethra. The last few drops of urine will often be bloody.
=Cystitis.=--Cystitis is the not infrequent result of the further
migration of the infectious process from the deep urethra to the
bladder. The process is usually acute and serves to further complicate
the case and to harass the patient. Except in the nature of the
exciting causes cystitis differs but little from the other varieties
to be considered in their appropriate place (_q. v._). Cystitis of
gonorrheal origin is likely to travel along the ureters and lead to
involvement of the kidneys. Ascending infection is most commonly of
gonorrheal origin. In proportion to the extent and rapidity with
which the disease travels upward the case is marked by expressions of
septic intoxication and infection, such as chills, fever, pain in the
loins, along the ureters, and in the testicles. The kidneys may become
enlarged. A more minute appreciation of the condition of affairs can
be obtained by microscopic examination of the urine. In proportion as
the kidney is involved, there is a preponderance of albumin, _i. e._,
more than pus alone would produce. One of the numerous ways in which
gonorrhea kills its victims is by the production of a _pyelonephritis_
of the type known as “_surgical kidney_.”
=Lymphangitis.=--No such invasion of mucous membrane by septic
organisms can take place without active participation of the lymphatics
in the region involved. In cases of gonorrheal or even non-gonorrheal
urethritis, not merely enlargement of the lymph nodes in the groin may
occur, but an active lymphangitis, manifested as a tender, sensitive
cord beneath the skin, especially along the dorsum of the penis. The
lymph nodes thus become involved and sometimes suppurate, and these
abscesses are referred to as _suppurating gonorrheal buboes_. The
suppurative feature is probably caused by contamination with the
ordinary pyogenic organisms.
=The Testicles.=--Gonorrheal infection seems often to extend along the
vas and thus invades the epididymis, where evidences of activity are
more frequent than in the vas itself. _Epididymitis_ complicates cases
of clap usually after the second week. It is characterized by pain,
tenderness, and swelling of the epididymis, which occupies the same
position relative to the testis proper that the heel does to the rest
of the foot when a person stands in the ordinary military position, _i.
e._, to the rear and inner side. The swelling becomes pronounced, and
it is not unusual for a certain degree of swelling to be manifested in
the testis proper, with the accumulation of a small amount of fluid in
the sac of the tunica vaginalis, thus constituting a mild degree of
acute hydrocele. While the inflammation is confined to the epididymis
the pain is not intense, but of a dull, heavy character; but when the
testis proper is involved there is a true _orchitis_, the inflammation
being confined within the inelastic sclerotic tunic, and the pain then
may be severe. Considerable fever accompanies many of these cases, with
occasionally some edema of the scrotum and congestion of the testicular
coverings. The weight of such a “swelled testicle,” as this condition
is called by the laity, is irksome, and occasionally causes extreme
discomfort. Under these circumstances physiological rest, _i. e._, in
bed, and the use of a suitable suspensory apparatus are essential.
While resolution of this swelling ordinarily begins early and proceeds
satisfactorily, the latter portion of the process is often slow and
tedious, and the epididymis thus once involved will for months contain
nodules and irregularities of contour. Usually the affection is limited
to one side; but both testicles may be involved. If the infection be
violent and the treatment inefficient abscesses may result.
This condition calls for early and effective treatment. If seen at the
very outset, progress of the lesion may be checked by embedding the
affected part in cold, wet compresses, and keeping them cold with ice.
Relief later is more likely to be afforded by hot applications, and a
hot poultice containing a small amount of fine-cut tobacco has been
popular as a local application--the tobacco apparently being anodyne
in its effect, although perhaps no more so than belladonna leaves.
This may be regarded as a good emergency dressing when it affords
the only means of treatment. The greatest relief will be obtained by
the application of guaiacol, diluted with three volumes of olive oil
or castor oil, well applied over the scrotum, and covered with oiled
silk or rubber tissue. This application should be made twice a day.
Later, in the more chronic and less painful stages, a reduced mercurial
ointment containing a little guaiacol or ichthyol may be used to
advantage, resolution being thereby assisted. In quite tedious cases
the flying application of the actual cautery is serviceable. Internally
tincture of pulsatilla has proved beneficial. It should be given in 1
Cc. doses every two hours. While the benefits accruing from its use are
questionable, it has helped to allay fever and subdue pain.
Much has been said about the _sterility_ which results from
epididymitis, especially when both sides have been involved. It is easy
to understand how the vas may become occluded in many cases, either
temporarily or permanently, and yet within my own observation men have
suffered from the double lesion and yet begotten children.
=Gonococcus Septicemia and Pyemia. Postgonorrheal Arthritis=
(=Gonorrheal Rheumatism=).--Considering the extent of the mucous tract
involved, the open port of entry for germs, and the virulence of these
organisms in many cases, it is remarkable that there are not more
conspicuous illustrations of septic absorption in cases of gonorrheal
urethritis. That these do occur and have a widespread, sometimes
disastrous, effect has long been recognized. The severe forms are
usually the more acute, and if they assume the septicemic type, go on
to abscess formation, and in parts which are not always accessible. In
rare instances septic disturbance assumes the pyemic type. The writer
believes that he was the first to report a case of typical pyemia
following gonorrhea, and to recognize it as such.
Aside from these acute manifestations, more chronic and mild
affections, especially of the serous membranes, are well known. The
most common of these exhibitions occur in the joints, mostly in the
knee. A gonococcus peritonitis, pericarditis, or endocarditis are,
however, well known. Because of the similarity of the discomfort and
the disability resulting from the joint complications of clap to the
ordinary joint manifestations of rheumatism, these lesions have long
been popularly called _gonorrheal rheumatism_. The name, however,
should be discarded as being incorrect, and for it the best substitute
would be _postgonorrheal arthritis_.
These lesions may be sudden in their onset or may come slowly. They
may occur at any time during the acute stage or after its apparent
subsidence. The first manifestations involve the serous membranes
proper; the fibrous tissues participate sooner or later, and the
infiltration resulting from the inflammation thus set up will often
permanently compromise their integrity and cause an impairment of
their function for the rest of the patient’s life. They are usually
confined to one of the larger joints, but may involve several,
either simultaneously or consecutively. In acute cases the swelling
is somewhat pronounced and the pain and soreness intense. The local
symptoms simulate those of acute articular rheumatism. In the
fluid drawn from these joints the gonococcus can be occasionally
demonstrated. The course of the disease is usually slow, and
convalescence may be protracted. Nor is the disability acute only
and temporary, but it is often made permanent by the formation of
adhesions resulting from the condensation of exudates. Partial or
complete ankylosis may result, with considerable deformity. The muscle
spasm provoked by the acute joint inflammation will occasion the same
distortions and subluxations as are produced by tuberculous and other
forms of arthritis, and operations varying in severity from forced
motion to joint exsection may later be necessary. (See pp. 392 and 393.)
