ON THE CAUSES, CONSEQUENCES, AND TREATMENT, OF INDURATED CHANCRE.

220

great pain to irritable sores. It must be remembered that these aqueous solutions do not keep well, they should therefore be made in small quantities at a time, in warm weather. The practitioner must not, however, expect the local application of opium to effect any other purpose than that of allaying pain; it will be enough, if, in doing this, opium should prevent the ulceration extending. It must be borne in mind, that the ulceration does not depend upon acute inflammation, as in phagedcena, but upon the effusion into the cellular tissue around the sore, thus strangulating the tissues, and causing their death. This effusion must, as we shall presently see, be removed by general treatment, and which has already been fully alluded to elsewhere.* When called upon to treat simple excoriation on the surface of induration, water-dressing may be resorted to; or if therebe any tendency on the surface of the excoriation to become converted into condylomatous growths, the very best application is sprinkling the parts with calomel, and placing dry lint between the glands and prepuce. I generally

takes place from simple separation of the placenta, the blood is chiefly discharged from the maternal vascular system, and the woman suffers in proportion to the loss, or relatively to her power to bear it. The child suffers comparatively little at first, and probably ultimately more by its being deprived of the vivifying influence of the maternal blood, than on account of a direct loss from its own system. But when the organization of the placenta is broken into, the effects upon the child are very different; the blood now comes from its own vessels, and cannot flow long without causing its death. When born, the blanched white surface of its body is strong evidence of the fatal cause which has led to it. I have endeavoured, in the preceding remarks, to show that the haemorrhage always proceeds from two, and sometimes three, sources, and that it comes not alone from the surface of the placenta, which is partly separated from the uterus. If further evidence is wanted to prove that the blood is profusely poured out from the open extremities of the veins, we have only to recollect that serious and fatal post-partum hmmorrhage frequently occurs when both the child and the placenta are delivered or expelled. February,1847.

cause

object to the employment of ointments, although many surgeons recommend them. I have found greasy applications become quickly rancid, from the heat and secretions of the parts, and thus produce much mischief. The idea formerly prevalent, that mercury would thus enter the system, has nearly exploded, inasmuch as most surgeons now believe that in all these cases, sores present a and not an absorbing surface, and our object is the opposite of encouraging

____

ON THE

CAUSES, CONSEQUENCES,

AND

TREATMENT,

OF

secreting,

INDURATED CHANCRE. BY

WILLIAM

ACTON, ESQ.,

secretion, longer imagine Nature capable of throwing off the peccallt humours, although some still treat syphilis as if this were possible. If, then, by means of one or other of these plans, ulceration, gangrene, or excoriation, has ceased, the induration alone remaining, the next question is, how are we to remove it ?-and various plans have been recommended. In my own private practice, I have derived the greatest benefit from compression. The way I proceed is the following, when the induration is so situated as to permit of my carrying the plan into eifect:—Folding a small pledget of lint, about the size of the induration, I apply it to the surface, and keep it bound down tightly by means of those small Indian-rubber bands now commonly used for tying up letters; they can be had of all sizes, and are admirably adapted for this purpose: they should be broader than usual, or they may be liable to rub the delicate skin of the penis. To prevent this, a piece of lint may be placed between the skin and band. This simple plan I have found the most efficacious, after experimenting as we no

SURGEON TO THE ISLINGTON DISPENSARY, AND FORMERLY EXTERNE TO THE VENEREAL HOSPITALS OF PARIS.

(Continued from p. 12.)

