Surgical observations on diseases resembling syphilis, and on diseases of the urethra

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SURGICAL OBSERVATIONS

ON

SECTION II. On Pseudo-syphilitic Diseases becoming ’well spontaneously

Mr. Hunter, in his excellent Treatise on the Venereal Disease, has related several cases supposed to be syphilitic, and some of which were certainly not so, as they got well without mercury ; but in the greater number the employment of this medicine rendered their nature doubtful. Mr. Hunter, also, who was as cautious in drawing conclusions as he was accurate in making observations, expresses himself in many instances so diffidently on the subject, as, in my opinion, not sufficiently to impress the minds of his readers with the certainty, importance, and frequency of such facts. He concludes his observations by intimating “ that undescribed diseases, resembling the venereal, are very numerous, and that what he has said is rather to be considered as hints for others to prosecute this inquiry further, than as a complete account of the subject.” As it has occurred to me very frequently to meet with such cases, and as the necessity for discriminating them from syphilitic diseases appears to me of the highest importance, I shall prosecute the subject by relating some unequivocal cases of diseases strikingly resembling syphilis, but which, however, were disorders of a different nature, provided it be admitted that syphilis does not spontaneously get well without the aid of medicine.

The necessity for discrimination between these diseases will appear upon a slight consideration of the subject. If a surgeon, who does not see that extent of practice which occurs in a metropolis, administers mercury in one of the diseases resembling syphilis, he finds, perhaps, that the symptoms yield slowly ; and even after a considerable and debilitating course of that medicine they may recur. They are then counteracted by a still more severe use of mercury, till they, perhaps, spontaneously cease, which may not happen till the patient’s constitution is so enfeebled, that if it do not fall into other states of disease, it very slowly regains the standard of health. Such cases would induce

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the surgeon to consider the venereal disease as peculiarly difficult to cure, and liable to recur on the remission of even a severe course of mercury. The consequence of this opinion is, that he employs mercury to an unnecessary and injurious degree in his general practice.

I do not mean, however, by these remarks to imply, that, in my opinion, syphilitic diseases are equally susceptible of cure in every instance by mercury; nor am I an advocate for what has been termed an alterative course of this medicine. Cases which frequently occur have convinced me that it requires a very considerable mercurial effect to cure syphilis in some instances ; and that this effect must be continued for a considerable time in order to ensure a cure. Mr. Hunter probably wished the subject of diseases resembling syphilis to be prosecuted, in hopes that some distinctive characters might be discovered as peculiar to them ; but the following cases show that these diseases ensue from primary infected sores of very dissimilar appearances, andsometimes arise without any primary sore having been observed.

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Whilst, then, the primary symptoms are thus variable, and such as may perhaps in the greater number of cases be distinguished from those of syphilis, the secondary or constitutional symptoms often so strikingly resemble those of that disease, as not to be discriminated from them by sight, though in general they may be by their progress.

I have kept no particular account of the numerous cases which I have met with ; but the five following instances happened in my own private practice within a few months, and the circumstances of them are still fresh in my memory. The cases are drawn up from narratives which I requested the patients themselves to make out of their own diseases.

CASE VII.

A gentleman had a sore on the lower part of the prepuce near the froenum, which was much irritated by travelling from the country. When he came to town there was a good deal of surrounding inflammation, and a thickening adjoining the edges of the sore,

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which were irregular, and seemingly disposed to spread. An appearance of granulations had taken place on the surface of the ulcer, which was at this time as large as a shilling. I gave him the pilulse hydrargyri, whilst I tried by local means to quiet the irritation of the sore, and of the surrounding parts. As the sore appeared to heal slowly, and seemingly ill proportion to the quantity of mercury taken, the patient rubbed in at the same time some mercurial ointment, and continued to do so till after the sore was well, which was in about a month. In three weeks after he had left off these medicines, this patient applied to me on account of an ulceration on the velum pendulum palati, and on the surface of one tonsil ; and soon afterwards ulcers took place on the edges of the tongue, and on the inside of the lips and cheeks. Copper-coloured spots also came out on his arms and legs, and all over his body. They were very numerous, but none appeared on his face. By waiting and watching the progress of the disease, I found that some of the ulcers amended spontaneously, and that the palate got well. I there-

