dicated, while in the late days of these diseases, or in subacute or chronic infections smaller and more numerous injections are to be used.

During the early days of an average acute infection in an average adult male, the initial dose of mercuric succinimide should be gr. 9/5; if at the end of twenty-four or thirty-six hours there has been no improvement, or if, following improvement, there has been a return of symptoms, a second injection of from gr. 5/5 to gr. 6/5 should be given, providing symptoms of mercurialism have not followed the first injection. In the more virulent and quickly fatal of the acute infections, such as meningitis, whatsoever its etiology, the initial dose should be gr. ii.

In chronic infections (late days of acute and in subacute infections) in the average adult male the initial dose should be gr. 5/5 to gr. 7/5.

Succeeding injections should then be given with from two to four day intervals, in such dosage as will not produce mercurialism, until ten or twelve injections have been given, providing the symptoms have not disappeared in the mean time. When ten or twelve injections have been given, the treatment should be interrupted for from two to five weeks, in order that the mercury may be eliminated and that the organisms may not become immune to its action through its constant presence in their environment.

In some of the more persistently chronic infections the interval of time between injections should be from four to eight days.

In females the dosage should average from gr. 1/5 to gr. 2/5 less than in males.

Should symptoms of mercurialism appear at any time during the course of treatment the injections should be stopped at once and appropriate corrective measures applied, the injections being resumed if necessary upon the disappearance of these symptoms.

During this treatment the oral cavity and the teeth must have the utmost attention and be kept perfectly clean at all times, and the bowels moved freely daily.

Surgical asepsis must be carefully observed in every particular relating to syringe, needles, solution, and skin at site of injection.

The solution should be made of the strength of mercuric succinimide gr. 1/5 in sterile, distilled water my iv. Inject deeply in gluteal muscles.

The only contraindication to this method that I know of is serious organic lesions of the kidneys. With the foregoing in view, I invite your attention to the following cases:

Tuberculosis (Thirty-five cases).-Between 1907 and 1910, at the United States Naval Hospital, Las Animas, Col., I treated thirty-five officers with this disease. They were not selected cases of incipient character, but ranged from moderately advanced to far advanced; one was a case of acute pneumonic phthisis that two months previously had been originally diagnosed typhoid fever. In addition to the lung involvement, two patients had tuberculosis of the knee-joint, one of the knee-joint and lower third of the femur, and one had tuberculous ulceration of the larynx.

I discharged from the hospital nineteen of these cases, or 54.2 per cent., as apparently cured, including the two knee-joint cases, and the case of laryngeal involvement.

Since then but five of these patients have relapsed, one of whom has died. Of the sixteen not

apparently cured, in ten the disease has been arrested, and the men are leading a fairly normal existence in various parts of the United States.

Among these the knee-femur case may be specially mentioned. When I operated on this patient in 1909 I removed the inner half of the lower third of the right femur, and this bone was in such bad condition that my colleagues and assistants urged me to amputate at the hip. This patient is now living in New York City with a sound limb, though a stiff knee-joint.

It is also of interest to note that in the case which began as an acute pneumonic phthisis, reaching me with a large cavity in the upper left lobe, the patient is now married and living in the State of New York.

Two of these patients showed no change, two I have lost track of, and two died while not under my care.

Lobar Pneumonia (Nine cases)'.-Of these eight were immediate cures following one injection; the crisis usually began in about seven hours after the injection, in several within an hour or so after in jection. In one the injection was given on the first day of the disease, in two on the second, and in six on the third day. The case that was not immediately cured received three injections, the fever falling by lysis on the fifth day, the involved area never completely undergoing resolution, and the evening temperature reaching 100° to 99° for the following two weeks, when a diagnosis of tuberculosis was made and the patient transferred from the ship to hospital. The following are fair examples of the eight cases of immediate cures.

W- S. A., 27 years of age. Admitted on board the U. S. S. Southery by P. A. Surgeon L. H. Wheeler, U. S. N., at 9.00 A. M., December 3, 1913. Chill-followed by cough, severe pain in apex of right lung and extreme nervous symptoms. Temperature 101.5°, pulse 90, respiration 20. Diagnosis undeterminedlobar pneumonia suspected. 3.00 P. M., all symptoms increased, temperature 104°, pulse 126, respirations 40, transferred to hospital. December 4, 9.00 A. M., condition about the same, excepting that nervous symptoms had increased, and respirations were 68. Physical signs of consolidation of right apex. Surgeon F. M. Bogan, U. S. N., injected gr. 8/5 mercuric succinimide. Following this rapid crisis took place. Convalescence established which proved uneventful. (See chart No. 1.) Chart 2 represents similar results in a boy seven years old.

