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may occur on the generative organs, wherein, by examination, no perceptible disease of the generative organs is observed in the person from whom the disease arises; that, farther, as consequences of constitutional ailments, ulcers and other affections may appear which resemble syphilis, so this does not disprove the above stated opinions, and we must herewith not forget how frequently the patient purposely deceives the medical attendant, and that especially all the circumstances which come into play in con tagion are still not sufficiently clear, as the existence of primary bubo, without previous affection of the generative organs, which, however, cannot be denied, proves the explanation of syphilis from simple irritation without contagion (a) is a mere crazy systematic fancy (6).
826. The same differences observed in primary are noticed also in se condary syphilis. Experience indeed seems to show that after venereal gonorrhæa and after superficial exfoliation a vesicular, eruption, inflammation and wound of the throat, and inflammation of the synovial membranes take place. After primary ulcers with everted edges without hardness, a pustular eruption, whitish ulcers on different parts of the palate, pains in the joints and gummatous swellings; afterwards eating and scurfy ulcers, tubercular growths on the skin, pustules, ulcers in the throat extending to the nose and destroying its bones, pains in the joints and tophi. After ulcers with lardaceous bottom and everted, hard, callous edges, a vesicular eruption which scales, deep, hollow ulcers in the tonsils, pains in and swellings of the bones. These relations between the primary and consecutive affections are not throughout constant; often is one kind of primary affection followed in the same patient by an eruption of entirely different kind, which may occur either at the same time on different parts of the body or may break out one after the other.
On these grounds I consider the admission of a gonorrhæal contagion, as proposed by RITTER (C), to be untenable.
827. In the prognosis of syphilis the following circumstances are to be observed :
Primary ulcers are more easily healed than secondary. The connexion of syphilis with other dyscrasies renders the cure difficult and may even make it impossible. The more recent is the disease, the more favourable is the prognosis. Syphilitic affections of the bones are more difficult to be subdued than those of the skin : those of the nose-bones are liable to more frequent relapses than those of the tubular bones. In warm climates and in summer the cure is more easy than in cold climates and in winter. Pregnant women in an advanced state of syphilis miscarry or bring forth a weak, ailing child. The ulcers in the throat and in the nose often easily produce extremely disfiguring destruction. All syphilitie growths are obstinate and easily recur. If, after the cure of primary syphilitic ulcers, hard scabs ( Tubercula callosa) remain, a relapse is always
So does not think JOHN HUNTER, for he observes :-“The gonorrhaa in its cure is the most uncertain of the three (forms of disease,) the chancre next, and the lues rererea the most certain, although cured by the same medicine which cures the chancre. *. A chancre may sometimes be cured in two weeks, and often requires as many months, which is in the proportion of four to one. The lues venerea in general may be cured in one or two months, which is only two to one.” (p. 353.)
* In the cure of chancres I have sometimes seen," he says further," when the original
(a) RicHond; in FrORIEP's Annalen, vol. viii. of Syphilis without Mercury; in Med.-Chir. Trans. No. 17.
vol. viii. (*) Evans, Pathological and practical Remarks WEDEMETER, Bemerkungen über die Syphila on Ulceration of the Genital Organs. London, und ihrer verschiedenen Formen und über die 1819. Svo.
Wirkungen und den Gebrauch des Quecksilbens in GUTHRIE, Observations on the Treatment Derselben; in Rost's Magazin, rol.ii. p. 195.
(c) Above cited.
chancre has been doing well, and probably nearly cured, that new ones have broken out upon the prepuce, near to the first, and have put on all the appearance of a chancre; but such I have always treated as not venereal. They may be similar to some consequences of chancre which will be taken notice of hereafter.” (p. 259.) * « Chancres," ABERNETHY observes, “ do sometimes heal spontaneously, generally, however, though not constantly, leaving a thickening or induration of the part affected. They may also be induced to heal by topical means, without mercury, with similar events. Some enlargements of glands in the groin will also, in like manner, subside. It may be fairly supposed that if some chancres heal spontaneously, constitutional diseases, arising from the same cause, may, in like manner, sometimes get well without mercury. The question can only be solved by experience. Delay will, I am sure, frequently enable a Surgeon to decide that the disease is not syphilis; but there are cases in which no amendment takes place, and the Surgeon is, as it were, forced, from the progress of the disease, to employ mercury, though doubtful of its nature.” (pp. 48, 9.)