Importance of 1’emoving all causes oj induration;employment of opium, advantage of an aqueous solution" application of wate1’.dressing, calomel, and ointments, con-

LOCAL TREATMENT:

side1’ed.-Compression by means qf Indian-rubber bands recoTAmended.- The plans of excision and cauterization disGENERAL TREATMENT: Course of the disease, if cussed. general treatment be not resorted to; necessity of waiting a few days, before deciding upon giving mercury,’ objections answered. - its it proper to wait until secondary symptoms commence? ? Difference in treatment between the poor and the rich.-Opinions of Sir B. Brodie, Wallcwe, and Ricord, on duration of a course of 1nercury.-Exceptional cases. IN speaking of the treatment of indurated chancre, I shall first allude to local applications, and subsequently dwell on general treatment, although one or the other must be employed to dissipate this formidable symptom. -

with many other substances. Mr. Busk tells me that compression has been long used on board the Dreadnought, by means of a watch-spring, which exercises considerable pressure on the induration, and with the best effects, in cases which have resisted other means of discussion. Authorst have recommended the local destruction of these masses of induration; the quotation given below will, however, show the danger of applying caustic, and Wallace-" corroborates this opinion. I can, from personal experience, speak of the objection to removing masses of induration, in imitation of Delpech,§ by the knife. During the time I was making my investigations on the microscopical appearance of induration, I removed several masses of induration from different persons, and in one instance the surface of the incised wound took on the same indurated appearance, although the original indurated mass had been entirely removed by the knife: I may mention that no mercury had been given to this patient. The case is so far interesting, as pointing out that the germ of the disease extends further than the mere mass of induration, and that something more is required than mere excision, and of which I now purpose to treat.

LOCAL TREATMENT. It has been shown that induration may be attended with simple ulceration, or that gangrene may come on in the centre of the ulceration, or the surface may become excoriated, and, lastly, that induration may exist without the slightest trace of ulceration, or may follow in the spot where a sore has existed, but which may have entirely healed. Now, in either one or other of these cases, the local treatment required may be somewhat different. If the surgeon have reason to believe that the induration attendant on a sore depend upon any irritating application the patient may have used, all such exciting causes must at once be left off, and water-dressing substituted. If induration disappears, the alarm of the surgeon vanishes, and the patient may be assured that he stands in but slight dread of secondary symptoms. If, however, under this treatment, the induration increases, the case comes under one of the heads we are! about to describe. Should the surgeon not be consulted until mollecular ganGENERAL TREATMENT. grene has commenced in the indurated chancre, as delineated in fig. 6 of part ii. plate 2, of my Atlas of Plates on My readers must be already prepared for the statement, Venereal Diseases, water-dressing would alone prove in- that general treatment will be required if we wish to effectually efficacious, and we must have recourse to opium, or the remove specific induration; with the exceptional cases of the ulceration and induration would increase very rapidly. I * Practical Treatise on Venereal Diseases, by Wm. Acton, p. 247, et seq. formerly recommended an ointment composed of calomel andl t Quand ane cicatrice a deja recouvert la tumefaction, nous faisons found . but I have this too entamer cette dernière par la potasse; et a la chute de 1’escarre, ]a plaie opium, frequently application touchée plusieurs fois avec la caustique mercuriel. 11 faut 6tre circonirritating. I usually now desire the patient to use a lotionlest dans 1’emploi de tout autre caustique en pareil cas : ces tuméfactions spect containing two drachms of the watery extract of opium, carede la funeste propriété de passer aisement à 1’etat cancéreux."rubbed of or I order a of fjouissent down in a fully pint water, quantity Delpech. lIlal Veneriens, p. 305. crude opium, the proportions varying from one drachm to} i "But with this recommendation I can by no means coincide; for the half an ounce, to be boiled for half an hour in a pint of water,, application of caustics to these indurations will often cause troublesome and peculiar ulcers and serious consequent disease."-Wrcllace on Venestrained through tow, and the lotion kept constantly to the real, p. 312. sore. I am obliged to have recourse to this solution, as Ir § " Si une sensibilite extreme se faisait remarquer apres chaque cauterifind the spirit, or acetic acid, contained in the preparations oifsation, il faudrait y renoncer et pratiquer 1’excision de la tumeur avec 1’ittthe Pharmacopoeia, even when largely diluted with water*2 strument tranchant."-Detpech, loc. cU., p. 306. ,

.

.

