833. If the ulcer heal with this local and general treatment, the internal use of the mercury must not at once be given up, but should be continued in smaller doses for some time. 834. The treatment of Buboes is to be guided according to the degree of their inflammation. If they be painful, the patient must be kept quiet, cold poultices of bread crumbs with lead wash, linen dipped in lead wash applied, and leeches, or even bleeding employed if the patient be strong and inflammatory affection of the whole body be present. In the more cold swellings gray mercurial ointment is to be rubbed in, and mercurial and hemlock plaster applied over it. In hard swellings softening poultices are especially serviceable. Idiopathic buboes have a decided disposition to suppurate; when, therefore, the dispersion of a bubo does not easily and soon follow, it must not be urged by violent remedies, but suppuration must be promoted by softening poultices, by mercurial and hemlock plasters; and this treatment must be continued till the bubo have opened itself (1). These remedies serve also, after the opening of the bubo, to resolve the surrounding hardness. The still remaining ulcer must be treated as a venereal sore. To prevent burrowing of the pus, enlargement of the opening is frequently necessary. The violent dispersion of an idiopathic bubo may accelerate the outbreak of the general venereal disease. If the bubo run on to hardening, then besides the proper mercurial cure must be employed friction of gray mercurial ointment with camphor, hemlock and mercurial plaster, or friction of iodine ointment. According to my experience, I assent to the opening of buboes in the same manner as abscesses, by a simple puncture, by a transverse cut, by the introduction of seton threads or by caustic, as advised by many persons. (a). The compression of buboes recommended by FERGUSON is especially employed by FRICKE in connexion with strict antiphlogistic treatment. Any hard properly-shaped body, for instance, according to FRICKE, a piece of wood or a stone sown up in linen will answer the purpose (2). For the dispersion of buboes without distinction of their nature and duration, REYNAUD, RICORD, and others have recommended the application of blisters of the size of a shilling or half-crown upon the middle of the swelling, and after the removal of the cuticle raised by the blister to touch the part with a feather moistened in a solution of sublimate, twenty grains to an ounce: if, after two hours, no slough has been produced, the touching is to be renewed and a bread poultice applied (3). The suppurating parts heal in a few days, and by continued use of the poultice, the bubo either entirely subsides, or it diminishes and disappears at the second or third application. [(1) A bubo should always be punctured, as soon as fluctuation can be felt near the surface, with a moderately large opening; about half an inch in length is generally I think sufficient, but some Surgeons prefer slitting it up from end to end, and believe it heals more readily, I think, however, the less large aperture is sufficient. Occasionally it happens, whatever be the size of the opening, that the pus will burrow and sinuses will form. If not irritable these may often be cured by gentle and well-applied pressure from the extremities of the sinuses towards the wound, care being taken to leave the latter free for the discharge of the pus. This, however, will not always be effectual, and it then becomes necessary to lay the cavities freely open and keep them so by inserting lint between their edges; and this may be either dipped in black wash or nitric acid wash, or smeared with red precipitate ointment. Oftentimes the ulceration continues eating beneath the skin of the edges of an indolent open bubo; which thus undermined, has a bluish appearance, with a white irregular and insensible edge, and has not sufficient power to take on the adhesive action and unite with the parts beneath. It must then be removed, which is sometimes done by shaving off with the knife. I think, however, destroying it with strong nitric acid is best, as it produces a healthy excitement, and the skin usually soon shoots over the sore surface. The quantity of undermined skin will show the medical attendant how much should be (a) FRICKE, chirurgische Annalen des Hamb. Krankenhauses, vol. i. destroyed at a time; if there be little, one application of the acid is sufficient; but if much, it will be advisable to destroy portions successively till the whole is got rid of If a bubo take to sloughing, as it will do occasionally, it must be soothed, or even treated with nitric acid as directed for sloughing chancre. I have known it destroy life by ulcerating the femoral artery and producing fatal bleeding. I doubt not much benefit would be derived by taking up the artery above the sore. (2) I am not in the habit of using pressure for dispersing buboes, but I have seen it occasionally beneficial. (3) Of the employment of sublimate after blistering to produce a slough I have no experience, but think it must be rather sharp practice. The application of blisters alone to indolent buboes is often very advantageous; sometimes they excite the absorbents, and the swelling is removed; at other times they excite increased vascular action, and the bubo suppurates, and after opening, or having been opened, gets well: so that in either case the blister does good service. I have occasionally removed the skin from the blistered surface and dressed it with iodide of potash ointment, or with mercurial ointment, and with beneficial result.