An essay on venereal diseases, and the uses and abuses of mercury in their treatment

Front matter

AN ESSAY

ON

^ AND THE

Preface

TO THE

SECOND AMERICAN EDITION.

Investigations relative to the nature and treatment of venereal diseases, commencing with the present century and carried on by some of the most able men of the age, have led to results subversive of the doctrines and practice hitherto inculcated by all the standard authors who have treated of this important subject. But it so often happens that innovations in medicine, though announced and received with all the eagerness and confidence of enthusiasm, are observed to sink when stripped of their novelty and specious gloss, that we are called upon to cherish suspicion as a professional virtue. It is only when this distrust becomes so great as to obscure reason and hinder inquiry, that it is to be considered as reprehensible ; for it certainly behooves us, in the present imperfect state of our science, to embrace with pleasure all such desirable improvements as have withstood the test of time, and been confirmed by the experience of the intelligent and dispassionate. Such, we think, should be the reception of the jiew principles and practice presented in this work by Mr. Carmichael, who has not only shown himself entitled to the credit due to Mr. Abernethy and other skilful pioneers, but to the still higher merit of having reduced his acquirements to systematic order.

Perhaps there may be some who will think that the editor of the present American Edition has undertaken a useless task in superadding any thing to the work of the author. Although he could, if necessary, adduce many good arguments in favour of his undertaking, he will trust his justification to a very few.

Plants of one soil usually undergo some variation when removed to another. This order of nature applies with great force to diseases, so that modes of treatment however well adapted to the climate and other circumstances of one country are not often perfectly applicable to those of another.* Some

X 1 1 PREFACE.

inoJifications will, therefore, oficn be found ^equi^ite to accommocJate the details of foreign works to new localities. For want of such adaptation, principles and discoveries have been often abandoned which otherwise might have augmented our stock of useful resources. Hence the utility of such comments as serve to point out variations, and to correct or confirm opinions and practice of foreign origin. To this task the editor felt himself strongly inclined, from having for many years followed in the same track with the author. Such in fact has been the success of his practice founded upon similar principles, that, independently of the testimony of other physicians of this country, whose more ample opportunities have added the strongest confirmation, he ventures to recommend their general adoption v»-ith unhesitating confidence. Early led to commiserate the sufferings of those unfortunate fellow beings whom he beheld in hospitals and private practice a prey to inveterate disease, and almost sinking under the remedy, plans for amelioration were naturally suggested to his mind. He had been taught to believe that the slightest ulceration or abrasion upon the genitals called for the routine of salivation, which was seldom less than two or three months, and so violent as rarely to admit of recovery without some serious local or constitutional injury, and therefore felt no reluctance in abandoning a miserable alternative when he discovered a course far more humane and efficacious. The established practice seems indeed to have fully verified the old opinion that the cure of the venereal disease, often entrusted to empirics and unskilful persons, is attended with the greater difficulty, that the repentance may be proportioned to the crime of unbridled lust and lasciviousness. That such ideas were formerly held by enlightened persons, may be inferred from the language of Dr. Paman, who, in a letter upon the subject written to Sydenham, observes that — " he seems to have been touched with a sense of humanity and sin at the same time, who openly wished that (his foul distemper might be but once cured." Although the wise and good Sydenham showed the most sincere inclination to alleviate with becoming humanity the condition of those whom thoughtlessness and greater faults had subjected to misfortune, it may well be doubted whether his meritorious intention was achieved by his scruple doses of calomel and moderate salivations of two quarts a day.

It may not be amiss for the editor to state, that so far from being inimical to mercury, he ranks himself among the truest friends to the cause of that invaluable medicine, regarding

PREFACE. Xni

those as its greatest enemies by whom it is indiscriminately and injudiciously employed. Those surely have reason to estimate its value most highly who find it can be employed with little or no inconvenience or injury to the patient, and with a certainty of its performing a cure. The popular notion of a mercurial disease superseding the venereal, he has always considered as founded in error, the specific title being generally misapplied to an aggravated train of syphilitic symptoms occasioned by the injudicious or immoderate use of mercury. As well might we call the injurious effects arising from the improper administration of Peruvian Bark, for the cure of an autumnal fever, the Bark disease. The misnomer in the one instance would not be exceeded by the other*

