WWLh K54IU. IS4S ARMY MEDICAL. LIBRARY WASHINGTON Founded 1836 Section. Number 1.3.3 ° 2 1 Form 113c, W. D., S. G. O. ofo 3—10543 (Revised June 13, 1936) t?Ni-^^*5s LAST DATE LECTURES m VENEREAL AND OTHER DISEASES ARISING FROM SEXUAL INTERCOURSE. DELIVERED IN THE SUMMERJ0F 184T, AT THE H^PITAL DU ipj^I, PARIS, "> f .// BY M. RICOED. ww******"' BY VICTOR DE MERIC, M.D., M.R.C.S.E. 3 3 > After having prescribed copaiba, I desired him to eva- cuate the contents of the bladder solely through the fistula. A few days afterwards, the discharge from the portion of the urethra situated posteriorly to the fistula had entirely disappeared, but it persisted in the part anterior to it. I continued the use of copaiba, but advised the whole of the urethra to be moistened by the urine ; in fact, I told him to allow his water to pass through the meatus. This settled the matter in a few days, and the spongy portion of the urethra was soon freed from all discharge. These facts will, I hope, suffice to prove the special action of copaiba. Some people have thought, in arguing from these un- doubted properties of the substance, that blennorrha- gia might be cured by applying the balsam directly 72 TREATMENT OF upon the affected mucous membrane; but this mode of administration has never succeeded ; and besides not curing the disease, it irritates the parts very much. Copaiba may be used in three different ways: first, by direct application : this has been entirely aban- doned ; secondly, as an agent upon the intestinal canal, being introduced by the mouth ; and as a similar agent, thrown into the rectum. Casualties to which copaiba may give rise.—It occa- sions, for the most part, very disagreeable eructations; vomitings, which are caused either by an insurmount- able repugnance, or by a gastric irritation; diarrhoea, brought on either by intolerance of the remedy, or an irritable state of the bowels; it may even produce en- teritis. Vomitings which are induced by repugnance or by intolerance are accidents yielding no benefit as regards the cure of the disease; but the diarrhoea which is produced by intolerance of the remedial agent may, on the contrary, be very beneficial. Co- paiba acts very rarely on the nervous centres, but in certain cases, congestion of the brain has been known to be the result of its administration, and in such cases the medical adviser is of course obliged to give it up. The use of copaiba sometimes gives rise to a cutaneous irritation, which may go so far as to pro- duce an exanthematous eruption. It is especially during the autumn and the spring, that this is liable to occur, and the rash usually makes its appearance soon after the first few doses. The most common of these eruptive forms are: roseola, lichen urticatus, and even sometimes urticaria. I have sometimes seen an eczema, and the different varieties of erythema, follow the use of copaiba ; but roseola is the most usual eruption connected with the use of this substance. Its appearance is preceded and followed by rather severe itching, and the patches, either disseminated or grouped together in certain parts of the body, are of a vinous, lively, and shining BLENNORRHAGIA. 73 colour. The cutaneous phenomenon may extend all over the frame, and be almost instantaneous; if par- tial, I am not aware that it shows a preference for any particular region, but its principal character is an evi- dent tendency to concentration upon isolated points. It often breaks out over the large joints, and mostly on the side where the extension of the limb is per- formed ; also behind the ears, and sometimes on the posterior part of the neck. Febrile disturbance never accompanies the eruption, unless the latter be connect- ed with a particular state of the system, which may ac- count for the pyrexia. If all these characters were not sufficient to establish an accurate diagnosis of the nature of the cutaneous manifestations, there is a pa- thognomonic one which will at once clear up any doubts—namely, the rapid disappearance of the erup- tion on the cessation of the copaiba. This roseola generally fades away from the first to the eighth day, after the balsam has been left off. This peculiarity alone (if attended to) would have been sufficient to prevent all mistakes; but it has too often happened, that many of those practitioners who confine them- selves to these diseases, and who ought to have known better, have confounded this exanthematous eruption with secondary syphilis. Copaiba may likewise give rise to another accident, which has led some astray : I allude to lumbar pains, which have so often been mistaken for symptoms de- pending on urethral mucitis. Patients placed under the influence of this substance are often attacked by a sharp pain in the lumbar region, which they com- pare to the reception of repeated blows. Do not fall into error on this head, and be careful not to set this down to blennorrhagic nephritis, as some have done. For if renal blennorrhagia were looked upon as the cause of these pains, it would turn out to be a very frequent complication of the disease ; whereas, on the contrary, it is extremely rare. A proof of the correct- 7 74 M. RICORD'S DEFENCE OF ness of the opinion which ascribes the lumbar pain to copaiba alone, may be obtained in a couple of days in most of the cases we have to treat. Let the drug be given up, and all the uneasiness in the back will disappear, thereby setting aside any idea that it de- pended on the extension of the blennorrhagia to the kidneys. LECTURE VIII. M. RICORD'S DEFENCE OF THE NEW DOCTRINE. Before I proceed to the consideration of the second portion of our inquiries—viz., the study of the viru- lent venereal diseases, I must beg leave to interrupt the methodical order we have hitherto followed in the history of the venereal affections, as the Acade- mie de Medecine, a learned body, whose scientific worth is so generally acknowledged, has just thought fit, in consequence of a paper on syphilis being re- ported upon, to discuss the new doctrines which I am advocating. Since I cannot defend my opinions viva voce among these gentlemen, not having the honour of a membership, I am induced to make use of this channel, in order to answer, in a few words, the ar- guments which have been brought against me. You, of course, understand that there cannot be any ques- tion about persons, I have only to deal with opinions, and when these are openly discussed, I think I have a right to take hold of them and examine them with unflinching impartiality. I am actuated by the love of truth, and by a sincere wish to promote the inte- rests of science, and I am, moreover, anxious that you should become acquainted with all the bearings of the question Two very important points have been discussed: first, that eternal hankering about the THE NEW DOCTRINE. 