-J. F. S.] 835. The treatment of the general venereal disease requires a more powerful use of mercury than in primary syphilitic affections. Mercury is employed internally or externally. 836. The external use of mercury is to be recommended only in those cases where the patient cannot bear it even in connexion with opium, mucilaginous remedies and so on, in consequence of habitual purging; in some persons also especially on account of pains in the bones. This mode of treatment, however, usually excites little salivation, and by many persons cannot be borne on account of the peculiar sensibility of the skin. From half a drachm to a drachm and still more of the gray mercurial ointment is to be rubbed on different parts of the body daily or at longer intervals. Sublimate baths have also been recommended, and the rubbing in of half a drachm of sublimate with as much muriate of ammonia every evening upon the soles of the feet, (after they have been softened by some days' previous warm foot-baths,) together with the simultaneous use of a lukewarm bath every other day, of decoction of sarsaparilla (a), as also the rubbing in of red precipitate, dry or mixed with spittle, and many other modes of treatment (b). The last two modes of treatment are, however, much less efficient than rubbing in gray ointment. 837. In the ordinary and not very old cases of venereal disease, the internal use of mercury is preferable to the external. The mercurius solubilis of HAHNEMANN, or calomel, are given; or because these preparations easily excite salivation, which prevents their continuance, sublimate is especially used. Under this treatment the patient must closely follow the dietetic rules already laid down, and according to the different degrees of irritation they must alternate with the preparations of mercury. 838. Besides this general treatment, certain appearances of Lues require especial attention. In syphilitic ulceration of the throat and palate the pencilling recommended by RUST (a) is especially useful, and to be applied once or twice a day to the surface of the ulcer by means of a pencil of charpie (1). In syphilitic eruptions washes of sublimate water, of aqua phagadenica, (a) CIRILLO, Praktische Bemerkungen über die venerischen Krankheiten, translated from the Italian by DÄHNE. Leipzig, 1790. There is also a French translation by AUBERT. Paris, 1803. I am sorry I have not been able to see either the original or the translations of this work, for I cannot imagine the possibility of half a drachm of sublimate being recommended to be rubbed in nightly. -J. F. S. HUFELAND, Journal der praktischen Heilkunst. 1819, March. (b) ANSIAUX, Clinique chirurgicale. Extract, cicutæ, flor. chamom. àâ Zij. sublimate baths, various kinds of mercurial ointments, and drinks operating on the skin, are employed (2). If the granulations do not diminish under the general mercurial treatment, they must be washed with a strong solution of sublimate, strewed with savine powder touched with caustics, especially with liq. hydr. nitr., or removed with the knife or scissors, and the places where they were, touched with caustic. Even when the general Lues has been long cured they are often extremely obstinate. Syphilitic diseases of the bones require a commensurate mercurial cure, according to some, especially Mercurius nitrosus and wood drinks. In nodes and gummatous swelling, hemlock poultices and rubbing in mercurial ointment with opium are used. In most cases, these swellings, which depend on exudation beneath the periosteum, become softer, less painful, and gradually diminish, and a slight depression and irregularity remains in their place. In tophus, irritating remedies, as mercurial and hemlock plasters with ammoniacum or blisters are to be used; and the same applies to exostosis. But if these swellings be accompanied with inflammation, leeches are to be applied and mercurial ointment rubbed in. In pains in the bones the combination of mercury with opium internally and externally is fitting, and the use of wood drinks (3). [(1) Mercurial fumigation of the throat in syphilitic ulceration of the tonsils and pharynx is a very efficient mode of treatment, as the mercurial fumes get at all those parts of the sores which cannot be reached by pencilling. Nitric acid, or chloride of soda gargle, are also very useful applications. (2) When secondary syphilitic sores have formed, which, as LAWRENCE has observed, are sometimes the result of pustules, and which pustules, it might have been added, often commence in vesicles, the scabs generally assume a conical form, and sometimes attain great height by circular rings being continually produced at their base, corresponding with the enlargement of the sores, resulting from the confined matter producing ulceration by its pressure; and, as at this part the scab is softest, it bulges around the sore, and thus ring below ring of scab, each of greater circumference