The writer has seen cases of postgonorrheal toxemia of extremely
chronic and even fatal type, where the joints were conspicuously
involved and where they did not constitute the most serious features
of the disease. These cases proved most intractable to treatment and
illustrate the possible complications of gonorrhea.
In addition to the joints various _bursæ_ and _tendon sheaths_ may
suffer in the same way as do the joint membranes. Such lesions are seen
about the hands and feet, especially about the tendo Achillis, and are
also seen in the muscles of the neck and of the orbit.
The treatment of these gonorrheal complications should be effected
largely by improving elimination and getting rid of the general
toxemia; thus hot-air baths, diuretics, and cathartics are advisable.
These eliminants, with free massage, are useful in dislodging the toxic
products.
=Treatment.=--The treatment of gonorrhea is directed not alone toward
the mere alleviation of symptoms, but to the destruction of the
invading germs. The patient should abstain from much exercise, and in
cases of severity should be kept in bed, avoid alcohol and tobacco, and
eat sparingly of meats and of richly seasoned foods. He should wear a
“gonorrhea bag,” or large condom, and there should be no obstruction
to the outflow of pus. His hands should be washed immediately after
contact with the parts involved, and all dressings and linen which may
have been contaminated should be promptly burned.
The actual treatment of gonorrhea should be both internal and local.
_Internal treatment_ should consist (1) of the administration of
laxatives; (2) of such amount of alkali as may be necessary to
overcome hyperacidity of the urine and mitigate the distress caused
during its passage; (3) of remedies which, being eliminated by the
kidneys, serve to medicate the urine and give it the effect of a
retrojection; (4) of such anodynes and sedatives as may be necessary to
give comfort, allay distress, and produce sleep or relieve and prevent
chordee.
Of the drugs which are supposed to be eliminated by the kidneys, the
balsams have sustained a high reputation. Among these is cubebs,
of which 2 or 3 Gm. may be taken every two or three hours, as this
remedy favorably influences the amount of discharge, though sometimes
disturbing the stomach. Of the oleoresin of copaiba a ¹⁄₂ Gm. capsule,
taken several times a day, is more pleasantly borne by the stomach,
and with nearly as good effect as cubebs. Copaiba is known to produce
a vivid scarlatiniform rash. The oil of sandal-wood, or santal oil, is
the most efficient of these remedies, and may be given in the same dose
as copaiba. That these drugs are eliminated by the kidneys is shown
by the odor which they impart to the urine. It must be said, however,
that these remedies are of but trifling benefit until the bladder is
involved; when this occurs, they may prove of great value.
The urine should be diluted that it may be less irritating, and also
to overcome its acidity. Fluids should be administered in profusion
and alkaline diuretics in considerable doses. Hyperacidity is readily
controlled by the administration of liquor potassæ, or the common
sodium bicarbonate.
Sedatives may be necessary even from the first. The stronger anodynes
are rarely needed during the first day or two, but by the end of the
first week vesical tenesmus and chordee may be so marked that remedies
such as cannabis indica, lactucarium, chloral, and the bromides may
prove insufficient, and an opiate should then be administered. When
required, morphine or heroine subcutaneously and in doses sufficient to
promptly bring about the effect desired are preferable.
The _local treatment_ of urethritis is directed to the alleviation
of discomfort and distress and the cure of the local disease. Much
has been said about _abortive_ treatment. There is no such thing
as aborting the disease. Much may, however, be done in the way of
mitigating and shortening its course, and mild cases, especially of the
non-specific form, may be considerably relieved within a few days.
The local treatment is carried out by injections into the urethra,
which must be made with a syringe, preferably of hard rubber, with
a blunt tip and without a nozzle, or by a douche bag connected with
a soft catheter, all of which should be kept constantly sterilized.
During the first days of an attack, when only the anterior part of the
urethra is affected, treatment can be made more readily and effectively
with a small “P” syringe, and at this time only 15 to 20 Cc. of
fluid will be required, which should be held in the urethra for some
time. When irrigation is decided upon a douche should be employed.
Accurate directions should be given the patient as to how to make the
injections, and he should be cautioned to first empty the bladder
before using the syringe. The patient’s comfort may be increased by
injections of water up to a temperature of 115° F. Antiseptics, _i.
e._, potassium permanganate, boric acid, or one of the new preparations
of the silver salts, may be added to the water. The parts may be
advantageously immersed in hot water at intervals during the day,
and for fifteen or twenty minutes at a time. There are many ways of
conducting local treatment in these cases. Those mentioned below have
given the best results in the practice of the writer.
A very satisfactory method would be to commence the local treatment
with the use of hot water, as above, every two to six hours, and to
follow it with a small injection of an emulsion of bismuth subnitrate,
with sufficient cocaine and a little morphine to blunt sensibility
and diminish tenderness and pain. The following formula, which may be
varied, will accomplish this purpose: Morphine sulphate 0.3, cocaine
muriate 2, bismuth subnitrate 20, cherry-laurel water 150, mucilage of
acacia 50.
The injection should be retained for a few moments and no effort made
to expel it. The bismuth salt is not only antiseptic, but is soothing,
slightly astringent, and non-irritating.
Belfield has recommended the use of the yellow hydrastia muriate in
connection with protargol. His formula is as follows: Yellow hydrastia
muriate 2.50, protargol 1.50, glycerin 15, water 500. After using
this for a few days the proportion of protargol may be doubled. Of
this preparation 15 to 20 Cc. should be injected several times a day.
The silver salts are the least irritating of all the stronger and
more reliable antiseptics, and drug manufacturers are putting upon
the market at frequent intervals new preparations for which much is
claimed. Among the latest of these is argyrol, a combination of silver
with albumen (vitellin), in such form as to make it antiseptic and
non-irritating. In solution it is of a dark mahogany color and stains
whatever it comes in contact with; these stains, however, are readily
washed out. Argyrol in solutions of 2 to 5 per cent. strength has
proved reliable, and if such a solution be retained in the urethra
for five minutes at a time a pronounced effect may be made upon the
disease. It is my custom to alternate the use of the bismuth formula
with a solution of argyrol as above, and in this way give the greatest
relief in the shortest time. It has been demonstrated that under the
influence of this preparation all gonococci which are reached by it
are destroyed; therefore the earlier it is employed the better. Before
using either of these formulas the anterior urethra should be washed
with hot water or with hot normal salt solution. No harm need be feared
should either of the above injections reach the deep urethra, and the
effort should be to make them reach at least as deeply as the disease
has gone.
