ALOPECIA. Falling of the hair due to syphilis is of two kinds. Where there are scabby sores on the scalp, and especially in later ulcerative disease, the hair-follicles over limited areas become destroyed, in which case the fallen hair is not reproduced. Ordinarily, however, general baldness occasioned by syphilis is only temporary. In fact, baldness usually produced, but only a considerable thinning of the hair generally, or in mottled patches, not only of the scalp, but of the eyebrows, eyelids, whiskers, and, to a degree, of the whole body. Alopecia is sometimes complete over the entire body. More or less local alopecia is sometimes met with (on the fronto-temporal region) in cases of inherited syphilis (Barlow,* Parrot f). In acquired syphilis the thinning of the hair is due to one of two causes (that is, when there is no eruption or ulceration involving the hair papillæ): (1) The syphilitic hydræmia, which, like thin-bloodedness from any other acute cause (fever), temporarily impairs the vitality of the hairpapillæ, causing the hair to lose its luster and then to fall out. (2) A seborrhoea, the sebaceous matter clogging the hair-follicle, pressing upon the papilla, ultimately leading to the fall of the hair, and possibly, in some cases, to the atrophy of the papilla. The dried sebaceous matter mixed with scales may usually be scraped away plentifully from the scalp around the hairs. Treatment.-Although some falling off of the hair is often inevitable, yet the quantity may be lessened by attention to the hygiene of the scalp, shampooing once a week with ammonia or borax in warm water (a teaspoonful to the pint) to get rid of the accumulating sebaceous matter, and the use afterward of a stimulating lotion, of which a little may be rubbed upon the scalp nightly. One of the best of these is : B Tr. capsici, Aquæ Cologniensis, 3 ij-v. 3 j. Where sores infest the scalp, general treatment alone is to be relied upon. INDOLENT GLANDULAR ENGORGEMENT. Coincidently with the first outbreak of general syphilis, sometimes preceding the eruption, more often shortly following it, there is a marked tendency to a general indolent engorgement of the lymphatic glands. This concomitant symptom rarely fails, and it furnishes a diagnostic mark of the first importance in all doubtful cases. The * "Lancet," August 22, 1877. "Progrés Médical," 1878, No. 22. enlargement of the glands does not necessarily depend upon the occurrence of an eruption, since it is encountered where close observation fails to detect any neighboring exanthem. This is particularly true of the post-cervical and epitrochlear glands. The engorgement of the glands is indolent, painless. They are usually of a cartilaginous hardness, insensitive to pressure, varying in size from a small pea to a marble. The coincident indolent engorgement of certain glands is almost pathognomonic of syphilis. These are the post-cervical (posterior chain), markedly two little glands lying high up on either side of the nucha, upon the occipital bone; a gland over the mastoid process of the temporal bone; and the epitrochlear gland (or glands) on either side, just above and without the inner condyle of the humerus. Other glands may also become indolently engorged, but more rarely; as, the lateral or the cervical, the axillary, the inguinal (where the chancre is extragenital, and where these glands consequently have escaped primary infection); but the glands of most assistance to diagnosis are undoubtedly the post-cervical and epitrochlear, and these should be sought for in all cases to confirm the diagnosis of general syphilis. SORE-THROAT. Sore-throat is a concomitant symptom of all stages of general syphilis. There are three type varieties: 1. A diffuse general redness, with or without ulceration. 2. A certain amount of chronic congestion, and brawny thickening about mucous patches or atonic ulcers. 3. Destructive ulceration from gummy deposit. The first variety is an early secondary phenomenon, and alone of the three is a concomitant of the early syphilides; the second may occur along with the later secondary and earlier tertiary lesions; the third is tertiary. They will be described in connection with the other symptoms. Recently Fournier * has noted, as a concomitant symptom of the earlier secondary period of syphilis, certain aberrations of cutaneous sensibility, such as loss of ordinary cutaneous sensitiveness (anæsthesia), inability to appreciate the sensations of heat and cold, and complete insensitiveness to pain (analgesia); these either general or more commonly confined to limited areas of skin, notably the extremities. The back of the hand over the wrist is a favorite location. The trouble is a passing one, not lasting more than a few months, and has been observed by Fournier chiefly in women. It is questionable whether hysteria may not often play a prominent part in the causa"Annales de Dermatologie et de Syphilographie," tome i, 1869, p. 486. Syphilis," Paris, 1873. "Sur la tion of these phenomena. Fournier's observations include over a hun dred cases. Iritis concludes the group of concomitant symptoms. It will be described later. CHAPTER V. GENERAL TREATMENT OF SYPHILIS. Hygienic, Tonic, Specific Treatment.-Syphilization.-Treatment of Early Syphilis. -Bad Effects of Mercury. Methods of administering Mercury.-Treatment of Late Syphilis.-Mixed Treatment. -Treatment by the Iodides.-Methods of administering Iodine in Syphilis.- Quantity of Iodide which may be required.-Duration of General Treatment. THE general* treatment of syphilis is hygienic, tonic, and specific. The latter is often ineffective unless aided by the former. Neither should be depended upon alone. They form component parts of one rational system. Hygienic Treatment.