times cases are found that have the appearance of general malaise. I doubt if we ever see a case of syphilis in which we can begin with the primary lesion wherein yellowness, et cetera, of the skin are not noticed, and certain neuralgic pains complained of. The difficulty, of course, lies in making the diagnosis. As an illustration, three men have been under my care during the last three months with exactly similar sores, just behind the glans, varying in size from a bead to a bean. There was enlargement of the glans and a certain amount of induration of the sores which were somewhat ulcerated, and red at the bases. Two of the men are married and were very anxious. I think that when a man comes to us with a suspicious sore the first desideratum is to gain his confidence. If we can impress him with the fact that we know what we are doing and what is best for him, we can treat him successfully. One of these men was in a great furore. He was, practically, insane. It took me some time to gain his confidence. I told him, “I cannot tell and will defy any man ro tell whether you have syphilis or not. No harm will come to you if I watch this for ten days or two weeks; just as soon as I find that you have syphilis, will I begin energetic treatment. Two of the men did not have syphilis; the other one did. Just as soon as I am sure that a man has a chancre I commence treatment, but I want to be positive that he has syphilis. There are a great many things that are exactly like exanthema. How do we know that this primary lesion is at the point at which the virus enters into the system? There have been experiments made in removing chancre a series of ten or twelve-in which five showed no symptoms of syphilis afterward. Of course there is much in DOCTOR BREAKEY's paper regarding the treatment, but I want to say just a word regarding the evidence that we are giving sufficient mercury. Never trust to colicky sensations of the bowels. They are not worth noting. The only evidence that a man could place any reliance upon is that condition approaching salivation. That the effluence is an eliminating process is a question. We regard the primary symptoms as a deposit of new and syphilitic material in those sites. It is reabsorbed and breaks down and the ulceration follows. DOCTOR NEWMAN: I do not believe in beginning treatment of a case until the approach of the secondary symptoms. It is impossible to be absolutely certain of the diagnosis until some of the secondary symptoms appear, and if we do begin treatment before that we simply obscure the symptoms and prevent a further treatment of the cases on definite principles. DOCTOR PARKER: The question of making a diagnosis before beginning the treatment is an important one. In regard to the tolerance of the individual to mercury, I have a working rule. I begin with a quarter of a grain of protoiodid of mercury twice a day for a few days; then three times a day; then after three or four days, I add a quarter of a grain more, making a full grain in a day; after three or four days more, I add to the original dose, watching the teeth in the meantime for blue lines. As soon as salivation begins I discontinue dosage a few days. DOCTOR BREAKEY: The point referred to by DOCTOR CARRIER as to the resemblance to exanthema I endeavord to make clear, and also that it was formulating an argument of inference and analogy as to any even remote resemblance between the exanthematous condition and the pure exanthema.. I have a few photographs illustrating tertiary syphilis in a patient whose initial lesion was cauterized. The sores were healed; and the patient was said to be cured. Many years ago I treated syphilis in much the same way that DOCTOR BIDDLE advises. I felt it my duty to begin treatment at once. I have gradually gotten over that idea. One must not necessarily be too active and officious in order to do good. No prominent author in this country recommends such a course of treatment. TAYLOR, FOX, DUHRING, ELIOT, HYDE, Culver, Keyes, VAN BUREN, and many others all endorse the treatment that I have outlined, and some wait until the eruption is well pronounced. As to DOCTOR BIDDLE'S patients, the older one I did not see until he came before you. I should class them as cases of tertiary rather than secondary syphilis. As to the colored man I wish to state that while the eruption is symmetrically and generally not inconsist ent with the syphilitic eruption, it also has the remarkable feature of itching which with the acne character of the lesions tends to bring it under the head of complications of some subacute condition. I still contend that cauterization or premature mercurial medication might delay an eruption a long time. Whether for a year I am not prepared to say. As to the question of cauterization, I would not consider the application of some of the things mentioned cauterization. If there is a condition present that leads to phagadena, that condition requires cauterization. I understand by cauterization a destruction of the tissue I endeavored to speak of typical cases. I think DoCTOR BIDDLE will find that even in those particular cases which he is anxious to have improve promptly it is a question whether they get better as quickly or stay better by that mode of treatment. Nitrate of silver is not a good cautery. It is liable to aggravate the condition. How will the curing of the sore hasten the recovery of the patient? If we keep the sore clean and dry it tends to heal spontaneously as long as it is typical. If the infection is chancroidal it should be treated as any other ulcer of an actively infectious character. I do not want the society to infer that the speculative part of my paper can be maintained except by analogy. It is not strange that we cannot demonstrate our theories; because we do not know how syphilis is caused or eliminated. We cannot demonstrate on the lower animals. 