+SPECIAL FORMS OF INFLAMMATION+
+Syphilis+ is a chronic, infectious, and sometimes hereditary,
constitutional disease. Its first lesion is an infecting area or
chancre, which is followed by lymphatic enlargements; eruptions upon
the skin and mucous membranes; affections of the appendages of the
skin, (hair and nails); chronic inflammation and infiltration of the
cellulo-vascular tissue, bones and periosteum, and later, often by
gummata. This disease is caused by a microorganism known as the
_spirochaeta pallida_ or _treponema pallidum_ of Schaudinn and
Hoffmann.
+Transmission of Syphilis.+ This disease can be transmitted (_a_), by
contact with the tissue-elements or virus acquired syphilis, and
(_b_), by hereditary transmission, hereditary syphilis.
The poison cannot enter through an intact epidermis or epithelial
layer; an abrasion or solution of continuity is requisite for
infection.
Syphilis is usually, but not always, a venereal disease. It may be
caught by infection of the genitals during coition; by infection of
the tongue or lips in kissing; by the use of an infected towel on an
abraded surface; by smoking poisoned pipes, and by drinking out of
infected vessels.
The initial lesion of syphilis may be found on the finger, penis,
eyelid, lip, tongue, cheek, palate, nipple, etc. Syphilis can be
transmitted by vaccination with human lymph which contains the pus of
a syphilitic eruption or the blood of a syphilitic person. Syphilis is
divided into three stages (1) the primary stage—chancre and indolent
bubo; (2) the secondary stage—disease of the upper layer of the skin
and mucous membranes, and (3) the tertiary stage—affections of
connective tissues, bones, fibrous and serous membranes, and
parenchymatous organs.
+Syphilitic Periods.+ (1) period of primary incubation—the time between
exposure and the appearance of the chancre, from ten to ninety days,
the average time being three weeks; (2) period of primary
symptoms—chancre and bubo of adjacent lymph glands; (3) period of
secondary incubation—the time between the appearance of the chancre
and the advent of secondary symptoms,—about six weeks as a rule; (4)
period of secondary symptoms—lasting from one to three years; (5)
intermediate period—there may be no symptoms or there may be light
symptoms which are less symmetrical and more general than those of the
secondary period; it lasts from two to four years, and ends in
recovery or tertiary syphilis; and (6) period of tertiary
symptoms—indefinite in duration; the fifth and sixth may never occur,
the disease being cured.
+Primary Syphilis.+ The primary stage comprises the chancre or infecting
sore or bubo. A chancre or initial lesion is an infective granuloma
resulting from the poison of syphilis. The chancre appears at the
point of inoculation, and is the first lesion of the disease. During
the three weeks or more requisite to develop a chancre the poison is
continuously entering the system, and when the chancre develops, the
system already contains a large amount of poison.
A chancre is not a local lesion from which syphilis springs, but is a
local manifestation of an existing constitutional disease, hence
excision is entirely useless. The hard chancre, or initial lesion,
never appears before the tenth day after exposure, it may not appear
for weeks, but it usually arises in about twenty-one days. The lesion
commonly appears as a round, indurated, cartilaginous area with an
elevated edge, which ulcerates, exposing a velvety surface looking
like raw ham; it bleeds easily, rarely suppurates, does not spread,
and the discharge is thin and watery.
The bubo of syphilis is multiple, consisting of a chain of glands,
freely movable, indurated, painless, small and slow in growth, and the
skin over the bubo is normal.
A positive diagnosis of syphilis can be made when an indurated sore is
followed by multiple indolent glands or buboes in the groin and by the
enlargement of distant glands.
+Secondary Glands.+ The symptoms are noticed from four to six weeks
after the stage of the induration of the chancre, and may continue to
appear at any time, up to twelve months. The most constant are certain
eruptions on the skin, faucial inflammation, and enlargement or
induration of the lymphatic glands; others are febrile reaction, pains
in the back or limbs, swelling of the joints, iritis and falling out
of the hair.
+Tertiary Syphilis.+ These symptoms appear from one to two years after
contagion and may continue to break out from ten to fifteen years, or
more. The characteristic lesions are certain late eruptions on the
skin, periostitis and nodes on the bones, and growths in the
subcutaneous tissue, muscle, and viscera, especially the liver and
spleen. These growths, in the viscera and other parts, which are so
characteristic of syphilis in its later stages, are known as gummata.
They consist of a substance like granulation tissue, with a varying
proportion of cells. In early stages they are grayish, gelatinous, and
transparent, but the cells undergo fatty change and caseation takes
place, so that the centre becomes yellow, and the circumference
develops into fibrous tissue, which contracts like a scar tissue.
Sometimes gummata break down completely, and suppuration, with
destruction of the tissues in which they are situated, takes place;
thus caries and necrosis not infrequently follow nodes on the bones.
+Treatment.+ Mercury is the drug of great benefit in syphilis. This can
be administered either internally, by inunction, or by injection. Of
all the preparations to be given internally, protiodide of mercury, in
one quarter grain doses, three times a day, is to be preferred.