When the discharge has reached what Finger has called “the mucous
terminal stage,” then the argyrol may be used two or three times a day
only, and one of the following solutions substituted for it part of
the time: Zinc sulphate 0.75, bismuth subnitrate 8, colorless liquor
hydrastis 15, cherry-laurel water 60. Of this solution 10 Cc. may be
used three or four times a day.
Belfield strongly recommends the use at this time of a solution of
muriate of berberine, in strength of ¹⁄₂ to 1 per cent., or the yellow
hydrastia muriate in about the same strength. He also recommends zinc
chloride 0.25, zinc iodide 0.50, water 500. Either of the above salts
may be added to this.
When nothing remains of the discharge but the so-called “morning” or
“military drop,” and the urine is almost clear, argyrol solution at
night and one of the above formulas once or twice through the day
will be sufficient. This, in brief, is a description of how a case of
urethritis may be satisfactorily treated.
The systematic use of potassium permanganate solutions was introduced
by Janet, and has been enthusiastically described and prescribed by
Valentine. The treatment is more complicated and less satisfactory than
that advised above.
With deep extension of the disease and its added symptoms of tenesmus,
pain local and referred, etc., the limit of the injection should be
extended and the entire urethra should now be treated. The bladder
being empty, the patient should make a strong effort to empty it
again at the moment when fluid is being injected into the urethra;
the compressor muscle being thus relaxed, the fluid passes into the
deep urethra. It will take a little practice to enable him to do this,
but when once learned the procedure is simple, and those who cannot
accomplish it in the standing position will succeed if they lie down
before making the attempt. In this way the entire urethra may be
traversed.
In the treatment of deep urethritis it is not necessary to change the
formulas or drugs above advised.
Under this line of treatment it may be possible to cure the majority of
cases of gonorrhea in from two to five or six weeks. This by no means
indicates that the lesion is actually cured, for trifling evidences,
such as adhesion of the lips of the meatus, with the retention of a
drop or so of mucopus, and the presence in the urine of the so-called
“clap threads,” _i. e._, threads of flocculent material that consist
of mucus and epithelial debris loaded with bacteria, will for a long
time be noted. These appearances indicate that there are still areas
along the urinary tract which are infected, and are sources of possible
danger.
The _vesiculitis_ which often follows deep urethritis, as shown by the
enlargement of the vesicles, detected by rectal examination, requires
physiological rest, hot sitz baths, hot enemas, and opiates, the latter
usually by suppository. After a short time the vesicles should be
“milked” with a finger in the rectum, gentle pressure being made toward
the prostate in the direction of their outlet. This will frequently
cause an outflow into the urethra of pus and debris and give great
relief. Should the infection persist and the above manipulation prove
insufficient, the vesicles may be opened through the rectum, washed
out, and packed with gauze.
CHRONIC GONORRHEA, OR GLEET.
Gleet is the name given to gonorrhea which persists, being only partly
influenced by treatment, and which has extended over an arbitrary
period placed usually at six weeks to two months. Strictly speaking
the term _gleet_ should be restricted to cases where there is a
mucopurulent discharge from the meatus, often complicated by formation
of strictures in the _anterior_ urethra; on the other hand, a _chronic
gonorrhea_ may for a long time persist in the _deep_ urethra and
the glands and ducts adjoining, whence will issue a discharge which
appears anteriorly, but, nevertheless, comes from the depths of the
genito-urinary tract.
It is possible to have a chronic gonorrhea with little or no true
gleet, the infection being latent, but nevertheless persisting. In
gleet the discharge varies from a thin watery flow to one which is
profuse and purulent, most noticeable in the morning on rising,
when the meatus may be occluded by adhesion of the surfaces and
there appears the so-called “morning drop.” Careful investigation
of the urethra will generally disclose at least some constriction,
with tender areas along the anterior urethra. To successfully treat
the disease these areas and constrictions should be determined and
suitably medicated. For this purpose two instruments especially are
necessary--the _bulbous bougie_, for which a sound of the same size is
an unsatisfactory substitute, and the _endoscope_, through which the
lesions may be not only viewed but suitably treated.
The peculiar discharge comes from a lesion of one of the following
varieties--either from isolated areas of inflamed mucous membrane
with underlying exudate, from follicles and vesicles which fail to
completely empty themselves, or from preëxisting strictures. The
endoscope will easily reveal the first and second of these; the bulbous
bougie the first and third, while further examination by the rectum may
be necessary to decide in regard to the seminal vesicles.
[Illustration: FIG. 28
Bulbous sound.]
The bulbous _bougie_ is an instrument of great importance in urethral
work. It should be carefully sterilized before introduction, and the
urethra should be cleansed before its use. The instrument should be
gently passed into the urethra; its course will be obstructed by any
constriction which will give rise to stricture of smaller caliber than
the bougie itself, while the discomfort or pain which it will excite
as it passes over a tender or ulcerated area will be significant. The
urethra is most distensible at its bulbous portion, while its caliber
varies in different individuals, ranging ordinarily from 30 to 35 of
the French scale, while the urethral diameter is about four-tenths of
the circumference of the penis. We owe more to the studies of Otis in
this matter than to any other investigator. He also showed that the
size of the meatal opening is not a criterion as to the size of the
urethra; that the contracted meatus often produced a certain degree
of reflex and spasmodic stricture behind it, and that when the meatus
is too small to permit the introduction of such an instrument as the
urethra should take it should be enlarged, the operation for its
enlargement being known as _meatotomy_, which may be easily effected
with a blunt bistoury under the local use of cocaine. The meatus having
been enlarged to suitable size, any consistent and organic constriction
which then prevents the passage of the bougie should be considered a
stricture and treated accordingly. Such a constriction may be of recent
origin, when it will be found easily dilatable, or it may be old,
resillient, and tough. Otis also devised an instrument known as the
_urethrometer_, which is of value in the accurate estimation but not
necessary in the treatment of many cases.
[Illustration: FIG. 29
Urethrometer.]
These instruments may be passed down to the bulbous portion of the
urethra; beyond this further investigation should be made with the
ordinary sounds. By their use much may be determined in regard to
prostatic tenderness, and the combined use of the sound in the
deep urethra with the finger in the rectum will give more accurate
information regarding the size of the prostate than can easily be
obtained in any other way. Much reaction, however, may occur from the
use of the sounds in this way, and it is a good rule never to introduce
an instrument into the deep urethra without having ample reason
therefor, and then doing it under antiseptic precautions; while, as a
formal measure after it, the patient should be placed at absolute rest.
