butchers and others, who carry, or in some way deal in carrion. It has
also taken place in consequence of the hand being introduced into the
rectum—a veterinary method of removing scybala—of an animal labouring
under putrescent disease. A pustule appears on the part affected,
containing a serous or a dark-coloured fluid; and the base ulcerates,
extending through the skin to the subjacent parts; at first it is
accompanied with a pricking sensation, afterwards the pustule enlarges
and becomes brown, and the pain is burning and itching. The vesicle
when opened, or when it has burst spontaneously, furnishes a few drops
of red serum, and the pain is thereby relieved for a few hours. A hard,
moveable, and circumscribed tubercle forms, without alteration of the
surrounding skin. The bottom of the sore is yellow, greenish, or livid,
and the sensation is that of acute heat and erosion. Phlyctenæ spread
around. The tubercle becomes black in the centre, and an eschar forms;
the patient becomes irritable and languid. The gangrenous point begins
to extend, and that alarmingly; great swelling takes place, elastic,
red, and shining, more emphysematous than inflammatory or œdematous.
The burning pain is aggravated; the patient has a feeling of weight
and stupor; great constitutional disturbance follows, there is slow
fever, with a small pulse, a dry and brown tongue, and unquenchable
thirst; a low muttering delirium ensues, and under these symptoms the
patient soon sinks. After death, the fetid body swells rapidly. The
disease sometimes terminates fatally in twenty-four hours or less;
but generally the patient’s sufferings are more protracted. In the
treatment, superficial scarifications are of little avail. The only
topical application which can be relied on is a powerful escharotic,
applied freely to the part, and at an early stage, before swelling
and constitutional affection have been added. By it the parts replete
with virus, being immediately deprived of vitality, are soon thrown
off. Thus the virulence of the poison is annihilated, it is rendered
inert, and is concentrated in the slough, and the surrounding parts are
stimulated, and receive vigour of action, which enables them to resist
any further inroad, and to detach quickly the mortified substance.
For this purpose, the most effectual and convenient escharotic is the
caustic potass, but the liquid muriate of ammonia may also be employed.
The vesicle is opened, and the caustic applied to the exposed surface;
and if necessary, the eschar may be afterwards divided, and the remedy
reapplied. In the absence of other escharotics, the actual cautery will
prove a valuable substitute. After the separation of the slough, the
sore is to be dressed with slightly stimulating applications. Bark,
camphor, and mineral acids, are given internally, and the patient is
enjoined a light diet, with a moderate allowance of wine.
OF ULCERS OF THE GENITAL ORGANS, AND THEIR CONSEQUENCES.
It were unprofitable to enter here upon the History of Venereal
Affections, as it is a subject of no practical utility, still involved
in uncertainty, and mystified by disputation. It will suffice to
describe the different forms of the disease, and state the treatment
applicable to each.
During the last century, and in the beginning of this, much greater
ravages were produced by the disease than at the present time; and
though this may be, perhaps, partly owing to a change in the poison
itself, it is mainly attributable to the mildness of the measures by
which it has been, and is, opposed. Every form of the affection, as
soon as it appeared, was at one time opposed by a counter poison,
mercury; and the practitioner, relying implicitly on this mineral as
a specific, and not being fully aware of its dangerous properties,
continued to gorge the system with the supposed remedy, subverting the
constitution of his patient, making, in many cases, no impression on
the disease, but still persevering in the use of a poison equal, if
not more potent, than the one which it was intended to destroy. The
change of treatment has been propitious to our science and to mankind.
But let it not be inferred that mercury now is, or ought to be,
entirely dismissed from the treatment of this disease, or from practice
generally: often no other means are effectual; but it should always be
prescribed most cautiously and sparingly.
The effects of the venereal virus are divided into primary or local,
and secondary or constitutional; and these present a great variety
in their appearances, characters, and tendencies. They are sometimes
modified by the constitution, or by the remedies ordered in the
first stage; but there can be no doubt that different poisons exist,
producing distinct kinds of ulcers, which again are succeeded by
different constitutional affections.
The most common kind of sore is the _simple ulcer_, at first excavated,
in consequence of the process of ulceration continuing; afterwards
the ulceration stops, and granulations, somewhat fungous, supply its
place, so that the surface is raised above the level of the surrounding
parts, and has a smooth, soft appearance; there is no hardness of the
edges, and there is no tendency to slough or extend by ulceration.
