or true pox. The primary sore, termed a chancre, “is somewhat of a
circular form, excavated, without granulations, with matter adhering
to the surface, and with a thickened edge and base. The hardness or
thickening is very circumscribed, not diffusing itself gradually and
imperceptibly into the surrounding parts, but terminating rather
abruptly.” Such is the appearance generally presented by the sore
when situated on the glans and prepuce. It generally commences in the
form of a pimple, without much surrounding inflammation. Sometimes
the ulcerated surface is very inconsiderable, but there is always the
abrupt and remarkably dense thickness which serves as a distinguishing
mark. The non-syphilitic ulcers may have surrounding hardness from
the first, or in consequence of the application of stimulants and
escharotics; but this is diffused into the neighbourhood, and is not,
it is said, of that remarkable solidity peculiar to chancre. It is
seldom that more than one chancre occurs: the usual situation is on
the glans and lining of the prepuce; but they occasionally form on
the outer surface of the prepuce, and on the dorsum penis. In the
latter situation the sore assumes a somewhat different appearance: it
is, in general, larger, the hardness of the base is not so great, the
excavation is less, and the surface is of a livid hue. When allowed to
proceed uninterrupted, the livid surface is alternated with that of a
light brown or tawny colour. Chancre is an indolent ulcer when compared
with the phagedenic or sloughing sore, the ulceration proceeds very
slowly, and, in proportion as it advances, the surrounding hardness
increases. It is also contumacious and obstinate in taking on any
reparative action. Phymosis occasionally takes place, in consequence of
chancre situated at the orifice of the prepuce, but not so frequently
as when that situation is occupied by superficial sores of a more
active nature. Bubo sometimes appears in both groins, or in one;
sometimes on the same side with the sore, often on the opposite, and
not unfrequently when the sore is healing, or after it has healed. It
may suppurate and give way, or may subside without having advanced to
suppuration. It differs in no respect from the swelling of the glands
from other causes, either in its swelled or open state. Neither does
the occurrence of a bubo render it more probable that constitutional
symptoms will follow. Enlargement of the glands is often caused, or
at least hastened, by the patient continuing to walk about and exert
himself during the existence of a sore, and whilst the absorbents
are in an irritable state; but a bubo may be caused by irritation
or excoriation in any way produced; and it not unfrequently occurs
without any apparent cause. In some cases of chancre or other ulcer,
the absorbents along the dorsum penis become swollen, and occasionally
suppurate. In former times, it was not uncommon for the surgeon to
insist that all swellings in the groin were venereal, though no primary
sore had ever existed: the virus was said to be absorbed from an
unbroken surface; the patient’s system was saturated with mercury; and
the use of that medicine was persevered in, with the view of opposing
those symptoms of a ruined system which itself had produced. Such
delusions have now happily passed away.
The eruption which follows the chancrous form of primary sore is scaly
from the commencement, and by this character is readily distinguished
from every other venereal affection. It is generally preceded by
an efflorescence or discoloration, rendering the skin of a mottled
appearance. The scaly eruption is a form either of lepra or of
psoriasis. The patches usually do not exceed a sixpence in size, are
distinct and separate from each other; their base is of a dark red
or coppery hue, the affected skin is not hard or rough, but soft and
pliable, and seldom covered with crusts; as they extend, the edges
are slightly elevated at the centre, which alone is covered with thin
white scales, appears flattened and somewhat depressed; when they
begin to fade, the margins shrink and become paler, and desquamation
proceeds slowly; a circular, purplish-red discoloration, with a central
depression, remains for some time after the blotches have declined: the
depression is permanent, but the discoloration disappears. The smaller
patches, which assume a variety of forms, continue for some time of a
dark colour, extend towards the circumference, become pustular, and
at length ulcerate superficially, enclosing an area of sound skin.