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fore exhorted him to refrain from mercurial medicine, and he went into the country. A medical gentleman, whom the patient consulted, was very anxious to try something to cure this disease, when his patientwas seized with a severe febrile complaint, during the continuance of which all these doubtful symptoms disappeared, and there has not been any return of disease since that time.

CASE VIII.

A gentleman had a small sore on the prepuce, at a little distance behind the corona glandis, which did not appear like a venereal chancre, and therefore no mercury was used. After about a fortnight, during which time it could scarcely be said to be better or worse, it suddenly became considerably indurated in its circumference, and the surrounding parts became inflamed. The hardness was so considerable that it resembled

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one of those indurated chancres which so frequently occur; and, in consequence of this striking resemblance, another surgeon, whom the patient consulted at this time, insisted on his confining himself to his chamber, and using mercury attentively.

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The quietude of the patient, with some little attention in regard to local applications, soon removed the inflammation and hardness, and the patient, who was controlled by nothing but his fears, discontinued his medicine after thrice using some mercurial ointment, and returned to his former mode of life.

About a month afterwards, he called on me with an ulcer in each tonsil, one of which was deeply excavated, with irregular edges, and covered by adhering matter. Shortly afterwards, copper-coloured spots appeared on his body, but these diseases all disappeared in about a month, without using mercury.

CASE IX.

A gentleman applied to me with a very irritable sore, or rather excoriation, extending itself over the left half of the corona glandis. It was unlike a syphilitic sore, as may be supposed from this description, yet, as the patient was young and healthy, I advised him to take some of the pilulee hydrargyri to guard against the possible conse-

VOL. II. D quences of absorption, and to bathe the parts affected with the aq. litharg. acet. comp. c. opio, and to apply folded linen moistened with the wash round the penis. The prepuce soon became swoln and inflamed, so that he was unable to retract it, and the attempt gave him great pain. He was, therefore, directed to cleanse the part by injecting frequently the decoction of white poppy heads of a lukewarm temperature. After a week he tried a very weak solution of vitriolated zinc, and other metallic salts, but they all increased his pain, and he was obliged to return to the use of the anodyne wash. When hehadpersevered in this course three weeks without any evident amendment, he consulted another surgeon, who recommended the discontinuance of the mercurial medicine, and in lieu of it, the free use of the bark. This medicine he took for a week without any amendment ; he then tried the nitrous acid for ten days, and afterwards took cicuta.

In about two months he was able to retract the foreskin, and then the solution of

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vitriolated zinc appeared to lessen the irritability and contribute to the skin-ring of the sore, which was merely on the surface, not having been attended with any loss of substance.

Afterwards the penis being subjected to some accidental irritation, the same kind of soreness spread over the other half of the corona glandis ; but this disease was not accompanied with so much tenderness as the former one, and got well in less than a month. As soon as it was well, the patient had an ulceration of the velum pendulum palati, round which the cuticle assumed a whitish colour ; the ulceration spread across the palate, but it was evident that the part first affected got better, whilst the ulcer became worse in the parts last affected. Two or three ulcers took place upon each edge of the tongue, and some on the inside of the lips. At the same time many copper-coloured spots appeared on the face, breast, arms, and lower extremities ; they came out in succession, were of an oval shape, about the size of a sixpence, and had a strikingly syphilitic aspect.

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Believing that the primary symptoms of this disease were not syphilitic, and observing that some part of the ulcer on the palate healed, and that some of the sores on the tongue and lips got better, whilst new ones broke out, I recommended the patient to use no mercury. He went into the country, where all these maladies gradually disappeared, and in about a month he was perfectly well.

