« PreviousContinue »
ing a sharp line between the two, acknowledging the acetic acid ester of salicylic acid, commonly that rheumatism is a systemic disease and that ar- called aspirin, to any of the other salicylates. I did thritis is not. I do not believe any such sharp line not mention the use of pyramidon, but will state of distinction can be made.
now that I consider it very useful as a pain reliever. Dr. W. T. WOOTTON, Hot Springs (closing): I do Have also had excellent effects from atophan, espenot deny that the so-called diplococcus rheumaticus cially in gout and neuritis. I do not think it necwill cause acute arthritis in many cases, but I do essary to make an attempt to render the blood more deny that it is the only organism that causes arthri- alkaline. The alkalies formerly used gave good eftis, pericarditis or endocarditis. Most any virulent fects but chiefly because they were also purgatives. organism will cause the same condition in a joint as One speaker has mentioned massage. We would the diplococcus rheumaticus.
certainly not expect any good results from the adDR. E. H. MARTIN, Hot Springs (closing): Dr. ministration of massage to an acutely inflamed joint. Hardingasks if the salicylates are useful in acute Any acute inflammation contraindicates massage. I articular rheumatism. I consider them the most im- did not include heartlesions or the lesion of the pleura portant part of the treatment next to relieving the or meninges in my paper for two reasons: First, I cause, for weshould, in every case, try to obliterate had very little time to cover the subject, and secthe focus of infection. As stated, I prefer the use of ond, I was trying to approach the subject from the the "salicylate of acetic acid,” or in other words, viewpoint of the layman.
Cold, dead and dumb to all the world contains
Life would come gladly back along my veins.
Not knowing what the poor clod chanced to be,
And throb again-warm, tender, true to thee.
Your eyes should drop some warm tears of regret
To prove death could not make my love forget.
And you should long once more my face to see,
Led by their beacon blaze, fell full on me.
I would as soon expect to see the sun
As thee unworth the worship thou hast won.
Like one who, with the grape within his grasp,
Out from his careless and unheeding clasp.
That gems life's petals in its hours of dusk.
-Mary Ashley Townsend.
Kansas City Academy of Medicine
Meeting every Saturday evening at the Coates House
Censor, C. B. Francisco, M. D.
Treasurer, C. B. Hardin, M. D.
DISCUSSION OF THE TREATMENT OF very low class of people, in which neither
SYPHILIS, AND THE ADMINISTRATION mercury or salvarsan, iodine or general OF 150 INJECTIONS OF SALVARSAN.* tonic treatment will be of any effect in
staying the process. We have had only FRANK M. DENSLOW, M.D., Kansas City, Mo.
three of such cases at the old City Hospital, Clinical Lecturer on Genito-Urinary Diseases. University Medical College; Staff Atterdant in Genito-Urinary
all of which died. Two of these cases were Diseases at Ord City Hosp
marked by extensive ulcerations of the This paper is not intended to be a scien- vulvo-anal region, and the other of the legs. tific resume of the subject of salvarsan, as Many tertiary syphilides, gummata, etc., regards its therapeutic efficiency, nor as re- have been much benefited by salvarsan. gards its utility from laboratory standards, However, we have no illusions about one but is rather intended to awaken discussion or two injections of salvarsan curing the upon a subject which is of great interest to disease. We always give mercury almost all of us from a clinical standpoint, and as though the other had not been taken. give us each the results of other's experi- To my mind, the principal use of salvarsan ence.
is for the purpose of getting a rapid effect At the time the subject was taken up in upon the symptoms of the disease, to reduce this society previously, there were not many the infective period as represented by who had had experience with the remedy, chancre and mucus patches, and to get rid and those few not to the present extent. in the shortest possible time, of a disfigur.
No attempt will be made by me to give ing eruption. All of this we know it will complete case histories and records, because do, but if it lulls the patient with second. I do not have them. Most of these injec- ary syphilis into a false sense of security, tions were made at the old City Hospital, it has done him harm. All of us have seen where the idea in giving them has been to recurrences after a single dose of salvarsan. get the patients out of the hospital and out What a considerable number of successive of the City's charge as soon as possible. doses may do, I do not know. I have Some of them were given in the G-U Dis- never given more than three doses to any pensary of the University Medical College, one patient, the last two of them being and a number in private practice.
always in the absence of symptoms, except In practically all the cases given in the the adenopathy, which does not readily City hospital, the Wassermann test was disappear under salvarsan any more than positive.
