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This is one of a series of articles written by eminent clinicians for the purpose of extending information concerning the official medicines. The twenty-four articles in this series have been planned and developed through the cooperation of the U. S. Pharmacopeial Committee of Revision andThe Journal of the American Medical Association.—Ed.In syphilis there is an active, motile organism which requires moisture and tissue for its further spread and vitality. It is well known that Spirochaeta pallida dies within one-half hour if exposed on a dry surface; e. g., a glass slide. On the other hand, if anywhere on the body the organism gains entrance into the skin, through a bruise, a cut or a crack, an infection will probably occur. Of this there is not absolute surety, for it is possible that certain individuals may have some resistance to the disease, perhaps enough at least to word off an

None of the mercurial preparations used, at present, in the treatment of syphilis are perfect. In the laudable quest for better ones Parke, Davis and Company submit a new mercurial preparation for which several claims have been made. The evidence from the literature that they submit in its favor is of little or no value, since, in practically all cases reported, the patients received arsphenamin as well as Mercurosal. In the first place, they claim that they have a preparation which can be used either by the intramuscular or by the intravenous route. This, of itself, would be advantageous in certain cases in which it would be found impossible to use one of these routes. Secondly, they affirm that the drug has no deleterious effects on the vessel walls. To quote their own words, "Following a long series of intravenous injections in dogs, there was no appreciable effect on the

In December 1942 the Council on Pharmacy and Chemistry was approached by Col. Otis O. Benson Jr., M. C., representing the commanding general, Army Air Forces, Matériel Center, Wright Field, Dayton, Ohio, in regard to the most effective protective substance for the prophylaxis of sunburn. The problem was as follows:The Matériel Center would like information on the most effective protective substance for the prophylaxis of sunburn. In essence, the problem is as follows:Men marooned on life rafts or in the desert following airplane crashes for various reasons seem to lose a good deal of their clothing and are subject to severe solar exposure.It has been definitely established that a protective substance (cream or ointment) to be stowed in life rafts and other emergency equipment in military aircraft is required, when the aircraft is operating in the southwest Pacific and Mediterranean theaters.The requirement per

In 1896, Marcuse1 first called attention to the dangers incident to exposure to the roentgen ray—the production of an alopecia and of a dermatitis "resembling sunburn." In the short space of twenty-eight years, how much valuable knowledge has been discovered concerning this wonderful physical agent? Incidentally, how many workers have learned to their own cost the dangers ensuing from being fully exposed to its unseen rays? In the early days, many a martyr to science was known, and the result was a long list of fatalities extending from 1898 to 1912. As the result of education and prophylactic measures, this list has since rapidly declined. Nevertheless, in the last few years, with the increasingly wide use of the roentgen ray by many physicians and dentists for picture work, for fluoroscopic work and for treatment, the question arises whether it will not be well to sound a new warning on

Intravenous injections of suspensions of finely divided mercury were made by Fuerbringer 1 in 1880 for the purpose of studying the fate of mercury in the tissues of animals. With the aid of acacia and glycerin, he prepared a stable suspension in which the mercury globules were smaller than the blood corpuscles. However, such injections of suspended metallic mercury do not appear to have been tried clinically until recently, when a proprietary preparation of this character was introduced, originally under the suggestive name of "lueside," which has been changed to "mercodel." The manufacturers claim that this produces very striking therapeutic results, with absolute safety, without injury to the vein; in fact, without any objectionable features. Since this method of introducing mercury for therapeutic purposes is a distinct novelty, the claims require careful control; a task that was assigned to us by the Council on Pharmacy and Chemistry, to which the

Since the earliest times, mercury inunction has been used for the treatment of syphilis. The drug, however, has always been employed in the form of an ointment of the metallic mercury. Recently Wile and Elliott1 and Schamberg, Kolmer, Raiziss and Gavron have suggested the use of an ointment made of calomel; this, for several reasons: The blue ointment is very uncleanly; it leads to discovery, and it frequently sets up an irritation of the skin. As calomel is more cleanly, and as the latter four authors felt that it is fully as well absorbed through the skin as the ordinary blue ointment, they suggested that it be used for inunction purposes in a formula consisting of:The arguments of these writers seemed convincing, and we commenced using calomel inunctions, especially in private practice, in the spring of 1917. Since then the use of the calomel rubs has become so

A disease known as climatic bubo has been, in part at least, recognized for the past seventy-five years. It was supposedly tropical in character, running a very chronic course with more or less suppuration of the affected inguinal lymph nodes. It was supposed to follow venereal exposure, especially to Negro women. The lymph node symptoms did not show up, as a rule, until an entrance for the infective agent was no more to be found. The cause was unknown. As long ago as 1865, the French clinician Trousseau1 gave a very good description of it:I must not forget to say a few words about a lymph node infection which I have often observed in the young Creoles, and more particularly in the Creoles of Réunion and Maurice.... In adolescence, and more in the boys, we see the superficial and deep nodes in the groin swell up on one