75 identity of blennorrhagia and chancre—an identity which is said to exist both in their nature, kind, spe- cific cause, and consequences, the latter circumstance being particularly dwelt upon, as both affections seem to produce secondary symptoms, similar in their na- ture but different in their form. The second point at issue is, the abortive treatment of blennorrhagia and chancre. You know how often, in this hospital, I have succeeded in showing you why secondary symp- toms sometimes appear to be the result of a simple blennorrhagia. On these occasions, I have proved that, strictly speaking, virulent blennorrhagia differs in no ways from chancre, for you have, in both, the same causes, the same lesions, the same consequences; and I hope I have left no doubt in your minds about the following axiom—Virulent blennorrhagia is the result of a urethral chancre. The foundation of this doctrine does not rest upon assertions of patients concerning the ailments they had twenty or twenty-five years ago, but upon the close watching of the sick, independently of their own tale. I firmly believe in the existence of ure- thral chancre, because 1 have seen it, both in the living and the dead. I will not say, like some people, that I have been fortunate enough to make a post-mortem examination on any patient of mine affected wTith blennorrhagia, but I will rather say,.that I have had the misfortune to lose some patients, in whose ure- thra I have found chancres. I have shown these pathological preparations to the Academie de Mede- cine, they were there recognised as genuine, and the committee appointed to report upon my communica- tion acknowledged the real existence of chancres, situated in the spongy, and some even in the mem- branous portion of the urethra. Now these were palpable facts, and it is only from such undeniable data, and after having thus seen the urethral chancre, that I drew the conclusions which have been so often 76 M. RICORD'S DEFENCE OF attacked since. In order to prove the possibility of chancre being placed so far back in the canal of the urethra, I have brought forward an argument which I beg now to mention again, and you may convince yourselves how rigorously correct is my mode of rea- soning, by observing the patient lying at No. 10 in the fifth ward. This argument may be briefly stated as follows:—A urethral chancre in the balanic region is very common ; in many cases you need but hold the lips of the meatus slightly apart to see it very plainly. This fact no one denies. Now this chancre may extend backwards in such a way that its anterior margin may be perfectly apparent, whilst its posterior limit may be entirely hidden to the eye, and this often takes place in cases which, in other respects, do not admit of the slightest doubt. It is plain, then, that this posterior limit escapes our observation ; but is this a reason for denying its existence ? This chan- crous ulceration must of course end somewhere or other behind the point which comes under the cogni- zance of your eye. But why should the chancre not just as well begin as end in parts which you cannot see? Is not this a fair deduction ? All that part of the canal that you can open to view may be healthy, whilst the posterior division may be affected with chancres. Reasoning alone might convince the most incredu- lous, but I will now state an actual proof. You are aware that my opponents call blennorrha- gia any discharge from the urethra, whether it be purulent, muco-purulent, &c. Now, you have all seen a patient lying in No. 16 of the third ward ; his symptoms were, on admission, purulent secretions per urethram, so that he would have been classed, by those who antagonize my opinions, among the blen- norrhagic category. A few days subsequently, we saw, at the meatus, a chancre, which no doubt had extended from behind forwards, since no trace of any thing of the kind had been found on admission. THE NEW DOCTRINE. 77 I might almost say that the urethra had driven for- ward its chancre to give you a sight of it. But if all this is not sufficient, how could the experiments which I daily perform here be resisted ? I take two patients, one affected with purulent balano-posthitis, and the other with chancre on the glans. I retract the prepuce in both cases, and I inoculate each with his own pus. The first invariably yields a negative result—viz., the inoculation does not take ; in the second, we always produce a chancre. In proceed- ing in this manner, we plainly see the parts affected and the results obtained. But if you were to try the same experiment over again, without raising the pre- puce from the glans, and merely collect the pus which issues from the preputial orifice, do you think that the result of this second trial would not be exactly the same as that of the first? The phenomena are the same; but in the one case you see whence the discharge proceeds—in the other you do not. Now, why should it be otherwise, when we operate com- paratively upon pus from simple blennorrhagia, and pus from blennorrhagia symptomatic of chancre ? I fearlessly ask whether it is logical or consequent to resist facts and arguments like these ? M. Gibert, who says that my doctrines have found a great many supporters (your presence here shows that herein he is not mistaken), maintains that my hypothesis of a urethral chancre is an error. But how does he at- tempt to prove that there are virulent blennorrhagiae without that ulceration which, in my opinion, is their necessary starting point ? How does he try to con- vince people of the non-identity of chancre and viru- lent blennorrhagia ? Merely by stating that he never saw a urethral chancre. But how can I help that? Feeling his weakness he calls Hunter to his assist- ance, and says that this great physiologist made a post-mortem examination of two culprits who had blennorrhagia upon them when they were executed; 7k 78 M. RICORD'S DEFENCE OF that he opened the urethra, and found no ulcerations. Of course he did not, since these men had only sim- ple blennorrhagia. If he had met with chancres, the case would no longer have been a blennorrhagic one, but a case of urethral chancre. Hunter found what might, a, priori, have been expected—viz., a simple inflammation of the mucous membrane. The facts cited by Morgagni are of the same description ; he, like Hunter, like Gimelle, performed the necropsy of four blennorrhagic subjects, and found no ulcerations, nor was it possible that he should find any. But the important question is this,—Was there one among all these individuals who, being merely affected with a phlegmasia of the mucous membrane, at the time when the post-mortem examination was made, had secondary symptoms upon him, proving that the sys- tem had been contaminated by blennorrhagia without the concurrence of chancres'? Not one. They all had blennorrhagia, but nothing more, and chancres in the urethra were out of the question. But Morgagni, who is always brought forwards, and from whose works people are so fond of deriving a little support for their views,—Morgagni, who searched in vain for ulcerations in the urethra of subjects who had died with blennorrhagia, had discovered urethral cica- trices upon some of the bodies he examined. Now it is clear that these cicatrices must have been pre- ceded by loss of substance and destruction of tissues; so that we may conclude that Morgagni has examined some subjects who, at their deaths, were affected with blennorrhagia, and who neither had nor could have urethral chancres, and others who really had had such chancres, as proved by the cicatrices found upon them. My learned friend, M. Velpeau, does not deny the possibility of urethral chancre ; he is too sensible to contend against averred facts, but he adds that they must be very rare. He states that he saw patients affected with secondary and tertiary symp- THE NEW DOCTRINE. 