CASE X.

A person whose irregular habits of life gave reason to suspect the existence of syphilis in the constitution, had ulcers in the tonsils, not superficial but deep. These were accompanied with copper-coloured spots on the face and breast, and eruptions on the head amidst the hair, accompanied with a great deal of scurf. These got well by anointing the head with ung. hydrarg. nitrat. mixed with simple ointment, which made

me doubt whether the other diseases were

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really syphilitic, and caused me to delay the use of mercury. The complaints did not amend, nor did they get materially worse. There was attending these diseases

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a good deal of general indisposition ; the appetite failed, and no sleep took place till the morning.

At this time a tenderness and thickening of the periosteum of the tibia took place. Though other medicines did not appear to be of any service, I still was averse to the use of mercury. Tired of delay, the patient consulted another surgeon, who declared the disease to be venereal, and desired that mercurial ointment might be used. The patient accordingly rubbed in two or three nights without feeling any effect from themedicine, and then set off on a party of pleasure to Brighton, where all the diseases gradually disappeared, without any further use of mercury,

CASE XL

A gentleman had an enlargement of a gland in the groin, probably from the absorption of some infectious matter, though he was not conscious of having had any sore. A second and a third gland became enlarged, the integuments became thickened and inflamed, and a very large bubo formed. It

d 3 suppurated and burst in three places. The general tumefaction subsided, but by no means dispersed, and sinuses remained where the abscesses had been. About this time I saw the patient, which was two months after the first appearance of the disease.

Shortly after this, he had an ulceration, which spread over the velum pendulum palati, and except that it was more superficial, much resembled a syphilitic ulceration. It continued so long without amendment, that I began to think it was syphilitic. Bark was now given plentifully, and the ulcer evidently amended. The patient went afterwards to the sea-side, where the bubo gradually dispersed : many months, however, elapsed before it entirely disappeared. The ulcerations of the velum pendulum palati also healed slowly ; and ulcers, which, afterwards appeared in the back part of the pharynx, got well likewise without mercury.

These cases are not related as being rare or curious, but because they all occurred to resembling syphilis.

me within the space of a few months, and because sufficient time has elapsed since their occurrence to show that there is no probability that there will be any recurrence of these or similar symptoms. It must be allowed that they are incontestable instances of diseases getting well without mercury, which could not be distinguished by mere inspection from similar diseases truly syphilitic. For though mercury was employed in some of the cases, it was used at such a time, or in such quantity, that it cannot in the least influence our decision as to this point, For instance, in the first case, though mercury was employed for the cure of the primary ulcer, and did apparently contribute to it ; yet the secondary symptoms got well without mercury, which, according to the opinions now prevailingamong surgeons, is a proof that neither was syphilitic. It may indeed be supposed that the syphilitic poison may be modified by certain constitutions, and its effects spontaneously disappear ; and some may question if the secondary symptoms were the consequences of the sores or absorption to which I attribute them.

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What I have written is, I believe, in conformity to prevailing opinions, and I forbear to enter into uncertain discussions.

These instances, however, though not selected for the purpose, show that the primary infected sores which are capable of producing secondary symptoms, strikingly resembling those of syphilis, do not themselves possess any uniform characters. In the first case the ulcer had no uncommon appearance ; it was of the size of a shilling, with fretful edges, and every where covered with granulations. In the second there were no apparent granulations, and a great degree of induration suddenly surrounded it, giving it a striking resemblance to the indurated venereal chancre. In the third, the sore surface was extremely irritable ; but though the disease existed for a long time, the ulcerative process did not eat into the part ; and at the conclusion of the case, there was no loss of substance. In the fourth and fifth cases, the absorption of the matter, which caused the secondary symptoms, either took place without any breach of

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surface, or the primary sores were too insignificant to excite attention. I lately attended a gentleman who had an ulcerated throat, and irruptions on the head, which broke out between the second and third month after the appearance of a sore on the prepuce, which sore healed in a few days with no other treatment than bathing it with a solution of acetated lead, and applying to it a piece of lint moistened with that liquor. This circumstance made him disregard the primary sore, but he was assured by a surgeon whom he consulted, that the secondary symptoms were syphilitic; they however got well without mercury.

