- Email: [email protected]
CLINICAL LECTURES AND REMARKS,
747
in the nervous system. Every thing in thegreat eloquence, all the audience wept; but air one could deny or affirm at will oi11 respect for the law," prevailed, and he was pleasure, or make use of subtleties to con.condemned to death. Here are the heads.of some parricides. See trovert an opinion, so long as the organs are’ perceptible to the senses. When one findshow meagre is all this upper region. Refer an organ for that faculty in the middle ofto LACENAIRE, or FIESCHI, and you will find others which correspond with different feel-that the predominances there are neither in ings, how can you object to the conductthe really superior feelings nor in the intelbeing in accordance with the organization?lect. There is, indeed, a little veneration One may deny the facts, as is practised atthere ; but conscientiousness is particularly the present time, but the line of observationswanting. It was SPURZHEIM who discovered is traced, and every one in going over it may this organ, and I consider that this discovery was one of the most important facts for moraverify them. Examples.-These are found in the ma- lity ever made, and phrenologists have not jority of superior men, who have always the hesitated to admit it. Here is the head of same kind of head. Here is the head ofFIESCHI, and you find in it an inclined slope CHARPENTIER, who, in fact, unites all the from behind forwards, on the summit of the mass of organs combined with conscientious- head, because all the organs of the middle ness. All superior heads are in the same and anterior regions are depressed. There condition. Observe that of MANUEL, and remain behind, self-love, with a little selfothers, for instance. Where conscience is esteem, with the passions and destruction wanting, the protuberance of the region which more or less on the sides ; that is to say, an corresponds with that faculty, does not sur- intellect governed by the baser instincts. Animals.-As to these, all the phrenolopass the neighbouring organs, or, rather, it is replaced by a depression. When, on the gists whom I know deny them this faculty. contrary, conscience exists, the protuberance However,I think myself that the outline of is prolonged, and the organ is found on a this feeling exists in the elephant, the dog, level with self-esteem and circumspection. and even the horse. When these animals are In the head of BAGNOL you see a sort of de- ill-treated without cause, they distinguish pression which seems to, but which really does the injustice. They are, to a certain point, not, correspond with the seat of this organ. like children. Children, even when very It rather occupies the seat of hope. young, know when a person is guilty of inWhat is most important in the organization justice towards them, and show it by rebelof an honest man, is the mass formed by the ling, while they submit if they feel that a just union of self-esteem, the love of the esteem of chastisement is imposed upon them. I have others, conscientiousness, and veneration ; for myself a belief in the existence of an outline a certain quantity of veneration is necessary of this feeling in those animals whose brain to complete a fine head. Here is the head of has some relationship with ours. Our next Foy, who was the idol of the Liberal party. subject will be -Hope. We have not fabricated all these heads on purpose; yet their forms are always found in accordance with their actions. Here is CLINICAL CASIMIR PERIER. The same concordance is AND REMARKS, LECTURES presented in it. We could refer to many such DELIVERED ON heads amongst living men, but, unfortunately, we cannot exhibit them to you in a theatre. DISEASES OF THE SKIN, VENEREAL You will not find a brigand in whom this mass DISEASES, AND is predominant. See, in fact, (shewing a SURGICAL C A S E S, bust) how meagre is this region, how hollow AT THE is the top of the head. It becomes a cave. I have in my possession forty heads of crimi- SKIN INFIRMARY, AND AT THE JERVISSTREET HOSPITAL, DUBLIN. nals, in almost all of whom this conformation strikes the eye. There are some varieties, ’, BY DR. WALLACE, but in not one of them does the group of good SURGEON TO THOSE INSTITUTIONS. feelings exhibit an average breadth at the crown of the head. These facts are valuable. EXANTHEMATIC VENEREAL ERUPTIONS. Jokes, and other ill-timed pleasantries, cannot THE primary exantheme, of which I spoke them. Here is the unfortunate destroy DODD, who was hung for having wished to oblige a at our last meeting, is, as I have already friend by forging a signature ; but he had said, followed by constitutional symptoms more certainty than the primary pustule. neither conscience, nor self-esteem, nor circumspection. But his is, notwithstanding, a Itveryseldom, indeed, happen s, if the disease allowed to run its course, that the former truly classical head. You see what organs should have predominated in him, and go- is not succeeded by an eruption; whereas verned his actions, and that those parts which the latter very often occurs without causing we study, possessed less action. In deliver- any constitutional symptom. This fact is ing the judgment on this man, who possessed the more remarkable, as the power possessed
with be
748
by the exanthematic virus of producing a pri- These larger spots are only modifications of marydisease, is inferior to that possessed by the smaller, for, if their growth be watched, the pustular virus. Hence, the direct ap- it will often be found that they are formed plication of the exanthematic virus often by a coalition of a number of the smaller produces no effect ; but, if the primary symptom be once produced, the constitutional symptom almost always follows. The period at which the exanthematic eruption succeeds the primary exantheme, is subject to as great variety as that at which the pustular eruption succeeds the primary pustule. But the exanthematic eruption follows its primary symptom, in general, more rapidly than the pustular eruption follows the primary pustule. The character of the symptoms of invasion, or of those constitutional symptoms accompany the exaiitheare, ceetei-is paribus, milder than, but of the same kind as, those which correspond in the same manner to the pustular eruption. The characters of the spots which constitute the exanthematic eruptions, are various, and, on a superficial view, very dissimilar. The only appearance or symptom constantly and necessarily attendant on them is a state ofhyperasmia, and consequent discoloration of the part affected. I say that this is the only essential symptom, because there are some varieties of the eruption which have no other, and because all its varieties have this. Of some, the state of hyperaemia constitutes only the first stage ; of others, the whole appearance. This appearance gives t3 the skin, in some cases, a mottled aspect, not unlike that observed on the front of the legs of persons in the habit of sitting over the fire. At other times, the discoloration is extremely like measles, and at others not unlike ephelis, rarely like erythema or roseola. It is sometimes in small spots, and sometimes in large which matic
precede and
eruption
orlentigo,more
patches. In the mildest form of the exanthematic
eruption, the discoloured spot is neither elevated nor tumid. There is a simple discoloration, which gives to the part a measled More frequently, however, appearance. there is someelevation or tumidity; but the character of this elevation is subject to great variety. For example, the form, the depth, the relief, the extent, the colour, are widely different in different cases ; and each of these varieties is wen deserving of consideration. The mildest form of elevation which the eruption presents has somewhat the appearance of those elevations which form the eruption, called byWILLAN, strophilas, or it may be compared to those which occur in the state of skin called 11 cutis anserina," or ,ose-slcin. These small elevations are placed on a slightly inflamed ground, and their centre is of a darker colour than their circumference. This form of elevation is not unfrequently intermixed with one of a larger size, vhi_h is flat on its surface and superficial.
on their decline, we find that they resolve themselves, before disappearance, into the more minute spots. To this it may be added, that we often notice the large spots to be evidently formed by a group of the smaller. Although this larger elevation in general occurs in combination with the smaller, I have often seen the former without the latter, and then the eruption very much resembled the wheals of ur. ticaria, being composed of numerous red spots, varying in size from a small to a very large pea. At other times, I have seen an eruption of the larger elevations succeed an eruption of the smaller. When the larger eruption is on the decline, it produces an appearance like BATEMAN’s plate ofVitiligo; and I believe that the disease described by him under this name is a venereal eruption. In neither of the preceding forms of elevation does the tumidity, upon which the elevation depends, sink into the cutis; and even when the spots are of a considerable thickness, this thickness is raised on the surface of the cutis, and does not go downwards, or into its substance. The elevations which I have just alluded to are in general numerous, and scattered We sometimes, over the whole surface. however, notice, limited perhaps to one or two regions, flat elevated patches, which vary in their size from that of the end of a finger to that of the palm of the hand. These patches of elevations enlarge by additions to their border, and, increasing in one direction, while they shrink in another, often traverse a great extent of surface. All the elevations of which I have as yet spoken, are either flat or pointed on their surface ; but there are other superficial tumid exanthemes, whose form is almost exactly spherical. These are sometimes, as well in form as in colour, extremely like red or black currants. There is a form which the exantheme!Þt times presents, and which, although fiat on its surface, seems to go so deep as to involve the texture of the cutis. It is, for the most part, broader and flatter than the one just n entioned. I do not know any common or ordinary diseases of the skin which it resembles. It, however, forms the transition from the more superficial to the more deeplyseated exantheme. In the remaining varieties of the tubercular exantheme, the deeper-seated parts of the skin seem to suffer more. In them the swelling is very often considerable; but in place of commencing, as in the examples already mentioned, on the surface of the skin, and never appearing to go deeper than its
elevations ; and,
substance, they seem to commence so deep, that it might be supposed they were seated
749
uader the skin. case, and
care
This is not, however, the face more rapidly than at their circumfermust be taken not to con- ence. The patch is thus formed into a cup,
found them with a symptom of syphilis or into a simple ring, according as it was, which forms, in the sub-cutaneous cellular in the first instance, tumid or otherwise.
tissue,tumoursortubercles,that subsequently approach the surface and ulcerate.