than the other, is produced, and thus a graduated or step-like conical scab is formed which has close resemblance to the scab of a rupial sore. If this scab be rubbed off the edges of the wound are very painful and irritable, and soon set about forming another, but imperfect scab, which worries the patient exceedingly. So long as such scabs reman on the sores, so long do they continue increasing and the sores spreading; and, as theiy are thick and hard, no application to them is of the least service. They should therefore always be removed by poulticing, after which, by the application of red precipitate ointment, together with constitutional treatment, they generally heal kindly. The same internal remedies for such eruption will not always be found suited to different cases. Sometimes the use of generous and strengthening diet, with porter or wine, is sufficient, as such patients are usually much out of health and worn down by the suppuration. It is, therefore, advisable always to commence with this mode of practice, with the risk of a reappearance of secondary symptoms, which is not unfrequent. But sometimes this treatment is utterly useless, and it is requisite to use mercury to affect the constitution: this must, however, be done with the greatest caution, and with constant watching. If the sores improve and the patient's appearance betters, and he begin to get flesh, it is a proof that this is the proper treatment; if, on the contrary, the sores become more irritable and spread, and there be increased general disturbance, the mercury must be left off, and the general irritation quieted if possible by merely soothing treatment with sarsaparilla or gentle tonics and sedatives-either opium or hyoscyamus. But it may be still necessary to resume the mercury, and sometimes, though the constitution will not bear it at its first or second use, it will at last seem to yield to the necessity of its employment, will first bear with it without seeming benefit, then gradually become accustomed to it, and at last improve under it, and be freed from the disease. I have seen this result again and again, and I am convinced of the occasional absolute necessity for the employment of mercury in this form of syphilitic eruption, although it may at first seem to be impossible to persist in its use. The other forms of syphilitic eruption are more quickly and effectually cured by the use of mercury, but they may also be cured by iodide of potash, which is a most valuable remedy for persons, who, as occasionally happens, cannot bear the use of mercury; which, however, I believe much less frequent than supposed, and that rather the failure is in want of proper attention on the part of the medical attendant in the use of the medicine, than in the action of the medicine itself. In the employment of iodide of potash in these eruptions it must not be expected that the disease is at once cured; for such is not the case. The eruption not unfrequently recurs two or three times, as if a contest were going on between it and the medicine, but it is at last worn out and appears no more. I must confess, however, that if the patient's constitutional appearance do not oppose it, I prefer treating these eruptions with mercury, as the cure is more speedy and most certain. (3) The best and most certain treatment for nodes is that by mercury which must be continued for six or seven weeks; and under its use these swellings, whether from fluid or from the actual diseased growth of the bones, slowly but steadily subsides, so soon as the constitution becomes affected. The same effect takes place even more rapidly by the use of iodide of potash, which may be taken internally in doses of from three to five grains, with a dram of syrup of poppies, and in either decoction of sarsaparilla, or compound infusion of gentian with some warm tincture. The quick absorp tion under this treatment is often very surprising, but the cure is not permanent, and the nodes reappearing again and again, call for the repetition of the medicine till the disposition to their production is overcome, just as in the eruptions already mentioned. It is rarely necessary in these cases to cut down through the skin and periosteum, as was formerly almost always practised when there was much fluctuation; and its absorption may be hastened by blistering, and either dressing the sore with simple ointment or with iodide of potash ointment. But when fluctuation is accompanied with much pain and tenderness, and with redness of the skin, and the swelling increases instead of diminishing, then it may be expected that suppuration has taken place, and it is best to make a free incision for the escape of the matter. If this be not done, the pus gradually separates the periosteum more extensively from the bone, and there is great danger of it being destroyed. This death of bone from syphilitic suppuration beneath the periosteum, is more common on the skull, than elsewhere and more serious, as not unfre quently both tables of the bone are destroyed. It rarely however happens except in persons of irritable habit and broken up constitution. Such fluctuating nodes should therefore be emptied by incision, if they do not early yield to the local and constitutional treatment.