This serious reaction, which occasionally follows instrumentation of
the deep urethral passage, is commonly known as _urethral fever_. It is
characterized by chills, elevation of temperature, and often by local
indications, the constitutional features being sometimes pronounced,
and in rare cases terminating fatally. Such serious symptoms are
difficult to explain. Doubtless the use of the instrument opens up
paths of fresh infection, and absorption rapidly follows, which may be
limited to the surrounding tissues or cause widespread trouble. This
may ensue after every precaution has been adopted, although doubtless
many of these cases have been the result of carelessness and failure
in antisepsis. Much may be done in the way of prevention when this
condition is feared, for these cases are rarely so urgent but that the
urine can be medicated and its quality improved, while a part of the
procedure may consist in having the patient empty the bladder and then
carefully washing it, or filling it with an antiseptic solution, which
may be expelled before any instrument is used except the catheter,
through which it may be necessary to introduce the bladder wash. The
administration of 2 or 3 Gm. doses of urotropin, with or without
quinine, previous to the exploration, may also be of great service. The
surgeon perhaps does not always take these precautions, but he should
when the history of the case shows that patients have already suffered
in this way. In the presence of such a history the urethra should be
explored with great caution.
When the rectal examination is made the intent should be to discover
any enlargement, irregularity, or undue sensitiveness of the prostate,
and then to pass the finger still farther and ascertain if there is
involvement of the seminal vesicles. At the same time a species of
manipulation described as “milking” may be conducted, by which the
contents of the vesicles as well as of the prostatic utricle may be
incited by gentle pressure, directed from above downward, to empty
into the deep urethra, whence they may be promptly expelled or may be
carried out by the urinary stream, or removed through the endoscope.
The discharge of pus or catarrhal debris in any visible amount is
suggestive, and indicates that these passages have participated in
the infectious process. This act may be repeated at three or four day
intervals; it should be so gently done as not to cause much pain, and
will be found of great value in cases calling for it.
=Treatment.=--The treatment of gleet is essentially treatment of the
causes which produce it, and these should be carefully determined. In
the urethra, as in all other tubular channels of the body, an abnormal
constriction is accompanied by an area of excitement behind it, from
which will issue more than the normal mucous discharge. We see this
in stricture of the esophagus, intestine, or any of the ducts. This
discharge is not to be subdued by mere applications nor by astringent
and antiseptic injections, but the stricture itself, being the most
important factor, must be suitably managed. In recent cases its gradual
distention by the use of conical sounds will usually suffice.
In long-existing strictures more radical measures should be adopted,
and they should be divided with one of the numerous urethrotomes
in general use. Mere division, however, is not sufficient, but the
patient should be impressed with the fact that cicatricial tissue
tends invariably to contract, and that persistent dilatation is to be
practised lest the stricture recur. The old saying used to be, “Once
a stricture, always a stricture.” If this is to be disproved, it can
only be by the frequent and long-continued use of sounds. Ignorance
or indifference impel many a patient to return for further treatment,
sometimes in a condition worse than at first, while occasionally the
penalty paid for carelessness is life itself.
No routine in the treatment of gleet will give satisfactory results
beyond this fact, that patients should be instructed to regulate their
lives by absolute rules as regards indulgence of every description,
and avoidance of intestinal inactivity and constipation. The urine
will be found concentrated and irritating in many of these cases, and
this should be overcome by the free use of water and diluent drinks.
Hyperacidity should be corrected by suitable alkaline medication,
and remedies administered, already mentioned, which are supposed
to medicate the urine. Capsules may be procured containing salol,
oleoresin of cubebs, balsam of copaiba, and pepsin, and except in cases
where there is already great irritation of the urinary tract, these
serve their purpose admirably.
When the anterior urethra alone seems to be involved, one of the
milder injections already mentioned in describing the treatment of
acute cases may be employed. When the deep urethra appears to be the
site of continued irritation, it should then be treated extensively
with deep irrigations and injections of suitable medicaments. The deep
irrigations can be practised with or without the use of a catheter.
The deep urethra may be flushed through a smaller catheter than the
urethra will comfortably take, allowing the fluid to return through the
urethral channel outside of the catheter itself. When this practice
is adopted, hot water which has been made antiseptic should be used,
preferably with one of the silver salts. The nitrate may be used in
proportion of 1 to 500, and the citrate or lactate in strength of 1 to
300 or 1 to 400. Protargol is effective in 1 per cent. solution, or
argyrol in 1 to 3 per cent. strength.
In the employment of irrigation in these cases a shield should be
used, by which the end of the penis may be covered and all danger of
spattering avoided. The simplest expedient for this purpose is one-half
of an old atomizer bulb, which may be punctured and slipped over the
catheter or irrigator tube.
Apart from mere irrigation it is well to deposit within the depths of
the urethra, in the membranous portion, by means of a deep urethral
syringe, a drop or two of a fresh solution of silver nitrate in
distilled water, in strength of ¹⁄₂ to 1 per cent. This should be
deposited behind the “cut-off” muscle, where it will cause a burning
sensation for a short time. The strength of the solution is to be
regulated by this complaint, as no benefit is derived from using it too
strong.
Of all the medication that has been suggested, nothing gives better
results for this purpose than this silver nitrate.
For ordinary urethral injections, besides those already mentioned,
formalin may be used, but in weak solution (1 to 2000, or stronger if
the patient can tolerate it); while picric acid has been recommended by
Belfield and others in strength of 1 to 1000 or 1 to 2000.
Some surgeons believe that patients can learn to flush the deep
urethra, or even the bladder itself, without the use of the catheter
or internal tubing of any kind. The procedure may have to be learned
in the sitz bath, the pelvis being immersed in warm water; the nozzle
of the irrigator tube is inserted into the urethra and the patient is
told to make an effort as if to void his urine. This will so relax the
“cut-off” muscle as to permit the passage of fluid into the bladder,
and this, which is most desirable in many cases of cystitis, where
the bladder washing is an essential feature of the case, is to be
avoided when the gonorrheal infection has travelled backward beyond
the prostate; no attempt should be made to pass the solution into the
bladder, but simply to wash out the urethra. The better plan is to
teach the patient the proper use of a small soft catheter, which may
also be used in the sitz bath, inserted to the proper extent.
Recent strictures should be treated by sounds after the urethra has
been thoroughly cleansed. For this purpose a conical cylindrical
sound should be selected, whose urethral end will comfortably enter
the stricture. Gentle force should then be brought to bear to pass it
beyond the stricture. If gradual dilatation be aimed at, it is well
not to go beyond the point of drawing a drop or two of blood; even
this may be avoided. On the other hand, should it be decided to use
sufficient force, the dilatation should be done thoroughly and at one
sitting, in order to avoid repetition of the irritation. The instrument
generally in use in this country for this purpose is the _Otis dilating
urethrotome_, by which the degree of dilatation and the size of the
cicatricial ring can be estimated and the extent of the division
and the effect gained also regulated. (See Operative Surgery of the
Urethral Canal.)