The exantheme, whether tumid or not, may disappear without producing or leaving after it any other symptom or appearance, If the exantheme be a simple discoloration, the original discoloration may change into another; that is, from being more red, it may become more brown. Even the tumid exanthemes may shrink away, and leave after them merely stains, which may contiIn some nue for a longer or shorter time. cases, these stains are of a colour so tawny to look not unlike that of a piece of singed paper. The venereal exantheme often desquamates, or throws off a succession of cuticles; and it is of importance to attend to the form of these layers of detached cuticle; for they afford a means of distinguishing between an exanthematic and a pustular eruption on its decline. In the exantheme, the scale covering the spot forms a disk. This disk has a circular edge, and it can by this edge be often pulled off the surface on which it lies. If the exantheme be not covered by this disk, it is covered merely by a kind of branny scurf. Now, the pustular spot, when scaly, in general desquamates in circles ; and although these circles somewhat resemble the circles formed by the disks of the exanthematic scale, they can be easily distinguished by the aspect or direction of their circular edge. In the exanthematic disk, its aspect is peripheral, and in the pustular, central. The cuticle of an exanthematic patch may be detached by an effusion under its surface, and thus form a vesicle or bulla. This is a rare form of the venereal exantheme. It is, however, to be observed; and when it occurs the eruption resembles sometimes pemphigus, sometimes herpes, sometimes eczema, and sometimes varicella, as I have seen in different cases. We find, and particularly under the influence of certain localities, that the exanthematic patch, whether tumid or not, will occasionally exude secretion from its surface, or else from a fungous growth, which may acquire a very considerable magnitude. This exuding and fungous state maybe preceded by desquamation or vesication. Exanthemes which have desquamated or vesicated, or which have formed fungous or exuding surfaces, may gradually become healthy, or may form ulcerations. When they become healthy without ulceration, they never leave any cicatrixes behind, though they may leave stains, which continue for a very long period. Exanthematic elevations and discolorations, whether fungous or desquamating, oftentimes shrink in the centre of their suras
The cup is very remarkable in some cases of tubercles. These I have called the cupped tubercles. The ulcers which the exanthematic patch forms, cannot, for the most part, be distinguished from those which have been preceded by pustules, unless by the manner in which they have been developed, or by the nature of the spot which preceded them. They are, however, in general, more superficial, considering their extent, than those ulcers which have been preceded by pustules, but, like them, they are characterized by the whiteness of their surface. This whiteness is often greater at their circumfe rence than at their middle, and is owing to a stratum of matter of a lardaceous aspect. This matter is sometimes pultaceous, and then it is generally greenish ; but, as I have already said, whether it be white or greenish, it is the original organic texture in a state preparatory to its separation from the body, and not, as is generally supposed, a lymph effused on the diseased surface. The exanthematic, as well as the pustular ulcers, may be covered by either of the two forms of crusts, which I have described, by that which is produced by indurated discharge, or by that which is formed by a desiccated slough. The latter kind of crust is more rarely to be met on the exanthematic than on the pustular ulcers. The exanthematic sores are often, however, covered by crusts formed of indurated discharge, which are so regular and so conical that they strongly resemble the truly limpet-shaped crust, which is always formed of indurated
slough. The exanthematic
eruptions,
in
their
arrangement or collocation on the surface of the skin, present varieties very analogous those presented by the pustular eruptions. the spots which form the eruption, may be either scattered, or grouped, or in circles. The grouped, or circular arrangement, is perhaps oftener to be met amongst the exanthematic than the pustular. This character is very frequent in those exanthe., matic cases, in which there have been relapses; and I have often had occasion to remark, that the exanthematic disease, though at first of the scattered form, presents in its relapses the grouped character. We observed, in speaking of the pustular eruptions, that in their relapses, the spots were often in groups, although the earlier eruptions presented the scattered arrangement. We also remarked, when speaking of the cicatrization of the pustular sores, that it sometimes commenced at one side, while the ulcerating process continued at the other. We observe the exanthematic disease to present analogous changes ; and to
Thus,
750
when ulcers are not formed. Forwhen great attention to cleanliness is not an exanthematic patch often be- given, may be the seat of very painful sorecomes well in the centre, or at one side, ness and stiffness, particularly at night, and while it extends at the other, or at the cir- after exertion. The uneasiness which atcumference. There are hence produced tends the other forms of the exantheme, is, patches, which have often very remarkable in general, an itchiness. This is sometimes appearances-sometimes they resemble a very troublesome. I have known severe cup-sometimes a circle-sometimes a itchiness, with discoloration of the skin crescent, but all their appearances, however round the anus, to form of itself the only diversified, are analogous in their nature, symptom, in a case of constitutional syphilis, and depend up:;n the principle, that the which followed the primary exantheme;at diseased patch gets well, or better, in one least this itchiness and discoloration yielded part, while it spreads in another. This is a to the same treatment which would have law of progression, which is followed by removed them if they had been symptoms of many other eruptions as well as by venereal the exanthematic form, that is, to mercury. diseases of the skin. Notwithstanding the varieties of appear. There are some remarkable differences in ance which the exanthematic venereal direspect to the situation which the exanthe- seases of the skin present, there exists the matic eruption occupies, as compared with most satisfactory proofs that they are all that occupied by the pustular eruptions. simply modifications of the same state. I have never observed the pustular eruption Thus, in the first place, we may frequently on the palms of the hands, or on the soles observe all the appearances which I conof the feet, but those parts are very fre- sider exanthematic, on the same patient, at quently the seat of the exantheme; and the same time; or, on the same patient at there it causes either deep cracks, named different periods, but resulting from the rhagades, or spots, which detach scales in a same infection. The stain, the scaly tucircular form. The pustular eruptions do bercle, and, scaly patch, the rhagade, the not seem to have any predilection for the ulcerating tubercle, and patch, daily occur anus, or for the genital organs; but the together. It is more rare to notice the exantlaematic eruptions very often occur in vesicular and bulbous venereal eruptions those regions; and are sometimes to be united with the other forms; but this is found there, when they are in no other part. owing to the rarity of these varieties of At all times they are perhaps more nu- disease. In the second place, there are merous on these, than on any other parts. certain circumstances under which one or The exantheme frequently occurs between other form of the exanthematic eruption the toes, under, or at the edge of the nails, alwaysoccurs, and never the pustular, as, in the angles of the lips, in the angles of for example, when the mother communicates the eyelids, and in the angle which the nose the venereal disease to the foetus in utero, forms with the cheek. When it occurs at when a contaminated foetus communicates the nail, it very often causes its exfoliation; the disease to a healthy nurse, and when and when in any of the other situations, the disease is contracted by a sound person those linear ulcers, called rhagades, are coming in contact with a person labouring produced. Now the pustular eruptions under constitutional symptoms of syphilis, whether pustular or exanthematic. It has very seldom attack any of these parts. The colour of the exanthemeis, is general, been, particularly in infants who have cona redish brown, particularly when on the tracted the disease in utero, that I have decline. On its first eruption, however, it noticed the bullous form of the exantheis not unfrequently of a bright red or crim- matic s philitic eruption, and traced its It is sometimes a more pale relationship with the other exanthematic son colour. red, and sometimes more yellow. It is also eruptions. Its more frequent occurrence at occasionally of so dark a brown as to this time of life, in a great degree, probably depends on the anatomical state of the approach to black. The exanthematic eruption is as variable ftietal skin. In the third place, if any adin quantity as the pustular. Sometimes the ditional proof were wanting of the conwhole body is thickly covered; and at other sanguinity of the varieties of the exantheme, times, there are only a few scattered spots it is afforded by the results of experiment, on some particular region. Thus, we find for the secretions from these eruptions unithis
even
axample,
which present no other traces of it crack at the angles of the lips, or a rhagade between the toes, or an onyxis, or a condylomatous slate of the anus ; while, at other times, the face, the trunk, and the extremities, are thickly covered. The degree of sensibility or pain attendant on the exanthematic eruption, is seldom considerable; yet the ulcers, and the excrescences, and the rhagades at the toes, cases
than
a
formly produces, by inoculation, when it succeeds, one of their own varieties of disease, and no other. In fact, both the primary and the secondary symptoms which follow inoculation in these cases, always belong to the exanthematic group symptoms.
