Syphilis.
Definition:—Syphilis is a chronic, infectious, contagious disease, characterized by a definite clinical course of six periods: (1) Period of incubation; (2) period of primary symptoms—the chancre; (3) intermediate period between that of the primary symptoms and the development of skin eruption; (4) period of secondary symptoms—skin eruptions; (5) latent period, characterized by absence of lesions; (6) period of tertiary- symptoms. The disease may be either congenital or acquired.
Etiology:—No specific micro-organism has yet been discovered, and the search for the infective agent is rendered difficult by the fact that the disease is peculiar to the human race, thus rendering inoculation experiments upon animals impossible.
The disease is usually transmitted during sexual intercourse, but many cases are the result of accidental inoculation, especially of the lips during the act of kissing, or of a finger during examinations, operations, etc., by physicians. Hereditary syphilis is most commonly found in children both of whose parents are diseased. Where one only is affected, the father is more liable to transmit the disease than the mother, and the more recent his contraction of the same, the more certain is he to transmit it. Fortunately, however, infection during the period of gravidity does not always seem to occur, either of the embryo from a syphilitic mother or of the healthy mother from a syphilitic embryo, and the apparent immunity which seems to be enjoyed in certain cases, during this period and later, has given rise to various theories or so-called laws of immunity, such as Colles'—that the child of a syphilitic father will render its mother immune against the disease, and Profeta's—that healthy children begotten of syphilitic parents are immune against syphilis. Many exceptions, however, have been found to both of these laws.
The contraction of syphilis in its acquired form depends upon the existence of some break in the cutaneous or mucous surfaces, such as a slight fissure or abrasion of either skin or mucosae of the genitals, or in the case of the accidental variety, of the lips or hands. Susceptibility to the disease is universal, and even re-infection, though rare, has been known to occur. The blood during the secondary period, and the secretions from all lesions except the tertiary, are infective. The saliva, sweat, milk and semen do not appear to convey the virus, though the latter is very liable to infect the embryo and through it the mother.
Symptomatology:—The symptoms of acquired syphilis occur typically in three fairly distinct stages, though in many cases these overlap to some extent, thus rendering absolute definition between them impossible.
During the primary stage the general symptoms are negative, but the typical initial lesion—the chancre—makes its appearance usually about three weeks after infection. This, which is also known as the primary sore, ulcus durum or Hunterian or hard chancre, begins as a red papule with a hard or indurated base, the surface of which rapidly breaks down and forms an ulcer which may vary in size from that of a pin-head to a silver dollar. When very small, and especially when situated on a mucous surface and presenting no marked evidences, the ulcer may be unnoticed altogether, and thus make the later diagnosis of the condition more difficult. Within one to two weeks of the appearance of the primary sore the glands of the immediate neighborhood become the seat of a hard and painless enlargement, and non-syphilitic complications, such as phimosis, paraphimosis, balanitis, vaginitis and stricture are not uncommon. The involved glands show no tendency to suppuration and are known as indolent buboes.
The secondary stage is inaugurated from six to ten weeks after infection by malaise, anorexia, headache, languor, impairment of digestion and usually some slight fever—101°-103° F., together with general rheumatic or neuralgic pains, exaggeration of reflexes, splenic enlargement, anemia and frequently icterus. Just preceding the appearance of these constitutional symptoms general adenitis sets in, when without the usual inflammatory signs all the glands of the body enlarge painlessly and become hard. The general symptoms already named do not occur in every case, or they may be so slight as to be unobserved by the patient. During this stage and accompanying the aforenamed phenomena, an eruption appears, varying in the type and distribution of the lesions, which are known as syphilides or syphilodermata. These on first appearance are usually macular in character and erythematous in color, though sometimes pigmentary or purpuric. The spots vary from a yellowish-red to a light rose tint, and under pressure the color disappears. They may be few in number and scarcely noticeable or quite profusely distributed, especially on the forehead, chest, abdomen, buttocks and thighs, and when difficult of detection may be made more prominent by having the patient remove the clothing from the trunk, when the diminished vascularity of the skin, incidental to the cooling of the surface, causes them to stand out more distinctly. In some cases a tendency to grouping of the macules may be noticed, and later on a roseola may occur with this tendency still more marked, in which the spots are larger and to a slight degree scaly. The pigmentary syphiloderm, noticed most frequently in women about the neck, is apparently the result of circumscribed areas of pigmentary atrophy, with contiguous areas of hypertrophy, both irregularly distributed, and causing the skin to appear as though covered with a brown network. It appears early and does not readily respond to treatment. The purpuric variety of this early eruption is most frequently seen in those of low vitality or during a course of vigorous mercurial treatment, and consists of small purplish spots which do not disappear under pressure.