79 toms twenty or twenty-five years after simple blen- norrhagia. I do not doubt it; I and many others have met with similar cases. But I may ask, and this is an important point,—Who diagnosed these patients' affections ? Who can come forward now, as having, so long ago, seen and observed the blen- norrhagia which is accused of having brought on this secondary mischief after so many years ? We have no one to refer to but the patients themselves; and how could they make out whether their disease was simple blennorrhagia or a discharge symptomatic of urethral chancre, when we medical men find it so dif- ficult to distinguish these two affections ? In circum- stances like these, nothing can be decided without actual experimentation. What value can we there- fore attach to cases of so doubtful a nature ? Again, it is urged : " The number of people who have se- condary symptoms after simple gonorrhoea is too large to allow us to suppose that they all had ure- thral chancres." But where are your figures ? Who stands for the veracity of patients? Must we not take into account all the licit and illicit modes of in- fection ? Have any facts been strictly watched and carefully verified during any lapse of time—say, fif- teen or twenty years ? Nay, had thirty and even forty or fifty cases been sc/aped together—a number which, in the eyes of many medical men, would be very large, how could these militate with the hun- dreds of cases of blennorrhagia which every year pass through these wards without any secondary symptoms ? Another member, who, like M. Vel- peau, is a professor of the faculty, said,—" When- ever I have opened the urethra of a subject affected with blennorrhagia, I always found swelling, red- ness, &c, but never any chancres." But this is plain enough, and I can only repeat what I was say- ing just now : These patients had simple blennorrha- gia only ; they could, of course, have no chancres in 80 M. RICORD'S DEFENCE OF their urethras ; and besides, this is merely talking of the few cases which have died, and no wonder that nothing like a chancre was found, for the urethral variety is very rare. For my part, in the space of sixteen years, I have only met with two subjects who, on a post-mortem examination, presented chancres in the posterior part of the urethra. Another distin- guished surgeon, M. Roux, so extensively known both by his skill and honourable conduct, is also against me, and will give no belief to the existence of the urethral chancre ; but he adduces no argument to support his incredulity ; he merely says that such is his intimate conviction. Of course I cannot dis- cuss convictions ; we require facts in the study of science — convictions have no weight. As for M. Lagneau, who some time back reported on my pa- per, and himself presented to the Academie the pa- thological preparations which I sent along with it, he states it to be his opinion, that out of ten thousand cases of blennorrhagia, there is not one where the discharge is kept up by a urethral chancre ; yet it was he who established from my preparations that the existence of chancre in the canal of the urethra is an acknowledged fact. But where are the cases which prove his opinions?—where are the necrop- sies ? There is nothing of the sort brought forward ; all that is offered are—convictions and strong belief: that goes for naught. People rarely die of blennor- rhagia, or during its continuance : this explains how, in the course of sixteen years, I have only twice found the urethral chancre in the posterior part of the urethra, in the many post-mortem examinations I made. As the number of persons labouring under blennorrhagia with whom I come in contact is infi- nitely above the number of those who die with the disease upon them, it is not surprising that I should have more opportunity of finding the urethral chan- THE NEW DOCTRINE. 81 ere on the living than on the dead. It is generally by pressure that its presence can be made out. Since January last, I have had no less than ten cases of blennorrhagia symptomatic of urethral chan- cre. The diagnosis and prognosis of these cases were clearly made by means of comparative experi- mentation, and I then showed that the urethral chan- cre may be followed by secondary symptoms, but that simple blennorrhagia has no such sequelae. I may, then, safely say that the attacks directed against my doctrines have in no way invalidated them, that my arguments have not been met, that the non-symp- tomatic blennorrhagia is essentially different from chancre, that the latter has no identity but with itself, and that these facts are proved by careful observation and experimentation. I moreover maintain that no observations are to be looked upon as possessing any value, except those made with due caution by the medical man himself; whilst the statements of" pa- tients are to be entirely rejected as insufficient, and made up of stories and fabrications. The second question which I have to enter upon now, relates to the abortive treatment of blennor- rhagia and chancre. You are fully acquainted with every particular concerning the former, but the latter I have not yet touched upon, although I am just on the eve of doing so. You will, then, allow me to anticipate a little upon what I have to say about chancre, as the abortive treatment, now to be dis- cussed, relates both to the latter and to blennorrhagia, and that they cannot well be separated. I will merely state, in order to forestal any misapprehen- sion, that my doctrine runs thus : a chancre destroyed by caustic within four days of improper intercourse may entirely disappear, without having time to con- taminate the system ; with this proviso, however, that the induration of the base have not commenced. Now, to return to the question at issue : I must say, 82 M. RICORD'S DEFENCE OF at the very outset, that the gentleman who reported on this matter thinks that it is possible to destroy a primitive chancre before it has had time to taint the system. M. Velpeau is of the same opinion, but he considers these cases very rare. I confess, likewise, that they are very rare, but simply because we are seldom consulted in time. M. Roux would like the disease to be left to itself; and M. Lagneau, in a matter of such importance,—in a question involving moral and physical responsibility,—forgets himself so far as to say that my method originates from the guard-house, and that my having been an army sur- geon accounts for this. He might just as well have said that Jenner's discovery originated in the cow- house. He goes on to say, " How do we know what we are doing when we cauterize a chancre ? Are we sure that we have to deal with a chancre ? And besides," he continues, " the author of the new theory declares that a chancre has no special charac- ters; this, however, is a complete error — chancre always has an especial stamp upon it." Now, / have been watching chancres for the last seventeen years, and I need not tell you how many pass undjer my notice every twelvemonth ; and I am not afraid to declare, were I even taxed with ignorance, that there have been cases where I found it impossible to give a decisive opinion with regard to a suspicious ulcera- tion ; and I am, unfortunately, not the only one thus puzzled. I have seen men of talent—men who, in fact, are our masters—look upon superficial, indu- rated chancres, which six weeks afterwards gave rise to a fine crop of secondaries, as slight non-syphi- litic ulcerations. But I find that the time is elapsed ; I shall continue this subject when we meet again. THE NEW DOCTRINE. 