" It often happens,” says JOHN HUNTER, “ that after chancres are healed and all the virus is gone, the cicatrices ulcerate again and break out in the form of chancres. Although this is most common in the seat of the former chancres, yet it is not always confined to them, for sores often break out in other parts of the prepuce; but still they appear to be a consequence of a venereal complaint having been there, as they seldom attack those who never had gonorrhea or chancres. They often have so much the appearance of chancres that I am persuaded many are treated as venereal that are really not such ; they differ from a chancre in general by not spreading so fast nor so far: they are not so painful nor so much inflamed, and have not those hard bases that the venereal sores have nor do they produce buboes; yet a malignant kind of them, when they attack a bad constitution, may be taken for a mild kind of chancre, or a chancre in a good constitution. I have seen several that have puzzled me extremely. Some stress is to be laid upon the account that the patient gives of himself; but when there is any doubt, a little time will clear it up. I have seen the same appearances after a gonorrhæa, but that more rarely happens. It would appear that the venereal poison could leave a disposition for ulceration of a different kind from what is peculiar to itself. I knew one case where they broke out regularly, every two months, exactly to a day.” (p. 265.)]
828. The opinions as to the treatment of syphilis are very much divided and may be arranged in two classes :
1. The treatment with mercury.
1.-OF THE TREATMENT OF SYPHILIS WITH MERCURY. 829. In the cure of the primary syphilitic ulcer the most especial indication is to prevent the general venereal disease ; it is therefore advisable to connect a general treatment to that effect with a suitable local treatment.
830. The local treatment has for its object the destruction of the syphilitic poison in the ulcer, the cleansing of its surface, and by a continued use of proper remedies to effect a cure. This is aimed at by touching the ulcers with nitrate of silver or caustic potash, most effectually with a saturated solution of mercury in nitric acid, or with a strong solution of sublimate. The ulcer should be frequently washed during the day with a weak solution of sublimate, or with phagedenic water and charpie moistened in either of these fluids applied over the ulcer; or it should be bound up with red or white precipitate, with citron ointment, and so on, and carefully kept clean. This treatment must always be guided by the degree of inflammation; in severe inflammation and great pain soothing remedies must be applied.
The destruction of the ulcer with nitrate of silver which has of late found in RiCORD a zealous advocate, is only of use when the disease is still merely local, a period of time which is extremely short and difficult to determine.
831. At the same time should be given internally the milder preparations of mercury, the mercurius solubilis of HAHNEMANN, or calomel, at a quarter or half a grain, and in increasing doses according to circum
stances. The patient during this mercurial cure must keep himself as quiet as possible and in an equal temperature, must live moderately, take neither heating nor acid food nor drink, and further perspiration by a decoction of woods.
- I should state decidedly" says LAWRENCE, “ as the result of my own experience that there are very few instances of secondary symptoms occurring where the primary sores of the descriptions I have already mentioned, were treated with mercury. It is my plan in private practice, to employ inercury moderately-not extensively, but mode ratels-in the treatment of primary syphilitie sores, (excepting in the cases of sloughing and phagedenic sores,) and certainly I have been in the habit of seeing secondary sympa toms very seldom occurring in such cases. * ** I would state then that in the de scription of sores I have mentioned, I should generally administer mercury in a moderate way. In the first instance, one would clear out the alimentary canal of such patients; one would keep them as quiet as possible, put them on a moderate diet, and administer mercury moderately; three, four, or five grains of the blue pill two or three times a day, and apply the black wash, calomel, and lime water, to the sores; and this kind of treatment is certainly, on the average, very successful in the cases of which I am now speaking. The employment of mercury is more particularly necessary in the cases of indurated chancre; and whether the chancre possesses that character originally, or whether the induration comes on subsequently, or whether the induration comes in a secondary way, after the primary sore is healed, and shows itself simply as induration without sore, I think the employment of mercury is equally required. We cannot consider our patients safe so long as such induration remains, and I think it is desirable to use mer. cury in those cases, and to continue the employment of it until the induration has comipletely disappeared." (p. 770–71.)
