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by the fact that treatment directed to improve elimination through the bowels, kidneys, and skin will relieve the symptoms greatly. Further evidence is given by the fact that the conditions with which chorea is so frequently associated are caused by autointoxication. We must not lose sight of other etiologic factors in the treatment of this disease. There is a distinct predisposing influence of much importance. Chorea occurs most frequently during later childhood when the functional development of the nerve centers has been effected, but the exercise thereof has not yet secured stability of function, leaving them very susceptible to outside influences. The normal restlessness of childhood manifests the predisposition to chorea. With this predisposition is to be associated the important fact that emotion has been frequently the exciting cause. In the case under consideration the condition developed rather late, but at a time when considerable strain was brought to bear upon an unstable nervous system by the responsibility of a child and other household duties, not to forget the untoward effects of a premature labor.
When the patient came to the hospital it was markedly evident that both nutrition and elimination were defective. The first attention, therefore, was given to these pathologic states. The patient was put to bed and kept at rest. Chloral hydrate was administered in ten-grain doses every three or four hours to the extent of controlling the involuntary muscular movements, and in addition five to ten drops of Fowler's solution were given three times a day. At present the patient is almost well. The choreic movements are slightly noticeable in the hands, but otherwise have entirely disappeared. Under this treatment the duration of the disorder is usually short and the prognosis extremely favorable.
CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC.
STATED MEETING, JANUARY 8, 1906.
THE PRESIDENT, JOHN J. MACPHEE, M. D., IN THE Chair.
READING OF PAPERS.
THE TREATMENT OF SYPHILIS. Doctor ANDREW R. ROBINSON read a paper on this subject. He referred to the different views held on the subject of the treatment of syphilis, and stated that he would endeavor to show that syphilis is a serious disease in a considerable percentage of cases, and especially on account of the tendency after immunity is reached to fatal parasyphilitic affections; that the tendency to these parasyphilides depends as a special predisposing factor upon the dyscrasic condition accruing in the active contagion stage; that the intoxication producing the dyscrasia and leading to immunity often is most severe in the period between the recognition of the primary sore and the appearance of lesions upon the cutaneous surface, and, therefore, that syphilis should be treated actively as soon as a positive diagnosis of the disease is made.
The object of such treatment is to inhibit the life action of the organism, so that only a small amount, comparatively, of toxin is produced, giving immunity with only a mild dyscrasia, and producing a minimum amount of injury to the tissues and consequently a comparatively slight tendency to parasyphilides or even tertiary lesions. He maintained, also, that in the acute infectious stage it is a rule that the less toxin produced in a given case, the earlier the system acquires the condition of immunity; and in syphilis this is important not only for the individual affected, but also from a social standpoint, as the sooner immunity is obtained the less danger of contagion to others.
An example of early immunity is that acquired by a mother in a case of parental syphilis, when she is not invaded by the syphilitic organisms, but acquires immunity by toxins from the fetus. Under these circumstances the amount of toxins passing to the mother must be small in quantity and therefore the immune condition is acquired in a comparatively short period as compared with the time necessary in acquired syphilis.
Syphilis is a serious disease, not only on account of the liability to fatal parasyphilitic affections, as locomotor ataxia, but also on account of its destructive action on the progeny of syphilitic parents when produced during the active stage of the disease, hence the shorter this period exists the fewer syphilitic children are produced.
If the tertiary parasyphilides depend very greatly or principally upon the severity of the dyscrasia, and this condition upon the amount of intoxication, that is, the amount of toxins produced, and this upon the number and activity of the syphilitic organisms in the system, it follows that in this special parasitic affection the treatment of syphilis must be based upon the microbes, the toxins produced, and the ground of the individual affection. Proper consideration of these three points constitutes the fundamental basis for the best treatment of the disease.
Syphilis is a continuous condition from the time of infection until the last microbe is gone; hence the division of the disease into stages is not scientifically correct, although for clinical description it is of some value.