Among those whose authority has greatly contributed ta sanction and favour the doctrines of Mr. Carmichael on this side of the Atlantic, the name of Professor Chapman stands deservedly conspicuous. From one of those coincidences which are by no means unfrequent in the relations of this and the mother country, he was early induced by the course of his inquiries to adopt and publicly inculcate in this city, views relative to venereal diseases very similar to those subsequently promulgated by Mr. Carmichael. The first edition of this work was gladly received, and promptly ushered before the public by him. In his preface, he expresses his gratification at the support it afforded to his sentiments, hitherto regarded as abominable heresies, and recommends it in strong terms to the students of the University of Pennsylvania. The value of the present work is greatly enhanced by a very considerable accession of original matter, the new and improved arrangement of the materials, a useful synopsis, additional plates, and what is of no less consequence, the increased weight to which the doctrines are entitled, from the ten years experience which they have since received. The editor has endeavoured to make the American copy more convenient as a book of reference for the practitioner and student, by the addition of a copious index, and the introduction of practical notes wherever the text appeared to be deficient in detail.

G, EMERSON.

Philadelphia, November, 1825.

Chap. VII

Diseases most likely to be confounded whh those of Venereal origin. — Synopsis of the Work * 341

AN ESSAY

ON

AXD

THE USES AND ABUSES OF MERCURY

IN THEIR TREATMENT, &c.

CHAPTER I.

OBSERVATIONS ON THOSE MORBID POISONS WHICH STAND IN NEAREST RELATION TO THE SYPHILITIC, AND EVI- DENCE OF THE EXISTENCE OF VENEREAL DISEASES WHICH DO NOTARISE FROM THAT POISON

It is a curious fact, that morbid poisons, which excite considerable fever, such as the small pox and measles, yield to the powers of the constitution, and are capable of a spontaneous cure, while, on the contrary, the poison of syphihs, which produces scarcely any fever, or one so low as in general to escape observation, yields so slowly and imperfectly to those powers as commonly to require, for its extinction, the intervention of art. In the former instance, the increased action of the system is suffi-

MORBID POISONS.

cient to overcome the poison ; but, in syphilis, it seems to be nearly, if not altogether, insufficient. Thence, it would appear, arises the necessity, in this disorder, of artificially raising an action by means of mercur}?^ ; which, though capable of superseding the influence of the poison, does not, however, extinguish, like the natural fever in small-pox, the susceptibility of receiving the disorder again.

From the accounts we have had of the yaws, a disease common among the African slaves in the West Indies, it seems to arise from a poison which holds a middle station between those of small-pox and syphilis, and has many symptoms which resemble those of both disorders. It may be suspended, but cannot be cured by mercury, or any other remedy as yet discovered ; and the unassisted powers of the constitution, after a struggle of many months, at length subdues the poison, and the patient loses afterwards all susceptibility of the disease. The pustules in small-pox and yaws, we are told by Doctor Adams, in his observations on a case of the latter disease, are much alike;* each begins with a pimple, the law of each is to induce a slough, and each has its period and decline ; the powers of the constitution being in both equal to the cure. The constitution is susceptible of either but once during life ; but the chief difference between them is in the slower progress of the yaws, which commonly continues for many months before it is exhausted.

*See Adams on Morbid Poisons, 2d ed. p. 196.

THE YAWS.

The ulcers of the throat which attend this disease, resemble those of syphilis so nearly, that, according to the same practitioner, it is impossible to distinguish the one from the other; and this circumstance and the pustular eruption of the skin, which resembles that of small-pox, would lead us to class it as the connecting link between syphilis and small-pox, in the chain of contagious diseases.

