several times daily and kept dusted with equal parts of bismuth and calomel,
iodoform — ^which should be used with care since an idiosyncrasy to this drug
is not rare — or other bland antiseptic powder. A dressing of mercurial
ointment may also hasten the healing process. Cauterization or excision
of the lesion is useless.

The secondary lesions should also be treated by the application of cleansing
agents. The teeth should be frequently brushed and a mouth wash of ^
saturated solution of potassiufn chlorate, which not only has a beneficial
effect upon the mucous patches but is prophylactic against mercurial stomatitis,
should be frequently employed. The use of tobacco and alcohol shoiild be
forbidden. Ulcers should be cleansed with the mercury bichloride solution,
dressed with mercurial ointment or dusted with calomel and if necessary
touched with silver nitrate stick or solution; the latter may also be employed
upon the mucous patches in the mouth. Condylomata should be kept thor-
oughly cleansed and either dusted with the powders mentioned above or
dressed with mercurial ointment.

Constitutional treatment should be instituted as soon as the diagnosis is
assured and consists in the administration of merciury during the secondary
stage and of iodine during the tertiary. The two may often, however, be
given together with advantage during the second stage. Mercury may be
administered in various ways; of these one of the best and one of the most
commonly employed is by inunctions. Its disadvantages are that it takes
considerable care and time and is not cleanly. The plan is as follows : The
patient should take a warm bath daily to cleanse the skin and render it more
capable of absorption. After the bath a drachm (4.0) of the ofiicial mercury
ointment is thoroughly rubbed into the skin, the friction to be continued
until the ointment has entirely disappeared. It is well to choose a different
site for the inunction each day, first taking the inside of one thigh, next that
of the other, the inner aspect of the arms, then the sides of the chest, etc.
When these parts have been exhausted the list should be begun again. The
rubbing should last at least ^ hour. Hairy parts should be avoided since
the follicles offer favorable foci for the beginning of a mercurial eczema and
the use of a potassium chlorate mouth wash is necessary to prevent, if possible,
stomatitis. Should this occur, as evidenced by soreness of the gums and teeth,
foul breath, etc., the inunctions should be stopped for a week or more until
the buccal symptoms disappear. The frictions should be continued for
about a month, when if the syphihtic symptoms have subsided they may be



SYPHILIS. 141

omitted and internal treatment begun. Here mercury may be given in
various forms, the preparations most usually employed being the yellow
iodide (protiodide) gr. -| (0.016), the red iodide (biniodide) gr. J (0.004)
or the bichloride gr. yV (0.005) three times a day. If the patient can be
made to understand how essential continued treatment is the tertiary mani-
festations may be prevented from making their appearance. To accomplish
this desirable object, however, the treatment must be continued for an indefi-
nite period.

Various substitutes for the inunction method of treatment have been advo-
cated and the one most in use at present is that by hypodermatic injection
of various mercury salts. The injections are given by means of a long needle
attached to the ordinary h3^odermic syringe, the solution is thrown into the
deeper muscular structures and the procedure must be carried out under
he most thorough aseptic and antiseptic precautions. The sites usually
selected are the buttock, the sides of the thorax or the flanks. Such solutions
as the following may be employed: Mercury bichloride 0.2 parts, sodium
chloride 2 parts, distilled water to 20 parts. Of this a daily injection of 15
minims (i.o) may be given. Mercury benzoate 0.25 parts, sodium chloride
and cocaine hydrochloride of each 0.06 parts, distilled water to 30 parts;
peptone and ammonium chloride of each 0.3 parts, mercury bichloride
0.2 parts, glycerin 5 parts, distilled water 15 parts; neutral mercury lactate
I part, distilled water 100 parts; mercury cyanide o.i part, distilled water
20 parts; mercury salicylate 4 parts, benzoinol 30 parts; of all the above the
dosage is 15 minims (i.o) which may be injected daily. In very grave cases
the dosage may be doubled or 15 minims (1.0) of a i percent, mercury cyanide
solution may be introduced slowly, directly into a vein ; a mixture of calomel
i| parts and sterile oil 15 parts may be given subcutaneously in doses of 15
minims (1.0) about once a week. The treatment by injections is especially
indicated when it is necessary to mercurialize the patient without delay, in
cases where the skin is badly affected by inunctions and the internal adminis-
tration of mercury disturbs the digestion and in instances where the disease
resists other methods.