It seems probable in cases of pneumonia complicated by preexisting pulmonary disease, more particularly tuberculosis or syphilis, whether active or latent, that the direct immediate curative action of mercury will not take place; therefore when such immediate cure does not follow the initial injection in the early days of the infection, the possibility of such complications should be considered.

Lobular Pneumonia.-Six cases of this disease have been treated, in all of which an immediate cure was obtained. In one, the action was somewhat delayed, due in this instance to infection of both middle ears, the latter condition not, however, progressing to suppuration; this in itself was gratifying, showing the value of mercury in preventing or at least aborting a complication that usually persists for some length of time.

B- -W. W. Disease began rather suddenly on June 13, 1913. Slight chill at 8.00 A. M., followed by severe cough; at 8.00 P.M., temperature 101.2°, pulse 118, respirations 48. June 14, 8.00 A.M., about the same, expectoration free and characteristic, the entire area of both lungs presented the physical signs of lobular pneumonia. 10.20 A.M., Surgeon Bogan injected

injection should be gr. 9/5 in average adult males, with a second injection of gr. 5/5 or gr. 6/5 in twenty-four hours if required. From the sixth to the tenth day the initial injection may be gr. 9/5, but the second injection must not be given until seventy-two or ninety-six hours have elapsed. After the tenth day the initial injection in an average adult male must not be more than gr. 5/5, and succeeding injections not repeated more often than every seventy-two hours, the dose gradually decreasing at the same time.

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22

The first case of this disease treated and reported was injected with mercuric succinimide gr. 7/5 on the seventh day of the disease, the temperature then being 103°; by the following morning it was practically normal, but shot up to 102° during the day, when a second injection was given; a third and fourth injection resulted in normal evening temperature and the patient was out of bed and around the ship before the temperature would have reached normal in the usually treated case. In another week he went to his home on ten days' leave, and upon his return he presented himself with a large abscess in right lumbar region. Was transferred to hospital at Boston, Mass., where he was found to be suffering from "typhoid spine"; had he been injected earlier in the disease I think this complication would have been avoided.

The second case was admitted 7.00 P. M., March 25, 1912; stated

SS X

December 1913.

Chart 1.

Feb

day before. Upper right lobe presented numerous subcrepitant rales, temperature 103.6°, pulse 132, respirations 36. Early lobar pneumonia suspected. Magnesium sulphate prescribed. By the following morning all symptoms had practically subsided and remained so during the day. February 2 all symptoms increased. 1.30 P.M., chill. P. A. Surgeon Wheeler and myself saw the case together at 2.00 P.M., diagnosis of lobular pneumonia made. 2.20 P.M., injected mercuric succinimide gr. 2/5. At 6.00 P.M., right middle-ear became involved. Patient extremely restless, and crying from severe pain in this part. Hot water bag locally. ruary 3, 6.00 A.M., apparently much worse, severe pain in right lung. Temperature 104.2°, pulse 130, respirations 48. Castor oil 15 c.c., administered. Improvement began by 9.00 A.M., and continued. February 4, all pneumonic symptoms disappeared, convalescence apparently established. 3.00 P. M. pain in right ear returned, asociated with rise of temperature, which rapidly subsided. February 5, without symptoms until midnight when severe pain developed in left ear. February 6, rise of temperature due to left ear involvement. February 7, no symptoms. February 8, up and about. February 11, cured. Visits discontinued. (See chart No. 4.)

Typhoid Fever (Five cases).In this disease I am under the impression that the sixth day is the limit of time during which the primary or direct parasitotropic action of mercury may be expected to take place. Therefore, up to and including this day the initial

9p.m 90 18

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motile bacilli in large numbers. 10.00 A.M., temperature 104°, pulse 88, respirations 20. 4.00 P.M., injection mercuric succinimide gm. 0.11 (gr. 17/10), immediate improvement. 10.00 P.M. temperature 102°, patient felt much better. March 27, marked improvement. 8.00 A.M., temperature 100°, pulse 80, respirations 20. Termination by crisis. (See chart No. 5.) From this time on convalescence uneventful, discharged to duty March 31, 1912, having been under treatment just seven days.