Dr. Bateman observes, in his Synopsis of Cutaneous Diseases, " that the practitioners in the West Indies soon learned by experience, that active preparations retard the natural progress of the yaws, and that mercurials, although they suspended it, and cleared the skin of the eruption, yet left the patient still susceptible of, or rather, still impregnated with the virus ; which speedily evinced its presence by a re-appearance of the symptoms more severe and tedious than before. In truth, the disease, it would seem, like the pustular and exanthematous fevers of our own climate, will only leave the constitution after it has completed the various stages of its course, and removed the susceptibility of the individual to future infection ; and no medicine, yet discovered, has had any influence in superseding this action, or in accelerating its progress. Unless, therefore, any urgent symptoms should require alleviation, (which seldom or never happens,) it is adviseable to dispense with the administration of medicine, and to be content with restricting the patient to a moderate and temperate regimen, during the first stage of the malady. When the eruptions begin to dry, or as soon as they

4 THE YAWS.

cease to multiply and enlarge, the disease seems to require the same management as other slow and superficial ulcerations, accompanied with a cachectic state of the system ; viz. a light but nutritious diet, a dry and wholesome air, warm clothing, moderate exercise, and a course of tonic medicine, especially of sarsaparilla and cinchona, with the mineral acids, or with antimonials, and small doses of mercury, according to the circumstances of the individual habit. The effects of mercury, however, exhibited so as to excite salivation, as the early West India practitioners recommend, seem to be of a very questionable nature, especially when it is unaccompanied by the vegetable decoctions ; and, it is certain, that patients have, in some cases, soon recovered under the use of the latter, when the mercurials w^ere omitted. The native Africans employ decoctions of the bark of two or three trees, which are gently purgative as well as tonic; and likewise wash the sores with them, after carefully removing the crusts."^

Such are the observations on the yaws, which Doctor Bateman has collected from the writings of Doctor Winterbottom, and other medical men, w^ell acquainted with the disease in the West Indies. Upon reading them, I was forcibly struck with the strong coincidence which exists betw^een that di sease, and the constitutional form of some of those complaints which have been hitherto confounded with syphilis. This coincidence is not only striking, with re-

* Dr. Batemaa's Synopsis of Cutaneous Diseases, p. 313.

SIVVENS.

gard to their form, the eruptions being alike composed of papulae and pustules, and attended with pains in the joints ; but also, in the circumstance, that, like the exanthemata, they will run their course, and not relinquish the constitution till they have completed their various stages. This is a remarkable fact, and will be elucidated in the course of this work, by the statement of a great variety of cases. We shall find that the exhibition of mercury, in those resembling diseases, produces the same effects as when prescribed for the yaws, viz. it may suspend the disease and clear the skin of the eruption, but will leave the patient still impregnated with, the virus, which evinces its presence as soon as the mercurial irritation has subsided, by a re-appearance of the eruption, or affections of the periosteum bones, and other deep-seated parts.

It is supposed by many that sivvens, a disease endemic in Scotland, is a peculiar modification of syphilis; but Doctor Adams who took particular pains to investigate the nature of this disease, and visited Scotland for the purpose, is of opinion that it is different, although approaching nearer to it than any other morbid poison with which we are acquainted. The primary ulcers of the two diseases have this difference, that the syphilitic are attended with a callous edge and base, and sivvens consists only in the clean phagedenic ulcer. In this particular, as well as in several others, it appears to bear a very close resemblance to that form of venereal disease which I have termed phagedenic.

The eruption is pustular, and hardens into a dark

SIVVENS.

brown crust. In syphilis we shall find that the eruption is scaly. Another circumstance universally admitted, with respect to sivvens, in which it differs from syphilis, is, that it never attacks the bones but by the extension of an ulcer of the soft parts in their vicinity.*

The primary symptoms of sivvens, we are informed, usually take place on the lips and mouth, the disease being commonly communicated by drinking out of a vessel, or smoking with a pipe which had been previously used by a person infected ; and Doctor Adams remarks, that the ulceration can hardly be propagated, like syphilis, by the genitals, on account of the rapidity of the primary ulcers, which are attended with high inflammation. But, before we discard the supposition of its being disseminated by sexual intercourse, we should recollect, that phagedenic ulcers, attended with high inflammation, are every day to be met with on the parts of generation.

When we consider the constant communication that exists between the people of that part of Scotland where the disease is most prevalent, and the inhabitants of the north of Ireland, it would be extraordinary to believe that the disease has not been communicated to this country : and, in fact, I am informed, by a medical friend, well acquainted with sivvens, that he met with many instances of it in the county of Antrim, but particularly in Belfast. It cannot be supposed, that the disease would re-

* Adams on Morbid Poisons, p. 187.