Mercurial fumigations have had a certain vogue. The patient, sitting on
a chair, is surrounded to the neck by blankets arranged in the form of a tent.
An alcohol lamp is placed under the chair and upon this is set a metal plate
containing about ^ drachm (2.0) of powdered calomel. The seance should
last about 20 minutes during which the calomel is volatilized by the heat of
the lamp and it, with the steam from a vessel of water also placed over the
lamp, is absorbed by the patient's skin. This treatment affects favorably
both the constitutional symptoms and the cutaneous eruption. Calomel
vapor when inhaled, the mouth being held about 20 inches from the containing
vessel, often exerts a favorable influence upon the mucous patches. After



142 THE INFECTIOUS DISEASES.

the inhalation the mouth should be thoroughly washed to prevent salivation.

Hutchinson prefers to give mercury with chalk (hydrargyrum cum creta)
in pill form, each pill containing i grain (0.065) ^^^h of this preparation and
Dover's powder; one pill to be taken from 4 to 6 times a day. Most excellent
results are said to be obtainable from this form of treatment.

While undergoing mercurial treatment the patient should be forbidden
to eat fruit and green vegetables.

Instances are often met in which greater benefit is achieved by the alternate
administration of mercury and iodine or by giving these drugs in combination,
the so-called "mixed treatment." Those in which this form of treatment
is particularly indicated are the cases with dry tubercular syphilides, cases
with the syphilitic rupia, those with choroiditis, onychia, periostitis and
cerebral syphilis. The following formula will be found useful: I^. Hydrar-
gyri iodidi rubri, gr. iii (0.2); potassii iodidi, 5" ss (lo.o); syrupi simplicis, q.
s. ad, 5iv (120.0). Misce et signa, one teaspoonful two or three times daily.

The potassium iodide in this formula may be increased as indicated.
Another useful prescription is composed of merciury bichloride two grains
(0.13), potassium iodide three to five drachms (12.0 to 20.0) and distilled water
and compound syrup of sarsaparilla equal parts up to four ounces (120.0).
Here the combination of potassium iodide with mercm"y bichloride results
in the production of a certain amount of red mercuric iodide which is dis-
solved in the excess of potassium iodide. The mixed form of treatment has
been considered especially effective in the intermediate period of the disease
when the secondary stage is passing into the tertiary. It is also indicated in
instances of sj^hilitic hepatitis and in the presence of the ascites of this con-
dition the so-called Guy's diuretic pill which is composed of i grain (0.065)
each of powdered digitalis, squill and calomel may be prescribed with benefit.

In the third stage of syphilis iodine, administered in the form of the iodides
and particularly potassium iodide, produces results which cannot be accom-
plished by any other means, the rapid absorption of nodes, gummata
and other deposits quite frequently being brought about. In order to
seciu"e the best effect it is necessary to give very large doses in many
instances, two to four drachms (8.0 to 16.0) being not an unusually large
daily dosage. In syphilis of the nervous system especially large doses are
called for and daily amounts of i ounce (30.0) are not infrequently required.
The drug may be administered in saturated aqueous solution, in milk or in
the compound S}Tup of sarsaparilla beginning with 10 drops (0.66) three times
a day and increasing the doses i drop (0.065) daily until the disease Id con-
trolled. Should the symptoms of iodism appear — nasal discharge, an erythem-
atous eruption, increased secretion of saliva and swelling of the salivary
glands causing a sense of tightness in the throat — the drug should be stopped
or the dose diminished until these disappear. It has been advised to enlarge



SYPHILIS. 143

the beginning dose to 30 to 40 minims (2.0 to 2.66), since when given in this
way the drug has seemed less Hkely to cause toxic symptoms. Another
most excellent method of giving iodine is in the form of the syrup of hydriodic
acid. The dosage of this preparation is from i to 4 drachms (4.0 to 16.0)
three times a day J hour before meals and diluted with a wine glass of water.
Iodine itself may be administered in capsules each containing from 10 to 20
drops (0.66 to 1.33) of a 10 percent, solution of resuhlimed iodine in oil of
sesamum. Strontium and sodium iodide have been suggested as substi-
tutes for the potassium salt since they, especially the former, are pleasanter
to take, are less likely to disturb the stomach and to cause toxic symptoms.

