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for the cure of syphilis. That too much mercury will reduce the red corpuscles has been demonstrated frequently by those men who are in the habit of counting them. The object to be gained in the treatment is to use a sufficient amount of mercury to en. rich the blood, and destroy the leucocytes, and, thereby, prevent the appearance of the various secondary symptoms. The gums are uncertain informers, and often mislead by reason of the local irritation produced by the tartar and decayed teeth, and general uncleanliness of the mouth. Preparatory treatment of the mouth, and other general conditions, are essential. I order my patient to a dentist as soon as he presents himself for treatment; have ths teeth and gums put in perfect order before I give him a dose for this disease. After giving him advice as to his morals, diet, habits and regularity with which he must take the treatment, I am prepared to commence a course of treatment which in no in: stance should be less than two years.
Excision of the Chancre.- Where the chancre can be readily removed, as in cases located on the prepuce or integiment of the penis, it is always advisable to remove it under strict antiseptic precautions. This can be done under local anæsthesia, without any inconvenience to the patient, and a primary union of the incision is the rule. Use a continuous suture, and place sutures close enough to get perfect apposition. In five to seven days, the wound is well, while it would take two weeks or more to cause the chancre to héal, besides leaving the customary induration. Treatment for syphilis must be carried on just the same, but you may hope for a modification of the after-symptoms, if they appear at all. I take occasion to report two cases of excision of the chancre, followed by very good results.
CASE I.-W. M., male, age 23; came in January, 1901, with a suspicious sore on the skin of penis, near the middle lateral surface. There were two small indurated sores, two lines in diameter, and one line apart. He gave a history of sexual in. tercourse three weeks before. Excision of the chancre, with primary union and dismissal in five days, with no treatment then or since, and yet no secondary symptoms have manifested them. selves. These sores were excised the day they appeared. No glanular enlargement followed. I was then in doubt as to diagnosis, and am still watching the case.
CASE II.-J. W., male, white; chancre on the prepuce; good history of syphilis; excision, primary union; constitutional treatment, a very slight secondary manifestation. Has been under treatment now about six months. Local treatment of chancres does very little good. Cauterizing often does harm, inducing in many cases phagedena, or severe sloughing. Antiseptic washes, and dry antiseptic powders are indicated, depending on constitutional measures for sure results. For convenience to the patient, I prefer Bernays' bichloride of mercury tablets, and nosophen, as local treatment.
This paper is written to emphasize the importance of mercury by inunction, and its advantages over the treatment by the stomach or hypodermatic medication. Many times I have seen patients with syphilis, with well developed papular and pustular syphilides yield most readily to the inunction treatment, where treatment by the stomach has been a signal failure. When I wish to make a pronounced impression on the system, as indicated by the increasing eruption over the body, limbs and face, or where the fauces are superficially ulcerated, or have the mucous patches, so frequently seen in untreated and badly treated cases, I use the mercurial inunction. I order an ounce of 50 per cent. ointment; have it divided into eight or ten papers, and order it applied to parts of the body free from hair. This should be rubbed in thoroughly, taking from ten to fifteen minutes to do it. Have the suface throughly scrubbed with soap and water before supplying the ointment. I prefer the back as the point of election for the application of the ointment, although, in cases where an assistant cannot be had, the side, breast, arm or popli. teal space can be used. At the same time, I order a saturated solution of the iodide of potash, and in the arly stages use from five to ten drops three times a day. If in older cases, I use larger quantities of the iodide. Many cases will not and cannot use the ointment from fear of detection, in which cases we are forced to give the mercury by the mouth. I believe small doses, often repeated, are more efficient than larger ones at longer intervals. The biniodide of mercury in solution, is the preparation most usually used. The dose at first will be as small as one-thirty. second of a grain, which can be given four or five times daily, but this dose is too small to be used continuously. An average of one-sixteenth to one-twelfth of a grain, which must be administered three times daily to get good results. The biniodide preparation is freshly made by the addition of a little potassium iodide to the bichloride solution. The iodi.les are not indicated in the early stages, the rule being large doses of mercury and small doses of iodide in the commencement of the treatment, the reverse of this in the latter stages. The protoiodide granules of Garnier and Lamoreaux, generally spoken of as the G. & L. pills, contain one centigramme each, are now and have been for many years in popular favor, by reason of the convenience at. tending their administration, and ease with which the tonic dose can be attained. Dr. E.L. Keyes bas, by his writings, given these pills more prominence than any one else, he using them in arriving at the "tonic dose.” The chief objection to the use of these pills is that they are not regular in their action, sometimes being more irritating to the abdominal organs than at other times. The griping they produce is very disagreeable to the patient, while diarrhea is not an infrequent condition. Then, too, I have not been able to control the symptoms as well with these pills as with the other preparations. I have been using, from time to time, with extremely anæmic patients, a combination of iron and mercury, with very good results. I usually call for the bichloride of mercury, and the tincture of chloride of iron, put up with compound ticture of gentian. I do not use the hypodermatic medication at all, nor have I used in but few cases vaporization.
Iodism.-Some patients have a peculiar idiosyncracy for the iodibe preparations, appearing wholly unable to take a small dose without signs of supraorbital neuralgia, acute coryza, nausea and spasm of the masseter muscle. They are inclined to push it aside with the remark that they cannot take it. Both doctor anid patient are iuclined to give it up too soon. Many cases that cannot take svall doses, can take the larger doses, twenty, thirty, or even sixty grains of the potassiun iodide, without any inconvenience whatever. I have seen several cases recently iu which small doses produced lockjaw, who afterwards took a teaspoon. full of the saturated solution three times daily, with no incon. venience. I maintain that the iodides are absolutely necessary in the later stagea of syphilis for complete eradication of the disease. Mercury has no effect whatever on the secondary lesion; iodide none on the primary. Each is an adjuvant to the other, and both necessary. After the iodide has reduced the gumma, and restored the parts to their normal condition, mercury, by inunction, should be administered to prevent a return of the gumma; otherwise it is almost sure to return.
Let me pay my respects to Hot Springs, and their efficiency in the treatment of syphilis, That cases are benefited by a Bojourn of three or four weeks at these springs, under the care of a good physician there is no doubt. But it is due principally to the regularity with which the treatment is taken, and the freedom from business cares (?). In the cities where the RussianTurkish baths can be procured, patients can receive the same treatment as at Hot Springs, if they will give it the same time and attention. There is no special virtue in the water, other than its natural heat, which seems to be more penetrating than the artificially heated waters in the cities. Nearly all of my patients who have been there returned disappointed-it does not come up to their expectation, besides being an expensive place. There is a good deal of humbuggery in Hot Springs.
AMENORRHEA AND ITS TREATMENT.
BY E. C. WILLEY, M.D., LOUISVILLE, KY.
Practitioners of medicine are consulted by no class of patients who display greater solicitude than those who have amenorrhea.
In the popular mind failure of the menses to appear is supposed to be due either to pregnancy or tuberculosis and either may cause a degree of anxiety that is truly intense.
The term amenorrhea is used to mean the total absence of the menstrual discharge, or a marked deficiency in the quantity of the flow. Amenorrhea may be physiological or pathological. During pregnancy the absence of the menstrual discharge is, of course, physiological and demands no consideration in this article. When pathological, the causes of amenorrhea may be said in general to be due to the following:
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