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SPIROCHÆTAL ULCERATION OF THE TONSILS IN SOLDIERS.
176 CASE 8.-Private -, wounded on Sept. 27th; bullet It is, however, readily detached and not tough. entered at the level of the left anterior superior iliac spine ; The surrounding tonsil and mucous membrane are of of exit on same side fracture bones ; not much swollen, but may be red and slightly point posteriorly ; very severe secondary haemorrhage ; extraction of numerous cedematous. There is usually no pain, and beyond " splinters on several occasions. Phlebitis of the right internal a of " the constitutional syinseediness feeling saphena, with considerable oedema of the limb. Three months under surgical treatment. Recovery from pain and ptoms are not grave. Temperature rarely exceeds oedema of leg much aided by douches and light dry 101° F., and the intense pain on swallowing so characteristic of acute peritonsillitis, or quinsy, massage. CASE 9.-Lieutenant -, injured on Sept. 13th, 1914. is absent. In a few days the slough is either Dislocation of knee by falling into a hole, with consecutive spontaneously detached or can be removed " en painful arthritis. Admitted on Oct. 4th with persistent morceaux"with a swab, leaving a deep rough Acute pain ; power- crateriform arthritis and considerable swelling. ulcer, which readily bleeds and is soon lessness of limb ; paralysis of muscles of leg and foot ; loss re-covered by more slough. The foetor is now unmisof knee-jerks ; atrophy of thigh and leg (3 centimetres). takeable and intense, closely resembling rotten fish. Treatment consisted of douche massage, shower baths, dry One striking feature is the sharply restricted area 3rd the On Dec. was able and electricity. patient massage, to walk several kilometres and able to return to active duty. of the ulceration, for it rarely attacks both sides and
10.-Sublieutenant -. Railway accident on August 23rd. Dislocation of knee, with very painful arthritis. Admitted to thermal hospital on Oct. 17th with painful arthritis of knee, paralysis of the muscles of the left foot, and almost complete loss of sensation ; diminished knee-jerk; muscular atrophy of thigh (4 centimetres); walking impossible. Considerably improved after 47 days of thermal treatment. Three weeks later was able to rejoin his regiment on active service. CASE 11. -Colonel ---, wounded by bullet on August 26th in left loin (posteriorly), traversing left psoas muscle, producing considerable haematoma and arterio-venous aneurysm. Fracture of vertebral column at fifth lumbar vertebra (as seen by radiography); bullet lodged in right I side of pelvis out of reach. Severe pain in sciatic and crural nerves of same side. Arrived at Aix three months after injury complaining of intense sciatic pains and inability to walk more than a very short distance. Followed thermal cure for one month and was able on leaving to walk 4 kilometres with ease ; three weeks later was able to do 17 without pain, and wrote that he was able to return to the front. Thermal treatment at Aix-les-Bains is given free to wounded soldiers of all ranks. CASE
SPIROCHÆTAL ULCERATION OF THE TONSILS IN SOLDIERS. BY
WYATT PATHOLOGIST,
extends across the middle line. Sloughing slowly diminishes, and healing is complete in a few days, but if untreated it may persist for several
never
weeks.