C
751 sent ? On several occasions they are evi- vesicle, or tubercle, the link which connects dent. On others, they are more conjectural. the exantheme with the pustule. Some of The influence of situation and structure in the phenomenon presented by contaminated producing modifications of the exantheme infants supports these opinions. If a female is very considerable. Upon the iniluence contracts syphilis while she is pregnant of situation, in a great measure, depends and hence infects with a constitutional disthe fungus, and the rhagadi; and to it, the ease her foetus, the symptoms presented by onyxis is entirely owing. The fungous ex- the foetus will have more alliance with the antheme occurs on surfaces opposed to other pustular group than if the mother had been surfaces, and rich in the sebaceous appa- for a long period the subject of constitutional ratus. Hence they are frequently seated disease, and consequently than if the poison round the anus, on the great labia, on the was of a more exhausted kind. The foetus scrotum, on the angle between the labia or will also be more likely to be dead-born, or scrotum and the thigh. But, although they to be born with symptoms of the disease, are seen in these parts, when they are not to than if it had been contaminated by a more be observed in others, they are sometimes exhausted virus. On the other hand, when to be found in other parts alone. For ex- a foetus is born to a mother in whose system ample, I have seen them on the arms, legs, it may be supposed, from the history of the shoulders, and back. Such occurrences are, case, that an exhausted virus exists, the dishowever, rare ; and to be observed only ease is often more tardy in appearing in the when the disease has a remarkable tendency foetus. Perhaps it will not occur for months to fungate. Rhagades may occur in any after birth, and when it does occur, it will situation where an angle is formed, as at the be of the fungous class Condyloma will angles of the toes, of the fingers, of the lips, most probably be the symptom. The disease of the eyelids, at the angle between the called in Ireland the "buttonscurvy," which nose and the cheeks, and in the angles is always a fungous disease, is the product formed by the rugae of the circumference of an exhausted venereal virus. The mode of living of the patient, his of the anus. The onyxis can form only where there exists a nail, and is owing to habits of cleanliness, the original character one of the exanthematic spots occurring of his constitution, and the treatment which under a nail, and causing its detachment. the disease has received, all powerfully conThe form of ulceration, which may be called tribute to modify its appearance. The want rounded or circular, to distinguish it from of habits of cleanliness has a great influthe linear ulcers, or the rhagades, occurs ence in determining the formation of fungi, most frequently in the lower extremities, of rhagades, and perhaps of onyxi. In fact, while the serpiginous ulceration, or that these symptoms are often produced by the where the destructive process advances in dirty habits of patients, when the opposite I do one direction, while the ulcer is healing in habits would have prevented, them. another, is met most frequently about the not, however, say that they never occur exnose, or on the penis. It is on the face that cept in such habits ; for I have known very the exauthematic patches present the conical cleanly persons to have the condytomatous or elevated crusts most fully formed. They form of disease. I only say that these forms are frequent on the eyebrows, and among of disease are certainly developed by dirt, the beard. The dark leaden hue which the in cases where they would not otherwise exautbematic spots sometimes assume, is have occurred; and that, whenever they do not so frequently observed on the upper as exist, want of cleanliness is a great cause of on the lower parts of the body. I have, their aggravation. however, seen the spots very dark on the Ihave oftenseenthediseasemuchincreased back, and very red, or of a livid crimson by the mode of living of patients, and by imcolour, on the face. In the latter case, on proper mode of treatment. The milder forms disappearing, they leftburned-looking stains are converted into the severer by impropriety after them, which were very remarkable, in living, and the severer changed into the and remained for a long time. milder by temperance, and by a medécine exThere can be little doubt but that some pectante. Thus, mere stains mayhe changed of the varieties which the exanthematic into tubercles, or ulcers, or fungi; or tuvcnereal eruptions present, result from mo- bercles and fungi may be reduced to mere dification of the poison which have caused scaly spots or stains. These conversions them. Many facts have occurred to me, demonstrate, as I have already remarked, which lead to the conclusion, that the more the consanguinity of these affections. exhausted the virus, the greater the tendency That original constitution greatly modifies it has to produce a scaly or fungous form of this disease, there can be no doubt. The disease ; and the less exhausted, the greater exanthematic virus will act on one constituthe tendency to produce the tubercular, or tion with gentleness, and on another with the vesicular, or bullous disease; or, in other severity. In some cases it produces one of words, those forms which ulcerate. The the mildest forms of venereal cutaneous disfungus seems to be the extreme of the ex- ease-the rubeoloid ; and in others, one of hausted exantheme ; and the bulla, or the the severest forms-the ulcerating tubercle.
752 We find that analagons varieties are produced by the pustular virus; and it is more than probable, that in a constitution in which the pustular virus would cause a mild disease, a similar form of disease would be caused by the exanthematic poison; and that, on the other hand, if the pustular virus would produce a severe disease in any given system, we might fairly expect, in the same .constitution, a severe exanthematic disease aerom the exanthematic poison.
Diagnosis. It is important, Gentlemen, to be able to ’distinguish the exanthematic group of ve- I
as well from the i from non-venereal cutaneous disk eases. In the first stage, exanthematic venereal eruptions often cannot be distinguished satisfactorily from pustular. The one, as well as the other, commences by spots, which are smaller or larger, more or less deeply seated in the skin, and variously arranged, in different cases. The characters of these
nereal eruptions group
pustular
as
however, quickly developed
eruptions
are,
to such
degree
a
as
enables
us
to say with
certainty to which group any given ease belongs. Thus, if the group be pustular, matter forms on the top, and in the substance of the spot; a crust follows ; and if this, or the top of the pustule, be removed, the characteristic
ulcer is
discovered underneath.
Whereas, this purulent top never forms on the exantheme ; and if the spots of this form of eruption persist, they proceed to desquamation, exudation, vesication, fungation, and I perhaps ulceration. There may, however, be some difficulty in distinguishing the vesicular and the bullous exantheme from the z, psydiaceous and bullous pustule, unless If attention be paid to the precise character of each. The spots in these exanthemes are purely vesicular, or bullous, in the first instance ; that is, they consist simply of a larger or smaller portion of cuticle detached by the effusion of a transparent fluid, while the detachment of the cuticle in the pustular forms of disease is produced by an effusion ofpurulent matter; and, in addition, the surface of the cutis is, from the first, more or less altered; that is, it is softened or ulcerated ; so that the pustule is, in the first I, instance, a much deeper affection than either the vesicular or bullous exantheme. I have already remarked on the danger of mistaking the small pustular venereal eruptious when on their decline, or when the pustular tops have disappeared, and the spots consist only of scaly patches, more or less red, and more or less elevated. There ,are, however, several means of distinguishing these cases. In the first place, the history will afford some assistance, for the patient will himself, in general, be able to give you such information as to the form of the spot as will enable you to judge of its original character. Thus, if it was pustu.lar, he will say that it corrupted, that it
or that it filled. In the se. it will seldom happen, unless the disease be very advanced, that you will not find a greater or lesser number of spots, in their earlier stages, mixed up with those iu a more advanced stage, which will elu. cidate the diagnosis. In the third place, the form of the scales which the spots throw off, will afford some assistance. The manner in which the scales of the pustular spot
formed cond
a
top,
place,
differ from those of the exanthematic spot, I have already point out. Lastly, in the advanced stage of the pustular disease, even when the pustules have been of the most minute kind, we will very often detect småll cicatrixes ; but these seldom, if ever, occur in the more minute forms of the exanthematic group ; and these are the forms most likely to be confounded with the mild varieties of the pustular group. So far as the treatment is concerned, when the difficulty of diagnosis between the ex. antheme aud pustule is great, the import. ance of the diagnosis is proportionably di. minished; for as the difficulty of distinguish. ing the one from the other can only exist when the pustular disease is becoming old, and its qualities approaching those of the exantheme, at that period the treatment ap-’ plicable to the one will be found to approach’ that which the other requires. There are none of the orders of cutaneous diseases as described by Dr.WiLLAN.among which there may not be observed species more or less resembling the varieties of the exanthematic group of venereal eruptions. Thus, the strjphulus and lichen among the’ papulas ; the eczema, herpes, andvaricella’ among the vesiculae; the pemphigus among the bullse; the lepra, psoriasis, and pityriasis among the squamas; the rubiola, erythema, roseola, and urticaria, among the exanthemata ; some of the varieties of acne among the pustulse; the molluscum, vitiligo, and lupus, among the tuberculae ; all resemble, more or less, the exanthematic varieties of venereal eruptions ; and the resemblance is occasionally so strong, that if we determined the diagnosis on a first view, we should frequently fall into error. The character of the eruption itself will, no doubt, often ma-’ terially assist the diagnosis. There is always something in the shade of colour, in the arrangement of the spots, or in their colloca. tion on the surface, in the sensations which accompany them, in the order of succession or synchronosity, if I may be allowed this expression, in which they appear, and in their persistence, or their mode of termination, which will, in general, remove all doubt from the mind of a man well acquainted with the ordinary diseases of the skin, and will enable him at once fb say that this is, or is not, venereal. At times, however, even the most experienced eye will require additional light to enable it to’ see its way in deciding on the venereal or non-venereal ‘
753 How much more will the practitioner be to go astray, who has not directed more than ordinary routine attention to these diseases ? Such a person would, on almost every occasion, be extremely likely to err. You may say, who could mistake measles, or chickenpock, or nettle-rash, for a venereal eruption ? But I tell you that I have known venereal eruptions to be so mistaken. I have known eruptions which were venereal, to be con-
qualities
of
an
eruption.
likely, therefore,
,
sidered measles ; others,
chicken-pock ; others, nettle-rash ; others, psoriasis ; others, lepra. I have not, however, ever known the !
converse.
