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THE TREATMENT OF LATE SYPHILIS, AND OF SYPHILIS IN MOTHER AND CHILD

THE TREATMENT OF LATE SYPHILIS, AND OF SYPHILIS IN MOTHER AND CHILD OF THE TREATMENT OF LATE AND SYPHILIS, SYPHILIS IN MOTHER AND CHILD R\l=E'\SUM\l=E'\ OF PRINCIPLES STOKES, JOHN H. M.D. Chief of Section on and Clinic Dermatology Syphilology, Mayo MINN. ROCHESTER, in The of the of late differs essential treatment problem syphilis or from that of of true syphilis. particulars early asymptomatic (latent) In we are in of the revelations of still, early syphilis spite disturbing of and and of for radical Warthin,1 Brown Eberson,3 Pearce,2 striving cure of the infection. In the late of the the disease, stages problem becomes of and arrest. The infec- one symptomatic improvement early involves the the late of tion human In usually unimpaired body. years are the infection the of added to physiologic changes years advancing the disabilities the action of the disease on vital structures. produced by infection The characteristic reaction of the to the opposes body syphilitic another obstacle to treatment. The fibrosis walls off slowly progressive the from the carriers of remedial the blood and organism agents, lymph. the induced obliterative the of foci to endarteritis, accessibility By or distributed it is into the blood probably spirocheticides injected by latent reduced. In the or infection there materially slowly progressing exist a balance between the offensive of the must also organism powers could be and of the host. If the confined the defensive powers organism individual maintained, within the infected and this balance be perfectly the commensalism would serve all the of the radical treatment purposes methods of the The of late have "extirpators." large majority syphilitics of effected measure with the some probably compromise spirochetal be of and must exercised in the disturbance this invader, judgment relation. Read at the Annual Session of the American Forty-Fourth Dermatological June 2-4, Association, Swampscott, Mass., A. S.: The Persistence of Active Lesions and in 1. Warthin, Spirochetes Inactive "Cured" Am. M. Sc. 152:508 the Tissues of Clinically or J. Syphilis, 2:425 New of Am. 1918. (Oct.) 1918; Pathology J. Syphilis (July) Syphilis, 2. and Louise: A Note the Dissemination of W. H., Pearce, on Brown, Pallida from the Focus of Arch. Dermat. & Spirochaeta Primary Infection, Syph. 2:470 Infection of Central Nervous the Syphilitic the System of (Oct.) 1920; Ibid. 2:635 1920. Rabbit, (Nov.) F.: Dissemination of Pallida in 3. Spirochaeta Experimental Eberson, Arch. Dermat. and 3:111 and Syphilis, Syph. (Feb.) 1921; Eberson, F., Engman, F.: An of the Latent a A. M. Experimental Study Syphilitic as Carrier, J. M. A. 76:160 15) (Jan. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 OF APPRAISAL POSSIBILITIES AND THERAPEUTIC DECISIONS The aim of treatment in late is to the infected individ¬ syphilis carry ual the fullness of his with maximum attainable through years, efficiency and minimum his and to contacts to the social order. The first danger in the treatment of late is an of step syphilis appraisal possibilities, including An estimate of life on on based expectancy age, damage already on done, the and rate of of the and supposed activity progress process, on its refractoriness to treatment. probable An estimate of the not handicaps imposed by complications due to such as mental directly syphilis, tuberculosis, nonsyphilitic disease, chronic interstitial so hypertension, and forth. nephritis, diabetes, An 3. estimate of the tolerance of the for the various methods patient of treatment available. An estimate of the to of treatment the most probable response vital structures involved. Treat late the indications in vital structures and not in syphilis by structures nonessential to a life. examination of the Only searching can entire the information an for stich While body provide appraisal. the milder forms of treatment be should sel¬ may begun, arsphenamin dom be administered until this is The appraisal reasonably complete. inherent of methods our of the condition of crudity estimating many structures must be remembered and allowed for in important making the estimates mentioned. in involvements the of vascular Particularly is this caution system important. The Herxheimer reaction is as a much feature of late as of syphilis the infection. acute It must never be lost and the sight of, possibility that it have serious will either location of effects, from the the involved as case in the of the or a cerebral structure, or from its larynx vessel, functional in as the case of the must importance, be myocardium, In it is conservative to all individuals carefully weighed. general, give affected with late mercurial syphilis preparation. of The control infectiousness in late while of syphilis, traditionally little deserves more in the of work import, consideration, recent light on in is carriers,4 the woman who or especially become pregnant may or in the father of children. I It a pregnant, potential is, believe, good rule that late cases deserve as much as nearly arsphenamin cases, early for the this control of under the limitations the aspect imposed by pre¬ and the of the case. liminary survey progress the of Adjustments required process are factors in by healing decisions in late When therapeutic syphilis. under treat- begins healing 4. Footnote second reference. 3, Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 the made the to for a ment, attempt by body compensate pathologic is made take another direction. An to disturbed, to change adjustment cicatricial as the Herxheimer the effects of contracture well as to in reaction must be at times with a increase made, paradoxical symptoms, as for cirrhosis. Cicatricial out Wile,5 pointed syphilitic hepatic by the stenosis of the and even of rectum, hour-glass stomach, esophagus occurs. I am so as inclined to believe far the heart is that, concerned, even attacks of increased acute ischemia, myocardial anginal severity, aortitis the of certain of and physical signs may development aneurysm, too too be the results of treatment and energetic rapid healing.6 In the of a consideration should be to appraisal case, given complete the serious¬ the of its and hepatotoxicity,8 vasculotoxicity arsphenamin,7 ness of cutaneous exfoliative accidents. At a theoretic considera¬ first items have a real in these tion, acquired experience very meaning my late for the with The low of arsphenamin syphilis. relatively toxicity a in there is a notable makes it serviceable but nephritis, kidney drug In low renal function from back and in exception. pressure, pyelone¬ often a of it must be used with phritis, complication neurosyphilis, dermatitis as a relative contraindica¬ caution. The of history previous receive the attention it deserves. tion to does not arsphenamin admin¬ of its certain modes of The mercury, renotropism ability, by to its to increase the cutaneous istration, arsphenamin, reactivity when overdone and the unfavorable effect on severe action depressant 5. of the Arch. Dermat. & Syph. 1:139 (Feb.) Wile, U. J.: Syphilis Liver, find Hubert Klinik und der Aorten- 6. I was interested to (Zur Behandlung in accord with me on this Deutsch. Arch. f. klin. Med. 128:317, 1919) syphilis, point. 7. that cardiac dilatation after is An interesting suggestion arsphenamin increased the obstruction of the circula- due to pressure produced by pulmonary the of the tion or and is on alkalinity preparation vasoconstriction, dependent Studies is made Smith on Arsphenamine, J. by (Further Pharmacologic This Pharmacol. & 15:279 combined with the Exper. Therap. [June] 1920). not in blood observation that is precipitated the (Schamberg, neo-arsphenamin Raiziss and Weiss: and Clinical Studies on the Laboratory Bearing Kolmer, of and Causes of the Reactions Intravenous Injections Arsphenamin Following Arch. Dermat. & 1:235 would seem to Neo-Arsphenamin, Syph. 1920) [March] cardiac the of in syphilis. suggest desirability neo-arsphenamin The numerous recent articles on as a due to the 8. jaundice complication reviewed the of a toxic action of are from standpoint possible arsphenamin in Ruedemann and Lemon's Infectious infectious factor Stokes, paper (Epidemic Arch. Med. 26:52 and its Relation to the of Syphilis, Int. Jaundice Therapy 1920. Milian continues his defense of treatment and [Nov.] vigorous (Jaundice A. M. A. 76:143 M\l=e'\dicine, Paris, 2:113, 1920; abstr., J. [Jan. 8] Arsphenamin, Lancet 1:1356 also Hallam 1921). Compare (Post-Salvarsan Jaundice, [June 26] 1920). Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 the described Foucar and are anemias, myself,9 principal by among to be considered. The old-time of stomatitis, salivation, points bugbears and disturbance have been reduced to relative gastro-intestinal insigni¬ and in ficance dental prophylaxis, diet, intelligence dosage. by As in its resistance to the disease itself the shows body generous of or the effect of massive margin safety, notwithstanding prolonged so no or recoveries result from the treatment, good symptoms may But I most abuse of both arsenic and have flagrant mercury. always or felt that the avoidance rather than the correction of toxic debilitating effects that end have insisted a of is the and to on number ideal, which in the end,-I precautions against complications, believe, protect from the small but cumulative insults which too often keep patients a condition intensive them in substandard under even treatment, though the individual not become in itself. In late by-effect conspicuous may in which the between and treatment syphilis, margin requirements treatment tolerance is often such measures small, may very protective make all the difference between success and failure. In the nine cardinal for the mechanism which shall rules the of I management excretory Institute here from discussion of this before the for point quote my Venereal Disease should mention that the on micro¬ Control, I emphasis blood as an evidence of renal is drawn from an damage unpub¬ scopic lished Wilder and of the effect of intensive study, by prolonged myself, on attention to treatment for the I want also to direct syphilis kidney. the influence atonic bladder with retention in retard¬ of the symptoms the who would otherwise do well. satis¬ of am ing patients progress fied that the terminal in than one arrested but more practically picture none the less fatal case of is of depressed neurosyphilis composite renal function and infection of the tract. ascending urinary THE MANAGEMENT OF EXCRETORY MECHANISM 1. A cathartic should be after each given arsphenamin injection, and a mild laxative the course. during A urine examination should the 2. be rule. weekly attention should red blood 3. be to cells, Special paid (a) casts, (b) and in the urine in (r) pus (catheterized women). 4. or casts mean renal irritation. Occasional Many persistent showers are not significant. 5. Red blood cells of renal mean renal origin injury. Pus or blood vesical be an index due 6. of of to origin may cystitis with retention. In search should be neurosyphilitics pyuria urinary 9. H. and H. : The Effect of Treatment for on Foucar, O., Stokes, J. Syphilis Severe Am. M. Sc. to Anemias, J. be published. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 or made for atonic "cord" bladder with residual urine, secondary and blood and urea, cystitis pyelonephritis, falling phenolsul- rising excretion. phonephthalein 7. The mechanism should be protected (a) extirpation excretory by of focal administration of fluids and alkaline diuretics infections, (b) catheterization and of (potus imperialis), (c) irrigation neurogenous diet or bladders, and proteins), (e) (d) regulation (low suspension moderation of treatment if other measures fail. 8. The should not a physician discharge neurosyphilitic patient without satisfied with to his renal his blood urea regard function, being and the of his bladder mechanism. content, integrity 9. tabetic should be as uremic. Every patient regarded potentially IN A FACTORS SUCCESSFUL THERAPY in has that the Schamberg, communication, personal suggested simultaneous administration in the of ana results arsphenamin mercury retention of the arsenic with increased risk of exfoliative accidents.10 so as That this retention is serious to the simulta¬ justify abandoning the have neous use of two I not as been able to convince drugs yet from clinical evidence. Exfoliative accidents in service come myself my in and have had what seemed to be more than a casual relation waves, to intercurrent and focal infection. The "broken of immunity" arsphenamin-treated early long syphilis, familiar in clinical and now verified Brown experience by experimentally and I occasional in late All Pearce,11 has, believe, homologs syphilis.12 no seen the of have doubt the marked acceleration of unfavorable you of some cases of progress neurosyphilis following arsphenamin, scarcely as mere I it a arsenic fastness. believe is conservative explainable never terminate a of treatment with to practice period arsphenamin, to but finish with if it be mouth. mercury, only by have little as In ; meaning therapeutic guides early syphilis, symptoms in their in late be fact, syphilis may supremely important ; disap¬ they the sole criterion of successful be pearance may therapy. Eighty-five of 10. V., and A.: The Urine in Klauder, J. Kolmer, J. Syphilis. Report Reaction, in A. the Wassermann Sixty Cases, J. Laboratory Studies, Including M. A. 76:102 1921. (Jan. 8) Louise: The Resistance 11. Brown, W. and (or Immunity) H., Pearce, the Reaction to Infection and Some of the Effects of the Developed by Syphilitic Arch. Dermat. & 2:675 1920. of this Reaction, Syph. (Dec.) Suppression 12. The unfavorable effect of minute is discussed Bronfenbrenner, dosage by M. Generalized Infection in Rabbits and Schlesinger, Resulting J., J.: Syphilitic Med. from the Salvarsan Proc. Soc. Biol. & Inadequate Therapy, Exper. 