Another early eruption is that of papular syphilodermata, which may be either dry or moist in character, types of the first variety being the ordinary miliary and lenticular cutaneous papules, while the moist includes such lesions as mucous patches and condylomata lata. These syphilides are very common and in color, situation and grouping are characteristic. They may be of any size up to that of a silver ten-cent piece, flat or conical, with color varying from a dark red to a ham color. This eruption in a slightly scaly form is common on the forehead—the "corona veneris"—and is also frequent on the scalp and chest.
The dry miliary variety occurs in patients whose general health has previously been bad; the lesions are pin-head in size, conical, diffusely distributed, copper-colored and may at first be surmounted by small vesicles which later dry up and form small scales. Lenticular papules, somewhat similar in general characteristics to those just described, are the syphilodcnnata most commonly seen; they are symmetrically distributed, are polymorphous and usually excite neither pain nor itching.
When this eruption affects mucous surfaces it causes flattened infiltrations of varying sizes, slightly raised above the adjacent surface, surrounded by a narrow, reddish areola and covered by a grayish film. They are known as mucous patches, may be single or multiple, are usually painful and later acquire an opaline appearance. Any of the visible mucous membranes may be affected, but they occasion special discomfort in the mouth, where they evince great resistance to treatment and strong tendency to recurrence. Ulcerative processes may supervene, especially upon the tonsils and soft palate, usually superficial in character but exceedingly painful. A somewhat similar condition arises when the papules appear in a locality where two cutaneous surfaces are in constant, contact, as between the nates, where the persistent irritation by the local secretions causes them to proliferate until they become flat; disc-like, warty growths—condylomata lata—which give off an offensive odor and a serous, highly infective discharge.
Usually following the above described papular varieties, but sometimes occurring primarily, syphilodermata of a pustular nature may develop, especially in unclean and poorly nourished individuals. These also may be miliary or lenticular in appearance and upon drying form coarse, dirty crusts from which the term crustaceous has been applied to this eruption in its later stages. Various modifications of these eruptions and combinations of their characteristics have caused them to be distinguished by descriptive designations, e. g., squamous, vesiculo-papular, pustulo-crustaceous, etc., which are self-explanatory. During this secondary stage of the disease, other symptomatic conditions, such as alopecia, laryngitis, iritis, choroiditis, retinitis, and epididymitis, frequently occur. Altogether the secondary symptoms extend over a period of from two to three months to a year or more and are succeeded by an interval varying from a few months to several years, during which the disease remains latent, the individual enjoying, apparently, perfect health. In occasional cases, however, this interval is absent entirely, instances having occurred where tertiary symptoms have appeared during the secondary stage.