Diagnosis.-There need be no difficulty in the diagnosis, even in the early stage. When deeply ulcerated it has a most unpleasant and doubtful appearance. This is somewhat important, as Vincent’s angina may occur in a syphilitic In the event of a suspicious history patient. Wassermann’s test should be made, but this is hardly called for as a routine practice, since a swab examination will at once reveal the nature of the lesion. Microscopical examination can be quickly done and is absolutely necessary. Collect an adequate quantity of the slough on a moistened " swab "; smear it on a clean slide ; place another one over it; press them together firmly and separate by " sliding." This will make two thin films. Do not pass through a flame, but allow each one to dry in a warm place by radiant heat. Negative staining should now be effected by pouring over the film a 5 per cent. solution of collargol in distilled water. Pour off quickly, then stand upright to drain, and dry in warm air. On no account must it be heated, or else fissures will appear in the film, which might be mistaken for
WINGRAVE, M.D. DURH., M.R.C.S.’ spirochaetes. CENTRAL LONDON THROAT AND EAR HOSPITAL. ,
Positive staining is best done by the usual Gram method, but ornittingthe alcohol bath (anilin-gentianDURING the last few months I have received for violet and iodine). By this means the spirochaetes diagnosis a striking succession of cases with deep are adequately stained, while other features are ulceration of the tonsils in soldiers, both officers overstained. and men. Films may also be examined "wentwithout They occurred, for the most part, in
Territorials who were taken straight from civil life and sedentary occupations and put through a trying
"
"
staining either by dark-ground illumination or by special adjustment of condenser and diaphragm. of referred them were This is, however, far more difficult and less reliable Many rapid training. by their medical officers, some with a suspicion of than negative staining. Indian ink is not recomsyphilis, but it may at once be said that although mended, and is entirely superseded by silver the Wassermann test was applied in several of colloid. them the results were negative with one exception The slide is now examined with a 1/12-inch -an old soldier who had rejoined from the Reserve immersion lens, but a good " dry1/8-inch may and had been invalided. sometimes prove strong enough. In the negative The affection is closely allied to, if not identical film spirocheates and fusiform bodies appear with, what is usually called " Vincent’s angina," brilliantly illuminated on a copper-coloured ground. and is characterised by three prominent features- The Spirochaeta fcstida, or Vincent’s spirochobte, (1) a deeply excavated and sloughing ulcer on one appears as a coarse undulating thread from 10 to tonsil; (2) offensively foetid breath; and (3) the 20 microns in length. It is not really spiral like presence of spirochsetes and fusiform bodies in Spirochccta pallicla, but may show all variations great numbers. It may be arbitrarily divided into from a slightly undulating filament bent, looped, or two groups-(l) acute, lasting from four to seven twisted, to a perfect spirocheete, either separate or days; and (2) subacute, a more persistent type in tangled groups or bundles, in striking contrast with the fine, closely coiled Spirochaeta pallida. which lasts from two to three weeks. The ulceration, which is always unilateral, gener- Vincent’s spirochaete is really more like an eel or aally begins as a sharply circumscribed raised white whip-lash, while Spi1’ochaeta pallida is like a coiled to grey patch, simulating a diphtheroid membrane. spring or corkscrew.
177 When viewed alive
the movements of these A CASE OF POLYORRHOMENITIS. The Spiroc7tceta different. entirely organisms W. A. B. YOUNG, M.D. VICT. MANCH., D.P.H., faetida wriggles across the field with a snake-like BY movement, while the pallida is much more rigid ACTING TUBERCULOSIS OFFICER, COUNTY BOROUGH OF BLACKBURN. and has a screw-like action. IT has long been recognised by pathologists The fusiform body (Bacillus hastilis) is characteristic and is the invariable associate of Vincent’s that the formation of tubercles in the tissues of spirochaete, but is not associated with the pallida. the human body is not associated with the presence It appears as a large rod, slightly bent, tapering of the bacillus tuberculosis alone, but may result towards each end, and often showing a clear from the activity of other agents. It is only in recent years, however, that it has also been found equatorial band. When foetor is at its maximum spirochaetes pre- that the bacillus not only may be present without dominate, later fusiforms are more numerous. They causing any lesion, but also may be associated with are both Gram-negative, but the fusiform body lesions quite different in type from those usually always stains more deeply. Some observers main- found. The latter variation was well illustrated tain that the