When depressions of the skin, as the folds of the nates, are affected,
a scaly eruption does not take place, but soft and moist elevations
arise, discharging a whitish matter, varying in form and size, and
accordingly receiving various appellations, as condylomata, fici,
or marisci. From them a secondary form of disease is occasionally
communicated. If no decided treatment is resorted to, and if the
eruption is consequently permitted to follow its own course, thick
crusts form, ulceration proceeds beneath them, the matter is confined,
and the patch becomes prominent. Another secondary symptom of chancre
is ulceration of the throat, sometimes extensive, but generally
situated in the tonsils, or their immediate neighbourhood. The ulcer is
not preceded by much pain or swelling: “it is a fair loss of substance,
(part being dug out, as it were, from the body of the tonsil,) with
a determined edge, and is commonly foul, with thick matter adhering
to it, like a slough, which cannot be washed away.” Such ulceration
may be simulated by excavated sores attending the phagedenic form of
disease; and it ought to be more especially distinguished from an
affection to which the tonsil is extremely liable, irregularity of its
surface, enlargement, and effusion of lymph, in consequence of chronic
inflammation.
A more serious part of the secondary disease is affection of the
deep-seated parts, ligaments, periosteum, and bones. The bones nearest
the surface are principally affected: a swelling gradually forms on the
tibia or ulna, without discoloration of the integuments, and without
pain occurring till after a long time. The pain is most severe during
the night. The inflammation of the periosteum is often very violent,
the subjacent bone, as in the head or extremities, becomes dead, and
exfoliates; but it remains to be seen whether this will take place
when mercury is more sparingly, if at all, administered. Ulcers betwixt
the toes, occurring along with the above symptoms, are supposed to be
venereal: they are unseemly, and peculiarly fetid.[24]
Such are the affections, local and constitutional, arising from a
venereal cause; but the latter may be simulated. Many affections of the
skin, mucous membranes, and bones, resembling the venereal disease,
may be produced by disorder of the constitution, by a decay of the
digestive organs, by unwholesome food, and exposure to inclement
weather, by inattention to cleanliness, and many other circumstances.
Morbid poisons, not venereal, but of various kinds, may exist, and
cause much mischief.
A disease resembling syphilis was produced by the cruel practice of
transplanting teeth from sound people into the jaws of persons in the
higher ranks of life, whose corresponding teeth were decayed. The
latter were the affected party, and that justly.
A very infectious disease was at one time common in the poorer parts
of Scotland, and known under the name of sibbens, or sivvens, chiefly
occurring amongst the poor, ill-fed, badly-clothed, and worse-housed
people in the Highlands. It was communicable by very slight contact
by kissing the lips of an infected person, smoking the same pipe,
drinking out of the same cup, or using the same spoon. Cases of it
are still occasionally seen. There are ulcers of the lips, mouth,
throat, and nose; ulcerated patches and warty excrescences in the
cleft of the thighs, in the axilla, and round the anus and pudenda.
A pustular eruption appears, and terminates in hardened crusts. The
same disease is known in Ireland, under the name of button-scurvy;
and a similar one, called raddesyge, has been described as occurring
on the sea-coasts of Norway and Sweden. In Canada, also, something
of a like nature was at one time prevalent. The yaws, at one time
common and destructive in the West India Islands, appear to be much of
the same nature. Some of these diseases, more particularly sivvens,
are very common amongst children. Even in these days children are
not unfrequently born with copper-coloured blotches of the skin and
desquamation of the cuticle; or they may come into the world with these
appearances, along with affections of the mucous membrane, hoarse
voice, redness round the anus, &c. These are forthwith attributed to
a syphilitic taint existing in either of the parents; and one or both
are put under mercury; but child after child comes into the world in
the same plight. Again, the disease is communicated by children to the
nurses, and _vice versâ_. All these affections are rendered much more
obstinate by full courses of mercury: the bones and ligaments become
affected in consequence; but small doses of that medicine may prove
useful towards the decline of the disease.
Some have believed mercury a certain test of syphilis; maintaining that
the disease, still checked by the specific, is never overcome by the
constitution; that it is unchangeable, and regularly and progressively
grows worse, where no mercury is employed; that, opposed by that
medicine, it is stationary, and is permanently cured by adequate
mercurial influence on the constitution. Whatever were the appearances,
if they went off under mercury, the advocates for this practice set
them down as those of syphilis, lues, or pox. If they did not yield
to that mineral, they were termed syphiloid, pseudo-syphilitic, or
mercurial; for they did admit, now and then, that their favourite
remedy produced unpleasant effects. Such theory and practice are now
very happily exploded.
