OF THE SYMPTOMS OF THE FIRST STAGE OF LUES.
Six weeks is the time usually allowed to elapse between primary and secondary symptoms; but it is not invariably the case, instances having occurred where the disease has embraced, and most severely, both stages in a fortnight, and others between which a much longer time has existed. The first symptoms of lues consist either of a sore throat or a spotted skin. When the skin is the seat, a red spot, not unlike a flea-bite, is perceived; the color soon dies into a brownish or copper-colored hue. Occasionally, at the outset, a small pimple is observed, which breaks and scurfs; the coppery-colored spot next feels rough, and a kind of scurf will exude that after a few days falls off to make way for more. The disease being more usually slow than rapid in its progress, weeks may be consumed before ulceration occurs, and merely a discoloration of the skin is seen in spots seldom exceeding the size of a sixpenny or fourpenny piece. Some of these spots will nearly disappear, leaving a faint scar, and new ones will spring up. The entire body may be covered with them, but usually those parts nearer the centre of circulation generally possess the most—such as the chest, neck, shoulders, arms, wrists, hands, and head. As the disease progresses, the scurf on the spots accumulates, falls off, re-forms, getting thicker each time, when upon being detached, for they cling now more closely, a sore and moist state of the skin is observable. This may be covered with a new crust, or may at once proceed to suppuration.
When an ulcer is formed, it will sometimes spread rapidly, and embrace a patch the size of a crown-piece, when the process of ulceration will assume the vigor of disease.
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The accompanying sketch portrays, perhaps, more the seat of the disease when attacking the upper part of the body, than the appearance; for to give a true portraiture, the drawing should be the size of life, and colored after nature. It is, however, I doubt not, sufficient to exemplify the site of the disorder. The eruption is smaller on the face, and less vicious, generally, than on the body; but it proves most unsightly, and indicates great advancement of the disease. The legs (see next page), and those parts of the skin least vascular, assume a mottled appearance resembling recent bruises; at other times, clusters of spots like grapes hanging together.
The shoulders, arms, and wrists, also present a somewhat similar appearance; though perhaps not to the same extent, owing to being more warmly clad, and less in exercise, than the lower extremity.
When the disease extends to the hands, it is marked by exfoliations of the palm, with occasional deep cracks that cause much pain. Nor are the fingers and nails exempt from this encroaching malady, which, during its occupation, shows itself by a redness under the nail, that at last ends in the destruction of the nail.
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The head, also, is a frequent seat of the disorder. It is generally discovered by running the hands through the hair, when a little crust will be detected by the fingers, or a slight itching will show its position, or the brush may break it off. The top and hind parts of the head are generally the situations selected. Occasionally the hair will fall off, leaving spots of a smooth baldness.
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The vital organs, fortunately, are never subject to syphilitic inflammation—such as the brain, the viscera of the chest, and abdomen; nor is even the mucous membrane of the interior of the body affected, its power being confined solely to those parts or structures subject to the influence of external causes.
When the venereal virus attacks the throat or palate, the membrane of the roof of the mouth becomes red and inflamed, patches ulcerate, and, if not cured, sooner or later expose the bony palate, which may be felt by the probe. This is the first stage. The exposed bone next exfoliates, and a communication is thereby formed between the mouth and nose, the fluids return through it, the voice is changed into a nasal twang, and a most offensive discharge is secreted.
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This drawing represents ulceration of the tonsils, uvula, and arch of the palate; also the edges of the tongue. The drawing, p. 102, shows the under surface of the tongue, the inner part of the lower lip, and the lower gums affected with venereal ulcers.
When the tonsils are attacked, ulcers appear, precisely similar in character to chancres, hollow in the centre, with raised ragged edges, yellow on the surface, with a livid color on the surrounding margin. A sense of dryness is perceived, extending up the eustachian tube to the ear. Sometimes the tongue, gums, and inner part of the lips, are attacked (see representation).
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In the progress of the disease, the pharynx, or top of the gullet, is brought under its influence, and the ulceration spreads through it to the vertebræ or back-bone. Extending its course, it next attacks the larynx, or top of the windpipe, when, if not arrested, it will soon destroy life. Attending this affection of the larynx, there is always loss of voice—the patient speaks in a low whisper. It is more fatal than any other form of the venereal disease.
