Part 11

The true phagedena seems always to confine its action to a particular spot[76]; but many of these diseases, which have been described under the same name, appear to be capable of inducing a general action, similar to the venereal disease, affecting different parts of the body in succession. A case of this kind is related by Mr. Adams, in his Observations on Morbid Poisons: A gentleman who had a small pustule on the prepuce, squeezed it so as to make it burst, and soon afterwards had connection with a woman whom he had long known. The sore remaining without healing, he applied a solution of caustic, and had recourse to mercurial frictions. But, notwithstanding these, the ulcer spread, and soon reached the scrotum. The mercury was now laid aside, and bark, with a good diet, were substituted, after which the ulcer put on a healing appearance; but, before cicatrization took place, a feverish fit supervened, with violent pain in the part. In the course of a short time, however, the unfavourable symptoms disappeared, and a healthy condition was again apparently induced. These paroxysms of fever, and subsequent amendment, alternated with each other for a considerable time, and each relapse was preceded by a livid appearance round the sore. These appearances at last went off, and the sore assumed more the aspect of the true phagedena. The cicatrizing process now began at the upper part, and proceeded rapidly until almost the whole sore was covered. But, nearly about this time, copper coloured spots appeared on the hands, and the inside of the right thigh; and, in a day or two afterwards, an ulcer appeared in the throat, with “bumps” on the head. Shortly afterwards a node appeared on the tibia, and the patient became bandy. The blotches speedily began to ulcerate, and another appeared on the sternum. Mercury was now given freely, and at first with apparent success, for the ulcers looked better, and no new affection appeared; but, whenever the mercurial action was beginning to be fully induced, the granulating appearance of the surface was destroyed, and it became of a dusky colour, discharging “bloody sanies.” The bones remained stationary. The medicine was now discontinued, and the patient went to the country; but, on his return, in about a fortnight, “his throat was again ulcerated[77]. Such of the old external ulcers as had not healed, threw up a kind of fungus granulations.” The sore on the penis, which never had been completely well, had spread to the size of a shilling, but had no phagedenic, or specific appearance. Mercury was afterwards tried, and some bones exfoliated from the nose. The ulcer healed; but, as soon as he recovered from the effects of the mercury, new blotches and ulcerations, with a new enlargement of the tibia, took place. “He is now under his fifth mercurial course.”

[76] The neighbouring glands sometimes swell and suppurate, but they heal kindly, and the disease proceeds no farther.

[77] From this, it would appear, that his throat had been at one time healed.

In this case, mercury evidently was prejudicial, except toward the end. It does not appear that the caustic had been freely applied to the original local disease, which might have destroyed it. These affections, which were by some considered as venereal, evidently differed from that disease, in the rapidity of its progress, in the appearance of the primary sore, and in the history of the whole of the symptoms. We are as yet in the dark with regard to a specific remedy for these, and similar affections.

There are several other ulcers, which appear upon the penis after coition, which probably depend upon the application of a peculiar contagion. These[78] are sometimes superficial and phagedenic; they spread fast, and heal rapidly, frequently in the course of a night after precipitate has been applied. At other times they are deeper, and more like a little cup; the surface is smooth and glossy, without any appearance of granulations; the discharge is thin, and the base and margin quite soft. The best remedy is the caustic, with the subsequent application, precipitate, or ung. hyd. nit. dilut. When buboes form, I have always found them heal without the use of mercury. If, however, the bubo be the first symptom which appears, as is sometimes the case, (for the morbid agent is occasionally absorbed before it excites action in the part to which it is applied), then it is generally much more difficult to heal than when it is preceded by a local action, and induced by the absorption of matter generated there.

[78] Many of these have been confounded with the venereal disease, and treated accordingly.

It were much to be desired that they should be accurately described, and one kind distinguished from another, for there are probably many different species.

If these local, or primary symptoms, be not speedily removed, a general disease is induced, as we see in the case already mentioned, and as is proved by numberless other instances. These general affections are marked by ulcerations of different parts; and the ulcers have a different appearance, according to the nature of the morbid agent. In some cases they are better and worse at intervals. Mercury has, in almost all these cases, been used; but, although some are ameliorated by it, yet others resist its action. At first, indeed, they generally appear to heal; for the mercurial action, when forming, interrupts the progress of the former diseased action; but, whenever the mercurial action is fully induced, we sometimes find that the appearances change, and the progress generally becomes quicker than formerly[79].