The _divulsion of strictures_, formerly in vogue, is now abandoned for
the more accurate division performed by this instrument. The strictures
having been thus divided, sounds should be passed at intervals of from
three to five days, by which the urethra is distended to its full
caliber and the divided surfaces not allowed to contract. This is an
important part of the treatment, and gives opportunity for widest
discretion in their employment. Ordinarily they should not be carried
farther back than the lesion calls for, as the deep urethra is best
let alone. On the other hand, there are many cases where the stimulus
of the cold metal passing the entire length of the urethra and the
effect which it seems to have in expressing from the various follicles
any retained contents seem beneficial. It has been stated that
instrumentation sometimes leads to epididymitis or “swelled testicle;”
should this take place in a case undergoing treatment for gleet it may
necessitate a temporary cessation of the mechanical treatment. It is
not good surgery to introduce any instrument into the urethra when one
or both testicles present this complication.
In the local treatment of these lesions, cocaine or one of its
substitutes should be employed. It is questionable whether the
full benefit of applications is obtained when the surfaces are so
anesthetized; on the other hand, the treatment can be made more
endurable by its use.
This is true, also, of the use of the _endoscope_, and applications
which may be made through it to inflamed or hypersensitive patches.
When these are recognized or exposed, they are best treated by a
probang moistened with silver nitrate solution, in 5 to 10 per cent.
strength, or by the solid stick or crystal of copper sulphate, pure or
mitigated, as used by the oculists.
One of the most important features in the consideration of gonorrhea is
to determine, if possible, when a given case has ceased to be dangerous
to others. In theory the danger passes with the disappearance of the
gonococci, but it is so difficult to determine when this has occurred
that it is almost impossible to fix a time limit in any given case. An
excellent method of determining the matter in a reasonably accurate
way is by having the patient void urine in two different glasses; a
small quantity in the first, which will contain, then, the washings
of the urethra. In this glass will be found those chains of gonococci
clustering around masses of epithelial cells or debris which have been
especially described as “clap threads” (tripper-faden of the Germans),
upon which, by careful examination, gonococci can often be recognized.
As long as these threads are in evidence it may be held that the
infection still persists, and might be either brought into activity
again by excitement or convey the disease in the sexual act.
Gonococci have been found in clap threads years after the last known
infection, and this will illustrate why they are such a source of
danger, and how an innocent woman has been made to suffer when it was
supposed that all danger of infection had passed away.
GONORRHEA IN WOMEN.
This naturally assumes the type of a _specific vaginitis_, usually
with active participation of the mucous membrane of the _vulva_ and
of the _vulvovaginal glands_, the urethra and bladder being sometimes
secondarily involved, while the role of the lymphatics is about as
described in the male. In the young, especially in young girls upon
whom rape has been attempted, the mucosa is extremely susceptible. In
adults, particularly in those who have borne children, the vaginal
walls offer more resistance. The nature of the parts permits of more
violent chemosis of the mucous membrane, while in serious cases there
will be well-marked edema of the labia. The urethral orifice is usually
inflamed and chemotic, even though the infection travel no farther in
this direction.
It has been stated that 80 per cent. of deaths from pelvic disease in
women are due directly or indirectly to gonorrhea, as well as one-half
of the cases of involuntary sterility.
As in the male, there may be different types of so-called gonorrheal
infection of the vagina, varying from the pure gonococcus type to that
in which the preponderating bacteria are of the ordinary pyogenic
varieties. The detection of gonococci in the discharges sometimes
assumes medicolegal importance, and upon it has depended the guilt or
innocence of more than one individual.
The intensity of the vaginitis will vary with that of the infection. In
the worst cases the discharge is profuse and acrid. It may amount to
50 Cc. or even 100 Cc. in twenty-four hours. The burning pain will be
extreme, while backache and pelvic soreness will be bitterly complained
of. In mild cases the disease assumes the clinical form of a low-grade
vaginitis with abnormal discharge, such as may be characterized as a
severe case of “whites.”
In these cases of either type the question is, whether infection has
already travelled upward beyond the vagina into the uterine cavity or
through it into the tubes.
Gonorrhea is the most common, and some believe almost the sole, cause
of _pyosalpinx_ with its attendant complications and dangers. Even when
not severe, vaginitis may permit of such extension, and so not only
induce sterility, but compromise the physical welfare of the patient;
while in acute cases the activity is so great that it occasionally
terminates in peritonitis, primarily of gonorrheal origin. When both
tubes have become involved, the patient is almost invariably sterile.
In nearly all of these cases strings of mucopus will be found hanging
out, or beads of it presenting at the external os, and when examined
this exudation will afford a fair test as to the character and degree
of the infection. Here, as in the male, there are so many follicles
difficult of access, and so many recesses in which germs may lurk, that
a complete disinfection of the parts is almost impossible. For this
reason, then, latent gonorrhea is a frequent outcome of the disease
when once it has existed, and a possible and more or less constant
source of danger to others.
=Treatment.=--A case of acute gonorrheal vaginitis with its
accompaniments will present a difficult problem. The discharge is
so great that the danger to others, and especially to the eyes, is
pronounced, while the exquisite tenderness of the parts makes radical
treatment difficult. The treatment should consist of antiseptic
douches, which in serious cases should be made as nearly continuous
as possible. The water used for the purpose should be as warm as
the patient can tolerate, and contain an antiseptic, of which
corrosive sublimate, in strength of 1 to 2000, silver nitrate in the
same strength, or formalin in double this strength, are the most
serviceable. The irrigating tube should be carried to the upper end
of the vagina and the stream made to flow outward. In milder cases a
douche at intervals through the day may suffice. The vaginal surface
should later be exposed through a speculum and the entire mucous
surface treated with nitrate of silver solution in from 6 to 10 per
cent. strength. Should the surface be tender, this will be painful, and
might justify the use of an anesthetic, especially of nitrous oxide.
If the disease extend upward and there is an _endometritis_ or a
_salpingitis_, external applications of ice may be used to lull the
pain; but probably hot poultices or some application of external heat
might afford greater comfort to the patient. Byford has used succinic
dioxide in the treatment of specific vaginitis with great satisfaction.
It is sold in the open market under the trade name “Alphozone.”
