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Commentaries on the Treatment of the Venereal Disease, particularly in its exasperated state; including a second edition of a former Publication on that subject, considerably augmented and improved. On the use of Mercury, so as to insure its successful effect. With an Appendix, on Strictures of the Urethra, and on Morbid Retention of Urine. By EDWARD GEOGHEGAN, Member of the Royal College of Surgeons in Ireland, &c. &c. London, 1814. 8vo. pp. 219.

THE HE difficulties which occur in the treatment of syphilis are so great, that it requires the employment of the best talents and experience to elucidate them. Various disputes have existed, whether the treatment of the disease ought to belong to the province of the physician or surgeon, and a great many arguments have been adduced in support of these two opinions. It is generally a constitutional disease, but the local symptoms are often very troublesome; and the separation of the healing art into medicine and surgery, has in no instance so materially impeded the improvement of both. It is also to be regretted, that writers on syphilis have not been sufficiently accurate in their descriptions, and have entered into theoretical discussions, instead of detailing the circumstances that constantly occur in medical and surgical cases, the careful attention to which can alone afford us correct rules for the treatment; and many considerations have been overlooked, which, if minutely attended to, would materially influence the practice.

The intention of the author of the present work is not to describe every form which the venereal disease exhibits, but to confine himself to some aggravated symptoms, in the treatment of which he has had considerable experience. These are, phymosis in its inflammatory stage, phagedenic chancre, venereal bubo, affections of the fauces, and on the use of mercury, so as to insure its success.

We have had an opportunity of witnessing the crowds of miserable wretches who daily apply for relief at the Lock Hospital in Dublin, labouring under all of the most aggravated forms of the disease; and the author mentions, that for many years his attention had been particularly turned to the treatment of these states, but that it was more particularly excited by the violence of the symptoms which occurred in the summer, au

tumn, and winter of 1799, and he found that other practitioners had made the same remark.

When a disease, which commonly presents mild symptoms, is unusually exasperated, we are naturally led to inquire, to what we are to attribute this change. If it were to the increased acrimony of the poison, mercury would be the antidote; but there is nothing more common, than to ascribe the venereal appearances which resist the effects of mercury, or are increased by it, to some peculiarity of constitution, and bark, wine, opium, sarsaparilla, are thrown in indiscriminately. After pointing out the indecision and fallacy of Mr Hunter's advice on this point, the author observes,—

"With respect to the question, whether increased acrimony of the poison has any share in producing these aggravated symptoms? Here it is necessary to take a view of the effects usually attendant on its application in the first instance-when applied to a non-secreting surface, ulceration is the usual consequence; and, although this state is accompanied by some degree of inflammation, yet it is rather circumscribed, and the ulcerative process goes on more rapidly than the inflammatory, and, indeed, the latter is often totally absent. Females having the slightest appearances, without any inflammatory symptoms, ignorant, indeed, of being infected, constantly communicate the disease, and the persons whom they have infected show the disease in various degrees and forms; in one man it will exhibit the most trivial, in another the most violent symptoms, although both have been infected by the same woman, and at nearly the same time. Taken into the stomach, it produces no effect, and even proves harmless to many persons who expose themselves to it; it also remains in the habit for years, without manifesting itself, or exciting the least disturbance. In the small-pox, we every day see the same infection produce the disease in one subject in the mildest, in another in the most malignant form. These facts establish the principle most unequivo. cally, that mild or violent symptoms, whether accompanied by inflammation, or ulceration, or in whatever form they appear, are not characteristic of the degree of acrimony in the infectious matter; hence we have no reason for attributing the aggravated state to the infectious matter alone; we are led. then, to look for an explanation of the phenomenon from some other cause. It is a common phrase, when things run untowardly, to say, this is owing to peculiarity of constitution; but in what this peculiarity consists we are uninformed, and, of course, are without any guide as to the treatment. Whilst I agree that the true source of the mischief is in the state of the constitution, I cannot but express my astonishment at the narrow view that is generally taken of this very material point. One would think, from the plans of cure laid down, and usually followed, that this condition of body meant something fixed and definite, not that fluctuating state which is liable to vary with every breeze."

The principle contended for is generally admitted, and we proceed to its application to the subject before us. The diseases of the penis are frequently aggravated independently of the poison, which merely predisposes the part to be acted on by remote causes. Therefore we find that these symptoms frequently supervene, when the true venereal chancre has healed, and the system is fully charged with mercury, or when the body is reduced to a state peculiarly liable to be acted on by adventitious diseases. We have recently met with cases of true chancre, which healed under the use of mercury; while ulcerations that have appeared during the course of the cure, having put on the malignant appearance, particularly at the moment when the true venereal chancre was healed. In such cases, we are disposed to coincide with the author, in considering the continuance of the mercury as not only unnecessary, but even hurtful; and it is in such cases that the use of the sarsaparilla, as mentioned by the author, is particularly beneficial; and the practice of many medical men, of resuming the mercury when the sores are nearly healed, is evidently attended with very injurious effects.

With the author's remarks on the treatment of phymosis, we perfectly agree. Many old practitioners, in such cases, seem to think the exhibition of mercury in larger quantities the sole point of practice to be attended to; but, as the author remarks, the inflammation is greater than that usually produced by the venereal virus; it often appears where the other symptoms are mild, and the mercury exerting its full effects; it is frequent in the ill-aired wards of hospitals, and when diseases arise depending on the state of the atmosphere; in short, it is an accessary disease, and requires to be removed, before the cure of the original complaint is attempted.