It is probable, that the poison of syphilis is of so acrid a quality, that it always excites local ulceration of a peculiar and progressive nature, whilst the morbific poisons which produce pseudo-syphilis may be absorbed without any evident ulcer, or from a trivial ulcer, which may heal spontaneously ; and if the consequent constitutional symptoms are considered as the effects of the former disease, and treated as such, I need not say what confusion must be produced in the mind of the surgeon who pursues this conduct, and how bewildered his opinions must be respecting venereal diseases. If, for instance, in the eleventh case, a surgeon had considered the secondary symptoms as syphilitic, and employed mercury successfully for their cure, he would set this down as a case of syphilitic bubo occurring without a previous chancre, and be inclined in his general practice to use mercury in all cases of buboes without chancre, lest constitutional diseases should ensue. There, however, does not appear any thing that should exempt the glands of the groin from enlargement, and diseases to which other absorbent glands are subject, whilst they are particularly liable to irritation and consequent disease from disorders of the urethra and other parts, to which they are connected by m,eans of their vessels. The use of mercury as a specific, therefore, in enlargement of these glands, unless they have been preceded by a chancre, must, I think, be considered as improper.

I have met with many similar cases since those five that have been related, and of

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which, from their sudden and almost simultaneous occurrence, I was induced to take a written account : within these two months I have seen two cases of eruptions and three of sore throats. The eruptions took place particularly about the hands and feet : in one case the patient has been salivated for them ; the disease, however, recurred, and afterwards got well without the use of mercury. In the other, there were warts and sores on the prepuce, and buboes in the groin, which suppurated and burst ; the eruptions so strikingly resembled those of syphilis, that all the medical men, who accidently saw the patient, exclaimed that they were so, with a confidence proportioned to their professional skill and accuracy of observation. Indeed, in this case, and in others, I have been almost impelled to use mercury, in consequence of the opinion and wishes of the patient and those of his friends. The history however of this disease did not accord with that of syphilis ; the warts had preceded the sores ; some sores healed, and others broke out ; and at last, some of the eruptions began to get well, and the rest gradually disappeared. The third patient had a sore throat for which he had been salivated ; it afterwards recurred, when it got well without mercury. The fourth and fifth had ulcers in the throat and on the lips and tongue. They all got well without mercury. One of the patients who had the sore throat had been salivated, but the disease recurred. In the other two, I forebore to use mercury, and I have reason to say they will do well without it. In one of the latter cases there were ulcers on the tongue and the inside of the lips.

If, then, the occurrence of such cases be frequent, and the necessity of discriminating them from those of syphilis be of great importance, we may solicitously enquire by what circumstances we are to distinguish between diseases so similar in appearance, but so different in their nature. Mr. Hunter seemed to wish the prosecution of this subject, probably from the expectation that some characters appropriate to these diseases might be detected : I have not, however, been able to discover any; the fictitious disease in appearance so exactly resembles syphilis that no observation, however acute,

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4 5 seems to be capable of deciding upon its nature. Although the ulcers in these ambiguous cases generally spread more extensively along the surface of the part which they affect, yet this does not constantly happen, as is shown in the eighth case. In this case, however, the induration which surrounded the chancre occurred suddenly, and went away as rapidly. The progress therefore of the two diseases was very dissimilar. *

* On the subject of induration surrounding chancres, I think it may be useful to relate the following case, and to mention that I have known similar ones in a less degree : A student in surgery showed me an indurated chancre, for the cure of which he had used a great quantity oi mercury, which had affected his mouth for a long time, though not severely. The sore so exactly resembled a bad indurated venereal chancre, that I did not hesitate to recommend him to remain at home, and rub in so as to produce a slight salivation. But as no amendment was perceived after a fortnight’s confinement, and under a considerable affection of the mouth, I was induced to enquire more strictly into the local treatment of the sore, which I found he was constantly irritating by various stimulating applications. He also affirmed that the hardness had several times gone away and returned again. By bathing the part with milk and water, and dressing it only night and morning with mild salve, the hardness quickly abated, and though he desisted from the mercurial course, it soon became perfectly well.