"

*

221

spurious hardened sores alluded to

in a article, local often been obliged to follow the plan. But observe the retreatment alone will fail in removing it. In spite of local sults : the symptoms are more severe, and less tractable, and applications, or when the case has been entirely neglected, the health suffers permanently. It is true that it becomes surgeon observes induration increase, or remain in difficult to distinguish the effects of syphilis, dissipation, exstatu quo for some weeks; secondary symptoms will then posure to cold, bad food, and the mischief of an ill-directed supervene, and we meet with relapses, again and again course of mercury, as all these influences may be brought to recurring, the indurated mass remaining as hard as when it bear upon the mechanic or prostitute unlucky enough to concommenced many months before; or every now and then, its tract syphilis, and it remains for the surgeon to weigh the surface will take on an excoriated or gangrenous appearance, consequences, and choose the lesser evil ; but among the if not controlled by general treatment. upper classes I have no hesitation in recommending the surMuch has been written of late years on the abuses of geon to treat indurated chancre, and not wait until secondary mercury, and every practitioner, whatever his opinion may symptoms appear. If my advice has been followed, the pabe on the subject, hesitates before subjecting a patient to a tient is told the true meaning of induration; and if he is at all a nervous person, he will not like the Damocletian sword held course of mercury; but I presume there are few in the present day who dare to treat indurated chancre without the over his head; he will call upon you to give mercury, and mineral. I have, it is true, met with some few cases that have blame you if you do not. ’Vhen secondary symptoms occur, been under treatment for months, by practitioners who object his friends will say-had you given mercury, these symptoms to mercury generally, but finally admit that indurated chancre would have been prevented. These objections might, howis the exception; it is the only form of syphilis, they say, ever, be overruled; but the surgeon will regret not having which requires mercury. The liomceopathic physicians, even, given mercury when he finds the eruption breaking out over prescribe it, and acknowledge the virulence of the symp- the face of his patient, and no longer amenable to a moderate toms, and that the usual infinitesimal doses are of little course of mercury; and believes, that had the mineral been avail. given, the primary sore, the eruption, (if relapses occurred,) Although, then, I believe that mercury will be absolutely would be slight, and his patient would not attribute blame requisite in specific induration, for the reasons above given, I to his surgeon, but ascribe them to the virulence of the comwould not recommend its employment for the first few days plaint." after the appearance of hardening. I would always advise I may now suppose that mercury is agreed to be given the surgeon to pause before commencing a course of mercury, either internally or by friction, so as to affect the system, and and see if Nature will not cause absorption of the mass, in the through it the sore.* In former papers, and in my work on hope that it may not be of a specific kind. Delay is dangerous venereal diseases, I have dwelt at so great a length on the in many things, but here it is only a wise precaution: in several manner, the dose, the precautions, and consequences of giving instances, it will enable you to avoid mercury altogether, and mercury, that I have no intention of repeating what I have supposing the induration to increase, we may always have re- advanced. There are, however, some points which remain course to the mineral. There are authors who pretend that still to be alluded to; among others, the time necessary for the cure of the indurated mass. As a general rule, the we should give mercury in the earliest stages of chancre, so that the antidote and the poison may enter the system together. mineral should be given as loug as any hardening remains This doctrine might be tenable, provided we held that all around or beneath the sore, and this must vary from a fortchancres require mercury, but as, nine times in ten, primary night to three months.t General rules, however, in this desymptoms do not require mercury, and as, during the first few partment of surgery, admit of a large number of exceptions, days, it is impossible to say ivhat sores will become hard, and as I have frequently had occasion to mention, and as I now therefore be followed by secondary symptoms, we should give propose showing. I have remarked, and I do not remember to have read or mercury unnecessarily in nine cases out often. The advocates of these opinions have not shown that their treatment is more heard of the observation elsewhere, that when induration successful than any other. I have not found it more difficult occurs in a person who has already had secondary symptoms, to treat an indurated chancre that has existed a fortnight