The mucous membrane of the nose stands next in order, as subject to the influence of syphilis. The patient’s attention is first directed to it by an incrustation which forms in the nostril. On this being removed, a quantity of blood, mixed with purulent matter, is discharged. In two or three days, similar incrustations are formed, and under them ulceration takes place, which frequently lays bare the bone, and occasions it to exfoliate; and this exfoliating often continues after the venereal action has ceased. The number of bones which come away is often very considerable, and horrible deformity is the result.
The periosteum and bones become in their turn affected by swellings called nodes—the periosteum first, and the bones subsequently. Of these, the cylindrical, being most exposed to vicissitudes of temperature, are commonly the first attacked. Those which are much covered by muscle are rarely affected, as, for instance, the back part of the tibia, or large bone of the leg, while nothing is more common than to see nodes on its anterior part, which is only covered with skin and periosteum. They occur on the fibula only when it is slightly covered, and only on the ulna, or elbow-bone, when similarly circumstanced. Nodes on the os humeri, or shoulder-bone, except on the outer side, are of very rare occurrence, but are frequently found on the clavicle, or collar-bone, at its scapular and sternal articulations.
In the following wood-cut is an illustration of the most frequent situation of nodes on the forepart of the tibia, or chief bone of the leg. The swelling is considerable; the upper one proceeding to suppuration, and the lower indicating merely a tumefaction of the lower part of the bone, near the instep.
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The symptoms which mark the disease are as follow: The patient experiences in the evening a sensation of pain in the bone which is afterward the seat of the node. In the course of a few days, a swelling appears in the evening, which disappears again on the following morning. It is excessively painful and tender at night, but in the morning it is hardly perceptible, and the tenderness is almost gone. At this particular period the periosteum is only affected; but when the inflammation has continued some time longer, the bone is diseased and becomes enlarged. The rationale is this: An inflammation of the periosteum ensues. In a short time a deposite takes place between it and the surface of the bone. This deposite, in the first instance, is only a serous fluid, but a cartilaginous substance is soon secreted, which is gradually converted into bone.
When attended to early, their treatment is very simple; but occasionally cases of considerable difficulty will arise.
Large quantities of fluid will be found fluctuating between the periosteum and the bone, which, when unaccompanied by redness and inflammation of the skin, may be absorbed by proper treatment, but which more usually is only curable by evacuation; and, unless great care be used, exfoliation of the bone will ensue to a very great, and sometimes fatal extent. The eyebrows, forehead, and temples, are often the seat of fluid tumors varying from the size of peas and beans. Their cure must be effected by absorption, or destruction of the bone is often produced.
The flat bones are also subject to syphilis. The one most commonly attacked is the os frontis, the symptoms being just the same as those on the skin. The side bones of the head now and then are affected; the os occipitis, or back-bone of the head, very rarely; and the os temporis, or temporal bone, being well covered with muscles, and exposed to very little change of temperature, is never affected.
The os frontis, being the most exposed, is the most frequently attacked. Suppuration sometimes takes place; and when this has occurred on the front, it has happened that the same suppurative process has occurred interiorly between the dura mater, or the external membrane of the brain, and the internal surface of the bone. The matter presses upon the brain, and death is the consequence, if the pressure be not removed by the use of the trephine or trepanning instrument. This is a degree of severity to which the disease rarely reaches now-a-days, from the more extended knowledge and improved treatment of modern times.
It must be observed, generally, of both these diseases—that of the throat and nose, and this of the bones—that they are oftener the result of improper treatment, such as the excessive use of mercury, and exposure to great vicissitudes of weather while under its influence, inducing what is called the mercurial disease (which in fact is, or was, of more frequent occurrence than the constitutional syphilitic one), than the result of the natural tendency of the disease in an otherwise healthy individual.