by the old style of treatment. This applies also to the private cases. A In tertiary syphilis we go right on with test was done even in the cases where the the iodides, and mercury as well. As to clinical history was clear, for the moral the effect of the newer treatment in preeffect upon the patient, so that he would be venting locomotor ataxia and general par willing to continue treatment in the latent alysis of the insane, we have no knowledge stage.
as yet. The whole thing is too new. So As to the therapeutic effect, the imme- far I have never heard of a case of tabes diate result in almost all cases has been or paresis developing, where the remedy gratifying. In two cases of syphilitic my- has been used in the secondary period. elitis there was very little response. In Probably in ten years from now we shall one of the cases the patient regained tem- have heard of many of them. Since Noguchi porary use of the sphincters. We have had has demonstrated the spirocheta pallida in three cases of malignant syphilis in the brains of paretics, it may be that the which the injection did no good. salvarsan, if it be the spirillocide its friend Whether or not other cause beside claim it to be, will go far to prevent the the syphilis militates in these malig- so-called parasyphilitic developments. nant cases against the recovery of the pa- It seems to me, based upon practical ob tients, I do not know. I only know that servation, that the logical method of treat there will occasionally be encountered a ment today, of cases seen in the early sec case, usually (in my experience), among a ondary period when they usually come
under observation, is to give a dose of gives doses of salvarsan repeatedly, meansalvarsan or neosalvarsan at once, then a while giving inunctions of mercury, has a course of mercury lasting six weeks, then blood test made frequently, and continues another injection of the drug followed by a the mercury by the mouth and by inuncsix month's treatment with mercury, push- tions for eighteen months after the serum ing the mercury pretty vigorously and giv- test becomes negative. ing potassium iodide about one week in This difference of opinion seems to apply every five, and having a serum test made only to the secondary cases. Practically about every six weeks.
all are united in the belief that where the It has long thought that the first six primary lesion can be positively diagnosed months were the most important period of by means of finding the spirochetae in the treatment, even under the old regime. lesion, that immediate and energetic treatThere was a dictum to the effect that if the ment by salvarasn should be begun. We patient could be well treated during the have abundant evidence of the possibility first six months, lie had little to fear after- of aborting the disease in the primary ward.
stage by the use of salvarsan. Boos reports One is here between the--Scylla and cases treated by his method as mentioned Charybdis. He is between the danger of above, that show a complete absence of insufficient treatment on the one hand, al- clinical symptoms and a permanently negalowing the disease in its period of highest tive serum reaction at the end of four amenability to treatment to lapse into a years. By Campbell and Patch, 21 cases state of refractory latency, and on the other of primary were followed after being given hand to overtreat the patient with drugs, "606", in 19 all the secondary symptoms which are undisputedly harmful to the or- were entirely aborted, in two cases recurganism generally, and greatly disorder the rences occurred at the site of the primary body metabolism.
lesion, which were cured by a second inAt this time I advise about three months'jection. Swift and Ellis think it possible rest, to give the patient a chance to re- to prevent the infection from becoming cover from his strenuous treatment, assist- general by early use of salvarsan, in those ing with tonics. At the end of the three cases in which the Wassermann test is not months a Wassermann may be taken, and positive at the time of appearance of the the subsequent treatment will sumewhat chancre. According to Bruck only 40 per depend upon the result of this. If it is cent are Wassermann positive at the time negative, a further respite may be allowed. of the appearance of the lesion, in the folIf it is positive, the salvarsan and mercury lowing three weeks only about 75 per cent treatment may be repeated, of course all become positive, but at the time of the apthe time fortifying the patient as much as pearance of the secondaries practically all possible with general tonic and hygienic are positive. Swift claims that if the treatment.
Wassermann is allowed to become positive, Among men who do a great deal of this the time of treatment is increased threesort of work, there seems yet to be a great fold. difference of opinion as to the proper kind Personally I have knowledge of two and duration of treatment. Campbell and cases of primary genital chancre diagnosed Patch of Montreal, recommend a dose of by the finding of the spirochetae in the salvarsan, repeated in two or three weeks lesion, which were given one intravenous in secondary cases and depend for further dose of salvarsan and remained Wassertreatment upon the further indications. mann negative for six months thereafter, Boos, of the Massachusetts General, recom- when they were lost to observation. In the mends eight injections of calomel at inter- Journal A.M.A., August 10, 1912, A. A. vals of four or five days, from 70 to 40 mg.