+Inunction+ represents the most efficient way of administering the
mercurial treatment, when the stomach is intolerant of drugs, or when
administered by the mouth in full doses, they do not favorably modify
the symptoms. The patient is instructed to take a warm bath, and the
mercury is then well rubbed in over the inner surface of the forearm
and arm and alongside of the chest for fifteen minutes. Either the
oleate of mercury, 10 per cent., or the ordinary mercury ointment is
commonly employed; the former is more clean, but less efficient. The
rubbings should be done by the patient, should be made over a large
surface of the body, and should be performed thoroughly; one dram
(4.0) of blue ointment is rubbed in daily. For the injections, a 10
per cent. salicylate of mercury in olive oil is to be preferred; 10 to
15 minums of this solution is to be injected into the buttocks, three
times a week. The dose is gradually to be increased until 30 drops are
employed. Recently salvarsan (606) in 0.6, or 10 grain doses is given
either intravenously or intraspinally. Neosalvarsan (914) is to be
similarly given. The latter has the advantage in that sterile water is
used, and that, as a rule, there is no reaction from its injection.
Iodide of potassium in large doses (60 to 90 grains) three times a
day, is also to be given.
+Tuberculosis.+ Tuberculosis is an infectious disease due to the
deposition and multiplication of the tubercule bacillus in the tissues
of the body. It is characterized either by the formation of
tubercules, or by a wide spread infiltration, both of these conditions
tending to caseation, sclerosis, or ulceration.
A tubercular lesion may undergo calcification.
A tubercule is an infective granuloma, appearing to the unaided vision
as a semitransparent mass, gray in color, and the size of a mustard
seed.
The microscope shows that a tubercule consists of a number of cell
clusters, each cluster consisting of one or of several polynucleated
giant cells, surrounded by a zone of epitheloid cells which are
surrounded by an area of leucocytes. Giant cells, which also form by
coalescence of the epithelioid cells, are not always present. The
bacillus, when found, exists in the epithelioid cells, and sometimes
in the giant cells; it may not be found, having once existed, but
having been subsequently destroyed. It is often overlooked.
In an active tubercular lesion, even if the bacillus be not found,
injection of the matter into a guinea-pig will produce lesions in
which it can be demonstrated.
A tubercule may caseate, a process that is destructive and dangerous
to the organism. Caseation forms cheesy masses, which may soften into
tubercular pus, may calcify, and may become encapsulated by fibroid
tissue. Tubercular disease of the bones and joints have already been
described in a previous chapter.
+Treatment.+ Destroy the bacilli present and radically remove infected
areas which are accessible. Incomplete operations are apt to be
followed by diffuse tuberculosis.
Bier’s venous or obstructive hyperemia is especially to be recommended
in tuberculosis of the ankle joint (for technic, see chapter on
Therapeutics).
Plenty of fresh air, good nourishing food and tonics are indicated as
a routine treatment.
+Tetanus.+ Tetanus is an infectious disease, invariably preceded by some
injury. The wound may have been severe or it may have been so slight
as to have attracted no attention.
The disease is commonest after punctured wounds or lacerated ones of
the hands or feet, and before it appears, a wound is apt to suppurate
or slough, but in some instances the wound is found soundly healed.
Tetanus is due to infection by a bacillus (first described by
Nicolaier, and first cultivated by Kitasato), the toxic properties of
which, absorbed from the infected area, poison the nervous system
precisely as would dosing with strychnine.
+Symptoms.+ The onset is usually within nine days of an accident. At
first, the neck feels stiff and there is difficulty in swallowing, and
then the jaw also becomes stiff. The neck becomes like an iron bar,
and the jaws are rigid as steel. If the injury is on the foot, that
extremity usually is found to be rigid. Opisthotonos is present and
spasms are very marked. Swallowing in many cases is impossible. The
mind is entirely clear until near the end, one of the worst elements
of the disease.
+Treatment.+ Careful antisepsis will banish it. Every wound must be
disinfected with the most scrupulous care. Every punctured wound is to
be incised to its depth and thoroughly cleaned and drained. Large
doses of the bromide of potassium, at least sixty grains, should be
given every four to six hours. Tetanus antitoxin should be given (5000
units), and repeated in twenty-four hours if no improvement is seen.
Recently a saturated solution of magnesium sulphate has been given
intraspinally, with very good results. In all suspicious cases, a
prophylatic injection of tetanus antitoxin is to be recommended (1000
units).
+Erysipelas.+ Erysipelas is an acute, contagious disease, characterized
by a peculiar form of inflammation of the skin. It is caused by the
streptococcus of erysipelas, which grows and multiplies in the smaller
lymph channels of the skin and its subcutaneous cellular layers, and
in serous and mucous membranes.
The disease is a rapid spreading dermatitis, accompanied by a
remittent fever, due to the absorption of toxins, having a tendency to
recur. It is always due to a wound. The involved area may or may not
suppurate.
+Symptoms.+ The onset is sudden, with a high fever, and at the time of
febrile onset, spots of redness appear on the skin. These spots run
together, and a large extent of surface is found to be red and a
little elevated. This combination of redness and swelling extends, and
its area is sharply defined from the healthy skin. The color at once
fades on pressure and returns immediately the pressure is removed. In
the hyperemic area, vesicles or bullae form, containing first serum
and later possibly sero-pus. Edema affects the subcutaneous tissues,
producing great swelling in the regions where these tissues are lax.
