GAILLARD'S MEDICAL JOURNAL. A MONTHLY JOURNAL OF MEDICINE AND SURGERY Scientia et Veritas Sine Timore. M. E. GAILLARD, (PUBLISHER.) 106 William Street, NEW YORK. All business communications should be addressed to Gaillard's Medical Journal, 106 William St., New York. All editorial communications to Carter S. Cole, M.D., 122 W. 73d St., New York. Articles for publication will be received with the understanding that they are contributed exclusively to this journal. Reprints will be furnished at actual cost, orders for which should accompany the manuscript. Authors of accepted articles may receive twelve copies of the issue in which they are published. Necessary illustrations will be furnished without expense to authors when suitable drawings or photographs are furnished. EDITORIALS. PRACTICAL POINTS CONCERNING SYPHILIS. A recent article in the Medical News by one of the best syphilographers of the country-Dr. R. W. Taylor-entitled "What conditions influence the course of syphilis," brings into prominence a number of facts more or less well known to those who have had much experience with the disease, as well as suggests not a few other things of considerable importance to those who will be called upon to manage specific cases. It has always seemed to us to be exceedingly desirable to first of all-after an exact diagnosis has been reached and demonstrated, impress upon the patient the fact that moral and social ostracism do not necessarily follow in the wake of the disease; and in the next place that there is no other disease more tractable, if the patient be willing to obey instructions, nor any other in which the effect of treatment is more easily demonstrable and more satisfactory. On the other hand,, there is perhaps no other disease more destructive if it assumes a malignant type, and if it be not promptly and properly checked. The materie morbi has not been demonstrated with certainty, but is almost without question a specific microbe. That acquired syphilis can only follow the chancre as its initial lesion has long been accepted as a dogma of the disease. The pathology of the initial lesion is stated that such clearness by the author mentioned that we quote him in extenso: "The initial lesion, from which the following facts were derived, was excised by me four days after its first appearance and eighteen days after the infecting coitus, consequently it presented the very earliest appearances of syphilitic infection which can be studied by means of the microscope. The chancre appeared as a minute red erosion, and consisted of a circumscribed mass of tissue resembling in structure ordinary granulation tissue, but under and beyond it, when examined microscopically, there was a very marked change in the condition of the blood-vessels. This change consisted in the distention of the perivascular spaces with small round cells. Nearly every vessel examined, both arteries and veins, was in this way enveloped by masses of small round cells, forming a sheath like a coat-sleeve around the arm. Besides this condition of the perivascular spaces there was a change in the endothelial cells lining the arteries and veins, which were swollen and seemed to be proliferating. In two or three places the process had gone on to such an extent as to produce thrombi of the medium-sized veins. Careful study showed that it was very probable that these perivascular cell-clusters were produced by the proliferation of the connective-tissue cells of the adventitia of the vessels or by the proliferation of the same cells, just exterior to the adventitia. The point deserving of attention, and it has been further demonstrated in the examination of chancres from other patients, is the extremely early and farextending involvement of the blood-vessels. Although the primary sore was but of a few days' duration, very small, and under the microscope was of such limited and circumscribed extent, the blood-vessels were very extensively surrounded by cell investments at a considerable distancefully an inch-from the ulcer. The microscope also showed how deeprooted syphilis is at the very beginning of the sore, having extended along the perivascular lymph-spaces, and how futile it is, as experience has already shown, to attempt to abort it by excising the primary sore. Apparently, judging from the appearance of the vessels in this case, their involvement begins before the appearance of the sore. The microscopic analysis of this and other cases also shows how it is that the infection of syphilis travels from the primary sore and infects the body. The perivascular spaces are lymph-spaces which communicate ultimately with the inguinal glands, and the enlargement of these glands is undoubtedly due to the advancement of this cell proliferation along the perivascular spaces until it reaches them. The same process extends from the inguinal to other sets of glands or lymphatics. The process of syphilitic infection, therefore, is one of constant growth and diffusion from the beginning. In the very first days of the existence of the chancre the poison is deeply rooted in the subcutaneous tissue; it is in a most active state and progresses along the course of the vessels until it