Thibaudeau states that he found spirochetae at a dose, the injections being given in the resembling the pallida, probably the S. miafternoon and the patient put to bed im- crodentia, in 41 per cent of normal mouths mediately afterward. This is to be fol- examined. This was in addition to several lowed by injections of salvarsan (0.5 to 0.6 other varieties. The presence of the s. regm.) at intervals of three or four days, and .fringens has many times been demonstrated five or six being given in all. He reports in non-luetic genital sores. 25 cases so treated to show absence of the Considering these facts, and the impossiserum reaction and all clinical symptoms to bility of other than the most highly trained the date of his article. A serological test laboratory men, by cultural methods estabwas made every two weeks. He claims lishing the exact form of organism, one that it is possible to finish the treatment in may find considerable difficulty in making four or five weeks. Corbus of Chicago, an exact diagnosis, especially in mouth
chancres. However, the benefit of an early the infection is well borne by the patient, treatment so far offsets the possibility of or that it is under better control, due to treating some cases that do not need it, treatment. It is natural to find cases with that I think it advisable in all cases where a negative Wassermann and a positive luetthe history as to possible contact and the in, although both are many times co-extime of appearance of the lesion and its istent. general characteristics, even in the absence In my personal experience with the luetin of the serum test, point strongly toward a test, I have been limited to the observation primary syphilitic lesion, to treat it as of some ten or twelve cases inoculated by such. The reports of such cases would be Dr. VanAtta at the old City Hospital. I worth very little as scientific observations, made a detailed report to Dr. VanAtta at but in my own mind I am satisfied that that time as to the subsequent appearances many cases would remain purely local le- at the site of inoculation, together with the sions rather than going on to be a general case histories and the result of the Wassersystemic infection as would be shown by mann tests as made in his laboratory. The the serum test becoming positive.
reaction at the site of the control was in The subsequent indications for treatment practically each instance as strong as at would depend upon the clinical symptoms the site of vaccination. With a very limand the Wassermann reaction.
ited knowledge of the test, I could not inVery difficult it is also to tell when the terpret the results of the injections which patient is cured. We all know that the
We all know that the were very carefully given. The only result Wassermann test disappears under treat- that I could see the rationale of was one ment, only to reappear later. Clinical given to a patient in the hospital for stricsymptoms remain quiescent for years. Not ture, who was not suspected of syphilis. He all patients can afford to pay for a serum gave absolutely no reaction. . There was test every few weeks. How, then, are we another case with gumma of the sternum to tell when the patient has had enough and probably visceral syphilis who was on treatment?
treatment and gave a very much delayed It is in this connection that the luetin reaction, practically none for the first five test of Noguchi comes in. He claims for it days and then only a slight one. This may that it is possible to tell by means of the have been due, as Noguchi states, to the lack clinical symptoms, the serological test or of allergic response at first, which aug. the luetin test if a case is in the latent mented under the treatment he was in the stage, or if a cure is had. That any two meantime subjected to. of the triad may be absent, but never the The occurrence of neuro-recurrences; three.
which is taken to mean the occurrence of a To quote Noguchi, “The luetin test has nervous lesion, generally in certain cranial its own sphere. The reaction does not ap- nerves (particularly those of the eye and ear) pear until an allergic state of the skin de- usually in secondary cases, from four to six velopes from the presence of the infection, weeks after the injection of salvarsan, has but seems to persist until to persist until the probable awakened a good deal of discussion.
Fineradication of the disease from the system, ger of Vienna and his followers allege that and it remains uninfluenced by ineffective these are more frequent under salvarsan treatment. During the late stage, when than under the mercury treatment. This the visceral organs are affected, the luetin latter assertion has been denied by equally test assumes an important position in de competent authority. Ehrlich asserts that termining the nature of the infection. In these lesions are caused by isolated nests of other words, the earlier stages can best be spirochetae, and by anatomical disadvantdiagnosed by the demonstration of the pal- ages of the parts, e.g., nerves passing lidum, by the clinical manifestations and through long bony canals offering a place by the sereological tests. The late stages of low resistance. These recurrences disby resorting to the luetin test."
appear under further treatment. However, Noguchi mentions having met Practically all of the observers unite in with a number of cases of hereditary syph- recommending the use of salvarsan or neo. ilis, where, in spite of a strong serum reac- salvarsan, differing only in the number of tion and extensive clinical manifestations, injections, the time of injection and the no luetin test was obtained.