83 LECTURE IX. M. RICORD'S DEFENCE OF THE NEW DOCTRINE. At our last meeting I took a rapid survey of the points at issue regarding my doctrines, and I think I was just considering the difficulties connected with the diagnosis of chancre, when the dial stopped me. These difficulties are certainly very great, and since men of eminence, as I before mentioned, fell into such strange errors, I began to consider whether there was not full excuse for such mistakes ? whether chancre was at all times identical as to periods, aspect, character, consequences, species ? whether its appear- ance is the same on all textures ? whether it is ever true to itself as to seat, complications, and peculiari- ties of the patient ? whether the characters which are ascribed to chancre are sufficiently constant to judge infallibly of any given ulceration ? Now with the assistance of inoculation I can answer all these ques- tions, and I can lay down this axiom, which you have often heard in this hospital—viz., that the pecu- liarities of chancre are to be found neither in its form, colour, induration, and shape ; nor in the physical characters of the ulceration, nor in its duration : all these are liable to endless variety ;—the diagnosis must entirely rest on the pus secreted by the sore, which, during a given time, is always identical: in- oculation is the only means to be relied upon in order to give an opinion ; although it is often possible in plain cases to diagnose by the aspect of the sore alone. Now comes the question about the abortive method both in blennorrhagia and chancre. It has been asked whether it is of any use, whether it generally 84 M. RICORD'S DEFENCE OF succeeds, and whether it is quite harmless ? One of the speakers considers that blennorrhagia ought to be al- lowed to take its course, because complications pro- voked by rather a violent treatment are very dan- gerous. To this I have nothing to answer but that the most destructive ulceration is the very one which infects the least. Now as to chancre, it is alleged that secondary symptoms have made their appear- ance in spite of cauterization. But let me ask at what period this cauterization was made ? Is it four, five, ten days, or a month after infection ? that is of no use, so far as secondaries are concerned. Again: it is brought against me that a cauterized chancre may be followed by a bubo ; but I need only tell my adversaries that a chancre which is not submitted to any treatment at all, will also produce it; and be- sides, we know that blennorrhagia and chancre, left to themselves, are more frequently followed by epi- didymitis than when treatment is used. How then can the remedy be accused of produciug bubo when it is proved that it occurs much oftener in the absence of any treatment ? After this, a very fair query was put by M. Bousquet—viz., Is it quite certain that the nascent chancre, which you expect to destroy, is at its outset a purely local disease ? why should not chancre, as well as the matter of cowpock, begin by general contamination ? M. Bousquet has written several excellent works on vaccination, and his opinion therein expressed is, that the virus of cow- pock has first a general effect on the whole system, and that the local phenomena follow this disturbance. But let us examine this subject carefully; and first I may ask whether it isabsolutely unavoidable and neces- sary every time a virus is placed in contact with an ab- sorbingsurfacethatitshould be absorbed? We all know that there are substances belonging to this class that cannot be absorbed at all. But is there no difference as to promptitude of action, constancy of effect &c. THE NEW DOCTRINE. 85 among those which are easily taken up ? Arsenic, for instance, placed upon an ulcerated surface, in the ointment of Frere Come, would give rise to very disastrous consequences, if absorbed. But look at tartar-emetic ; does it excite emesis when applied on the skin in the form of ointment? By no means ; its effects are merely local; it produces a decided ec- thyma clearly of a variolous character. Now this pustule takes from three to eight days to attain its full development, and the mean between these two figures is just about the time which the cowpock pustles take to form. Now I am sure no one will for a moment suppose that the action of tartar-emetic is general before it becomes local ; and yet you cannot help perceiving the close analogy between the develop- ment of pustules resulting from tartar-emetic and those springing up by the absorption of the cowpock matter. If the effect of the antimonium tartarizatum were general at first, vomiting would be one of the earlier symptoms, and the pustule would appear sub- sequently to the emesis. Now I mean to say that the matter of cowpock acts exactly in the same man- ner as the tartar-emetic; its characteristic pustule takes just the same time for making its appearance as the ecthyma from tartar-emetic, and where is the proof that vaccine matter acts generally before its local effect can be noticed ? To this, some have answered, " if you inoculate the cowpock matter again just at the moment the pustule of the first vac- cination appears, you produce no effect." This is not correct, for the experiments daily performed around us prove the contrary position. M. Husson used to call the interval during which the vaccine matter remains powerless, the period of inertia. And, moreover, you must notice that it sometimes happens that in the most favourable cases for inocu- lation, when every thing seems to favour absorption, the matter will not take. Nay, the virus may even 8 86 M. RICORD'S DEFENCE OF be placed in contact with absorbent vessels, and fail to be taken up ? To resume then : we may fear- lessly say that there are some circumstances in which a virus, although applied, is not absorbed, and that in others the surface acted upon by the virus may be modified in such a manner as either to favour or pre- vent absorption. Just allow me one illustration. Suppose you make six little punctures with your inoculating lancet; three sometimes will take and three not, or it may happen that none at all will pro- duce any effect, and yet six months afterwards you perform the same operation, and you thoroughly suc- ceed. How can you explain that 9 But this is not all; remember the experiments of Eichhorn. He takes several children and vaccinates them all. A week after, when the pustules are fully developed, he begins the same operation over again. With one the aptitude is lost, and nothing appears. With a second, the pustule comes forward, but modified, and runs through its stages in half the time which the first pustules took. With a third, the reproduction of pustules is just as complete as if the child were vaccinated for the first time, and yet he has been a whole week under the influence of the virus. What must we conclude from these facts ? That in the first of these three children the matter has acted com- pletely ; in the second incompletely; and in the third the virus has evidently acted but locally. Now I have, I think, proved that the effect of vacci- nation is not necessarily general at first, but were I even to grant the reverse, I cannot for a moment side with those who maintain that the action of the sy- philitic virus must, like the vaccine matter, act first on the system at large and locally afterwards. For, with regard to the syphilitic virus, we must admit either one or other of these positions—namely, that there is, in pathology, but one single virus, and'then frjere would be no need of searching for differences • THE NEW DOCTRINE... 