SYPHILIS.**

**LUES VENEREA, or French Pox.**

*Siphylis, Sauv. gen. 3086. Lin. 6, Veg. 319. Seg. 126.*

*Lues venerea, Boerh. 1440. Hoffm. III. 413. Junck. 96. Afruc de Lue Venerea.*

Dr Afruc, who writes a very accurate history of the lues venerea, is fully convinced that it is a new disease, which never appeared in Europe till some time between the years 1494 and 1496, having been imported from America by the companions of Christopher Columbus; though this opinion is not without its opponents. Dr Sanches in particular has contended with much learning and ability, that it appeared in Europe at an earlier period: But it is at least certain that it was altogether unknown to the medical practitioners of Greece and Rome, and that it was a very common disease in America when the Europeans first visited that country. But at whatever period it may have been introduced into Europe, or from whatever source it may have been obtained, there can be no doubt that, as well as smallpox or measles, syphilis depends on a peculiar specific contagion; on a matter *sui generis*, which is alone capable of inducing this disease.

The venereal infection, however, cannot, like the contagious maladies of the smallpox and some other diseases, be carried through the air, and thus spread from place to place: for unless it is transmitted from the parents to the children, there is no other way of contracting the disease but from actual contact with the infectious matter. Thus, when a nurse happens to labour under the disease, the infant that she suckles will receive the infection; as, on the other hand, when the child is infected, the nurse is liable to receive it; and there have even been instances known of lying-in women being infected very violently, from having employed a person to draw their breasts who happened to have venereal ulcers in the throat. It may be caught by touching venereal sores, if the cuticle be abraded or torn; and in this way accoucheurs and midwives have sometimes been infected severely. Dr Macbride says, the most inveterate pox he ever saw was caught by a midwife, who happened to have a whitelow on one of her fingers when she delivered a woman ill of the lues venerea.

But by far the most ready way of contracting this disease is by coition, the genital parts being much more bibulous than the rest of the body. When the disorder is communicated, the places where the morbid matter enters are generally those where it first makes its appearance; and as coition is the most usual way of contracting it, so the first symptoms commonly appear on or near the pudenda.

The patient's own account will, for the most part, help us to distinguish the disease: but there are sometimes cases wherein we cannot avail ourselves of this information, and where, instead of conferring, the parties shall conceal all circumstances; while, on the other hand, there are now and then people to be met with, who persuade themselves that symptoms are venereal, which in reality are owing to some other cause: and therefore it is of the utmost importance to inform ourselves thoroughly of the nature of those symptoms and appearances which may be considered as pathognomonic signs of lues venerea.

In the first place, when we find that the local symptoms, such as chancres, buboes, phymosis, and the like, do not give way to the usual methods; or when these complaints, after having been cured, break out again without a fresh infection; we may justly suspect that the virus has entered the whole mass of fluids: but if at the same time ulcers break out in the throat, and the face is deformed by callous tubercles, covered with a brown or yellow scab, we may be assured that the case is now become a confirmed lues, which will require a mercurial course.

When eruptions of the furfuraceous and superficial kind are venereal, they are not attended with itching; and the scale being picked off, the skin appears of a reddish brown, or rather copper colour, underneath; whereas leprous eruptions are itchy, throw off a greater quantity of scales, and rise in greater blotches, especially about the joints of the knees and elbows. Venereal tubercles or pustules are easily distinguished from carbuncles of the face, by not occupying the cheeks or the nose, nor as having a purulent apex, but are covered at top, either with a dry branny scurf like the superficial eruptions just now mentioned, or else with a hard dry scab of a tawney yellow hue; they particularly break out among the hair or near to it, on the forehead or on the temples.

Venereal ulcers affecting the mouth are distinguishable from those which are scorbatic, in the following manner: 1. Venereal ulcers first affect the tonsils, fau- ces and uvula; then the gums, but these very rarely; on the contrary, scrofulous ulcers affect the gums first of all; then the fauces, tonsils, and uvula. 2. Venereal ulcers frequently spread to the nose; scrofulous ones almost never. 3. Venereal ulcers are callous in the edges; scrofulous ones are not so. 4. Venereal ulcers are circumscribed, and, for the most part, are circular, at least they are confined to certain places; scrofulous ones are of a more irregular form, spread wider, and frequently affect the whole mouth. 5. Venereal ulcers are for the most part hollow, and generally covered at bottom with a white or yellow flough; but scrofulous ones are more apt to grow up into loose fungi. 6. Venereal ulcers are red in their circumference, but scrofulous ones are always livid. 7. Venereal ulcers frequently rot the subjacent bones, the scrofulous ones seldom or never. 8. And lastly, Venereal ulcers are generally combined with other symptoms which are known to be venereal; scrofulous ones with the distinguishing signs of the scurvy, such as difficult breathing, little breathes, swelling of the legs, rotten gums, &c.