On the treatment of Syphilis.—I consider it a fair presumption that any invalided reader, except he be an accidental one, of this book—by which I mean one, not having sought its possession—must be acquainted with the association of mercury and syphilis. If not, let him be told for the first time, that such association exists as between copaiba and gonorrhœa; or perhaps what may be rendered more familiar to him, namely, as between quinine with ague, or colchicum with rheumatism. That for upward of three hundred years past mercury has been held an antidote to venereal affections; and still is, in many forms of the same, acknowledged indispensable for their removal.
From old notions afloat, that syphilitic patients to be cured must be salivated to the extent of furnishing or filling two or three wash-hand basins daily with saliva—that the teeth drop out, that the breath becomes horribly fetid, and that the consumer of the poison sacrifices one third of his probable existence, even though he get well—the greatest possible prejudice exists against mercury, and the generality of uninformed patients have acquired a most uncompromising dread of the remedy. From the frequent difficulty in getting patients to submit knowingly to mercurial treatment, many new means have been caught up, and some judiciously applied.
This new method has its advantages; but it does not realize all that is promised. It consists in advising rest, cleanliness, simple soothing applications, and, on the other hand, mild astringent ones, a temperate diet, fresh air, an easy mind, sarsaparilla, and other alterative medicines. There are many believers in the efficacy of simplicity; and the success that follows such treatment of nine tenths of the ailments of humanity, bears out the usefulness of the preceding methods; but the remaining tithe have alike a claim upon our consideration, and of this tithe the syphilitic invalids form a large portion.
The anti-mercurial advocates have, however, a salvo, and admit now and then, an exception to exist, that particular cases do require a mercurial course, but then it should only be adopted in its mildest possible form, merely with a view to act on the general health, rather than for any specific property of its own. Again, there are books, which are very elaborate, and what is equally important, modern ones, written by talented men,[4] which still profess faith in the curative powers of mercury, and employ it as the chief agent in the cure of the venereal disease. Instead of administering it to the same extent as formerly—instead of attempting to produce salivation to the flow of quarts—they merely aim at producing an impression on the constitution; they are satisfied with a proof that their patient is under mercurial influence: this is ascertained by a coppery taste in the mouth, a slightly increased secretion of saliva, and the presence of the accompanying, but temporary depression.
Now the question to be resolved is, which of the two methods is the correct one. The many forms of disease of the sexual structures satisfy me, that their treatment should be modified by circumstances; but I believe I am wise enough to know, and certainly old enough to have observed, that the severer forms of syphilis, and even the milder in some constitutions, require the aid of mercury for their cure; in fact, will yield to no other plan of treatment, thereby admitting the specific virtues of the remedy.
The principles, therefore, which I advocate in the treatment of syphilis, are precisely those I depend upon in gonorrhœa, or, to familiarize the analogy, in a fit of indigestion, or an attack of local or general inflammation. Where the health is disturbed, the first step is to attempt restoration. The fact is almost too familiar to every one to need repetition, that, as is the condition of the health, so is the resistance it is capable of opposing to disease. The next proceeding is, to attempt the subdual of the prevailing symptoms. Syphilis, whether in the form of chancre, bubo, or any of its secondary varieties, induces more or less fever, inflammation, and interruption to the important offices of digestion, and other vital processes, which consequently require the promptest attention. Equally various are the local indications of syphilis—the ulcers may be common, superficial, phagedenic, or sloughing, each requiring various treatment, as hereafter will be specified; but, above all, too much reliance can not be placed on the dietetic and physical regimen—two comprehensive significations, which are, after all, the Alpha and Omega of the Materia Medica. With this declaration, I pass on to the treatment in detail of the more frequent and, I may add, leading features of syphilis.
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Treatment of Chancre.—Preliminary remarks.—Chancres are of various kinds. The most remarkable are:—
1st. That characterized by its circular form, its excavated surface covered by a layer of tenacious and adherent matter, and its hard cartilaginous base and margin.
2d. Another form of chancre, unaccompanied by induration, but with a very high margin, appearing often on the outside of the prepuce, and seldom existing alone, called, from the preceding description, the “superficial chancre, with raised edges.” These kinds of ulcers are sometimes very tedious, neither getting better nor worse, but resisting every plan of treatment for their removal. I have known instances where they have existed for several months.