than but little mercury is requisite to cure the induration; whereas, one which has become hard during the last few days; I have had secondary symptoms not preceded, probably larger quanobserved no severer secondary symptoms follow the one than tities would have been required. The first instance which the other: why should we then give mercury thus rashly ? directed my attention to the subject was the following:-In However, in advocating caution, I would not be supposed to the summer of 1845, a gentleman contracted chancre, which recommend the surgeon to put off its use for an indefinite became indurated, raised, and the centre took on a gangrenous period: if the hardness does not abate, or if it increases with- action. A simple plan of treatment was followed at first, out any assignable cause, or if gangrene is set up in the centre but at length mercury was resorted to, when what was my of the indurated mass, I would at once commence mercury; for surprise to see the symptoms totally and rapidly disappear. delay can now be of no use, and it is well for the patient Having learnt that this patient had suffered some years beto see, that although you do not choose to give mercury inad- fore from secondary symptoms, I left off mercury a few days vertently, you are not afraid of recommending it when neces- after the entire disappearance of the induration, and my pasary. Patients are often impressed witli the idea that you tient has had no relapse since. At the time I witnessed this avoid giving them mercury as something very dreadful; they case, I was a believer in the doctrine of M. Ricord, that a have heard of noses being lost, and think, by your hesitating, person could not have a second infection followed by seconthat some grand calamity will happento them. These alarms dary symptoms. This case proved, however, that at any rate should be quieted by a true statement of the case; it a,voids indurated chancre could occur in an individual who had had much misunderstanding or misinterpretation. secondary symptoms; and the professor of the Hopital du In consultation, I have heard the following objections to Midi now admits, I believe, that there are exceptions to his my views: " You admit the quantity of mercury must be rule. It is for others to corroborate the opinion I advance, with large, and the duration of a course long, to dissipate indura- some hesitation, as the occurrence of these cases is very rare, tion, and even then you dread the occurrence of secondary but on that account no less interesting, as bearing upon the symptoms; why give mercury at present ? why not wait till treatment of induration. the occurrence of secondary symptoms ? thus you may avoid * Wallace states : " In two courses of mercury." short, genuine primary syphilis will be found parwell suited to mercurial treatment; for there is no medicine whose My reply has been something to the following effect: ticularly beneficial influedee can in way be compared to that of mercury in this " Your objection is valid in manycases among poor patients, form of disease." * * any * Mercury, administered for the cure of inbut cannot be carried into effect among the upper classes for durated syphilis, must be employed in larger doses, and continued for a the following reasons:-A dispensary or hospital out-patient longer time, than in the treatment of the regular form of this disease. doses will often be of no use, and the symptoms will frequently too often considers himself well as soon as the sore is healed; Alterative remain obstinate, until a decidedly mercurial state of the system has been he absents himself, or, it may be, discontinues mercury too produced, after which it will rapidly disappear."—HtHoce, Zoe, cit., p. 309. This frequently happens in consequence of the fear of soon. t Sir B. Brodie says : " If it (mercury) be taken for a primary sore, the losing his work by attending at a public institution, and per- patient should never leave it off until the hard cicatrix has disappeared. You must exhibit it until the sore has healed, and for some time afterhaps not one in ten go through a proper course of mercury. wards."-THE LA.NCET, vol. i. 1843-4, p. 676. it becomes a question, whether Now, as this so often which regulates my conduct in this point of practice, is it be good or bad treatment to give such a man mercury for to The principle persevere with the use of mercury, provided it agree with the system, for an indurated sore, seeing that probably he cannot or will not at least ten days or a fortnight after the induration or contraction have attend the requisite time. Scientifically, the treatment may ceased to diminish; and whatever degree of these states may then remain or to be removed at a future period be right, but the surgeon may be unable to carry it into I leave to the slow operations of Nature, by the knife, in case this should be desired by the patient, for the purpose is the As order of the we practice. expediency day, may of curing a phymosis, or any other inconvenient deformity."-Wallace, loc. have to apply it to the treatment of the poor, and I have ct., p. 313.