18:94, Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 a cent, of late in our selected with per syphilitics, experience, only of as reasonable discrimination to should outlook, degree therapeutic on arrest and be observa¬ undergo symptomatic ultimately placeable tion.13 One is disconcerted the Herxheimer occasionally symptomatic by or which dominates the the first three four weeks flare-up picture during a course. reac¬ of intensive The in the Wassermann moderately changes while of are not the sole evidence of the of tion, a interest, efficacy times an method of and are in fact at not even treatment, important consideration. In a reaction is a for a general, persistent positive signal and of the fundamental examination of the case, rechecking appraisal and a Wassermann calls for in the absence of more treatment relapse contraindications. distinction should be in the A drawn, legitimate estimating progress evidences of of late under between scars and treatment, activity. syphilis a a recover It is matter of little moment that tabetic does not his patient or a with cardiac disease rid of his aortic knee jerks patient get it is in if attacks murmur. On the other hand, decidedly point anginal in or increase in if a with diffuse sclerosis, frequency coronary patient has a of or the liver fails to decrease in recurrence hepatitis jaundice, times which size. Paradoxical at in the occur, signs pictures represent¬ as scars become more the func¬ ing conspicuous symptoms representing tional Ascites in cirrhosis impairment disappear. developing hepatic under bone sinus, treatment,5 discharged through sequestrums atrophy of the nerve as a marked neuroretinitis in an involutes, optic pulsation in as the are Failure of subsides, aneurysm periaortitis examples point. structural to occur even with marked improvement symptomatic is familiar in and gastric syphilis. improvement enough aneurysm all based Functional also on improvement outstrip expectations may in the structural particularly inflammatory recognized change, processes. in In the and and sometimes have a eye ear, gains sight hearing qualita¬ rather tive than character and exceed all quantitative may again expectations. How far shall treatment be carried after the of symp¬ disappearance as a when the are not such to furnish to the toms signs guide progress In I the case? should to the of as much of general, say point giving as an tolerance This is a treatment in case, early provided permits. of vital The abuse a tolerance of treatment in late proviso. patient's even more than in I a serious believe, syphilis early syphilis is, error, that the his infection since it is to course of not predict impossible may be such that he will be under treatment at intervals all his life. On the and G. A Clinical of Wassermann-Fast 13. Stokes, H., Busman, J.: J. study with Reference to and Am. M. Sc. Syphilis, Special Prognosis Treatment, J. 160:658 (Nov.) Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 other measures in effective be the hand, timidity using may precisely which the the other horn of the dilemma. onto thing projects patient It is for these that reasons I much stress on the use of every lay available means in late to the status the of syphilis improve general and to him from patient protect specifically therapeutic by-effects. When to the effect of treatment I have found it objective guides exist, well to the first so as to persist beyond negative relapse. finding, prevent The to whether can as be question relapse indefinitely postponed by this means remains as unsettled. In I for yet general, prefer mercury the of the resistance that but I have seldom supporter relapse, prevents felt it a to the rubs if the urge necessary life-long year" patient "forty would consent to examination. Dismissal the of periodic complete with such blanket directions seems to me to him to patient any lay open all the uncertainties an infection of below threshold of his the kept own observation self-medication. by The in late a must outlook therapist, syphilis, modify symptomatic with a trend of mind. This will stimulate him to more com¬ preventive with a view to all the examination, of involvement plete finding types in case.14 It will a lead him to the of his given life so regulate patient as to the least strain on his weakest to and conduct put possible points, his treatment so that an involvement come in its not just beginnings may to the more front later as some subsides. conspicuous symptom The test is so much more late in than therapeutic important syphilis in infections that attention should be called to of its some early pitfalls. tests in have the when Therapeutic meaning general only patient pre¬ a as sents far as a visible definite, and, lesion, on possible, pathologic which estimates of can be made. Mere quantitative improvement gain in of indefinite malaise or sub¬ weight, disappearance pains, nondescript are Iodid jective tests, symptoms usually meaningless. therapeutic with the So are are popular departing generation, untrustworthy. have and tests. I made, seen erroneous arsphenamin therapeutic made, of of the nodes with Wasser¬ diagnoses partial gtimma lymph positive mann tests. I have seen tuberculous keratitis confused with syphilitic and tuberculids keratitis, lupus vulgaris, erythematous lupus, sarcoids, make under is improvement striking arsphenamin. probably Mercury more immune from such effects than either iodids or nearly nonspecific it is well to recall its action in lichen and arsphenamin, although planus, in occasional Carcinoma cases of of the stomach makes sporotrichosis. false to alone and sometimes in combination arsphenamin responses with One of the reasons a noted for neurologist object- mercury. gave 14. Studies of the multiform of involvement often types presented by with late seem have been made internists con- patients syphilis to largely by with conditions. cerned cardiovascular also Footnote 13. Compare Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 to the as a of was his the ing dermatologist syphilographer ignorance false Pseudo- test for in sclerosis. positive therapeutic syphilis multiple Herxheimer reactions in tuberculous create a processes occasionally effect.15 deceptive STANDARDIZATION OF TREATMENT Standardization and routinization of the treatment of is syphilis much easier in the or months of the disease than in the late. early years Yet would not for a moment substitute unlimited individualization for the effects cases. of and in the of good system regularity majority But back of of treatment must lie a to any willingness systematizing think of the disease a and the as whole, of as a human patient being. I have in to the already emphasized, referring complete sufficiently the need of of involvement in a examination, identifying type every case. The same can be transferred man¬ to given emphasis therapeutic In to I wish their patients eyes, tonsils, agement. explaining teeth, why and to have attention when their trouble bladders, stomachs, appendixes is the heart the often of or of I use the maxim the syphilis liver, of service chief of the best automobile I know: "Don't listen repair plant to the owner's about this that creak and and that. story rattle, go by Go the car and her as as into back the through put possible nearly she was in when she left the Do that with late shape factory." syphilis and it will not need the studies of a Brown or a Pearce experimental to teach that the course of is often as much modified you syphilis by the we leave undone as the we do. the things things by Bring patient, in the course of of his as the to your management case, nearly up standard of his for and sex as so far as normality age possible. Do, an and not a possible, overhauling job. patching In words few I not treatment shall even my concerning organized an account of the endless variations different attempt proposed by I do want in a to that we bear mind few therapists. however, suggest, rests on the principles. First, of heavy responsibility proposers more nor is after more systems. Nothing eagerly sought frankly abused the and even the than the rule of thumb. by tyro, by expert, on the other if one in Yet, hand, there is factor which any my experience the arrest or cure of it is and prevents syphilis, desultory unsystematic In late I in for believe, management. syphilis, roughly speaking, trying radical results combined and methods, by spirillicidal resistance-building The observations on this have been confirmed original point by my experience, Herxheimer, and K.: Weitere zur K., Mitteilungen Altmann, Reaktion des nebst Lupus zur desselben durch vulgaris Beitr\l=a"\gen Therapie Salvarsan, Arch. f. Dermat. u. 110:249, Syph. Ueber eine Reaktion 1911; Prozesse nach Deutsch. Salvarsaninjektion, med. Wchnschr. tuberk\l=u"\loser 1:441, Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 rather than the or the other Whether we obtain one by exclusively. or can decide. radical results time arrest means not, only Life-long almost much to the as A as patient extirpation. frankly spirillicidal lü of technic such as that of Pollitzer seems to me to most inapplicable the cases which I am do not feel that its to reverse considering. ability so is full sufficient the Wassermann mentioned, and test, frequently evidence of its effectiveness. It is too difficult to the extent and judge the of involvement even with the most of structures, type important careful to of justify unqualified examination, system preliminary Recent continental seems to be therapeutic opinion bludgeoning. toward in the months increasingly tending moderation, early especially of the treatment of late For the occasional with syphilis.17 patient resistance to treatment and a not as high threatening, though yet actually of the intervals between lesion, arsphenamin injections, grave shortening an with is in to reach otherwise doses, large justifiable endeavoring inaccessible The favorable of of such methods as focus. users reports individual and with its enormous total and minute Sicard's,18 dosage, enormous the enthusiasm of the with their individual "Pollitzerizers," and total are not to small tributes, relatively really any dosages, disease and individual but to the wonderful of the variability system, for that wide of most which enables almost to margin safety patients, of that violate the few rules does not any outstanding system grossly in delicate and the the to the balance between arrest, game, tip progress favorable direction. To mind the essence of the modern treatment my and in the end those of is and of the modern observation, syphilis system technics which the observational will show treatment best perfect aspect, the lowest ultimate mortality. TREATMENT OF SPECIAL TYPES a of before of in series some I, sentences, you May idiographic lay the on the of of observations treatment of special types high points my late syphilis? of Cutan. Dis. 16. S.: The of the Treatment Syphilis, J. Pollitzer, Principles O. S.: A Valuable Method of 34:633 (Sept.) 1916; Ormsby, Employing 75:1 1920. in A. M. A. (July 3) Arsphenamin Syphilis, J. 17. This is of of vascular especially true, complications. Compare course, luetischen Erkran- and M\l=u"\ller-Deham bei Kothny (Zur Neosalvarsantherapie des der Wien. klin. Wchnschr. 33:77 Herzens und Aorta, [Jan. 22] 1920), kungen who review the German literature with reference to this question. Presse m\l=e'\d.28:281 18. A.: Traitement de la syphilis nerveuse, Sicard, J. 1920. The French seem to have had for small as (May 8) penchant dosage, Pinard to Cure the Paris 2:101 witness and (How Syphilitic, Medicine, Queyrat Diseases A. M. A. 76:143 1921). Gougerot (Skin [Nov.] 1920; abstr., J. [Jan. 8] Medicine, Paris 2:85 A. M. A. 76:143 and Syphilis, [Nov.] 1920; abstr., J. doses states that the are gaining popularity in early [Jan. 8] 1921) larger syphilis. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 a Osseous deserves for conspicuous Syphilis.