Every physician devoting his life work to a specialized line of endeavor is bound to have more or less correspondence with various colleagues and lay persons in regard to problems arising along that line.It is not often, however, that the same specialist goes to the trouble of collecting and analyzing this correspondence.This has recently been done by Stokes and Ingraham1 in two related publications, the one that is of particular interest here being entitled "Two Thousand Questions the Doctor Asks About Syphilis." In the period from July 1928 to July 1938 nine hundred and fifty-five letters have been answered either by them or in the Queries and Minor Notes of The Journal. In the case of the latter, they have been answered anonymously by various correspondents. The total number of questions answered by Stokes and by the correspondents was 2,115. Statistical break down of the 2,115 inquiries

Intramuscular bismuth therapy against syphilis ranges between the extreme of very slow absorption from the oil suspensions of compounds that dissolve very slowly in water, such as the subsalicylate, and the other extreme of the relatively rapid absorption from watery solutions. With the watery solutions an effective concentration of bismuth in the blood and tissues is reached in a short time, perhaps after a single injection. As the excretion of these solutions is also more rapid, their action is relatively brief and they must be administered more frequently. The oil suspensions have the advantage that they may be given at longer intervals. They tend to become cumulative when injected once a week. The effective concentration in the blood is therefore approached more slowly, probably only after from two to four weeks. These extremes are bridged by a variety of bismuth preparations, such as oil suspensions of more soluble compounds and the oil-soluble compounds. It occurred to us that it might be advantageous to approach the problem in a different way, namely by an interlocking sequence of watery solutions and salicylate suspensions, adjusted to build up an effective concentration rapidly by use of the watery solution and a continuous concentration meanwhile by use of the salicylate suspension, the injections of the watery

Several very complete reports on the toxic effects of arsenical preparations used in the treatment of syphilis have been made in the past few years, notably the Medical Research Council Survey of Great Britain,1 the report by Phelps and Washburn2 on cases observed in the venereal disease service of the United States navy, and Kerl's3 article in the Jadassohn Handbuch.Nevertheless, if one scans the literature from day to day and from month to month, one still notes the frequent observation of further arsenical reactions supervening in the treatment of syphilis. Either past experiences have not taught us sufficiently to prevent these occurrences; or there is still something to learn along these lines, or, finally, arsenical reactions must be looked on by the medical man as phenomena bound to happen sooner or later in many cases, and this despite every precaution. This is the excuse that we

Paul Ehrlich worked for years synthesizing an arsenical compound to cure syphilis. The therapia magna sterilisans, he thought, had been achieved with his six hundred and sixth preparation, arsphenamine (introduced as salvarsan), to be injected intramuscularly, one injection sufficing. Relapses as well as reactions disclosed differently and he synthesized another arsenical, neoarsphenamine, and later still others. When none of these worked he and his collaborators suggested use of more than one injection. Every physician agreed to the effect of the trivalent arsenical salts on Treponema pallidum, but it required trial and error as well as evaluation of enormous amounts of case material before medicine finally awakened to the profound effect of these compounds on syphilis. Injections of the arsenical were at first widely spaced between other forms of therapy—mercury. Later a physician here and there had the temerity to use injections perhaps once a month, later once a week. It

The extragenital chancre is by no means an uncommon sight — to the dermatologist, at any rate — and I feel a hesitancy in reporting to this section such a short series of cases. However, the affection is rather rarely encountered by the general practitioner and, consequently, the diagnosis is deferred, as a rule, until the appearance of the secondary symptoms, a time when much damage often has been done both to the patient and to his family. DEFINITION By the term "extragenital chancre" I mean the primary invasion of the Spirochaeta pallida on other parts of the body than the genitalia — hence the frequently used term "syphilis insontium." This type of syphilis has been known since the earliest times, and authentic epidemics of innocent syphilis have been reported as early as 1577 in Austria, 1592 in Switzerland and 1596 in Germany. Most of the earlier ones were due

An American dentist, Guilford,1 first reported a case of congenital ectodermal dysplasia of the anhidrotic type. The man, aged 48, was edentulous and had almost complete absence of taste and complete anosmia. He was hypotrichotic and never perspired. At almost the same time Atkinson2 presented before the Philadelphia Medical Society a man aged 40 who had never had teeth or any distinct growth of hair on the scalp except the downy hairs which are seen in early infancy. He was also destitute of the sense of smell and almost of that of taste. His skin appeared to be unprovided with sweat glands, as he never perspired, and when working actively he was obliged to wet his clothes in order to moderate the body heat. He could sleep in these wet clothes in a damp cellar without catching cold. His jaws presented the appearance seen in persons who have