3d. The phagedenic chancre, a “corroding ulcer without granulations,” and distinguished by its circumference being of a livid red color. This is the kind of chancre that is invariably rendered worse by mercury: indeed, cases have occurred where, from the injudicious administration of that medicine, the whole of the penis has been destroyed.
4th. A most formidable kind of chancre, denominated the sloughing ulcer. It first appears as a black spot, which spreads and becomes detached, leaving a deepened and unhealthy looking surface. The sore is very painful, and encircled with a dark purple areola. If neglected, or improperly treated, the process of mortification goes on until all the parts of generation are destroyed.
The last-named chancre is more often the consequence of neglect on the part of the patient, than the natural progress of the disease.
Now the usual method adopted by surgeons to remove chancres, has been to excise them, or to apply caustic; the latter is the plan I adopt, and would recommend; but all chancres are not to be treated alike, some requiring antiphlogistic remedies, others soothing, others stimulant. Some practitioners rely entirely upon constitutional remedies.
On the first appearance of a chancre, I would enjoin an alteration in the diet, regulating it according to the strength of the patient. Abstemiousness should be the motto, avoiding extremes, however, lest debility should be induced. Quietude and rest, in the recumbent position, are two essential adjuncts in the treatment of primary syphilis throughout.
With respect to the treatment of the ulcer, characterized by its circular form, excavated surface, and hardened base, as detailed, the plan I almost invariably adopt is, immediately on its appearance, at least as soon as the pimple has broken or desquamated, to smear it with a hair pencil filled with the solution of caustic, sometimes twice, at least once a day (see Form [27]), and to keep it frequently washed in the daytime with a lotion of the chloride of soda (see Form [28]), or the black, red, or blue wash (see Forms [29], [30], [31]).
If the patient be strong, and otherwise in good health, I simply recommend a dose of purgative medicine, in anticipation of any irritation that may arise. After which, I suggest a middle diet to be adopted for the next few days. From the sedative and salutary effects of the warm bath, I recommend its employment immediately after the operation of the medicine, and its repetition at frequent intervals. Independently of its effect on the system, it is the best general cleanser that can be resorted to. The subsequent treatment is regulated by the result of the above, which can be ascertained about the third day.
In numberless instances, and where the disease is thus early detected and similarly treated, the mere continuance of either the chloride lotion, or black wash, the middle diet, an occasional aperient, the bath, with as much rest as possible, are all that will be found needful to cure the disease, which generally is effected in about a week or ten days at farthest. From the universal dread that so sudden a disappearance of the sore occasions, lest it should “be driven into the system,” and from the apprehension that it is incurable without taking mercury, I verily believe that, in many cases, the practitioner, participating in the fears of his patient, and anxious to allay them, reluctantly administers that mineral; and to such weak judgment may be traced the relapses, or the occurrence of other symptoms sometimes mistaken for secondary. Even when the case terminates favorably, and within the space of time alluded to, I would not be considered as recommending a sudden return to free living; on the contrary, I would not release the patient from the restrictions imposed upon his diet, exercise, and regimen, for at least the same time as was occupied in the cure, nor would I predict that, in every instance, secondary symptoms should not ensue. Mercury was supposed to possess some antisyphilitic property, inasmuch that, when chancre healed during its exhibition, secondary symptoms were averted. Facts, however, have been wanting to corroborate that supposition; for secondary symptoms have appeared despite the external and internal employment of mercury, even to the extent of salivation. Authors there are who attach similar properties to other medicines, such as nitric acid, sarsaparilla, and such like. Now, how do these medicines act upon the system? Or what is their tendency of action? Why, by increasing some particular function, such as the secretive process of the salivary and other glands; by increasing perspiration or absorption, &c. The remedies whereby these changes are induced are termed alteratives. I am not going to deny that these, or some such changes in the system, are unessential for the eradication, particularly of morbid conditions of structure and function, dependent probably upon altered condition and diminished action in others. On the contrary, they are the only antagonists to disease which we possess.