CANADIAN DISEASE. 7

main confined to the north of Ireland, if once admitted into it; and I long suspected, that cases of sivvens were to be met with every day in the Lock Hospital of Dublin, as I had observed many patients whose symptoms strongly resembled those which were pointed out to me in the hospitals of Edinburgh and Glasgow, as constituting that disease. These conjectures were afterwards verified ; for in the summer of 1812, Doctors Hamilton and Heenan, of Glasgow, visited the Lock Hospital with me, and recognised the disease as that with which they were well acquainted in Scotland. The disease w^as in its constitutional form, and exhibited a good number of ulcers about the size of a shilling, covered by large brown irregular crusts, and accompanied by a few pimples and pustules.

This eruption disappeared under the use of solution of corrosive sublimate, and decoction of sarsaparilla; but, the above-mentioned practitioners informed me, that though the disease may be suspended by mercury, it will return after the most protracted courses of that medicine ; an event which I have myself witnessed in more cases than one in the disease, which these gentlemen recognised as sivvens.

There is a very imperfect account of a disease nearly resembling sivvens, by Doctor Swediaur, which made its appearance in Canada, shortly before 1785, and became so general in that year, that five thousand eight hundred persons were discovered to be infected with it, besides many who concealed the disorder. The disease, we are informed,

8 CAx\ADIAN DISEASE.

from the statement of a Mr. Bowman, " first manifests itself by little ulcers on the lip, tongue, and inside of the mouth. These ulcers are of a very corrosive nature, and were observed in many children to have nearly destroyed the tongue. They first appeared in the form of little pustules, filled with a whitish purulent matter; the poison of which is so infective, that it communicates by eating with the same spoon, by drinking out of the same vessel, by smoking with the same pipe, na}^, it is even observed that it is communicated by linen, clothes, &c." We are also told that it seldom affects the genitals, and that, like the small-pox, " it is capable of being: communicated without immediate contact or coition." — " Children form a large proportion of the infected."

The constitutional symptoms of this disease have a near resemblance to those of syphilis, sivvens, and the yaws, and chiefly consist of "buboes in the axillae, groin, or throat, which sometimes inflame and suppurate, and at others, remain hard and indolent." Also "tetters, itching crusts, and ulcers, which appear coming and going in different parts of the body." " Pains in different parts, which increase during the night time, or when the patient takes some violent exercise." — " The bones of the nose, palatum, cranium, clavicula, tibia, arm and hand, grow carious, or tophi appear in several parts of the bones ; at last, pains of the breast, cough, loss of appetite, sight, hearing, smell, and falling off of the hair, close the scene before death." The disease we are told is contagious in all its stages, and may continue to

CANADIAN DISEASE. 9

harass the patient for many years ; but it is worthy of observation, that Mr. Bowman saw some children who recovered without the aid of medicine.

The mode of treatment is very imperfectly detailed. We learn " that dock and burdock roots, sarsaparilla and spruce have been generally made use of, and with some appearance of success : most success, however, has been observed from a decoction of the branches of hemlock spruce, (a tree so called on account of the resemblance of its smell to hemlock;) but we are afterwards informed, that none were cured radically without mercury, and that it is necessary to continue that medicine three weeks after all symptoms have disappeared."*

From the whole of the information to be derived from the imperfect account of this disease in Doctor Swediaur's work, I should be inclined to infer, that, like the yaws and sivvens, it is capable of yielding to the powers of the constitution, and that mercury is only of service, when the disease is on the decline, and has begun to yield to those powers. For if that medicine was capable of curing the disease, with the same certainty as attends its employment in syphilis, we should not find those vegetable remedies resorted to in the first instance, which, according to Mr. Bowman's account, greatly forwarded the recovery of the patients; yet it seems they were not radically cured without the assistance of mercury, although in another place, we are inform-

* Practical Observations on Venereal Complaints,, p. 169,

B

10 LEPRA SEPTENTRIONALIS.

ed, that some affected with the disease, recovered without the aid of that medicine.