It is said that the iodide should be suspended during menstruation if there
is any tendency to menorrhagia.

During a course of antisyphilitic treatment the patient should be advised
to regulate his mode of life in accordance with strict hygienic principles;
fresh air, moderate exercise and nutritious diet are essentials. The elimina-
tory functions should be kept properly active and co-existent disease, especially
tuberculosis or anaemia, should receive appropriate tonic treatment.

The treatment of syphilis at mineral — especially sulphur — springs has no
advantage over a thoroughly carried out home treatment. At such places
it is perhaps easier for the patient to lead a regular and healthful life and the
frequent employment of baths may render the skin more receptive to inunc-
tions of mercury.

The treatment of hereditary syphiHs should be instituted as soon as the
symptoms of the disease appear or even sooner if the parents give distinct
evidence of the disease. Mercury and potassium iodide are as potent here
as in adults and may be administered in the same way. Usually the inunction
method is preferable. The technique of the treatment has been already
described and about 20 grains (1.33) of a mixture of equal parts of mercurial
ointment and lanoline or vaseline are employed at each friction. For a child
of two years 30 grains (2.0) may be used and at three years of age the dose
may be increased to 40 grains (2.66). The inunctions should be continued
for three weeks, suspended for a week or ten days and then repeated. The
internal administration of mercury should then be begun. Either mercury
with chalk i grain (0.065) or mercury bichloride -gV of a grain (0.00 1)
four times a day may be given unless it is desirable to mercurialize the patient
as quickly as possible when -yo oi o. grain (0.006) of calomel should be given
three or four times daily. The mercurial treatment should be continued for
a year with occasional intermissions of a week or two at the least, at the end
of which period, mixed treatment may be prescribed. Here we may give a
mixture consisting of -^V part of mercury biniodide, 5 parts of potassium
iodide, simple syrup 250 parts; this maybe given in milk in the following doses.
To a child of from i to 3 years, 15 to 30 minims (i.o to 2.0); 3 to 5 years, i



144 THE INFECTIOUS DISEASES.

drachm (4.0); 6 to 10 years, 2 drachms (8.0). The treatment by hypo-
dermatic injections may be employed in instances of digestive disturbance
and where the mercurial frictions irritate the skin.

In tertiary infantile syphilis with gummata, visceral, osseous and other lesions
potassium iodide should be prescribed in sufficient dose to meet the indica-
tion. ' In general it may be said that the daily dosage for a child of from i to
15 months is from f to 3 grains (0.048 to 0.2), from 15 months to 3 years
3 to 6 grains (0.2 to 0.4), from 3 to 5 years, 7^ to 15 grains (0.5 to i.o) and
from 5 to 10 years, 15 to 45 grains (i.o to 3.0). The drug should be given
well diluted with milk and if it is not well borne the substitutes suggested
on p. 143 may be employed.

Antisyphilitic treatment should be continued as long as luetic manifesta-
tions are present.

The local treatment of infantile syphilis is identical with that of the disease
in adults and it is often of great advantage, particularly if the child's nutrition
is poor and anaemia is present, to either intermit the specific treatment for a
time or to diminish the dosage, in the meantime giving various tonics partic-
ularly iron, codliver oil and the bitters.

Attempts have been made to elaborate a serum for the treatment of syphilis
but up to the present time little or no success has attended these efforts.

TUBERCULOSIS.

Definition. Tuberculosis is an infectious disease characterized by genera
or local inflammatory processes resulting from the presence and growth within
the organism of the tubercle bacillus. The typical lesions consist of nodules
or diffuse tissue infiltrations which gradually become caseous, sclerosed,
ulcerated or more rarely undergo calcification.

.etiology. While tuberculosis was considered a disease of infectious
character previous to Koch's demonstration of the bacillus tuberculosis in
1882, it remained for this observer to prove beyond question its specific origin.
Koch's bacillus is a long, narrow, straight or shghtly curved bacillus, staining
at times irregularly so as to present a beaded appearance. It is found in
tuberculous lesions and discharges and in the dust of apartments occupied
by affected patients as a result of the drying of unproperly cared for sputum.
It is also found in the meat and milk of diseased animals, those most frequently
harboring the infection being the bovines; it is rare in sheep and horses but
pigs in certain districts are prone to suffer. Tuberculosis is very likely to
attack apes in captivity but is unknown amongst them in the wild state.

