(Mr. Pirie Watson's case—Radiogram by Dr. Hope Fowler.)

The treatment varies with the conditions present, and must include measures directed to the lesion from which the sinus has originated. The extent and direction of any given sinus may be demonstrated by the use of the probe, or, more accurately, by injecting the sinus with a paste consisting of white vaseline containing 10 to 30 per cent. of bismuth subcarbonate, and following its track with the X-rays ([Fig. 35]).

It was found by Beck of Chicago that the injection of bismuth paste is frequently followed by healing of the sinus, and that, if one injection fails to bring about a cure, repeating the injection every second day may be successful. Some caution must be observed in this treatment, as symptoms of poisoning have been observed to follow its use. If they manifest themselves, an injection of warm olive oil should be given; the oil, left in for twelve hours or so, forms an emulsion with the bismuth, which can be withdrawn by aspiration. Iodoform suspended in glycerin may be employed in a similar manner. When these and other non-operative measures fail, and the whole track of the sinus is accessible, it should be laid open, scraped, and packed with bismuth or iodoform gauze until it heals from the bottom.

The tuberculous ulcer is described in the chapter on ulcers.

CHAPTER IX
SYPHILIS

Syphilis is an infective disease due to the entrance into the body of a specific virus. It is nearly always communicated from one individual to another by contact infection, the discharge from a syphilitic lesion being the medium through which the virus is transmitted, and the seat of inoculation is almost invariably a surface covered by squamous epithelium. The disease was unknown in Europe before the year 1493, when it was introduced into Spain by Columbus' crew, who were infected in Haiti, where the disease had been endemic from time immemorial (Bloch).

The granulation tissue which forms as a result of the reaction of the tissues to the presence of the virus is chiefly composed of lymphocytes and plasma cells, along with an abundant new formation of capillary blood vessels. Giant cells are not uncommon, but the endothelioid cells, which are so marked a feature of tuberculous granulation tissue, are practically absent.

When syphilis is communicated from one individual to another by contact infection, the condition is spoken of as acquired syphilis, and the first visible sign of the disease appears at the site of inoculation, and is known as the primary lesion. Those who have thus acquired the disease may transmit it to their offspring, who are then said to suffer from inherited syphilis.

The Virus of Syphilis.—The cause of syphilis, whether acquired or inherited, is the organism, described by Schaudinn and Hoffman, in 1905, under the name of spirochæta pallida or spironema pallidum. It is a delicate, thread-like spirilla, in length averaging from 8 to 10 µ and in width about 0.25 µ, and is distinguished from other spirochætes by its delicate shape, its dead-white appearance, together with its closely twisted spiral form, with numerous undulations (10 to 26), which are perfectly regular, and are characteristic in that they remain the same during rest and in active movement ([Fig. 36]). In a fresh specimen, such as a scraping from a hard chancre suspended in a little salt solution, it shows active movements. The organism is readily destroyed by heat, and perishes in the absence of moisture. It has been proved experimentally that it remains infective only up to six hours after its removal from the body. Noguchi has succeeded in obtaining pure cultures from the infected tissues of the rabbit.