The edema of the vulva will subside with the general improvement of the
case. Abscesses in the vulvovaginal glands are not uncommon. These are
easily recognized, are often painful, and should be incised early or as
soon as recognized, cleaned out thoroughly, the interior of the cavity
cauterized to prevent the result of fresh infection, and then packed
and left to heal by granulation.
Urethritis and cystitis may be treated as when they occur in the
male. There is the same liability in women as in men to lymphatic
involvement, with the consequent bubo, which may perhaps suppurate.
They are less liable to the widespread manifestations of postgonorrheal
infections of the joints, etc., although they are even more liable
to infection of the endocardium, and, as will be readily understood,
more so to infection of the peritoneum. It will then be seen that the
treatment of the disease is essentially the same in either sex, certain
differences in method rather than in principle having to be made in
accordance with anatomical requirements.
As to the rectal mucous membrane participating in gonorrheal infection,
under ordinary circumstances it would escape. In the treatment of any
of these cases by the sitz bath, the question might arise whether there
would be danger of extending the contagion in this direction. It does
not appear that much fear need be felt, for two reasons: the grasp
of the sphincter is usually sufficient to prevent entrance of fluid,
and, furthermore, the rectal mucosa is itself extremely resistant to
the gonococcus. _Gonorrheal proctitis_ is an exceedingly uncommon
infection, and one rarely seen, except in extreme cases of sexual
perversion. It should be treated in about the same manner as gonorrheal
vaginitis, _i. e._, by continuous irrigation with hot water, and
stretching the sphincter in order to overcome the spasm into which it
would be thrown by reflex activity.
_Gonorrheal urethritis_ in women is best treated with local
applications of argyrol or one of the other silver compounds. These
can be made with a syringe or with a small swab. _Cystitis_ is to be
treated in the same manner as when it occurs in the male.
CHAPTER XIII.
SCURVY AND RICKETS.
SCURVY.
Scurvy is placed among the so-called surgical diseases, since it
manifests many distinctly surgical features and is possibly of
parasitic character, although this feature of its existence has not
been incontrovertibly established. It is a _starvation_ disease, its
principal characteristic being that of _malassimilation_, accompanied
by profound _anemia_. Well-marked cases are seen during long sieges,
like that of Paris, in 1871, or during long imprisonment, as in
Andersonville prison. It has certain points of resemblance to that
condition of multiple neuritis met with in warm climates, and known
usually as _beriberi_. The former is apparently due to the absence of
a vegetable regimen, while beriberi is largely due to the absence of
an animal regimen, nature having intended that man’s diet should be
mixed, and having ordained that suffering and disease always follow
confinement to one or the other.
=Pathology.=--The pathology of scurvy is obscure. It has been shown
that gastric digestion is seriously at fault, that there is much
intestinal putrefaction, that the urine shows great absorption of
toxins, that the hematopoietic function is incomplete: that scurvy is
a toxemic or chronic ptomain poisoning, which may in part or at times
be due to the use of tainted food. Morphological changes are, however,
neither distinct nor pathognomonic. It has been described as a disease
of diet and occupation rather than of race, age, sex, or season. The
ease with which hemorrhagic effusions occur, the degeneration of
muscles and other tissues, the frequent detachment of cartilages, can
be accounted for by conditions thus summarized, for which, however,
we have no minute explanation. Scurvy may so complicate various other
diseases, and usually does when occurring in large bodies of men--as in
armies, prisons, among convicts, etc.--that it is hard to dissociate
morbid phenomena and assign to each its proper place.
=Symptoms.=--The disease begins by a condition of generalized
prostration, with an icteric tint of the skin, malaise, mental torpor,
loss of appetite, insomnia, etc. The first recognizable or distinctive
local appearances occur about the margins of the gums. Here, in the
intervals between the teeth, the gums become livid, friable, and bleed
easily, while the breath assumes a characteristic fetid odor. The
skin becomes dry and brittle, and covered with minute prominences,
which give it the popular name “goose-flesh.” These appearances are
followed by local pains, diversified and sometimes excessive, and
extravasations of blood in the skin and under the visible mucous
membranes, causing small ecchymoses, which by themselves would be
considered as simple purpura hæmorrhagica. These pass through the usual
phases of extravasations, while it is made evident by pain, nodular
masses, etc., and by postmortem examination, that similar hæmorrhages
occur in the deeper tissues, especially in the muscles, even in the
bones and epiphyses. So easily do hemorrhages occur in advanced stages
that there is often external bleeding, particularly from the gums and
mucous membranes, while from points thus involved pyogenic infection
may proceed internally. Near the close the victim presents a picture
apparently of an animated corpse, with surface discolored and mottled,
often appearing bruised, with ulcerations where extravasations have
failed to resolve, and where infection has occurred, possibly with
epiphyses loosened, and necrosis of the bones of the extremities. In
such cases death results from marasmus and sepsis.
=Treatment.=--As long as the patient is not in the desperate condition
just described the prognosis and outlook for treatment are promising,
as all the milder manifestations of scurvy can be dispersed by suitable
feeding and medication. Loss of teeth and cicatrices of ulcers leave
permanent traces, but function can be restored. The _purpura_ is but
one expression of the scorbutic condition. Nearly all cases of scurvy
will present purpuric manifestations, but all cases of purpura are not
necessarily scorbutic. The course of treatment may be summed up in
proper diet and in the administration of certain drugs. _Proper diet_
should be prescribed at once, but administered, especially in severe
cases, _with extreme caution_. The food selected should be given in
small quantities, but frequently. It should consist in large measure of
fresh fruits and vegetables, while cranberries and lime-juice figure
largely among the former. Buttermilk is excellent, and cider may be
allowed; also lemonade, with but little sugar.
[Illustration: PLATE XI
FIG. 1
Rickets. Rib. Very low power. (Gaylord and Aschoff.)
FIG. 2
Rickets. Flat Bone of Skull (Craniotabes). (Karg and Schmorl.)]
For the local condition in the mouth an antiseptic mouth-wash
containing a fair proportion of hydrogen dioxide is advisable.
Alcoholic stimulants are called for, at least up to a certain point.
Strychnine and cinchona preparations will give force to the heart’s
action, and the horizontal position, for a time at least, will prevent
sudden heart failure. Compound syrup of the hypophosphites, with meat
preparations, will supply lacking material, while the hemorrhagic
manifestations are best controlled by the fluid extract of ergot and
aromatic sulphuric acid, separately or combined. Particular attention
should be given to cleanliness and fresh air.