'If I had a patient on whom I would dare to experiment I should like to try infecting by scales of skin in the secondary stage. I did not go into details about this in the paper. It seems to me that DOCTOR BIDDLE has a wrong conception of the disease if he supposes that the constitutional infection will be materially influenced by local treatment, whether it be cauterization, excision, or medication. I think in my paper I did advise waiting for the secondary eruption. At the same time I should probably do, in exceptional cases with phagadenic or other complications, somewhat as Doctor BiddlE says. I still contend that as a rule nothing is lost by waiting until some secondary lesions of the skin appear. They do not always appear, but my experience is that if the case is not interfered with enough appear to make diagnosis positive. Patients have often gone through the state of secondary eruption and never known it. As to waiting, we do not wait inactively or indifferently. Before pronouncing sentence upon a patient to undergo a course of treatment for two or three years, we shouid wait and be sure. I have little difficulty in holding. patients because of the local sore. I try to teach them that the lesion is not the disease and that constitutional infection already exists, that an eruption is to be expected and is favorable. I have many cases in which the lesions had been cauterized and otherwise treated specifically on first appearance, and pronounced cured or not to have been syphilis. How ever, after a latent period constitutional effects develop in unexpected and unusual ways—as gumma, ulceration, or paralysis. DOCTOR ROBBINS: What has been your experience in finding a small sore followed after the proper length of time by a mild efflorescence which seemed a positive symptom but disappeared after six or seven days? Do red eruptions ever follow? DOCTOR BREAKEY: I have known of several such cases. Many, no doubt, get well-extra strong, vigorous fellows who will live through almost anything, and sometimes even recover from syphilitic infection without any treatment. DOCTOR ROBBINS: A young, vigorous man showed a small indurated sore on the foreskin, one-third of an inch back of the narrowing. The glans was larger on the crown than I believe it should have been. I told him to come back in a week. On his second visit I found the crown somewhat larger than when I saw him the week before, but the body was covered with a beautiful efflorescence. I pronounced the affection syphilis. He recovered and has been perfectly well since. EDITORIAL ARTICLES. THE USE OF MERCURY AND THE EFFLORESCENCE OF SYPHILIS. ELSEWHERE in this number will be found an excellent and very readable essay on "The Elimination and Curability of Syphilis." The writer has not only summed up the results of a lifetime of observations but also gauged pretty accurately the authoritative opinions of syphilographers generally. The views expressed cannot be disdainfully rejected, no matter how strongly one may oppose to them their own judgment and experience. However, until the subject is cleared up at every point there is room for honest contraopinions. It is a common view, in which the writer of the essay referred to shares, that the typical efflorescence of syphilis not only aids materially in the diagnosis of the disease but also constitutes an important and even desirable link or stage in its course; that the exhibition of mercury previous to the appearance of this eruption at least modifies if it does not interrupt it; and that therefore mercury should not be used until the full bloom has appeared. It may be that any difference of opinion that may exist will depend solely upon what is to determine a sure diagnosis. In this respect, however, practice is certain to vary, for one may see sufficient evidence in a case to assert a diagnosis while another will postpone his decision until the efflorescence is seen. The former see only folly in waiting, since in many cases the typical eruption does not appear, and the latter is fully satisfied, providing he is not the patient. No one will assume syphilis to be a desirable affliction. It is a good thing to be cocksure of the diagnosis. But once sure of it what is to be done? Shall we wait for the disease to evolve? for the body to become saturated with the loathsome poison before taking active steps to rid our . patient of it? Do we withhold quinin in the presence of malaria? Do we allow diphtheria to evolve a membrane within the larynx before administering antitoxin? Why do we vaccinate before the smallpox has broken out? Such questions are significant in this connection and much fuller of meaning than the superstitious analogy, between