Treatment of Chancre.—Preliminary remarks.—Chancres are of various kinds. The most remarkableare:—
1st. That characterized by its circular form, its excavated surface covered by a layer of tenacious and adherent matter, and its hard cartilaginous base and margin.
2d. Another form of chancre, unaccompanied by induration, but with a very high margin, appearing often on the outside of the prepuce, and seldom existing alone, called, from the preceding description, the “superficial chancre, with raised edges.” These kinds of ulcers are sometimes very tedious, neither getting better nor worse, but resisting every plan of treatment for their removal. I have known instances where they have existed for several months.
3d. The phagedenic chancre, a “corroding ulcer without granulations,” and distinguished by its circumference being of a livid red color. This is the kind of chancre that is invariably rendered worse by mercury: indeed, cases have occurred where, from the injudicious administration of that medicine, the whole of the penis has been destroyed.
4th. A most formidable kind of chancre, denominated the sloughing ulcer. It first appears as a black spot, whichspreads and becomes detached, leaving a deepened and unhealthy looking surface. The sore is very painful, and encircled with a dark purple areola. If neglected, or improperly treated, the process of mortification goes on until all the parts of generation are destroyed.
The last-named chancre is more often the consequence of neglect on the part of the patient, than the natural progress of the disease.
Now the usual method adopted by surgeons to remove chancres, has been to excise them, or to apply caustic; the latter is the plan I adopt, and would recommend; but all chancres are not to be treated alike, some requiring antiphlogistic remedies, others soothing, others stimulant. Some practitioners rely entirely upon constitutional remedies.
On the first appearance of a chancre, I would enjoin an alteration in the diet, regulating it according to the strength of the patient. Abstemiousness should be the motto, avoiding extremes, however, lest debility should be induced. Quietude and rest, in the recumbent position, are two essential adjuncts in the treatment of primary syphilis throughout.
With respect to the treatment of the ulcer, characterized by its circular form, excavated surface, and hardened base, as detailed, the plan I almost invariably adopt is, immediately on its appearance, at least as soon as the pimple has broken or desquamated, to smear it with a hair pencil filled with the solution of caustic, sometimes twice, at least once a day (see Form27), and to keep it frequently washed in the daytime with a lotion of the chloride of soda (see Form28), or the black, red, or blue wash (see Forms29,30,31).
If the patient be strong, and otherwise in good health, I simply recommend a dose of purgative medicine, in anticipation of any irritation that may arise. After which, I suggest a middle diet to be adopted for the next few days. From the sedative and salutary effects of the warm bath, I recommend its employment immediately after the operation of the medicine, and its repetition at frequent intervals. Independently of its effect on the system, it is the best general cleanser that can be resorted to. The subsequent treatment is regulated by the result of the above, which can be ascertained about the third day.
In numberless instances, and where the disease is thus early detected and similarly treated, the mere continuance of either the chloride lotion, or black wash, the middle diet, an occasional aperient, the bath, with as much rest as possible, are all that will be found needful to cure the disease, which generally is effected in about a week or ten days at farthest. From the universal dread that so sudden a disappearance of the sore occasions, lest it should “be driven into the system,” and from the apprehension that it is incurable without taking mercury, I verily believe that, in many cases, the practitioner, participating in the fears of his patient, and anxious to allay them, reluctantly administersthat mineral; and to such weak judgment may be traced the relapses, or the occurrence of other symptoms sometimes mistaken for secondary. Even when the case terminates favorably, and within the space of time alluded to, I would not be considered as recommending a sudden return to free living; on the contrary, I would not release the patient from the restrictions imposed upon his diet, exercise, and regimen, for at least the same time as was occupied in the cure, nor would I predict that, in every instance, secondary symptoms should not ensue. Mercury was supposed to possess some antisyphilitic property, inasmuch that, when chancre healed during its exhibition, secondary symptoms were averted. Facts, however, have been wanting to corroborate that supposition; for secondary symptoms have appeared despite the external and internal employment of mercury, even to the extent of salivation. Authors there are who attach similar properties to other medicines, such as nitric acid, sarsaparilla, and such like. Now, how do these medicines act upon the system? Or what is their tendency of action? Why, by increasing some particular function, such as the secretive process of the salivary and other glands; by increasing perspiration or absorption, &c. The remedies whereby these changes are induced are termed alteratives. I am not going to deny that these, or some such changes in the system, are unessential for the eradication, particularly of morbid conditions of structure and function, dependentprobably upon altered condition and diminished action in others. On the contrary, they are the only antagonists to disease which we possess.