But what I contend is, that, in our selection, we should prefer those which produce most speedily and effectively the desired change, with the least detriment to the general health. And to this end, I invariably enjoin, where practicable, warm or vapor bathing. I have elsewhere considered this subject at length, to which I refer the reader; but I will fearlessly assert that no one, or any plan of treatment, will be found so effectual toward increasing physical power to repel disease, or so permanently preservative of health, as the modified employment of the warm or vapor bath; and, therefore, in all cases of doubt and apprehension, or independent of either, the use of the warm or tepid, plain, or salt-water bath, two or three times a week for a month, or the vapor bath about every fourth or fifth day for the same period, is the best preventive that can be adopted to avert secondary symptoms. Where bathing of every kind is impracticable, as is the case in some country places, and the same necessity exists, I advocate the administration of alterative medicines; nor do I object to the employment of mercury, where, under other circumstances, without reference to its imaginary efficacy in syphilis, it would be prescribed. But of this as we proceed.
Where, at the expiration of a week, the chancre neither recedes nor advances, and is the only symptom present, it is to be presumed that the condition of the patient’s health has something to do with it, and that condition should be minutely inquired into. There may be diminished or increased appetite, with imperfect digestion; there may be fever, with restlessness at night; there may be torpor or irritation of the bowels; or the patient may consider his only ailment to be the chancre, the irritation of which may be found to arise from too active exertion. To whichever cause it may be ascribed, the treatment should be directed. In conjunction with local remedies, which may be varied, alteratives may be given—five grains of the blue pill twice a day; for instance, the Plummer’s pill in doses of five grains every night, the occasional application of an active aperient (see Forms [33], [34]), the decoction of sarsaparilla (see Forms [49], [50], [51]). This plan, carefully pursued, seldom fails in setting up a permanent cure. The patient should be apprized of the vast importance of quiet, rest, and abstemiousness; for, where they can be attended to, the duration of the disease will be diminished one half; whereas, he who is continually in the erect posture, and subject to much walking about, who is indifferent to his diet, and lives as free as formerly, incurs the risk of bubo, and all its alarming consequences. Now, in no case or description of chancre, do these remarks apply so aptly as to the phagedenic and sloughing ulcer; in fact, they are applicable to all, but more particularly the two latter, as they are the result of already increased action. Mercury, violent aperients, and other active remedies, should also be avoided in these two forms of chancre; the local appliances should be poultices of bread and water, linseed meal, and a solution of opium, or poppy water; the sloughs or mortified portions we should endeavor to detach, by the application of a smear of nitric acid, or the chloride lotion (Form [28]), or stimulative ointment (Form [38]). The superficial sore usually gets well by the same means as the ordinary chancre.
Where the chancre is situated under the prepuce, and the latter covering is so inflamed and swollen as to prevent its being drawn back to exhibit the sore, the discharge should be carefully washed out by any of the lotions already recommended, by means of a syringe, several times in the twenty-four hours. Much good is often done by varying the local remedies, occasionally flouring or filling up the ulcer with calomel, tutty powder, blue ointment, or in fact any substance which alters the morbid action of the part; but, as a general rule, the lotions of soda, lime, zinc, or oxymuriate of mercury, will be found sufficient, if persevered in.
Treatment of Bubo.—Bubo I have already stated to be an inflamed and enlarged condition of the inguinal (as its name implies, signifying the groin), or, in fact, any other gland, occasioned by the passage of the venereal poison from the adjacent ulcer through it, preparatory to its contaminating the constitution. But it is as well to know that the system may become affected, or, in other words, the poison may pass through the glands without involving them in the disease, or that the poison may there stop, and be expelled as the bubo is cured. It is also observed, that buboes are more frequently consequent upon an ulcer seated on the prepuce than on the glans. Buboes are not always, however, a sure criterion of the venereal disease, for they will occur wherever irritation is superficial and adjacent. Leeches applied to the temples will affect the cervical glands, a graze or wound in the leg enlarge the inguinal, and a whitlow on the finger, or any inflammation of the hand or arm, will very often irritate the glands in the axilla. In gonorrhœa, the glands in the groin become swollen and painful, from sympathizing with the sensibility of the urethra; but these and the preceding may, in general, be distinguished from true venereal buboes by their disinclination to proceed to suppuration; whereas, in syphilis, that process runs through its several stages with remarkable celerity, unless timely prevented. Buboes in the groin are much more troublesome, and more likely to betray the disease, than chancres, because they constitute an augmentation to the patient’s suffering, seldom occurring, unless preceded by a chancre, and because they occasion a visible and necessary lameness. They also produce more general disturbance of the patient’s health.