The bacillus effects entrance into the body in most instances upon the
inspired air which may be contaminated by dried sputum or may contain the
moist particles which are emitted by tuberculous individuals in coughing.



TUBERCULOSIS. I45

sneezing and even during conversation. These fine bits of spray have been
proven to contain the baciUi. These facts account for the frequency with
which those closely associated with subjects of the disease, such as nurses,
members of the family, etc., contract the disease, although there is no doubt
that by careful attention to cleanliness and proper hygiene this danger can
be almost wholly averted.

The contagium may also be taken into the alimentary tract with the food,
cases having been traced to the milk, meat and even the butter from infected
animals. Food may become contaminated by proximity to tuberculous
cooks, bakers, etc., and the milk from a diseased mother may infect her
infant, accounting for the occurrence of tuberculosis of the digestive tract in
children.

Contact with the excreta of the tuberculous, with the meat of diseased
animals, with the lesions of bodies dead from the infection, etc., may cause
tuberculosis by inoculation. To the acquirement of the disease in this way
the contact of the infective matter with an abrasion of the skin or mucous
membrane is necessary.

With regard to the hereditary transmission of tuberculosis it may be said
that the disease has been noted in rare instances in the foetus and that infants
have been born with tuberculous lesions; this circumstance also has been seldom
observed. It is a fact that the children of tuberculous parents are more
prone to the acquirement of the disease and possess poorer powers of resis-
tance than do those of more healthy heredity.

Other predisposing causes are:

a. Race. The disease is met in all races, the negro and the American
Indian living under civilized conditions being especially prone to the affection.
Hebrews seem to a certain degree exempt, perhaps owing to the peculiar
supervision exercised over the meat consumed by them.

h. Age. Tuberculosis may occur at any time of life but certain types
of the infection seem more common at certain ages than at others, thus
pulmonary tuberculosis is most frequent between 20 and 35 while children
are particularly prone to the glandular, meningeal and mesenteric forms.

c. Sex. Females appear to be shghtly more susceptible than males, per-
haps because their duties confine them to the house more than do those of
the opposite sex. The progress of the disease becomes more rapid during
pregnancy and lactation.

d. Climate. Regions which are subject to dampness and sudden changes
of temperature are most favorable to the development of tuberculosis, possibly
because under such conditions catarrhal affections are common, these dimin-
ishing the resisting power of the body and offering an acceptable nidus for
lodgment of the contagium. The disease, however, does occur in all climates.

e. Sanitation. Unhealthful surroundings, overcrowding, lack of fresh air,



146 THE INFECTIOUS DISEASES.

and of proper food, and unhygienic occupations such as those which entail
the respiration of dust-laden atmosphere are distinct predisposing factors.

Further, any acute or chronic disease, particularly catarrhal affections of the
respiratory tract, influences which bring about a diminished pulmonary
blood supply, congenital or acquired narrowing of the pulmonary artery
and other circiilatory diseases predispose to the occmrrence of tuberculous
affections. Traumatisms of the thorax, although there may be no injury
to the lung itself, also may be followed by pulmonary tuberculosis.

Pathology. The characteristic morbid change is the occurrence in various
tissues and organs of miliary tubercules. The most frequent sites for their
development are the lungs, liver and spleen, they are also found in the
meninges, the bone-marrow, the peritonaeum, the heart muscle and the
choroid. The tubercles vary from microscopic size to that of a pea and histo-
logically are made up of a number (from 10 to 50) of smaller tubercles. The
fact that many of them resemble in size and form a millet seed has led to the
term miliary. The tubercle is formed as follows: Bacilli having lodged in a
certain tissue they act as an irritant, as a result of which there is an emigration
of leucocytes from the neighboring blood-vessels; these, with the epithelioid
and giant cells which are produced by proliferation from the cells of the adja-
cent structures and with a supporting frame-work of connective tissue, which
is most abundant near the periphery make up the miliary nodule. The
bacilli occur within the substance of the epithelioid cells and the giant cells
and the fact has been noted that where the latter are most plentiful the
bacilli are fewest; accordingly in lupus, tuberculous joint lesions and adenitis
the giant cells are many and the bacilli few, while in pulmonary lesions the
opposite condition obtains.

