THE TREATMENT OF SYPHILIS. By Henry Alfred Robbins, M. D., Washington, D. C. THE TREATMENT OF SYPHILIS. Ry Henry Alfred Robbins, M. D., CLINICAL LECTURE DELIVERED AT THE SOUTH WASHINGTON (D. C.) FREE DISPENSARY, DECEMBER 7, 1896. SECOND PAPER. Reprinted from the Maryland Medical Journal, February 13, 1897. It seems as if material comes to us just when we want it. We were anx- ious to show you a case of maculo-papu- lar syphiloderm and here you see it all over this quadroon girl, who is pretty and nineteen years old. There is a his- tory of a sore on the genitals, which the girl says she noticed two months ago. Dr. Armine has called our attention to an indurated spot, located on the left labium externum. You feel also slight enlargement and hardness of the ingui- nal glands, just above Poupart's liga- ment. Feel above each elbow and you will find something that will roll under your fingers like little marbles. They are the epitrochlear glands. Her face alone seems not to blush with the erup- tion. This patient reminds me very much of one that a brother practitioner sent me to see some years ago. He told me that he did not know what it was, unless it was a case of " erythema universale." It did itch, however, and very badly, too. That is not the case with a syphiloderm. There were no catarrhal symptoms and no typical tongue of scarlatina. I glanced around the room and saw on the washstand a black, shiny-looking thing, which had a very blunt-looking nozzle. Such an instrument is sometimes used for wash- ing out ears. In close proximity there was a six-ounce bottle. It occurred to me that it might contain that good, old- fashioned mixture named after Wash- ington's most intimate friend, the Mar- quis de la Fayette. I suggested that the patient had an attack of gonorrhea and that the eruption was a medicinal one, caused by the copaiba in the mix- ture. It turned out to be the case, and stopping the administration of the Mis- tura la Fayette, the patient made a rapid recovery, as far as the skin trouble was concerned. The Marquis, however, is not respons- ible for the girl's eruption. Under spe- cific treatment it will rapidly disappear. It is one of the most benign of the man- ifestations of syphilis. We formally present to you for exam- ination another girl, aged twenty years, whose skin is not so lily white. No white man's blood courses through her veins. In Vienna there is no mock modesty. It makes no difference as to the sex or age of the patient. When one appears a transformation act takes place and you behold a being as bereft of wearing apparel as Venus was, as she is represented on the big sea-shell, with nothing to cover her but her hair. When I was in Paris I never missed going to the studio of an artist friend, which exactly resembled that of the studio of Du Maurier's friends " Taffy, 2 the Laird, and little Billee," when he was painting from '' the altogether." Now imagine that the girl is a black '' Trilby." Do not look at her feet, because if you do the illusion is gone. Keep your eyes fastened on her arms and legs. You notice that there is a large collection of epidermic scales. They are dry and thick and of a dirty, grayish color. It is the papulo squam- ous syphilide. There is only one skin eruption that you could possibly mistake it for and that is psoriasis. Some writ- ers call it psoriasis syphilitica, but there is no such thing. Arsenic, in its effects, is magical in psoriasis. In this case you might give it in all its forms, but it would have no effect on this syphilo- derm. Under specific treatment you will notice marked amelioration in a very short space of time. It belongs to the late secondary stage. You find a syphilitic history in this case, as far as enlarged glands are concerned, espe- cufily of the epitrochlear. The history of an initial lesion is sometimes very difficult or impossible to obtain, as you find in this case. If hereafter you see much of this dis- ease you will lose confidence in man- kind. We are not influenced by any false statements of any patient. Fortunately the disease is not in the air, as some would have you believe. Then it makes no difference to us how any person was contaminated. We are here to recognize and treat diseases of the skin and to the best of our abil- ity impart our knowledge to you. How shall we begin treatment ? That depends entirely upon the stage of the disease'and the idiosyncrasies of the pa- tient. Let us give reasons for what we do and not go to work in a blindfolded, hap-hazard sort of way. The two medicines that you have seen us prescribe so often are mercury and iodide of potassium. The micro-organism of syphilis has not yet been discovered, but we know that the lymphatics have absorbed something, which, if left alone, goes on to multiply indefinitely, causing cell accumulations and connective tissue de- posits. The various syphiloderms are manifestations. If the disease is not arrested in the secondary stage this pro- cess goes on, resulting in changes of the arteries and formation of gummata, not only externally, but in the vital or- gans. Later on I will report examples, as I have taken the trouble to study the subject and some of my writings have found their way into print. The diagnosis of visceral syphilis is made, not from any particular symp- toms, but a combination of many, going back, if possible, to a history of a chancre, occurring years before. The object of treatment is to give something that will hasten the destruc- tion and elimination of the poison and its products and that corresponds to the properties ascribed to only one drug and that is named after one of the mytho- logical gods-Mercury. This reminds me that years ago when the old-fashioned stages used to run up and down Broadway, New York City, a well-known physician crawled into the rear end of one and found seated there " a maiden fair but frail." He was in- vited to spend half an hour with Venus. The physician sighed at the moral de- pravity of the invitation and replied that half an hour passed with Venus means many months passed with Mer- cury. The answer contained ''more truth than poetry." You find a good many here passing their time with mercury, but as yet we have not had any "Nymphs de Paved' The name venereal conies from Venus, ''the goddess of love or pleasure." The sooner she is dethroned the better it will be for the world. We do not propose, however, to take up the " social evil " question, only so far as to inform the public as to the danger of acquiring syphilis in an un- merited way. Having decided to begin treatment