Paratyphoid (1 case).-Hospital apprentice reported to me at 7.00 P.M., one evening in November, 1912, saying that he had been feeling badly for a few days and had kept a chart of his morning and evening temperatures, thinking he had tuberculosis. The chart showed the typical rising curve of typhoid, and that evening had reached 102° (4th day). He was placed in bed on liquid diet under observation. The following morning miscroscopic examination of urine showed numerous motile bacilli. Culture made and sent to the laboratory of U. S. Naval Medical School, Washington, D. C., for identification. That evening temperature reached 103°, and he was given gr. 9/5 of mercuric succinimide by injection. Following morning temperature was normal,

At

cinimide, gr. ii, was injected at 4.20 P.M., and the patient was transferred to the contagious wards. A telegram sent to Philadelphia for Flexner's serum. 7.00 P.M., lumbar puncture was done and 90 c.c. of extremely cloudy cerebrospinal fluid under great pressure withdrawn. This contained a large amount of pus, a high percentage of albumin, and was positive for the Diplococcus intracellularis. The following morning the temperature was 99°, blood pressure 187, the delirium had disappeared and the patient recognized the fact that he was in hospital. 10.00 A.M., lumbar puncture was done, the spinal fluid was almost clear, almost free from pus cells, with a faint trace of albumin. In spite of the very marked improvement the medical officer in charge of the case felt that he must administer serum, which was done, at the same time gr. 8/5 of mercuric succinimide was injected into the gluteal muscles; rapid improvement took place. The following morning he was still further improved; a second dose of serum was injected into the canal after drainage, and gr. 5/5 mercuric succinimide injected into gluteal muscles. The following day his condition was nearly normal, lumbar puncture and drainage was done. The next day (fourth since admission) patient normal,

106

106

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MONTH.

June

1913

but went to 102° in the afternoon when second injection gr. 6/5 was given. The following morning temperature was normal and remained so, and in three or four days he was returned to duty at his request. Some days later the laboratory reported the culture to be one of the Gartner group, none of which excepting B. paratyphoid B. would have produced the clinical symptoms of typhoid.

Cerebrospinal Meningitis (1 case).-In December, 1912, I was transferred to the Naval Hospital, Norfolk, Va., for treatment. Several weeks before they had received a case of cerebrospinal meningitis; the clinical symptoms and laboratory findings confirmed the diagnosis. Lumbar puncture with drainage and the introduction of antimeningococcic (Flexner's) serum was instituted at once and continued; the patient died during the sixth week of the disease.

About the middle of December his former room-mate was admitted to the medical ward, about 4.00 P.M., diagnosis undetermined, health record stating that he had been taken sick suddenly the day previous, with moderate temperature and delirium. On admission the patient was delirious, and presented all the classical symptoms of cerebrospinal meningitis; this diagnosis (etiology not determined) was made. Mercuric suc

convalescence established.

Mercuric succinimide gr.

4/5 injected. Following this convalescence was uneventful, resulting in complete recovery in every respect.

Erysipelas (Two cases).-First case on fourth day had upper half of face, including nose and ears, involved, temperature 106°, profound toxemia, delirium. Injections gr. 8/5, 7/5, 5/5 on successive days. After first injection delirium disappeared, maximum daily temperature did not go above 103°. Reaching port, patient was transferred to hospital.

Second case on the first day; nose involved, temperature 102.5°, injection gr. 17/10 at 10:00 A. M., following morning normal, all symptoms disappeared. Cured and to duty in forty-eight hours. Infectious Arthritis (Thirty-nine cases).-Acute Rheumatic Fever (Eight' cases).—In this particular infection where the normal alkalinity of the blood is known to be reduced, I have found it advantageous to correct this by giving fairly large doses of

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potassium or sodium citrate or sodium bicarbonate either the day before or on the day of the injection. The following cases are examples of the results that may be expected.

In the first case the patient was admitted to Naval Hospital, Portsmouth, N. H., September 8, 1913, from the U. S. S. Hannibal, as with acute rheumatic fever. A Wassermann proved negative and the diagnosis was confirmed. All previous treatment discontinued. Injection mercuric succinimide gr. 7/5. At this time both shoulders, both ankles, and the joints of left hand involved. Immediate improvement followed the injec tion. September 11, injection gr. 5/5; September 15, pain about disappeared, injection gr. 4/5; September 16, practically well. A few more injections were given as precautionary measures. The heart did not become involved and the patient returned to his ship and duty perfectly well.

In the second case the patient was a boy, aged 9 years; I first saw the patient on March 5, 1914, which was about the twenty-second day of the disease, and confirmed a diagnosis of acute rheumatic fever, com

lar rheumatism. Came under my observation April 7, 1913. The heart, lungs, and abdominal viscera were apparently normal. Urine normal. Both knee joints, ankles, and the joints of both hands were considerably swollen, and extremely tender and painful. The lower limbs were edematous, and the abdominal cavity contained some fluid. The bladder was extremely irritable and painful. She was given the following injections of mercuric succinimide: April 11, gr. 5/5; 13, gr. 7/10; 16, gr. 3/5; 20, gr. 7/10. All symptoms disappeared by April 24, and she remained apparently well until May 12, when the bladder symptoms returned. Injections resumed as follows: May 13, gr. 9/10; 16, gr. 7/10; 20, gr. 7/10. Since this date she has remained perfectly well, has resumed her social duties and pleasures, eats freely of an unrestricted diet and is normal in every respect.

