THE TREATMENT OF SYPHILIS. By Henry Alfred Robbins, M. D., Washington, D. C. CLINICAL LECTURE DELIVERED AT THE SOUTH WASHINGTON (D. C.) FREE DISPENSARY, DECEMBER 7, 1896. THIRD PAPER. This colored man, aged 35 years, who has just entered our service for treatment, gives promise of being a peculiarly interesting case, illustrating the ravages caused by syphilis. To appreciate at a glance what is presented to you, it is necessary to be well versed in syphilography. Unless you have been properly instructed, and as it were have your knowledge at your finger ends, you will in general practice be treating many cases for other diseases, which in reality are only the manifesta- tions of the protean forms of syphilis. We will ask the patient to walk across the room. You notice that his right arm hangs limp by his side, and that it is with considerable effort he lifts and swings his right knee, with the big toe of the foot pointed inwards. Syphilis causes genuine apoplectic attacks with succeeding hemiplegia, as you find in this man. Not long ago I read a paper before the Medical So- ciety of the District, in which I gave examples. Dana of New York says that syphilis causes one-third of all cases of apoplexy. There are changes in the cerebral arteries, diminishing their caliber, etc. The brain is also the seat of tumors known as gummata, but it does not require one skilled in brain surgery to remove them. Dr. Dowse, in speaking of iodide of potassium, says : " The physician com- mands this drug to carry out his object, and it does it, too, as surely, as com- pletely and effectually as the surgeon's knife in excising a tumor." ■ You will notice, if you hereafter see much of syphilis, that hemiplegia due to syphilis is nearly always on the right side. Aphasia is not uncommon. This man, however, is not at a loss for words, nor does he make use of wrong ones.- He is very complimentary, and very voluble, and has a head, and bless-you-my-cliildren " style of oratory. Now observe the eruption on his forehead. It is what is called the ulcerative pustular syphiloderm, the pustules varying in form and color. Some are covered with crusts. My colleague, Dr. Arwine, lifts one with a pin, and you notice a yellowish puri- form secretion. The late Professor von Zeissel, whose service I belonged to in Vienna, used to liken this syphiloderm to " little islands floating in their own pus." They are destructive and leave permanent scars. Of all the various forms of' treatment of syphilis, I prefer the Vienna method and that is the inunction. Generally, and always at Vienna, the mercurial ointment is used. When I am sure that I can get the oleate of mercury (io per cent.) properly made, I prefer that, but unless it is- properly and freshly made, it sometimes acts as an escharotic. As we do not have the patient under our own control, to see that the method is properly carried out, we will give him our tertiary mixture, and apply to the forehead on ointment containing calomel 5 j, zinc ointment 3j. November 23. Thiscoloredgirl, aged 25 years, has just put in an appearance for treatment. You find that she has enlargement of the posterior cervical, submaxillary and epitrochlear glands. You notice located on the neck, over the sterno-mastoid region, a large, flat tumor, which she says is painful. If it is what we think, pain is a very unusual accompaniment. To our eyes, and finger ends, it can not be mistaken for anything but a gummy tumor. Any pressure on a cutaneous nerve may cause pain, especially upon the skull, where gummy tumors are occasionally found. In this case we can account for it, by the frequent applications of the tincture of iodine, which have been 2 m ide. Snne one not well versed in syphilis has mistaken this tumor for an abscess. Way tincture of iodine is al- ways applied to a suspected abscess I can not comprehend. In my hands it has prove I worse than useless in aborting a boil or abscess, and no one but an idiot would apply it to a gummy tumor. I have ceased to be astonished at any- thing after seeing a medical man poul- tice a gummy tumor, and with a pro- found air, order syrup of hydriodic acid. A gummy tumor is the most charac- teristic manifestation of tertiary syphi- lis. They rarely develop before the third or fourth year after acquiring the disease. They are met with not only on the tegumentary surface, but post- al irtems have revealed them in the brain, heart, lungs, liver, stomach, spleen and kidneys, as I described in a paper called '' Syphilis of the Vital Organs." What is a gummy tumor? It is a cell infiltration in the subcutaneous cel- lular tissue. After the formative stage under the skin, if not properly treated, it will go on to the ulcerative stage, and sometimes is attacked with gan- grene and phagedena. This case seems easy enough to diag- nose, as the girl has enlarged glands, and she says that three years ago she had a sore on her genitals, which was followed by a " waxing kernal." Gummatous tumors have been mis- taken for cancer, and have been re- moved by the knife. I referred to this in a paper that I read before the Medi- cal Sicety, entitled " Lues Venerea." I gave examoles, and could have more. Only yesterday I came across a clinical lecture of Professor von Esmarch, in which he stated that an American had consulted him who had ''his penis, the scrotum, and the testes, as well as a large piece of the ab- dominal skin, cut away." Our sur- geons of the Pacific slope had regarded the case as carcinoma, and had made as good a eunuch of him as you can find in Constantinople. After castrating, him, they fixed him so that the only way he could be re-infected by syphilis was in a non-venereal manner. Our California surgeons failed to see unmis- takable evidences of syphilis, so von Esmirch stated. What can you expect when syphil- ology is not considered of sufficient im- portance to be taught in our medical schools ? The very name is so offensive to the ears and eyes of our professors that it is *never