Reviews.

Grundsätze bei Behandlung der Syphilis. Von DR. BERNHARD BRANDIS, Arzt in Aachen. Berlin: Hirschwald. 1870.

THIS pamphlet, which escaped our notice at the time of its publication, deals with questions which happen to have been recently brought under our personal notice in a striking manner; and as no time can be inappropriate for the discussion of a topic of such constant importance in practice as the treatment of constitutional syphilis, we hope to be excused for commenting upon it at some length.

It would probably be impossible to find, even in the notoriously debateable territory of therapeutics, a question which has excited such disputes and evoked such point-blank contradiction of opinions as that of the use of mercury in syphilis. The fluctuations and diversities of judgment with regard to it have at no time been more remarkable than during the last thirty years; and even now, though the weight of professional opinion is leaning strongly towards the affirmative view, there are persons of intelligence, and even of considerable experience, who denounce the anti-syphilitic employment of mercury in unmeasured terms, declaring it to be both useless and mischievous. To our mind, this last fact affords a very striking proof of the small amount of preliminary mental discipline with which men too commonly undertake the investigation of therapeutic questions. The scepticism that was pardonable and even very salutary as a rebound from the indiscriminate faith in mercurialisation, which formerly did such an immensity of mischief, is now wholly without excuse. Everyone now admits (in theory at least) that the production of ptyalism is needless and wrong; but the very authorities who have most strenuously urged this view have adduced most copious and varied proofs of the beneficial action of small doses of mercury. On the whole it seems evident that the wholesale opponents of mercury in syphilis must have altogether failed to follow up their cases, or they would certainly have encountered numerous instances of

the recurrence of the constitutional disease in the most violent and uncontrollable forms in patients of whose "cure" they had complacently assured themselves. And, on the other hand, it appears impossible that they can have paid any attention to large special classes of syphilitic affections-e.g., infantile and visceral or the superiority of mercurial treatment, for the majority of such cases must have forced itself upon their notice. To all such unbelievers we should recommend the perusal of Dr. Brandis's pamphlet; and if they feel inclined (as we also do) to discount some of the author's opinions on the score of a too enthusiastic bias which makes itself evident here and there, they will nevertheless scarcely fail to perceive that his evidence immensely strengthens the position of mercury as a curative agent in constitutional syphilis. Dr. Brandis calls mercury the "Gegen-gift" (counter-poison) of syphilis; and the use of this word, whether perfectly accurate or not, by so acute and experienced an observer, speaks strongly for the positive character of the facts which have come under his notice.

To those who have never visited Aix-la-Chapelle, it may be necessary to say a few words as to the character of the treatment employed there. The ancient reputation of the sulphurous and alkaline waters is well known, but the special use of mercury (as a supplement to the waters, in syphilis) by Dr. Brandis is probably not very generally understood by English medical men. The mode of application which he uniformly adopts is exclusively that of inunction, and it will certainly surprise a good many persons to learn that an average of thirty-three consecutive daily frictions are administered, 60 to 80 grains (for an adult) or 24 to 32 grains (for a child) of mercurial ointment being used in the course of each day; and sometimes a far longer course of continuous frictions is employed. One would naturally expect that ptyalism must be a not infrequent result of this treatment; but Dr. Brandis expressly states that salivation ought always to be avoided. We shall have to refer to this subject again presently; meanwhile we may quote at length two very interesting examples of the benefits from prolonged mercurial treatment in Dr. Brandis's hands:

1. A boy, four years old, came under treatment in the early part of 1866. His father and mother had suffered long from syphilis, and the former was dead of consumption. The boy was badly nourished, and had from infancy suffered from diarrhoea and bronchitis; it had often seemed doubtful if he could be reared. An inflammation of the cornea was now added to his other afflictions: the eyes streamed with tears, and the child buried its head deep in the clothes in the darkest room. The boy was immediately submitted to the inunction treatment: he had a lukewarm bath daily, after which half a drachm of mer

curial ointment was rubbed in at two places, while the gums were carefully rinsed with tincture of galls; mydriasis was steadily maintained by means of atropine. As the opacity of the cornea continuously increased during the first weeks, Dr. Brandis employed, in addition, iodide of potassium, by the stomach, 10 grains daily. At the same time he paid attention. to the ventilation of the room, and fed the child with milk and concentrated meat-soup. Under this treatment, while not a trace of salivation appeared, nor any other unpleasant consequences, the boy was kept for eight weeks before he could even open his eyes; but from this point there was good progress, and in the course of the following year both cornea were completely cleared of opacity. It was remarkable that the boy increased in general strength after the treatment; at the date of writing (1870) he was attending school, and had ceased to require any special care.

The other child was treated in 1867. His father had been under Brandis some years before, with perforating ulcer of the soft palate, and was cured by a six weeks' course of inunction: the cure remained permanent. This child's case was almost exactly similar in its course to that just related; but on the one hand this boy became much stronger after treatment than the other; and, on the other hand, the last traces of opacity much more gradually cleared up.

If it be remarkable enough, as it surely is, that patients should undergo mercurial frictions for months together without being ptyalised, there is something else which is still more curious. The attendants who carry out the frictions are not allowed to use any glove (as this is supposed to render the inunction much less complete), but work always with the naked palm; they are in the habit of performing inunction on many separate patients in the same day; yet they do not appear ever to become salivated, or show any other signs of mercurial poisoning.