87 or that there are various kinds of virus; originating from different sources, and producing effects which ^ are not analogous. Now, if we admit this latter sup- f position, why should the syphilitic poison be expected to act like the vaccine matter ? If the syphilitic virus were to act in the same manner as the cow- pock, it would no longer be true to itself—it would lose its identity; in short, it would become vaccine matter. And yet, independently of this discussion, there are certain analogies between these two virulent agents, which have not, as yet, fixed the attention of pathologists, and which I will now point out to you. When the syphilitic virus has produced its effect on the system, it exhibits, like the virus of cow- pock, its own peculiar pustule. When the general infection is thoroughly established, in syphilis, there is still a possibility of provoking the appearance of a pustule ; but the chancre is then quite local, never assumes any induration, and has a great tendency to abnormal forms—viz., the phagedaenic, serpiginous, &c. M. Bousquet has tried the experiment of burning the vaccine pustule, but failed, by this means, to prevent the general effect; and the aptitude of the individual for absorbing the virus was not regain- ed by this cauterization. M. Itard has gone still further ; for immediately after the pricking of the lancet with vaccine matter he washed the part with water, yet it took in spite of that. He washed it, another time, with chloride of lime ; the pustules ap- peared just the same. In a third instance he used diluted ammonia, with the identical results. Now, so much for vaccine matter; let us now see how I fared with the syphilitic virus. I have repeated Itard's experiments with great care, substituting the pus of chancre to the cowpock matter, and have ob- tained the same results—viz., the chancre always made its appearance after inoculation, in spite of the ablutions. I succeeded, however, in preventing the 88 M. RICORD'S DEFENCE OF development of the pustule by cauterizing the inocu- lated surface with potassa fusa cum calce (Pate de Vienna). Now to return to M. Bousquet, to whom I was alluding just now : you must notice that his experi- ments will afford us some instruction as to the time when cauterization is of any use. He cauterized the pustule as soon as it appeared; but it takes three, four and even five days, in coming forward after the inoculation, and sometimes more ; and this is just the space of time which I fixed (three or four days) as the probable limit after which the individual can no longer expect to be shielded, by cauterization, from the occurrence of secondary symptoms. In such a case you can only act locally—the general symptoms are beyond your reach. M. Renault, one of the most distinguished pro- fessors of the Veterinary School of Alfort, has per- formed several experiments on the inoculation of glanders: he cauterized the puncture forty-eight, twenty-four, and even twelve hours after inoculation, and in all cases did that frightful disease appear, with the whole train of terrible phenomena which usually accompany it. What does this show ? That in the inoculation of glanders twelve hours are amply suffi- cient to contaminate the system, and that cauteriza- tion is useless after that time. But the Alfort pro- fessor has had the good sense not to attempt the es- tablishment of false analogies; he has merely stated what he has seen, without subjecting syphilis to the same laws as glanders—unlike those who have con- cluded from the phenomena of cowpock to those of syphilis. Remember, that what is true of the one is not necessarily true of the other. For instance, does arsenic pass as rapidly into the circulation as hydrocyanic acid ? Why should we expect that variola, hydrophobia, syphilis, glanders, and cow- pock, should run through the different stages of their THE NEW DOCTRINE. 89 evolution in a period identically the same ? If the venom of the rattle-snake kills a man in a few hours, is that a reason why syphilis should do the same ? So, then, it is clear that there is no sort of connexion between glanders and syphilis, etther as regards rapidity of progress or incurability. Malignant pus- tule and carbuncle are much more rapid in their pro- gress than all the affections I have hitherto men- tioned ; and yet no medical man will be so imprudent, so negligent, nay, so dishonest, as to remain inactive when he sees an individual upon whom carbuncle or malignant pustule is springing up. Will he not immediately try to destroy the local mischief, in the hope of preventing the disturbance of the system which follows it ? You will not find one surgeon who will do nothing at all, and quietly look on, for fear of its being too late. My idea is, that it is our duty to contend tooth and nail against the disease, and that wTe ought always to give a chance to our patient by energetic interference. All these observations and arguments of mine have been met by mere assertions, unsupported by proofs, whereas I am asking for facts. And to show you how anxious I am of being fairly attacked, I defy any one to bring forward a patient deeply and com- pletely cauterized by me, within the three days that follow the inoculation, who has exhibited, six weeks or two months afterwards, symptoms of constitutional taint. I do not work in the dark ; the doors of this hospital are open to every one ; and I invite all those who doubt to come and convince themselves with their own eyes. Now to resume, in a few words. The various virulent substances comport themselves differently as to their absorption ; in fact, there is a distinct and peculiar kind of absorption especial to each virus. This position being granted (and I think it can hardly be disputed), we at once see the possibility of attacking the inoculated surface when S* 90 M. RICORD'S DEFENCE OF the tissues are still contending against the invasion of the virus ; whilst they still possess sufficient vigour to prevent its entrance into the torrent of the circula- tion. Every one, besides all these considerations, acknowledges that cauterization is very good prac- tice as regards the removal of the local accident; and why, then, should this same cauterization be refrained from ? why should this merely local symptom be al- lowed to progress, when it can be healed in a few days ? Were the advantages of cauterization con- fined to this alone, it would be sufficient to induce every right-thinking surgeon to use it. But some object that the appearances of the local ulceration guide the medical man as to the treatment to be em- ployed against the general infection ; that the sore is, in some degree, a touchstone, a sort of syphilometer, an outlet for the virus. If this were true, I would no doubt advise you not to interfere with the chancre: but it is no such thing ; the constitutional infection bears no ratio whatever to the number, the extent, or the duration, of the primary sore. On the contrary, the observation of facts proves that the indurated chancre, which is almost sure to be followed by the taint of the system, is generally solitary. And if you were strictly to act according to the opinions of my opponents, do you know what would happen ? You would be led to multiply the chancres artificially by inoculation, and to cover the patient with specific ulcerations, to render the constitutional infection less probable. The more chancres you could produce, the less fear of general contamination there would be. But this is too absurd for me to dwell upon it any longer. Keep then in mind, that the local accident can in no way prove beneficial; that the general infection is not in proportion with the size of the chancre (since a very