Yet there
are cases
of
common
lepra and of psoriasis, which resemble very much venereal eruptions. In all cases, therefore, it will be prudent to take the assistance afforded by diagnosis, the history of the case, and by the a:;companying symptoms. The previous occurrence of primary symptoms, but particularly i of the symptoms of invasion, will go far to all doubt. But the existence, at the same time with the eruption, of other symptoms, more or less decidedly venereal, will afford still more valuable information; and as such collateral symptoms are seldom absent, they would, of themselves, in the greater number of cases, clear up all doubt in the diagnosis. remove
and among the exanthematic group, the
vesicular, bullous, tubercular, and fungous eruptions, also form collateral varieties. Now, the prognosis of these eruptions will vary in each case, according to the eud of the chain to which it approaches, when it is referable to one or other of the varieties which form the direct line; and according to the character of the collateral variety.8 with which it corresponds, when it does not belong to any of those in the direct line. Thus, it will be milder according as it approaches more nearly the end of the chain formed of mere stains, or very minute pa pulas; and more severe, according as it approaches the end occupied by the ulcerating patches. Again, it will be more mild, when it pertains to those collateral varieties, which denote an exhausted virus, as the fungous; and more severe, when it belongs to those that denote an approximation to the pustular forms, as, for example, when it is vesicular, or bullous, or tubercular.
We very frequently meet certain inveterate forms of venereal disease of the skin, whose exact characters it is difficult to determine, for the spots which compose it are sometimes of the tubercular, and sometimes of the tuberculo-pustular character. They form ulcerations, which often heal in one
and extend in another, or new out at the circumference of a patch, white those more in the centre heal up. This form of disease I have never seen, except when mercury had been given. It often continues for a series of years, at one most severe, as well as some of the mildest time better, and at another worse. Mercury forms of constitutional venereal disease. very quickly heals the ulcers, and for a time Their varieties are, in this point of view, removes the disease. Whether these cases analogous to those of the pustular group. are originally pustular or exanthematic, or In the pustular group we noticed the exist- whether they be sometimes of the one and ence of a chain, or series of eruptions, one sometimes of the other, or whether they are end of the chain being composed of minute all deserving of being considered exanthepustules, which often formed large ulcers, matic, whether originally pustular or not, and the other end of larger pustules, which inasmuch as the virus, upon which they often formed ulcers of great magnitude. depend, must be in an exhausted state, I The exanthematic group forms a similar, or shall not at present say. Their characters an analagous, scries, or chain. At one end are sufficiently determined to prevent any of this chain we have eruptions which form mistake in diagnosis. I have placed them a mere stain, or very minute pimples ; at among the exanthematic class, as they have, the other, we have very large tubercles, or upon the whole, more resemblance to them ulcerating stains, or bullae ; and between than to the pustular. I am in the habit of the mild and severe ends of the chain, we calling these cases by the name of lupiform have as many varieties in severity as we syphilis, because of the resemblance of have in the pustular chain. The varieties their ulcerations to those of lupus,-and like which compose these chains, whether pus- lupus it very often occurs on or about the tular or exanthematic, do not, however, nose. The principles of Treatment form, as it were, merely a straight line, the links of which progressively increase or to be adopted in respect to the varieties of decrease in severity, for they are, in each the exanthematic eruptions, are precisely chain, what may be called collateral links ; those which regulate us in treating the and which depend not merely on a greater pustular eruptions. We endeavour to free or lesser degree of severity of the disease, the system from the disease, with as little exbut, perhaps, on a modification of the poison pence to the constitution as possible ; and which produced the disease. Thus, among at the same time to prevent, as far as in our the pustular group, the bullous and the power, the recurrence of disease in-either tubercular pustules formcollateral variety; the skin or any other part. To accomplish
Prognosis. The prognosis, Gentlemen, of the various eruptions which constitute the exanthematic group, is very different. Among these eruptions will be found some of the
direction, spots
come
754 these
objects
we
are, in
some
varieties, edges with
a
red-hot
iron, introduced into
to have recourse to mercury, and in the vagina by means of a speculum. Reothers, to the hydriodate of potash. The membering the precept of Dupuytren, that former remedy is to be preferred, when the sutures were of no avail against the inju.
obliged
disease is more purely exanthematic ; for example, in the rubeoloid, scaly, and fungous varieties, while the hydriodate of potash is much more suited to the tubercular class, and to these moreand more, according as they show a greater disposition to form groups, or to end in ulceratioiis ; or in other words, according as they appear to bear more alliance with the pustular group. The ulcerations of the exanthematic group are not so much benefitted by the application of the nitrate of silver as those of the pustular group. I have now, Gentlemen, concluded what I had to say respecting the history of the primary and constitutional forms of both the pustular and exanthematic varieties of venereal diseases of the skin; and when I shall have made some further general remarks, which I shall do when we next meet, on those affections of the lymphatic, mucous, osseous, and fibrous systems, and of some other parts, as of the eyes and testis, which are common attendants on those primary and constitutional symptoms which we have already considered, you will, I trust, be fully prepared for an examination of the symptoms and treatment of individual cases, or groups of cases. By these, I shall not only test the accuracy of the general descriptions which I have been giving you, but shall, with their assistance, make you acquainted with the details of many facts, at which I could only glance, when my aim in description was merely to catch at generalities.
ON THE CURE OF
VESICO-VAGINAL FISTULA, AND
LACERATION
By
OF THE
BLADDER
AND
VAGINA.
Professor DIEFFENBACH, of Berlin.
BEFORE I commenced the study of medicine I had occasion to witness an operation for the cure of vesico-vaginal fistula, performed by one of our most celebrated surgeons on a young woman in whom the accident had been produced by difficult labour. The operation lasted several hours, and consisted in an attempt to pare the edges of the fistulous opening with the scissars, and afterwards unite the wound by suture. There was little effort made by nature to heal the wound, and the woman died in a few days from violent inflammation of the bladder and peritoneum. During my stay at Paris, fourteen years ago, I had an opportunity of seeing a patient whom Dupuytren had cured of a narrow
vesico-vaginal
fistula, by
cauterizing its
rious influence of the urine on the wound, and that nothing but the actual cautery was sufficient to excite the necessary degree of action in the edges of the fistula to produce full granulation, I tried this means in several cases of fistula not larger than a hazel-nut in circumference, but I failed in every case. Two attempts made anterior to this by Drs. Baum and Mayer were equally unsuccess-
ful. Some time after these
experiments,
a
of weakly constitution, fifty years of age, came under my care, with a peculiar vesico-vaginal fistula, not the result of labour, but from a tumour which had spontaneously opened into the vagina. The external orifice was half an inch behind the clitoris ; a fine elastic bougie passed ohliquely backwards into the bladder. The urine was discharged periodically, and the woman was sometimes several days without passing any through the fistulous opening. The latter was finally healed by washing and injecting the traject with decoction of camomile flowers, and touching its edges with the tincture of cantharides, the catheter being at the same time employed. 1 was equally fortunate in a second case, which, like the one just mentioned, was very mild. A vesico-vaginal fistula, opening an inch behind the clitoris, was pro’ duced as a result of difficult labour in a woman of thirty years of age. The traject ran obliquely backwards,and communicated with the bladder itself, as I was convinced by careful examination. In this case also the passage of urine through the fistula was only periodical. The treatment, successful in the former case, was repeated, but without any benefit for five weeks. I then freely slit up the anterior portion of the fistulous traject, and afterwards re-united it with a point of suture : a catheter was kept in the bladder, and the parts frequently bathed with cold water. However, on the third day, the thread had cut through one edge of the wound, and a few drops of pus, mixed with urine, flowed out; warm poultices, with camomile fomentations, were immediately applied to the genital organs; and, after a lapse of eight days, I began by sti. mulating the traject of the fistula. By this means the orifice of the fistula was closed in about four weeks; however, in a short time after a small quantity of urine escaped through an opening which was almost im. perceptible ; I therefore dilated this minute canal with a fine cat-gut cord, and was fortunate enough to heal it at length by stimulating the parietes with strong tincture of cantharides. I now conceived some hope of being able to relieve the distressing accident by mrp’ woman