—Arsphenamin place of in its action and the relief which it affords promptness symptomatic osseous Since the Herxheimer reaction is syphilis.19 unimportant, administration renders iodids be at once. Arsphenamin may begun out Cases with and as response unnecessary, pointed by Jeans. delayed much should searched for be suppuration sequestrums by roentgen-ray and direct should be but removal not examination; surgical attempted of treatment.20 until after some months intensive osseous Progressive nose searched and of the should be for epithelioma, epithelioma syphilis in the nose simulate late or be on syphilis very closely, superposed may it. and administered in osseous Mercury arsphenamin together syphilis effective Osteo-arthritis can made are more than either alone. be once to involute under but the Charcot when treatment, joint fully on does not No work bone should be developed, respond. syphilis plastic a a until after at least of intensive with treatment, attempted year Wassermann reaction. The coincidence of Wasser¬ negative negative mann reactions with a still active of the nasal is syphilis septum for than fallen inter¬ more one responsible bridge operative following ference. of focal or tuberculous not Hydrarthroses, frankly origin, should have a test. There is no in always therapeutic object making on healed osseous lesions. tests therapeutic Cardiovascular involvement is Syphilis.—Cardiovascular probably late to some in all and should be searched present degree nearly syphilis for. The obvious means a of advanced signs fairly process.21 presence of The condition the difficult to from either arteries, predict coronary examination or is, believe, history, important. Necropsy experi¬ very are ence has made us realize that who patients seemingly good symp¬ tomatic risks a of death have such occlusion that results may degree Herxheimer under treatment from the or the effects too reaction, of even in rapid healing.22 Myocardial protest against arsphenamin, early can edema be transient and a dilatation which cases, recognized by C.: Treatment of 19. P. The of Jeans, Hereditary Syphilis. Description with Discussion of Results After Four Years' M. A. 76:167 Method, A. Use, J. (Jan. 15) For the of this in osteitis of the surgical management complication when it is skull, especially obstinate, Adson Surgical Treatment compare (The of Gummatous Osteitis of the A. M. A. 74:385 Skull, J. [Feb. 1920). 7] 21. Reid's article is 105 an excellent review of the in with a findings cases, of the literature Boston 183:67 digest (Specific Aortitis, M. & S. J. [July 15] 183:105 1920; cont. also Babcock Practical [July 22] 1920). Compare (Some Considerations with to Am. Regard Syphilitic Aortitis, Syph. 4:34 [Jan.] J. and 1920) Hoover (Aortitis A. M. A. 74:226 Syphilitica, J. [Jan. 24] 1920). 22. I have been to find glad that my observations accord with those of Hubert from clinic Romberg's (Footnote 6). Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 or sometimes even months of mercurial to W7eeks responds digitalis. are with inunctions and moderate doses of iodids preferable preparation the to the immediate use of If is used arsphenamin.23 arsphenamin observers have a decided should be and several expressed dosage small, In with combined neuro- for neo-arsphenamin.24 dealing preference and the cardiovascular lesion is cardigvascular syphilis syphilis, usually the and makes treatment necessary. handicap usually intraspinal too treated with and Aneurysms early arsphenamin, may rupture, in the form of certain amount of advance, developing symptomatic sometimes resolution the follows too of expansile pulsation25 rapid mesaortitis mediastinitis under intensive treatment. Rest in bed and affects and but cannot be introspective hyperactive types unfavorably, neurosis avoided in threatened or actual The decompensation. anxiety their of these is often more serious and obstinate than patients syphilis. a matter-of-fact outlook and a uni¬ The must be reeducated to patient reduced as the situation form level of without of strain, activity, peaks in a times an assumed consultant trans¬ At even require. optimism may a with car¬ forms the Bromids are valuable Patients picture. adjunct. from in diac disorders must be weight. Hypertension protected gains 2e heart or a well valvular lesion with an compensated hypertrophied iodid admin¬ an excellent tolerance of treatment. Heroic as a rule, has, no istration in cardiovascular has over special syphilis advantages able smaller that we have been to recognize.27 dosage below the and liver just Hepatic Splenic Syphilis.—A palpable the first or second with costal following arsphenamin injection, margin of evidence of diffuse the sclerae is sometimes all the slight tinging in a Obvious to the liver case. given damage hepatitis recognizable the for some caution with On the other calls hand, post arsphenamin. due for is hoc conclusion that all treatment jaundice following syphilis and their citations from the literature 23. The various authors mentioned The value of show that no of on this exists as yet. unanimity opinion point with is conceded now. Hirshfelder is a used caution, generally arsphenamin, Ed. B. notable of the Heart and Philadelphia, J. exception (Diseases Aorta, 3, Company, 1918, 346). Lippincott p. 24. and M\l=u"\ller-Deham Kothny (Footnote 17). 25. evidence of the Hubert 6) gives orthodiagraphic enlargement (Footnote of the Goldscheider die Erkrankung der Aorta, aneurysm. (Uber syphilitische Klin. Med. 1912). 8:471, 26. Hirschfelder and Reid discuss the fall in (Footnote 23) (Footnote 21) contraindication. blood due to arsphenamin as a pressure der Bauch- und der 27. syphilitischen Erkrankungen Hoppe-Seyler: (Die der Leber und der und ihr Einfluss auf Circulationsorgane [besonders Aorta] Med. Klin. advocates iodid die Felddienstf\l=a"\higkeit. 1914) given 10:1727, intravenously. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 to the medication is unwarranted.28 The with patient average hepatitis, diffuse or tolerates and is the better for from well, gummatous, mercury six or two to weeks of inunctions and if much mixed iodids, debilitated, treatment mouth with in bed. in the rest late cases is by Only very exhibited the of ascites with therapeutic paradox shrinkage increasing of the liver. In transient an increase or my experience although ascites, of fluid with the Herxheimer is a true reaction, common, therapeutic is rare. When it and intervals paradox occurs, progres¬ tapping grow the Talma should be resorted to. The shorter, operation sively good results have been attested Riesman.29 The of by hepatic prognosis if treatment is too and not hard, the is not syphilis, pushed patient is to the usual belief.30 Renal is moribund, good, contrary irritability sometimes serious and demands much attention to foci of matter, and so forth. of the while infection, diet, degeneration kidney, Amyloid serious does not contraindícate complication, flatly fairly energetic therapy. In marked the of the fibrous in splenomegaly response spleen, my has not been and when there is experience, accompanying very good, anemia, splenectomy performed by competent operator yields good I an more effective results.31 have that tests on impression therapeutic would more and mean fewer splenomegaly syphilis recognized splenec- tomies performed.32 Gastro-Intestinal the frank Syphilis.—Gastric symptoms, excluding in about one fourth of the cases of crises of tabes dorsalis, are present If the clinical be other than with a late carcinoma, syphilis.33 picture over Wassermann takes reaction, positive therapy precedence operation. deformities. if This of true of But course, is, hour-glass especially are carcinoma is the and probable diagnosis operability prospects good, if the at should come first and treatment second, findings exploration of confirm the Persistence of exploration diagnosis syphilis. gastric considered 28. acute is not here, Syphilitic yellow atrophy (toxic hepatitis) since it is of A to the recent French quasi- an accompaniment early syphilis. key on this be obtained from Milian subject can (Footnote 8). polemic writings the Liver. 29. D.: and Cure of Cirrhosis of Riesman, Spontaneous Operative of Illustrative Cases. A. M. A. 76:288 1921. Report J. (Jan. 29) 30. Wile takes the McNeil of the (Footnote 5) opposite view; (Syphilis Am. 1:738 with me. Liver, J. Syph. [Oct.] agrees 1917) of the status of in thera- 31. A recent summary splenectomy complete is that of Giffin Status of as a peutics (Present Splenectomy Therapeutic Minnesota Med. 4:132 1921). Measure, [March] 32. The Treatment of with Anaemia in Eason, J.: Splenomegaly Syphilitics. M. 21:258 1918. Edinburgh J. (Nov.) This the the Clinic summarized Stokes and 33. is of as by experience Mayo Brehmer in Railroad Indust. 1:419 1920). (Syphilis Employees, J. Hyg. [Jan.] Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 in other than frank after the first few weeks of crises, Symptoms in which clinician will often calls for further an astute treatment, search, or be rewarded with the of duodenal other ulcer, finding appendicitis, or lost of when the Was¬ conditions, slighted sight positive pathologic Persistent instead of sermann reaction was found. nausea, morning a of has in sometimes been attacks, periodic experience symptom my crises. In this cannot connection, morphinism complicating gastric refrain from at the readiness with which at physicians protest large abdominal The tradition has for spasmodic pain. prescribe morphin than a cost lives for there are few more unmanageable problems addict with crises. is the of election in Arsphenamin drug morphin in the entire The is one of the most response syphilis. gratifying gastric of late and but on the extent field of seems syphilis, rarely dependent as indicated the in the case of anatomic roentgen ray, except change by of in occurred in a linitis A 100 weight plástica.34 gain pounds patient cm. a stricture 10 near in at influenza, whom, necropsy following long found which would not a lead the end of the stomach, was pass pyloric cases need consideration. The starvation acidosis in these may pencil. the outlook is the and of the With involvement of rectum, esophagus active infiltration and to the ratio between inflammatory proportional a medical relief. in the late have outlook for scar. Patients stages poor of tests for Renal instituting therapeutic gumma Syphilis.—Before that is not with the should be sure one one reasonably dealing kidney to Infected react unfavorably arsphenamin. kidneys hypernephroma. and tolerate it better than of much Other nephritis nephroses types it with a and be output may employed phenolsulphonephthalein mercury, due to ill this low function be not of zero without effect, provided are not tests for retention. nephritis Therapeutic syphilitic urinary the even the at outset, infallible, though nephritis may respond, always with albuminuria, some to A to extent nephrosis high arsphenamin. with normal blood and casts and function, in the absence of develop may of treatment.35 late in a course vigorous which a rare severe anemias form com¬ Anemia in Syphilis.—The on the or of late whole, syphilis respond, accompaniment plication neither is able than to better to mercury, although perma¬ arsphenamin a in the influence the course of large to pernicious type very nently 157:321 advises Am. M. Sc. [March] 1916) 34. Sailer Plastica, J. (Linitis associated with a Wasser- when linitis is positive treatment for syphilis plastica occurrence of structural in syphilis reaction. The improvement gastric mann of the Stomach: A Clinical and demonstrated Eusterman (Syphilis has been by Am. Sc. with of M. a Report Cases, J. Study Twenty-Three Roentgenological 153:21 [Jan.] 1917). Nederlandsch. v. and 35. Lankhout Kidney Disease, Tijdschr. (Syphilis A. 76:626 abstr. A. M. [Feb. 26] 1921). Geneesk 2:2649, 1920; J. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 of cases.36 In I have seen case of fact, one majority only primary in anemia which the led me a cure. to Avoidance of response expect reactions is occurrence The of false Wasser¬ highly positive important. mann reactions in anemias has led to more than one primary disappoint¬ of test. Anemias of ing therapeutic secondary type, great persistence, uninfluenced or at most influenced largely any only by temporarily form of occur in late One that I recall treatment, syphilis. responded to removal of a septic gallbladder. Wassermann-resistant instead of dismissed with patients,37 being I intensive and observation. reassurances, need, believe, study lifelong I do believe not the reversal of the Wassermann Paradoxically, however, in reaction to be an end since its relation to the structural or itself, functional is of as obscure. As one's integrity expe¬ any organ yet rience with modern fixed reactions become increases, therapy positive the of inunctions. The use fewer, especially following prolonged Pollitzer technic as a is extolled3S means of especially reversing be a resistant but should used after cases, survey only comprehensive of the case. Other conditions besides underlie an irreversible paresis may test. The resistant Wassermann reaction in children has not reputed materialized either or own. I seen in have Jeans'19 experience my to confirm Strickler's as to the influence of nothing impressions in the or of false arsphenamin production positives.40 persistent Ehrlich's the am to belief Syphilis of Eye.