PART II. PRACTICE OF SURGERY

SECTION III. DISEASES

Part 14. 4. Veneral Diseases

Three distinct affections are included under this term—gonorrhoea, tions of chancroid, and syphilis. At one time these were regarded as dif-venereal ferent forms of the same disease ; and, though gonorrhoea is now diseases, generally held to be quite distinct from the other two, there are not wanting eminent authorities, including Mr Jonathan Hutchinson, who are inclined to look upon chancroid and syphilis as essen-tially one and the same disease. The present writer believes that gonorrhoea, chancroid, and syphilis are three distinct diseases, due to separate causes, which have nothing in common except their habitat. The cause in each case is a specific virus, probably a micro-organism. In the case of gonorrhoea the virus attacks mucous membranes, especially that of the urethra ; in chancroid mucous membranes and the skin are affected ; in syphilis the whole system comes under the influence of the poison. Gonorrhoea and chancroid correspond to the process of septic intoxication. The organisms on implantation set up a local disturbance, and the products of this fermentative process pass into the system and give rise to constitutional effects ; but the organisms themselves do not pass into the system generally. In syphilis, on the other hand, there is a true infective process: the organisms pass into the general circulation and live and multiply wherever they find a suitable nidus. The joint affection commonly called "gonorrheal rheu-matism," which sometimes follows gonorrhoea, is in all probability an infective condition. If this is true, then in these rare cases gonorrhoea is infective. The chancroid poison may pass into the lymphatics and cause inflammation of the lymphatic glands in the groin, giving rise to chancroidal bubo. These clinical facts are undoubtedly opposed to any generalization such as that laid down above, and it is right to note them ; but the general comparison between gonorrhoea and chancroid as non-infective and syphilis as distinctly infective in its character holds good in the great major-ity of cases. A further study of these quasi-infective varieties of gonorrhoea and chancroid must undoubtedly throw light upon the physiological classification of pathogenic organisms. These three affections are generally acquired as the result of impure sexual intercourse ; but there are other methods of contagion, as, for example, when the accoucheur is poisoned whilst delivering a syphi-litic woman, the surgeon when operating on a syphilitic patient. An individual may be attacked by any cne or any two of the three, or by all of them at once, as the result of one and the same connexion; but they do not show themselves at the same time ; in other words, they have different stages of incubation. In gonorrhoea the disease appears very rapidly, so also in chancroid, the first symptoms commencing as a rule three or four days after inoculation. It is very different, however, with syphilis. Here the period of incubation is one rather of weeks, the average length being twenty-eight days, though it may vary from one week to eight. The length of the period of incubation, therefore, is the great primary diagnostic in the case of syphilis.

Syphilis is an infective fever, and its life history may be best Syphilis, considered by comparing it with vaccinia. A child is vaccinated on the arm with vaccine lymph. Tor the first two or three days nothing is observed ; but on the fourth day redness appears, and by the eighth day a characteristic vaccine vesicle is formed, which bursts and frees a discharge, which dries and forms a scab. If on the eighth day the clear lymph in the vesicle is introduced at another point in the child's skin, no characteristic local effect follows. The system is protected by the previous inoculation ; this protection will last for some years, and in certain cases for the rest of the patient's life. We have here, then, exposure to a poison, its introduction locally, a period of incubation, a charac-teristic local appearance at the seat of inoculation, a change in the constitution of the individual, and protection from another attack for a variable period. So with syphilis. The syphilitic poison is introduced at the seat of an accidental abrasion either on the genital organs or on any part of the surface of the body. The poison lies quiescent for a variable period. The average period is four weeks. A characteristic cartilaginous hardness appears at the seat of inoculation. If this is irritated in any way, an ulceration takes place ; but ulceration is an accident, not an essential. From the primary seat the system generally is infected. The virus is multiplied locally and, passing along the lymphatic vessels, attacks the nearest chain of lymphatic glands. If the original sore is in the genital organs, the glands in the groin are first attacked ; if in the hand, the gland above the inner condyle of the humerus ; if on the lip, the gland in front of the angle of the jaw. The affected glands are indurated and painless; they may become inflamed, just as the primary lesion may ulcerate; but the inflammation is an acci-dent, not an essential. From the primary glands the mischief will affect the whole glandular system. The body generally is so altered that various skin eruptions, often symmetrical, break out. Any irritation of the mucous membrane is followed by superficial ulcer-ations, and in the later stages of the disease skin eruptions, pustular and tubercular in type, appear, and in weakly people in severe cases, or in cases that have not been properly treated by the surgeon, syphilitic deposits termed gummata are formed. These, if irritated, break down and give rise to deep-seated ulcerations. Gummata may attack the different organs in the body ; the muscles, liver, and brain are the favourite sites. Their presence interferes with the functions of the organs, and, if the organ affected is one functionally important in the economy, may cause death. The individual is as a general rule protected against a second attack, although there have been rare cases recorded in which individuals have been attacked a second time.