previous

the

happens,

11

222 In carrying out the general rule, that mercury should be given as long as induration lasts, the surgeon must not forget, that in old-standing cases, the mass may consist of something more than specific induration, and may be made up of organized tissue, which it is in vain to think of removing by mercury, as is so ably stated by M. Ricord and Wallace.* I have mvself seen persons bearing traces of induration for two years after a course of mercury has been left off, and yet no secondary symptoms follow ; but in these instances it has been impossible, from the situation of the hardened mass, to apply compression. I now generally find these "remains" less common than formerly: the surgeon, however, must be prepared to leave them occasionally, particularly when he thinks lie has given mercury enough, or the constitution of his patient will not allow him to carry it further. In concluding these remarks,I have to apologize to my readers for dwelling so long on the subject of indurated chancre; but let it be remembered that induration is the keystone to the arch of syphilis, and that I have attempted to collect together all the available knowledge which science possesses, and have added my own observations. Much, however, still remains unknown ; and I hope others will undertake the investigation of this scientific question, particularly the influence of climate and treatment on the hardening of sores. Queen-Ann-street, Caceudish-square.

ON A RARE FORM OF DISLOCATION OF THE ASTRAGALUS. BY J. H. MACDONNELL, M.D., Dublin. IN THE LANCET for January 30th, (p. 133,) there is a report from the London Hospital, of a highly interesting and rare case of dislocation of the astragalus, in which the head of this bone was forcibly driven inwards, and slightly upwards, from its connexion with the navicular bone. Mr Adams remarks, that he knows of no recorded case similar to his ; and I am satisfied, after a careful search for such cases, that they are of extreme rareness. No such case is mentioned, as of ordinary occurrence, by Sir A. Cooper, Boyer, Chelius, or Gibson; from which I infer that the dislocation is not in the list of those recognised by the surgeons of England France, Germany, or the United States. I have, however, met with a case very nearly resembling this, which occurred in the person of Mr. Carmichael, the distinguished surgeon of the Richmond Hospital, Dublin, in 1839. The dislocation was occasioned by the sudden fall of Mr. Carmichael’s horse, while lie was moving at a brisk trot. Mr. Carmichael’s weight was thrown, with great violence, on the anterior part of the right foot, which alone came to the ground. About half an hour after the accident, he was seen by Dr. Hutton and myself, when we observed the following deformity. The toes were turned outwards, the inner edge of the foot forming an angle of about thirty degrees, with its natural direction; the sole was slightly turned outwards, and the outer edge slightly elevated. The concavity of the tendoAchillis posteriorly was increased, and the heel lengthened. On grasping the soft parts between the tendo-Achillis and tibia, we found the distance between them much greater than in the other leg. The absence of the hard projection, which would have been formed by the upper part of the astragalus, had it passed backwards with the rest of the tarsus, was evident. Each malleolus was perfectly defined: below and before the inner, there was a hard prominence, over which the skin was tense, formed by the inner surface of the astragalus, brought into relief by the dislocation and the slight eversion of the sole of the foot. Much the most striking * " We will lay down as a general rule, that the surgeon should continue the mercury as long as induration remains. To remove a moderate-sized induration, treatment should be persisted in for six months, p! ovided the mineral produces no ill consequences. But (adds he) a six months’ treatment is no slight matter, and you should not prescribe it except when you are unable to do otherwise; and it would be well for our patient if this could be avoided." Arain, lower down, he says : " We ought to continue mercury until the entire disappearance of the induration around the chancre. But here springs up a difficulty, Is this induration always easy to distinguish? By no means. When this specific induration has been destroyed, there remains sometimes due tüsu i2zodul(iii-e, des tisius de cicatricr, des nodulcs de ti,ySU fihro-cartilaginextse, which may impose upon Mibtrust generally an induration which us as the remains of induration. resists, during six or eight months, a well-regulated mercurial treatment." des I1ópitau,t’. - Ricard, Ga>>ette " lt is, to be observed, that it will not be always in our power to disperse indurations of this kind; for it sometimes happens that a state of hardness and tightening will continue long after the period at which mercury ought to be omitted. Indeed, a state of induration and contraction of the parts which had been the seat of primary syphilis may persist even for life."- WaUl/ceo loco cit., p. 312.