=Infantile Scorbutus.=--Infantile scorbutus sometimes furnishes the
surgeon with very young patients who are brought to him especially
for disability of the limbs, with pain and fretfulness, leading to
immobility, followed by enlargement of the lower ends of the femurs
(due to subperiosteal hemorrhages) with fixation by muscle spasm; this
may be followed by “spontaneous” fractures. The gums will show the
same changes as are seen in adults, while subcutaneous hemorrhages
and infiltrated muscles, with foul breath, ashen pallor, listlessness
and apathy, and perhaps several swollen joints, will complete an
unmistakable picture.
Fresh milk with orange-juice in small amounts between feedings,
combined with more strictly surgical measures if needed, will secure
good results in these little patients.
RICKETS.
Rickets, or _rachitis_, is another of the diathetic conditions, in
this instance not yet considered of parasitic origin, most commonly
occurring in infancy and early childhood, although its resulting
lesions may persist throughout life. It is characterized by nutritional
disturbances and organic irregularities.
=Pathology.=--Rickets is generally referred to as “fetal” or
“congenital,” according to whether the infant presents characteristic
markings at birth or whether they develop later. The most marked
constitutional defect seems to be in the supply of calcium salts, which
leads apparently to formation of bone which has not sufficient compact
tissue to make it strong. Especially along the line of junction between
bone and cartilage do we see the most marked expressions of rachitic
lesions. Here the cartilage is evidently actively growing, while the
bone formation proceeds with difficulty, and the proportion of vascular
tissue is excessive. The result is prolongations of soft vascular into
the cartilaginous tissue, by which the latter becomes more or less
absorbed, and this essentially interferes with _ossification_. In
severe cases it may be lacking. At epiphyseal lines one may see a layer
of osteoid tissue which is not cartilage and will not become bone.
Because of its yielding nature it warps under the mechanical strain to
which the bones of the extremities in young children are constantly
subjected.
The obscure but unmistakable relations existing _between rickets and
the status lymphaticus_ will be referred to in Chapter XIV.
The osseous lesions of rickets differ from those seen in osteomalacia,
since in the latter the softened tissue is practically decalcified
bone, while in the former case most of the affected tissue has never
gone so far as genuine bone formation, but is arrested in its perverted
state.
The result of rickety changes in the skeleton is a thickening of
the shafts of the long bones, of the outer table of flat ones, of
the epiphyseal extremities of shafts, and frequently a stunting of
their development, so that they do not attain their normal length.
The periosteum is also affected in rickets, with the result that
when the changes occur, mostly subperiosteally, there are warpings
and curvings of the bone shafts, while so long as the disturbance is
epiphyseal more or less abrupt curvatures and angular deformities will
be produced as the result of muscle action. So marked are the changes
in some instances that it has been stated that bones may even lose
three-fourths of their calcium salts. When rachitic bones are so soft
as to be easily cut with a knife, marked deformities occur as the
result of muscular activity. (See Plate XI.)
In the extremities we see _bow-legs_, _knock-knees_, _clubbing of the
ends of the long bones_, bending of the neck of the femur, _flat-foot_,
_club-foot_, etc.; while the clubbing of the bone ends also may be well
marked in the bones of the upper extremity, where, however, marked
deformity is less common, because the upper extremity does not bear
the weight of the growing body. In the skull the bones remain soft
and yielding to pressure, with a tendency to return to their original
membranous condition, and this is the condition comprised under the
term _craniotabes rachitica_. The _fontanelles always remain open_ for
an undue time; the sutures are broad and membranous. The _bones of the
face grow less rapidly_, giving to the face a disproportionately small
size; _dentition is delayed_ and the _teeth decay easily_. The upper
incisors often project far over the lower.
In the thorax there are enlargements of the sternal ends of the ribs,
causing a row of nodules referred to as the _rachitic rosary_. The ribs
tend to sink in, the sternum to be protruded forward, and the deformity
known as _pigeon-breast_ becomes often pronounced. Curvatures of the
spinal column, especially _kyphosis_, are common, and distinct degrees
of _lateral curvature_ are frequently begun as rachitic deformities, to
be magnified by perverted muscle action as the child grows older. In
the pelvis the innominate bones approach each other, causing the pelvic
cavity to become contracted, or the sacral promontory projects too
far, or in various other ways the normal pelvic diameters are so far
compromised that _rachitic deformities of the pelvis_ constitute the
most common and serious obstacles to normal labor in adult women, and
are frequently the cause of major obstetric operations.
While the rachitic changes in the osseous system are the most
distinctive and easily recognized, numerous other organs and tissues
of the body are more or less seriously compromised. _Ventricular
dilatation_, leading to chronic _hydrocephalus_, is one of the common
results of rachitis of the skull, which may be followed by convulsions
and terminate fatally. _Porencephalon_ and _cerebral sclerosis_
may also ensue. Disturbances of digestion are common in rickety
children--the _liver_ may decrease in size or become much enlarged;
the _spleen_ often enlarges, sometimes to enormous dimensions. In
various other parts of the body there are the same expressions of
malnutrition as are met with in tuberculous disease. Rickety children
_perspire easily_, particularly at night, when the head will often
be found bathed in perspiration. They are fretful and irritable, as
a rule, and difficult to control. A child with protuberant belly,
due to enlargement of liver and spleen, as well as to crowding of
pelvic organs, with relaxation of abdominal walls, and a contracted
and distorted thorax, the skull flattened on the top, clubbed bone
ends, a history of resting badly at night and sweating profusely,
constitute a clinical picture of rachitis so marked that it can be
recognized at a glance. Between this picture in its worst forms and the
slightest deviation from the ideal type there may be met all degrees
in manifestations of rickets in the children of the rich or the poor,
while in adults may often be seen evidences of that which prevailed
during early childhood. In order that all these features may be made
out the child should be stripped and examined from head to foot.
_Laryngismus stridulus_ is a frequent accompaniment. It may be followed
by general convulsions and tetany. (See Chapter XIV.) While rickets
may be a very acute disease, it is as a rule chronic, and children
dying essentially from this disease die rather from cerebral or other
manifestations which may be regarded as in some degree accidental.
_Scurvy_ and other nutritive disturbances may be associated with
rickets.
=Treatment.=--The treatment for the condition consists mainly in
_proper nutrition_. Mothers’ milk is certainly preferable to any other,
and should be demanded. If feeding must be artificial, it should be in
accordance with the best precepts of modern therapeutics. Cod-liver-oil
emulsions are of advantage; compound syrup of the hypophosphites is
a remedy of great virtue. Minute doses of phosphorus seem to be of
value--1 Mg. _pro die_. It is a mistake to let rickety children begin
to walk or even to creep too early. They should be kept upon the back
in their cribs.
The modern opotherapy of rickets includes the employment of _thyroid_
and _pituitary extracts_. The dose should be graduated to the age of
the patient, based upon 30 Cg. for an adult, and given thrice daily.