—I returning original that is contraindicated in some cases of arsphenamin distinctly simple neuroretinitis or choked to optic secondary disk), primary atrophy (not I seen a at least in the months of the course. have with early patient vision blind with four and good go totally arsphenamin injections, with due to have to be another, primary optic atrophy, high myopia, to of its On the other transferred because action. focal hand, mercury infections in the stirred cause trouble mouth, up by mercury, occasionally direction. Treatment for with from the other syphilis, especially the has marked effects in and iodids, the nonspecific eye, arsphenamin 36. Gorke von An\l=a"\mienach M\l=u"\nchen. (Auftreton apastischer Salvarsan, med. Wchnschr. 67:1226, Compare also Footnote 9. 1920). 37. Footnote 13. also W. and C. K.: Compare Wile, J., Hasley, Serologic the of Sensitive Wassermann A. M. A. Cure in Light Increasingly Tests, J. (?) 72:1526 1919. (May 24) 38. Footnote first reference. 16, and M.: A Positive Wasser- 39. H. G., Sidlick, D. Strickler, A., Munson, mann Test in Patients After Intravenous A. M. A. Non-syphilitic Therapy, J. 75:1488 1920. 27) (Nov. of the merits this 40. For a critical consideration of question, compare A.: The of Positive Wassermann Reactions Caused the Question by Kolmer, J. of A. Intravenous Administration Arsphenamin, correspondence, M. A. J. 75:1796 1920. (Dec. 25) Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 in which could be more utilized the treatment of uveitis, widely epis- tuberculous and so forth. are cleritis, keratitis, all Ophthalmologists unfamiliar too with the effect of on intestitial keratitis, arsphenamin which is an immense advance over the effect of it mercury, although be combined with it for The must value of months and permanence. of in has been cases years persistence seemingly hopelessly impaired on me. impressed the Ear.—Deafness in or Syphilis of acquired syphilis hereditary should be of its duration. The treated, always intensively regardless exhibits occasional it unexpected patient improvement (test by speaking from behind the to him from In acute patient keep lips). reading I mercurial but I have seen no ill effects onsets prefer preparation, Patients with an from associated make neurosyphilis arsphenamin. may Patients with reactions response. especially good positive Bárány make but believe the some objective improvement, specificity may is still of this to open response question. the Nose and Throat.—The to is Syphilis response arsphenamin of miraculous and sometimese when has been life-saving, deglutition if the involves but the or the obstructed, trachea, process laryrfx immediate use of this even in trivial is lesions, drug, danger¬ seemingly because of the Herxheimer reaction. Provocative ous must procedures used in such On the coincidence not be cases. the of lesions tongue, and new of recurrences is crops undergoing malignant changes possible. have seen for carcinoma on while hemiglossectomy performed gumma, because for the no treatment was another later, given syphilis, gumma allowed to and the other side. The confusion was on develop degenerate of the of with that tuberculosis the of of pathology gumma tongue with a Wassermann reaction is (so-called "tuberculoma") positive more common is than realized. perhaps AND SYPHILIS IN MOTHER CHILD in the mother is one of the richest fields for Syphilis prophylactic effort indicated the influx now available, as of favorable by steady the obstetric services of work of and care clinics,42 reports prenatal 41. Skinner (Syphilis at a Venereal Clinic: An of Cases Admitted Analysis Twelve Lancet 1:650 During Months, [March 20] 1920) points out, however, how few women or for examination treatment short of a report fully developed infection. 42. Williams of in (The Significance Syphilis Prenatal Care and in the Causation of Foetal Bull. 31:141 Death, Johns Hopkins Hosp. [March] 1920) found 53 cent, children of per syphilitic untreated 7.4 cent, of mothers, per mothers treated during also Treatment pregnancy. Compare Adams, J.: of Ante-Natal and Post-Natal Brit. M. 2:541 Syphilis, J. and (Nov. 16) 1918; La mortinatalite Chambrelent: en France. Elle est evitable dans la majorit\l=e'\ des Nourrison 1920. cas, 8:321, Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 in which the is to receive the attention it deserves. problem beginning in should in the child receive the same treatment as Syphilis syphilis the in to a that from adult, response growing appreciation apart and the of untreated uterine infections, stigmatization high mortality it no essential differences. In the untreated presents fact, surviving child has a resistance that is a valuable in Instead of asset treatment. with a recital of technical let summarize what details, me you boring conceive to be essential The relative of the principles. immunity woman from external manifestations of the disease and the suppressing effect and lactation a of has in women in pregnancy placed syphilis field itself. The institution of for the of the child by therapy protection seems to me in in whom evidence of infection women justified syphilitic so is doubtful that the of treatment would be questionable advisability under other circumstances. The studies of Widakowich on sperma- tozoal anomalies and the Eberson in of the male findings syphilitic furnish the first hint of direct influence and raise tangible paternal the of whether or not the father should have treatment as a question as for as much the mother for preparation conception quite gestation. This constitutes what I have both and as "treatment preached practiced for life insurance" in the of a child. have Of late I syphilitic parents radical no can almost to believe that at time the woman grown enough who has had be advised to without a syphilis go through pregnancy treatment course While this would bear hard on the coincidently. mother of nineteen it need not be a to the children, hardship average and if observation of the children thus born should family, might, a relaxation of rules with to it, permit marriage. justify respect methods must be feature of the treatment Spirillicidal prominent the since a maximum of of destruction is, woman, pregnant organisms so as our at least far the best to goes, present knowledge protection the child. There me be from one seem to to reasons for good giving thirds of half to two the full doses all to the woman. around, pregnant Her infection is inhibited her to some extent her liver by pregnancy,45 and are both under as evidenced the familiar intoxi- strain, kidneys by The 43. V.: of Semana med. 27:633 Widakowich, Spermatozoa Syphilitics, A. A. 76:414 (Nov. 11) 1920; abstr. J. M. (Feb. 1921. 5) 44. Routh Action of the Chorionic (Antenatal Suggested Ferments, Syphilis: abstr. Brit. M. 1:47 makes an for a J. [Jan. 12] 1918) interesting argument factor on the basis of also to paternal Noguchi's spirillolysis, attempting explain infection of the fetus in untreated cases. delayed 45. W. and On Brown, Louise: the Reaction of and H., Pearce, Pregnant Females to Inoculation Lactating with Treponema Pallidum\p=m-\APreliminary Note. Am. 4:593 1920. J. Syph. (Oct.) Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 cations and her metabolic and eliminative mechanism of pregnancy, treatment.46 therefore cannot be to massive equal Whether the child will remain is the born crux symptomless so, of the of treatment in mother and child.47 The prophylactic phase after birth in children treated of of periods latency possibility long uterine familiar in the untreated infection as demands well, life, during the fullest of facilities for the and observation development following up of the before the of the child treatment of the cure syphilitic family by as established. mother is accepted of child a commendable toward the show trend Systems treating the realization that most uterine increasing intensity, tempered by and Rosen's of intra¬ is late syphilis syphilis.48 Fordyce advocacy muscular is intended to the arsphenamin apparently popularize drug with those I with that the agree technically inexperienced.50 Jeans seldom or never has need to other than the intravenous use expert route.01 is The tolerance of children for proportionately mercury I than that of and the intramuscular and adults, believe, greater, are a well-deserved As relief inunction routes gaining popularity. from effects of the mercurialization, debilitating prolonged arsphenamin in of children than in that of adults. is even more welcome the treatment in The effect of the two is also valuable obstinate drugs synergistic cases. measures have been used. Intraspinal effectively of for the combined The the school-hospital conception Weylander not and education of children with has received treatment heredosyphilis the attention it should have in this The from the reports country. solves countries and indicate that it the Scandinavian Germany problems of social rehabilitation. care and hospital second reference) liberal doses of 46. Adams (Footnote 42, praises arsphena- mouth. for but his mercurialization is all Williams min mothers, practically by first reference) does not his but it seems to have (Footnote 42, specify technic, been conservative. 47. Much rather is on the child's unguarded emphasis being placed negative test after birth. Wassermann and P. C.: The and Treatment of "Late" 48. B. S., Jeans, Diagnosis Veeder, Am. Dis. Child. 8:283 1914. J. (Oct.) Hereditary Syphilis. 49. and Rosen, I.: A Method of Fordyce, J. A., Treating Congenital Syphilis. M. A. 75:1385 (Nov. 20) 1920. A. J. second commends in one 50. Adams 42, reference) galyl glucose, (Footnote the adult dose. seventeenth of the neo\x=req-\ 51. would be to doses of It interesting apply huge proportionally Mehrtens (Rectal Injections of Massive arsphenamin by rectum, employed by A. M. A. 76:574 1921). Doses of Neo-Arsphenamin, J. [Feb. 26] Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 CONCLUSIONS This rather review the certain of principles underlying cursory defeat of will its own if it leaves the special phases syphilis purpose that the treatment of the disease should be out in impression parceled each self-sufficient its we and own laws. as segments, governed by Just are that is no even at the earliest finding early syphilis longer localized, of the so we shall as the our find of lesion, intensity appearance primary increases that late does not in the first decade, study syphilis begin but in the first hour. the transmission of the disease in its Preventing earlier and the individual to forestalling stages, tendency complications on of based the of the strain the and the host, peculiarities parasite, method of is the whole of treatment, problem syphilis. Forestalling that an a so implies detection, alertness, increasing diagnostic develop¬ ment of methods for the earliest and not the late of detecting signs in vital and is not but tissues, mere pathologic change organs diagnosis, a our of effective treatment. For all so-called effort, part prophylactic will the of late in certain development complications nothing prevent who combination of the fatal of patients group present predisposed It that smaller soil and is true an even tropic organism. equally group of will master the infection for themselves, of our patients irrespective interference. these come Between two extremes will those whom we have those whom we have to in com¬ radically cured, managed place mensal relation to their those whose we infecting organism, immunity have broken whose for treatment measures future potentialities by as harm as well we do not and those understand, present good yet whom we have treatment itself. The of the destroyed outright by study interrelation one of these is of the most of groups complex problems of Its not be the medicine solution will a today. accomplished by or a of of mental the various and physical separation phases syphilis into each with its own compartments technic, syphilotherapy air-tight and ideals aims. that mode of will leave a Only approach significant on our future which the entire disease, impress knowledge envisages one or two methods in a series cases over a of employs large period of the and records which, observation years, results, lifelong many by and detects serious reexamination, periodic complete impending patho¬ and and evaluates in detail with the of response logic change, accuracy and host. parasite Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology and Syphilology Unpaywall

THE TREATMENT OF LATE SYPHILIS, AND OF SYPHILIS IN MOTHER AND CHILD

Archives of Dermatology and SyphilologyDec 1, 1921

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Unpaywall
