CHAPTER III-MEDICINE Injection Treatment of Syphilis by Means of a New Mercurial Formula By M. L. HEIDINGSFELD, Ph. B., M. D., Cincinnati Professor of Dermatology, Laura Memorial Medical College, Clinical Lecturer on Dermatology and Venereal Diseases, Miami Medical College, Dermatologist Presbyterian Hospital In 1853 Alex. Wood,1 of Edinburgh, introduced hypodermic therapy. Mercurial injections were first administered in 1856 by two Englishmen, Charles Hunter and Barclay Hill.2 Hebra,3 in 1864, made a vain effort to treat syphilis constitutionally by means of large injections of corrosive sublimate, and Scarenzio1 one year later carried on more. successful and prolonged investigations by means of calomel injections suspended in gummatous solutions. All the above mercurial investigations, on account of the severe painful reaction induced by their administration, were short-lived, and would doubtless have remained unnoted and obscure had not Lewin,5 in 1868, aroused new and well-sustained interest in this now generally conceded important field of therapy. Mercury, and mercury alone, is the sheet-anchor in the treatment of the earlier stages of syphilis. It matters not through what avenue the administration takes place, whether through the lungs, intestinal tract or skin, or in what particular form, metallic, protoiodid, biniodid, sublimate, yellow-oxid, red-oxid, calomel, salicylate, foramid, soziodol, tannate, etc., it is administrated, it is the assimilated mercury which is effective; each preparation and each form of administration has its peculiar advantages and objections, and the method which presents the happiest combination of large dosage, easy tolerance, convenient administration, absolute control, and excellence in clinical results will readily appeal to be the most acceptable and preferable. The inunction method is the oldest, and though eminently reliable, efficacious, and very generally employed, it has its serious objections. The rubbing of a dirty ointment over the entire body is uncleanly, courts comment and publicity, soils bed-linen and undergarments, frequently induces an artificial dermatitis, is contraindicated in hairy individuals, precludes frequent bathing, and without the aid of an attendant is applied with difficulty. Inasmuch as mercury is volatile at ordinary temperatures, and more rapidly at body temperature, this form of administration is essentially an inhalation treatment, and as such is strongly contraindicted in hemoptysis and phthisis, an objection which applies to the inhalation treatment in every form, whether it be worn in sacks (Welander), or as Mercolint (Blaschko).7 Moreover the treatment is inexact. The internal administration is a simple, convenient and popular form of treatment. It is eminently an inaccurate method because it is impossible to determine how little or how much mercury is assimilated. This is particularly true if, as frequently happens, gastrointestinal symptoms intervene, or if old, inspissated-gelatin-coated pills, or too strongly compressed tablets, are administered. The gastrointestinal disturbance is often sufficient to distress the patient, impair digestion, induce loss of weight and to exert debilitating influences of considerable moment to this class of patients. What is probably the most serious of all objections is the fact that the assimilated mercury, for the most part, is carried directly to the liver, which, as we are beginning to believe, exerts a marked filtering, altering, and eliminating influence on toxic substances. This form of treatment also permits the patient to continue indefinitely, discontinue, or renew treatment in accordance with his own volition, and thereby removes him from the regulating attention and vigilance of the physician. Other forms of treatment, vapor-baths, water-baths, wearing of mercurial cloth, sacks, etc., though useful as adjuvants, have not as yet received the stamp of general approval of being sufficiently active and reliable to merit special consideration in the presentation of this paper. The method of injection which has been employed since 1856, as already stated, has at times received popular favor, and at times has fallen into disrepute, according to the conditions which on the one hand recommend it above all other methods, and on the other renders it more objectionable. If the objections, which are largely technical, can be overcome, the features which commend this form of treatment are so pronounced as to render the method justly popular and ideal.. White,20 as early as 1894, when the method was relatively in its infancy, and its technic imperfect, in a series of interrogations addressed to all the leading writers and teachers of syphiology, demonstrated that the method at that