But what I contend is, that, in our selection, we should prefer those which produce most speedily and effectively the desired change, with the least detriment to the general health. And to this end, I invariably enjoin, where practicable, warm or vapor bathing. I have elsewhere considered this subject at length, to which I refer the reader; but I will fearlessly assert that no one, or any plan of treatment, will be found so effectual toward increasing physical power to repel disease, or so permanently preservative of health, as the modified employment of the warm or vapor bath; and, therefore, in all cases of doubt and apprehension, or independent of either, the use of the warm or tepid, plain, or salt-water bath, two or three times a week for a month, or the vapor bath about every fourth or fifth day for the same period, is the best preventive that can be adopted to avert secondary symptoms. Where bathing of every kind is impracticable, as is the case in some country places, and the same necessity exists, I advocate the administration of alterative medicines; nor do I object to the employment of mercury, where, under other circumstances, without reference to its imaginary efficacy in syphilis, it would be prescribed. But of this as we proceed.
Where, at the expiration of a week, the chancre neitherrecedes nor advances, and is the only symptom present, it is to be presumed that the condition of the patient’s health has something to do with it, and that condition should be minutely inquired into. There may be diminished or increased appetite, with imperfect digestion; there may be fever, with restlessness at night; there may be torpor or irritation of the bowels; or the patient may consider his only ailment to be the chancre, the irritation of which may be found to arise from too active exertion. To whichever cause it may be ascribed, the treatment should be directed. In conjunction with local remedies, which may be varied, alteratives may be given—five grains of the blue pill twice a day; for instance, the Plummer’s pill in doses of five grains every night, the occasional application of an active aperient (see Forms33,34), the decoction of sarsaparilla (see Forms49,50,51). This plan, carefully pursued, seldom fails in setting up a permanent cure. The patient should be apprized of the vast importance of quiet, rest, and abstemiousness; for, where they can be attended to, the duration of the disease will be diminished one half; whereas, he who is continually in the erect posture, and subject to much walking about, who is indifferent to his diet, and lives as free as formerly, incurs the risk of bubo, and all its alarming consequences. Now, in no case or description of chancre, do these remarks apply so aptly as to the phagedenic and sloughing ulcer; in fact, they are applicable to all, but more particularly the two latter, as they arethe result of already increased action. Mercury, violent aperients, and other active remedies, should also be avoided in these two forms of chancre; the local appliances should be poultices of bread and water, linseed meal, and a solution of opium, or poppy water; the sloughs or mortified portions we should endeavor to detach, by the application of asmearof nitric acid, or the chloride lotion (Form28), or stimulative ointment (Form38). The superficial sore usually gets well by the same means as the ordinary chancre.
Where the chancre is situated under the prepuce, and the latter covering is so inflamed and swollen as to prevent its being drawn back to exhibit the sore, the discharge should be carefully washed out by any of the lotions already recommended, by means of a syringe, several times in the twenty-four hours. Much good is often done by varying the local remedies, occasionally flouring or filling up the ulcer with calomel, tutty powder, blue ointment, or in fact any substance which alters the morbid action of the part; but, as a general rule, the lotions of soda, lime, zinc, or oxymuriate of mercury, will be found sufficient, if persevered in.
Treatment of Bubo.—Bubo I have already stated to be an inflamed and enlarged condition of the inguinal (as its name implies, signifying the groin), or, in fact, any other gland, occasioned by the passage of the venereal poison from the adjacent ulcer through it, preparatory to its contaminating the constitution. But it is as well to know that the system may become affected, or, in other words, the poison may pass through the glands without involving them in the disease, or that the poison may there stop, and beexpelled as the bubo is cured. It is also observed, that buboes are more frequently consequent upon an ulcer seated on the prepuce than on the glans. Buboes are not always, however, a sure criterion of the venereal disease, for they will occur wherever irritation is superficial and adjacent. Leeches applied to the temples will affect the cervical glands, a graze or wound in the leg enlarge the inguinal, and a whitlow on the finger, or any inflammation of the hand or arm, will very often irritate the glands in the axilla. In gonorrhœa, the glands in the groin become swollen and painful, from sympathizing with the sensibility of the urethra; but these and the preceding may, in general, be distinguished from true venereal buboes by their disinclination to proceed to suppuration; whereas, in syphilis, that process runs through its several stages with remarkable celerity, unless timely prevented. Buboes in the groin are much more troublesome, and more likely to betray the disease, than chancres, because they constitute an augmentation to the patient’s suffering, seldom occurring, unless preceded by a chancre, and because they occasion a visible and necessary lameness. They also produce more general disturbance of the patient’s health.