As to the _treatment_ of local venereal affections, it may be, in
the first place, remarked, that prevention is better than cure. The
means employed for accomplishing this end are very various: oily
applications, alkaline and spirituous washes, &c., with the view
either of preventing the matter from coming into contact with the
genitals, or of completely removing it, when it has been but a short
time applied. There is one certain method of avoiding disease, which
it is unnecessary to mention. In all affections of the penis, it
is of the utmost importance to keep its extremity bound up to the
abdomen, in order to prevent congestion or inflammatory swelling.
Celsus knew this well; “Sursumque coles ad ventrem deligandus est,
quod in omni curatione ejus necessarium est;” rest and quiet must
be strictly observed; the patient must be confined to the recumbent
position, particularly when the sore is irritable, when swelling or
bubo has occurred or is threatened; and when the system is excited,
and the eruption has commenced, the bowels must be kept gently open,
the patient’s diet must be low, and the parts surrounding the sore are
to be kept carefully clean. Whatever the nature of the ulcer may be,
it is safe and prudent, in the first instance, to change its action
by the use of the nitrate of silver, or to destroy the surface by the
free application of escharotics, as nitric acid, or solution of nitrate
of mercury: the morbid poison is thus got rid of, and the surrounding
parts stimulated to a proper degree of action. This is absolutely
necessary in the phagedenic form of ulcer, whether of an acute or
chronic nature. But, in most cases, the patient does not apply for
medical assistance till the sore has been of so long duration as to
preclude all hope of counteracting the virus by any local application.
The simple superficial sores, and those with elevated margins, must be
treated on the same principles as if they were totally unconnected with
any specific cause; and the applications must be varied according to
the peculiarities of the part affected, and the different appearances
which the surface assumes during the progress of cure. Lotion is the
form of application found preferable in most cases, and may consist
of calomel and lime-water, with mucilage, called the black wash; of
muriate of mercury, with lime-water, called the yellow wash; of a
solution of sulphate of zinc, with spirit of a solution of nitrate of
silver, or of sulphate of copper. The linimentum æruginis or Barbadoes
naphtha, are often useful in foul sores. Ointments, if at all, ought to
be used sparingly. The application of dry lint, or the sprinkling of
a little fine powder, is often all that is requisite. Of course these
applications must be varied, according to the particular circumstances
of each case.
Buboes are to be treated in the same way as any other inflammatory
swellings; local means being taken at the commencement to subdue the
inflammatory action, and resolve the swelling. Rest is indispensable.
When they are stationary, the application of a blister will either
cause resolution or suppuration, and so the enlargement will be got rid
of, either in the one way or the other. The painting of a rubefacient
solution of iodine occasionally on the swelling is also useful, and
preferable to frictions with iodine ointment. When they have passed
into a decidedly chronic state, absorption may be promoted by pressure,
or, again, means must be taken to hasten suppuration, and the matter
which forms is to be early evacuated. If suppuration occur in the
cellular tissue, and not in the substance of the enlarged gland,
neither cicatrisation, nor a permanent cure, can be expected until
the prominent and indurated parts have been destroyed by the caustic
potass. In phagedena, bread and water poultices or tepid-water dressing
are, in the first place, to be applied, and the pain and irritation
may be soothed by solutions of opium, or extract of poppy. If bands of
skin intersect the ulcerated parts, they are to be divided, as being
a source of irritation which prevents healing. If the frænum præputii
be surrounded by ulceration and undermined, it must be incised for a
similar reason. It is often advisable, also, to divide the prepuce.
After the process of destruction has ceased, gently stimulating washes
will promote contraction of the sore.
It is an important fact, that the majority of primary ulcers can be
made to heal without mercury. Cavillers object to the mercurial washes,
supposing that they may act by affecting the constitution. The sores
with hardened edges, chancres, heal as well as others, when mercury
is not employed, but much more slowly. In some mercury is injurious:
in chancres it promotes the cure. In any case, I would never think of
ordering it, unless the progress were very tedious, the ulcer being
indolent and contumacious; then mercury may be advantageously used,
and moderately continued, until the callosity disappear. It is no
easy matter to say, judging from the appearance of the ulcer, whether
secondary syphilitic symptoms are likely to arise in consequence of it
or not, or what their nature may be should they occur: they follow upon
sores of all characters, and, again, do not appear, after what might
be set down as the genuine Hunterian chancre. Whatever the nature and
appearance of the ulcer may have been in the first instance, should it
become stationary, and show no disposition to heal under local means,
mercury may then be given cautiously, and with advantage. Considering
that very obstinate sores are now seldom met with, it would seem that
very little mercury is required in the treatment of primary venereal
ulcers. During the progress of acute inflammatory action, this medicine
should not be given for the primary affection, whatever the nature of
the ulcer. Mercury cannot prevent constitutional affections.