Sometimes it commences in the form of a pustule, which soon gives way,
discharging its contents, and leaving an exposed surface, in which
the process of ulceration quickly proceeds; but often it arises from
simple abrasion of the surface. Different forms of sores may exist on
the glans and prepuce at the same time; and it is maintained, that
one sore may produce another of a different kind, and the same is
asserted with regard to eruptions. The simple ulcer, as well as other
sores, is produced by the contact of secretions, generally morbid,
but often apparently healthy, with a susceptible surface. Sores, with
eruption and sore throat, sometimes appear in one or both individuals
immediately after marriage, and probably arise from the acrimony of
the female secretions causing tenderness and ulceration of the parts.
The application of gonorrhœal matter readily produces the simple
ulcer on the glans or prepuce, particularly if an abrasion or rawness
existed; and if the matter be allowed to remain on an unbroken surface,
a pustule will form, and ulceration follow. From this latter cause
numerous sores are produced, separated from each other by sound parts,
and not extending into one continuous ulcer; and this condition may
have been preceded, on the glans, by a rawness of the surface and a
profuse discharge, or by a herpetic eruption on the mucous lining of
the prepuce. One man may be affected with gonorrhœa, and another with
ulcer, from connection with the same female, the same day or hour; and
it is doubtful whether the effect is not similar, in both cases, viz.,
ulceration; for it is supposed, that in gonorrhœa, the discharge, in
some rare cases, proceeds from patchy ulceration of the mucous lining
of the urethra, similar to the ulceration usually met with on the
glans. In examining women who have communicated infection, very often
no sores are found, and but little unhealthy discharge. In short, the
simple elevated sore may arise from the application of secretions from
an unbroken surface, from inoculation of matter from a similar sore,
or spontaneously, from inattention to cleanliness. Sores with elevated
surface, more extensive than those of the glans and prepuce, occur
on the skin of the penis and scrotum, or in the folds of the thigh;
and in women they are often met with in the perineum, or the cleft of
the nates. Sores of different kinds arises at various periods after
the application of their cause, from a day or two to some weeks, or
longer, but the usual time may be said to be from four to eight days.
The duration of the simple elevated sore may be modified by various
circumstances—by the constitution of the patient, his mode of living,
and the attention paid to the affected part. It seldom remains open
above a few weeks, but occasionally it may be seen unhealed at the end
of several months in those who lead careless and irregular lives.
Such ulcers produce, as readily as any other sores, enlargement of the
inguinal glands; they are a source of irritation, the effects of which
may be extended along the lymphatic vessels, to the cluster of glands
through which the absorbents pass, so as to cause inflammatory action,
ending in indurated enlargement; or venereal virus from the sore may
be taken up by the lymphatics, deposited in the glandular structure,
and produce a similar affection. Buboes thus caused are situated in the
upper cluster of inguinal glands; if the lower cluster is affected, it
is to be presumed that the cause is not in the organs of generation,
but in some part of the inferior extremity. From the existence of bubo,
nothing can be deduced as to the nature of the poison, or the probable
effects to be produced on the constitution; for enlargement of glands
in the course of their lymphatics will occur from irritation, whether
connected with a mild or malignant virus, or with one totally devoid of
any poisonous quality.
From the simple ulcer there arises a constitutional affection, in all
respects resembling that which follows gonorrhœa (a disease which will
be treated of under affections of particular mucous surfaces); but
before attending to this, it will be proper to advert to another form
of ulcer, which differs but slightly from the preceding in primary and
secondary symptoms. It is a sore with a brown surface, either on a
level with, or above the surrounding parts, with defined and elevated
edges, with no cartilaginous hardness of base or margins, and with
no tendency to spread either by sloughing or by ulceration. Such may
occur in the same situation as the simple sores, but they often form
on the outer surface of the prepuce, or on the scrotum; and are not
unfrequently met with round the orifice of the prepuce, which is a most
troublesome situation, as, in healing, they generally produce phymosis.
Sores and fissures in this situation are very often kept up by the
tense and irritable state of the aperture. The bubo which follows
this differs from that caused by the simple sore, in having, after
ulceration of the integument, a greater disposition to burrow; and this
tendency is more marked where mercury has been employed. From either
of these forms of ulcer, it sometimes happens that constitutional
affections arise, either during the existence of the sore, or some
weeks after it has cicatrised.
The usual secondary symptoms are those attendant on a papular eruption.