In the treatment of a bubo, venereal or not, the same principles recommended in the section devoted to the cure of chancre, should be followed in this instance—comprising attention to the general health, and a subdual of the prevailing symptoms.
In no form of syphilis is rest more essential than in bubo. The patient will be apt to plead the necessity of following his business, and the utter impossibility of staying at home; that is his affair, mine is only to protest against exercise, and urge the importance of rest, and even the recumbent posture, and I can assure him,thatalone will strip the disease of three fourths of its terrors.
Certain local diseases produce more constitutional disturbancethan others—among them may be classed buboes; it would, therefore, be as impolitic suddenly and violently to repel an inflammation of a gland or glands, without establishing some outlet for the increased action to vent itself, as it would be to check a flux or suppress an exanthematous eruption, like measles or scarlatina.
If the bubo is, therefore, painful and inflamed, my advice is as follows: Stay at home, and rest; descend to middle diet; take some aperient; and should chancres alone be present, and a treatment going on for their extinction, continue the same; or, as bubo often immediately succeeds the ulcer, and probably may be the first symptom noticed, adopt, in addition to that recommended above the treatment as advised for chancre, namely, the administration of some alterative—for instance, five grains of blue pill every night—or the Plummer’s pill every night—the aperient powder every other day; and let the local treatment be directed to remove the prevailing symptom, to subdue the inflammation, and, if possible, thereby prevent suppuration. It was formerly supposed that, unless buboes were allowed to suppurate, the system could not escape the venereal taint. Lower somewhat the vital powers, or, what may be more intelligible, diminish the general inflammatory action, establish some slight drain, by determining the secretions to the intestines or skin: and buboes, even when matter has absolutely formed, may be fearlessly absorbed, which judicious treatment will effect, in nine cases out of ten, without at all impregnating the constitution. To attain this object, warm fomentations constantly applied, and if possible the warm (hip or full length) bath every night. When rest is determined upon, if the swelling is great, red, and painful, leeches are eminently serviceable, but they must be applied in numbers of at least a dozen at a time, and repeated twice or thrice if necessary. Three or four, by the irritation of the bites when healing, and especiallyif the patient will not or can not remain quiet, only worry and aggravate the disease. Where the inflammatory symptoms are great, where there is fever and much heat of skin, bleeding is the speediest and most effectual plan to subdue them; and, in my opinion, it is to be preferred before the trouble and bother of leeches. Where, however, there is no remarkable excitement, local or universal, the topical application of any of the ointments suggested will often promote absorption (see Forms35,36,37).
Blisters applied over the bubo, very often disperse the swelling. Pressure also, made by means of a pad covered with tin foil (as seen in the subjoined cut), and continued for several days, frequently urges the absorption of the accumulated deposition in the gland.
Described in surrounding textView larger image
View larger image
View larger image
Wherebubohas been suffered to proceed, and the suppuration appears inevitable, it would be highly improperto retard it: poultices and warm fomentations should be applied, and when fit, an opening should be made to permit the exit from, and prevent the extension of, the matter in the surrounding cellular membrane; the operation should not, however, be prematurely performed; the skin should be permitted to become thin before an opening is made, and that opening should be made in the most dependent position, in order to allow complete escape of the matter, lest fistulæ and sinuses should form. When an abscess is thus established, its healing must be promoted with all expedition, and care taken to preserve the strength of the patient. For the former purpose, poultices, mild healing ointments, or strapping plaster applied near the edges of the wound, should be used. Poultices may be applied with a bandage, as seen in the subjoined cut.
Described in surrounding textView larger image
View larger image
View larger image
When the abscess appears indolent and not disposed to heal, carrot and linseed-meal poultices may be substituted. Astringent ointments should also be employed (see Forms38,39,40), or lotions (see Forms41,42), and the topicalapplication of caustic to the edges of the wounds, or even paring them with a scalpel. The occasional use of the warm or vapor bath will give a healthy tone to the frame, invigorate the depressed powers, and promote recovery. The strength should be supported by more generous diet, and any of the formulæ comprised under the head of tonics, may be taken internally (see Forms43,44,45,46,47,48). As the patient becomes convalescent, change of air, gradual exercise, the cold shower bath, or sea bathing, will be of essential service.
———<>———