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0096-6029
DOI
10.1001/archderm.1921.02350250057005
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Abstract

OF THE TREATMENT OF LATE AND SYPHILIS, SYPHILIS IN MOTHER AND CHILD R\l=E'\SUM\l=E'\ OF PRINCIPLES STOKES, JOHN H. M.D. Chief of Section on and Clinic Dermatology Syphilology, Mayo MINN. ROCHESTER, in The of the of late differs essential treatment problem syphilis or from that of of true syphilis. particulars early asymptomatic (latent) In we are in of the revelations of still, early syphilis spite disturbing of and and of for radical Warthin,1 Brown Eberson,3 Pearce,2 striving cure of the infection. In the late of the the disease, stages problem becomes of and arrest. The infec- one symptomatic improvement early involves the the late of tion human In usually unimpaired body. years are the infection the of added to physiologic changes years advancing the disabilities the action of the disease on vital structures. produced by infection The characteristic reaction of the to the opposes body syphilitic another obstacle to treatment. The fibrosis walls off slowly progressive the from the carriers of remedial the blood and organism agents, lymph. the induced obliterative the of foci to endarteritis, accessibility By or distributed it is into the blood probably spirocheticides injected by latent reduced. In the or infection there materially slowly progressing exist a balance between the offensive of the must also organism powers could be and of the host. If the confined the defensive powers organism individual maintained, within the infected and this balance be perfectly the commensalism would serve all the of the radical treatment purposes methods of the The of late have "extirpators." large majority syphilitics of effected measure with the some probably compromise spirochetal be of and must exercised in the disturbance this invader, judgment relation. Read at the Annual Session of the American Forty-Fourth Dermatological June 2-4, Association, Swampscott, Mass., A. S.: The Persistence of Active Lesions and in 1. Warthin, Spirochetes Inactive "Cured" Am. M. Sc. 152:508 the Tissues of Clinically or J. Syphilis, 2:425 New of Am. 1918. (Oct.) 1918; Pathology J. Syphilis (July) Syphilis, 2. and Louise: A Note the Dissemination of W. H., Pearce, on Brown, Pallida from the Focus of Arch. Dermat. & Spirochaeta Primary Infection, Syph. 2:470 Infection of Central Nervous the Syphilitic the System of (Oct.) 1920; Ibid. 2:635 1920. Rabbit, (Nov.) F.: Dissemination of Pallida in 3. Spirochaeta Experimental Eberson, Arch. Dermat. and 3:111 and Syphilis, Syph. (Feb.) 1921; Eberson, F., Engman, F.: An of the Latent a A. M. Experimental Study Syphilitic as Carrier, J. M. A. 76:160 15) (Jan. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 OF APPRAISAL POSSIBILITIES AND THERAPEUTIC DECISIONS The aim of treatment in late is to the infected individ¬ syphilis carry ual the fullness of his with maximum attainable through years, efficiency and minimum his and to contacts to the social order. The first danger in the treatment of late is an of step syphilis appraisal possibilities, including An estimate of life on on based expectancy age, damage already on done, the and rate of of the and supposed activity progress process, on its refractoriness to treatment. probable An estimate of the not handicaps imposed by complications due to such as mental directly syphilis, tuberculosis, nonsyphilitic disease, chronic interstitial so hypertension, and forth. nephritis, diabetes, An 3. estimate of the tolerance of the for the various methods patient of treatment available. An estimate of the to of treatment the most probable response vital structures involved. Treat late the indications in vital structures and not in syphilis by structures nonessential to a life. examination of the Only searching can entire the information an for stich While body provide appraisal. the milder forms of treatment be should sel¬ may begun, arsphenamin dom be administered until this is The appraisal reasonably complete. inherent of methods our of the condition of crudity estimating many structures must be remembered and allowed for in important making the estimates mentioned. in involvements the of vascular Particularly is this caution system important. The Herxheimer reaction is as a much feature of late as of syphilis the infection. acute It must never be lost and the sight of, possibility that it have serious will either location of effects, from the the involved as case in the of the or a cerebral structure, or from its larynx vessel, functional in as the case of the must importance, be myocardium, In it is conservative to all individuals carefully weighed. general, give affected with late mercurial syphilis preparation. of The control infectiousness in late while of syphilis, traditionally little deserves more in the of work import, consideration, recent light on in is carriers,4 the woman who or especially become pregnant may or in the father of children. I It a pregnant, potential is, believe, good rule that late cases deserve as much as nearly arsphenamin cases, early for the this control of under the limitations the aspect imposed by pre¬ and the of the case. liminary survey progress the of Adjustments required process are factors in by healing decisions in late When therapeutic syphilis. under treat- begins healing 4. Footnote second reference. 3, Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 the made the to for a ment, attempt by body compensate pathologic is made take another direction. An to disturbed, to change adjustment cicatricial as the Herxheimer the effects of contracture well as to in reaction must be at times with a increase made, paradoxical symptoms, as for cirrhosis. Cicatricial out Wile,5 pointed syphilitic hepatic by the stenosis of the and even of rectum, hour-glass stomach, esophagus occurs. I am so as inclined to believe far the heart is that, concerned, even attacks of increased acute ischemia, myocardial anginal severity, aortitis the of certain of and physical signs may development aneurysm, too too be the results of treatment and energetic rapid healing.6 In the of a consideration should be to appraisal case, given complete the serious¬ the of its and hepatotoxicity,8 vasculotoxicity arsphenamin,7 ness of cutaneous exfoliative accidents. At a theoretic considera¬ first items have a real in these tion, acquired experience very meaning my late for the with The low of arsphenamin syphilis. relatively toxicity a in there is a notable makes it serviceable but nephritis, kidney drug In low renal function from back and in exception. pressure, pyelone¬ often a of it must be used with phritis, complication neurosyphilis, dermatitis as a relative contraindica¬ caution. The of history previous receive the attention it deserves. tion to does not arsphenamin admin¬ of its certain modes of The mercury, renotropism ability, by to its to increase the cutaneous istration, arsphenamin, reactivity when overdone and the unfavorable effect on severe action depressant 5. of the Arch. Dermat. & Syph. 1:139 (Feb.) Wile, U. J.: Syphilis Liver, find Hubert Klinik und der Aorten- 6. I was interested to (Zur Behandlung in accord with me on this Deutsch. Arch. f. klin. Med. 128:317, 1919) syphilis, point. 7. that cardiac dilatation after is An interesting suggestion arsphenamin increased the obstruction of the circula- due to pressure produced by pulmonary the of the tion or and is on alkalinity preparation vasoconstriction, dependent Studies is made Smith on Arsphenamine, J. by (Further Pharmacologic This Pharmacol. & 15:279 combined with the Exper. Therap. [June] 1920). not in blood observation that is precipitated the (Schamberg, neo-arsphenamin Raiziss and Weiss: and Clinical Studies on the Laboratory Bearing Kolmer, of and Causes of the Reactions Intravenous Injections Arsphenamin Following Arch. Dermat. & 1:235 would seem to Neo-Arsphenamin, Syph. 1920) [March] cardiac the of in syphilis. suggest desirability neo-arsphenamin The numerous recent articles on as a due to the 8. jaundice complication reviewed the of a toxic action of are from standpoint possible arsphenamin in Ruedemann and Lemon's Infectious infectious factor Stokes, paper (Epidemic Arch. Med. 26:52 and its Relation to the of Syphilis, Int. Jaundice Therapy 1920. Milian continues his defense of treatment and [Nov.] vigorous (Jaundice A. M. A. 76:143 M\l=e'\dicine, Paris, 2:113, 1920; abstr., J. [Jan. 8] Arsphenamin, Lancet 1:1356 also Hallam 1921). Compare (Post-Salvarsan Jaundice, [June 26] 1920). Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 the described Foucar and are anemias, myself,9 principal by among to be considered. The old-time of stomatitis, salivation, points bugbears and disturbance have been reduced to relative gastro-intestinal insigni¬ and in ficance dental prophylaxis, diet, intelligence dosage. by As in its resistance to the disease itself the shows body generous of or the effect of massive margin safety, notwithstanding prolonged so no or recoveries result from the treatment, good symptoms may But I most abuse of both arsenic and have flagrant mercury. always or felt that the avoidance rather than the correction of toxic debilitating effects that end have insisted a of is the and to on number ideal, which in the end,-I precautions against complications, believe, protect from the small but cumulative insults which too often keep patients a condition intensive them in substandard under even treatment, though the individual not become in itself. In late by-effect conspicuous may in which the between and treatment syphilis, margin requirements treatment tolerance is often such measures small, may very protective make all the difference between success and failure. In the nine cardinal for the mechanism which shall rules the of I management excretory Institute here from discussion of this before the for point quote my Venereal Disease should mention that the on micro¬ Control, I emphasis blood as an evidence of renal is drawn from an damage unpub¬ scopic lished Wilder and of the effect of intensive study, by prolonged myself, on attention to treatment for the I want also to direct syphilis kidney. the influence atonic bladder with retention in retard¬ of the symptoms the who would otherwise do well. satis¬ of am ing patients progress fied that the terminal in than one arrested but more practically picture none the less fatal case of is of depressed neurosyphilis composite renal function and infection of the tract. ascending urinary THE MANAGEMENT OF EXCRETORY MECHANISM 1. A cathartic should be after each given arsphenamin injection, and a mild laxative the course. during A urine examination should the 2. be rule. weekly attention should red blood 3. be to cells, Special paid (a) casts, (b) and in the urine in (r) pus (catheterized women). 4. or casts mean renal irritation. Occasional Many persistent showers are not significant. 5. Red blood cells of renal mean renal origin injury. Pus or blood vesical be an index due 6. of of to origin may cystitis with retention. In search should be neurosyphilitics pyuria urinary 9. H. and H. : The Effect of Treatment for on Foucar, O., Stokes, J. Syphilis Severe Am. M. Sc. to Anemias, J. be published. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 or made for atonic "cord" bladder with residual urine, secondary and blood and urea, cystitis pyelonephritis, falling phenolsul- rising excretion. phonephthalein 7. The mechanism should be protected (a) extirpation excretory by of focal administration of fluids and alkaline diuretics infections, (b) catheterization and of (potus imperialis), (c) irrigation neurogenous diet or bladders, and proteins), (e) (d) regulation (low suspension moderation of treatment if other measures fail. 8. The should not a physician discharge neurosyphilitic patient without satisfied with to his renal his blood urea regard function, being and the of his bladder mechanism. content, integrity 9. tabetic should be as uremic. Every patient regarded potentially IN A FACTORS SUCCESSFUL THERAPY in has that the Schamberg, communication, personal suggested simultaneous administration in the of ana results arsphenamin mercury retention of the arsenic with increased risk of exfoliative accidents.10 so as That this retention is serious to the simulta¬ justify abandoning the have neous use of two I not as been able to convince drugs yet from clinical evidence. Exfoliative accidents in service come myself my in and have had what seemed to be more than a casual relation waves, to intercurrent and focal infection. The "broken of immunity" arsphenamin-treated early long syphilis, familiar in clinical and now verified Brown experience by experimentally and I occasional in late All Pearce,11 has, believe, homologs syphilis.12 no seen the of have doubt the marked acceleration of unfavorable you of some cases of progress neurosyphilis following arsphenamin, scarcely as mere I it a arsenic fastness. believe is conservative explainable never terminate a of treatment with to practice period arsphenamin, to but finish with if it be mouth. mercury, only by have little as In ; meaning therapeutic guides early syphilis, symptoms in their in late be fact, syphilis may supremely important ; disap¬ they the sole criterion of successful be pearance may therapy. Eighty-five of 10. V., and A.: The Urine in Klauder, J. Kolmer, J. Syphilis. Report Reaction, in A. the Wassermann Sixty Cases, J. Laboratory Studies, Including M. A. 76:102 1921. (Jan. 8) Louise: The Resistance 11. Brown, W. and (or Immunity) H., Pearce, the Reaction to Infection and Some of the Effects of the Developed by Syphilitic Arch. Dermat. & 2:675 1920. of this Reaction, Syph. (Dec.) Suppression 12. The unfavorable effect of minute is discussed Bronfenbrenner, dosage by M. Generalized Infection in Rabbits and Schlesinger, Resulting J., J.: Syphilitic Med. from the Salvarsan Proc. Soc. Biol. & Inadequate Therapy, Exper. 