however,

feature of the deformity consisted in

a prominence on the dorsum of the foot. Immediately in front of the tibia, this prominence presented a flat surface, broad, from the tibia forwards, about a finger’s breadth, from which there was an abrupt descent to the anterior part of the tarsus. Over this projection, caused by the head of the astragalus thrown on the upper surface of the scaphoid and cuneiform bones, the integuments were so tense, that it was evident a very small additional force would have driven the astragalus through them. Lastly, on taking the distance from the point of the internal malleolus to the extremity of the great toe with a tape measure, I found it to be almost an inch less than the distance between the same points in the left foot. We could detect no fracture. The foot could be flexed and extended ; but, as any movement occasioned great pain, we did not ascertain to what extent flexion and extension could be carried. There was no obscurity about these deviations from the natural form. There had not been time for inflammatory tumefaction to arise, and no effusion of blood had taken

place.

The conclusion we came to was, that the violence had reo sulted in tearing the astragalus from its bed, on the os calcis, the inferior calcanco-seaphoid ligament, and scaphoid bone, and throwing it on the upper surface of the scaphoid and cuneiform bones. Unlike the case recorded in THE LANCET, we experienced considerable difficulty in the reduction of the dislocation. ’Ve were under the necessity of having recourse to pulleys, and even with their assistance, the reduction was dimcult. A detail of the manner in which the luxation was produced, and of the means used in the reduction, may be seen in the fourteenth volume (p. 235) of the Dublin J01t1’1wl fir Medical Science. Except in the precise direction of the luxation, the London Hospital case was, I think, very similar to this. The reporter (Mr. Adams) would, I am sure, gratify the profession, if he would favour them with a more minute detail than he has given of his very interesting case. Dublin, Feb., 1817.

THE LAW OF THE MORPHOLOGY OR METAMORPHOSIS OF THE TEXTURES OF THE HUMAN BODY. BY WILLIAM

ADDISON, M.D., F.R.S., Malvern. II.—ANIMAL TEXTURES.

IT may with great certainty be affirmed, that the blood contains the elements from which, in animal structures, the solid textures and the secretions arc produced. Blood consists of a limpid fluid, holding in suspension a multitude of cells of two kinds; the one red, the other white or colourless; it may therefore with propriety be termed a cellular or corpuscular fluid. On its first discharge from the living vessels, blood is thin-that is to say, it drops like water, but it speedily becomes viscous or stringy, and then coagulates into a soft solid, which ultimately separates into two parts-a red clot, and a yellow, fluid serum. But blood, before it coagulates, frequently separates into two fluid portions; the uppermost and termed plasma, lymph, or liquor sanguinis, the lower red: both these portions coagulate, so that the solid clot is in part colourless and in part red. The colourless part of the clot, which is uppermost, and formed by the coagulation of the plasma or lymph, is a coherent and elastic fibro-cellular texture, ordinarily termed the buffy coat; it is usually depressed in the centre, with thin, fibrous edges, and there is frequently a viscous, colourless, gelatinous mucus in the cup-like depression, that may be drawn out in strings like

colourless,

ordinary mucus. The microscopic appearances in a film of blood not disposed to exhibit a colourless layer of lymph or plasma, are very different from those of a film of blood that is disposed to do In blood not disposed to exhibit a buffy coat upon the so. clot, we see with the microscope numerous red corpuscles orcells, slightly cohering in strings and rolls, and a few colourless ones floating in a clear, limpid fluid. In blood that is disposed to have a buffy coat upon the clot, we see a much larger proportion of colourless cells, and multitudes of minute molecules floating with the red cells in the clear and limpid fluid; the red cells adhere more firmly to each other, and are congregated in larger and more irregular masses; and in the fluid, a network or tissue of interlaced filaments or fibrils is shortly observed to form. If a film of the colourless fluid, plasma,, or lymph, be separately examined with the mier,)-