spoken, and never printed in their catalogues. The old world makes mistakes too. In my paper " Lues Venerea," I quoted the following from Maissoneuve : '' A patient underwent a serious oper- ation for a supposed encephaloid cancer of the pharynx. After six months the tumor began to grow again, and grew so rapidly that the patient was given up in despair, and sent to the hospital to die. When examined upon his en- trance, an enormous tumor was found occupying the left lateral region of the neck and the entire parotid gland. It projected into the pharynx, oblit- erated the velum palati, and threatened the patient with death by asphyxia. Under specific treatment, the tumor vanished without leaving a vestige." This mirning I received part III of the Pictorial Atlas of Skin Diseases, and Syphilitic Affections-taken from photo-lithochromes of the models in the Museum of the Saint Louis Hospital, Paris. It contained, among other superb il- lustrations, a colored photo-lithochrome of a broken-down ulcerative syphilitic gumma of the thigh. This patient was a man aged thirty-nine years. The patient went to a hospital and was admitted to a surgical ward. He states that the surgeon thought of oper- ating on him, and even auscultated his thigh '' to hear pulsations " ; soitseems possible that an aneurism was suspected. However, after two surgeons had con- sulted together, the operation was aban- doned, and he was discharged, with means of treatment directed mainly to- wards his pains (opiates internally, bel- ladonna plaster on the thigh, etc.). In one month he returned to the hos- pital, in a w.orse condition. ''A different surgeon from those who first saw him 3 now attended him. The thigh was now missive and hard, but the skin was pur- ple, the ecchynuses having partially disappeared. Probably the new surgeon diagnosed a malignant tumor - likely enough an osteo-sarcoma-for he pro- posed to the patient the amputation of his leg at the h>p joint." Terrified, the patient left the hospital. " A few weeks afterwards (December, 1890), the poor fellow was sent to the Saint Louis Hospital. The appearance of the lesions, as we have already de- scribed them, left no room for doubt as to their nature. Despite the lack of evidence of antecedent syphilis, and de- nials of the patient, the diagnosis of syphilis was made, and specific treat- in mt instituted. This treatment con- sisted of daily mercurial inunction (mer- curial ointment, four grammes ( pi), and of iodide of potassium, of which the patient took at first two ( pss), then three (gr. xlv), and finally four grammes ( 5i), daily. The disease, which had lasted for two years, was cured in two months. In my paper (Lues Venerea) I wrote as follows : ** Gammy tumors have been diagnosed to be sarcomata, and the ever ready knife of the surgeon brought into use, but the happy administration of the proper treatment has caused them to melt away, like snow under the midday sun." S> far I have not been called to account for thus indulging in poetic license. We will apply the oleate of mercury, ten per cent., to this tumor, and give the girl our tertiary mixture, and when you see her again you will, I suspect, find that the tumor has melted away, with- out leaving a vestige. November 25.-This white woman, who appears to be about thirty years old, has brought her girl baby, aged eight months, for us to treat the infant's hand. Before Dr. Arwine removes the dress- ings, we will call your attention to the unusual formation of the infant's skull. There is a bulging out of the frontal bone, and a general lack of symmetry. You will notice that its eyes are bright, and tfiere is no evidence of its having had interstitial keratitis, and the mother says that it has never had ear trouble, and there does not appear to have been an arrest of development. You notice, about the commissures of the lips, little groups of vesicles, which look herpetic. Let us examine the mouth. We see irregular grayish-white patches, which have the appearance of having been brushed over with a solu- tion of nitrate of silver. These are called opaline patches, because they re- semble the opal, and they are charac- teristic of syphilis. On examining the hand, what do we find ? A most typi- cal case of what is called dactylitis syphilitica, called so from the Greek word meaning finger. Nelaton reported two cases about thirty years ago, and ten or eleven years years later Dr. R. W. Taylor wrote an essay on the subject in his usual mas- terly way. The acquired form is very rare. Only five cases had been reported up to the time that Dr. Taylor wrote his paper on the subject. You will ob- serve that the upper phalanges of the index middleandring fingers appeartobe gummatous. They feel gummy and are puffed out more than twice their normal size, and at the end of the index finger there is a deep ulcer, and it looks as if there might be necrosis of the lower phalanx. The doctor is dressing it with iodoform gauze. We will photo- graph this case, if possible. We will give the little patient % grain doses of hydrargyrum cum creta, and will tell the mother to keep its bellyband smeared with mercurial ointment. Let us question the mother. You notice that she is good looking and ap- parently healthy. She has had five children, no miscarriages. She says that all have been healthy, except this last one; it had a breaking out, shortly after birth, and the child has constantly had " a cold in the head." She says that her husband is a healthy man, has had no skin trouble, no rheumatism, etc. As this woman looks so well, we would, if we had time, call your attention to the law of Colles. That is where a healthy woman can give birth to a syph- iliticchild. Dr. R. W. Taylor has given 4 examples, where such appears to have been the case. We will refer to that in a lecture, when we do not have to keep patients waiting. We will investigate still further, and report on some future clinic day. Reprinted from the Maryland Medical Journal, February 20, 1897.