In the period between the appearance of the primary sore and the so-called secondary stage, represented by cutaneous lesions, the general nutrition of the person is lowered, fever is present in varying degree, the red-blood corpuscles are diminished in number, the lymph glands throughout the body may be affected, the spleen swollen and tender, liver enlarged and the nervous system injured, as shown by the presence of neuralgia, headache, lassitude, pains in the joints, bones, and periosteum, and occasionally by an extensive multiform erythematous eruption. This shows that before secondary lesions occur upon the skin there may be intoxication of the general system, which leaves its impress on the tissues and acts as the main disposing factor in the causation of parasyphilides. If this be true, it follows that treatment should be commenced in every case as soon as a positive diagnosis is made, and if this is done at a stage before cutaneous lesions appear, so much the better for the patient.
Existing lesions in the secondary stage are treated to lessen danger of contagion, remove deformity and save tissue, but surely it is better, more philosophical, to prevent the formation of lesions, especially as they are hotbeds for toxin formations, than to wait until they are formed and damage has occurred. The treatment of syphilis should be offensive, not defensive. Keep the disease in as quiescent a state as possible by inhibiting the life action of the organism; prevent contagion from lesion formation; promote the elimination of the toxins as quickly and completely as possible, and pay attention to the general nutrition of the patient. This constitutes the correct treatment of syphilis according to our present knowledge.
Mercury is the only agent that acts upon the microbe, hence it should be given during the entire microbic stage in such manner as to secure the best action. Iodid of potassium should be given only as an aid to the mercury or as an alternative in later stages and at all times when tertiary lesions are present. It is rarely indicated during the first six months of the disease, and never during the microbic stage, as the only agent.
Against the parasyphilides one should produce a proper degree of alkalinity of the system, advise avoidance of everything that causes circulatory disturbances and of things that interfere with tissue metabolism, especially alcohol, local irritating agents, et cetera.
Doctor EDWARD L. KEYES, JR.: While I agree with all the conclusions reached by the author, I disagree wholly with all the premises. Briefly, in his opinion, the way to treat syphilis is as a disease and not as an array of symptoms. The most practical method is to settle in one's mind the amount of medicine considered necessary in all cases to overcome the disease. One grain of iodide of mercury every day for three years will conquer it, and even though the skin lesions have disappeared, together with the mucous patches in the throat and all other outward manifestations, the physician should still try to live up to his ideal of the amount of mercury or iodid that should be taken by the patient, whether he stands it well or not. I disagree absolutely with the speaker regarding the method of treatment at the beginning of syphilis. It is extremely dangerous to proclaim that syphilis should be treated before the appearance of a cutaneous lesion, because, in a very fair proportion of cases, one is unable to make a positive diagnosis until the appearance of the secondary lesions. Theoretically, if it is proved that the existence of the spirocheta pallida is conclusive of syphilis, treatment may begin as soon as it is recognized, but until this is possible, it is wiser to wait for secondary evidence. I recall two instances in which patients who presented themselves for treatment within twelve hours of the supposed inoculation had developed a chancre six weeks later.
Doctor CHARLES H. CHETWOOD: There seems to be a general tendency at the present time to question whether syphilis should be treated in the primary or in the secondary stage. The reader of the paper has emphasized the point that the question is not when to treat it, but that it should be treated when the diagnosis has been made. For my part, I have always treated it when the secondary eruption appeared, and consider it a safe procedure. I would not advise commencing treatment earlier unless the presence of the disease should be positively substantiated by the spirocheta pallida or some other germ. I treat all cases according to the general exigencies of each individual condition, and the results have been most satisfactory.