syphilis and scarlet fever or measles. For neither measles nor scarlet fever have we a specific remedy. Both are treated symptomatically, empirically. It is true we do not know what mercury does with the poison of syphilis. It forms albuminates in the body and most always acts magically in curing the patient. It is positive and specific. Why then not have recourse to it at once? The question is a fair one to ask, is there not too much sentimentality about the mere fact of having or not having syphilis? If syphilis is to be successfully treated mus it not be attacked as soon as the system is invaded? With reference to the insufficiency of mercury in preventing recurring symptoms cases are cited in which tertiary symptoms have appeared even after a course of mercurial treatment. Such criticisms are worthless since it may be insisted with as firm tenacity that those symptoms might have been ten fold more severe had not the treatment been given, and no one could gainsay it. In surgery we have fortunately gotten away from the theory of laudable pus and we evacuate or remove the abscess before metastasis has taken place, but in syphilitic practice we seem still to cling to the dark ages of treatment. Syphilis strikes a mortal blow; its effect is slow and yet it begins at once its deadly work. In mercury we have a weapon of great power, but we generally refuse even its defensive aid at the time when, according to analogy, it should prove most effective. ANNOTATIONS. THE BATTLE CREEK MEETING. TIME has gone on apace and the date for the next meeting of the State society is near at hand. PREsident PatteRSON, of Charlotte, will rap the meeting to order at Battle Creek on May 15th. The General Secretary and the officers of the sections have industriously prepared an attractive program. As the place of meeting is centrally located and the time convenient there should be an unusually large attendance. This is a year when the so-called country doctors should be largely in the majority. Lay your plans now to be away from home and business for two days. THE PANAMERICAN EMERGENCY HOSPITAL. WHEN it is noted that about three thousand cases were treated at the Omaha Exposition, and that at the World's Fair at Chicago nearly twelve thousand were cared for, and that there were sixty-nine deaths, the necessity of ample arrangements on all such occasions becomes apparent. Information has been publicly given out relative to the Emergency Hospital at the Buffalo Exposition. An artistic and convenient structure has been put up and equipped with the requisite number of cots, baths, medical and surgical appliances, litters and ambulances, and a staff appointed, of which DOCTOR ROSWELL PARK has been announced as director. The management assures us that it is hoped there will be little need for this department, but there is no doubt that many will have just cause for appreciating the wise provision. THE HOSPITALS OF JAPAN. ACCORDING to DOCTOR E. C. REGISTER, who recently made a tour through Japan, and contributed to the Charlotte Medical Journal an interesting description of her hospitals, that country of forty-five million people has only ten hospitals worthy of the name. Two of these are located at Tokyo, the capital, two at Kioto, the old capital, two at Kobe, and one at each of the following cities: Yokohoma, Nagoya, Osaka, and Nagasaki. The Imperial University Hospital at Tokyo is as large as all the others combined. It has eighty resident physicians and six hundred trained nurses. The average number of patients treated there is twenty-two hundred, and in the various outdoor departments many thousand sick people are treated annually. It is well equipped and up-todate, as are also the General Hospital at Tokyo, the Kioto Hospital Medical School, and the Kobe Hospital. Tubercular patients constitute from thirty-five to forty per cent. of the inmates, due undoubtedly to modes of living. Rheumatism was observed to be the next most prevalent disease while skin diseases are very rare. Surgical practice is limited, owing to long established prejudice, but the most modern methods and appliances were seen to be skillfully used. Apparently no regard was paid to sex either in wards or operating rooms. Both sexes were often in the same ward, being bathed and dressed at the same time, without any embarrassment to any one, In the Kobe Hospital seven operations were observed in the same room at one time. It had no preparatory anteroom for undressing and dressing. Female as well as male patients were admitted and treated or operated upon as their time came. One surgeon was operating for urethral stricture in the male, another setting a broken arm for a little boy, while another was doing gynecologic work. Nudity is everywhere but is never looked at. MEDICAL NEWS. PROGRAM OF THE THIRTY-SIXTH ANNUAL MEETING OF GENERAL SESSION. First Day-Wednesday, May 15, 8:30 a. m. 1. Called to order by the President, P. D. Patterson. 2. Opening prayer by Reverend Wm. S. Potter, Battle Creek. 3. Address of welcome by the Mayor, Doctor L. M. Gillette. 4. Report of Executive Committee, W. H. Haughey, Battle Creek, Chairman. 5. Annual Reports of Secretary, Treasurer and Chairman of Publication Committee. 6. First Report of Committee on Admis sion, J. B. Griswold, Grand Rapids, Chair man. |