The tubercle also occurs in solitary form; here it is not composed of an
aggregation of small miliary bodies but is a single cheesy mass of size varying
from that of a pea to that of the fist. It consists principally of round cells
in which the bacilli are found; these are supported by a fibrous reticulum and
the latter may exist in such amount as to render the entire nodule fibrous
in consistency. These single tubercles are found in different situations such
as the spinal cord, the liver, the heart, the spleen and especially in the brain
in children and are subject to caseous, suppurative and calcareous degen-
eration.

The Degenerations of Tubercle. Of these the most common is caseation.
This begins at the center of the tubercle and is a process of coagulation necrosis
of its cells; these gradually lose their outline, their nuclei become indistinct
and are no longer demonstrable by staining and finally a structureless granu-
lar mass results. The bacilli persist and the cheesy substance resulting may
undergo softening, calcification or may become encapsulated by a fibrous
wall. The first of these processes is the most frequent and the caseous mass



TUBERCULOSIS. I47

degenerates into a piiriform substance which is not pus, strictly speaking, but
which consists of fat droplets, granular matter, and disintegrated cells and
contains tubercle bacilli in abundance.

Calcification is less common; here a form of healing takes place by infil-
tration of the tubercle with calcium salts. Tuberculous deposits in the lymph
glands are particularly likely to undergo this change and exceptionally it
may occur in the lungs.

The sclerotic change in which the tubercle is converted into fibrous tissue
consists of a metamorphosis, which, as the disintegration at the center of
the nodule takes place, is characterized by hyaline degeneration and increase
of fibroid tissue, a firm hard mass resulting; this is a healing process and
depends upon the body's power of resistance to the growth and development
of the bacilli. It is frequently observed in peritonaeal tuberculosis and at
times in the lungs.

Secondary inflammatory processes are changes, set up, not in the tubercle
itself, but in adjacent tissues by the development of this structure; for instance
an overgrowth of connective tissue may result causing a fibroid phthisis
or a catarrhal pneumonia. Suppuration is a frequent associate of tuber-
culous pulmonary inflammation but is the result of a mixed infection with
pyogenic bacteria. Whether the tubercle bacillus is capable alone of produc-
ing pus is a moot question. Certainly the fluid contents of a cold abscess
is not true pus and does not contain the bacteria of suppmration. On the
other hand in tuberculous inflammations of bones and joints pus is often
observed; this, however, may be the result of mixed infection just as is the
purulent sputum of pulmonary tuberculosis.

Acute Miliary Tuberculosis.

Synonym. Diffuse General Tuberculosis.

Definition. An acute disease characterized by the presence of numbers
of tubercle bacilli in the blood which find lodgment in various parts of the
body and there cause the development of miliary tubercles. The disease is,
as a rule, secondary to the softening of a tuberculous nodule, usually in the
lungs or a lymph gland, and is the result of the dissemination of the bacilli
by means of the blood or lymph circulation. The rupture of the nodule may
be directly into a blood-vessel, an example of a veritable embolic process.

This form of tuberculosis is most common in adolescents and young adults.

Pathology. In considering acute miliary tuberculosis from its pathologic
aspect it is not to be forgotten that it is the result of an old tuberculous lesion.
The tubercles which are disseminated through the various tissues in this form
of tuberculosis have already been described (p. 146).

Acute tuberculosis occurs in three principal types: i. With symptoms



148 THE INFECTIOUS DISEASES.

pointing to general infection, 2, General infection with pronounced pulmo-
nary symptoms. 3. General infection with marked symptoms referable to the
central nervous system.

I. Acute General Miliary Tuberculosis.

Symptoms. These are those of a severe general infection without marked
local manifestations and there is great possibility of mistaking the disease
for enteric fever. Prodromata, consisting of indefinite malaise, loss of ap-
petite, etc., are common but an abrupt onset with fever may occur; afebrile
instances of the disease have occasionally been observed. The pulse is rapid,
the tongue dry and cerebral symptoms analogous to those of enteric fever
are common. The temperature is usually lower in the morning (101° F. —
38.3° C.) and higher at night (103° to 105° F. — 39.4° to 40.5° C), although an
occasional reversal of this type of temperature may occiu"; this is considered an
important point in the differentiation of the disease as is also the fact that
the temperature curve taken as a whole is more irregular than that of enteric