+Treatment.+ Isolate the patient; asepticize the wound; and give a
purge. If a person is debilitated, stimulate freely.
Tincture of iron and quinine are usually administered. Nutritious food
is important. For sleeplessness or delirium, use the bromides; for
light temperature, cold sponging and antipyretics. Locally, strict
antiseptic treatment of existing wounds or other lesions; cold
compresses to relax the skin; rest; elevation of the limb; and
incisions, only if pus forms.
Where the disease is spreading, good results are obtained by spraying
the affected surface with a weak solution of corrosive sublimate in
ether, or painting the borders of the affected area with contractile
collodion. The affected part may also be painted with a 50 per cent.
ichthyol and water solution. Alcohol, Burow’s solution, and a great
many other liquid applications are recommended. Antistreptococci serum
is also to be recommended; an initial dose of 20 c.c. followed by
doses of 10 c.c., as often as necessary, being the usual procedure.
+Cellulitis.+ In cellulitis, redness of the skin is not very pronounced
and is late in appearing, following swelling, and not preceding it. It
is essentially the same condition as a mild form of erysipelas. Its
spread is heralded by red lines of lymphangitis, ascending from a
wound (infected), swelling of glands, and fever.
In slight cases, the lymphatics may dispose of the poison, and
suppuration fails to occur. In severe cases septicema arises.
Cellulitis is usually a result of infection not only with
streptococci, but also with other pyogenic cocci.
+Treatment.+ Incise and curet the wound and apply one of the wet
dressings. (See chapter on same).
+Actinomycosis.+ This is an infectious disease characterized by chronic
inflammation, and is due to the presence in the tissues of the
actinomyces, or ray fungus. At the point of inoculation arises an
infective granuloma, around which inflammation of connective tissues
occurs; suppuration eventually taking place. Inoculation in the mouth
is by way of an abrasion of mucous membrane or through a carious
tooth. The fungi may pass into the bones and joints, causing
inflammation of the parts. The bones in actinomycosis enlarge and
become painful; the parts adjacent are infiltrated and soften; pus
forms and reaches the surface through fistulae and the skin is often
involved secondarily. In actinomycosis the adjacent lymphatic glands
are not involved.
+Treatment.+ Free incision, if possible, otherwise incision, cauterizing
with pure carbolic acid, and packing with iodoform gauze. Internally,
large doses of iodide of potassium should be given, as this drug alone
has cured many cases.
+Trench Foot.+ This results from exposure to wet and cold in the
trenches, and soldiers who were compelled to have their feet immersed
in water for any length of time and were then exposed to cold, are
afflicted with this condition. The symptoms are similar to frost bite
and the prevention of frigorism (Trench Foot) is as follows: adequate
feeding; perfect circulation; moderate exercise; good general health;
and warm clothing, which all tend to give the body its maximum power
of resistance to cold.
It is obvious that anything that tends to impair the circulation and
the nutrition of the tissues is favorable to the occurrence of
frigorism. Tightness of the clothing of the extremities, such as tight
boots, leggins, etc., is particularly detrimental. Heavy clothing and
other equipment, by increasing fatigue, also has a predisposing
influence.
With regard to the protection against cold water, it is necessary that
the external covering should be impervious to and not affected by
water. India rubber stockings, waders, and boots have been used by men
working in water, not only as a protection against wet, but also
against cold. The best results have been obtained by the use of a
waterproof covering that can be worn inside the boot, not because it
is the only, or even the best possible method, but because it appears
to be the simplest and most practical. A waterproof top boot, so
devised as to leave a fairly wide air space between the boot and the
greater part of the foot, ankle, and lower part of the leg, would be
more efficient and probably more convenient, provided the material
used was soft and light, and did not interfere with movements. To
obtain this result a new type of boot would be required.
The treatment of trench foot is similar to that of frost bite.
+Motorman’s Foot.+ This is a condition caused by occupation, and the
symptoms found are usually those of a flat foot combined with enlarged
veins. The chief complaint is that of pain in the calf of the legs,
which is increased upon standing for any length of time. The treatment
is that for flat foot and enlarged veins.
+Chauffeur’s Foot.+ This is a condition also caused by occupation. On
account of the position assumed in driving an automobile, the tendons
and muscles of the leg are usually affected and a tendosynovitis very
frequently occurs. The symptoms and treatment have already been
described. Rest is without doubt the best therapeutic measure.
+Bicycle Foot+ is another occupational disease. The chief symptoms are
those of cramps in the calves of the leg, and pains of a severe
neuritic character.
At times the onset is very sudden, and the cramps are so severe that
it is impossible to extend the leg without causing great pain. Flat
foot is usually associated with the above condition. The treatment is
rest and the administration of the salicylates for the relief of pain.
Bicycling is ordinarily a beneficial exercise for the foot muscles.
When bicycle foot results from this exercise it is usually evidence
that the bicyclist had an abnormal condition of his foot muscles and
foot joints before he took up the exercise in question.