1847] Treatment of Syphilis at Val de Grace. 59 induration existed. The diphtheritic appearance is given this chancre by its surface being covered with the tissue destroyed by the ulcerative process-resembling the pulpous variety of hospital sore-and better named pultaceous. There is, however, a form of simple non-destructive chancre which is covered by a thin white pseudo-membrane, which may be properly termed simple pseudo-membranous chancre. As long as this pseudomembrane continues, cicatrization will not usually take place, but this must not be mistaken for the white pellicle sometimes seen at the circumference of a healing chancre. There were several examples of bleeding or hæmorrhagic chancres-usually very tedious in cicatrizing. Induration. As this is the point upon which M. Ricord's views may be said to hinge, M. Souhaut enters into the subject of induration somewhat elaborately. M. Ricord considers it as an indication that the economy is infected, and that the disease has become constitutional. M. Marchal hardly goes so far as this, believing rather that it is an indication that infection is imminent, unless therapeutical agents are forthwith resorted to. Induration is not always visible, and must be sought for by seizing the base of the sore between the thumb and index finger. It may often be felt in this way when no-wise in relief, giving the sensation of half of a great pea or a semilunar body under the fingers. There is one form which, to the touch, seems like an empty space under the mucous layer, returning upon itself, like a dry leaf, after the pressure is removed. The induration will vary in degree, according to whether mercury has been employed or not. Until it is removed, slight irritation of any kind suffices to re-produce the ulcer. Treatment of Chancre by Cauterization.-Believing that as long as the chancre continues open the danger of general infection of the economy exists, M. Marchal endeavours to bring about a change in its character, and its prompt cicatrization by its destruction by caustic. The nitrate of silver is applicable to a great number of cases, but, in others, where it is desirable to act more deeply, the Vienna paste is preferable. Employed on the prepuce, however, this acts too deeply, and gives rise to the pigeonnest chancre. The cauterization must be repeated as long as there is a pultaceous or pseudo-membranous matter re-produced on the surface of the sore. As soon as the sore puts on a healthy rose-coloured aspect, we must cease. If the chancre is phagedænic, the most active cauterization is indicated. When there are chancres within the prepuce producing phymosis, M. Marchal injects a strong solution of nitrate of silver (2 parts to 20) between this and the glans, morning and evening, using injections of opiated aromatic wine in the intervals. This relieves the pain, soon enables the prepuce to be drawn back, an operation is thus usually averted, and the painful tedious wound which results avoided. If called to a patient, while the sore is still in the form of vesicle, it will be the surgeon's fault if this ever become a chancre. A layer of Vienna paste is to be applied to it and beyond its edges. Although so useful for the prevention or changing the character of chancre, cauterization sometimes causes adenitis, but this proceeding not from venereal absorption, but from irritation, soon subsides. This however should prevent our employing caustic, when, from the healing disposition in the sore, it is not required. For local application to the chancre, M. Marchal employs aromatic wine alone, united with laudanum, if there is much pain and irritation, which this much assuages, or with rhatany, tannin, iodine, &c., when the sore is atonic, or retains a bad aspect in spite of repeated cauterization. In some stationary chancres, seated on the glans, diachylon plaister has served to hasten the reparative process; but in chancres of the prepuce this may induce infiltration. The induration requires treatment for two reasons, namely, that it may oppose or retard cicatrization, and that it is a sign of general infection. For the first reason it must be treated with the Vienna paste, and, for the second one, by the internal use of mercury. So, too, induration persisting after cicatrization, slight irritation may lead to the reproduction of the sore, and, as it indicates the continuance of the constitutional disease, as a general rule mercury must not be discontinued as long as it is present. Its disappearance, which is sometimes exceedingly slow, is always to be looked upon as a proof of the satisfactory action of the specific. Blenorrhagic Epididymitis (Hernia Humoralis.) This disease, in the great majority of cases, is an epididymitis; for, of more than 60 examples in Val de Grace, in only two was the testicle itself affected. On examining the scrotum, the enlarged epididymis may usually be easily felt at some point or another, resembling in shape an acorn and its capsule. The testicle, generally placed in front, retains its characteristic softness, and if pressed, providing the compression do not include the epididymis, no suffering is caused, while acute pain is induced if the epididymis be touched. The error of supposing the testis affected arises from the common occurrence of effusion into the tunica vaginalis, which sometimes becomes exceedingly distended. The treatment employed at Val de Grace as a general rule is antiphlogistic. A general bleeding, and from 20 to 30 leeches being resorted to, repeating these latter (and warm cataplasms) once or oftener. Afterwards, mercurial