Treatment

In former times it was a question whether the disease or its treatment caused the greater inconvenience or suffering to the patient.

The treatment of a given case of syphilis will, of course, depend on the stage of the disease and the condition of the patient; but if the case comes at the beginning - that is, during the period of the chancre - the early or subsequent treatment may be pretty clearly mapped out in advance.

When a patient presents a venereal sore, the question of diagnosis must be settled at the outset, and settled in the most definite manner prior to the institution of a direct anti-syphilitic treatment. If the diagnosis cannot be made with absolute certainty, defer the specific treatment until the secondary eruption appears. Granting however, that the diagnosis of syphilitic chancre has been made, let us first consider what shall not be done. Some have fancied that they could produce an abortion of the syphilis by early destruction of the initial lesions; and, to this end, the chancre was excised or cauterized. Experience shows that this hope cannot be realized. Neither excision nor cauterization, no matter how early they are practiced, will prevent the further development of the disease, while they do add very materially to the discomfort of the patient. What, then, shall be done? There is but one drug, so far as known, that is positively and directly curative in this disease - namely, mercury; and the sooner the patient is brought under its influence the better. The two schools employ it in different ways. We will first look at the method employed by the old school, and afterwards the method as employed by the new school. An eminent writer of the old school, in speaking of the treatment of syphilis, uses the following language: "My own practice is to use this agent (mercury) both internally and externally, believing as I do that the drug acts by virtue of its particles being brought into direct contact with the lesions, externally by means of lotions, salves, or other applications, internally through the medium of the blood and circulation. To the chancre, then, we may make a mercurial application, and the old black wash answers admirably, except that it should contain about four times as much calomel as the official prepara­tion allows. This should be applied two or three times daily. At the same time mercury should be given internally. Before commencing treatment, however, it is my custom to have a distinct understanding with the patient on two points - namely, the use of tobacco and alcohol. If the patient is in a fair state of general health, and will consent to the absolute abandonment of these two substances, it will not be going too far to promise him a very easy time in connection with his disease, provided, of course, that he pursues the direct medical treatment with persistence and regularity.

"The choice of the mercurial preparation to be given is not a matter of indifference. During the early period of the disease - say, for the first six months or a year - metallic mercury or the protosalts are to be preferred to persalts.


Later the persalts seem to be more useful. Metallic mercury, either in the form of blue-pill or in trituration, may be given, so that the patient receives a half-grain of the metal three or four times a day. The dose, however, should be pushed until the patient is on the verge of salivation, but never in the slightest degree beyond this. When this point is reached, we have a guide to the patient's tolerance of the drug, and omission of treatment for a day or two is recommended. It should then be resumed in somewhat smaller doses, and, with the gums and salivary glands for a guide and warning, the drug should be administered with scrupulous regularity for weeks and months. In former times salivation was considered the sheet-anchor of safety. Now, we know that it is a danger to be avoided. Under this treatment many a patient will go on for a year or more with only the slightest inconveniences from his disease. Instead of metallic mercury, the protoiodide may be em­ployed; and this, indeed, is the favorite with most venereal surgeons. After this period, if all has gone well, I prefer to give either the bichloride or the biniodide. Some cases, however, will not go well, and, instead of superficial and not very serious eruptions, we find a tendency to ulcera-tion developing quite early. This opens the gate for another drug - namely, the iodide of potassium. There are physicians who appear to be afraid of mercury, and who, believing the iodide to be comparatively a benign and innocent drug, give it in even the earliest stages of the disease. Personally I regard the early administration of this drug as harmful. The iodide of potassium, in the writer's judgment, does not exert the slightest curative influence on the disease itself, or tend in the slightest degree to eradicate it from the system. It does, however, possess a wonderful power over certain manifestations of the disease. In syphilitic ulcerations, in gummatous lesions, and in periostitis, the effects of the iodide are not only positive but marvellous. Per contra, in early superficial lesions and in late necrotic affections of the bones, it is not only useless but harmful. In syphilis we have two types of ulceration. In one the process is sluggish, and in the other active and rapid in its destructive effects. In both of these the iodide should be employed. In the former it should be given in small doses - say, five to ten grains three times a day - and combined with small doses of either the bichloride or biniodide; while in the rapidly destructive forms of ulceration the mercury should be omitted, and the iodide given in full and increasing doses. "As soon, however, as the particular lesions for which the iodide is given are brought under subjection, the drug should be given in diminished doses and soon discontinued, and mercury in small doses substituted for it.


"In the sluggish ulcerations of cutaneous syphilis there is no question as to the benefit to be derived from local mercurial applications, and a favorite with the writer is fifteen grains of the protoiodide to an ounce of simple ointment.

"Instead of administering mercury by the mouth, it may be used in the form of blue ointment rubbed into the groin or axilla. Or it may be given in hypodermic injection, employing either a soluble or an insoluble preparation. There are, doubtless, occasional cases in which these methods may be preferred; but as habitual or routine methods of treatment they are mentioned only to be condemned.

"There remains one drug, however, that is useful in certain syphilitic conditions, but of which very little mention is made in modern text-books. I allude to gold. In necrosis of the bones, especially the nasal and palatine, gold unquestionably hastens the separation of the sequestrum by promptly determining the line of demarkation between the healthy and the diseased tissues. A grain of the chloride of gold and sodium may be dissolved in an ounce of water, and five to ten drops be given once or twice a day. No advance, we believe, will be derived from increasing this dose. It should be continued for a short time after the separation and removal of the bone, as it seems to decidedly promote the healing process." In contrast with this heroic treatment comes the recommendation of Hahnemann to use Mercurius vivus in the 30x potency, one dose of which will usually be sufficient to establish a cure.