small one can do much constitutional mischief, and a very large one, none at all) ; that the chancre does nothing but irritate the textures upon which it THE NEW DOCTRINE, 91 is seated ; and that in the cowpock contamina- tion, as well as the syphilitic, when you implant into the system a new dose of contagious virus, the general infection having already been brought about by a former dose, you cannot produce the constitutional contamination over again. From all this I may deduce that any virulent puru- lent matter may—first, act locally ; or, secondly, re- main without the least effect upon the part on which it had been deposited ; or, thirdly, may even in some instances enter the economy without giving rise to any manifestation at all. One word more, and I have done. Professor Moreau expresses an opinion which is more likely to convince us of his excellent moral principles, than of any scientific truth. He says, first, that blennorrhagia and chancre are one and the same disease, and can both contaminate the system ; secondly, that syphilis, under whatever form it may appear at first, is con- tagious in all its stages, and transmissible even when no manifest symptoms of the disease can be detected, particularly when the individual who has once been affected did not use any specific treatment. To sup- port his opinion, he tells us of women who, being models of virtue, and placed above any kind of sus- picion, have presented symptoms of syphilis because they were married to men who had had the disease a long time before, and who for many years had been supposed perfectly cured. Now upon this I have only one thing to answer to M. Moreau—namely, that medical men of honourable and upright principles are often made the dupes of their patients ; and that in morals, as well as in many other things, there is an enormous amount of decep- tion, the major part of which is practised by the fair sex. 92 TREATMENT OF LECTURE X. I am sure I need not apologize for having detained you some time with the defence of my doctrines. I trust I have fairly met all attacks which have been directed against them, and I will now conclude the treatment of blennorrhagia. (Vide Lecture VII.) Mode of administration of copaiba, and its doses. Some practitioners give copaiba in increasing doses, beginning with fifteen grains a-day ; they go on aug- menting until they have reached five drachms per diem, and they very rarely push so far as seven or eight drachms. When the maximum has been reached they diminish the doses until they reach again the quantity they started with. It seems to me that this is bad practice, for it tends to accustom the economy to the therapeutic agency of the drug, and thereby to diminish its effects. I greatly prefer commencing by pretty strong doses, three or four drachms a-day, and then increase the dose gradually. It has also been attempted to divide the administration of the drug in such a way as to keep the disease constantly under its influence, and to avoid any purgative effects. But it is here to be noticed, that when this balsam is con- tinually in contact with the intestinal canal, it may oc- casion in the same the development of morbid pheno- mena of a very unpleasant nature. The best part of the day for taking the copaiba is in the intervals be- tween the meals, and three doses per diem are quite sufficient. The same dose is to be persevered in until the discharge has disappeared, and it is wise to go on for a few days after the apparent cure, in order to fore- stall any thing like a relapse. The action of copaiba BLENNORRHAGIA. 93 upon blennorrhagia is generally gradual, but it is some- times very rapid. In the latter case great caution should be used, for the cure is mostly but temporary. Three or four days after the cessation of the discharge it is advisable to diminish the doses, in such a man- ner as to extend the treatment ten or twelve days after the cure. I then confidently let the patients give up the drug, and they generally do well. People who are taking copaiba are subject to very intense thirst, accompanied by a peculiar dryness of the throat, which makes them take an enormous amount of liquid ; but they should be recommended to drink moderately, and to pass water less frequently, so that the active principle of the copaiba may be in a more concentrated state in the urine. A practitioner sometimes congratulates himself on having cured his patient when he ascertains that every kind of discharge has ceased, but he often finds him- self deceived ; nocturnal emissions come on, and these, which the patient looks upon as very favourable, from the relief they procure him, seldom fail to recall the mucous discharge. In these cases there is no other alternative but to resume the copaiba. Sexual inter- course must be strictly interdicted until about fifteen or twenty days after the cure, and even at that period indulgences of this kind are very liable to occasion a relapse. The disease, in such a case, is no longer contagious, but it reappears with renewed intensity upon the patient, who was just rejoicing in the con- sciousness of having got rid of it. Formulae for the administration of the copaiba.—The less the drug has been triturated the more efficacious it will be. The most powerful formula, but at the same time the most disagreeable to take, is Chopart's prescription—viz., Copaiba, rectified spirit, syrup of tolu, peppermint-water, orange-flower water, of each, two ounces; spirit of nitric ether, two drachms: mix. One ounce and a half or two ounces to be taken in the morning. 94 TREATMENT OF But this is extremely repulsive to the taste, so that efforts have been made to modify this formula in dif- ferent ways. The following is the mode of adminis- tration which I am very fond of using:—Copaiba, syrup of poppy, syrup o'f tolu, of each, one ounce; peppermint-water, two ounces ; orange-flower water, an ounce ; powdered gum acacia, sufficient to form an emulsion, of which three, six, or nine tablespoon- fuls may be taken daily. Patients sometimes take this with much difficulty, so that I generally give a few corrigents along with it: for instance, a glass of lemonade, charged with carbonic acid gas, after each spoonful, &c. Copaiba has been given in the form of pill, or in capsules, in order to avoid its immediate action upon the stomach. It has even been given in an electuary, united with cubebs ; but I prefer keeping each substance distinct, and when one of them is but ill borne, I have recourse to the other. I have already mentioned, I think, that copaiba acted very efficaciously when it produced no purging effects. To insure its not running off by the bowels, practitioners often combine it with rhatany or opium; but when the balsam causes too inconvenient a constipation, this must be obviated by purgatives. It may now be seen that copaiba stands foremost among the anti-blennorrhagic remedies; but it must not be forgotten that its use is fraught with certain un- pleasant effects, from which cubebs is quite free. Cubebs is generally much better tolerated by the sys- tem than copaiba; it does not occasion eructations, rarely vomiting, and the drug is generally borne very well in cases where copaiba cannot be given. Cubebs acts in some degree as a tonic to the stomach, seldom produces any diarrhoea, but is rather apt to constipate; it rarely gives rise to a cutaneous eruption, and suc- ceeds as quickly as copaiba in stopping blennorrhagic discharges. The daily dose of cubebs is from halt an ounce to an ounce, to be divided into three equal BLENNORRHAGIA. 