18:94, Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 a cent, of late in our selected with per syphilitics, experience, only of as reasonable discrimination to should outlook, degree therapeutic on arrest and be observa¬ undergo symptomatic ultimately placeable tion.13 One is disconcerted the Herxheimer occasionally symptomatic by or which dominates the the first three four weeks flare-up picture during a course. reac¬ of intensive The in the Wassermann moderately changes while of are not the sole evidence of the of tion, a interest, efficacy times an method of and are in fact at not even treatment, important consideration. In a reaction is a for a general, persistent positive signal and of the fundamental examination of the case, rechecking appraisal and a Wassermann calls for in the absence of more treatment relapse contraindications. distinction should be in the A drawn, legitimate estimating progress evidences of of late under between scars and treatment, activity. syphilis a a recover It is matter of little moment that tabetic does not his patient or a with cardiac disease rid of his aortic knee jerks patient get it is in if attacks murmur. On the other hand, decidedly point anginal in or increase in if a with diffuse sclerosis, frequency coronary patient has a of or the liver fails to decrease in recurrence hepatitis jaundice, times which size. Paradoxical at in the occur, signs pictures represent¬ as scars become more the func¬ ing conspicuous symptoms representing tional Ascites in cirrhosis impairment disappear. developing hepatic under bone sinus, treatment,5 discharged through sequestrums atrophy of the nerve as a marked neuroretinitis in an involutes, optic pulsation in as the are Failure of subsides, aneurysm periaortitis examples point. structural to occur even with marked improvement symptomatic is familiar in and gastric syphilis. improvement enough aneurysm all based Functional also on improvement outstrip expectations may in the structural particularly inflammatory recognized change, processes. in In the and and sometimes have a eye ear, gains sight hearing qualita¬ rather tive than character and exceed all quantitative may again expectations. How far shall treatment be carried after the of symp¬ disappearance as a when the are not such to furnish to the toms signs guide progress In I the case? should to the of as much of general, say point giving as an tolerance This is a treatment in case, early provided permits. of vital The abuse a tolerance of treatment in late proviso. patient's even more than in I a serious believe, syphilis early syphilis is, error, that the his infection since it is to course of not predict impossible may be such that he will be under treatment at intervals all his life. On the and G. A Clinical of Wassermann-Fast 13. Stokes, H., Busman, J.: J. study with Reference to and Am. M. Sc. Syphilis, Special Prognosis Treatment, J. 160:658 (Nov.) Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 other measures in effective be the hand, timidity using may precisely which the the other horn of the dilemma. onto thing projects patient It is for these that reasons I much stress on the use of every lay available means in late to the status the of syphilis improve general and to him from patient protect specifically therapeutic by-effects. When to the effect of treatment I have found it objective guides exist, well to the first so as to persist beyond negative relapse. finding, prevent The to whether can as be question relapse indefinitely postponed by this means remains as unsettled. In I for yet general, prefer mercury the of the resistance that but I have seldom supporter relapse, prevents felt it a to the rubs if the urge necessary life-long year" patient "forty would consent to examination. Dismissal the of periodic complete with such blanket directions seems to me to him to patient any lay open all the uncertainties an infection of below threshold of his the kept own observation self-medication. by The in late a must outlook therapist, syphilis, modify symptomatic with a trend of mind. This will stimulate him to more com¬ preventive with a view to all the examination, of involvement plete finding types in case.14 It will a lead him to the of his given life so regulate patient as to the least strain on his weakest to and conduct put possible points, his treatment so that an involvement come in its not just beginnings may to the more front later as some subsides. conspicuous symptom The test is so much more late in than therapeutic important syphilis in infections that attention should be called to of its some early pitfalls. tests in have the when Therapeutic meaning general only patient pre¬ a as sents far as a visible definite, and, lesion, on possible, pathologic which estimates of can be made. Mere quantitative improvement gain in of indefinite malaise or sub¬ weight, disappearance pains, nondescript are Iodid jective tests, symptoms usually meaningless. therapeutic with the So are are popular departing generation, untrustworthy. have and tests. I made, seen erroneous arsphenamin therapeutic made, of of the nodes with Wasser¬ diagnoses partial gtimma lymph positive mann tests. I have seen tuberculous keratitis confused with syphilitic and tuberculids keratitis, lupus vulgaris, erythematous lupus, sarcoids, make under is improvement striking arsphenamin. probably Mercury more immune from such effects than either iodids or nearly nonspecific it is well to recall its action in lichen and arsphenamin, although planus, in occasional Carcinoma cases of of the stomach makes sporotrichosis. false to alone and sometimes in combination arsphenamin responses with One of the reasons a noted for neurologist object- mercury. gave 14. Studies of the multiform of involvement often types presented by with late seem have been made internists con- patients syphilis to largely by with conditions. cerned cardiovascular also Footnote 13. Compare Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 to the as a of was his the ing dermatologist syphilographer ignorance false Pseudo- test for in sclerosis. positive therapeutic syphilis multiple Herxheimer reactions in tuberculous create a processes occasionally effect.15 deceptive STANDARDIZATION OF TREATMENT Standardization and routinization of the treatment of is syphilis much easier in the or months of the disease than in the late. early years Yet would not for a moment substitute unlimited individualization for the effects cases. of and in the of good system regularity majority But back of of treatment must lie a to any willingness systematizing think of the disease a and the as whole, of as a human patient being. I have in to the already emphasized, referring complete sufficiently the need of of involvement in a examination, identifying type every case. The same can be transferred man¬ to given emphasis therapeutic In to I wish their patients eyes, tonsils, agement. explaining teeth, why and to have attention when their trouble bladders, stomachs, appendixes is the heart the often of or of I use the maxim the syphilis liver, of service chief of the best automobile I know: "Don't listen repair plant to the owner's about this that creak and and that. story rattle, go by Go the car and her as as into back the through put possible nearly she was in when she left the Do that with late shape factory." syphilis and it will not need the studies of a Brown or a Pearce experimental to teach that the course of is often as much modified you syphilis by the we leave undone as the we do. the things things by Bring patient, in the course of of his as the to your management case, nearly up standard of his for and sex as so far as normality age possible. Do, an and not a possible, overhauling job. patching In words few I not treatment shall even my concerning organized an account of the endless variations different attempt proposed by I do want in a to that we bear mind few therapists. however, suggest, rests on the principles. First, of heavy responsibility proposers more nor is after more systems. Nothing eagerly sought frankly abused the and even the than the rule of thumb. by tyro, by expert, on the other if one in Yet, hand, there is factor which any my experience the arrest or cure of it is and prevents syphilis, desultory unsystematic In late I in for believe, management. syphilis, roughly speaking, trying radical results combined and methods, by spirillicidal resistance-building The observations on this have been confirmed original point by my experience, Herxheimer, and K.: Weitere zur K., Mitteilungen Altmann, Reaktion des nebst Lupus zur desselben durch vulgaris Beitr\l=a"\gen Therapie Salvarsan, Arch. f. Dermat. u. 110:249, Syph. Ueber eine Reaktion 1911; Prozesse nach Deutsch. Salvarsaninjektion, med. Wchnschr. tuberk\l=u"\loser 1:441, Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 rather than the or the other Whether we obtain one by exclusively. or can decide. radical results time arrest means not, only Life-long almost much to the as A as patient extirpation. frankly spirillicidal lü of technic such as that of Pollitzer seems to me to most inapplicable the cases which I am do not feel that its to reverse considering. ability so is full sufficient the Wassermann mentioned, and test, frequently evidence of its effectiveness. It is too difficult to the extent and judge the of involvement even with the most of structures, type important careful to of justify unqualified examination, system preliminary Recent continental seems to be therapeutic opinion bludgeoning. toward in the months increasingly tending moderation, early especially of the treatment of late For the occasional with syphilis.17 patient resistance to treatment and a not as high threatening, though yet actually of the intervals between lesion, arsphenamin injections, grave shortening an with is in to reach otherwise doses, large justifiable endeavoring inaccessible The favorable of of such methods as focus. users reports individual and with its enormous total and minute Sicard's,18 dosage, enormous the enthusiasm of the with their individual "Pollitzerizers," and total are not to small tributes, relatively really any dosages, disease and individual but to the wonderful of the variability system, for that wide of most which enables almost to margin safety patients, of that violate the few rules does not any outstanding system grossly in delicate and the the to the balance between arrest, game, tip progress favorable direction. To mind the essence of the modern treatment my and in the end those of is and of the modern observation, syphilis system technics which the observational will show treatment best perfect aspect, the lowest ultimate mortality. TREATMENT OF SPECIAL TYPES a of before of in series some I, sentences, you May idiographic lay the on the of of observations treatment of special types high points my late syphilis? of Cutan. Dis. 16. S.: The of the Treatment Syphilis, J. Pollitzer, Principles O. S.: A Valuable Method of 34:633 (Sept.) 1916; Ormsby, Employing 75:1 1920. in A. M. A. (July 3) Arsphenamin Syphilis, J. 17. This is of of vascular especially true, complications. Compare course, luetischen Erkran- and M\l=u"\ller-Deham bei Kothny (Zur Neosalvarsantherapie des der Wien. klin. Wchnschr. 33:77 Herzens und Aorta, [Jan. 22] 1920), kungen who review the German literature with reference to this question. Presse m\l=e'\d.28:281 18. A.: Traitement de la syphilis nerveuse, Sicard, J. 1920. The French seem to have had for small as (May 8) penchant dosage, Pinard to Cure the Paris 2:101 witness and (How Syphilitic, Medicine, Queyrat Diseases A. M. A. 76:143 1921). Gougerot (Skin [Nov.] 1920; abstr., J. [Jan. 8] Medicine, Paris 2:85 A. M. A. 76:143 and Syphilis, [Nov.] 1920; abstr., J. doses states that the are gaining popularity in early [Jan. 8] 1921) larger syphilis. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 a Osseous deserves for conspicuous Syphilis.