VI. GENERAL DIAGNOSIS, PROGNOSIS, AND TREATMENT OF SECONDARY SYPHILIS
Secale 88. Diagnosis.
In most cases, if the question is merely to distinguish syphilitic products from similar products of syphilitic diseases, such a diagnosis is comparatively easy. All syphilitic products are so characteristic in their appearance that any one who has seen them only once, and has read our description of these products in the following paragraphs, can scarcely ever remain in doubt concerning their true nature, so much more as, besides the anamnestic influences bearing upon the case, the diagnosis is facilitated by this other circumstance, that these secondary forms or products never occur singly, but always in company with others; for instance, ulcerations of the mucous membranes, or affections of bones, in company with suspicious cutaneous eruptions, or several kinds of the different syphilidae, such as pustules, maculae, herpes, etc., at one and the same time. At the same time, a close examination will very frequently reveal the existence of old chancres in the period of reproduction, or remnants of badly healed cicatrices, even mucous tubercles, or other remnants of the second or transition-stage of the primary period; for the reason that the secondary period does not set in after the completion of the primary period, but while the transition-stage is still running its course, or even simultaneously with its commencement. This takes place likewise with other diseases, where the different stages are not always sharply circumscribed. This simultaneity, in the manifestation of different forms, likewise distinguishes the secondary period of syphilis with great definiteness from the primary. If, in the course of a neglected chancre, sycosic, gonorrhoea, or other primary appearances, pustules or other syphilitic manifestations on the skin supervene, we may rest assured that the secondary period has already commenced and that the existence of a general constitutional infection will very soon become manifest by the supervention of other symptoms. If the diagnosis of true syphilis is in all cases unattended with any marked difficulties, on the other hand, it is not always equally easy to diagnose the true character of similar appearances in case they appertain to non- syphilitic diseases; the probability is, therefore, that phenomena which have not the remotest connection with syphilis may be mistaken for syphilitic symptoms much more frequently, than that a somewhat practised physician should misapprehend truly syphilitic phenomena for manifestations of a non-syphilitic disease. Such misapprehensions are more apt to occur in regard to mercurial symptoms, which, after the effects of mercury have reached a certain point, share with secondary syphilis the faculty of not only producing local phenomena that are readily mistaken for syphilitic appearances, but of producing several of them at once and at the same time. There is no other way of avoiding such misapprehensions than to become perfectly familiar with the analogous effects of Mercury. In order to facilitate this study, I have added at the close of this work an article on the so-called mercurial syphilis, which the practitioner will do well to compare with the symptoms in the case of patients, who, some time previous, had been treated with large quantities of Mercury for real or supposed syphilis, who had been much exposed to the influence of Mercury in their business. Many of these mercurial symptoms I have seen breaking out even after a persistent homoeopathic treatment with large doses, not only ulcers and aphthae in the buccal cavity, but likewise papulae and flat ulcers on the skin, of a very suspicious look, but distinguished from syphilitic ulcers by the pruritus which is never present with the last-named products of disease.
Secale 89. Prognosis.