Another strong sign of the confirmed lues is often afforded from certain deep-seated nocturnal pains, particularly of the thins, arms, and head. As for any superficial wandering pains that have no fixed seat, and which affect the membranes of the muscles and ligaments of the joints, they, for the most part, will be found to belong to the gout or rheumatism, and can never be considered as venereal unless accompanied with some other evident signs; but with regard to the pains that are deeply seated, and always fixed to the same place, and which affect the middle and more solid part of the ulna, tibia, and bones of the cranium, and rage chiefly and with greatest violence in the forepart of the night, so that the patient can get no rest till morning approaches, these may serve to convince us that the disease has spread itself throughout the whole habit, whether they be accompanied with other symptoms of the lues or not. Gummatous in the fleshly parts, nodos in the periosteum, ganglia upon the tendons, tophi upon the ligaments, exostoses upon the bones, and fisti at the verge of the anus, are all of them signs of the confirmed lues; these are hard indolent swellings; but as they sometimes arise independently of any venereal infection, and perhaps may proceed from a scrophulous taint, unless they be accompanied or have been preceded by some of the more certain and evident symptoms of the lues, we must be cautious about pronouncing them venereal. When these swellings are not owing to the syphilitic virus, they are very seldom painful, or tend to inflame and suppurate, whereas those that are venereal usually do, and if they lie upon a bone generally bring on a caries.

These carious ulcers are most commonly met with upon the ulna, tibia, and bones of the cranium; and when accompanied with nocturnal pains, we can never hesitate about declaring their genuine nature. Frequent abortions, or the exclusion of scabby, ulcerated, half-rotten, and dead fetuses, happening without any manifest cause to disturb the fetus before its time, or to destroy it in the womb, may be reckoned as a sign that at least one of the parents is infected.

These then are the principal and most evident signs of the confirmed lues. There are others which are more equivocal, and which, unless we can fairly trace them back to some that are more certain, cannot be held as signs of the venereal disease: Such are, 1. Oblitinate inflammations of the eyes, frequently returning with great heat, itching, and ulceration of the eyelids. 2. A ringing and hissing noise in the ears, with ulcers or caries in the bones of the meatus auditorius. 3. Oblitinate headaches. 4. Oblitinate cutaneous eruptions, of the itchy or leprous appearance, not yielding to the milder methods of treatment. 5. Swellings of the bones; and, 6. Wandering and oblitinate pains. None of these symptoms, however, can be known to be venereal, except they happen to coincide with some one or other of the more certain signs.

It may, perhaps, be considered as a singularity in this disease, that the diagnosis is often more difficult in the advanced than in the early periods of the affection. That is, with those who have been certainly subjected to syphilis, it is often very difficult to say whether certain symptoms, remaining after the ordinary modes of cure have been employed, be syphilitic or not. Very frequently, as appears from the sequel, nocturnal pains, ulcerations, and the like, remaining after a long course of mercury has been employed, are in no degree of a venereal nature, but are in reality to be considered as consequences rather than the remedy than of the disease; and are accordingly best removed by nourishing diet, gentle exercise, and tonics. But as long as any symptoms of any kind remain, it is often impossible to convince some patients that they are cured; and it is often impossible for a physician with certainty to affirm that the disease is altogether overcome.

Upon the whole, we are first to distinguish and consider the several symptoms apart; and then, by comparing them with each other, a clear judgement may be formed upon the general review.

Prognosis. Being thoroughly convinced that the case is venereal, we are to consider, first of all, whether it be of a longer or shorter date; for the more recent it is, it will, ceteris paribus, be less difficult to remove. But there are other circumstances which will assist us in forming a prognostic as to the event. As,

1. The age of the patient. This disorder is more dangerous to infants and old people, than to such as are in the flower and vigour of life, in whom some part of the virus may be expelled by exercise, or may be subdued in some degree by the strength of the constitution.

2. The sex. Though women are for the most part weaker than men, and therefore should seem less able to resist the force of any disease, yet experience shows that this is easier borne by them than by men; perhaps owing to the menstrual and other uterine discharges, by which a good portion of the virus may be carried off immediately from the parts where it was first applied; for it is observable, that whenever these discharges are obstructed, or cease by the ordinary course of nature, all the symptoms of this disease grow worse.