95 parts, each to be taken morning, noon, and night. Some practitioners begin with ten drachms, and even two ounces. During the administration of cubebs, it is often requisite to give purgatives; yet I combine it very often with alum, in the proportion of half a drachm to the ounce, or with the subcarbonate of iron, in the proportion of half a drachm or a whole drachm to the ounce of cubebs. A good menstruum is water or bread, or else it may be taken in capsules. As for the mode of administration, the same rules are to be observed as those laid down for copaiba. A succedaneum of cubebs and copaiba may be oil of turpentine, Venetian turpentine, Canada balsam, &c.; but the action of these substances is very weak, and by no means comparable to that of copaiba and cubebs. This completes what I have to say on the abortive treatment, and it now remains to be inquired whether, in using it, we always succeed in cutting short the disease. I am unfortunately obliged to answer in the negative ; and besides, not curing, it is liable to give rise to very inconvenient accidents—viz., inflamma- tions, gastro-intestinal irritation, cutaneous eruptions, &c. In such cases we must stop the anti-blennorrha- gic treatment, and combat these peculiar complica- tions, in order to prevent their assuming a dangerous character. You must not fall into the mistake of sup- posing that the fact of the economy tolerating the ad- ministration of the remedy is a guarantee of its efficacy against the disease. It is no such thing; and if we persist in going on with the drug in spite of its ineffi- ciency, we allow the affection to proceed; it then soon reaches a decided inflammatory state, and the remedy leaves no traces but the remembrance of its very dis- agreeable taste. The patients, in these cases, revolt against the copaiba, and we are obliged to change the treatment altogether. It is advisable then to give diluent drinks—to recommend to the patients to pass water often, and in small quantity—and to prescribe 96 TREATMENT OF baths, but tepid ones only, for a high temperature is liable to cause congestions in the urethra. The state of the bowels ought to be closely watched, for consti- pation is one of the causes of the inflammation of the prostate gland, the testis, the vesiculae seminales. Castor-oil or saline purgatives will be the most effica- cious and trusty purgatives in these cases. Should the inflammation proceed or increase, antiphlogistics ought to be had recourse to. Abstraction of blood from the inguinal regions ought to be prescribed if the affection has not reached beyond the glans, and from the perinaeum if the inflammation has had time to proceed backwards towards the membranous por- tion of the urethra. Be careful never to apply any leeches to the penis itself; many well-known and very unpleasant consequences may be the result of this practice. If the blennorrhagia were to produce a ge- neral febrile disturbance of the system, it would be advisable to take blood from the arm. Antiphlogis- tic means alone will sometimes effect a cure, but these cases are very rare. When you perceive that the dis- ease is on the decline, you must modify your treat- ment if you would not allow a chronic affection to set in ; this is generally effected by the use of copaiba. In some very rare cases, very large doses of the latter or of cubebs have been given, when the antiphlogistic means have failed to control the inflammation. This is rather a violent way of going to work, but it is well to know the fact, and such doses may be given where emollient applications and bleeding have been of no avail. Balsams may also be introduced into the sys- tem by the rectum, but their action is then extremely limited; this should never be prescribed but when the stomach cannot be brought to tolerate them. Should you, however, determine to throw in the co- paiba by the rectum, you may use the following for- mula:—The yolk of an egg; copaiba, five drachms; decoction of poppy, three ounces and a half: mix, for a cold injection. BLENNORRHAGIA. 97 Patients should be recommended to take first a sim- ple non-stimulant injection, merely to evacuate the rectum, and to endeavour to retain the enema, of which I have just given the composition. They have sometimes much difficulty in doing that. The injec- tion will be borne all the better for a few drops of laudanum; the tolerance is sometimes very long in being established, and three or four enemata are re- jected before we succeed in accustoming the intestine to this peculiar medication. I must not forget to state that M. Ratier has advised capsules of copaiba to be placed in the rectum: this, when well managed, may turn out an advantageous mode of administration. Be- fore closing what I have to say concerning the anti- blennorrhagic medication, I wish to take a glance at the accidents which may complicate the acute stage of the disease. First. Erections.—They must be controlled by an- tiphlogistics; but they sometimes yield very easily to camphor, either in the form of enema or pills. As to injections, about three grains of camphor maybe dis- solved in four yolks of eggs, and a fourth part of this thrown up at different times; or from four to six of the following pills may be administered:—Camphor, two scruples; extract of lettuce, two scruples: mix for twenty pills. Soft and warm beds must be es- chewed. You will be pleased to notice that camphor does not act similarly upon all individuals. Secondly. Retention of urine.—The obstacle to the passage of the urine is often situated in a circum- scribed point of the membranous, spongy, or prostatic regions. As long as the obstruction is not well de- fined, we must refrain from using the catheter; on the contrary, we ought merely to enforce antiphlogistic measures and emollient applications ; baths also may do a little good. But if the retention has been com- plete for a certain time, if it resist the antiphlogistic treatment, and the bladder is getting distended, delay 9 98 TREATMENT OF would be dangerous, and a catheter is to be intro- duced with great caution. The textures with which the instrument comes in contact are soft, in a state of inflammation, and very apt to get lacerated; we must therefore go very gently to work, using either a gum- elastic or a silver catheter. By neglecting to proceed slowly and cautiously, we run the risk of making false passages, which would be another very unpleasant complication. When the catheter has reached the bladder, the urine is to be drawn off, and if the instru- ment passed freely along the urethra, it may be with- drawn again as soon as the vesical contents are eva- cuated ; and then we should proceed vigorously with antiphlogistic means. If, however, the catheter passes with difficulty,—if it be held tightly by the urethra,— if the parietes of the canal seem to exercise an irre- gular pressure upon it, the best practice is to leave the instrument in the urethra; for there may be,doubts as to the possibility of introducing it again after hav- ing withdrawn it. I must not omit to say, that by leaving the catheter, we may cause the development of a higher degree of inflammation, and even some- times of extra-urethral abscesses; but in the mean- time we secure to the patient the due performance of a very important function—viz., that of passing urine. It will then be requisite to leave the catheter until it moves freely in the canal. In those extreme cases, where no instrument whatever will pass, forced ca- theterism with the sonde a dard, or even puncture of the bladder, may be had recourse to. I think I may dispense with describing these operations just at pre- sent. Thirdly. Urethral haemorrhage.