Characteristic of the third or tertiary stage are certain skin eruptions, one of the commonest of which is a pustule which dries to form crusts arranged in laminae, somewhat resembling an oyster shell. This variety is known as rupia. Other pustules may appear, which are tubercular in form, very slow to heal and sometimes manifesting a serpiginous or creeping tendency. Vegetating growths are also often seen among the moist types of eruption. True gummata may form in the skin and subcutaneous tissues during this stage, as in almost all other parts of the body. When they appear in the skin or mucous membranes they form nodules, involving usually only the superficial and subjacent tissues, varying in size up to that of a lemon, the overlying skin remaining normal in appearance until just preceding rupture, when it becomes purplish. When softening sets in they break and discharge a gummy material, to which the lesion owes its name, leaving ulcers, often kidney-shaped when affecting the skin and always difficult to heal. During the process of ulceration and cicatrization a great deal of contraction occurs, ultimately resulting in considerable deformity, which, when the lesion involves one of the tubular organs, such as the esophagus, rectum or trachea, is often attended by stenosis. None of the eruptions mentioned as occuring during the tertiary stage are capable of transmitting the infection; they are not symmetrical in their appearance and are more liable to be attended by itching. Any of the appendages of the skin may be affected in this stage, alopecia often resulting from loss of hair involved in destruction of the scalp; onychia, when the nails are affected, and paronychia, when the surrounding tissues are also diseased.
Periostitis is another common manifestation, causing the development of nodes, especially over the tibiae and forehead, but also on the nose, palate and, though less frequently, upon other bones. They are accompanied by severe pain, especially at night, and also manifest great tenderness upon pressure. These may degenerate into gummata, but usually, unless they are absorbed, undergo fibrous or osseous changes, very rarely suppurating. The lymphatic glands and testicles are often the seats of chronic enlargement which has no tendency to suppurate. If pregnancy occurs in the female at this time, abortion or miscarriage will probably terminate it, owing either to syphilitic poisoning of the ovum or to the development of gummatous growths in the placenta. These growths may also occur in the internal organs, giving rise to the condition known as visceral syphilis, which, except in rare instances, is the most dangerous form the disease assumes.
The brain or cord may be attacked any time from one to thirty years after the initial infection, and this form of the disease is most likely to occur in those cases in which the early manifestations have either been absent or overlooked. Cerebral syphilis usually affects those in whom the disease has been acquired, but victims of the congenital form are not exempt; imbecility and idiocy being often traceable to this cause. Nervous syphilis usually presents symptoms of one of three conditions: (a) epilepsy, (b) brain-tumor or (c) paralysis. Epileptic manifestations coming on in middle life and not traceable to alcohol or uremia are usually of syphilitic origin. Hysterical or various atypical symptoms may also be presented. Headache, convulsions, optic neuritis and other characteristic symptoms of brain-tumor should, even in the absence of confirmatory evidence or history, excite suspicion of cerebral gummata and lead to trial of anti-syphilitic treatment. Syphilitic paralysis may be hemiplegic in type or may simulate general paralysis (dementia paralytica). An atypical paralysis in the presence of syphilitic history will suggest spinal gumma or myelitis.
The liver is another organ frequently affected either with a hyperplasia of the connective tissue elements throughout the organ or with a development of gummatous growths. Neither of these conditions gives rise to any marked symptoms until the resulting contraction causes pressure upon the portal vein or its branches, when the usual evidences of portal obstruction will appear. Some pain is also frequently present, with tenderness upon pressure over the painful area, while the syphilomata may often be detected by palpation as rounded prominences upon the hepatic surface.
Syphilitic ulceration may involve any part of the gastrointestinal tract, being especially common in the neighborhood of the two orifices. The oral manifestions have already been described and similar conditions may affect the stomach or intestines, occasionally leading to perforation and peritonitis. Gummatous growths may develop in the tongue, pharynx, esophagus, stomach, and especially the rectum, the involvement of the structures of which, is more frequent in women than in men, often resulting fatally from the subsequent stenosis. The lesions are usually situated close enough to the anus to be detected by digital examination, when the edge of the cicatricial ring can be made out. This evidence, together with the history of the case, will insure recognition of the condition if cancer can be excluded by the absence of the characteristic margin of a cancerous ulcer.