[79] Some actions cannot be induced during the continuance of others. Other actions can, in these circumstances, be formed, and displace completely the former action. A third set seem to give a modification to the original disease: They change it to a certain degree; but the change is not salutary, and they never displace it. The mercurial action, when induced during the existence of some of the diseases which I am describing, comes under the last, or third class. At first, during the formation of the mercurial action, the former diseased action is interrupted, in the same way as the natural action is injured during the period of formation of other actions, when no peculiar disease previously existed. On this account, the sore assumes a better appearance; and, if the action be nearly terminating naturally (as some actions do, and as the primary action in these diseases more readily does than the secondary), it quickly heals up; but, if this be not the case, the appearances soon change, and the disease becomes much worse.

There is a disease which is not unfrequently confounded with syphilis, but which is distinct from it; I mean small ulcers about the mouths of children, which are more like aphthæ than any thing else; but, soon after their appearance, small blotches appear in the body, which become first raised into a little flat vesicle, and then ulcerate superficially. These ulcers have a watery appearance, not much unlike tetters; but the appearance of the vesication, and dark colour of the preceding blotches, prevent any confusion. Nurses who suckle these children have generally small calyciform ulcers on the nipples, of a pale colour, and discharging a thin watery matter. I have had no opportunity of ascertaining what constitutional symptoms would be produced by the continuance of the disease in the nurse, as I have generally found that the application of diluted citrine ointment to the nipple produced a cure, without any internal medicine. The constitutional symptoms in the children were cured by the same local applications, with small doses of calomel internally[80].

[80] There are some cases, described by different authors, of affections of the nipples and breasts, in which the ulcers appear to have been chiefly of the phagedenic kind.

I have likewise observed ulcers on the lips, throat, and mouth, which at first had a very doubtful appearance; but they evidently are distinct from syphilis, and belong to the suppurating sores. When superficial, the buff-coloured matter, or inorganised substance which covers them, has a fibrous, or thready appearance, the margins are slightly tumid, and of a florid, or kind of pink colour. The application of caustic, or burnt alum, is often sufficient of itself to cure these; but small doses of mercury sometimes accelerate the cure. At other times these sores penetrate deeper, and affect the bones. The surface, which is deep, is covered with a thick yellow slough, like an overacting ulcer. The margins are tumid, ragged, and of a light, or pink colour. Sometimes the disease spreads along the gum, which becomes soft, ulcerated, and separates from the teeth, which very frequently become black, and, when the sockets are affected, drop out. I have not had an opportunity of observing these sores go the length of inducing constitutional symptoms. It is not easy to ascertain the cause of these sores; sometimes they succeed the use of mercury; but, at other times, it is impossible to blame any evident agent. The transplanting of teeth sometimes has been the mean of inducing sores similar to these; and, in these cases, the disease has generally passed for syphilis[81]. But although the venereal disease may have been inoculated in this manner, it is certain, from the appearance of the ulcers, from their rapid progress, and from the sudden effect produced by a very small quantity of mercury, that the disease, which is commonly induced by transplanting teeth, is not syphilitic.

[81] Cases of this kind may be found in Mr. Hunter’s Treatise on the Venereal Disease, and in the third volume of the Medical Transactions.

Sibbens is another disease which has been very frequently confounded with syphilis, and is by many considered to be only a variety of that disease; but they evidently are different, as appears from the mode of infection, and the properties of the contagion[82], the appearance of the ulcers, their progress, and certain circumstances in their cure, particularly their requiring less mercury than venereal ulcers in the same state, and from their yielding readily to preparations of mercury, which do not accomplish a cure of syphilis.

[82] This disease is communicated even by drinking out of the same vessel with an infected person, even although that person have no sores on the lips, but only in the throat. The contagion then must either be dissolved in the saliva, or remain very powerful, even when reduced to a state of halitus.

This disease appears first on the part which is most directly acted on by the contagion. This part becomes red and inflamed, having an erysipelatous appearance. Ulceration quickly takes place on a particular spot, and spreads rapidly along the whole inflamed part. The disease then advances more slowly; the erysipelatous appearance spreads around the margin of the ulcer, and ulceration follows upon the inflammation. In the course of some time (the precise period is not fixed), the skin becomes affected with blotches, or sometimes clusters of small pustules, the intervening space betwixt each being affected with an erysipelatous inflammation. These spots soon ulcerate, and the surface rises up into a fungous, which is irregular, and has an aspect somewhat betwixt the look of the venereal sore and a very bad scrophulous ulcer. The bones next become affected, particularly at the articulating surfaces, which swell, and become carious. It is said that the secondary ulcers in general appear first upon the genitals; but, of all those whom I have examined, no affection of these parts had taken place, from which I would infer, that the disease has no peculiar tendency to affect these in preference to other parts. It is likewise said that the disease sometimes disappears from one part, whilst it breaks out in another; but this also I have never witnessed. The primary ulcers also have no tendency, like some others, to change their appearance, and become milder, or heal by continuance, but spread, destroying the nose, orbits of the eyes, and face. The constitution seems to suffer much more from this disease than from syphilis, in the same length of time; for the patient soon assumes a pale sallow look; and hectic comes on much sooner than in syphilis.