It must also be remarked, that true syphilitic spots and ulcers sometimes assume the appearance of other diseases, and do not possess their ordinary characteristics.

Since, then, our senses fail us in our endeavours to discriminate between these two diseases, and since the most important circumstance is to distinguish whether the disease be syphilis or not, we may enquire whether there are any circumstances in the progress of these different diseases which will serve us in distinguishing one from the other. It appears to me that there are ; and these cases are published not merely to show the frequency of such occurrences, and the necessity for discrimination, but to engage a more general attention to the means by which such distinction mav be made. A very simple fact has enabled me in most cases to distinguish between the two diseases ; yet, simple as it is, if it be generally true, it is very important ; and if it were universally true, it would be of the highest consequence. - The fact alluded to is, that the constitutional symptoms of syphilis are generally progressive, and never disappear

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unless medicine be employed. It may be added too, they are as generally relieved under an adequate effect of mercury on the constitution. An attention to such plain and simple circumstances has been of great use in directing the medical treatment which I have pursued, and I am induced to solicit the public attention to them, that others may determine the value of such remarks.

I have asked the opinion of several surgeons of great practice and abilities respecting this question ; Whether constitutional symptoms of syphilis do ever spontaneously amend ? and no one has decidedly replied in the affirmative, whilst all, without hesitation, agreed that they were generally progressive till checkedby the effect of mercury. It seemed useless to seek further information ; for what surgeon is there at present, if he sees diseases that cannot be distinguished by the sight from syphilis, and hears that they arose in consequence of a chancre, that would suspend his judgment, and forbear to administer mercury ? If I have lived in the habit of so frequently detecting the imposing appearances of the secondary effects of these diseases, it is because I have been upon the watch, and because they have occurred in patients in whom I have seen the primary sores, the appearance and progress of which have excited my suspicion as to their nature. I have stated the rule as general, but not universal ; for I could myself relate cases of diseases, in which, form the great abatement, and even disappearance of symptoms, I have concluded the disease was not syphilitic ; yet from the duration of the disorder, or from the subsequent aggravation of its symptoms, the patient has desired, and I have recommended the use of mercury, and the disease has been successfully treated as syphilitic without its real nature being ascertained.

The rule which has been mentioned relates to the constitutional symptoms of the venereal disease, for the primary ones, chancres, do sometimes heal spontaneously, generally, however, though not constantly, leaving a thickening or induration of the affected part. They may also be induced to heal by topical means, without mercury,

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with similar events. Some enlargements of glands in the groin will also in like manner subside.

It may be fairly supposed, that if some chancres heal spontaneously, constitutional diseases arising from the same cause, may, in like manner, sometimes get well without mercury. The question can only be solved by experience. Delay will, I am sure, frequently enable a surgeon to decide, that the disease is not syphilis ; but there are cases in which no amendment takes place, and the surgeon is as it were forced, from the progress of the disease, to employ mercury, though doubtful of its nature.

In recommending prudent delay and attentive observation, 1 hope and believe that I am not recommending any thing likely to be of dangerous consequences. The venereal disease is generally soon checked by the use of mercury ; and in constitutions where much medicine is required to counteract its effects, that medicine may be given with freedom. By delay and observation we perhaps may perceive that eruptions and sore

VOL. II. E throats, which could not from appearance • be distinguished from venereal, spontaneously amend: that some eruptions scale and become well, and the probability will of course be that the rest will do so likewise : or that an ulcer mends in one part though it may spread in another, when the natural inference is, that the diseased actions in the sore will gradually cease, and health return spontaneously ; and that what has occurred in one part of an ulcer will successively take place in the others.