method of administering. He considers these cases of bad prognos- So we come to the question of the best tic character, as indicating that the disease method of administering the salvarsan. is too severe to enable the patients to re- This will be sure to give rise to a good deal spond by the development of allergy. of discussion, as each of us who has had Thus the luetin test indicates either that experience with the drug will be convinced that his is the only way to properly use it. the particular substance injected. Neutral We have given about twenty of the intra- inflicted less injury than
inflicted less injury than either acid or muscular injections, after several different alkaline solutions. However, in the intratechnics. The method of Alt we found muscular use of neosalvarsan, the absorpvery painful, even with the use of mor- tion is much more rapid and complete. phine. We also tried the method of making After one week as much absorption has up a small alkaline solution, about 50 c.c. taken place as after six weeks following in all, and injecting it in about six different the salvarsan injection. After one week locations along the back muscles and in the only about 15 per cent remains unabsorbed buttocks. This was very painful. We also this being slowly taken up until at the tried the iodipin suspension in a few cases, end of six weeks only about 5 per cent rebut there was a good deal of waste to this mains. method in our hands, as some of the sus- From the foregoing it would seem that pension would stick to the mortar, some to as an intramuscular injection, the neosalthe syringe. The iodipin suspension was varsan would be preferable. However, as less painful than any other intramuscular there is no especial advantage in giving method tried.
the remedy in the muscles other than the In the use of neosalvarsan we tried the ease of administration, and there is the dismethod of Wolbarst, using as a menstruum advantage of considerable pain and disa bilabout 5 c.c. of glycerin and 1 c.c. of a 1 per ity, I think the intravenous method prefercent solution of beta-eucaine, mixing in the able. neosalvarsan with a good deal of triturition The reasons for preferring the intravenand getting practically a clear solution. ous method are: The lack of pain or disWe also used plain. sterile water as a solv- comfort on the part of the patient. ent, about 15 c. C., and precedeå the injec- The almost immediate efficacy of the tion with about 1 c.c. of 1 per cent novo- dose. caine-dividing up the dose so that only The freedom from troublesome nodules about 5 c.c. was injected in any one place. or possibly abscesses at the site of injecIn any case, in almost every instance the
tion. site of injection begins to give a good deal The fact that the full dose is utilized, of pain after a few hours, when the effect and not from 5 to 20 per cent remaining unof the anesthetic is gone, and may swell in absorbed at the end of ten weeks. a most alarming way. Some of our pa
The possibility of repeating the dose as tients were kept in bed for the greater part often as may be necessary, the patient not of a week, but we fortunately have had no being deterred by dread of the pain. sloughs. I can find no reason for the severe Although there is nothing difficult about reactions that some cases show. I have in- the intravenous injection of salvarsan or serted a needle in a corresponding location neosalvarsan, it is a surgical procedure, in either buttock, put half the dose in one and should be approached with a healthy side and half in the other, at an equal respect for the possibility of the result of depth, and have had one side to swell and poor technic. In the fairly large number gave severe pain- look almost like a phleg- of injections we have made in this way, we mon-while the other side would give al- have used water that has been distilled not most no pain and no swelling. At any more than six hours before the injection. rate these unpleasant happenings were al- This is boiled again in a sterile flask just together beyond our control The studies before using it. of Swift on rabbits have shown that there For the injection we use a 50 c.c. serum is always necrosis at the site of injection syringe with an asbestos plunger, that will whether salvarsan or neosalvarsan be used, stand boiling the former the more severe.
He also anal- The reason for taking this seemingly exyzed the tissue at the site of injection traordinary care in the matter of the water quantitatively for the amount of arsenic re- is due to the studies of Wechselmann (who maining unabsorbed, at the end of different has given several thousand injections) in periods of time. There seems to be, after the matter of the solvent used. He holds the injection of salvarsan, a slow steady that many if not all the reactions following absorption for about three weeks. After the intravenous use of salvarsan were due this period the absorption was much slower, to dead saphrophytic bacteria or the prodso that after ten weeks from 5 to 20 per ucts of their metabolism, which may be cent of the arsenic could still be recovered present in distilled water after it has been from the tissues. The reaction seemed to allowed to stand. The contamination is be dependent to some extent on the degree a chemical rather than a bacteriological of injury, due to the irritative reaction of one.