"From this view, namely, that this symptom is not occasioned by the virus, and that mercury is not only unnecessary, but preju dicial, I would reject its use in toto, and treat the complaint as common inflammation, demanding prompt and vigorous measures for its cure. The great functions of the penis require that it shall be often distended, and for this purpose, an extraordinary quantity of blood is determined more frequently to it, than to any other part, and its return is in a great measure impeded. This structure and its natural sensibility dispose it to be rather suddenly inflated when irritated, and I think points out a leading feature in the treatinent; to lessen the determination of blood to the part, and to allay local irritation; the former will be best effected by blood-letting, and the other evacuations; the latter, by such applications as are refrigerant and sedative. If the symptoms run high, I take off a pound of blood at the onset, when there is no contra-indication, and I never find it necessary to repeat it; if the symptoms are moderate, I omit bleedVOL. XII. No. 47.

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ing, and direct brisk purging in the day, and at night two grains of antimonial powder, and one grain of opium in a pill, which latter I repeat after six hours, if the distress continues. The tongue is generally furred, skin hot, and pulse frequent; a state that forbids every medicine of the astringent kind, and, I think, opium also, unless its use is preceded by evacuations, and it is combined with antimonials or ipecacuanha in the proportion before mentioned."

In the local treatment, in these cases, we have often seen very severe symptoms rather aggravated by the application of leeches; and the author observes, that the bites of these animals are very liable to slough where there is a tendency to mortification. All stimulant injections are hurtful; and warm fomentations of milk and water, or a weak solution of acetite of lead, applied warm, prove the best applications for allaying the morbid sensibility of the parts; or the ointment of the acetite of lead, spread on linen, may be wrapt round the parts.

Of phagedenic chancre. In the treatment of this description of sore, we find considerable difference of opinion among authors: many advise the continuance of the mercury, and al most all of them stimulant applications to the sore. On this treatment, the author observes,

"The theory and practice for which I have contended, in treating of phymosis, apply here, namely, that phagedenic chancre is not a truly venereal ulcer, but a supervening disease, and that the habit liable to it is apt to suffer materially from the use of mercury; an high degree of morbid sensibility is manifest in every such subject, which condition is invariably increased by mercury; and I have ob served, that a sloughy state, whatever might have been its original cause, is increased by this medicine. From this view of the disease, and of the remedy, as more particularly noticed in another part of this work, I am decidedly of opinion, that mercury is injurious in phagedenic chancre, and should be excluded entirely from practice, as an internal and external remedy. I know that several practitioners discontinue it for a time, and resume it on a change of appearances; in the opinion that it is dangerous long to withhold the venereal antidote; to which practice 1 object for the following reasons; once that a morbid condition of body has taken place, under the influence of mercury, that state, in such constitutions as we now speak of, will be continued a length of time, partly because it becomes habitual, from bemg slowly induced, and partly because the recuperative energy is so feeble in them, as to require a long restorative process, which mercury will readily interrupt, and in which it will soon shew its deleterious effects; hence the confused appearance of the sore, and the difficulty of its being so unequivocally characterised, as to fix the rule of practice; all is uncertainty, whether the venereal or the mercurial action prevails; experience has confirmed me in the opinion, that it is always the latter, or an accessary disease, that forbids the use of mercury,

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To establish this point is of the first importance, but it can never be effected, whilst the practice is pursued of discontinuing mercury for a few weeks, and resuming it after that time. It is also the practice of some surgeons to give acrid preparations of mercury, often in conjunction with frictions."

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Having decided that the restoration of the health is the chief indica tion, the means of effecting this is particularly to be attended to. When phagedena, or a burrowing sore, is an early symptom, it is almost invariably accompanied by quick pulse, dry skin, furred tongue, and great pain; hence the necessity of purging until the tongue becomes clean, and the anodyne and sudorific medicines, as directed in treating of phymosis. If the distress is excessive, bleeding in proportion to the strength will be advisable at this early period; and in the more advanced stage, warm baths, and the soothing plan. In obstinate cases, a dry and warm atmosphere, particularly in the country, will be of material service. The only medicine I can recommend from experience is sarsaparilla given alone; when it is combined with guaiacum, and the other ingredients that form the decoctum lignorum, the habit is too much excited, an effect that is unfriendly to an irritable condition. I also object to mercury in any form accompanying sarsaparilla, on the same principle, and also for the reasons advanced before, namely, that this description of ulcer is not perpetuated by the venereal poison, and that it has not a venereal origin, in some cases. The effects of mercury appear to me to be of a different nature from those that are produced by sarsaparilla; the former evinces all the properties of an irritant, the other of a demulcent; hence the mercury will countervail the sarsaparilla, provided that the case forbids irritating medicines; that medicines of opposite properties will produce effects, when combined, which, separately, they would be unequal to, I am aware, and am satisfied, that this very combination I now forbid, is advisable in some particular cases of the venereal disease; but having witnessed the worst consequences from the use of mercury in every form, and finding that the records of practice abound with similar cases, I feel warranted in insisting, that its administration as an antisyphilitic is improper in the treatment of the particular sore, and state of body, I speak of, whatever might have been the original cause."

It has been often remarked, that the scrofulous diathesis is frequently roused by the venereal virus, and the long continued use of mercury, and it is in such cases that the sarsaparilla is most beneficial. The best mode of using it is in the form of decoction; and, at the same time, attention should be paid to the diet. The food should be of easy assimilation, and not stimulating; milk and vegetables form the best articles; and, in all irritable habits, animal food, wine and cordials, and the tonic plan, should be used with caution.

With regard to the local remedies, the author recommends the fermenting poultice of a large size; but it is sometimes too

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