In 1913 Ito, working with Carl Bruck at Neisser's clinic, devised a specific intradermal test for chancroid —Ducrey bacillus infection. The diagnostic value of this test was later confirmed by Reenstierna, working with a serum containing antibodies of the Ducrey bacillus. Today this test is spoken of as the Ito-Reenstierna reaction.Ito, for his cultures, used 24 hours old streptobacillus colonies from two Besançon blood agar tubes. The bacilli are suspended in physiologic solution of sodium chloride with the addition of 0.5 per cent phenol and heated at 60 C. for two hours. Reenstierna employed unheated material in the presence of phenol for fourteen days in the icebox. Frei1 in his survey of the entire subject up to 1927 says that he employed the water of condensation. He also states that it makes little difference what method of preparation is employed.The antigen is employed as an intradermal test,

"Doctor, I am suffering from eczema"—most often pronounced with the emphasis on the second syllable. What physician has not heard this expression hundreds of times, and how often even the best physicians and dermatologists have been at their wits' end before seeing the last of the patient! That the condition is common goes without saying, and even in dermatologic practice, where more careful elimination of related conditions would be achieved, one finds that the percentage of eczema and dermatitis is very high in comparison with the number of dermatoses diagnosed. Moreover, even in the practice of the general practitioner, the problem of eczema and dermatitis comes up so often that I feel that it would be well worth a little consideration; at least, that is my excuse for presenting it for study.The word eczema is an old term. As early as 1800, Robert Willan defined it as "a condition

From a careful study of seventy cases and from a review of the literature, Ziegler,1 in 1911, felt that one fourth of all cases of Hodgkin's disease, at some time or another in the course of their trouble, showed evidence of skin involvement. Bunting and Yates2 quote Westphal as finding 15 per cent of his cases with skin lesions.To me, these percentages seemed rather high until I began to go deeper into the subject and look more particularly for these manifestations. After about two years of careful observation of such cases, I feel that these writers are probably correct in their figures. It is my belief that all too frequently cutaneous lesions of lymphogranulomatosis are not noted because they have not been sought after, and it is my object to call the attention of the medical profession to this interesting and as yet not generally recognized series of

The use of cosmetics has become, unfortunately, more and more common. What was once considered poor form is now the mode with the average woman, certainly in the cities. Most women paint; all of them use powders of different types, and if one were to read over the list of all the different cosmetics it would be indeed startling. Statistics recently furnished by the Cleveland Public Library show that the general use of cosmetics has reached such proportions that, in 1919-1920, on the basis of taxes paid, there were some $205,000,000 worth of these preparations sold; and the Department of Commerce tells us that, in 1921, $75,000,000 worth were manufactured—at what price they were sold one can only venture a guess. We say that the average woman uses at least some of the long list of cosmetics, and yet many of these women are unaware of the danger they are

Anyone who has had the pleasure of studying at, or of visiting, Cambridge University, England, will remember Queens College. Queens College, the second royal institution in Cambridge, was established by Margaret of Anjou, queen of Henry VI, in 1448. Andrew Dokett was its first president, and held the office for many years. The college, which is famous for its principal court, gate house, and great gateway, was completed in 1451 and still functions. There are several courts and cloisters, varying in their dates of establishment. All of them are beautiful, as well as ancient, and Pump Court is especially renowned as being the study of the scholar, Erasmus. It is appropriately called Erasmus Tower. In the gallery of the President's lodge there is a high, stiff, uncomfortable chair—Erasmus' chair. Just across the river Cams, there is a walk in the college gardens known as Erasmus' Walk. Erasmus was in residence

An exact cutaneous test for syphilis is greatly desired by syphilologists. From a practical diagnostic standpoint, an easy, exact and cheap cutaneous test for syphilis is a thing much to be hoped for.As early as 1909, Charlet, Gautier, Favre and Nicholas had experimented with congenital syphilitic liver extract, which they termed "syphilin," and like experiments had been tried in Neisser's and Jadassohn's clinics and in several others. Fischer and Klausner, with the same idea, had also worked with "pallidin," a suspension made from pneumonia alba (the lungs of congenital syphilitics rich in Spirochaeta pallida).Noguchi's report on his luetin reaction was received, therefore, with satisfaction, and the test is used quite extensively in this country and more or less abroad.In attempting to explain its mechanism, Neisser noted that the skin of patients with late syphilis reacted not only to the luetin test but also with many other foreign

Mrs. J. S., aged 33, a patient of Dr. Sroub's, complained of a persistently painful little finger of the left hand, Nov. 8, 1935. She stated that seven years before the tip of this finger began to be tender and that this had increased to the present time. It was at this time so exquisitely painful that she could get no relief, day or night. The pain traveled up her arm to the shoulder. She was constantly shielding the finger. There was no history of previous trauma. The nail had been trimmed by Dr. Sroub. Roentgenograms showed nothing. All local measures had been in vain. The patient was frantic.Physical examination showed a blood pressure of 200 systolic, 110 diastolic, with the left border of the heart in the nipple line. The second aortic sound was accentuated. A roentgenogram showed no cervical rib. Otherwise the general physical examination was negative.The