3. The habit of body. Persons who have acrid juices will be liable to suffer more from the venereal poison than such as have their blood in a milder state; hence, when people of a scrofulous or scrophulous habit contract venereal disorders, the symptoms are always remarkably violent, and difficult to cure. And for the same reasons, the confirmed lues is much more to be dreaded in a person already inclined to an asthma, phthisis, dropsy, gout, or any other chronic distemper, than in one of a sound and healthy constitution. For as the original disease is increased by the accession of the venereal poison, so the lues is aggravated by being joined to an old disorder. The more numerous the symptoms, and the more they affect the bones, the more difficult the cure. Of all combinations the union of syphilis with phthisis is perhaps the most difficult to overcome; but if the acrimony should seize on the nobler internal parts, such as the brain, the lungs or the liver, then the disease becomes incurable, and the patient will either go off suddenly in an apoplectic fit, or sink under a consumption.

Cure. Viewing this disease as depending on a peculiar contagious matter introduced into the system, and multiplied there, it is possible to conceive that a cure may be obtained on one of three principles; either by the evacuation of the matter from the system, by the destruction of its activity, or by counteracting its influence in the system. It is not impossible that articles exist in nature capable of removing this complaint on each of these grounds: but we may venture at least to assert, that few such are yet discovered. Notwithstanding numbers of pretended infallible remedies for syphilis, mercury is perhaps the only article on which dependence is placed among European practitioners; and with regard to its mode of operation, all the three different opinions pointed out have been adopted and supported by different theorists.—But although many ingenious arguments have been employed in support of each, we are, upon the whole, inclined to think it more probable that mercury operates by destroying the activity of the venereal virus, than that it has effect either by evacuating it, or by exciting a state of action by which its influence is counteracted. Some practitioners have affirmed, that the disease may be totally extirpated without the use of mercury; but, excepting in slight cases, it appears from the most accurate observations, that this grand specific is indispensable; whether it be introduced through the pores of the skin, in the form of ointments, plasters, washes, &c.; or given by the mouth, disguised in the different shapes of pills, troches, powders, or solutions.

Formerly it was held as a rule, that a salivation ought to be raised, and a great discharge excited. But this is now found to be unnecessary: for as mercury probably acts by some specific power in subduing and correcting the venereal virus, all that is required is to throw in a sufficient quantity of the medicine for this purpose; and if it can be diverted from the salivary glands so much the better, since the inconveniences attending a spitting are such as we should always wish to avoid.

Mercury, when combined with any saline substance, has its activity prodigiously increased; hence the great variety of chemical preparations which have been contrived to unite it with different acids.

Corrosive sublimate or the murias hydrargyri corrosivus is one of the most active of all the mercurial preparations, insomuch as to become a poison even in very small doses. It therefore cannot safely be given in substance; but must be dissolved in order to render it capable of a more minute division. We may see, by looking into Wisseman, that this is an old medicine, though seldom given by regular practitioners. How it came to be introduced into so remote a part of the world as Siberia, is not easily found out; but Dr Clerc, author of the Histoire Naturelle de l'Homme Malade, assures us, that the sublimate solution has been in use there time out of mind.

It appears to have been totally forgotten in other places, until of late years, when Baron Van Swieten brought it into vogue; so that at one period, if we may credit Dr Locker, they used no other mercurial preparation at Vienna. The number of patients cured by this remedy alone in the hospital of St Mark, which is under the care of this gentleman, from 1754 to 1761 inclusive, being 4880.

The method of preparing the solution is, to dissolve as much sublimate in any kind of ardent spirit (at Vienna they use only corn brandy) as will give half a grain to an ounce of solution. The dose to a grown person is one spoonful mixed with a pint of any light pithan or barley water, and this to be taken morning and evening: the patients should keep principally in a warm chamber, and lie in bed to sweat after taking the medicine; their diet should be light; and they ought to drink plentifully throughout the day, of whey, pithan, or barley water. If the solution does not keep the belly open, a mild purge must be given from time to time; for Locker observes, that 'those whom it purges two or three times a day, get well sooner than those whom it does not purge: he also says, that it very seldom affects the mouth, but that it promotes the urinary and cutaneous discharges. This course is not only to be continued till all the symptoms disappear, but for some weeks longer. The shortest time in which Locker used to let the patients out was six weeks; and they were continued on a course of decoction of the woods for some weeks after they left off the solution.

This method has been introduced both in Britain and Ireland, though by no means to the exclusion of others; but it appears, that the solution does not turn out so infallible a remedy, either in these kingdoms, or in France, as they lay it has done in Germany. It was seldom if ever found to perform a radical cure, and the frequent use of it proved in many cases highly prejudicial. It has therefore been succeeded in practice, even at Vienna, by mercury exhibited in other forms; and, among these, by a remedy first recommended by Dr Plenck, and since improved by Dr Saunders; consisting of mercury united with mucilage of gum arabic, which is said to render its exhibition perfectly mild and safe. For particulars, we refer to Dr Saunders's treatise.