There is fever, with pains referred to the head, to the joints, chiefly
the larger ones, and to the chest, which latter symptom is sometimes
attended with dyspnœa. This indisposition is followed by the appearance
of a papular eruption, termed lichen, on the face and trunk, the
extremities being less thickly studded. The fever subsides in a great
measure after the eruption appears and comes fully out; but fresh crops
of papulæ may appear, and, in this case, the fever continues little
abated until the eruption begins to fade. The eruption consists, in the
first instance, of simple elevations or pimples of a red colour, and
these do not appear at once, but gradually: so that some have assumed
the form of cones, with minute collections of matter in their apices,
whilst others are mere elevations of the cuticle. When they fade the
spots are of a copper tint, and become covered with thin scales, in
consequence of the cuticle desquamating; but this latter appearance
can never be confounded with the scaly eruptions following another
description of primary sore. In all cutaneous eruptions, attended with
any febrile action, there is a tendency to sore throat, with tenderness
of the eyes; and this eruption is not exempt from a similar affection:
the fauces feel raw and tender, and are pained in deglutition; on
looking into the throat, the mucous surface is found red and swollen,
and the tonsils are generally enlarged; but there is seldom any breach
of surface; and, when this does occur, it is rather entitled to the
appellation of excoriation than of ulceration. Occasionally the
surface is covered with a thin coating of lymph, and sometimes this is
confined to the situation of the mucous crypts, so as to give a false
appearance of small sores. As in similar affections, unconnected with
any discoverable cause, the lymphatic glands, at the angle of the jaw,
are not unfrequently swollen and painful.
Such is the usually mild character of this affection; but if its
progress has been interrupted by any means, more particularly by
mercury, it assumes a more complicated form, and a less tractable
nature. If that mineral is administered in the usual style, and at the
commencement, when the fever and other symptoms are high, the patient’s
sufferings are all much aggravated. After the fever has subsided, the
eruption will often be found to disappear under the use of mercury;
but it is extremely apt to recur, as soon as the system has shaken
itself free from the effects of that medicine. The mercury produces an
irritation, which supersedes the eruption, but by frequent repetition
its effects on the system diminish: it at last fails to create an
irritation more powerful than the disease to which it is opposed,
and, consequently, the eruption does not yield, but during its use
is frequently reinforced by fresh crops of papulæ. If the eruptive
fever, and advanced stage of the disease, are imprudently and suddenly
arrested by the use of mercury, by exposure to cold, or by other means,
inflammation of the iris or joints often follows, of a very violent
form, and not to be easily moderated. No one thinks of repelling
measles or other eruptive diseases, and with good reason, for such
practice would almost certainly induce serious affections of internal
organs. For the same reason, every precaution must be used to allow
this form of eruption to take its own course, while we merely regulate
the constitutional symptoms as they obtrude.
Another form of eruption, which occasionally, though much less
frequently, results from either of the above mentioned sores, is
the pustular. It is preceded by fever, and consists of rather large
pustules, separated from one another, and not very numerous. After
their apices give way, and the contained pus is discharged, a thin
scab is formed, and on its separation a small ulcer is left, which in
general soon heals from its margins, leaving a dark-coloured spot to
mark its situation. The papular and pustular eruptions are sometimes
blended; a few pustules appearing amongst numerous papulæ, or _vice
versâ_. The pustular disease is not of frequent occurrence; and in
proportion as it approaches the papular, with desquamation, it becomes
milder and more easily removed. In it, as in the papular, mercury
proves injurious.
The phagedenic form of ulcer is the most dreadful and unmanageable
of all; most uncertain in progress, and direful in event, and often
rendered still more destructive by the mode of treatment adopted.
Fortunately, it is now seldom seen, though not long ago it was well
known, as a perpetrator of dreadful havoc, under the name of black pox.
It is a corroding ulcer, without hardness of the surrounding parts,
presenting no appearance of regeneration of the tissues which have
been destroyed. It may follow either upon a pustule or an abrasion.
Sometimes it destroys the prepuce and glans in a few days, or again,
when chronic, it spreads deceitfully, healing at one part and
destroying at another. The ulceration is often deep, penetrating the
corpora cavernosa, or the corpus spongiosum urethræ: in such cases
it is followed with violent hemorrhage, which often produces a great
and sudden improvement in the sore. After slow cicatrisation it not
unfrequently happens that the scar gives way, and the ulceration
returns.
