Elements of Surgery

by Robert Liston

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.