However, the circumstances detailed, I conceive, afford sufficient grounds to conclude, that the Canadian disease is not syphilitic, but that it is another instance of a contagious malady which commences with ulceration, and is followed by bubo, eruptions, and ulcers of the skin, pains, nodes, and caries of the bones. A train of symptoms very generally supposed to appertain exclusively to the syphilitic poison, but which, as I hope to convince my reader,^ may derive their origin from primary ulcers which are not syphilitic, and are still more common in this country than syphilis itself.

There is another disease similar, if not identical with sivvens and the Canadian distemper, which infests the maritime parts of Norway, some provinces of Sweden, and the northern parts of Russia. It is also found, as we learn from Callisen, on the shores of Iceland, in all the Feroe Islands and in some provinces of Scotland. This disease, which is called radesyge by the Norwegians, and is denominated lepra septentrionalis by Callisen,* commences with the premonitory symptoms of lassitude, want of appetite, severe pains resembling those of rheumatism, rigidity of the limbs, dyspnoea, and violent headach; the face either assumes a singular shining silvery appearance, or a deep red or livid colour. These feverish symptoms may continue for many

LEPRA SEPTENTRIONALIS. 1 1

maiiths, before the formidable train of maladies to which they are the prelude, ensues. A dry branny efflorescence of the skin first takes place; the regenerated cuticle gradually becomes more rough and thickened. In many patients there occurs an eruption of small spots of various colours not larger than flea bites. These appearances are, however, but the precursors of copper-coloured tubercles or knots on the skin, and herpetic spots on the forehead, nose, chin, lips, and eyebrows; afterwards they become scattered over every part of the body.

The integuments of the forehead become thickened and corrugated, the eyelids swell and are everted, the bloated cheeks assume a livid colour, in fact the entire countenance becomes frightfully distorted. The spots afterwards degenerate into malignant ulcers, which even extend to the bones underneath, and render them carious. Every part of the fauces is also liable to be affected with similar tubercles and ulcers which extend to the nares. The bones of the palate and nose soon become carious. Frightful deformity ensues; and the patient, exhausted by so great an extent of disease, dies of hectic fever.

Such is the account of a malady which has long ravaged the coasts of the northern peninsula. It has of course attracted the particular attention of the medical men of Norway. I have had the advantage of conversing with a respectable member of that body. Doctor Hoist of Christiana, when he visited this city a few years since, on the subject,

12 LEPRA SEPTENTRIONALIS.

and from whose accurate work* I have chiefly taken the above detail.

It is not considered by him, or I believe by any of the numerous authors who have written on the subject, as arising from sexual intercourse, but is attributed to the mode of living followed by the northern Swedes and Norwegians, but more particularly by the fishermen inhabiting the coasts of these high latitudes. Indeed he draws a picture not very inviting of rural life in this part of the world. Their houses or huts are low, damp, and rarely consist of more than one apartment, in which the entire family (with the smaller domestic animals of the establishment) remain for many days and nights together, and in which they eat, drink, and cook their victuals. Into these wretched hovels the air is never intentionally admitted, the windows, which are scarcely pervious to the light of the sun, being always closely bolted down. The fishermen returning from their laborious occupations in these rainy and stormy regions hang their clothes soaked in wet, or embued with the filth of fishes, to dry in their smoky huts, which still adds to the impurity of the air. The food of the inhabitants is of the most rancid description, and consists chiefly of salt dried beef and pork, and too often semi-putrid fish. They have no esculent vegetables; and are frequently under the necessity of using in place of bread the pulverized bones of fishes, or the dried

LBPllA SEPTENTRIONALIS. 13

fish itself, mixed with the bark of trees or with Iceland moss.

Is it then to be wondered at that people leading such a life, living on the most rancid, indigestible food, breathing a pestilential atmosphere, and filthy in their persons, should suffer the necessary consequence of such habits in the attacks of the dreadful disease in question ?

The chief part of Dr. Hoist's work is occupied with a consideration of the best mode of averting this evil, and it consists of course in recommending ventilation, cleanliness, bathing, and the cultivation and use of esculent vegetables.