With regard to the extent to which the use of mercury should be pushed, LAWRENCE proposes two very pertinent questions, to which he gives equally good replies,- First, whether a slight degree of action of mercury on the mouth may be considered a proof that it has produced all the effect necessary for the removal of the venereal disease; or, secondly, whether a more considerable effect is necessary generally, or in particular cases! It has been much the habit, in modern times, to produce a sensible effect on the mouth, and then to discontinue the mercury, under a notion that when the mouth is affected at all, the system has experienced a sufficient influence for the removal of the disease. I cannot coincide with this opinion. In a great pumber of instances a slight effect of mercury on the mouth is sufficient; but there are instances in which that slight effect does not remove the symptoms, and which, when the remedy is carried further, so as to produce more considerable influence, the symptoms give way. In fact, I think we never see the symptoms of syphilis yield so rapidly, and so favourably, as in certain cases, where the remedy, perhaps, without our wishing it, has produced a pretty pro fuse salivation. Under these circumstances we may notice a sudden and rapid smelioration of the symptoms, which we are not in the habit of seeing when the mouth is affected in a slighter degree only. Another question immediately connected with the same point is, how long the remedy should be continued ? Is it sufficient to destroy the venereal character of a sore and to produce the healthy process of restoration? Would you leave it off then and leave the cicatrization to form of itself? May you discoutinue the use of the mercury the moment the cicatrization is complete, or should you try to secure the patient from the occurrence of secondary symptoms, by proceeding with the employment of the remedy after that? These are important questions, and we have not, perhaps, the means of answering them satisfactorily. With respect to the first, however, it is certainly not safe to discontinue the use of the mercury before the sore is cicatrized all over. Then, secondly, is any good produced by continuing the use of the mercury after the cicatrization is complete, with a view of preventing, a return of the symptoms? This is a very important question, and if you refer to the best writers on the subject you will find but little to assist you. * * * General expe rience, however, has led to a belief that perseverance in the use of mercury for some time, say about ten days or a fortnight after cicatrization, has a beneficial effect in pro. tecting the constitution; so that persons when they have used mercury to the extent ! had mentioned, are not in the habit of suddenly discontinuing it, but of carrying it on for a short time after the apparent removal of the disease, under belief that its contineance tends to prevent the recurrence of further evil." (p. 732.)
“ There are many in the present day," observes GREEN (a), “who seem to have a great aversion to mercury, and certainly if our opinion is to be formed from the price
(a) Unpublished Clinical Lecture on the Treatment of Syphilis.
tice which was adopted by some, within my recollection, and even to a degree within these hospitals, there is no doubt very sufficient ground for not following the practice of our predecessors. But it would be evidently most injudicious to reject the aid of mercury in the cure of the venereal disease on the ground of the ill effects that may result from its mismanagement, or have been produced by its abuse. We now see the error of the older Surgeons, and do not think it necessary that patients should spit saliva by the pint, nor do we see them in what were fitly enough, from their stench and ill ventilation, called the foul wards' of the hospital, with their tongues ulcerated, svollen, and protruded, their faces tumified, and under all the miseries attendant upon a thorough salivation. We give mercury now in moderate quantities, and it is, I believe, from this improved method of treatment that we now see comparatively few cases of horrible mutilations from sloughing of the penis, from losses of the palate and nose, and from extensive and destructive disease of the bones. Mercury may no doubt be regarded as a specific in the cure of the venereal disease. What this peculiar action of mercury consists in it is impossible to say, and it is equally obscure with the effects of other specific remedies; but we judge of its operation from its sensible effects, and experience guides us in determining the quantity of the remedy which may be necessary, and the degree of effect which may be requisite for the cure of the disease; mercury, in short, requires the same caution and judgment in its administration as any other remedy. And although, as I said before, a much milder course than was formerly exhibited may be sufficient to cure the disease, yet it will be necessary to adopt it in particular cases, and to vary the mode of using it in different stages of the complaint, or you may have some of the ill effects which were formerly observed, and the patient's health may be destroyed without curing the disease. The advantage and benefit of mercury are not then derived from the quantity introduced or from the violence of its effects, but from keeping up a regular and continued action for a certain period. In general the action of mercury should be kept up three weeks for a chancre, a month where the primary sore has been succeeded by bubo, and from six weeks to two months in cases of secondary symptoms; and if the symptoms should disappear quickly, still it will be right that the remedy should be continued, for the mercury is not given to cure the local symptoms only, but to ensure the system against their recurrence, and to destroy the disposition to disease in those parts which have been contaminated by the poison.
“Something may be said too with respect to the form of giving mercury. Where you wish to continue it for a length of time you should give the mild form ; where you wish to affect the system quickly, those kinds should be exhibited which are calculated to operate more rapidly. Hence it is not an unimportant matter whether we should give calomel, blue pill, hydrarg. c. creta, or the oxy-muriate of mercury. What we ordinarily employ in private practice is the blue pill; but in the hospital we commonly use mercarial friction, Mercurial friction can be very thoroughly effected in the hospital; but in private practice it is seldom effectually accomplished, as it is troublesome, dirty, and leads to the exposure of the complaint, and, therefore, except in peculiar irritability of the bowels, is seldom adopted. Five or ten grains of blue pill twice a day, with the addition of opium if the bowels should be irritable, will very commonly be sufficient to cure any complaint similar to that which we have been considering, in short, any secondary form of the disease; but then it must be a sustained course of mercury, its influence must be kept up on the system for six weeks or two months, or even for a longer period when the bones have been effected. It is necessary not so much to be guided by time as by the disappearance of the symptoms; and it is right to continue the effect of the mercury somewhat longer, a week, ten days, or a fortnight after the symptoms have subsided.