reaches the body, and then infects the whole economy. In consequence it is very certain that excision of the chancre will not cause the abortion of the disease. Reasoning by analogy, we are warranted in assuming that this new, highly infectious, and rapidly growing tissue gives off, probably by means of its microbes, a poison which diffuses itself through the system. We have then in syphilitic infection two orders of morbid changes: (1) the heterologous new cells; (2) the diffusible poison." This then compels the belief-as statel in the quotation--that the excision of the chancre, its cauterization or any other method of disposing of it than by systemic treatment, is utterly useless. We are therefore under still heavier obligations to our patients and ourselves to make a diagnosis that admits of no question. The next fact of especial interest brought out in the article is that "there is a well-marked uniformity in the infectious quality of the virus, no matter from whom it may be derived, and that this poison may produce in some subjects a mild and in others a severe form of syphilis. It, therefore, logically follows that the benignity or severity of syphilis is determined by the condition of the individual." Keeping this in mind we will not be slow to bring our patients up to the best standard of health, besides treating the special disease for which the patient happens to consult us; more than this we must carefully enquire into the mode of living, the surroundings, habits, company and every attendant circumstance that may throw any light upon the way to improve the general condition of the patient. The author goes on to say: "In a general way it may be stated that the larger number of persons who contract syphilis are those who are in average good health and have not grown old. In a smaller number the standard of health is less high, and in many patients certain morbid conditions exist which are due either to disease or bad habits, and which lower their power of resistance. Extended clinical observation shows very clearly that syphilis when untreated by mercurials runs a somewhat uniform course. Following the chancre, in due time the secondary cutaneous and mucous-membrane manifestations appear, and remain for a short or long period, and then they seemingly undergo, resolution. Next a more advanced form of lesions, such as large papules or papulo-tubercles, are observed, and these may in time wither, and later on-in months or years- true tertiary lesions may develop. The tendency of syphilis, luckily for mankind, is to expend its force on the superficies of the body, and it seems. very probable, particularly in healthy subjects, that the lesions of the deeper parts are, in the main, due to various determining causes, such as traumatisms (bones, joints, tendons, and fascia), antecedent pathologic processes (liver, spleen, kidneys, intestines, and testes), and to a neuropathic tendency (cerebrospinal affections). When any of the abovementioned causes exist in untreated syphilis, the grave order of lesions may follow or coexist with the more superficial ones. Some of these mild cases, in persons previously healthy, sooner or later become grave, and even malignant, but in general the gravity or malignancy of syphilis is due to some inherent defect in the constitution of the patient, to some diseased condition, or to a lowered state of health due to privation or bad. habits. The pathology of early syphilis is revealed to us in the cell-infiltrations constituting the essential lesions which are distributed in a symmetrical manner over the whole body. With the evolution of this new growth a diffusible poison is developed which is carried throughout the entire system and gives rise to the various phenomena (fever, debility, emaciation, headaches, neuralgias, arthralgias, periosteal pains, splenic engorgement, and sometimes pleuritis). With the destruction of the newly formed cells by treatment the tangible lesions undergo involution and disappear, and in proportion to the completeness of their cure so does the poison secreted by them grow less and less in potency and quantity. When a perfect cure does not take place, some of these morbid cells remain (in all probability in little masses around the blood-vessels, and not stored in the ganglia), but as they grow old they lose their vitality and increase slowly, and, having lost much of their virulency, produce very little, if any, of the diffusible poison. This is what takes place in tertiary syphilis, in which the new growths are indolent, aphlegmasic, and show a marked tendency to localization and to asymmetrical distribution. The gumma is the direct and feeble descendant of the virulent round-cell infiltration of the secondary stage of syphilis." The subject is always as interesting as it is varied, and we shall again consider other questions relating to it; the facility with which some excellent ones allow a patent syphilitic lesion to escape them when it happens to occur in "high places," reminds us of the fact that we must be ever ready to recognize and treat the disease-whether or not we see fit to make mention of it to the patient or friends--entirely independent of rank or person. |