or opiated camphorated liniments are applied, and pills, containing equal parts of hemlock and calomel, given-the action of the mercury on the mouth being prevented by maintaining a lax condition of the bowels by the aid of injections or Seltzer water. The horizontal position and a spare diet are insisted upon. In spite of this treatment, there is usually left an indurated point of the epididymis, which time alone seems competent to disperse. M. Marchal has very frequently put into practice M. Velpeau's plan of evacuating the serum of the tunica vaginalis by means of numerous punctures, and has observed great relief to the pain, and a more prompt resolution of the inflammation, as the consequences. Frequently, however, the fluid is rapidly re-produced. M. Vidal (de Cassis) has proposed the division (debridement) of the tunica albuginea in parenchymatous orchitis-a variety so rare that in more than 60 cases not one example presented itself. In more than 20 cases M. Marchal tried with great care the plan recommended by M. Songy,* of keeping the scrotum covered with a thick layer of cotton and wool, well supported in a suspen * Medico-Chirurgical Review, No. VII. N. S., page 100. 1847] Novellis on Scorbutus. 61 sory against the external ring, by which means, according to its author, the patient is enabled at once to walk about. In three slight cases this succeeded very well. In several, so great pain was created as to require the instant discontinuance of the attempt, and the rest of the cases remained stationary (save some diminution of pain), and required recourse to be had to antiphlogistics. Several patients, treated antiphlogistically, found the cotton, after the acute stage had disappeared, and while employing ointments and liniments, a better application than poultices. The plan is only of service, therefore, in slight cases. SULLO SCORBUTO INDAGINI, OSSERVAZIONI ED ESPERIENZE DI Carlo Novellis, Dottore nelle Facultà Medico-Chirurgica. [Annali Universali di Medicina, Vol. CXVIII. 1846. Researches, Observations and Experiments concerning Scorbutus. By Charles Novellis, M.D. THE Italian physicians seem to have greater opportunities for the observation of the phenomena of Scorbutus than fall to the lot of their brethren in this part of Europe at the present day-the comparative extinction of a disease which once committed such dreadful ravages, being one of the greatest achievements of modern hygiene. Dr. Novellis, as physician to the military prison of Alexandria, has had a great number of cases under his care, and an abstract of the interesting account of the disease he has furnished to the " Annali Universali," will we doubt not be acceptable to our readers. The term Scorbutus was unknown to the ancients, and Ronseo was the first writer who employed it (in 1564), although long prior to this it was in popular use. Much difference of opinion prevails amongst authors as to whether the disease itself was known to the ancients or not, Dr. Novellis agrees with those who believe in the affirmative, and cites certain passages from Hippocrates and Paulus Ægineta in support of this view. Predisposing Causes.-The principal of these are circumstances which operate changes in the organism, such as tedious convalescence, chronic disease, and cachexia, however induced. In a given number of persons, the indolent and inactive will be those most liable to suffer, and thus, in long voyages, it is upon the marines rather than upon the crew the disease commits its ravages. Hence the necessity of keeping the inmates of prisons employed. A sedentary life, confinement in close places or in the vicinity of foul air, prolonged moral affections-and in fact all that can influence the gastro-hepatic systems, in like manner predispose. If a too inactive life has this effect, so on the other hand have exhausting labours, as the forced marches of armies, &c. The cold and humidity of the climates have been cited as explanatory of the endemic prevalence of the disease in Greenland, Russia, Holland, &c.; but, if this be correct, Dr. Novellis observes some unknown influences must, in other regions, neutralize the effects of these. "In our Alps are districts that, for six months in the year, enjoy not the sun's rays, which are damp, and peopled by filthy peasants, who, for months together, breathe an atmosphere into which a ray of light scarcely penetrates, and who are yet unaffected by this disease. I had an opportunity of verifying the same fact in the valley of the Chison, when on duty at the fortress of Fenestrelle, near where an immense number of districts contain only damp, dirty, dark caves and huts, in which human beings are shut up with the dirtiest animals, fed with the worst aliments, deprived of all fresh articles of diet, especially vegetables-and yet is the scorbutus unknown to the inhabitants of these alpine rocks." Occasional Causes.