“ But you will ask me what proof you are to have of the system being sufficiently influenced by the mercury, and how you are to know that its action is kept up without prejudice to the patient? During the mercurial treatment we ought to be satisfied that it has a due effect, and we commonly look for this in the affection of the gums, which become spongy, swollen, red, and tender. An increased flow of saliva is the usual accompaniment of this state of the gums, and the term ptyalism is often used as an equivalent term for the requisite influence of the mercury on the system; but the increase of the saliva is not at all a necessary consequence of the affection of the system, and is no proof in itself of the efficacy of the remedy; indeed, in some persons it does not take place at all, although there is abundant proof of mercurial action. In fact, the operation of mercury is that of producing a febrile action in some respects similar to hectic, that is, there is increased action of the heart and arteries, with an augmentation of the secretions; and we shall find, in a person who is the subject of mercurial action, that the VOL. I.
pulse is quickened, that the secretions are increased, and the predominant increase may be in the saliva, in the urine, in the perspiration, or in the secretion from the bovels, that the muscular strength is diminished, and that the body wastes. We may be there fore satisfied if any of these effects are produced, and we must be careful not to push tha operation too far."]
832. If the ulcer be obstinate, or the condition of the patient render the observation of the dietetic treatment already mentioned impossible, then sublimate must be used, beginning with the eighth of a grain daily and gradually ascending. In chancres which spread unusually quickly even during the internal and external use of the sublimate, in which the edges of the ulcer are extremely hard, and their surface has a carcinomatous appearance, the quieting and cleansing of the ulcer is effected merely by the external use of the red precipitate, and smart touching of the whole surface of the sore with lunar caustic. This'local treatment is however, hurtful if there be general irritation present, under which circumstances only a soothing treatment to diminish the irritation should be employed.
The recommendation that in the treatment of primary syphilitic affections nothing should be applied locally, so that the changes of the sore may indicate more certainly the corresponding destruction of the disease by the mercury employed only internally, is objectionable, because by local treatment the sore is often easily brought to a simple state, and the longer the ulcer exists, the more is the general infection to be feared from absorption of the poison,
DELPECH (a) considers that in primary syphilitic affections, mercury in the way of friction of ung. hydr. cin, may be most efficiently employed in the neighbourhood of the infected part for the prevention of general infection.
[When a chancre takes on a sloughing character, as described by LAWRENCE, it must not on any account be treated with mercury in any form, either internally or ex. ternally, for its employment will only aggravate the mischief, render the sore still more irritable and active, and hasten and extend the spread of the sloughing process. When, therefore, a chancre begins to slough under the use of mercury, that must be immediately suspended. The local treatment of brushing over the whole surface with strong nitrie acid as recommended by WELBANK (6), once or twice, is the best that cau be adopted. In the course of a few hours, generally, the pain subsides, the sloughing process is arrested the angry red edges around the slough begin to grow pale, suppuration is set up, and the line of demarcation between the living and dead parts appears, and gradually deepening, the slongh is completely defined, and slowly separates from the healthy parts beneath. After the application of the acid, a stimulating poultice of yeast, stale beer, or treacle, should be applied, either directly to the surface of the sloughing sore, or lint dipped in nitric acid wash, or in solution of chloride of soda, may be interposed. As in these cases there is always great restlessness as well as depression of the constitutional powers, opium, either as laudanum, or as the salts of morphia, must be given in sufficient quantity to produce quiet and sleep. The patient's strength must be supported by the most nourishing diet, and brandy, or gin, or porter, or both, in sufficient quantity, must be given; two, four, or six ounces of the former, with one or two pints of the latter daily, are almost always requisite, as these frightful cases usually occur in persons, especially women, who are accustomed to live almost entirely on spirits and can take little food. Some recommend the application of leeches upon the inflamed circumference of the sore, but they should never be used as they only assist in diminishing the patient's powers, already too much depressed
The recovery from this complaint, after the separation of the slough, is very slow, and the discharge very profuse; good diet, with the spirits, or porter, in diminishing quantity, is, therefore, to be continued ; and the wound may be treated, either simply with nitric acid wash and poultice, with the latter alone, or with some mild greasy ap plication, to which the medical attendant will be guided, by observing what best agrees with the sore, and which will not be the same with all patients.
It is a very interesting fact, that secondary symptoms, after sloughing chancre, are extremely rare, the disease seeming to exhaust itself by the virulency with which it has seized on the part attached. Therefore, mercury ought not on any account to be e. hibited as a preventive against symptoms which probably will never occur.-J. F.S.
(a) Above cited.