If the syphilitic disease has left the primary stage, and has passed into the second stage, the prognosis is, in so far, some- what unfavorable, as the symptoms of the second stage are rather changeable, sometimes disappearing suddenly in order to reappear again in other localities, and in different forms, so that the physician can scarcely ever be certain whether, after the existing phenomena have apparently been cured, other phenomena may not break out in their place. What has been said of the greater or less curability of some of the above-mentioned forms- such as that cutaneous affections generally admit of a more favorable prognosis than affections of the mucous membranes, and these again of a more favorable prognosis than the affections of the osseous system can only refer to the more or less accelerated, or retarded disappearance of these forms, but not to the morbid process in the interior of the organism in which these forms originate. To eradicate this process, and not merely to suppress a few isolated manifestations thereof, should be the task of the true healing art. If we keep this task in view, there is no doubt that the solution of this problem is infinitely more difficult than the removal of primary, and more particularly of protopathic symptoms, which, if accomplished by means of a rational internal treatment, always results in a simultaneous annihilation of the whole morbid process. Even during the transition-period, when no other than primary symptoms are as yet in evidence, it may happen, as in Dr. Thorer’s cases, quoted in No. 78, that, after the cure of the existing form, another form may break out, for the reason that one single remedy is scarcely ever sufficient, in the secondary period, to overcome and excrete the contagium after its nature had become modified by the most diversified combinations. Nevertheless, radical cure is still possible even in these cases, provided the physician knows what remedies will surely lead to this result; although we should never expect to accomplish such a cure as rapidly as we cure primary ulcers; notwithstanding that, even after curing them, we still have to keep a watchful eye on that which may yet happen to come afterwards. That the probability of the supervension of the subsequent symptoms is the greater, the more remotely from the primary symptoms the manifestation of secondary phenomena takes place, and the more complete the disappearance of the earlier symptoms appertaining to this period, is self-evident. If the physician, while the primary signs of the disease are still visible upon the sexual organs, should be very cautious in his promises concerning the possible supervention of subsequent phenomena; he will have to push this caution to the highest degree if, when taking charge of his patient, every symptom of the primary disease has already vanished from the sphere of ocular observation. However, under a truly rational treatment, the symptoms will gradually become weaker at every successive outbreak, so that even in the worst cases, the patient may be dismissed as cured, after the lapse of two or three years, provided no new symptoms have appeared for the last year. But, if the patient had been treated with large doses of Mercury, and if the syphilitic symptoms had become mixed up with the effects of Mercury, the final radical treatment may have to be conducted for a much longer period, for the reason that the mercurial symptoms like the syphilitic, may reappear at intervals, and, unless over- come from their very foundation, may, if left to themselves, continue their assaults for a period of ten, and even twenty years.
Secale 90. General Treatment of Secondary Phenomena.
Howsoever indispensable the mercurial preparations may be to the cure of syphilis, more specially during the primary period, or the period of protopathic phenomena, and even to some extent during the second stage of these phenomena, yet in treating secondary symptoms, we shall most generally have to employ more than one remedy, in order to meet the diversified combinations which the infectious virus had entered into during this stage with the other tissues of the organism. Even during the transition stage, when the chancre is on the point of passing into the secondary stage, it frequently happens that in spite of the cure which Mercurius had achieved, other symptoms, such as figwarts, against which Mercurius was unable to exert either a prophylactic, or a curative action, make their appearance. Nevertheless, mercurial preparations may continue to prove curative as long as the symptoms of the primary period, namely the original ulcers are still existing, or have not yet commenced to pass into the stage of fungoid growth. I have witnessed this more than once in the case of chancres, where initial symptoms of the secondary period had already broken out upon the skin; where the chancre had already become converted into a red surface without having become fungoid, and where Mercurius sol., healed this chancre together with the attending maculae, without any secondary symptoms appearing at a subsequent period. If, in the second stage of the primary period, or the period of fungoid growth, or in treating the products peculiar to this stage, such as buboes, mucous tubercles and figwarts, Mercurius sol. had frequently to be replaced by other remedies, such as Nitric ac., Thuja, Lycopodium, Sabina, etc., this necessity occurs so much more frequently in purely secondary affections, where Mercurius specially if no primary phenomena are any more to be seen, is not only without any curative effect, but, when given in large and continued doses, frequently produces the utmost ominous aggravations. At any rate, if secondary symptoms become manifest while the primary ulcers are still existing, Mercurius sol. should be employed with great caution, and should at once be replaced by some other remedy, such as Nitri.ac., Thuja, Phosphoric ac., Sulphur, Lycopodium, etc., if its use superinduces the least appearance of aggravation. In the ulceration of the secondary period, specially in ulcers of the throat and mouth, Mercurius may be of great use (though Nitri. ac. is no less efficient for these phenomena); but in such a case, it has to be given in smaller and less frequent doses. In ulcerations of the transition period, and even in decided cases of secondary ulcers, I always commence the treatment, provided the patient has not yet taken any Mercury, with a suitable mercurial preparation, of which, in case the products of the primary period are still existing, I give half a grain of the first or second centesimal trituration, at least once a day; and, if the secondary phenomena have already made their appearance, the same dose every two, three, or four days, according to circumstances, when it soon becomes evident whether this agent will be of any use in the present case or not. If Mercurius improves the symptoms, I continue it is long as the symptoms continue to improve; but discontinue it at once, and select some other remedy in its stead, as soon as the improvement ceases. What remedies are chiefly required in all such cases will be stated when the different forms are treated of: we subjoin hereafter a list of the different remedies, with a reference to the different stages for which they are most adapted.