The cure of this disease is effected by washing the sores with solution of corrosive sublimate, or dressing them with precipitate ointment, at the same time that we use mercury internally, without which no escharotic, or local application whatever will effect a cure. In general, less mercury cures this disease than syphilis; and it is worthy of remark, that permanent cures may be obtained by the hyd. mur. corros. which is not the case with syphilis. When the bones are affected, we must, in conjunction with the specific remedy, use such applications as the state of the bone, considered as a simple affection, will require.

The cynanche maligna, and scarlatina, are also diseases producing ulceration in the throat. The sores are of the suppurating kind, a thick lymphatic-looking, or inorganised substance being thrown out, instead of organic particles, or granulations. This, in the former disease, very soon becomes black, and putrefies; but the slough so formed differs materially from that caused by gangrene; for, in this disease, unless in the very last stages, there are no real gangrenous sloughs. It is unnecessary here to make any particular observations on these diseases.

Herpes[83] is a disease which is very frequent, and often prevents large ulcers from healing, as these come to assume the action of herpetic ulcers, although, from their magnitude and depth, they do not put on the same appearance as when the disease is confined to the skin. The large ulcers are of a dark sloughy appearance, discharge thin matter, are painful, and are surrounded with herpetic ulcers, and scabs in the skin. This is a very frequent disease on the legs, and is very tedious. Bathing with warm sulphureous water is often of service, at the same time that we dress the parts in the intervals with camphorated ointment. Citrine ointment is also very useful; but the following liquor is one of the best, and most effectual applications:

[83] There are many different divisions of herpes; as, for instance, into the scurfy, scabby, miliary, &c.; but, for a description of these, I must refer to the writers on the diseases of the skin.

R. Pulv. Calcis Vivi Recen. unciam. Flor. Sulph. semiunciam. Aq. Font. sesquilibram. Coque ad dimidiam dein cola.

This ought to be applied with cloths to the parts.

When, by these means, the disease of the skin, and the specific action of the ulcer is removed, pressure is often of service in completing the cure.

There is a specific ulcer, which is met with most frequently on the legs, and which is very troublesome. The skin becomes in several points inflamed, or of a dark red colour. These parts speedily ulcerate, and the sores belong to the suppurating kind, for no distinct granulations, or organic particles, are formed; but the surface is smooth and glossy, and the discharge thin and copious. These sores are generally pretty deep, in proportion to their extent, or of a cup-like appearance. They not unfrequently occur in scrophulous habits. Mercury, exhibited in small doses internally, appears to be useful. Precipitate, as a local application, generally answers very well; but, when the sores become irritable, or spread under this treatment, hemlock poultices succeed better.

There is a small ulcer, which sometimes is met with on the foot, of an irregular shape, fiery appearance, and surrounded with thick jagged margins, which, in particular parts, are white, and callous. The neighbouring integuments are of a dark red colour. The discharge is thin, and the pain considerable. Caustic, and afterwards the application of the adhesive plaster, are the best local applications. Internally, the use of hemlock is sometimes of service.

It occasionally happens, that, nearly about the same time, most of the patients in a ward of an hospital shall have their ulcers rendered unhealthy. They become foul, dark coloured, and spread: The discharge is thin, and the pain is greater than formerly. The application of cloths dipped in gastric juice is sometimes of service in these sores, and is one of the best remedies; but, not unfrequently, the patient must be removed to a different situation before a cure can be obtained.

Having made these detached remarks on some specific ulcers, I shall, in the succeeding dissertations, consider, at greater length, others, which are, in the general estimation, considered as more dangerous and alarming.

DISSERTATION IV.

_On the Spongoid Inflammation._

The disease which I am now going to consider, has either not been described at all by any author, or has, when it was noticed, been considered as of a cancerous nature. It is perhaps one of the most alarming diseases to which we are subjected; because, as yet, we know of no specific remedy; and an operation can only be useful at a time when it is very difficult to persuade the patient to submit to it.

I have named it the spongoid inflammation, from that spongy elastic feel which peculiarly characterises the disease, and which continues even after ulceration takes place.

