In a case of real and unmistakable tertiary nature the question will arise—Should the iodide be commenced at once without waiting for the action of mercury ? This will depend upon various points in the history of the treatment of the case, and also upon the exact locality and gravity of the lesion. Where mercurial treatment had not been patiently carried out in the secondary stage, the best results are to be expected from it. It is in these cases that Mercury injections do so well, even after the failure of the drug by the mouth.
If, then, the tertiary lesion resists mercury, or if it appears, say, in the form of a cerebral tumour. the iodide should be commenced at once. a rule it is useless to begin with small doses.
The writer's plan is to begin with c; grs. three times a day, and gradually increase till zo grs. are taken in each dose. It is not an uncommon experience to find a patient who has taken fair doses of the iodide for many months for nodes without the least result. If the dose he suddenly in creased, say to 20 or 3o grs., the nodes begin to disappear as if by magic.
dr. in the day meets the requirements of the great majority of cases, and it is remarkable how soon all coryza and other unpleasant symptoms disappear when full (loses are given.
Wood laid down the law that where very large doses of iodides are tolerated it amounts to a proof that the disease under treatment is syphilitic, so satisfied was he of the great toleration of the drug which this disease estahlishes. This law is at variance with all clinical ex perience; one sees very large doses constantly tolerated even for long periods in the treatment of many diseases as psoriasis, diabetes, etc., where there is no reason to suspect that the patient had ever contracted syphilis. But if his remark had applied to mercury the truth of the statement could not be challenged. Syphilis, as pointed out by Hutchin son, is a vital antidote to mercury, and in this fact lies the keynote to all successful treatment of the disease by mercury. The dosage of the metal must be arranged according to the severity of the attack, and as long as the syphilitic toxin is present the patient can take doses which would be highly injurious to a healthy subject.
The law may be laid down that in tertiary syphilis the local action of mercury and iodides is greater than in the secondary lesions, and just in proportion to the remoteness of the tertiary affection from the secondary, so does the importance of local treatment increase. This is demonstrated
in cases of rupia, serpiginous lupoid growths and oaena, where iodoform or mercurial applications act speedily after failure of internal treatment with both iodides and mercury.
Acid Nitrate of Mercury solution very lightly and cautiously employed and Iodoform applied in powder freely or as a strong ointment are the best agents for local treatment. The internal administration of iodides and mercury must be persevered with at the same time, but oftener mercury is found to disagree with tertiary patients than with those suffering from the primary or secondary stages of the disease. It is in such cases that the Calomel bath, injections or inunction do so well when the drug by the mouth appears to fail.
Various formula: for administering mercury and iodine together in tertiary syphilis are used. The Biniodide of Mercury in the form of pills, each containing ,L to gr., is very effective. Donovan's solution has long maintained its reputation, and the B.P. formula (containing I in moo) may be given for long periods in doses of 2 o mins. Perhaps the best of all combinations is Corrosive Sublimate, prescribed in Iodide of Potassium solution. Its great advantage lies in the facility with which the iodide or the mercury can he increased or diminished at pleasure according to the effe( is requited: Hydrarg. Perchloridi gr. j.
Potassii 1 odidi 5v.
..Iq/ue Des/ill. Misce.
Fiat mis/nra. Ca/dal web. ;nag. ter in die ex aqua post cams.
This mixture may be given for a month at a time, when the mercury may be stopped, the iodide being administered without it. At the end of the second month the mercury can be added, and so on each alternate month. Tannate of Mercury is recommended in tertiary syphilis in doses of i gr. twice or three times a day, but it has no advantages over other preparations.
Iodide of Sodium should be selected where large doses of the iodide are to be continued for long periods, as it has a less depressing effect. Some authorities advise the use of a combination of the Iodides of Sodium, Potassium and Ammonium. For tertiary brain, cord, and vascular lesions the combination of iodides with Nitrites is considered advantageous, and some authorities advise short courses of Thyroid feeding in the in tervals of suspension of iodine treatment.