fusiform body simply represents a by a case which some time ago came under my phase in the life-history of the spirocheete. It isi notice whilst engaged in an investigation into not strictly a bacillus. They are both very difficult certain aspects of tuberculous infection in young to grow and are facultative anaerobes. children. Its publication perhaps maybe considered Although occurring in such vast numbers in this to be not without interest. disease, it has still to be proved that these bacteria The patient, aged 2 years, was admitted to the Manchester are the specific organisms, for they occur in a great Children’s Hospital, Pendlebury, on Jan. 22nd, 1914, said to variety of other regions and diseases, all of which be suffering from a cough and weakness following an attack The history of the illness given by the parents are associated with putrefaction (brain abscess, of measles. chronic middle-ear suppuration, pulmonary gan- at the time of admission was as follows. The child, who had been fed at the breast until he was 18 months old, had grene, noma, &c.). They are found an almost always had a " weak chest." He had measles followed by constant mouth saprophyte. Other bacteria are three months before being brought to the pneumonia always present, saprophytes, and pyogens such hospital, and since then had never been entirely without a as streptococci and staphylococci, which may cough, which had become worse the week before admission. account for any rise in temperature. This During the illness the appetite was very poor, but for the has spirochaete many names.:......Spirochaeta refringens, last fortnight all solid food had been vomited ; the stools I were frequent, loose, and foul, and the child had lost flesh Spirochaeta dentiwn, Spii-oc7iota buccae, &c.-but have provisionally called it Spirochaeta faeticZa from rapidly. Severe night sweats were also complained of. On examination the patient was seen to have well-marked its invariable association with foetor, which is not he was pale and in very poor condition, and had rickets; a characteristic of Spirochaeta pallida. Morpho- a distressing cough, with some shortness of breath. The logically it is not a spirillum, as it is not jointed, physical signs in the chest were slight dullness at the right although sometimes it seems to be "beaded." base, with impaired resonance at the left root behind, Spirochastal ulceration is essentially a disease and generalised rhonchi and moist rates on both sides. The These signs persisted almost without alteration, but the which calls for vigorous local measures. be found in child gradually grew weaker and died on March lst. most efficient antiseptics will trikresol and formalin. Iodine is useless. The The patient had always been very miserable slough should be thoroughly removed and the during his stay in the hospital, lying in bed on ulcer swabbed with a 5 per cent. solution of his back, usually with the knees drawn up, fretrikresol in alcohol or a 25 per cent. solution of quently crying out in a manner very similar to lysoform three or four times daily. A frequent that sometimes heard in cases of meningitis. mouth-wash of weaker solutions should also The temperature was intermittent in type throughbe ordered. When there is much swelling an out, with a maximum of 102’80 F., the average pulseexcellent astringent wash is permanganate of zinc, rate was 130, and the weight fell from 17 lb. to half a grain in one ounce of warm water. These 16 lb. 2 oz. The von Pirquet skin test was applied cases are often asso:ia’:ed with pyorrhoea alveolaris, twice; on the first occasion no reaction was obtained, which calls for frequent cleansing, and an excellent and on the second the reaction was so slight that it and pleasant mouth douche can be made by adding was considered very doubtful. The case was treated five minims of English oil of lavender to the 5 per as one of rickets with broncho-pneumonia, the latter cent. solution of trikresol in alcohol (or to lyso- probably of a tuberculous nature. At the necropsy form). Of this a few drops may be added to half a the following notes were made by me. tumblerful of water. Beyond a preliminary dose of There is considerable emaciation and the child has wellgrey powder, mercury is not called for. marked rickets, affecting especially the bones of the head. There is no evidence that the condition is in- On opening the thorax both lungs and the pericardium are fectious. The chief factor in its pathogeny seems found to be intimately adherent to all adjacent structures to be its association with lowered vitality and over- by fairly dense and continuous fibrous adhesions, the pleural cavities being quite obliterated, and the pleuras thickened training. Rapid and complete recovery invariably and difficult to separate. The lungs are pale and not confollows a short rest, with good food and fresh air. gested, and feel fibrous and tough when cut. There is a Bloomsbury-square, W.C. marked increase of fibrous tissue around the larger bronchi, are
.