This disease begins with a small colourless tumor, which, if there be no thick covering over it, such as the fascia of a muscle, or the aponeurosis of the foot, is soft and elastic, but tense if otherwise. It is at first free from uneasiness; but, by degrees, a sharp acute pain darts occasionally through it, more and more frequently, until the sensation becomes continued. For a considerable time, the tumor is smooth and even, but afterwards it projects irregularly in one or more points; and the skin at this place becomes of a livid red colour, and feels thinner. It here readily yields to pressure, but instantly bounds up again. Small openings now form in these projections, through which is discharged a thin bloody matter. Almost immediately after these tumors burst, a small fungus protrudes, like a papilla, and this rapidly increases, both in breadth and heighth, and has exactly the appearance of a carcinomatous fungus, and frequently bleeds profusely. The matter is thin, and exceedingly fœtid, and the pain becomes of the smarting kind. The integuments, for a little around these ulcers, are red, and tender. After ulceration takes place, the neighbouring glands swell, and assume exactly the spongy qualities of the primary tumor. If the patient still survive the disease in its present advanced progress, similar tumors form in other parts of the body, and the patient dies hectic.

On examining the affected parts after death or amputation, the tumor itself is found to consist of a soft substance, somewhat like the brain, of a greyish colour, and greasy appearance, with thin membranous-looking divisions running thro’ it, and cells, or abscesses, in different places, containing a thin bloody matter, occasionally in very considerable quantity. There does not seem uniformly to be any entire cyst surrounding the tumor, for it very frequently dives down betwixt the muscles, or down to the bone, to which it often appears to adhere. The neighbouring muscles are of a pale colour, and lose their fibrous appearance, becoming more like liver than muscle. The bones are uniformly caries, when in the vicinity of these tumors. If large, they are found rough, and broken off into fragments; if small, they are generally soft and porous. This tumor is sometimes caused by external violence; but often it appears without any evident cause.

I know of no remedy which has a power of checking the progress of the complaint, or removing it. Friction, with anodyne balsams, sometimes gives relief in the early stages; but it does not seem to retard the progress of the disease. Extirpation is the only remedy which has a prospect of being successful; but it is only adviseable in the early stages, whilst the disease is entirely local, and has not extended to the neighbouring glands; for, after they become affected, the chance of recovery is greatly diminished. It is, however, sometimes difficult to persuade patients at this time to submit to amputation, or extirpation, because the pain and inconveniences are inconsiderable; but the operation ought to be urged with all the eagerness which a conviction of its absolute necessity, and its precarious issue, if delayed, will inspire.

After making these observations, I shall illustrate the subject with the following cases, the first of which is intended to show the difficulty of extirpating the disease, when the operation is delayed after the first appearance of the tumor. In the second, we see the destruction which the bones suffer by it, and the extent of parts which it may affect. The third gives us an instance of the affection of the glands: And the fourth, of the most advanced stage, or that in which distant parts have suffered. The last is an instance of the good effects of an early operation.

CASE I.

William Stirling, without any very evident cause, perceived a small tumor on the top of the shoulder, about midway betwixt the termination of the neck and the articulation of the humerus. This gradually increased for some months, and by the time when I saw him was larger than a goose’s egg: It was spongy and elastic, and attended occasionally with pain.

Although the duration of the tumor was an unfavourable circumstance, yet I undertook the operation. I made an incision through the whole length of the skin, and dissected it off the tumor, (the upper part of which was covered with a coat, or cyst), down to its base; but, when I now began to separate it from the parts below, I found that it had no defined bottom, but penetrated down betwixt the muscles, which were soft, pale, and had lost their fibrous structure. I therefore cut off the tumor close by the muscles, and then separating them with the back of the scalpel, I removed with the finger as much of the tumor as I could observe. Several arteries sprung; but these were pretty readily tied, although the vessels were very tender. A troublesome oozing, however, took place from many points of the diseased muscles. This was moderated by applying the sponge dipped in cold water, after which the skin was laid down, and its lips brought close together.

On dressing the patient on the third day after the operation, the skin was found not to have united; but its lips were red and inflamed. In this state it continued for several days, when the part began to grow tumid, and discharge a thin fœtid matter. The skin then retracted still more, and a fungus protruded, which gradually increased; but it was smooth and regular, and of a pale colour, so that it rather had the appearance of a superficial ulcer, raised up by a tumor from below, than the ulcerated surface of a diseased substance itself. In this state it continued for two or three months, when irregular projections appeared on the ulcerated surface of the new tumor. These soon burst, and a fungus protruded, of a carcinomatous appearance, and bleeding very frequently and profusely. Swellings of the axillary glands succeeded this, and the patient became much enfeebled, and evidently hectic. As I have not heard of him for several weeks, I suppose that he has died.

In this case a second tumor succeeded to the first, owing to the impossibility of extirpating the whole, and this exactly resembled the original one, except in having its surface covered from its commencement with an ulcer; but this ulcer was not the specific one of the spongoid inflammation.

CASE II.