Syphilis may, though rarely, attack the lungs, causing the development of (a) pulmonary gummata, (b) interstitial pneumonia or fibrous infiltration, or (c) fetal pneumonia characterized by appearance of miliary gummata which coalesee to form what Virchow described as "white hepatization." The symptoms will probably be too indefinite to give rise to more than a suspicion of the true nature of the condition, and the results of a therapeutic test will be necessary for its recognition. In the heart there may develop (a) gummata, (b) a form of fibroid myocarditis, or (c) a sclerotic type of endocarditis. The symptoms will be similar to those attending these conditions from any cause as described under Chronic Valvular disease. The arteries may suffer from an obliterating endarteritis in which the lumen is gradually occluded by the proliferation of subendothelial tissue, or from gummatous periarteritis which predisposes to aneurism and atheroma.
Amyloid degeneration of the kidneys is a common sequel of syphilis, and these organs may also be the seat of the development of gummata.
The joints may present synovitis, acute during the secondary stage, chronic in the tertiary, perisynovial gummata or arthritis. The pain in these conditions is usually severe at night, especially when due to the presence of bony nodes.
The testicle is frequently the seat of a nodular gummatous enlargement, characterized by the absence of pain. An interstitial orchitis of a fibro-sclerotic nature and leading to gradual atrophy is also a common conditon.
All the symptoms heretofore described have been those of the usual chronic form of syphilis. There is also a rapidly fatal form of the disease known as malignant syphilis, fortunately of rare occurrence, in which the course is very rapid, tertiary symptoms manifesting themselves as early sometimes as the second month and resisting all treatment.
Symptomatology of Congenital Syphilis:—In congenital syphilis the characteristic symptoms usually appear between the first and fourth months after birth. Occasionally, however, there are present at birth well-defined evidences of the condition, such as marked emaciation, a general appearance of senility with wrinkled and flaccid skin, snuffles, pemphigus neonatorum appearing as bullae on palms and soles, fissures affecting the mouth and anus, ulcers on the mucous surfaces, hyperostoses of long bones or enlargement of the liver and spleen.
Usually, however, the child is apparently in good physical condition when born, but about the second or third month a syphilitic rhinitis appears, causing a sero-purulent or bloody discharge from the nose and obstructing the breathing (snuffles). These symptoms are due to the presence of a rhinitis which is very apt to be followed by ulceration leading to necrosis of the nasal bones and ultimately resulting in a sunken nose, which is a highly characteristic deformity. The spreading of the rhinitis often leads to the development of a middle ear inflammation accompanied by deafness and otorrhea, and the ends of the long bones frequently exhibit inflammatory symptoms. The skin becomes grayish-yellow in color, a coppery-colored erythematous eruption may make its. appearance over the buttocks and genitals, or papules may distribute themselves over these localities. Palmar and plantar pemphigus will probably develop, the nails frequently become inflamed, labial fissures and mucous and cutaneous ulcers are often seen. The hair is generally slow in its growth and falls out, the lymphatic glands enlarge slightly and the liver and spleen frequently manifest enlargement; that of the latter being specially significant. Restlessness is the most prominent nervous symptom and the presence of shooting pains is indicated by the constant utterance of a shrill, harsh cry.
"Syphilis hereditaria tarda," by which is meant the appearance of lesions between the seventh and eighteenth years in individuals who have shown no symptoms during childhood, is indicated by various stigmata, such as a generally undeveloped condition of the body, with muddy complexion and scanty, late-appearing hair. Numerous scars in the skin or mucous membrane of some limited area of the body-surface, are often found, particularly in the mouth, nose, soft palate and over the buttocks. The skull usually presents a disproportionately long transverse diameter and is flattened in the middle; the typical hydrocephalic contour, or general lack of symmetry, is also suspicious. The sunken nose, "sabre-shaped" tibia and pigeon-breasted thorax are other characteristic bony deformities. The testicles may be infantile in type, due to atrophy. Hutchinson's triad of stigmata, which includes abnormal conditions of teeth, eyes and ears, is pathognomonic: the permanent superior central incisors are peg-shaped and betray crescent-shaped erosions of the cutting-edge, the teeth in general may also be irregular in arrangement, number, shape and time of appearance; the cornea presents a reddish patch due to interstitial keratitis, choroiditis or iritis frequently accompanies it; in addition to the otitis media with consequent otorrhea and interference with hearing previously mentioned, there develops an incurable deafness apparently of labyrinthine origin.