Sometimes another character is given to the sore, by the rapid
sloughing of the parts. In this modification, a small black spot is
first observable, unattended with pain: it enlarges rapidly, and, after
no long time, the mortified part separates, exposing an unhealthy
surface, which is immediately attacked and progressively destroyed
by phagedena. The part may again slough, and, by an alternation of
mortification and phagedenic ulceration, the external organs of
generation, male or female, may be wholly destroyed. In the present
day, however, its ravages are much less extensive and more easily
combated than formerly, and it seldom, if ever, proves fatal. One very
troublesome case is in my recollection, where the patient suffered
two attacks at the interval of two years. During the progress of
the disease he was seized with delirium tremens; a bubo formed and
ulcerated; a violent hemorrhage occurred from the sore; sloughing and
phagedena alternated; and both prepuce and glans were entirely lost.
An eruption followed, accompanied with ulceration of the throat and
nostrils. He recovered much mutilated. Ulcers originally of a simple
character may become affected with phagedena, or sloughing, from the
state of the constitution, from mismanagement, or from exposure to an
unhealthful atmosphere. But in such cases, after the separation of the
slough, the exposed surface is found to be of a healthy granulating
character, contrary to what is observed in the originally phagedenic
disease. Buboes, when they occur, have the same malignant action as the
primary sore: the breach of surface is extended either by sloughing
or by phagedenic ulceration, and the edges of the sore are ragged and
undermined.
The secondary eruption which follows the phagedenic form is pustular,
though differing from that which has been already noticed. The pustules
soon give way, and ulcers remain, covered with thick scales or crusts,
which sometimes increase, layer by layer, so as to become prominent,
dense, and of a conical form,—the rupia prominens. After the separation
of the crusts the ulcers are found, superficial, rather unhealthy, and
showing a disposition to extend, chiefly towards the circumference.
When healing, the process of cicatrisation frequently proceeds from
the centre of the sore, which is still enlarging at its circumference.
The reason for this unusual mode seems to be that ulceration does not
commence in the secondary sores till the crusts which cover them have
been removed: they then are very superficial, not extending through
the thickness of the true skin; and the ulceration does not go on in
the centre of the original sore, but towards its margins, so that a
portion of true skin remains in the centre of the sore, whilst it is
gradually destroyed towards the margins. Then, whilst the surrounding
skin, which usually forms the new cutaneous texture necessary for
reparation, is gradually and progressively destroyed, the remaining
old skin in the sore assumes an excited action, as in ordinary cases,
and from it the requisite new texture is formed, and gradually extends
over the surface, until it meet with a similar substance, which has
been produced by the surrounding skin after the ulceration in that
quarter has ceased. Thus the general principle that skin is formed
by skin is, even in such instances, found to be correct; the healing
from the centre not following, as some have supposed, the complete
destruction of the cutaneous tissues, but from its having remained
unaffected, or nearly so. The appearance of the eruption is preceded by
general indisposition, and occasionally by smart fever. It is sometimes
extensive, but is in general confined to the upper parts of the body.
Ulcers of the throat occur, of a very alarming kind, quickly destroying
the parts attacked, spreading chiefly towards the posterior part of the
fauces, rapidly extending to the pharynx and to the nostrils, and in
some instances also involving the larynx. The pendulous velum of the
palate and the tonsils are often wholly destroyed, the bones of the
nose, more especially the turbinated, are deprived of their coverings,
and exfoliate, the osseous and cartilaginous portions of the septum
are discharged, and the nose becomes sunk, or is supported merely by
the columna. The patient’s breath is fetid, respiration is in some
degree obstructed, a foul ichorous discharge flows from the nares,
and the surrounding parts are inflamed, swollen, and excoriated. The
countenance is greatly disfigured. On looking into the throat, nothing
is seen but an extensive ulcerated surface covered with white adherent
matter, and exhaling an offensive fetor, particularly when the bones
are affected. Respiration is nasal, and the speech indistinct. When
the larynx becomes affected, the patient may be almost considered as
lost: phthisis laryngea is established, the symptoms and treatment of
which will be afterwards mentioned. The mutilating affection of the
nose does not seem to be produced by any other form of the venereal
disease, if not in any way aggravated. Along with the eruption and
its after effects, severe pains in the articulations, particularly in
the knee-joint, often occur, and are always much increased during the
night. Nodes seem to be produced only in those cases in which mercury
is exhibited; their most usual situation is on the fore part of the
tibia; severe pain is felt in the part, which becomes slightly swollen,
and of a bright red colour; the swelling feels dense and firm, being
a simple enlargement of the bone. They often occur when the patient
is taking mercury, and when, in fact, the constitution is completely
saturated with it. This medicine may interrupt the progress of the
disease, may remove the eruption and the ulcers of the throat, but it
at the same time transfers the disease to deep unyielding parts, to the
bones and their coverings, and the fasciæ.