In a preliminary paper, we1 pointed out that the mercury in the practice of mercurial inunction is probably absorbed only from that part of the ointment which has been rubbed into the hair follicles and into the entrance of the sebaceous and sweat glands; and that therefore any mercury remaining on the surface of the skin, after the rubbing is stopped, would be only an objectionable nuisance, without any therapeutic effect.In order to test this assumption, a series of forty-four patients was treated with mercury rubs in the usual manner, except that the skin was carefully cleansed with benzin at the end of the half-hour rubs, so as to remove all mercury that had remained on the surface.The results bore out our expectations: Mercury absorption, as judged by gingivitis, etc., occurred in the same proportion of cases, and after the same average number of rubs, as one

In spite of the attempts of several workers to disprove the claims made for sodium cacodylate as a powerful remedy in the treatment of syphilis, the drug is still extensively used by the general practitioner and by many specialists in the treatment of this disease. Yet Nichols,1 notably, by his work on rabbits, has proved that it is worthless as a spirocheticide.To clear up the question as to its value, we undertook the study of its action2 in a series of selected syphilitics in our wards at the Cleveland City Hospital.At first we started with a dose of 0.25 gm. intravenously, followed by a dose of 0.45 or 0.5 gm. every five days up to five or six injections. After one or two trials, however, we were convinced that we would have to use it either in larger doses or oftener if we were to obtain

To the Editor:—I have read with great interest the suggestion of Dr. S. J. Thannhauser (Differential Diagnosis of Ectodermal Dysplasia and of Rothmund's syndrome, The Journal, January 26, p. 238) that the patients described are examples of Rothmund's syndrome. I am inclined to agree with his suggestion after looking up the pertinent literature on the subject (including Rothmund, A.: Ueber Katarakt in Verbindung mit einer eigenthümlichen Hautdegeneration, Arch. f. Ophth.14: 159, 1868. Seefelder, R.: Ueber familiäres Auftreten von Katarakt und Poikilodermie, Ztschr. f. Augenh.86:81 [May] 1935. Schnyder, H. F.: Ueber Katarakt bei poikilodermieartiger Hauterkrankung, Klin. Monatsbl. f. Augenh.92:408, 1934. Thannhauser, S. J.: Wermer's Syndrome [Progeria of the Adult] and Rothmund's Syndrome: Two Types of Closely Related Heredofamilial Atrophic Dermatoses with Juvenile Cataracts and Endocrine Features: A Critical Study with Five New Cases, Ann. Int. Med.23:559 [Oct.] 1945). I apologize that this syndrome

TO THE EDITOR:— I have never denied that acetarsone is effective in the treatment of congenital syphilis. The difficulty, however, is that the dose that is effective is so near to the dose that causes severe reactions that it is felt that it is unwise to have this remedy employed indiscriminately. For example, among the authorities that Dr. Traisman mentions, the article by Maxwell and Glaser states that in their series of cases from one of the best university pediatric clinics in the United States there was one death and one severe toxemia following acetarsone. The death occurred after 7.68 Gm. of acetarsone over a period of thirty-four days. They quote Martin as having had two cases of flaccid paralysis after use of the drug. They conclude: "Acetarsone probably has a definite place in the treatment of congenital syphilis. That the drug cannot be used indiscriminately is amply demonstrated by

To the Editor:—In reply to the note of Dr. Donovan, I would say that I appreciate his calling my attention to the fact that erosive and gangrenous balanitis has been spoken of as the fourth venereal disease; in fact, I have already used this term, I am afraid, with my students in the past. It seems to me, however, that erosive and gangrenous balanitis will never assume the prominent position that lymphogranuloma inguinale has already taken.In the first place, the average case of erosive and gangrenous balanitis is comparatively benign, if a correct diagnosis is made and if the proper type of measures is used, including the use of oxidizing agents, for example, potassium permanganate or hydrogen peroxide and, exposing the infected area to the open air.Moreover, erosive and gangrenous balanitis is a far rarer disease than is lymphogranuloma inguinale, and finally the prognosis of an erosive

To the Editor:—I note that in the discussion of the article "Lymphogranuloma Inguinale" (The Journal, September 24, p. 1065) the remarks of Dr. J. V. Van Cleve, in closing the discussion, on page 1071, are in error. The sentence reads in this discussion: "The antigen used is an alcoholic one." This is incorrect.The antigen should be prepared according to the method described in the article itself on page 1067. The antigen is prepared in normal saline solution.