—Arsphenamin place of in its action and the relief which it affords promptness symptomatic osseous Since the Herxheimer reaction is syphilis.19 unimportant, administration renders iodids be at once. Arsphenamin may begun out Cases with and as response unnecessary, pointed by Jeans. delayed much should searched for be suppuration sequestrums by roentgen-ray and direct should be but removal not examination; surgical attempted of treatment.20 until after some months intensive osseous Progressive nose searched and of the should be for epithelioma, epithelioma syphilis in the nose simulate late or be on syphilis very closely, superposed may it. and administered in osseous Mercury arsphenamin together syphilis effective Osteo-arthritis can made are more than either alone. be once to involute under but the Charcot when treatment, joint fully on does not No work bone should be developed, respond. syphilis plastic a a until after at least of intensive with treatment, attempted year Wassermann reaction. The coincidence of Wasser¬ negative negative mann reactions with a still active of the nasal is syphilis septum for than fallen inter¬ more one responsible bridge operative following ference. of focal or tuberculous not Hydrarthroses, frankly origin, should have a test. There is no in always therapeutic object making on healed osseous lesions. tests therapeutic Cardiovascular involvement is Syphilis.—Cardiovascular probably late to some in all and should be searched present degree nearly syphilis for. The obvious means a of advanced signs fairly process.21 presence of The condition the difficult to from either arteries, predict coronary examination or is, believe, history, important. Necropsy experi¬ very are ence has made us realize that who patients seemingly good symp¬ tomatic risks a of death have such occlusion that results may degree Herxheimer under treatment from the or the effects too reaction, of even in rapid healing.22 Myocardial protest against arsphenamin, early can edema be transient and a dilatation which cases, recognized by C.: Treatment of 19. P. The of Jeans, Hereditary Syphilis. Description with Discussion of Results After Four Years' M. A. 76:167 Method, A. Use, J. (Jan. 15) For the of this in osteitis of the surgical management complication when it is skull, especially obstinate, Adson Surgical Treatment compare (The of Gummatous Osteitis of the A. M. A. 74:385 Skull, J. [Feb. 1920). 7] 21. Reid's article is 105 an excellent review of the in with a findings cases, of the literature Boston 183:67 digest (Specific Aortitis, M. & S. J. [July 15] 183:105 1920; cont. also Babcock Practical [July 22] 1920). Compare (Some Considerations with to Am. Regard Syphilitic Aortitis, Syph. 4:34 [Jan.] J. and 1920) Hoover (Aortitis A. M. A. 74:226 Syphilitica, J. [Jan. 24] 1920). 22. I have been to find glad that my observations accord with those of Hubert from clinic Romberg's (Footnote 6). Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 or sometimes even months of mercurial to W7eeks responds digitalis. are with inunctions and moderate doses of iodids preferable preparation the to the immediate use of If is used arsphenamin.23 arsphenamin observers have a decided should be and several expressed dosage small, In with combined neuro- for neo-arsphenamin.24 dealing preference and the cardiovascular lesion is cardigvascular syphilis syphilis, usually the and makes treatment necessary. handicap usually intraspinal too treated with and Aneurysms early arsphenamin, may rupture, in the form of certain amount of advance, developing symptomatic sometimes resolution the follows too of expansile pulsation25 rapid mesaortitis mediastinitis under intensive treatment. Rest in bed and affects and but cannot be introspective hyperactive types unfavorably, neurosis avoided in threatened or actual The decompensation. anxiety their of these is often more serious and obstinate than patients syphilis. a matter-of-fact outlook and a uni¬ The must be reeducated to patient reduced as the situation form level of without of strain, activity, peaks in a times an assumed consultant trans¬ At even require. optimism may a with car¬ forms the Bromids are valuable Patients picture. adjunct. from in diac disorders must be weight. Hypertension protected gains 2e heart or a well valvular lesion with an compensated hypertrophied iodid admin¬ an excellent tolerance of treatment. Heroic as a rule, has, no istration in cardiovascular has over special syphilis advantages able smaller that we have been to recognize.27 dosage below the and liver just Hepatic Splenic Syphilis.—A palpable the first or second with costal following arsphenamin injection, margin of evidence of diffuse the sclerae is sometimes all the slight tinging in a Obvious to the liver case. given damage hepatitis recognizable the for some caution with On the other calls hand, post arsphenamin. due for is hoc conclusion that all treatment jaundice following syphilis and their citations from the literature 23. The various authors mentioned The value of show that no of on this exists as yet. unanimity opinion point with is conceded now. Hirshfelder is a used caution, generally arsphenamin, Ed. B. notable of the Heart and Philadelphia, J. exception (Diseases Aorta, 3, Company, 1918, 346). Lippincott p. 24. and M\l=u"\ller-Deham Kothny (Footnote 17). 25. evidence of the Hubert 6) gives orthodiagraphic enlargement (Footnote of the Goldscheider die Erkrankung der Aorta, aneurysm. (Uber syphilitische Klin. Med. 1912). 8:471, 26. Hirschfelder and Reid discuss the fall in (Footnote 23) (Footnote 21) contraindication. blood due to arsphenamin as a pressure der Bauch- und der 27. syphilitischen Erkrankungen Hoppe-Seyler: (Die der Leber und der und ihr Einfluss auf Circulationsorgane [besonders Aorta] Med. Klin. advocates iodid die Felddienstf\l=a"\higkeit. 1914) given 10:1727, intravenously. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 to the medication is unwarranted.28 The with patient average hepatitis, diffuse or tolerates and is the better for from well, gummatous, mercury six or two to weeks of inunctions and if much mixed iodids, debilitated, treatment mouth with in bed. in the rest late cases is by Only very exhibited the of ascites with therapeutic paradox shrinkage increasing of the liver. In transient an increase or my experience although ascites, of fluid with the Herxheimer is a true reaction, common, therapeutic is rare. When it and intervals paradox occurs, progres¬ tapping grow the Talma should be resorted to. The shorter, operation sively good results have been attested Riesman.29 The of by hepatic prognosis if treatment is too and not hard, the is not syphilis, pushed patient is to the usual belief.30 Renal is moribund, good, contrary irritability sometimes serious and demands much attention to foci of matter, and so forth. of the while infection, diet, degeneration kidney, Amyloid serious does not contraindícate complication, flatly fairly energetic therapy. In marked the of the fibrous in splenomegaly response spleen, my has not been and when there is experience, accompanying very good, anemia, splenectomy performed by competent operator yields good I an more effective results.31 have that tests on impression therapeutic would more and mean fewer splenomegaly syphilis recognized splenec- tomies performed.32 Gastro-Intestinal the frank Syphilis.—Gastric symptoms, excluding in about one fourth of the cases of crises of tabes dorsalis, are present If the clinical be other than with a late carcinoma, syphilis.33 picture over Wassermann takes reaction, positive therapy precedence operation. deformities. if This of true of But course, is, hour-glass especially are carcinoma is the and probable diagnosis operability prospects good, if the at should come first and treatment second, findings exploration of confirm the Persistence of exploration diagnosis syphilis. gastric considered 28. acute is not here, Syphilitic yellow atrophy (toxic hepatitis) since it is of A to the recent French quasi- an accompaniment early syphilis. key on this be obtained from Milian subject can (Footnote 8). polemic writings the Liver. 29. D.: and Cure of Cirrhosis of Riesman, Spontaneous Operative of Illustrative Cases. A. M. A. 76:288 1921. Report J. (Jan. 29) 30. Wile takes the McNeil of the (Footnote 5) opposite view; (Syphilis Am. 1:738 with me. Liver, J. Syph. [Oct.] agrees 1917) of the status of in thera- 31. A recent summary splenectomy complete is that of Giffin Status of as a peutics (Present Splenectomy Therapeutic Minnesota Med. 4:132 1921). Measure, [March] 32. The Treatment of with Anaemia in Eason, J.: Splenomegaly Syphilitics. M. 21:258 1918. Edinburgh J. (Nov.) This the the Clinic summarized Stokes and 33. is of as by experience Mayo Brehmer in Railroad Indust. 1:419 1920). (Syphilis Employees, J. Hyg. [Jan.] Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 in other than frank after the first few weeks of crises, Symptoms in which clinician will often calls for further an astute treatment, search, or be rewarded with the of duodenal other ulcer, finding appendicitis, or lost of when the Was¬ conditions, slighted sight positive pathologic Persistent instead of sermann reaction was found. nausea, morning a of has in sometimes been attacks, periodic experience symptom my crises. In this cannot connection, morphinism complicating gastric refrain from at the readiness with which at physicians protest large abdominal The tradition has for spasmodic pain. prescribe morphin than a cost lives for there are few more unmanageable problems addict with crises. is the of election in Arsphenamin drug morphin in the entire The is one of the most response syphilis. gratifying gastric of late and but on the extent field of seems syphilis, rarely dependent as indicated the in the case of anatomic roentgen ray, except change by of in occurred in a linitis A 100 weight plástica.34 gain pounds patient cm. a stricture 10 near in at influenza, whom, necropsy following long found which would not a lead the end of the stomach, was pass pyloric cases need consideration. The starvation acidosis in these may pencil. the outlook is the and of the With involvement of rectum, esophagus active infiltration and to the ratio between inflammatory proportional a medical relief. in the late have outlook for scar. Patients stages poor of tests for Renal instituting therapeutic gumma Syphilis.—Before that is not with the should be sure one one reasonably dealing kidney to Infected react unfavorably arsphenamin. kidneys hypernephroma. and tolerate it better than of much Other nephritis nephroses types it with a and be output may employed phenolsulphonephthalein mercury, due to ill this low function be not of zero without effect, provided are not tests for retention. nephritis Therapeutic syphilitic urinary the even the at outset, infallible, though nephritis may respond, always with albuminuria, some to A to extent nephrosis high arsphenamin. with normal blood and casts and function, in the absence of develop may of treatment.35 late in a course vigorous which a rare severe anemias form com¬ Anemia in Syphilis.—The on the or of late whole, syphilis respond, accompaniment plication neither is able than to better to mercury, although perma¬ arsphenamin a in the influence the course of large to pernicious type very nently 157:321 advises Am. M. Sc. [March] 1916) 34. Sailer Plastica, J. (Linitis associated with a Wasser- when linitis is positive treatment for syphilis plastica occurrence of structural in syphilis reaction. The improvement gastric mann of the Stomach: A Clinical and demonstrated Eusterman (Syphilis has been by Am. Sc. with of M. a Report Cases, J. Study Twenty-Three Roentgenological 153:21 [Jan.] 1917). Nederlandsch. v. and 35. Lankhout Kidney Disease, Tijdschr. (Syphilis A. 76:626 abstr. A. M. [Feb. 26] 1921). Geneesk 2:2649, 1920; J. Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 of cases.36 In I have seen case of fact, one majority only primary in anemia which the led me a cure. to Avoidance of response expect reactions is occurrence The of false Wasser¬ highly positive important. mann reactions in anemias has led to more than one primary disappoint¬ of test. Anemias of ing therapeutic secondary type, great persistence, uninfluenced or at most influenced largely any only by temporarily form of occur in late One that I recall treatment, syphilis. responded to removal of a septic gallbladder. Wassermann-resistant instead of dismissed with patients,37 being I intensive and observation. reassurances, need, believe, study lifelong I do believe not the reversal of the Wassermann Paradoxically, however, in reaction to be an end since its relation to the structural or itself, functional is of as obscure. As one's integrity expe¬ any organ yet rience with modern fixed reactions become increases, therapy positive the of inunctions. The use fewer, especially following prolonged Pollitzer technic as a is extolled3S means of especially reversing be a resistant but should used after cases, survey only comprehensive of the case. Other conditions besides underlie an irreversible paresis may test. The resistant Wassermann reaction in children has not reputed materialized either or own. I seen in have Jeans'19 experience my to confirm Strickler's as to the influence of nothing impressions in the or of false arsphenamin production positives.40 persistent Ehrlich's the am to belief Syphilis of Eye.