Constitutional symptoms do not often occur, taking place scarcely in
one case out of a hundred of all the forms of sores which present
themselves. In the _papular_ form mercury is hurtful, as already
remarked; it interferes with the natural and mild progress of the
affection, frequently gives rise to iritis, and produces pains of the
joints and bones. The powers of the constitution, aided by simple
remedies, are sufficient: the cure may be tedious, but cannot be
destructive. Whereas, if mercury be considered as the only specific,
its use will be long continued; it will frequently be resumed after it
has been dispensed with on the supposition that the virus is destroyed;
and by the effects of excessive mercurial irritation, combined with
those of the disease, tampered with and aggravated, the patient may
ultimately perish. The fever, which precedes and attends the eruption,
must be moderated by depletion, antimonial medicines, and purgatives;
but depletion ought not to be carried far, lest the eruption be thus
checked and disappear; and the patient ought to be carefully removed
from external circumstances which might produce a similar effect. After
the eruption has come fully out, and the febrile symptoms subsided,
it will be sufficient to attend to the general health, and employ the
decoction of sarsaparilla, a medicine which excites the secretions, and
more especially promotes diaphoresis. In short, the treatment may be
said to consist in allowing the disease, in a great measure, to follow
its own course, taking measures to prevent it from being interrupted,
and merely moderating such violent symptoms as may precede or accompany
it.
In the _pustular_ form of eruption the general treatment is the same
as in the papular. Mercury is hurtful, and increases the tendency to
burrow. When the surface is nearly covered with pustules and ulcers in
all stages, desquamation may be hastened by fumigations of sulphur, the
general sulphur baths, lotions of sulphuret of potass, nitro-muriatic
baths, vapour baths, or by smearing the affected surface with equal
parts of tar and sulphur ointment.
In phagedena the patient ought to be, if possible, placed in an airy
and healthful situation. In most cases free bloodletting may be
necessary at the commencement, and will be advantageously followed
by purgatives and antimonials. The patient ought to be strictly
confined to his room, and ordered low diet with diluents. Afterwards,
the internal use of nitric acid, the decoction of sarsaparilla, and
an occasional dose of Dover’s powder at night, will be beneficial,
particularly if sleep be disturbed with pain of the bones and joints.
Mercury, even in small quantities, protracts the disease, and in
large doses it hastens the ulceration and sloughing. When all febrile
symptoms have subsided, when the ulcers are nearly healed, when no
fresh pustules appear, and when desquamation is begun, alterative
doses of mercury, as a blue pill or grey powder every second night,
may sometimes be ventured upon, will tend to hasten the cure, and will
not, possibly, be followed by any unpleasant symptoms. The safe course
is to promote the secretions by some safe substitute—preparations of
sarsaparilla, ipecacuan, taraxacum, &c.
In fact, in all scaly eruptions, whether scaly from their commencement,
or having become so in their latter stages and previously to their
disappearance, mercury, prudently administered, will be useful by
expediting the cure, and not injurious by deranging the system. The
tar or citrine ointments may be applied to the eruptions and cutaneous
ulcers.
For the ulcers of the throat, unless in a sloughing state, the lunar
stone appears to be almost a specific, removing the irritability of
the sores, and protecting them from further irritation by coagulating
the discharge, which then more effectually covers and protects them.
The application requires to be repeated every second or third day, as,
by the frequent and necessary motions of the parts, the crust loosens
and separates, leaving the surface exposed and irritable. At the same
time the sore will contract very considerably under each successive
crust. The lunar stone may also be applied in solution; or a solution
of the bichloride of mercury in spirits or laudanum may be used, in
the proportion of from four to six grains to the ounce, or stronger.
