Elements of Surgery

by Robert Liston

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.

The last distinct form of the venereal disease is the scaly—syphilis, 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]

Of the bad effects of mercury on the constitution much might be said. Treatises have been written on mercurial pox, a species reported to be much the most violent; and others have detailed an accumulation of evils, under the title of mercurial disease. There is no doubt that extensive, deep, and sloughy ulcers of the throat are produced by mercury; and of this I witnessed the following unexceptionable instance:—The fauces presented one extensive mass of ulceration, sloughing at its margins, and the uvula was almost detached. The patient was an old and emaciated woman, who neither had, nor could be supposed to have, any venereal complaints. She employed herself in coating mirrors with quicksilver, and to that she ascribed her malady. In fact, her system had been long under the influence of mercury, in consequence of her occupation. When I visited her, her daughter and husband, the latter of whom was paralytic, and almost bedridden, were affected, from the same cause, with a pustular eruption of the face, with disease of the nostrils, and snivelling. Another old woman had numerous and deep ulcers of the fauces, tongue, and lips, having been kept unmercifully under mercury for nine continuous months. She had, besides, taken it from time to time, for upwards of four years, though her sole complaint was slight sore throat. Pains of the joints, too, I believe, are attributable to the use of mercury. That medicine has no power to prevent the occurrence of nodes, for these often form during its action. Affections of the periosteum are very frequent in horses and other lower animals, and also easily excited in some human subjects who have neither had pox nor been put under mercury; but in no instance of venereal disease have I observed serious affections of the bones where mercury had not been given. Even the advocates for mercurialising speak of mercurial nodes. It has been asserted that nodes do not occur when mercury has been given for liver or other complaints; but they do form under such circumstances, though not so frequently as when the medicine has been exhibited during venereal symptoms. A cachectic state is often induced by a continued use of mercurial preparations, or at least by mercury and disease together, in constitutions not originally strong. It is marked by pale lips; bloodless conjunctiva; a rough anserine skin; a relaxed state of the mucous membranes; hemorrhages from these, particularly from the gums, which may prove fatal, as I have myself witnessed; exfoliations of the alveolar processes; slimy stools; pale urine; pains of the limbs; sores, showing great indolence, or even assuming malignant action; dropsical symptoms, and other evils, of which a lengthened catalogue might be made out. Such symptoms were often met with when mercury was exhibited for every trifling or suspected sign of disease arising from carnal conjunction. On this subject, Mr. Samuel Cooper has well remarked: “Experience has fully convinced me, that in no forms of chancre, nor in any other stages of the venereal disease, is it proper to exhibit mercury in the unmerciful quantity, and for the prodigious length of time, which custom, ignorance, and prejudice, used to sanction in former days. Violent salivations ought, at all events, to be for ever exploded. When I was an apprentice at St. Bartholomew’s Hospital, most of the venereal patients in that establishment were seen with their ulcerated tongues hanging out of their mouths, their faces prodigiously swelled, and their saliva flowing out in streams. The wards were not sufficiently ventilated, and the stench was so great, that the places well deserved the appellation of foul. Yet, notwithstanding mercury was thus pushed (as the favourite expression was), it was then common to see many patients suffer the most dreadful mutilations, in consequence of sloughing ulcers of the penis; other patients, whose noses and palates were gone; others who were covered with nodes and dreadful phagedenic sores.” This woful picture is not exaggerated, and cannot be too strongly impressed on the minds of young practitioners. A small quantity of mercury will affect violently some constitutions; as of those who have been in warm climates, or who have taken much of the drug, even in this country.

Eczema Rubrum, a disease resulting from external causes, but which may also be produced by mercury, often arises from but a very small quantity of that medicine even applied externally. It most frequently affects the scrotum and upper and inner parts of the thighs. It is preceded by heat and itching in the part; a diffused redness appears, and the affected surface is rendered rough by the eruption of numerous minute vesicles. In a short time, these vesicles, if not ruptured, attain the size of a pin’s head, and the included serum becomes opaque and milky. The affection soon extends over the rest of the body in successive large patches, and is accompanied with considerable swelling of the integuments, tenderness of the skin, and itching. The vesicles burst, and discharge a thin acrid fluid, which renders the surrounding surface painful, inflamed, and excoriated. The discharge becomes thicker, adhesive, and fetid, and by its drying, partial yellowish incrustations are formed. The disease terminates in desquamation, and in some cases, the hair and nails are also lost. It is preceded and accompanied with smart fever, and general disorder of the system.

Erethismus is another occasional consequence of mercury, characterised by remarkable depression of strength; small, quick, and often unequal pulse; anxiety, sighing, and trembling; a pale contracted countenance, and occasional vomiting. While in this state, sudden exertions are apt to prove fatal.