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in whom the syphilis is not in active efflorescence, will

VOL. XVII.

JANUARY, 1892.

ORIGINAL ARTICLES.

NO

cal Lesions.1

BY G. FRANK LYDSTON, M. D.,

Professor of the Surgical Diseases of the Genito-urinary Organs and Syphilology, in the College of Physicians and Surgeons, Chicago.

I am frequently asked whether a proposed surgical operation is safe, in view of the fact that the patient upon whom it is proposed to operate is suffering from more or less recent syphilis. I also find that general practitioners often advise patients that fall under my care against surgical operations, for the sole reason that said patients are affected with constitutional syphilis more or less remote.

I have been quite observant of the phenomena attending the healing of operation wounds in syphilitic subjects, and I have come to the conclusion that per se syphilis has little or no effect in retarding repair. In many syphilitics I have had operation wounds heal with exceptional promptness. An excellent illustration of the favorable course of simple incised wounds in syphilitic subjects is to be found in the excision of the primary lesion of syphilis. In a large number of cases of excision of hard chancre I have found that primary union was the rule. In mixed sores I have on several occasions seen reinfection and chancroidal ulceration following excision. I will state that these cases of mixed sores were operated upon entirely experimentally, as I do not consider it good practice to deal with such sores in this manner. In some cases -and in a far greater proportion than those that practice excision have acknowledged-induration of the cut edges will occur, but this only happens several days after primary union of the incision has occurred. If the operation be performed some days after the chancre has ceased to progress, and has become stationary, induration of the cut edges is not likely to occur. In some instances induration of the cicatrix will occur as a consequence of irritation a week or more after the incision is perfectly healed; but these untoward phenomena are not the result of imperfect repair, but are the result of a rapid prolifera

tion of cells determined by irritation of the cicatrix after the process of ordinary tissue-repair is completed. The question of the possible local character of the chancre and reinfection of the cut surfaces enters into consideration in this connection, but does not concern us here.

In patients with latent secondary syphilis, suppur ation, sloughing, and ulceration in operation wounds. are frequently attributed to the constitutional taint when the fault lies in the technique of the operation. Notwithstanding the fact that this explanation is very consoling to the surgeon, it is my opinion that a clean aseptic operation in patients that are syphilitic, but 'Read before the Chicago Academy of Medicine, July 10, 1891.

The difference between a clean, incised wound (which, when aseptically made and antiseptically dressed, is productive of little or no irritation from the first and of absolutely none after the lapse of a few hours), and tation, is very marked in syphilitic subjects. We know that the latent tendency of connective tissue cells to proliferation and degeneration greatly exceeds the physiological limits when once the organism becomes tainted with syphilis; continuous irritation is prone to develop this latent energy of syphilized cells, plasia, ulceration, and perhaps sloughing. If we add with resulting prolonged suppuration, tissue-hyperto the irritating effects of the lesion itself the condition of sepsis, the morbid process is necessarily exaggerated.

When secondary syphilis is active and severe syphilides are present, any surgical lesion may determine a deposit of syphilized material at the particular point involved. This material may break down and ulceration of tissue result. So far as my observations go, it would, however, seem that this tendency is modified chiefly by the primary resistance of the patient, rather than by the severity of the syphilis, and I think it will be found that when once patients with active syphilis do badly, more reliance is to be placed upon tonics than upon vigorous anti-syphilitic measures. Virulent surgical processes, such as erysipelas, vaccinia, and chancroid, occurring in broken down. patients with constitutional syphilis, whether latent or active, are especially liable to determine a deposit of syphilitic neoplasm in the affected tissues.

With regard to the behavior of erysipelas in this respect, I will call attention to the fact that it has been recently claimed that erysipelas is curative of syphilis. I think that I am justified in being a little dogmatic regarding this particular point, as at the New York Charity Hospital, which has a number of pavilions devoted exclusively to cases of erysipelas, of which a large number are annually treated, I had exceptional opportunities for the study of erysipelas as seen in syphilitic patients. I have seen many cases of erysipelas occurring in syphilitic subjects, but I have failed to see any constitutionally curative effects from erysipelas; on the contrary, syphilitic patients that became debilitated by severe erysipelas were quite apt to be returned to the hospital within a comparatively short time suffering from an outcropping of syphilitic lesions. It was an experience so familiar as to be a matter of routine observation, that the sinuses and suppurating surfaces remaining after phlegmonous erysipelas in syphilitic patients were very obdurate until constitutional treatment was instituted.

Horwitz' reports a case in which a patient with deep and extensive syphilitic rupia was apparently cured by a severe attack of erysipelas. The same author reports another case in which an ulcerating gumma of the leg was attacked and apparently cured by an attack of erysipelas. Neumann reports two

'The Medical News, March 21, 1891. 'Allg. Wiener med. Zeitung, 1888.

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