time had come into very general and popular favor, and elicited the expression of a satisfactory past and a hopeful future. To Lewin8 belongs the credit of demonstrating that the injection treatment can be successfully employed in supplanting, with desirable effect, the other forms of constitutional treatment of syphilis, an observation that was promptly confirmed by Sigmund and Zeiss1.10 Lewin11 demonstrated by means of a series of 14,000 cases that the duration of treatment was shortened from 10 to four weeks, that recurrences diminished from 80% to 40%, and that rapidity of action, exactness of dose, and immunity from gastrointestinal disturbances, aside from the numerous objections to other forms of treatment, strongly recommended the method of injection. For the injection treatment, mercury in almost every form, sublimate, calomel, yellow-oxid, salicylate, soziodol, formamid, metallic, bicyanid, glycocol, asparagin, alanin, thymoloaceticum, and in almost every combination, albuminates, peptonates, benzoated, suspensions in mucilage, oil of vaselin, olive-oil, paraffin, oil of sweet almonds, etc., has been employed. A brief survey of this unusually large field of literature, and a careful estimation of its results, will serve to demonstrate that in injection therapy also efficacy and success depend largely, if not solely, on tolerance, convenience, and dosage. That the injection method, by meeting certain requirements, possesses decided advantages over other forms of treatment, is evidenced by the innumerable attempts at substitution; that these requirements have not as yet been satisfactorily fulfiled is evidenced by the fact that nearly all have been short-lived or their use limited to relatively few individuals, and that the other forms of administration still find a large and generous patronage. This paper will not permit me to enter into the consideration of the nonsuccess of the many remedies which have been employed and recommended for injection use. It will suffice to say that bichlorid, which has been received into most generous favor, proved too painful to be well tolerated, causing patients to involuntarily withdraw from treatment, often induced abscess-formation and severe induration, and could be administered only in such small doses as to require almost daily visits which is ordinarily too expensive and too time-consuming for the patient. Pain, abscess formation, and induration militated against calomel and salicylate injections, and graver complications in intravenous injections. A preparation which meets the requirements more successfully, I believe, than any other is the Ol. Cinereum, or gray-oil after the formula of Lang.12 This formula, with the following modifications, has been almost exclusively employed by me in both clinical and private practice for almost a year with most gratifying results. I found the injection as originally prepared, according to Lang, to be somewhat irritating and difficult to preserve. The modified form is prepared by using bidistilled mercury, the same that dentists use in preparing amalgams. Six grammes of bidistilled mercury can be readily incorporated in the course of a few minutes with two grammes of lanolin, when rubbed together in a clean mortar, which dispenses with the use of chloroform, which is a decided irritant, and is not, I believe, completely eliminated in the ordinary process of preparation. This simple modification did not suffice in itself to render the preparation as unirritating as desirable. Substitutions for oil of vaselin were successively tried with oleic acid, liquid paraffin, castor-oil, cotton-seed oil, olive-oil, etc., before a preparation was found which successfully combined stability with nonirritability. This ingredient proved to be liquid albolene, which not only held the constitutents well suspended and rendered them unaffected by ordinary temperature 'changes, but made the preparation so fluid that it could be readily utilized for injection purposes, though the mercury was increased from 50% to even 75%. The following has proved to be an excellent working formula, and can be readily prepared, with a proper regard for asepsis and cleanliness, by an office girl of average intelligence: Conteratur usque ad perfect extinctionem hydrargeri. 2.0 6.0 2.0 S. inject one minim grain (.06) every three or four days. This preparation can be readily drawn to a hypodermic syringe, the needle applied, and successive doses measured off by means of the retaining screw (A, Fig. 1) until the syringe is exhausted. One additional syringeful can be held in reserve, and in this manner the treatment of each individual patient requires but a few moments of time. The inctions should be preferably into the buttocks, at their most |