Diagnosis:—It is often very difficult to determine the exact nature of venereal lesions and sometimes it is impossible, in which case it is necessary to wait for the appearance of the first secondary symptoms before making a positive diagnosis. A few of the most characteristic features of the hard chancre, which will help to distinguish it from the chancroid, are: It occurs in those who have never had syphilis; no specific germ can be demonstrated in the secretion (the bacillus of Ducrey and Unna is present in the chancroidal discharge); incubation-period is always over ten days, varying from ten to thirty days (in the simple venereal ulcer this period is always under ten days) ; the lesion may be rounded or oval, usually presents but slight erosion, gives off a clear serous fluid, is usually single, not being auto-inoculable, and the base and adjacent tissue manifests a characteristically indurated feeling; is followed within a few weeks by systemic and other secondary symptoms. It is especially important that care be exercised in the diagnosis of extra-genital chancres, which constitute, according to some authorities, from one-sixth to one-seventh of the total number of cases. Whenever a sore of any kind occurs about the lips, finger, nipple, anus, or elsewhere, which is slow to heal, the possibility of its being a chancre must be taken into consideration.
When the history of a primary lesion is clear, the secondary symptoms will not usually be difficult of recognition, although the presence of complicating eruptions may for a time confuse the diagnosis. It should be kept in mind that the larger number of secondary siphilides show no acute inflammatory symptoms, but rarely cause pain or itching and are symmetrical in their distribution.
In the determination of the existence of syphilis in the tertiary stage the following points are important: (a) obscure cases of various kinds and symptom-groups not typical of any well-recognized condition are often due to a syphilitic dyscrasia; obtain, if possible, by careful inquiry direct information as to the actual occurrence of the primary and secondary stages, keeping in mind the fact that these are sometimes denied, though they certainly have existed, or that they may have been so mild as to be unobserved; examine the patient closely for the remains of old lesions, such as iritic adhesions, cutaneous and mucous scars, nodes upon bones or areas of depression, indicating loss of substance due to pre-existing necrosis, and the testes for evidence of sclerotic atrophy; bear in mind the significance of nocturnal pains, deafness, which may be bilateral and present no pathologic lesions explanatory of same, paralysis of single cranial nerves, etc.; the therapeutic test may be necessary in obscure cases.
Conditions in which errors of diagnosis have most frequently been made are: labial and other extra-genital chancres have frequently been regarded as of carcinomatous origin; chronic cutaneous eruptions and the exanthematous diseases, especially smallpox in the pustular stage, have often been mistaken for secondary syphilides; syphilitic arthritis in the secondary stage must be distinguished from the rheumatic type of the disease, and in the tertiary stage, from the arthritis of chronic gout or rheumatism; periostitis, with the subsequent production of nodes similar to those seen in syphilitics, may follow typhoid and typhus fevers, smallpox or vaccination.
Prognosis:—Syphilis must always be regarded as a grave and chronic disease, and it is not possible to state in any particular case, the length of time for which treatment must be persisted in to insure non-recurrence. At the same time the disease is now regarded as perfectly amenable to treatment, provided the latter is systematically and persistently carried out. Permission to marry should be withheld in all cases where the patient has not been subjected to thorough and prolonged treatment, and even where vigorous treatment has been undergone marriage should be prevented until the elapse of four years since contraction of the disease. In the tertiary stage however, especially of severe cases, and in malignant cases, a modification of the progress of the disease, and of the severity of the symptoms is about all that can be promised. It is doubtful if more can be accomplished, with any course.