This will not preclude the necessity for a careful regulation of diet,
etc., but will constitute a valuable adjunct in treatment.
The deformities due to rickets are so numerous as to constitute a large
part of those to which special or orthopedic surgery is addressed. The
mechanical and operative treatment of these cases will be referred to
in their appropriate place.
CHAPTER XIV.
THE STATUS LYMPHATICUS.
Under the term _status lymphaticus_ has been described a condition
which is of interest to the surgeon, as it includes not only minor
complications, and even those which are serious, which follow surgical
procedure, but it also has reference to the cases of sudden death
during or after operation, some of which have been attributed to the
anesthetic, while others have been considered absolutely unexplainable.
The condition is so easily described or defined that it should be
recognized during life, but it has often been discovered only after
sudden death.
The essential feature of the condition is _enlargement of the
lymphatic tissue and apparatus_, perhaps throughout the entire body,
more frequently through its internal portions. It usually occurs
in children. It is accompanied by much lowering of the power of
resistance, and results in sudden death from cardiac failure, as
the result of causes which seem disproportionately trivial; as, for
instance, such deaths as occur not merely during anesthesia, but during
bathing, convalescence from the exanthemas, etc. It stands in close
relation to diphtheria, perhaps because of its peculiarly depressing
toxins, and probably accounts for cases of sudden demise in that
disease, even when mild.
The status lymphaticus is also designated by other names, as
_lymphatism_, _lymphatic constitution_, and _status thymicus_, the
latter because of the active participation of the thymus. Enlargement
of this body has been noted at autopsy, but its relation to the other
features of status lymphaticus were unknown until Rokitansky, in 1842,
first recognized the condition in its entirety, but confused it with
the tuberculosis of the lymphatics formerly called scrofula.
The death of a son of a German professor, a few years ago, shortly
after an injection of antitoxin to protect him from diphtheria, and the
subsequent discovery that the boy was the victim of this condition,
caused a widespread interest in and a most careful study of the
problems involved. They occur in the thymus more frequently than in
any other organ of the body. Normally the thymus begins its involution
within a few months after birth, and this process should be completed
at puberty. In the status lymphaticus this involution does not occur,
but enlargement persists or increases even into adult life, varying in
different cases, the weight of the thymus varying from 20 to 135 grams.
While the thymus may for some purposes be grouped among the lymphatic
tissues of the body, little is known as to its function. Its juice
contains leukocytes, which find their way into the general circulation,
and it is supposed to have an internal secretion correlated with that
of other ductless glands.
Injections into dogs of thymus extract produce a fall in the blood
pressure, with acceleration of the heart, and, in fatal doses, dyspnea
and collapse. While enlargement of the thymus may cause death by
pressure on important structures other than the trachea, it produces
a type of asthma known as _thymic asthma_, in which death sometimes
occurs unexpectedly and rapidly by strangulation.
An examination of the thymus rarely shows anything more abnormal
than the enlargement of its natural structure, with perhaps acute
hyperemia, while occasionally the cut surfaces will exude a milky
fluid; there will be found, in addition to these changes in the thymus,
a general hyperplasia of the lymphatic system, with enlargement of
the superficial and deep nodes, especially the cervical and axillary,
the inguinal and those in the abdomen. The spleen enlarges and the
Malpighian bodies seem to be packed with lymphoid cells. There may be
enlargement of the heart and increase in the thickness of the arterial
walls. This is so marked that Virchow suggested the name _lymphatic
chlorotic constitution_. It has been suggested that the narrowing of
the aortic valve in these cases is due to this lymphoid infiltration.
_The relations between rickets and the status lymphaticus_ are so
frequent and so conspicuous as to make one suspect a more than casual
connection between them. Nearly all cases of lymphatism show the
ordinary clinical evidences of rickets. By some such relation may be
explained the benefit which accrues in rickets from the administration
of the extract of thymus, as well as of the thyroid and the pituitary
body.
Enlargement of the lymphoid tissue in the wall of the alimentary canal
also occurs, and in those rings of adenoid tissue which mark the site
of the embryonic canals. This tissue may be seen around the origin
of the appendix, while its most conspicuous illustrations are seen
about the pharynx, where not only the faucial, but the lingual and the
pharyngeal tonsils are enlarged. In many of these cases there are the
so-called “adenoids” of the throat specialists, while, of still greater
interest to the surgeon, the deaths that have occurred from the status
lymphaticus have happened repeatedly in operations for these growths
within the nasopharynx. Furthermore, the yellow marrow of the bones
seems to be replaced by red marrow, but whether this is due to the
anemia which always accompanies the condition is not known.
Kaposi some years ago described under the name _lymphodermia
perniciosa_ a rare condition characterized by a scaly and itching
skin, exuding fluid, with later a diffuse and doughy condition of the
affected parts, and then by nodules which sometimes ulcerate, lymph
nodes and spleen being also enlarged, and the general health impaired.
While some have held that this is a variety of mycosis fungoides, it is
supposed that it is only another expression of lymphatism.
Another variety of this condition occurs in young people, in which
coma comes on suddenly, followed by death in twelve to eighteen hours.
Vomiting may occur during the coma, but it is convulsions and spasm of
the glottis that cause the death of the patient.
_Thymic asthma_ has been called _laryngismus stridulus_. Whether the
latter can ever occur without the former is not definitely known, but
doubtless the asthma is very frequently the cause of the obstruction
and the difficulty in breathing.
Medicolegal questions arise in this connection which are of interest.
Death occurs, except under anesthesia, after a series of convulsions,
yet it may happen almost instantly. Some claim that death may take
place as the result of pressure of an enlarged thymus upon the vessels,
and especially upon the nerves, while others claim it to be due to a
sudden arrest of heart action by reflex activity.
Convulsions of any character in adolescent individuals and young
children should raise a suspicion of this condition, and, of greater
importance for the surgeon, all possibility of existence of the
condition should be eliminated before operation is undertaken. Deaths
occurring during anesthesia are often attributable to the anesthetist;
nevertheless there are instances where he is absolutely blameless, and
where death may occur as by a flash of lightning.
It does not follow that chloroform is the agent at fault in these
cases, and opinion seems to trend in the direction of ascribing the
censure to the status itself rather than to the anesthetic used.
Deaths may occur at any stage of anesthesia, or some minutes after
the anesthetic has been stopped. It is significant that the most
conspicuous illustrations of the relations between the condition and
sudden death have occurred during operations upon the throat and nose.
This seems to show the role played by the adenoid tissue.
Another interesting question is why individuals with well-marked status
lymphaticus should live, apparently comfortable for years, and then
suddenly succumb from apparently trifling causes.