-Dr. Novellis' investigations lead him to agree with Millman, in assigning indigestible, insufficient, or innutritive food and vehement passions of the mind as the chief causes of the development of this disease; and does not believe in the supposed injuriousness of salted meats, providing these be of good quality and properly prepared. The explanation of the development of the disease during long voyages sometimes defies the ingenuity of the most attentive observers, the vessels being supplied with every appliance conducive to the health of their inmates; while other vessels in defective sanitary conditions entirely escape. "In this point of view the citadel of Alexandria presents circumstances worthy of attention. It possesses two prisons, one civil the other military. The former is exposed to the north and is damp, dark, and badly ventilated. The latter has a north-western aspect and consists of two floors, the ground one being a little damp, but the other perfectly healthy. The civil prisoners were not subjected to any labour, but led completely idle lives, only going into the air for two hours in a kind of court. Their diet consisted of 24 ozs. of bread per diem, 4 ozs. of rice morning and evening, with 4 ozs. of fresh or 2 ozs. of dry vegetables, with butter or lard as a condiment in proportion. After two years of such seclusion, no example of scorbutus presented itself. The military prisoners are usually young and robust, are much in the open air, and actively employed. Their diet is somewhat more sparing (24 ounces in all) than the above, except when very laboriously employed, when it is somewhat increased, and a few ounces of meat and wine added. Among them scorbutus is of very frequent occurrence. "I can only explain this difference by supposing that the civil prisoners, more advanced in years, and leading sedentary lives, are sufficiently nourished; so that a physiological condition of nutrition still being maintained, though amid so many morbigenous causes, they continued exempt from scurvy. I am the more persuaded of the correctness of this opinion, as formerly this civil prison was the receptacle for convicts condemned to hard labour, and who, living upon the poorer diet as the soldiers, were continually scourged by this diseaseassimilation in them being in a vitiated condition." Most writers upon this disease have noticed the agency of the various passions in its production. Dr. Novellis relates the case of an officer confined in a warm, dry, comfortable apartment of the fortress of Fenestrelle, having ample food with exercise in the open air for several hours, but who was firmly persuaded that at a given epoch he should be set at liberty. Disappointed of this he fell into a state of the deepest dejection, under the influence of which scorbutus soon became developed, which obstinately resisted all remedial agency, until at last the desired pardon arriving, joy again illumined his features, and his health was rapidly re-established. 1847] Apyretic or Chronic Form.-Pathology. 63 The powerful effect of humidity upon the development of the disease was shown in the military prison of Alexandria, wherein our author observed thirty cases among those who slept on the ground-floor, and but one in those who slept above-the men being all placed under similar circumstances excepting as regards dormitories. He considers that the cold humidity exhaling from walls is especially pernicious, dampness uniting with heat inducing a different class of affections. The disease has been divided into varieties according to the circumstances under which it has been observed or the nature of dominant theories. Dr. Novellis believes a natural division to be a non-febrile and a febrile variety. Apyretic or Chronic Scorbutus is by far the most common affection, and perhaps no other disease presents so multiform a category of symptoms. It possesses no one pathognomic sign, several concurrent symptoms being required to characterize it. Of these, the chief are a pallor of the countenance, and an expression of melancholy which is sui generis—swollen, red, and bleeding gums-fetid breath-more or less deeply-coloured violaceous spots dispersed over the surface, especially of the lower extremities-pains in the hips and legs-induration or swelling of the calves, knees, or feet-amidst all which infirmities the patient retains his appetite and relish for food, and digests it. These symptoms are liable to endless varieties and anomalies, and none more so than the spots which assume different shapes and colours. Of one of these varieties Dr. Novellis re marks: "Few authors make mention of the granular eruption, cases of which are yet by no means rare. The skin of the lower extremities puts on the aspect of what is called goose-skin,' each little pustule having a livid brownish apex. Rarely do they enlarge, but some of them which have taken on a furuncular aspect I have opened with a lancet and found them to consist of only a subcutaneous sac filled with black blood. Sometimes they cicatrize afterwards and sometimes fill again, but they are always insensible." The progress of the disease may be naturally divided into four stages, namely, the precursory, that of invasion, of increase, and the extreme stage. As the author's description of these in no-wise differs from that usually given we need not cite it. Morbid anatomy, he observes, has, as yet, thrown little light upon the nature of the affection. The post-mortem examination of a person who has so long suffered in every form and in every system of the economy, always presents to the anatomist a mass of strange and inconstant phenomena, useless as a guide to practice." Few parts of the body indeed are there but offer traces of the diseased actions which have prevailed. Pathology of Scorbutus.-The great diversity of opinions that have prevailed upon this subject sufficiently testifies to its difficulty. To cite only some of these: Hippocrates, Celsus, Willis, Riverio and a number of other writers placed the seat of the disease in the spleen; Hoffman in the liver; Murray in the pancreas; Allen and Boerhaave in the blood. Milman, Haller and others opposed this hypothesis. Lind believed the disease to consist in a relaxation of the solids with a tendency of the blood |