We learn from Callisen, that the disease admits of cure during the first stage, before the eruption occurs, and even afterwards, under favourable circumstances. The methodus medendi consists in removing all the causes of the disease enumerated; the use of baths, and a milk and vegetable diet, with fresh animal food. With respect to medicine " cicuta, trifolium fibrinum, cortex ulmi, rosmarinus sylvestris, evacuentia leniora, et antimonialia," are those he recommends. As to mercury, he observes, that carried to the extent of salivation, it always proves injurious; and that all external repellents are to be strictly avoided, as they drive the disease from the surface to the more important internal organs.

Doctor Hoist, from the circumstance that this disease begins with fever, which ushers in an eruption, conceives that we would be right in classing it with the exanthemata, were it not for its tedious-

J 4 BUTTON SCURVY.

ness; and therefore places it between the exanthemata and cachexiae.* I leave this objection for others to consider ; for my own part, since it possesses the true essentials which characterize the exanthemata, — fever followed by eruption, — I should feel no hesitation in placing it amongst them.

It appears to me extremely probable that sivvens is the same disease, rendered milder by the improved habits of the peasantry of Scotland, and the use of vegetable aliment ; and that this is the distemper to which Callisen alludes, when he says that the lepra septentrionalis is found in Scotland.

There is an eruption, peculiar, I understand, to this country (Ireland,) termed by the natives the Button Scurvy. It has not, I believe, been mentioned by any medical writer, and certainly has not been noticed by either Wilian or Bateman. It is so general that I am seldom without a case or two of it in the hospital ; but never yet saw an instance of it in the better ranks of society; nor even among the manufacturers or artisans who live in the city. In the instances I have seen, as far as my recollection extends, it was only found among the peasantry" engaged in agriculture. The spots of this eruption are convex iubercles, varying from the size of a split pea to that of a shilling, seldom so large as half-acrown ; they exhibit an appearance somewhat like the surface of a raspberry, and discharge a white tenacious matter, which forms thin yellow crusts,

ON DISEASES RESEMBLING SYPHILIS. 15

that are in general rubbed ojff by tlie patient's clothes. The spots are seldom seen on the face, but are scattered over the trunk and extremities, and are almost always observable on the inside of the thighs, or close to the axillge. The general health does not appear disturbed ; but whether it is ushered in by pyrexia, I have not ascertained, not having witnessed any case at its commencement. This disease, which continues for months, nay, years, on the same individual, is generally cured by the use of the tepid bath, and the exhibition of pitch pills, in as large doses as the stomach can bear, in the course of six or seven weeks. I notice the disease here, because the eruption might be readily mistaken by those unacquainted with it, for that which attends the phagedenic venereal disease ; and because I believe that no account of it has as yet been published. As it is found only in one class of society, it is probably owing to the peculiar habits of that class ; and the smoky, unventilated, and filthy state of the habitations of the majority of the peasantry of this country, with inattention to personal cleanliness, may well account for the presence of any chronic cutaneous disease. Whether or not it is infectious I am ignorant ; but believe it is not, although it is generally thought to be so by the country people.

The organs of generation are subject to a variety of ulcers, destitute of the characteristics of chancre — the hardened edge and base ; yet most practitioners look on them as chancres, and treat them as such, imagining that inflammation, peculiarity of consti-

16 GENERAL OBSERVATIONS

tution, or some accidental circumstance, has deprived them of the usual character of the primary syphilitic ulcer.

To discover whether chancres may be altered by peculiarity of constitution, or accidental causes, we should look to the analogous symptoms of other contagious diseases, and inquire, whether the pustule of small-pox, or the vesicle of cow-pock is^ ever so altered, as no longer to display the characteristic marks by which they are distinguished the one from the other, and from all diseases with which they might be confounded.

It must be admitted that these diseases are obedient to certain laws, from which there is seldom or ever any departure ; and if any deviation does occur, it is not sufficient to deprive the disease of those characteristics by which it is distinguished from other disorders. Thus, small-pox is seldom so varied from its usual appearance, as to be mistaken by any practitioner of experience for any other disease. It is the particular law and character of the small-pox poison, as Doctor Adams remarks, to form a slough under every individual pustule, and this essential property of the disease is never wanting. We never find, says that accurate observer, the pustules running into phagedenic ulcers, or throwing up a callous edge and base like chancre. If the disease is in excess, as when the pock is confluent, the character of the poison is only more strongly heightened, and the sloughs become more extensive.