with mercury, we at first think of the most convenient and acceptable way to give it to the patient and that is by the mouth. Before doing so we should make a careful examination of the buc- cal cavity and see if the teeth are in a 3 good condition. If not, send your pa- tient to a dentist, Prescribe a tooth wash containing the tincture of myrrh. For- bid the chewing of tobacco. Remember that the favorite seat of mucous patches is in the mouth. Jullien says the history of an average case of syphilis may be summarized as follows: ''A chancre, a transitory erythematous rash, and following this, mucous patches, re- lapses of mucous patches, more mucous patches." You know that the secretion of a mucous patch is in a high degree contagious. Next to the chancre it is the commonest source of infection. I might as well state here, that noth- ing is equal to black wash (lotio hydrar- gyri nigra) either in full strength, or diluted with water, for the cure of mu- cous patches of the mouth, used as a gargle several times a day. After attending to the cleanliness of the mouth, we give some form of mer- curial pill. I am not going to burden your minds with a lot of formulae. Nearly every patient that you .will have in private practice will show you several, which a physician or friend has given him I have had them presented to me for examination by former patients of phy- sicians from Portland, Maine, to New Orleans, and across the continent to the Hot Springs of Arkansas, and San Diego, California. Remember that in giving mercury it is your object to give the patient as much as can be absorbed, or as much as he can take, without injuring his gen- eral health. Look out for the symp- toms of salivation, such as increased and thickened mucous saliva, pain felt on snapping the teeth together, a feeling as if the teeth were elongated, etc. Stop when the gums are slightly touched. If ptyalism does occur, give the satu- rated solution of the chlorate of potas- sium, every hour or two as a gargle, and a little to be swallowed. You notice that we generally prescribe during the first year of syphilis the proto-iodide of mercury or the hydrar- gyrum cum creta; the latter is the form of mercury that is preferred by Jona- than Hutchinson. We begin with one-fourth of a grain of the proto-iodide three times a day; if we do not see almost immediate good results, we give four, then two in the morning, one at noon, then two at night, then six a day; and so on until we have slightly touched the gums. Sometimes you will find that the patient will not get along well, until you add iron to the prescription. Such a one is recom- mended by Dr. F. R. Sturgis of New York, which contains two grains of blue mass to one of iron. It has an excellent tonic effect. Some people can not take the proto- iodide of mercury without its producing colicky pains and diarrhea. I had such a case, a short time ago. When I dis- continued it, and gave in place of it the tannate of mercury in one grain doses three times a day, it agreed perfectly with the patient. Since then I have prescribed it for several and with satisfactory results. The dose is from one to five grains. How long shall we keep up treat- ment by this method ? Formerly I kept the patient on a mercurial pill for one year or eighteen months. Now act- ing on the published recommendation of Dr. R. W. Taylor, at the end of six months, I give the patient a period of rest. That is, I give the pills in as large doses as he can absorb for twenty days and stop ten. If all goes on well, then at the end of a year, and during six months, I give the drug for fifteen days, and stop fifteen. During the in- tervals I give freely of tonics. Lately I have alternated this treatment with the inunction method, which I will ex- plain to you on another day. At the end of a year and a half, I give what is called the " mixed treat- ment." That is a combination of mercury and iodide of potassium. There isa great difference ofopinion in relation to the action of this combination. The object of treatment is to destroy and eliminate from the system the products of the syphilitic virus. Perhaps mer- cury is the destroyer, and the iodide of potassium removes the debris. As good a prescription for the mixed treatment as you can find is the re- nowned " Sirop Gibert." Its value has 4 added to the reputation of a famous syphilographer, and it is still often pre- scribed at home and abroad. li.-Hydg. biniodid. . gr. j Potass, iodid. . 5j Aquae . . . f 'j Filter through paper and add Syrupi Simplicis. . f 5 v M. Sig. A tablesponful three times a day. The mixed treatment is also given in tablet triturate form. This treatment we continue for twenty days, and then give ten days' rest. During the third and fourth years of the disease we give the patient a rest from treatment of one, and sometimes two, months if there is no symptom of the disease present, Really, at this age of syphilis, you have to deal with the sequelae of the primary and secondary stages, and now it is the time when the iodide of potassium is your sheet anchor. If syphilis had not been properly treated, there comes a day of reckoning, and the victims of the disease (and ig- norance somewhere) are attacked with apoplexy, albuminuria, heart disease, etc., when in. reality they are dying from the structural changes of syphilis, which proper treatment would have eliminated. Many years ago I had the honor of walking the wards of Guy's Hospital, under the tutelage of that great phy- sician Dr. Samuel Wilks, who still lives enjoying the honors of a long and dis- tinguished career. In 1886, Dr. Wilks,. in a lecture on " Medical Treatment," said : ''I think I can show how an im- proved treatment has come about, not by the discovery of new drugs, but by a better knowledge of the nature of disease, and by clinical observation. Thousands of persons are now cured of epilepsy, paralysis and various other nerve disorders by means of iodide of potassium, and why ? Because syphilis was found to attack the brain and inter- nal organs, when a more extended and closer observation of morbid structures was begun to be made in the post-mor- tem room. Let me most emphatically dwell upon this point, that an improved treatment saving thousands of lives an- nually arose, not from the discovery of a new drug, but from work in the dead- house."- At the conclusion of our next service, I will continue the subject of iodide of potassium. How it should be prescribed with care. Its dangers as well as vir- tues. Then we will go on to other methods of treating syphilis.