DOCTOR JOSEPH H. ABRAHAM: Next to the dermatologist and the genitourinary surgeon, the nose and throat specialist sees as many cases of syphilis as any of the specialists. They rarely see any primary syphilis, but many secondary and tertiary cases come to their notice. Personally, I have seen five cases. One patient had the initial lesion on the lip and the other four on the tonsils, and in one case the upper respiratory glands showed marked symptoms of intoxication. Another marked feature is the enlargement of the leutic glands. I agree with the principles laid down by the reader of the paper for the treatment of primary syphilis. Secondary syphilis of the larynx should be treated entirely by personal rule. I rely upon one drug, carbolic acid. An application of ten per cent chromic acid to the larynx gives rise to practically no pain and accomplishes the desired result. If the patient is given a sufficient amount of mercury for a long enough period of time, he is less liable to require the iodides or to suffer from a marked tertiary form later. I have never found it necessary to give more than seventyfive or eighty grains of the iodid at one dose, and always begin with five grains and increase one grain daily or every other day. The absorption occurs as desired and the digestive tract is not disturbed.
DOCTOR ROBERT H. M. DAWBARN: I believe the wisest course is to begin treatment of syphilis as soon as one is sure of the character of the lesion. I do not agree with the statement that the iodid of potassium has no direct bearing upon the foundation of syphilis. In my opinion, overeating and overdrinking may so change the metabolism of the human system as to render the effects of syphilis more intoxicating.
Doctor John A. BODINE: The time to begin treatment depends greatly on the character of the patient. The primary duty of the physician is to effect a cure. If the patient is a highly intelligent one, the treatment may begin as soon as the diagnosis is positively made, as that character of patient may be depended upon to carry the treatment through to its logical conclusion. With a more ignorant patient, it is often necessary to first convince him that he is a victim of this disease in order to impress upon him the necessity for systematic and longcontinued treatment and in this case the appearance of the skin eruption following the sore convinces him that he has syphilis.
Doctor ROBINSON: I still think the treatment should be begun, if possible, during the first stage of the disease. If the patient presents what he considers the initial lesion, I recommend a six weeks' course of treatment with mercury, and if, at the end of that time, there remains any question as to the diagnosis, it is very easy to bring out a small lesion as convincing proof.
REPORTS OF CASES. URETHRAL FISTULA AND PROLAPSED KIDNEYS. Doctor CHARLES H. CHETWOOD: I wish to show a patient on whom I operated two years ago for urethritis, and who at the present time has an incomplete fistula. When first examined his symptoms seemed to point toward the urethra and prostate, the latter being about the size of a small orange and very hard. The history indicated a gonorrheal infection, and, apparently, a syphilitic abscess of the prostate. The patient urinates every half hour, day and night, and the bladder contains about twelve ounces of residual urine. The appearance of the urine is indicative of kidney pus. Both kidneys are prolapsed and the right one is very palpable, enlarged and tender. The interesting feature of the case is the prolapse of both kidneys without any apparent explanation. There is no tuberculous history and none suggestive of kidney disease. My intention is to drain the prostatic abscess through a perineal incision, examine the bladder through the opening, and possibly catheterize one of the ureters.
SYRINGOMYELIA OR LEPROSY ? Doctor JOHN A. BODINE: I desire to present this patient. She is twenty-one years of age, and her family history is negative. About six years ago she first noticed that she was unable to distinguish the impact of the soles of her feet against the sidewalk and began to have aching pains in her feet and legs. Later, pus formed beneath callous spots on the feet and discharged, leaving sinuses leading down to the metatarsal bones. Rest in bed healed the sinuses, but on resumption of her occupation they reopened. Pain was present in her spine from the neck to the coccyx. She was operated on for contractures of the feet in 1902. Her general health is now fair. The soles of her feet are covered with multiple perforating ulcers. The discharge is thick, brownish in color, and has a peculiar sickening, penetrating odor. There is an abscess under the skin in one thigh and another over the sacrum. There are marked motor and sensory disturbances of the feet and legs. The case is presented for diagnosis, which I think lays between syringomyelia and leprosy.
DISCUSSION DOCTOR WILLIAM B. PRITCHARD: I consider this patient an example of syringomyelia presenting the exception in a distribution of symptoms in the lower rather than the upper extremities, though both are involved.
The trophic disturbances in the feet, with bladder symptoms, scoli