In the treatment of a bubo, venereal or not, the same principles recommended in the section devoted to the cure of chancre, should be followed in this instance—comprising attention to the general health, and a subdual of the prevailing symptoms.
In no form of syphilis is rest more essential than in bubo. The patient will be apt to plead the necessity of following his business, and the utter impossibility of staying at home; that is his affair, mine is only to protest against exercise, and urge the importance of rest, and even the recumbent posture, and I can assure him, that alone will strip the disease of three fourths of its terrors.
Certain local diseases produce more constitutional disturbance than others—among them may be classed buboes; it would, therefore, be as impolitic suddenly and violently to repel an inflammation of a gland or glands, without establishing some outlet for the increased action to vent itself, as it would be to check a flux or suppress an exanthematous eruption, like measles or scarlatina.
If the bubo is, therefore, painful and inflamed, my advice is as follows: Stay at home, and rest; descend to middle diet; take some aperient; and should chancres alone be present, and a treatment going on for their extinction, continue the same; or, as bubo often immediately succeeds the ulcer, and probably may be the first symptom noticed, adopt, in addition to that recommended above the treatment as advised for chancre, namely, the administration of some alterative—for instance, five grains of blue pill every night—or the Plummer’s pill every night—the aperient powder every other day; and let the local treatment be directed to remove the prevailing symptom, to subdue the inflammation, and, if possible, thereby prevent suppuration. It was formerly supposed that, unless buboes were allowed to suppurate, the system could not escape the venereal taint. Lower somewhat the vital powers, or, what may be more intelligible, diminish the general inflammatory action, establish some slight drain, by determining the secretions to the intestines or skin: and buboes, even when matter has absolutely formed, may be fearlessly absorbed, which judicious treatment will effect, in nine cases out of ten, without at all impregnating the constitution. To attain this object, warm fomentations constantly applied, and if possible the warm (hip or full length) bath every night. When rest is determined upon, if the swelling is great, red, and painful, leeches are eminently serviceable, but they must be applied in numbers of at least a dozen at a time, and repeated twice or thrice if necessary. Three or four, by the irritation of the bites when healing, and especially if the patient will not or can not remain quiet, only worry and aggravate the disease. Where the inflammatory symptoms are great, where there is fever and much heat of skin, bleeding is the speediest and most effectual plan to subdue them; and, in my opinion, it is to be preferred before the trouble and bother of leeches. Where, however, there is no remarkable excitement, local or universal, the topical application of any of the ointments suggested will often promote absorption (see Forms [35], [36], [37]).
Blisters applied over the bubo, very often disperse the swelling. Pressure also, made by means of a pad covered with tin foil (as seen in the subjoined cut), and continued for several days, frequently urges the absorption of the accumulated deposition in the gland.
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Where bubo has been suffered to proceed, and the suppuration appears inevitable, it would be highly improper to retard it: poultices and warm fomentations should be applied, and when fit, an opening should be made to permit the exit from, and prevent the extension of, the matter in the surrounding cellular membrane; the operation should not, however, be prematurely performed; the skin should be permitted to become thin before an opening is made, and that opening should be made in the most dependent position, in order to allow complete escape of the matter, lest fistulæ and sinuses should form. When an abscess is thus established, its healing must be promoted with all expedition, and care taken to preserve the strength of the patient. For the former purpose, poultices, mild healing ointments, or strapping plaster applied near the edges of the wound, should be used. Poultices may be applied with a bandage, as seen in the subjoined cut.