in the nervous system. Every thing in thegreat eloquence, all the audience wept; but air one could deny or affirm at will oi11 respect for the law," prevailed, and he was pleasure, or make use of subtleties to con.condemned to death. Here are the heads.of some parricides. See trovert an opinion, so long as the organs are’ perceptible to the senses. When one findshow meagre is all this upper region. Refer an organ for that faculty in the middle ofto LACENAIRE, or FIESCHI, and you will find others which correspond with different feel-that the predominances there are neither in ings, how can you object to the conductthe really superior feelings nor in the intelbeing in accordance with the organization?lect. There is, indeed, a little veneration One may deny the facts, as is practised atthere ; but conscientiousness is particularly the present time, but the line of observationswanting. It was SPURZHEIM who discovered is traced, and every one in going over it may this organ, and I consider that this discovery was one of the most important facts for moraverify them. Examples.-These are found in the ma- lity ever made, and phrenologists have not jority of superior men, who have always the hesitated to admit it. Here is the head of same kind of head. Here is the head ofFIESCHI, and you find in it an inclined slope CHARPENTIER, who, in fact, unites all the from behind forwards, on the summit of the mass of organs combined with conscientious- head, because all the organs of the middle ness. All superior heads are in the same and anterior regions are depressed. There condition. Observe that of MANUEL, and remain behind, self-love, with a little selfothers, for instance. Where conscience is esteem, with the passions and destruction wanting, the protuberance of the region which more or less on the sides ; that is to say, an corresponds with that faculty, does not sur- intellect governed by the baser instincts. Animals.-As to these, all the phrenolopass the neighbouring organs, or, rather, it is replaced by a depression. When, on the gists whom I know deny them this faculty. contrary, conscience exists, the protuberance However,I think myself that the outline of is prolonged, and the organ is found on a this feeling exists in the elephant, the dog, level with self-esteem and circumspection. and even the horse. When these animals are In the head of BAGNOL you see a sort of de- ill-treated without cause, they distinguish pression which seems to, but which really does the injustice. They are, to a certain point, not, correspond with the seat of this organ. like children. Children, even when very It rather occupies the seat of hope. young, know when a person is guilty of inWhat is most important in the organization justice towards them, and show it by rebelof an honest man, is the mass formed by the ling, while they submit if they feel that a just union of self-esteem, the love of the esteem of chastisement is imposed upon them. I have others, conscientiousness, and veneration ; for myself a belief in the existence of an outline a certain quantity of veneration is necessary of this feeling in those animals whose brain to complete a fine head. Here is the head of has some relationship with ours. Our next Foy, who was the idol of the Liberal party. subject will be -Hope. We have not fabricated all these heads on purpose; yet their forms are always found in accordance with their actions. Here is CLINICAL CASIMIR PERIER. The same concordance is AND REMARKS, LECTURES presented in it. We could refer to many such DELIVERED ON heads amongst living men, but, unfortunately, we cannot exhibit them to you in a theatre. DISEASES OF THE SKIN, VENEREAL You will not find a brigand in whom this mass DISEASES, AND is predominant. See, in fact, (shewing a SURGICAL C A S E S, bust) how meagre is this region, how hollow AT THE is the top of the head. It becomes a cave. I have in my possession forty heads of crimi- SKIN INFIRMARY, AND AT THE JERVISSTREET HOSPITAL, DUBLIN. nals, in almost all of whom this conformation strikes the eye. There are some varieties, ’, BY DR. WALLACE, but in not one of them does the group of good SURGEON TO THOSE INSTITUTIONS. feelings exhibit an average breadth at the crown of the head. These facts are valuable. EXANTHEMATIC VENEREAL ERUPTIONS. Jokes, and other ill-timed pleasantries, cannot THE primary exantheme, of which I spoke them. Here is the unfortunate destroy DODD, who was hung for having wished to oblige a at our last meeting, is, as I have already friend by forging a signature ; but he had said, followed by constitutional symptoms more certainty than the primary pustule. neither conscience, nor self-esteem, nor circumspection. But his is, notwithstanding, a Itveryseldom, indeed, happen s, if the disease allowed to run its course, that the former truly classical head. You see what organs should have predominated in him, and go- is not succeeded by an eruption; whereas verned his actions, and that those parts which the latter very often occurs without causing we study, possessed less action. In deliver- any constitutional symptom. This fact is ing the judgment on this man, who possessed the more remarkable, as the power possessed
with be
748
by the exanthematic virus of producing a pri- These larger spots are only modifications of marydisease, is inferior to that possessed by the smaller, for, if their growth be watched, the pustular virus. Hence, the direct ap- it will often be found that they are formed plication of the exanthematic virus often by a coalition of a number of the smaller produces no effect ; but, if the primary symptom be once produced, the constitutional symptom almost always follows. The period at which the exanthematic eruption succeeds the primary exantheme, is subject to as great variety as that at which the pustular eruption succeeds the primary pustule. But the exanthematic eruption follows its primary symptom, in general, more rapidly than the pustular eruption follows the primary pustule. The character of the symptoms of invasion, or of those constitutional symptoms accompany the exaiitheare, ceetei-is paribus, milder than, but of the same kind as, those which correspond in the same manner to the pustular eruption. The characters of the spots which constitute the exanthematic eruptions, are various, and, on a superficial view, very dissimilar. The only appearance or symptom constantly and necessarily attendant on them is a state ofhyperasmia, and consequent discoloration of the part affected. I say that this is the only essential symptom, because there are some varieties of the eruption which have no other, and because all its varieties have this. Of some, the state of hyperaemia constitutes only the first stage ; of others, the whole appearance. This appearance gives t3 the skin, in some cases, a mottled aspect, not unlike that observed on the front of the legs of persons in the habit of sitting over the fire. At other times, the discoloration is extremely like measles, and at others not unlike ephelis, rarely like erythema or roseola. It is sometimes in small spots, and sometimes in large which matic
precede and
eruption
orlentigo,more
patches. In the mildest form of the exanthematic
eruption, the discoloured spot is neither elevated nor tumid. There is a simple discoloration, which gives to the part a measled More frequently, however, appearance. there is someelevation or tumidity; but the character of this elevation is subject to great variety. For example, the form, the depth, the relief, the extent, the colour, are widely different in different cases ; and each of these varieties is wen deserving of consideration. The mildest form of elevation which the eruption presents has somewhat the appearance of those elevations which form the eruption, called byWILLAN, strophilas, or it may be compared to those which occur in the state of skin called 11 cutis anserina," or ,ose-slcin. These small elevations are placed on a slightly inflamed ground, and their centre is of a darker colour than their circumference. This form of elevation is not unfrequently intermixed with one of a larger size, vhi_h is flat on its surface and superficial.
on their decline, we find that they resolve themselves, before disappearance, into the more minute spots. To this it may be added, that we often notice the large spots to be evidently formed by a group of the smaller. Although this larger elevation in general occurs in combination with the smaller, I have often seen the former without the latter, and then the eruption very much resembled the wheals of ur. ticaria, being composed of numerous red spots, varying in size from a small to a very large pea. At other times, I have seen an eruption of the larger elevations succeed an eruption of the smaller. When the larger eruption is on the decline, it produces an appearance like BATEMAN’s plate ofVitiligo; and I believe that the disease described by him under this name is a venereal eruption. In neither of the preceding forms of elevation does the tumidity, upon which the elevation depends, sink into the cutis; and even when the spots are of a considerable thickness, this thickness is raised on the surface of the cutis, and does not go downwards, or into its substance. The elevations which I have just alluded to are in general numerous, and scattered We sometimes, over the whole surface. however, notice, limited perhaps to one or two regions, flat elevated patches, which vary in their size from that of the end of a finger to that of the palm of the hand. These patches of elevations enlarge by additions to their border, and, increasing in one direction, while they shrink in another, often traverse a great extent of surface. All the elevations of which I have as yet spoken, are either flat or pointed on their surface ; but there are other superficial tumid exanthemes, whose form is almost exactly spherical. These are sometimes, as well in form as in colour, extremely like red or black currants. There is a form which the exantheme!Þt times presents, and which, although fiat on its surface, seems to go so deep as to involve the texture of the cutis. It is, for the most part, broader and flatter than the one just n entioned. I do not know any common or ordinary diseases of the skin which it resembles. It, however, forms the transition from the more superficial to the more deeplyseated exantheme. In the remaining varieties of the tubercular exantheme, the deeper-seated parts of the skin seem to suffer more. In them the swelling is very often considerable; but in place of commencing, as in the examples already mentioned, on the surface of the skin, and never appearing to go deeper than its
elevations ; and,
substance, they seem to commence so deep, that it might be supposed they were seated
749
uader the skin. case, and
care
This is not, however, the face more rapidly than at their circumfermust be taken not to con- ence. The patch is thus formed into a cup,
found them with a symptom of syphilis or into a simple ring, according as it was, which forms, in the sub-cutaneous cellular in the first instance, tumid or otherwise.
tissue,tumoursortubercles,that subsequently approach the surface and ulcerate.