—The hygienic treatment of syphilis includes all the ordinary laws of health. Regularity of the habits-especially of those of eating and sleeping, and of those involved in the performance of intestinal functions-is all-important. No deviations need be made from ordinary diet. Excesses of any kind are bad, even emotional (fear, anger), and especially excesses in strong drink, in work, in venery. The function of the skin should receive attention through scrupulous cleanliness. Warm baths are more cleanly and relaxing to the skin than cold. If baths be too hot early in the disease, they are apt to call out a more plentiful crop of eruption. Catching cold should be avoided. It is apt to induce and prolong mucous and ulcerative patches about the mouth, nose, and throat. Singing, and loud and continuous talking, are objectionable in subjects having weak throats. Experience has taught that tobacco in all forms, and even highlyseasoned food, is certainly injurious, in irritating and keeping up an outcrop of mucous patches. Air, exercise, and light, essentially necessary to all animal well-being, are particularly so in the case of obstinate chronic or advancing disease. Change of air in some of these cases is essential to the success of treatment, as a trip to the country, change from the seaboard to the mountains, or from inland to the shore, and then perhaps back again, six weeks being usually long enough in any locality to obtain its maximum effect for good. I have more than once observed, when I could not so manage it with a patient in New York that his stomach could be made to toler *The local and special means required for the different manifestations of the disease will be detailed under the heads of the symptoms requiring them. ate a high enough dose of the iodide of potassium to control his lesions (this notably in tertiary conditions), that a few days in the country would so hold the patient up that he could take his dose, and that his symptoms would promptly change for the better. I have noticed the same fact in connection with patients sent to me from Chicago and elsewhere; they could with ease and advantage tolerate heavier medication in New York than at home. The rule is positive. Many obstinate bad cases of late secondary and tertiary disease, which fail to respond to treatment in their homes, especially if that home be in the city, make rapid strides toward recovery as soon as the air and surroundings have been modified. Mercury and the iodides will not cure all syphilis, as many practitioners seem to believe. The old chronic cases, remaining from year to year in our large hospitals, and relapsing endlessly in the damp and crowded tenements of our large cities, are not in need of medical treatment, for this they have and of the best; but what they need is intelligent hygiene, and with its assistance many of them would recover. In the hygienic category naturally belongs all tonic and supportive medication. Cod-liver oil, iron, quinine, and all lesser helps, find ample space to vindicate their claims at some part of the treatment of most cases. Without them specific treatment is often unworthy the name. In the hydræmic stage, just before and during syphilitic fever and the earlier exanthemata, as well as during portions of the later cachexiæ, these remedies are of the greatest value, and may occasionally be used alone with advantage until the general tone of the patient can be elevated; after which the prompt efficiency of the specifics, intelligently administered, gives them a claim to the title of being the most reliable drugs used in the practice of medicine. There are, however, certain phases of syphilitic cachexia over which no tonics act with the same efficiency as minute doses of mercury, especially corrosive sublimate, in women preferably combined with iron. Specific Treatment of Syphilis.-But few known remedies have been left untried in the treatment of syphilis. Besides the old-fashioned sarsaparilla, guaiac, mezereon, stillingia, cundurango, and a host of other vegetable remedies, we have in these modern days cascara amarga, tuyuya, the vegetable combination suggested by Simms, called succus alterans, and many other inferior and purely quackish remedies. The claims of few of these need detain us. Most of the syphilides, especially the earlier varieties, are self-limiting, and will get well under any treatment-one might even say in spite of treatment. Mild cases, especially in married women, often go untreated, unrecognized indeed, and the patients never suffer any considerable inconvenience. It is on cases of this order that anti-mercurialists build their theories, substantiating the latter by reference to cases in themselves inveterate and malignant in spite of the use of mercury, or perhaps in connection with its improper use. No treatment may be better than overtreatment. Indeed, the lesions often get well spontaneously upon the advent of some other malady.* This seems to be especially true of erysipelas. Ch. Mauriac,† in a monograph, maintains that erysipelas acts upon syphilis in a general as well as in a local way, lesions getting well which are never touched by the erysipelatous redness, but less promptly as they are more distant. The different vegetable decoctions and infusions, of which sarsaparilla takes the lead, assist digestion, promote the action of the skin, encourage the functional activity of the kidney, and please the patient. They may be adjuvants in certain cases, and should be perhaps ranked along with hygienic and tonic means, but they have not merited by their action any right to the term curative in its narrowest sense, since they do not demonstrably postpone relapses or shorten the duration of existing symptoms any more than other hygienic and tonic means. I think it is not doubtful that Zittmann's decoction is a remedy of positive value, especially in late syphilis, when there is cachexia, anæmia, irritable stomach, loss of appetite, moderate constipation, and particularly when the stomach will not take the iodides kindly. The senna encourages intestinal action, the sarsaparilla undoubtedly has an influence, because if left out the remedy is decidedly less effective, and the mercury is presented in a suitable way to exercise its tonic effect. But the old-fashioned Zittmann's decoction was full of unnecessary ingredients in its composition, and was troublesome to make, difficult to take on account of the quantity required as a dose, and its administration was surrounded by unnecessary rules and precautions. Starting with the original decoction, and then modifying it by McDonnell's formula, I have gradually dropped one thing after another until I have now come to use (often with decided advantage in cachectic cases of old syphilis needing a tonic course) the following formula, of which I usually order a tablespoonful to be taken several times a day, regulating the dose somewhat according to the purgative effect: I have not found the advantage in pilocarpine which it has been suggested it would afford. As to the succus alterans alone, I am sure it is unnecessary in sec* Petrowsky, referred to in "Medical Record," May 6, 1882, p. 487. "Étude clinique sur l'influence curative de l'erysipele dans la Syphilis," Paris, 1873. |