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When the abscess appears indolent and not disposed to heal, carrot and linseed-meal poultices may be substituted. Astringent ointments should also be employed (see Forms [38], [39], [40]), or lotions (see Forms [41], [42]), and the topical application of caustic to the edges of the wounds, or even paring them with a scalpel. The occasional use of the warm or vapor bath will give a healthy tone to the frame, invigorate the depressed powers, and promote recovery. The strength should be supported by more generous diet, and any of the formulæ comprised under the head of tonics, may be taken internally (see Forms [43], [44], [45], [46], [47], [48]). As the patient becomes convalescent, change of air, gradual exercise, the cold shower bath, or sea bathing, will be of essential service.
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Treatment of secondary symptoms.—Secondary symptoms usually appear from the sixth to the sixteenth week, but are not unfrequently protracted beyond that period; they are commonly ushered in with fever—a general sense of being ill—a quickened pulse, headache, loss of appetite, pains in various parts of the body, and restlessness at night; in short, there is disturbance of all the vital functions, until it is determined which structures are to be the retreat of the common enemy. Some authors assign the skin and throat as more liable to attack than others; but I think the distinction dependant mainly upon the natural or morbid idiosyncrasy of the invalid. At all events, the inquiry here would be foreign to the design of this work, and less useful than the advice, how best to combat the evils when and wherever they occur. I have already stated secondary symptoms to consist of eruptions, ulcerations, and disfigurations of the skin, ulcerations of the mucous membranes of the mouth, throat, and nose, pains in the joints, swellings of the bones and their coverings, and inflammation of the various fibrous textures of the body.
Treatment of syphilitic eruptions.—The cutaneous eruptions of syphilis present considerable varieties, assuming a scaly, papular, tubercular, or pustular appearance. Formerly it was the opinion that no eruption was venereal, unless characterized by a scurfy exfoliation, and teinted of a copper color. This test is not now relied on. In the simpler forms, we find that the skin becomes mottled at first, which appearance may partially die away and reappear, deeper in color, and the spots become more numerous in extent. The patient should be apprized that, when the disease has progressed thus far, it is not in its nature to depart unbidden; but it advances usually from bad to worse.
The mottled dots enlarge, exfoliate, or scurf, or desquamate, as it is called, leaving the subjacent circle thicker and thicker, and of the same color as the cuticle which peels off. In the ordinary uninterrupted progression, scabs form, suppurate, and constitute an ulcer, like a chancre, which ulcer assumes all the varieties of chancre. In other cases, the eruption, instead of being scaly, “has a raised surface, from which a whitish matter usually oozes.”
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The scaly copper-colored eruption, denominated, according to its severity and appearance, syphilitic lepra or psoriasis, is regarded as most characteristic of true syphilis, and is the most frequent. The annexed is a drawing copied from nature; it is alluded to a few pages further on: its pattern is frequently to be met with. A celebrated writer, Mr. Carmichael, attaches considerable importance to the character and appearance of the eruptions. He divides the venereal disease into four species or varieties: 1st, the scaly venereal disease, which he considers consequent upon the ordinary chancre; 2d, the papular, consequent upon gonorrhœal ulceration; 3d, the tubercular; and 4th, the pustular, he names from its appearance. These distinctions, if correct, must be more interesting to the surgeon, than serviceable to the patient, for the principles of treatment must be alike in all. Now, although mercury may be denied to possess any specific influence over the syphilitic poison, either by its chemical action or neutralizing power, except as a counter-irritant to the system, yet the inability of nature to shake off the pestilential hydra, unassisted by the weapons of the physician, is most apparent; and the most powerful of which is, that class of medicines called alteratives, none of which are more deserving, none more manageable, if the least judgment be displayed, than mercury.