The exantheme, whether tumid or not, may disappear without producing or leaving after it any other symptom or appearance, If the exantheme be a simple discoloration, the original discoloration may change into another; that is, from being more red, it may become more brown. Even the tumid exanthemes may shrink away, and leave after them merely stains, which may contiIn some nue for a longer or shorter time. cases, these stains are of a colour so tawny to look not unlike that of a piece of singed paper. The venereal exantheme often desquamates, or throws off a succession of cuticles; and it is of importance to attend to the form of these layers of detached cuticle; for they afford a means of distinguishing between an exanthematic and a pustular eruption on its decline. In the exantheme, the scale covering the spot forms a disk. This disk has a circular edge, and it can by this edge be often pulled off the surface on which it lies. If the exantheme be not covered by this disk, it is covered merely by a kind of branny scurf. Now, the pustular spot, when scaly, in general desquamates in circles ; and although these circles somewhat resemble the circles formed by the disks of the exanthematic scale, they can be easily distinguished by the aspect or direction of their circular edge. In the exanthematic disk, its aspect is peripheral, and in the pustular, central. The cuticle of an exanthematic patch may be detached by an effusion under its surface, and thus form a vesicle or bulla. This is a rare form of the venereal exantheme. It is, however, to be observed; and when it occurs the eruption resembles sometimes pemphigus, sometimes herpes, sometimes eczema, and sometimes varicella, as I have seen in different cases. We find, and particularly under the influence of certain localities, that the exanthematic patch, whether tumid or not, will occasionally exude secretion from its surface, or else from a fungous growth, which may acquire a very considerable magnitude. This exuding and fungous state maybe preceded by desquamation or vesication. Exanthemes which have desquamated or vesicated, or which have formed fungous or exuding surfaces, may gradually become healthy, or may form ulcerations. When they become healthy without ulceration, they never leave any cicatrixes behind, though they may leave stains, which continue for a very long period. Exanthematic elevations and discolorations, whether fungous or desquamating, oftentimes shrink in the centre of their suras
The cup is very remarkable in some cases of tubercles. These I have called the cupped tubercles. The ulcers which the exanthematic patch forms, cannot, for the most part, be distinguished from those which have been preceded by pustules, unless by the manner in which they have been developed, or by the nature of the spot which preceded them. They are, however, in general, more superficial, considering their extent, than those ulcers which have been preceded by pustules, but, like them, they are characterized by the whiteness of their surface. This whiteness is often greater at their circumfe rence than at their middle, and is owing to a stratum of matter of a lardaceous aspect. This matter is sometimes pultaceous, and then it is generally greenish ; but, as I have already said, whether it be white or greenish, it is the original organic texture in a state preparatory to its separation from the body, and not, as is generally supposed, a lymph effused on the diseased surface. The exanthematic, as well as the pustular ulcers, may be covered by either of the two forms of crusts, which I have described, by that which is produced by indurated discharge, or by that which is formed by a desiccated slough. The latter kind of crust is more rarely to be met on the exanthematic than on the pustular ulcers. The exanthematic sores are often, however, covered by crusts formed of indurated discharge, which are so regular and so conical that they strongly resemble the truly limpet-shaped crust, which is always formed of indurated
slough. The exanthematic
eruptions,
in
their
arrangement or collocation on the surface of the skin, present varieties very analogous those presented by the pustular eruptions. the spots which form the eruption, may be either scattered, or grouped, or in circles. The grouped, or circular arrangement, is perhaps oftener to be met amongst the exanthematic than the pustular. This character is very frequent in those exanthe., matic cases, in which there have been relapses; and I have often had occasion to remark, that the exanthematic disease, though at first of the scattered form, presents in its relapses the grouped character. We observed, in speaking of the pustular eruptions, that in their relapses, the spots were often in groups, although the earlier eruptions presented the scattered arrangement. We also remarked, when speaking of the cicatrization of the pustular sores, that it sometimes commenced at one side, while the ulcerating process continued at the other. We observe the exanthematic disease to present analogous changes ; and to
Thus,
750
when ulcers are not formed. Forwhen great attention to cleanliness is not an exanthematic patch often be- given, may be the seat of very painful sorecomes well in the centre, or at one side, ness and stiffness, particularly at night, and while it extends at the other, or at the cir- after exertion. The uneasiness which atcumference. There are hence produced tends the other forms of the exantheme, is, patches, which have often very remarkable in general, an itchiness. This is sometimes appearances-sometimes they resemble a very troublesome. I have known severe cup-sometimes a circle-sometimes a itchiness, with discoloration of the skin crescent, but all their appearances, however round the anus, to form of itself the only diversified, are analogous in their nature, symptom, in a case of constitutional syphilis, and depend up:;n the principle, that the which followed the primary exantheme;at diseased patch gets well, or better, in one least this itchiness and discoloration yielded part, while it spreads in another. This is a to the same treatment which would have law of progression, which is followed by removed them if they had been symptoms of many other eruptions as well as by venereal the exanthematic form, that is, to mercury. diseases of the skin. Notwithstanding the varieties of appear. There are some remarkable differences in ance which the exanthematic venereal direspect to the situation which the exanthe- seases of the skin present, there exists the matic eruption occupies, as compared with most satisfactory proofs that they are all that occupied by the pustular eruptions. simply modifications of the same state. I have never observed the pustular eruption Thus, in the first place, we may frequently on the palms of the hands, or on the soles observe all the appearances which I conof the feet, but those parts are very fre- sider exanthematic, on the same patient, at quently the seat of the exantheme; and the same time; or, on the same patient at there it causes either deep cracks, named different periods, but resulting from the rhagades, or spots, which detach scales in a same infection. The stain, the scaly tucircular form. The pustular eruptions do bercle, and, scaly patch, the rhagade, the not seem to have any predilection for the ulcerating tubercle, and patch, daily occur anus, or for the genital organs; but the together. It is more rare to notice the exantlaematic eruptions very often occur in vesicular and bulbous venereal eruptions those regions; and are sometimes to be united with the other forms; but this is found there, when they are in no other part. owing to the rarity of these varieties of At all times they are perhaps more nu- disease. In the second place, there are merous on these, than on any other parts. certain circumstances under which one or The exantheme frequently occurs between other form of the exanthematic eruption the toes, under, or at the edge of the nails, alwaysoccurs, and never the pustular, as, in the angles of the lips, in the angles of for example, when the mother communicates the eyelids, and in the angle which the nose the venereal disease to the foetus in utero, forms with the cheek. When it occurs at when a contaminated foetus communicates the nail, it very often causes its exfoliation; the disease to a healthy nurse, and when and when in any of the other situations, the disease is contracted by a sound person those linear ulcers, called rhagades, are coming in contact with a person labouring produced. Now the pustular eruptions under constitutional symptoms of syphilis, whether pustular or exanthematic. It has very seldom attack any of these parts. The colour of the exanthemeis, is general, been, particularly in infants who have cona redish brown, particularly when on the tracted the disease in utero, that I have decline. On its first eruption, however, it noticed the bullous form of the exantheis not unfrequently of a bright red or crim- matic s philitic eruption, and traced its It is sometimes a more pale relationship with the other exanthematic son colour. red, and sometimes more yellow. It is also eruptions. Its more frequent occurrence at occasionally of so dark a brown as to this time of life, in a great degree, probably depends on the anatomical state of the approach to black. The exanthematic eruption is as variable ftietal skin. In the third place, if any adin quantity as the pustular. Sometimes the ditional proof were wanting of the conwhole body is thickly covered; and at other sanguinity of the varieties of the exantheme, times, there are only a few scattered spots it is afforded by the results of experiment, on some particular region. Thus, we find for the secretions from these eruptions unithis
even
axample,
which present no other traces of it crack at the angles of the lips, or a rhagade between the toes, or an onyxis, or a condylomatous slate of the anus ; while, at other times, the face, the trunk, and the extremities, are thickly covered. The degree of sensibility or pain attendant on the exanthematic eruption, is seldom considerable; yet the ulcers, and the excrescences, and the rhagades at the toes, cases
than
a
formly produces, by inoculation, when it succeeds, one of their own varieties of disease, and no other. In fact, both the primary and the secondary symptoms which follow inoculation in these cases, always belong to the exanthematic group symptoms.