which are filled with a muco-purulent exudation, but there THE BRITISH HOSPITALS ASSOCIATION.-A meet-appear to be no definite areas of consolidation. The two ing of this association will be held at Charing Cross Hos- layers of the pericardium are closely adherent by firm pital, London, on Friday next, July 30th, at 3 P.M., whenadhesions similar to, but less dense than, those found in Mr. J. Courtney Buchanan (secretary and house governor of the pleural cavity; and the pericardial cavity is almost the Metropolitan Hospital) will open a conversation on completely obliterated. The heart and large vessels are "The Shortage of Medical Officers in the Voluntary Hos-normal. i Similar adhesions are found matting together 1 whole of the abdominal contents to each other and pitals." Mr. H. Wade Deacon, chairman of the Royal the 1 the parietal peritoneum, though they are much less Infirmary, Liverpool, will preside, and amongst those who to are expected to take part in the proceedings are Sir W. J. ( than in the thorax. The peritoneum is also somedense Collins, Sir Cooper Perry, Mr. T. Jenner Verrall, andwhat thickened, but not markedly so. There are small (
Dr. Alfred Cox.
,collections
of
fibrinous exudation between
the coils of
10.-Sublieutenant -. Railway accident on August 23rd. Dislocation of knee, with very painful arthritis. Admitted to thermal hospital on Oct. 17th with painful arthritis of knee, paralysis of the muscles of the left foot, and almost complete loss of sensation ; diminished knee-jerk; muscular atrophy of thigh (4 centimetres); walking impossible. Considerably improved after 47 days of thermal treatment. Three weeks later was able to rejoin his regiment on active service. CASE 11. -Colonel ---, wounded by bullet on August 26th in left loin (posteriorly), traversing left psoas muscle, producing considerable haematoma and arterio-venous aneurysm. Fracture of vertebral column at fifth lumbar vertebra (as seen by radiography); bullet lodged in right I side of pelvis out of reach. Severe pain in sciatic and crural nerves of same side. Arrived at Aix three months after injury complaining of intense sciatic pains and inability to walk more than a very short distance. Followed thermal cure for one month and was able on leaving to walk 4 kilometres with ease ; three weeks later was able to do 17 without pain, and wrote that he was able to return to the front. Thermal treatment at Aix-les-Bains is given free to wounded soldiers of all ranks. CASE
SPIROCHÆTAL ULCERATION OF THE TONSILS IN SOLDIERS. BY
WYATT PATHOLOGIST,
extends across the middle line. Sloughing slowly diminishes, and healing is complete in a few days, but if untreated it may persist for several
never
weeks.
Diagnosis.-There need be no difficulty in the diagnosis, even in the early stage. When deeply ulcerated it has a most unpleasant and doubtful appearance. This is somewhat important, as Vincent’s angina may occur in a syphilitic In the event of a suspicious history patient. Wassermann’s test should be made, but this is hardly called for as a routine practice, since a swab examination will at once reveal the nature of the lesion. Microscopical examination can be quickly done and is absolutely necessary. Collect an adequate quantity of the slough on a moistened " swab "; smear it on a clean slide ; place another one over it; press them together firmly and separate by " sliding." This will make two thin films. Do not pass through a flame, but allow each one to dry in a warm place by radiant heat. Negative staining should now be effected by pouring over the film a 5 per cent. solution of collargol in distilled water. Pour off quickly, then stand upright to drain, and dry in warm air. On no account must it be heated, or else fissures will appear in the film, which might be mistaken for
WINGRAVE, M.D. DURH., M.R.C.S.’ spirochaetes. CENTRAL LONDON THROAT AND EAR HOSPITAL. ,
Positive staining is best done by the usual Gram method, but ornittingthe alcohol bath (anilin-gentianDURING the last few months I have received for violet and iodine). By this means the spirochaetes diagnosis a striking succession of cases with deep are adequately stained, while other features are ulceration of the tonsils in soldiers, both officers overstained. and men. Films may also be examined "wentwithout They occurred, for the most part, in
Territorials who were taken straight from civil life and sedentary occupations and put through a trying
"
"