Syphilis is treated by many surgeons by giving careful attention Treat-to the general health, to diet and regimen and tonics, by placing ment of the patient in the most favourable hygienic circumstances, in the syphilis, belief that it runs a natural course and has a tendency to natural cure. Special symptoms are treated as they arise. Other surgeons administer small doses of mercury, in the form of grey powder, iodide of mercury, or corrosive sublimate. If the physiological effects of mercury are observed—tenderness of the gums and a metallic taste in the mouth—this treatment is desisted from and iodide of potassium is administered, mercury being given again when its physiological symptoms have disappeared. Oleate of mer-cury or mercurial ointment, or mercury with lanoline, is applied to the primary lesion and rubbed in over the enlarged glands. This is continued for six months or a year. In the later stages of the com-plaint iodide of potassium is the main remedy used. There are therefore two distinct methods of treating syphilis,—the non-mer-curial and the mercurial. Both methods have been extensively tried by the present writer, and he believes that the mercurial is infinitely preferable to the non - mercurial method. Recent investigations point to the value of corrosive sublimate as a germicide, and in all probability the good results which follow saturation of the system with mercury are to be explained in this way. It is said by the non-mercurialists that the administration of mercury masks the symptoms. There can be no doubt that the symptoms often appear after the mercury is stopped, but in a modified form, and there is no evidence that the mercurial treatment prolongs the disease. Syphilis has a tendency to natural cure, like all the continued fevers, and along with the administration of mercury careful hygienic treat-ment must receive particular attention, and often in weakly un-healthy people a long sea voyage is of great value. Any means which causes a free action of the skin, as, for instance, by periodic visits to thermal baths, is of great assistance in eliminating the poison.

Syphilis as commonly met with nowadays is not of so severe a type as it formerly was. One reason often given for this is that mercury was formerly always pushed until its full physiological effects were observed, and that the lowering of the patient's con-stitution by this severe treatment aggravated the primary com-plaint. There may be some truth in this explanation ; but the principal reason in all probability is that the syphilitic organism does not now find so suitable a nidus or soil for its growth and development as it once did. Syphilis in the United Kingdom at the present moment is in the stage of an epidemic in its decline. This may be looked on as a startling statement; but it is true of syphilis as of all infective diseases. A time must come when the soil is practically worn out, when it becomes so poor that the organ-ism grows only in a stunted form, producing a mild disease, till in time it ceases to grow altogether. It is not asserted that it will necessarily die out, because after lying fallow for a time the soil may recover its power and the disease be revived in a more virulent form, analogous to the luxuriant crop which follows after a period of fallow. Syphilis can be conveyed by the discharge from any syphilitic lesion occurring within two years after the commence-ment of the complaint. It cannot be conveyed by the normal secretions of the syphilitic person except in the case of the semen, which, impregnating the ovum in the female, causes the foetus to be syphilitic. Syphilization of the foetus is followed by syphiliza-tion of the mother. The blood of a syphilitic person is infectious for two years after the commencement of the attack. Pure vaccine lymph cannot convey syphilis ; if, however, it is mixed with blood it may convey it. No person who has had syphilis should marry until he has been entirely free from the complaint for two, or better still for three, years. If a person marries before this time pregnancy greatly increases the risk to the mother. If there is any suspicion of syphilis the mother should take mercury during the period of pregnancy. It is interesting to note how time has a modifying influence in a case of repeated pregnancies occurring in a syphilitic woman. At first there may be miscarriage in the early stage of pregnancy; after a time abortions in the later stage ; there may then be a still-born child; then one born alive but syphilitic; then a child born apparently healthy but soon becoming syphilitic; and ultimately a healthy child is born and remains healthy, showing no evidence of syphilitic disease. The disease has worn itself out. The relation of apparently healthy people born of syphilitic parents to syphilis acquired during the course of their life may explain those remarkable cases of escape from syphilitic infection which constantly come under the observation of the surgeon.







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