—I returning original that is contraindicated in some cases of arsphenamin distinctly simple neuroretinitis or choked to optic secondary disk), primary atrophy (not I seen a at least in the months of the course. have with early patient vision blind with four and good go totally arsphenamin injections, with due to have to be another, primary optic atrophy, high myopia, to of its On the other transferred because action. focal hand, mercury infections in the stirred cause trouble mouth, up by mercury, occasionally direction. Treatment for with from the other syphilis, especially the has marked effects in and iodids, the nonspecific eye, arsphenamin 36. Gorke von An\l=a"\mienach M\l=u"\nchen. (Auftreton apastischer Salvarsan, med. Wchnschr. 67:1226, Compare also Footnote 9. 1920). 37. Footnote 13. also W. and C. K.: Compare Wile, J., Hasley, Serologic the of Sensitive Wassermann A. M. A. Cure in Light Increasingly Tests, J. (?) 72:1526 1919. (May 24) 38. Footnote first reference. 16, and M.: A Positive Wasser- 39. H. G., Sidlick, D. Strickler, A., Munson, mann Test in Patients After Intravenous A. M. A. Non-syphilitic Therapy, J. 75:1488 1920. 27) (Nov. of the merits this 40. For a critical consideration of question, compare A.: The of Positive Wassermann Reactions Caused the Question by Kolmer, J. of A. Intravenous Administration Arsphenamin, correspondence, M. A. J. 75:1796 1920. (Dec. 25) Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 in which could be more utilized the treatment of uveitis, widely epis- tuberculous and so forth. are cleritis, keratitis, all Ophthalmologists unfamiliar too with the effect of on intestitial keratitis, arsphenamin which is an immense advance over the effect of it mercury, although be combined with it for The must value of months and permanence. of in has been cases years persistence seemingly hopelessly impaired on me. impressed the Ear.—Deafness in or Syphilis of acquired syphilis hereditary should be of its duration. The treated, always intensively regardless exhibits occasional it unexpected patient improvement (test by speaking from behind the to him from In acute patient keep lips). reading I mercurial but I have seen no ill effects onsets prefer preparation, Patients with an from associated make neurosyphilis arsphenamin. may Patients with reactions response. especially good positive Bárány make but believe the some objective improvement, specificity may is still of this to open response question. the Nose and Throat.—The to is Syphilis response arsphenamin of miraculous and sometimese when has been life-saving, deglutition if the involves but the or the obstructed, trachea, process laryrfx immediate use of this even in trivial is lesions, drug, danger¬ seemingly because of the Herxheimer reaction. Provocative ous must procedures used in such On the coincidence not be cases. the of lesions tongue, and new of recurrences is crops undergoing malignant changes possible. have seen for carcinoma on while hemiglossectomy performed gumma, because for the no treatment was another later, given syphilis, gumma allowed to and the other side. The confusion was on develop degenerate of the of with that tuberculosis the of of pathology gumma tongue with a Wassermann reaction is (so-called "tuberculoma") positive more common is than realized. perhaps AND SYPHILIS IN MOTHER CHILD in the mother is one of the richest fields for Syphilis prophylactic effort indicated the influx now available, as of favorable by steady the obstetric services of work of and care clinics,42 reports prenatal 41. Skinner (Syphilis at a Venereal Clinic: An of Cases Admitted Analysis Twelve Lancet 1:650 During Months, [March 20] 1920) points out, however, how few women or for examination treatment short of a report fully developed infection. 42. Williams of in (The Significance Syphilis Prenatal Care and in the Causation of Foetal Bull. 31:141 Death, Johns Hopkins Hosp. [March] 1920) found 53 cent, children of per syphilitic untreated 7.4 cent, of mothers, per mothers treated during also Treatment pregnancy. Compare Adams, J.: of Ante-Natal and Post-Natal Brit. M. 2:541 Syphilis, J. and (Nov. 16) 1918; La mortinatalite Chambrelent: en France. Elle est evitable dans la majorit\l=e'\ des Nourrison 1920. cas, 8:321, Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 in which the is to receive the attention it deserves. problem beginning in should in the child receive the same treatment as Syphilis syphilis the in to a that from adult, response growing appreciation apart and the of untreated uterine infections, stigmatization high mortality it no essential differences. In the untreated presents fact, surviving child has a resistance that is a valuable in Instead of asset treatment. with a recital of technical let summarize what details, me you boring conceive to be essential The relative of the principles. immunity woman from external manifestations of the disease and the suppressing effect and lactation a of has in women in pregnancy placed syphilis field itself. The institution of for the of the child by therapy protection seems to me in in whom evidence of infection women justified syphilitic so is doubtful that the of treatment would be questionable advisability under other circumstances. The studies of Widakowich on sperma- tozoal anomalies and the Eberson in of the male findings syphilitic furnish the first hint of direct influence and raise tangible paternal the of whether or not the father should have treatment as a question as for as much the mother for preparation conception quite gestation. This constitutes what I have both and as "treatment preached practiced for life insurance" in the of a child. have Of late I syphilitic parents radical no can almost to believe that at time the woman grown enough who has had be advised to without a syphilis go through pregnancy treatment course While this would bear hard on the coincidently. mother of nineteen it need not be a to the children, hardship average and if observation of the children thus born should family, might, a relaxation of rules with to it, permit marriage. justify respect methods must be feature of the treatment Spirillicidal prominent the since a maximum of of destruction is, woman, pregnant organisms so as our at least far the best to goes, present knowledge protection the child. There me be from one seem to to reasons for good giving thirds of half to two the full doses all to the woman. around, pregnant Her infection is inhibited her to some extent her liver by pregnancy,45 and are both under as evidenced the familiar intoxi- strain, kidneys by The 43. V.: of Semana med. 27:633 Widakowich, Spermatozoa Syphilitics, A. A. 76:414 (Nov. 11) 1920; abstr. J. M. (Feb. 1921. 5) 44. Routh Action of the Chorionic (Antenatal Suggested Ferments, Syphilis: abstr. Brit. M. 1:47 makes an for a J. [Jan. 12] 1918) interesting argument factor on the basis of also to paternal Noguchi's spirillolysis, attempting explain infection of the fetus in untreated cases. delayed 45. W. and On Brown, Louise: the Reaction of and H., Pearce, Pregnant Females to Inoculation Lactating with Treponema Pallidum\p=m-\APreliminary Note. Am. 4:593 1920. J. Syph. (Oct.) Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 cations and her metabolic and eliminative mechanism of pregnancy, treatment.46 therefore cannot be to massive equal Whether the child will remain is the born crux symptomless so, of the of treatment in mother and child.47 The prophylactic phase after birth in children treated of of periods latency possibility long uterine familiar in the untreated infection as demands well, life, during the fullest of facilities for the and observation development following up of the before the of the child treatment of the cure syphilitic family by as established. mother is accepted of child a commendable toward the show trend Systems treating the realization that most uterine increasing intensity, tempered by and Rosen's of intra¬ is late syphilis syphilis.48 Fordyce advocacy muscular is intended to the arsphenamin apparently popularize drug with those I with that the agree technically inexperienced.50 Jeans seldom or never has need to other than the intravenous use expert route.01 is The tolerance of children for proportionately mercury I than that of and the intramuscular and adults, believe, greater, are a well-deserved As relief inunction routes gaining popularity. from effects of the mercurialization, debilitating prolonged arsphenamin in of children than in that of adults. is even more welcome the treatment in The effect of the two is also valuable obstinate drugs synergistic cases. measures have been used. Intraspinal effectively of for the combined The the school-hospital conception Weylander not and education of children with has received treatment heredosyphilis the attention it should have in this The from the reports country. solves countries and indicate that it the Scandinavian Germany problems of social rehabilitation. care and hospital second reference) liberal doses of 46. Adams (Footnote 42, praises arsphena- mouth. for but his mercurialization is all Williams min mothers, practically by first reference) does not his but it seems to have (Footnote 42, specify technic, been conservative. 47. Much rather is on the child's unguarded emphasis being placed negative test after birth. Wassermann and P. C.: The and Treatment of "Late" 48. B. S., Jeans, Diagnosis Veeder, Am. Dis. Child. 8:283 1914. J. (Oct.) Hereditary Syphilis. 49. and Rosen, I.: A Method of Fordyce, J. A., Treating Congenital Syphilis. M. A. 75:1385 (Nov. 20) 1920. A. J. second commends in one 50. Adams 42, reference) galyl glucose, (Footnote the adult dose. seventeenth of the neo\x=req-\ 51. would be to doses of It interesting apply huge proportionally Mehrtens (Rectal Injections of Massive arsphenamin by rectum, employed by A. M. A. 76:574 1921). Doses of Neo-Arsphenamin, J. [Feb. 26] Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015 CONCLUSIONS This rather review the certain of principles underlying cursory defeat of will its own if it leaves the special phases syphilis purpose that the treatment of the disease should be out in impression parceled each self-sufficient its we and own laws. as segments, governed by Just are that is no even at the earliest finding early syphilis longer localized, of the so we shall as the our find of lesion, intensity appearance primary increases that late does not in the first decade, study syphilis begin but in the first hour. the transmission of the disease in its Preventing earlier and the individual to forestalling stages, tendency complications on of based the of the strain the and the host, peculiarities parasite, method of is the whole of treatment, problem syphilis. Forestalling that an a so implies detection, alertness, increasing diagnostic develop¬ ment of methods for the earliest and not the late of detecting signs in vital and is not but tissues, mere pathologic change organs diagnosis, a our of effective treatment. For all so-called effort, part prophylactic will the of late in certain development complications nothing prevent who combination of the fatal of patients group present predisposed It that smaller soil and is true an even tropic organism. equally group of will master the infection for themselves, of our patients irrespective interference. these come Between two extremes will those whom we have those whom we have to in com¬ radically cured, managed place mensal relation to their those whose we infecting organism, immunity have broken whose for treatment measures future potentialities by as harm as well we do not and those understand, present good yet whom we have treatment itself. The of the destroyed outright by study interrelation one of these is of the most of groups complex problems of Its not be the medicine solution will a today. accomplished by or a of of mental the various and physical separation phases syphilis into each with its own compartments technic, syphilotherapy air-tight and ideals aims. that mode of will leave a Only approach significant on our future which the entire disease, impress knowledge envisages one or two methods in a series cases over a of employs large period of the and records which, observation years, results, lifelong many by and detects serious reexamination, periodic complete impending patho¬ and and evaluates in detail with the of response logic change, accuracy and host. parasite Downloaded From: http://archderm.jamanetwork.com/ by a Oakland University User on 06/13/2015

Journal

Archives of Dermatology and SyphilologyUnpaywall

Published: Dec 1, 1921

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