Treatment:—In the treatment of this disease the three stages must be considered separately. It was Prof. King s opinion that there was no infection of a general character until the papule ulcerated. He advised the immediate cleansing of the ulcer and that it should be at once thoroughly cauterized with full strength nitric acid. He treated all ulcers with suspicion, the mild ones as well as those which were plainly infective in character. This opinion was confirmed in his mind by the fact that in over thirty years' experience in the treatment of many hundreds of cases but few cases of the constitutional disease developed after this treatment.
I have followed this same course myself for nearly an equal number of years with excellent results. My plan is to cleanse the ulcer thoroughly, in whatever stage I find it, evacuating any contained scrum or pus. I then dip a toothpick into fuming nitric acid and touch the entire surface of the ulcer and especially its edges. I then apply a powder made of seven parts of bismuth subnitrate to one part of boric acid rubbed very thoroughly together. If after three days there is still any point on the ulcer that looks red and irritable, I cleanse it thoroughly and re-apply the acid. I have never made more than two applications. This agent, while somewhat severe for a few moments, does the work very effectually and promptly. Care must be taken that no excess of acid be on the applicator and if the effect of the application persists with extreme pain for more than one minute, a solution of soda or other alkaline solution to neutralize the acid may be applied.
Inasmuch as we cannot know to what extent infection has taken place I am a strong advocate of beginning the constitutional treatment at the time of the treatment of the sere, and it is not a bad plan to apply at once and repeat daily the compound tincture of iodin over the inguinal glands, as a precautionary measure against the development of buboes.
For constitutional treatment preliminarily, I would give the patient a mixture, each dram of which contained one drop of specific podophyllum, ten drops of specific phytolacca and twenty drops of echinacea, this to be taken every three hours, unless it should act too freely upon the bowels, when the quantity of podophyllum should be reduced one-half for a short time. If there be no infection the remedy will do no harm, and if the infection should be severe the remedy will anticipate its development and be ready to antagonize the infective principle as it develops. If in the course of three weeks the ulcer has healed and no local or general symptoms of infection appear the remedy may be given only three times a day, to be dropped entirely at the expiration of three weeks more if no symptoms appear, or to be increased if the symptoms appear.
With the first appearance of glandular enlargement the tincture of iodin should be used externally and phytolacca should be given internally to its maximum dosage. Febrile symptoms must be immediately treated with aconite, and it is an excellent plan to give from ten to fifteen grains of potassium acetate three times a day during the development of the glandular inflammation.
The throat should be treated as soon as any soreness appears with a gargle composed of an infusion of white oak bark, three and one-half ounces, boric acid, two drams, and the tincture of myrrh, four drams. This gargle should be used very freely.
Immediately evidences of constitutional infection appear, a plan of treatment must be laid out which will extend over a period of from six to twelve months. It has been my custom to select from among our vegetable alteratives those which seem to be more specifically indicated, and persist in these for from six to eight weeks, being constantly on the alert for new indications. If these should appear, the prescription should be changed to meet the indications. At the expiration of the time named I have changed the formula to other well selected alteratives, and continued these for an equal length of time, to then return to the original formula or to some other equally efficient combination which would seem to be indicated.
The remedies I first named I consider the most active, and have often continued these in varying doses and with other alteratives during a period of five or six months, without interruption. I have at this moment in mind a very thoroughly infected case in a man forty-nine years of age, with a previous good history; he took the above combination for six months, with two periods of three weeks each, in which he took the baths at Hot Springs, Ark., with complete recovery at the expiration of the period named. I had him under observation for eighteen months subsequently, during which time his anxiety lest symptoms of the disease should appear was intense, but no trace of the disease manifested itself. This case had neither mercury nor the iodids at any time.