The constitution, when under the influence of syphilitic poison, is being led like a willing horse to its own destruction; and unless the system be entirely revolutionized, that event is not likely to be retarded. Here mercury[5] may lend its powerful aid, and may be carried even so far as to produce mild ptyalism or salivation. But there are instances where mercury is inadmissible. The patient, however, need not despair; extensive resources are still open for him—the preparations of antimony,[6] the mineral acids, sarsaparilla (Forms [49], [50], [51]), iodine (Form [52]), and a host of others may be resorted to; and last, though not least in importance, is the medicated vapor and fumigating bath. From my connexion with an establishment of that kind, my disinterestedness might be questioned in advising the employment of bathing. As well might the apothecary who deals in his own drugs, or the tradesman who vends his own wares, be suspected of disingenuousness; the reply I would offer should be, that the reader or invalid need not pin his faith on my assertion, unless it so please him; or if he does, may the onus lie at my door. But for his sake, and to bear out my own assertion, I offer this declaration, that, for the last twenty years, in conducting my establishment (wherein more cases of syphilitic eruption have presented themselves, than probably have fallen under the notice of any other medical man in London within the same period), no case, of which I have had the management, has failed of being cured.
Where syphilitic eruptions terminate in ulceration, the same local treatment should be used as advised for chancres. Among the prescriptions will be found formulæ for many useful topical applications, such as ointments, lotions, and fumigations, for all the external developments of syphilitic disease, with appropriate observations appended to each.
Treatment of syphilitic sore throat.—It has already been mentioned, that the order of appearance of secondary symptoms depends more upon the modified state of health than any fixed law of disease. Syphilitic sore throat may precede or follow the cutaneous eruptions; and it not unfrequently happens, that all forms of the disease are present at the same time: therefore, although they are here separately considered, it will be found that the treatment corresponds nearly in all, the only difference being in the local applications.
Syphilitic sore throat consists of ulcerations of the fauces, tonsils, and soft palate. The inflammation begins in the part affected. There is a redness, and sensation of dryness. A small white spot is perceptible, which rapidly spreads, is detached, reappears, and in four-and-twenty hours, if seated on the tonsils, a cavity, as if a portion of them had been scooped out, is observable. The ulcer has a sharp margin, and its excavated surface is covered by a whitish or yellowish adhesive matter. At other times, the ulceration will be more superficial, but not less rapid in its progress, extending over the upper part of the palate, and back part of the throat. Here the general treatment is precisely the same as in the other forms of the disease, viz., rest, abstemiousness, low diet, aperient, saline, and alterative medicines, the blue pill, preparation of antimony, the bath, and total exclusion from all excitement. The topical treatment consists of fumigations, gargles, styptic lotions, nitrous acid gas, blisters over the larynx, rubbing in of any counter-irritating ointment; the object being throughout to watch, and endeavor to improve the patient’s health, support the strength, and mitigate and remove the local symptoms.
In the affections of the nose and palate, the fumigations are indispensable; injections must also be used, and styptic lotions applied with a camel’s-hair brush. These cases are very tedious, and, fortunately, in the present day, of rarer occurrence than formerly; and the patient, thus severely attacked, would be more prudent to rely upon some confidential medical adviser, than to trust in his own management.
Treatment of venereal affections of the bones and joints.—Nodes are alleged, by medical men of great authority, to be of rare occurrence, except the patient has been taking mercury; but the observation is not always correct.
Their treatment, of course, must be regulated by various circumstances. When the pain and inflammation are severe, leeches, bleeding, warm fomentations, or cold evaporating lotions composed of vinegar and water, must be resorted to. When they are chronic and painful, without redness and inflammation, the greatest relief will be experienced by the application of the ointment of iodine and morphine (see Form [53]), also by the internal employment of iodine in doses of five to ten drops twice or three times a day. Where they are very obstinate, blisters will be often useful in promoting absorption. When they ulcerate, the treatment for chancres must be had recourse to. But the most invaluable remedy, alone or in conjunction with any of the preceding, is the vapor bath; it seldom fails to give instantaneous relief. I have seen patients, who were rendered almost insensible by the pain of nodes in the head, chest, and other parts of the body, experience an entire remission of the pain, and a diminution of the swelling, by the application of one bath; and a course of six or a dozen is rarely inefficient in effecting permanent recovery.
It has already been mentioned that rheumatism of the bones and joints, and in fact of various parts of the body, is unfortunately but too frequently an accompaniment or a consequence of syphilitic disease: and an observer will discover that nodes rarely exist without rheumatic inflammation (of which by-the-by they are a species) being more or less present.