Gonorrheal Arthritis.-Twenty-four cases. The following case is an average example.

Disease first treated at the Marine Recruiting office, Topeka, Kans., March 7, 1911, since which time he has been practically under continuous treatment, and has had several negative Wassermann tests. From To

plicated by a severe endocarditis. Examination of the lungs was negative. Previous treatment aspirin, for which I substituted methyl salicylate and sodium bicarbonate, the family not being willing at the time for me to inject. On March 8 developed severe cough. March 9, morning, upper right lobe presented harsh respirations and subscrepitant rales. 10.30 A.M., injection mercuric succinimide gr. 3/5, 3.00 P.M., physical signs of consolidation entire upper right lobe posteriorly (confirmed by my colleague P. A. Surgeon L. H. Wheeler, U. S. N.). Some time after 6.00 P.M., crisis began and was complete by 4.00 A.M. (See chart No. 6.) All pain practically ceased also. March 14 injection of mercuric succinimide gr. 2/5, following which temperature became normal and has continued

So.

Chronic Articular Rheumatism.-Seven cases. The following case is an average example:

Mrs. age 52, two adult children and one minor child. Perfect health until March, 1911, when she developed a severe attack of acute rheumatic fever, confined to bed until following June, since which time she has been a confirmed sufferer from chronic articu

peka, he was sent to the Post-Graduate Hospital, Kansas City, Mo., transferred to the Naval Hospital, Philadelphia, Pa., where he remained 59 days, being discharged June 14, "condition improved." Did duty at the Marine Barracks, Philadelphia and New York, up to January 24, 1913, during which time he was receiving treatment. Admitted to the sick list on board the U. S. S. Southery, Portsmouth, N. H., February 1, 1913. Transferred to hospital, Portsmouth, N. H., March 4, 1913, as "not improved."

U. S. Naval Hospital, Portsmouth, N. H., March 4, 1913; patient walked with great difficulty. The action of the heart was very rapid and irregular. Salol gr. xx, t.i.d. March 25, no improvement. April 7, rapid pulse continued (150 9.00 A.M.), no relief from pain. May 3, 1913, Surgeon F. M. Bogan requested the writer to ask for a survey on this man, with the view of having him discharged from the service, or in lieu of that to see the patient in consultation and suggest a line of treatment. Patient was bent forward at the hips, unable to extend the trunk into a vertical position. The right knee, considerably swollen, flexed, and fixed at an angle of 60°, was extremely tender and painful. The left knee and both ankles were involved, the bladder was extremely

tation of motion in any joint, temperature and pulse were normal, weight 163 pounds. Since this date he has remained perfectly well. Lack of time prevents further details.

In addition to the above there have been treated by my method 15 cases of acute tonsillitis, all immediate cures; 5 cases of epidemic catarrh, cures; 1 case acute cystitis (staphylococcic), immediate cure; 3 cases chronic cystitis (gonococcic), 2 to 3 injections (rapid cure); 10 cases furunculosis, 2 to 3 injections; 32 cases of colon bacillus infection," rapid cures; 1 case acute pleurisy, immediate cure; 2 cases lymphangitis, immediate cure; 4 cases cellulitis, 2 immediate and 2 rapid cures; 1 case of mumps, right parotid swollen and painful, left parotid painful, injected first day gr. 9/5, immediate cure; Vincent's angina, 1 case, rapid cure.

In addition to these cases, several independent foreign investigators claim and report the most excellent results from the use of mercury in the treatment of diseases of vegetable parasitic origin.

In October, 1912, Doctor Charles Souligoux, surgeon on the staff of the Hospital of Paris, Paris, France, reported to the Surgical Society of France. 144 cases of puerperal septicemia treated by deep muscular injections of gr. 1/6 of mercuric cyanide daily, with but three deaths. This report was published in detail by his assistant, Doctor Giru, in the Archives de Chirurgie of November 25, 1912.

In the course of his practice in Kiev, Doctor P. Krohl noticed that women who were undergoing a mercury treatment or who had recently finished one had a completely normal puerperium after a normal delivery or an abortion, in spite of the fact that they lived under the most unfavorable hygienic conditions. "Moreover I noticed that syphilitic patients during and after a mercury treatment had a peculiar power of resistance to infection of every kind. Not only did they not take the ordinary infectious diseases, but in cholera epidemics they seemed immune to that infection."