-J. F. S.] 839. I have endeavoured to point out the various preparations of mercury according to their special and ascertained operation on the several conditions of the disease; it must, however, be premised on this point, that there are indefinable peculiarities in certain constitutions. There must therefore be a variation of these preparations, when one preparation has at first produced improvement, but on long continuance and more powerful application no further benefit results; or if from one preparation even in an increased dose scarce any advantage is gained, in such cases the preparation selected is not suited to the constitution. In syphilitic ulcers with severe inflammatory symptoms, every employment of mercury is at the onset improper; baths, softening and purgative remedies are alone to be employed, and in strong persons blood-lettings. Besides the mercurial preparations already mentioned, there have been of late brought into use Hydrarg, phosphor. to grain doses, (ŠTARKE,) the iodide and bromide of mercury ath of a grain three times a day, (VON GRAËFE,) and the Hydr. cyanic. to rd and th of a grain dose (MENDAGA, PARENT.) 840. The Flow of Spittle (Salivation) is not necessary for the cure of the venereal disease, and is rather to be avoided, as thereby the further use of the mercury is interfered with, and often no trifling destruction of the mouth and teeth produced. When, therefore, the precursors of salivation, as swelling of the gums, metallic taste, and offensive breath have set in, the dose of mercury must be diminished, the preparation changed, or it must be entirely given up. The patient must be kept warm, and when these symptoms have subsided, the mercury must be resumed. When salivation has commenced, many remedies are advised; as purgatives, sulphur, camphor, opium, blisters, and so on, but experience does not confirm their particular effect. The most suitable, however, are keeping warm, change of linen, warm bed, attention to keeping the bowels open, the use of astringent gargles for the mouth; internally, bark, acids, especially the phosphoric. It must not, however, be overlooked that in confirmed Lues it is necessary for its fundamental cure, that the mercury should be continued to incipient salivation, which should be kept up for several weeks, as frequently that alone proves the sufficient operation of the mercury upon the constitution. 841. In cases of very old venereal disease, in which often the modes of treatment prescribed are insufficient, several very active modes of cure have been proposed, among which may be especially reckoned, 1, the Friction and Hunger Cure; 2, the Mercurial Cure, after WEINHOLD'S plan; and, 3, ZITTMANN'S Decoction. 842. The Friction-Cure, long since (a) highly esteemed, has recently been brought into great repute by LOUVRIER (b) and RUST (c). The latter has also extended its employment to diseases not syphilitic, of which, however, a complete destruction is the foundation of the reproductive processes. The mercury does not, in this treatment, operate as a specific against scrofulous, gouty, syphilitic and other diseases, but simply as exciting the activity of the lymphatic system, by which the absorption may go on to completion, the previous degeneracy return to the natural condition, the entirely useless deposits be got rid of, and so a perfect consent of the organism produced. 843. This cure is indicated in syphilitic disease where disordered digestive organs forbid the internal use of mercury; when from the mercury a too little or too great affection of the bowels or of the whole system occurs; when the syphilis, having become a general affection, attacks the bones and tendons; when caries, exudation into the joints, hardening or disorganization of the different tissues are present; and when the syphilis will not yield to the internal use of mercury in diseases not syphilitic, in which from mere gouty, scrofulous, or rickety causes, swellings in the skin, glands, and bones, growth or other diseased affections are produced as the result of an anomalous vegetation, and cannot be removed by other means, for instance, swellings of the joints, dropsy of the joints, spina ventosa, and wide-spreading ulcers: also in herpetic, leproid eruptions, hardening of the testicles, of the breasts, and so on. Even in those cases where diseases arise from simply local causes, hardening and degeneration of the cellular tissue, callous changes, carious destructions, fistulous ulcers and the like, which on account of their unnatural condition and situation often for years withstand every kind of treatment, even the repeated application of the knife, or even render the latter impossible. 844. The friction cure is always a very severe mode of treatment, and for the patient, accompanied with much trouble (1). It must therefore not be employed on those patients who are very weakly, who have very irritable nerves, in hysterical, hypochondriacal patients, in those who are much disposed to agitation or are affected with other diseases, as complaints of (a) FABER, above cited. (b) Above cited. (c) Ueber die Heilkraft der methodischen Queck silbereinreibungen in syphilitischen und nicht syphilitischen Krankheiten; in his Magazin für die gesammte Heilkunde, vol. i. p. 354. |