[That the fact is so, we know, not merely from Dr. Brandis's statements, but from private inquiries which we have ourselves made.]

No doubt the thickness of skin upon the palms is one hindrance to the absorption of mercury into the rubber's system; in part it must also be attributed to the fact that the palms are soaped before the inunction is begun, and well washed with soap and water when it is finished; still, when we consider that each of the rubbers performs from ten to fifteen inunetions daily, their universal immunity from mercurial poisoning seems very remarkable.

Dr. Brandis lays great stress upon the necessity of giving the patients thoroughly pure air to breathe, and an excellent nutrition, during the progress of the inunction treatment. He speaks

strongly of the disastrous results which followed the old plan of salivation and residence in a heated room during the process.

As regards the part which the internal use of the sulphur waters plays in the cure of syphilis, Dr. Brandis believes this is entirely in virtue of their action in producing watery purgationtheir eliminative action, in fact. We confess to a very strong suspicion that this is an error, and that sulphur eliminates not one particle of syphilis, though it may (possibly) eliminate some mercury which is in dangerous excess. That purgation, per se, in anywise helps the cure of constitutional syphilis we steadily decline to believe, for we have seen the subjects of this disease submitted to the severest treatment of that nature, with the invariable result that harm, and not good, was done. In short, it may be doubted whether the Aix waters are in anywise effective against syphilis, save by virtue of their heat: and it is plain enough that the main cause of success, at least in Dr. Brandis's hands, is the employment of an unusual, careful, and prolonged mercurial treatment, together with special attention to hygiene and nutrition. One very interesting matter is the way in which the author speaks of iodide of potassium. He does not seem to think it safe even to trust to the use of the iodide alone, but for three reasons he thinks it an indispensable element in treatment : first, because of its utility in bone and periosteum affections; secondly, because of the possibility of pushing its use rapidly, in large doses, when danger is imminent; and, thirdly, because of its great influence at those periods when mercury, having benefited for a time, has temporarily lost its curative power.

We have personally verified, with much curiosity and interest, the effects of the Aix treatment in Dr. Brandis's hands; and in the first place we may say, unreservedly, that as far as immediate effects go, the treatment is remarkably, we might say startlingly, successful. We could more especially speak of several instances in which most lingering cases of syphilitic paralysis have been entirely or almost entirely cured: but we prefer to devote our limited space to one narrative, which is not merely interesting as regards the results of treatment, but exhibits the type, we suspect, of a considerable class of misunderstood cases which are in reality due to syphilis.

A gentleman, aged 32, single, applied to us for advice early in March last, suffering from severe and intractable dyspepsia, which had been, on the whole, constantly and steadily increasing for the last two years, but also was distinctly traceable back to an earlier period, which will be presently referred to. There was no doubt, from his story, that various minor circumstances concurred to aggravate the dyspepsia from time to time: excitement and excess of any kind (he did not exceed in drink) would at once bring on a bad attack; but independently of

this there were almost constant uneasiness at the epigastrium, flatulence, and regurgitation of a portion of any food that might be taken. He was low-spirited and hypochondriacal, and had lost flesh a good deal; said that he had consulted a number of medical men with very little benefit, until three months before his visit to ourselves, when a physician prescribed Easton's syrup. Although this could not be continued for more than a week (as the strychnia produced uncomfortable effects), the patient felt better, and travelled abroad during some weeks succeeding this, with comparatively little discomfort. Almost immediately on his return to England, however, the dyspepsia returned, attended with much agitation and inability to sleep, from the feeling of great discomfort in the stomach.

Following somewhat the lead of his former physician, we commenced the treatment of this patient with nux vomica and bismuth; but he made no progress. We then inquired more particularly into his history, and the following particulars appeared. His health was "magnificent" up to seven or eight years before, when he caught syphilis, and had secondary eruptions: the disease appeared to subside under treatment: nevertheless, he said, he had not been the same man since; and his tendency to dyspepsia began to show itself. Three years ago he got a herpetic rash, sore throat, and other symptoms of what seemed to have been either "mumps" or catarrh, but was followed by an obstinate purulent discharge from the left nostril, which lasted almost down to the time of his visit to ourselves: he at last suppressed it, as he believes, by the use of snuff, but (whether post hoc or propter hoc) he immediately afterwards got "irritable red-brownish blotches" all over the backs of the hands, the wrists, ankles, legs, and trunk. The patient himself suggested, rather earnestly, that the syphilitic taint was the true origin of the dyspepsia, for that the tendency to the latter had always existed since the constitutional disease, though he had been perfectly free from it up to that time. We yielded to his suggestion, and administered grain of hyd. bichl. ter die. The improvement which he made was remarkably rapid; not merely did the regurgitation and other dyspeptic symptoms diminish, but he expressed himself as greatly relieved from his mental depression. After about a week the bichloride was reduced to

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gr. ter die; he took this for another fortnight, and then finally went to Aix-la-Chapelle to finish his cure, as certain traces of the dyspepsia clung to him still. Here he stayed, on the whole, for about five weeks (though in two visits, broken by a journey to England on business), and was submitted by Dr. Brandis to the mercurial inunction. He had, in all, thirty-seven rubbings.

On June 2 this patient called upon us, looking the picture of