The solution of the nitrate of mercury is sometimes employed with
advantage. Fumigation of the throat with the red sulphuret of mercury
has been extolled as a powerful means of checking the alternating
sloughing and ulceration which often accompany the ulcers of these
parts, but the propriety of its employment is doubtful; the system
is thereby rapidly put under the influence of the mineral, which, as
already remarked, generally aggravates the violent disturbance under
which the constitution labours. More permanent good may be expected
from means taken to remedy the constitutional evils than from such
violent remedies as are directed against the affected part, but which
also produce a baneful effect on the system. In ulcers of the nostrils,
with fetid discharge, snivelling, exfoliation of the inferior spongy
bones, affections of the palate, &c., the nitrate of silver is also
very efficacious; or the affected parts may be occasionally touched
with a hair pencil, dipped in a liniment composed of lime-water, olive
oil, and the golden ointment. They ought to be frequently washed
with tepid water, and all sources of irritation must be removed. If
the patient be in the habit of taking snuff, the practice must be
abandoned, and the powder already impacted in the nostrils removed.
If there be carious teeth or stumps in the upper jaw, the sores can
scarcely be expected to heal till these be extracted, as constant
irritation is kept up by them. When the affection proves obstinate, a
recourse to mercury is recommended by some writers; but this will make
bad worse. Sarsaparilla in these cases, with attention to diet and
air, will always prove a better alterative than any form of mercury.
It may be combined, according to circumstances, with the nitric or
nitro-muriatic acids, or with the hydriodate of potass, in which many
practical men have great faith. This medicine is employed in cachexia,
following or not the use of mercury, and is directed against eruptions,
sore throat, and pains in the limbs.
The constitutional symptoms of the _scaly_ disease, or true pox, when
they occur, which is now but seldom, are decidedly benefited by a
prudent employment of mercury. It may be administered externally or
internally, though the latter method is the one generally adopted. It
may be introduced into the system under various forms, according to the
particular circumstances of the case, or the ideas of the practitioner.
The most common form, and the simplest, is the pil. hydrargyri; but
for this may be substituted hydrargyrum cum creta, Plummer’s pill, or
calomel with antimony. In painful affections of the bones, with or
without swelling, the muriate of mercury (bichloride) is the form which
I have found most efficacious; one-eighth of a grain of the muriate
being given thrice a day in a pill; or the medicine may be given in
solution. The iodide of mercury is also a very useful medicine in some
cases. It is impossible, and would be absurd, to lay down any precise
rules as to the quantity of mercury which is necessary for the cure
of pox: in some patients the system is with difficulty put under its
influence, whilst in others a single grain will produce salivation,
constitutional disturbance, and eczema. When the mouth becomes affected
the mercury ought to be discontinued: much harm and no good resulting
from the medicine being pushed to profuse salivation; the tongue swells
hideously, the teeth loosen, and portions of the jaw die and exfoliate.
It is sufficient that the system be under the influence of mercury;
and that circumstance is marked by the tenderness of the gums. If,
after the medicine has been disused, the disease does not appear to
recede, it may be resumed in the same moderate way as before; but there
certainly can be no use in continuing mercury after the symptoms of
venereal affection have ceased. Nodes may still exist, portions of bone
may be dying, abscesses forming, and various other changes of structure
going on, but these are no reasons for a continuance of the mercury.
If they have originated from the venereal affection, that cause has
been removed, and the diseased actions will now proceed altogether
independently of their original cause. Mercury proved beneficial in
removing a disease of which they are not a part but a consequence; and,
if that medicine be now blindly persevered in, the only effect will be
to ruin the constitution, and thereby greatly retard the cure of those
affections which, if the natural powers of the system had been merely
supported, or in a great measure left to themselves, would have soon
ceased to annoy the patient or alarm the antisyphilitic mercurialist.
Slight swellings and pains of the bones often yield to local
abstraction of blood, friction, and the internal use of the compound
decoction of sarsaparilla. Nodes, however, sometimes continue to
enlarge, and occasion much pain, notwithstanding these means; and in
such circumstances much relief will be afforded by a free incision over
the affected part, from whatever cause the swelling may proceed. When
the pain has subsided, and the swelling remains stationary, a decrease
of it may be sometimes effected by a blister.[25]