staining either by dark-ground illumination or by special adjustment of condenser and diaphragm. of referred them were This is, however, far more difficult and less reliable Many rapid training. by their medical officers, some with a suspicion of than negative staining. Indian ink is not recomsyphilis, but it may at once be said that although mended, and is entirely superseded by silver the Wassermann test was applied in several of colloid. them the results were negative with one exception The slide is now examined with a 1/12-inch -an old soldier who had rejoined from the Reserve immersion lens, but a good " dry1/8-inch may and had been invalided. sometimes prove strong enough. In the negative The affection is closely allied to, if not identical film spirocheates and fusiform bodies appear with, what is usually called " Vincent’s angina," brilliantly illuminated on a copper-coloured ground. and is characterised by three prominent features- The Spirochaeta fcstida, or Vincent’s spirochobte, (1) a deeply excavated and sloughing ulcer on one appears as a coarse undulating thread from 10 to tonsil; (2) offensively foetid breath; and (3) the 20 microns in length. It is not really spiral like presence of spirochsetes and fusiform bodies in Spirochccta pallicla, but may show all variations great numbers. It may be arbitrarily divided into from a slightly undulating filament bent, looped, or two groups-(l) acute, lasting from four to seven twisted, to a perfect spirocheete, either separate or days; and (2) subacute, a more persistent type in tangled groups or bundles, in striking contrast with the fine, closely coiled Spirochaeta pallida. which lasts from two to three weeks. The ulceration, which is always unilateral, gener- Vincent’s spirochaete is really more like an eel or aally begins as a sharply circumscribed raised white whip-lash, while Spi1’ochaeta pallida is like a coiled to grey patch, simulating a diphtheroid membrane. spring or corkscrew.
177 When viewed alive
the movements of these A CASE OF POLYORRHOMENITIS. The Spiroc7tceta different. entirely organisms W. A. B. YOUNG, M.D. VICT. MANCH., D.P.H., faetida wriggles across the field with a snake-like BY movement, while the pallida is much more rigid ACTING TUBERCULOSIS OFFICER, COUNTY BOROUGH OF BLACKBURN. and has a screw-like action. IT has long been recognised by pathologists The fusiform body (Bacillus hastilis) is characteristic and is the invariable associate of Vincent’s that the formation of tubercles in the tissues of spirochaete, but is not associated with the pallida. the human body is not associated with the presence It appears as a large rod, slightly bent, tapering of the bacillus tuberculosis alone, but may result towards each end, and often showing a clear from the activity of other agents. It is only in recent years, however, that it has also been found equatorial band. When foetor is at its maximum spirochaetes pre- that the bacillus not only may be present without dominate, later fusiforms are more numerous. They causing any lesion, but also may be associated with are both Gram-negative, but the fusiform body lesions quite different in type from those usually always stains more deeply. Some observers main- found. The latter variation was well illustrated tain that the fusiform body simply represents a by a case which some time ago came under my phase in the life-history of the spirocheete. It isi notice whilst engaged in an investigation into not strictly a bacillus. They are both very difficult certain aspects of tuberculous infection in young to grow and are facultative anaerobes. children. Its publication perhaps maybe considered Although occurring in such vast numbers in this to be not without interest. disease, it has still to be proved that these bacteria The patient, aged 2 years, was admitted to the Manchester are the specific organisms, for they occur in a great Children’s Hospital, Pendlebury, on Jan. 22nd, 1914, said to variety of other regions and diseases, all of which be suffering from a cough and weakness following an attack The history of the illness given by the parents are associated with putrefaction (brain abscess, of measles. chronic middle-ear suppuration, pulmonary gan- at the time of admission was as follows. The child, who had been fed at the breast until he was 18 months old, had grene, noma, &c.). They are found an almost always had a " weak chest." He had measles followed by constant mouth saprophyte. Other bacteria are three months before being brought to the pneumonia always present, saprophytes, and pyogens such hospital, and since then had never been entirely without a as streptococci and staphylococci, which may cough, which had become worse the week before admission. account for any rise in temperature. This During the illness the appetite was very poor, but for the has spirochaete many names.:......Spirochaeta refringens, last fortnight all solid food had been vomited ; the stools I were frequent, loose, and foul, and the child had lost flesh Spirochaeta dentiwn, Spii-oc7iota buccae, &c.