But a late French writer, supposed to be Dr Petit, in a small book, entitled, A parallel of the different methods of treating the venereal disease, infers, that there is neither certainty nor safety in any other method than the repeated frictions with mercurial ointment.

If, therefore, it is determined to have recourse to the mercurial frictions, the patient may with advantage be prepared by going into the warm bath some days successively; having been previously blooded if of a plethoric habit, and taking a dose or two of some proper cathartic. The patient being fitted with the necessary apparatus of flannels, is then to enter the course.

If he be of a robust habit, and in the prime of life, we may begin with two drams of the unguentum hydrargyri fortius, (Ph. Lond.) which is to be rubbed in about the ankles by an assistant whose hands are covered with bladders; then having intermitted a day, we may expend two drams more of the ointment, and rest for two days; after which, if no soreness of the mouth comes on, use only one dram; and at every subsequent friction till the ointment shall reach the trunk of the body; after which the rubbings are to be begun at the wrists, and from thence gradually extended to the shoulders. In order to prevent the mercury from laying too much hold of the mouth, it must be diverted to the skin, by keeping the patient in a constant perspiration from the warmth of the room, and by drinking plentifully of barley-water, whey, or pifan; but if, nevertheless, the mercury should tend to raise a spitting, then, from time to time, we are either to give some gentle cathartic, or order the patient into a vapour or warm bath; and thus we are to go on, rubbing in a dram of the ointment every second, third, or fourth night, according as it may be found to operate; and on the intermediate days either purging or bathing, unless we should choose to let the salivation come on; which, however, it is much better to avoid, as we shall thus be able to throw in a larger quantity of mercury.

It is impossible to ascertain the quantity of mercury that may be necessary to be rubbed in, as this will vary according to circumstances: but we are always to continue the frictions, for a fortnight at least, after all symptoms of the disease shall have totally disappeared; and when we have done with the mercury, warm bathing, and sudorific decoctions of the woods, are to be continued for some time longer.

This is a general sketch of the methods of treatment for the confirmed lues; but for a complete history of the disease, and for ample directions in every situation, we refer to Afric, and his abridger Dr Chapman.—We have to add, however, that a method of curing this disease by mercurial fumigation has been lately recommended in France, but it seems not to meet with great encouragement. One of the most recent proposals for the cure of the venereal disease is that of Mr Clare, and consists in rubbing a small quantity of mercury under the form of the fulminaris hydrargyri, or calomel as it is commonly called, on the inside of the cheek; by which means it has been supposed that we will not only avoid the inconveniences of union, but also the purgative effects that are often produced by this medicine when taken into the stomach. But after all, the introduction of mercury under the form of unction, as recommended by the latest and best writers in Britain on the venereal disease, Dr Swedjaur, Mr John Hunter, and others, is still very generally preferred to any mode that has yet been proposed.

Where, after a long trial of mercury, distressing symptoms still remain, particularly obstinate ulcerations and severe pains, benefit has often been derived from the use of opium: but there is little reason to believe, as has been held by some, that of itself it affords an infallible cure of this disease; at least we are inclined to think, that all the facts hitherto brought in support of the cure of syphilis by opium are at the utmost very doubtful.

The same observation may perhaps be made with regard to another remedy which has of late been highly extolled in syphilis, viz. the nitric acid. This article seems to have been first introduced both against affections of the liver and venereal complaints by Dr Scott of Bombay. It has since been highly extolled by Dr Beddoes and other writers in Britain. And there are many well authenticated cases on record in which it has produced a cure. But it is very rarely preferable to mercury; and it is chiefly useful when, from some peculiarity of constitution, mercury cannot be exhibited.

In obstinate ulcerations, remaining probably after the venereal virus has been overcome, and resisting the use of mercury, a complete cure has in many instances been obtained from the use of the root of the mezereon, the daphne mezereum of Linnæus. This article has been chiefly employed under the form of decoction; and it now appears that it is the basis of an article at one time highly celebrated in venereal complaints, under the title of Lisbon diet drink. But, upon the whole, these sequelae of this disease are perhaps more readily overcome by country air, gentle exercise, and nourishing diet, particularly a milk diet, than by the use of any medicine whatever. It must indeed be allowed, that for combating different sequelæ, various practices accommodated to the nature of these will on particular occasions be requisite. But into the consideration of these we cannot here propose to enter.