In recommending delay it cannot, I suppose, be thought that I would advise any one to wait till an ulcer destroyed the velum pendulum palati, or did material injury to any important part. There are cases where the progress of the disease obliges the surgeon to use mercury, even though he may be suspicious that it is not syphilitic. The effect of exciting a mercurial affection of the constitution, where we feel ourselves under the necessity of employing that medicine, in diseases resembling syphilis, is, as far as my observation enables me to determine, very various. It sometimes cures them very suddenly, and very differently from the gradual amendment which it produces in truly syphilitic diseases. Sometimes, however, these diseases yield more slowly to its operation, and are cured permanently. Sometimes the diseases recur in the same parts after a severe course of mercury ; sometimes mercury merely checks the disease, and can scarcely be said to cure it ; in which case it seems important to support the strength of the constitution, and to keep up that mercurial effect which controls the disease, and can be borne without material derangement of the constitution for a great length of time. Sometimes also the use of mercury aggravates these diseases.

Again, in some constitutions, syphilitic disease may assume unusual characters, and be very difficult of cure. It must then be scarcely possible to discriminate between these anomalous cases of syphilis and those of diseases resembling it, unless some new distinctions are discovered.

But I suppress any further observation on the subject, having accomplished the inten-

e 2 tion of this paper, which was to depict a kind of cases which very frequently occurs in this metropolis, and which is, I believe, too comonly treated as syphilitic, but which may be distinguished not to be so by a little prudent delay and attentive observation. The frequent cases of such disorders which I have recently met with has suggested the idea that they are increasing of late ; nor is it improbable, since they are like syphilis, propagated by promiscuous intercourse from secretions or sores not so readily curable by mercury as those that are syphilitic, and some of which are not from their nature so prohibitory of that intercourse.

It is now many years since this paper was drawn out as a subject for discussion at a medical society; and, after such an interval, the chance of any of the disorders which are described in it returning is diminished almost to nothing. I have since met with considerable numbers of similar diseases, which give confirmation to the opinion that they are frequent occurrences. In some later cases, when the disease has been long protracted, and the patient very anxious to get resembling syphilis.

rid of it, I have given a little calomel for that purpose, but not so as to in\alitiaie the opinion that the disease was not syphilitic. Having waited, for instance, four months from the occurrence of a sore throat with eruptions, and being assured by the piogress of the disorders that they were not syphilitic, I have directed that the compound calomel pills should be taken in such doses as to controul the disease without weakening the constitution, which generally disposes the sores in the throat to heal, but I have taken care to remit the use of even this small quantity of mercury if it seemed to heal the sores too speedily ; for it seems to me better to let the disease exhaust itself than suddenly to cure it, as in the latter case it is very likely to return. In confirmation of this opinion I may mention, that, about five years ago, a gentleman applied to me to undergo a salivation for the cure of a sore throat, for which he had been salivated three times, once in each

* The pill, as prescribed in the pharmacopeia of St. Bartholomew’s Hospital, contains 1 grain of calomel,

1 grain of the precipitated sulphur of antimony, and

succeeding year. I need scarcely say that it was one of those ulcerated throats which have been described. All medicine was abstained from ; and in between three and four months the sores spontaneously became well, and have never since recurred. The whole of this paper has been written upon the presumption that diseases which spontaneously get well are not syphilitic, which is, I believe, the general opinion. It may, perhaps, be questioned by some, whether the diseases here recorded may not be modifications of the venereal disease. The practical rules of conduct will not, however, be altered, even if such a supposition were verified, so that it does not seem necessary to discuss this point : it may however be right to remark, that there are cases which would induce the belief that ulcerated sore throats, eruptions, and nodes on the bones, similar to those described in this paper, may occur from a general disturbance of the constitution, without the absorption of any infectious matter.