-but have provisionally called it Spirochaeta faeticZa from rapidly. Severe night sweats were also complained of. On examination the patient was seen to have well-marked its invariable association with foetor, which is not he was pale and in very poor condition, and had rickets; a characteristic of Spirochaeta pallida. Morpho- a distressing cough, with some shortness of breath. The logically it is not a spirillum, as it is not jointed, physical signs in the chest were slight dullness at the right although sometimes it seems to be "beaded." base, with impaired resonance at the left root behind, Spirochastal ulceration is essentially a disease and generalised rhonchi and moist rates on both sides. The These signs persisted almost without alteration, but the which calls for vigorous local measures. be found in child gradually grew weaker and died on March lst. most efficient antiseptics will trikresol and formalin. Iodine is useless. The The patient had always been very miserable slough should be thoroughly removed and the during his stay in the hospital, lying in bed on ulcer swabbed with a 5 per cent. solution of his back, usually with the knees drawn up, fretrikresol in alcohol or a 25 per cent. solution of quently crying out in a manner very similar to lysoform three or four times daily. A frequent that sometimes heard in cases of meningitis. mouth-wash of weaker solutions should also The temperature was intermittent in type throughbe ordered. When there is much swelling an out, with a maximum of 102’80 F., the average pulseexcellent astringent wash is permanganate of zinc, rate was 130, and the weight fell from 17 lb. to half a grain in one ounce of warm water. These 16 lb. 2 oz. The von Pirquet skin test was applied cases are often asso:ia’:ed with pyorrhoea alveolaris, twice; on the first occasion no reaction was obtained, which calls for frequent cleansing, and an excellent and on the second the reaction was so slight that it and pleasant mouth douche can be made by adding was considered very doubtful. The case was treated five minims of English oil of lavender to the 5 per as one of rickets with broncho-pneumonia, the latter cent. solution of trikresol in alcohol (or to lyso- probably of a tuberculous nature. At the necropsy form). Of this a few drops may be added to half a the following notes were made by me. tumblerful of water. Beyond a preliminary dose of There is considerable emaciation and the child has wellgrey powder, mercury is not called for. marked rickets, affecting especially the bones of the head. There is no evidence that the condition is in- On opening the thorax both lungs and the pericardium are fectious. The chief factor in its pathogeny seems found to be intimately adherent to all adjacent structures to be its association with lowered vitality and over- by fairly dense and continuous fibrous adhesions, the pleural cavities being quite obliterated, and the pleuras thickened training. Rapid and complete recovery invariably and difficult to separate. The lungs are pale and not confollows a short rest, with good food and fresh air. gested, and feel fibrous and tough when cut. There is a Bloomsbury-square, W.C. marked increase of fibrous tissue around the larger bronchi, are
.
which are filled with a muco-purulent exudation, but there THE BRITISH HOSPITALS ASSOCIATION.-A meet-appear to be no definite areas of consolidation. The two ing of this association will be held at Charing Cross Hos- layers of the pericardium are closely adherent by firm pital, London, on Friday next, July 30th, at 3 P.M., whenadhesions similar to, but less dense than, those found in Mr. J. Courtney Buchanan (secretary and house governor of the pleural cavity; and the pericardial cavity is almost the Metropolitan Hospital) will open a conversation on completely obliterated. The heart and large vessels are "The Shortage of Medical Officers in the Voluntary Hos-normal. i Similar adhesions are found matting together 1 whole of the abdominal contents to each other and pitals." Mr. H. Wade Deacon, chairman of the Royal the 1 the parietal peritoneum, though they are much less Infirmary, Liverpool, will preside, and amongst those who to are expected to take part in the proceedings are Sir W. J. ( than in the thorax. The peritoneum is also somedense Collins, Sir Cooper Perry, Mr. T. Jenner Verrall, andwhat thickened, but not markedly so. There are small (
Dr. Alfred Cox.
,collections
of
fibrinous exudation between
the coils of