Some of the specific indications for the remedies are as follows: Echinacea is of general benefit, influencing the blood-making organs throughout the system and antagonizing the development of the infective material. It may be given in any combination, although I prefer to give it in alternation rather than in combination with the iodids when they are indicated. Podophyllum exercises its alterative influence by preserving the integrity of the liver and promoting its normal functional action. It should never be given in a quantity sufficient to produce any gastro-intestinal irritation. Iris works much in the same manner, but I believe has a wider influence; it is of benefit when the eruption is at its worst, at which time it should be given in conjunction with berberis. Iris is a general glandular stimulant and in this it is an excellent auxiliary to the other alteratives. The influence of berberis is almost solely upon the skin, and in proper combination its action is very satisfactory. Phytolacca is our reliable remedy for glandular difficulties. So direct is its influence upon all glands, especially those of the lymphatic system, that we do not hesitate to give it during the entire course of the treatment, to preserve the integrity of these important organs, and to stimulate their influence in antagonizing the development of the infective principle. Corydalis exercises a satisfactory influence where there are syphilitic nodules of the bones or syphilitic ulceration; it antagonizes the breaking down of tissue, and exercises a stimulating effect upon all the emunctories, especially those of the skin and kidneys. It influences the elimination of morbific material in a very satisfactory manner. Chimaphila exercises an influence that goes hand in hand with that of phytolacca, greatly increasing the efficacy of that remedy. Kalmia was a remedy much prized by Dr. King in this disease; he believed that syphilis in mild cases could be cured with this remedy alone. He advised it when there were conspicuous symptoms of a disordered liver or an enlarged spleen as a result of the syphilitic infection. Plantago is a remedy that was very highly prized by the older eclectics in the treatment of this disorder, they gave it in infusion and persisted in its use. The specific remedy is a very excellent preparation. It may be given in from two to ten minim doses. It is certainly an active alterative and exercises an efficient influence. Sarsaparilla and stillingia are among our older and better known alteratives, their influence is a general one. I used the syrups of these preparations as the vehicle for the administration of the more specific alteratives. Polymnia is indicated when there seems to be a persistent inclination toward enlargement on the part of the glandular organs, where there is a plethoric condition of the system, with passive fullness of the circulation, with a general tendency to passive engorgement. An occasional case will be greatly benefited by it. Thuja is a remedy for protracted cases, it acts upon chronic disease of the laryngeal or post-nasal region. It acts upon veruccae and upon any enlargements of a persistent character affecting the bones or muscular structures.
Veratrum is an important alterative and has been given in doses of five minims of the tincture three times a day, in syphilis, with excellent results.
The iodids exercise their most direct influence in the tertiary stage of this disease. I believe, however, in giving them early, but prefer to give them as I have stated concerning echinacea, in alternation rather than in combination. I would have a saturated solution of sodium iodid prepared, of which each minim would represent a little less than one grain of the iodid, of this the initial dose should be about five minims, administered four times daily in half an ounce of water. This may be increased by one minim each day until the patient is taking twenty minims, if no disagreeable symptoms appear. The sodium salt exercises a full alterative influence with the least disturbance of the stomach. If there be any chronic stomach disorder, which prevents the administration of this class of remedies, the strontium iodid may be given, which in some cases improves the condition of the stomach, while exercising its alterative influence. The potassium salt has no advantages over either of these compounds and is usually very irritating to the stomach and more difficult of elimination, causing an irritation of the kidneys and also of the skin, which results in acne often of an intractable and persistent character. When there is renal irritation during the period in which it is deemed advisable to administer an iodid, the lithium salt will be preferable.
A course of treatment carried out strictly in accordance with the indications for the remedies named will effect a complete cure of this disease in a period of time usually shorter than that demanded for mercury, and it leaves the patient in excellent tone, and with no impairment of any of the organs. I am in favor of systematic bathing, including the use of frequent hot baths, or the Turkish bath. Attention to the habits of the patient, to his mode of living, diet, and other hygienic conditions, must be assiduous on the part of the physician.