C
751 sent ? On several occasions they are evi- vesicle, or tubercle, the link which connects dent. On others, they are more conjectural. the exantheme with the pustule. Some of The influence of situation and structure in the phenomenon presented by contaminated producing modifications of the exantheme infants supports these opinions. If a female is very considerable. Upon the iniluence contracts syphilis while she is pregnant of situation, in a great measure, depends and hence infects with a constitutional disthe fungus, and the rhagadi; and to it, the ease her foetus, the symptoms presented by onyxis is entirely owing. The fungous ex- the foetus will have more alliance with the antheme occurs on surfaces opposed to other pustular group than if the mother had been surfaces, and rich in the sebaceous appa- for a long period the subject of constitutional ratus. Hence they are frequently seated disease, and consequently than if the poison round the anus, on the great labia, on the was of a more exhausted kind. The foetus scrotum, on the angle between the labia or will also be more likely to be dead-born, or scrotum and the thigh. But, although they to be born with symptoms of the disease, are seen in these parts, when they are not to than if it had been contaminated by a more be observed in others, they are sometimes exhausted virus. On the other hand, when to be found in other parts alone. For ex- a foetus is born to a mother in whose system ample, I have seen them on the arms, legs, it may be supposed, from the history of the shoulders, and back. Such occurrences are, case, that an exhausted virus exists, the dishowever, rare ; and to be observed only ease is often more tardy in appearing in the when the disease has a remarkable tendency foetus. Perhaps it will not occur for months to fungate. Rhagades may occur in any after birth, and when it does occur, it will situation where an angle is formed, as at the be of the fungous class Condyloma will angles of the toes, of the fingers, of the lips, most probably be the symptom. The disease of the eyelids, at the angle between the called in Ireland the "buttonscurvy," which nose and the cheeks, and in the angles is always a fungous disease, is the product formed by the rugae of the circumference of an exhausted venereal virus. The mode of living of the patient, his of the anus. The onyxis can form only where there exists a nail, and is owing to habits of cleanliness, the original character one of the exanthematic spots occurring of his constitution, and the treatment which under a nail, and causing its detachment. the disease has received, all powerfully conThe form of ulceration, which may be called tribute to modify its appearance. The want rounded or circular, to distinguish it from of habits of cleanliness has a great influthe linear ulcers, or the rhagades, occurs ence in determining the formation of fungi, most frequently in the lower extremities, of rhagades, and perhaps of onyxi. In fact, while the serpiginous ulceration, or that these symptoms are often produced by the where the destructive process advances in dirty habits of patients, when the opposite I do one direction, while the ulcer is healing in habits would have prevented, them. another, is met most frequently about the not, however, say that they never occur exnose, or on the penis. It is on the face that cept in such habits ; for I have known very the exauthematic patches present the conical cleanly persons to have the condytomatous or elevated crusts most fully formed. They form of disease. I only say that these forms are frequent on the eyebrows, and among of disease are certainly developed by dirt, the beard. The dark leaden hue which the in cases where they would not otherwise exautbematic spots sometimes assume, is have occurred; and that, whenever they do not so frequently observed on the upper as exist, want of cleanliness is a great cause of on the lower parts of the body. I have, their aggravation. however, seen the spots very dark on the Ihave oftenseenthediseasemuchincreased back, and very red, or of a livid crimson by the mode of living of patients, and by imcolour, on the face. In the latter case, on proper mode of treatment. The milder forms disappearing, they leftburned-looking stains are converted into the severer by impropriety after them, which were very remarkable, in living, and the severer changed into the and remained for a long time. milder by temperance, and by a medécine exThere can be little doubt but that some pectante. Thus, mere stains mayhe changed of the varieties which the exanthematic into tubercles, or ulcers, or fungi; or tuvcnereal eruptions present, result from mo- bercles and fungi may be reduced to mere dification of the poison which have caused scaly spots or stains. These conversions them. Many facts have occurred to me, demonstrate, as I have already remarked, which lead to the conclusion, that the more the consanguinity of these affections. exhausted the virus, the greater the tendency That original constitution greatly modifies it has to produce a scaly or fungous form of this disease, there can be no doubt. The disease ; and the less exhausted, the greater exanthematic virus will act on one constituthe tendency to produce the tubercular, or tion with gentleness, and on another with the vesicular, or bullous disease; or, in other severity. In some cases it produces one of words, those forms which ulcerate. The the mildest forms of venereal cutaneous disfungus seems to be the extreme of the ex- ease-the rubeoloid ; and in others, one of hausted exantheme ; and the bulla, or the the severest forms-the ulcerating tubercle.
752 We find that analagons varieties are produced by the pustular virus; and it is more than probable, that in a constitution in which the pustular virus would cause a mild disease, a similar form of disease would be caused by the exanthematic poison; and that, on the other hand, if the pustular virus would produce a severe disease in any given system, we might fairly expect, in the same .constitution, a severe exanthematic disease aerom the exanthematic poison.
Diagnosis. It is important, Gentlemen, to be able to ’distinguish the exanthematic group of ve- I
as well from the i from non-venereal cutaneous disk eases. In the first stage, exanthematic venereal eruptions often cannot be distinguished satisfactorily from pustular. The one, as well as the other, commences by spots, which are smaller or larger, more or less deeply seated in the skin, and variously arranged, in different cases. The characters of these
nereal eruptions group
pustular
as
however, quickly developed
eruptions
are,
to such
degree
a
as
enables
us
to say with
certainty to which group any given ease belongs. Thus, if the group be pustular, matter forms on the top, and in the substance of the spot; a crust follows ; and if this, or the top of the pustule, be removed, the characteristic
ulcer is
discovered underneath.
Whereas, this purulent top never forms on the exantheme ; and if the spots of this form of eruption persist, they proceed to desquamation, exudation, vesication, fungation, and I perhaps ulceration. There may, however, be some difficulty in distinguishing the vesicular and the bullous exantheme from the z, psydiaceous and bullous pustule, unless If attention be paid to the precise character of each. The spots in these exanthemes are purely vesicular, or bullous, in the first instance ; that is, they consist simply of a larger or smaller portion of cuticle detached by the effusion of a transparent fluid, while the detachment of the cuticle in the pustular forms of disease is produced by an effusion ofpurulent matter; and, in addition, the surface of the cutis is, from the first, more or less altered; that is, it is softened or ulcerated ; so that the pustule is, in the first I, instance, a much deeper affection than either the vesicular or bullous exantheme. I have already remarked on the danger of mistaking the small pustular venereal eruptious when on their decline, or when the pustular tops have disappeared, and the spots consist only of scaly patches, more or less red, and more or less elevated. There ,are, however, several means of distinguishing these cases. In the first place, the history will afford some assistance, for the patient will himself, in general, be able to give you such information as to the form of the spot as will enable you to judge of its original character. Thus, if it was pustu.lar, he will say that it corrupted, that it
or that it filled. In the se. it will seldom happen, unless the disease be very advanced, that you will not find a greater or lesser number of spots, in their earlier stages, mixed up with those iu a more advanced stage, which will elu. cidate the diagnosis. In the third place, the form of the scales which the spots throw off, will afford some assistance. The manner in which the scales of the pustular spot
formed cond
a
top,
place,
differ from those of the exanthematic spot, I have already point out. Lastly, in the advanced stage of the pustular disease, even when the pustules have been of the most minute kind, we will very often detect småll cicatrixes ; but these seldom, if ever, occur in the more minute forms of the exanthematic group ; and these are the forms most likely to be confounded with the mild varieties of the pustular group. So far as the treatment is concerned, when the difficulty of diagnosis between the ex. antheme aud pustule is great, the import. ance of the diagnosis is proportionably di. minished; for as the difficulty of distinguish. ing the one from the other can only exist when the pustular disease is becoming old, and its qualities approaching those of the exantheme, at that period the treatment ap-’ plicable to the one will be found to approach’ that which the other requires. There are none of the orders of cutaneous diseases as described by Dr.WiLLAN.among which there may not be observed species more or less resembling the varieties of the exanthematic group of venereal eruptions. Thus, the strjphulus and lichen among the’ papulas ; the eczema, herpes, andvaricella’ among the vesiculae; the pemphigus among the bullse; the lepra, psoriasis, and pityriasis among the squamas; the rubiola, erythema, roseola, and urticaria, among the exanthemata ; some of the varieties of acne among the pustulse; the molluscum, vitiligo, and lupus, among the tuberculae ; all resemble, more or less, the exanthematic varieties of venereal eruptions ; and the resemblance is occasionally so strong, that if we determined the diagnosis on a first view, we should frequently fall into error. The character of the eruption itself will, no doubt, often ma-’ terially assist the diagnosis. There is always something in the shade of colour, in the arrangement of the spots, or in their colloca. tion on the surface, in the sensations which accompany them, in the order of succession or synchronosity, if I may be allowed this expression, in which they appear, and in their persistence, or their mode of termination, which will, in general, remove all doubt from the mind of a man well acquainted with the ordinary diseases of the skin, and will enable him at once fb say that this is, or is not, venereal. At times, however, even the most experienced eye will require additional light to enable it to’ see its way in deciding on the venereal or non-venereal ‘
753 How much more will the practitioner be to go astray, who has not directed more than ordinary routine attention to these diseases ? Such a person would, on almost every occasion, be extremely likely to err. You may say, who could mistake measles, or chickenpock, or nettle-rash, for a venereal eruption ? But I tell you that I have known venereal eruptions to be so mistaken. I have known eruptions which were venereal, to be con-
qualities
of
an
eruption.
likely, therefore,
,
sidered measles ; others,
chicken-pock ; others, nettle-rash ; others, psoriasis ; others, lepra. I have not, however, ever known the !
converse.
