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.