Yet there
are cases
of
common
lepra and of psoriasis, which resemble very much venereal eruptions. In all cases, therefore, it will be prudent to take the assistance afforded by diagnosis, the history of the case, and by the a:;companying symptoms. The previous occurrence of primary symptoms, but particularly i of the symptoms of invasion, will go far to all doubt. But the existence, at the same time with the eruption, of other symptoms, more or less decidedly venereal, will afford still more valuable information; and as such collateral symptoms are seldom absent, they would, of themselves, in the greater number of cases, clear up all doubt in the diagnosis. remove
and among the exanthematic group, the
vesicular, bullous, tubercular, and fungous eruptions, also form collateral varieties. Now, the prognosis of these eruptions will vary in each case, according to the eud of the chain to which it approaches, when it is referable to one or other of the varieties which form the direct line; and according to the character of the collateral variety.8 with which it corresponds, when it does not belong to any of those in the direct line. Thus, it will be milder according as it approaches more nearly the end of the chain formed of mere stains, or very minute pa pulas; and more severe, according as it approaches the end occupied by the ulcerating patches. Again, it will be more mild, when it pertains to those collateral varieties, which denote an exhausted virus, as the fungous; and more severe, when it belongs to those that denote an approximation to the pustular forms, as, for example, when it is vesicular, or bullous, or tubercular.
We very frequently meet certain inveterate forms of venereal disease of the skin, whose exact characters it is difficult to determine, for the spots which compose it are sometimes of the tubercular, and sometimes of the tuberculo-pustular character. They form ulcerations, which often heal in one
and extend in another, or new out at the circumference of a patch, white those more in the centre heal up. This form of disease I have never seen, except when mercury had been given. It often continues for a series of years, at one most severe, as well as some of the mildest time better, and at another worse. Mercury forms of constitutional venereal disease. very quickly heals the ulcers, and for a time Their varieties are, in this point of view, removes the disease. Whether these cases analogous to those of the pustular group. are originally pustular or exanthematic, or In the pustular group we noticed the exist- whether they be sometimes of the one and ence of a chain, or series of eruptions, one sometimes of the other, or whether they are end of the chain being composed of minute all deserving of being considered exanthepustules, which often formed large ulcers, matic, whether originally pustular or not, and the other end of larger pustules, which inasmuch as the virus, upon which they often formed ulcers of great magnitude. depend, must be in an exhausted state, I The exanthematic group forms a similar, or shall not at present say. Their characters an analagous, scries, or chain. At one end are sufficiently determined to prevent any of this chain we have eruptions which form mistake in diagnosis. I have placed them a mere stain, or very minute pimples ; at among the exanthematic class, as they have, the other, we have very large tubercles, or upon the whole, more resemblance to them ulcerating stains, or bullae ; and between than to the pustular. I am in the habit of the mild and severe ends of the chain, we calling these cases by the name of lupiform have as many varieties in severity as we syphilis, because of the resemblance of have in the pustular chain. The varieties their ulcerations to those of lupus,-and like which compose these chains, whether pus- lupus it very often occurs on or about the tular or exanthematic, do not, however, nose. The principles of Treatment form, as it were, merely a straight line, the links of which progressively increase or to be adopted in respect to the varieties of decrease in severity, for they are, in each the exanthematic eruptions, are precisely chain, what may be called collateral links ; those which regulate us in treating the and which depend not merely on a greater pustular eruptions. We endeavour to free or lesser degree of severity of the disease, the system from the disease, with as little exbut, perhaps, on a modification of the poison pence to the constitution as possible ; and which produced the disease. Thus, among at the same time to prevent, as far as in our the pustular group, the bullous and the power, the recurrence of disease in-either tubercular pustules formcollateral variety; the skin or any other part. To accomplish
Prognosis. The prognosis, Gentlemen, of the various eruptions which constitute the exanthematic group, is very different. Among these eruptions will be found some of the
direction, spots
come
754 these
objects
we
are, in
some
varieties, edges with
a
red-hot
iron, introduced into
to have recourse to mercury, and in the vagina by means of a speculum. Reothers, to the hydriodate of potash. The membering the precept of Dupuytren, that former remedy is to be preferred, when the sutures were of no avail against the inju.
obliged
disease is more purely exanthematic ; for example, in the rubeoloid, scaly, and fungous varieties, while the hydriodate of potash is much more suited to the tubercular class, and to these moreand more, according as they show a greater disposition to form groups, or to end in ulceratioiis ; or in other words, according as they appear to bear more alliance with the pustular group. The ulcerations of the exanthematic group are not so much benefitted by the application of the nitrate of silver as those of the pustular group. I have now, Gentlemen, concluded what I had to say respecting the history of the primary and constitutional forms of both the pustular and exanthematic varieties of venereal diseases of the skin; and when I shall have made some further general remarks, which I shall do when we next meet, on those affections of the lymphatic, mucous, osseous, and fibrous systems, and of some other parts, as of the eyes and testis, which are common attendants on those primary and constitutional symptoms which we have already considered, you will, I trust, be fully prepared for an examination of the symptoms and treatment of individual cases, or groups of cases. By these, I shall not only test the accuracy of the general descriptions which I have been giving you, but shall, with their assistance, make you acquainted with the details of many facts, at which I could only glance, when my aim in description was merely to catch at generalities.
ON THE CURE OF
VESICO-VAGINAL FISTULA, AND
LACERATION
By
OF THE
BLADDER
AND
VAGINA.
Professor DIEFFENBACH, of Berlin.
BEFORE I commenced the study of medicine I had occasion to witness an operation for the cure of vesico-vaginal fistula, performed by one of our most celebrated surgeons on a young woman in whom the accident had been produced by difficult labour. The operation lasted several hours, and consisted in an attempt to pare the edges of the fistulous opening with the scissars, and afterwards unite the wound by suture. There was little effort made by nature to heal the wound, and the woman died in a few days from violent inflammation of the bladder and peritoneum. During my stay at Paris, fourteen years ago, I had an opportunity of seeing a patient whom Dupuytren had cured of a narrow
vesico-vaginal
fistula, by
cauterizing its
rious influence of the urine on the wound, and that nothing but the actual cautery was sufficient to excite the necessary degree of action in the edges of the fistula to produce full granulation, I tried this means in several cases of fistula not larger than a hazel-nut in circumference, but I failed in every case. Two attempts made anterior to this by Drs. Baum and Mayer were equally unsuccess-
ful. Some time after these
experiments,
a
of weakly constitution, fifty years of age, came under my care, with a peculiar vesico-vaginal fistula, not the result of labour, but from a tumour which had spontaneously opened into the vagina. The external orifice was half an inch behind the clitoris ; a fine elastic bougie passed ohliquely backwards into the bladder. The urine was discharged periodically, and the woman was sometimes several days without passing any through the fistulous opening. The latter was finally healed by washing and injecting the traject with decoction of camomile flowers, and touching its edges with the tincture of cantharides, the catheter being at the same time employed. 1 was equally fortunate in a second case, which, like the one just mentioned, was very mild. A vesico-vaginal fistula, opening an inch behind the clitoris, was pro’ duced as a result of difficult labour in a woman of thirty years of age. The traject ran obliquely backwards,and communicated with the bladder itself, as I was convinced by careful examination. In this case also the passage of urine through the fistula was only periodical. The treatment, successful in the former case, was repeated, but without any benefit for five weeks. I then freely slit up the anterior portion of the fistulous traject, and afterwards re-united it with a point of suture : a catheter was kept in the bladder, and the parts frequently bathed with cold water. However, on the third day, the thread had cut through one edge of the wound, and a few drops of pus, mixed with urine, flowed out; warm poultices, with camomile fomentations, were immediately applied to the genital organs; and, after a lapse of eight days, I began by sti. mulating the traject of the fistula. By this means the orifice of the fistula was closed in about four weeks; however, in a short time after a small quantity of urine escaped through an opening which was almost im. perceptible ; I therefore dilated this minute canal with a fine cat-gut cord, and was fortunate enough to heal it at length by stimulating the parietes with strong tincture of cantharides. I now conceived some hope of being able to relieve the distressing accident by mrp’ woman