—It is generally caused by chordee, the introduction of a catheter, la- cerations, or rupture of the urethra. This complica- tion may easily be controlled by cold applications, or by making the patient sit on a thick plug, kept forci- bly applied to the perinaeum ; cold injections will BLENNORRHAGIA. 99 sometimes succeed just as well. If the haemorrhage were to persist, in spite of these means, a catheter should be introduced, in order to exercise a certain compression on the textures which yield the blood; and when the rupture is situated in front of the scro- tum, a circular pressure may be added; for by this means the whole of the parts are tightly applied on the catheter. But you must be very careful how you use this circular compression; for I need not tell you here of the disastrous consequences that may arise from an ill-directed or too long-continued pressure on the genital organs. If you should be able to make out that the haemorrhage you have to contend with proceeds by way of exhalation, you might try the er- got of rye ; it often controls the bleeding in a remark- able manner. Fourthly. Cystitis situated at the neck of the blad- der.—I shall not repeat now what I said, some lec- tures back, upon the symptomatology of this acci- dent. The treatment requisite in this case may be entirely confined to the use of antiphlogistics, seda- tives, and laxatives. However, it happens pretty often that these means entirely fail, and that we have the mortification of seeing the vesical tenesmus, and the uncontrollable desire to pass urine, continue un- abated. When things have come to this pass, we must have recourse to cauterization with M. Lalle- mand's porte-caustique. A quotidian intermittent is a peculiar complication sometimes accompanying cystitis in the neck of the bladder: this will gene- rally give way by the very means directed against the vesical inflammation. If we should perceive that the fever becomes tertian, if it were to turn into an independent affection, we should have recourse to the usual treatment of intermittent fevers. Fifthly. Abscess.—An abscess of the urethra should be opened very early, when it is of easy access; for I must say, that I prefer the opening of the sac to be 100 TREATMENT OF premature than to be delayed too long; but be care- ful, before you open such an abscess, to tell your pa- tients of the possible consequences of such an opera- tion; for they are, as you know, but too much dis- posed to ascribe the results of the natural progress of the disease to the means employed to combat it. It is therefore of great importance to apprize them, that in spite of the external opening the pus may still per- forate the urethral parietes, and thereby establish a complete fistula. Whatsoever the peculiar condition of the abscess may be, you must adopt as a general rule, to keep away from the urethra when you give exit to the purulent matter. An abscess of the pros- tate gland may, according to the part of the organ which is affected, point towards the urethra, the pe- rinaeum, or the rectum; in the latter case, I would advise you to evacuate as soon as you are satisfied that the tumour fluctuates. When the abscess points towards the urethra, we often open it by the mere in- troduction of the catheter. Treatment of blennorrhagia when the disease is on the decline. When the acute period is over, we see all the in- flammatory symptoms gradually disappear. Micturi- tion gives no longer any pain, but the discharge per- sists. This is the time for having recourse to anti- blennorrhagic remedies, and it will be advisable to give up baths while the patient is under the influence of these agents. He had better likewise drink little, refrain from any violent exercise, and wear a suspen- sory bandage; for the neglect of these precautions would considerably interfere with the successful re- sults of the treatment. Cubebs and copaiba ouo-ht to be the principal substances employed in this stage, and they are to be used in the same form and the same doses as was advised for the abortive treatment. In- jections must be allowed to stand over for a later pe- BLENNORRHAGIA. 101 riod. The internal anti-blennorrhagic agents just mentioned are often sufficient to cure urethral blen- norrhagia completely ; but if they should, after some time, be found ineffectual, they ought to be aided by means of a more direct nature—viz., injections. These will give rise to no inconvenience, provided the pain on micturition have ceased, and there be no chordee, or painful erections. Even in this declin- ing period very large proportions of nitrate of silver may be injected, and any unpleasant consequence arising therefrom is easily removed. But I prefer pre- scribing the following injection:—Sulphate of zinc, acetate of lead, of each fifteen grains; rose water, seven ounces. Mix for an injection. Three injec- tions may be made daily, and care must be taken to shake the bottle so as to suspend in the liquid the sul- phate of lead, which forms a sediment. The acetate of lead might be left out without incon- venience; the injection would thereby be rendered simpler, and no less effective; about fifteen grains of laudanum will be a great improvement. Some use the acetate of lead by itself, and others the nitrate of silver, in a small proportion—viz., one grain of the salt to seven ounces of water. Hunter generally pre- scribed an injection of one grain of corrosive subli- mate to seven ounces of water. The immediate effect of these injections is to increase the discharge; but it soon diminishes again,and this diminution either leads to its total disappearance, or to the re-establishment of its original amount. In the latter case, fresh in- jections must be used. The treatment should be ex- tended eight or ten days after the cure, and the injec- tions are to be left off before the copaiba. Chronic stage.—When the discharge has reached the chronic stage, it will be important to ascertain whether some pathological alteration of the urethra is not the cause of its long-continuance. When, after a careful investigation, no lesion is discovered in the 9* 102 TREATMENT OF canal, we may confidently have recourse to a well- regulated treatment, which must, however, be less active than in the periods before mentioned. I have used with great advantage, Venetian turpentine in pills (six-grain pills, the turpentine being solidified by the agency of calcined magnesia); tar-water ; de- coctions of the leaf-buds of the pine, of the leaves of the uva-ursi, &c. These may be sweetened by the following syrups :—Balsam of tolu, a pound ; cate- chu, three drachms. Mix. Or, Balsam of tolu, a pound ; citrate of iron, half a drachm to two drachms and a half. I have very often seen these gleety discharges ar- rested by these means, particularly when the diet was good, without being too stimulating. Cold sea or river baths may be prescribed, due regard being had to the peculiarities of the patients. It often hap- pens, however, that the disease continues unabated, in spite of all treatments, and this goes sometimes so far, that the patients get tired of drugs. An attempt should then be made to get rid of the discharge by powerful injections as used in the abortive treatment, or by weak ones often repeated. Tonic and astrin- gent substances, like wine, tannin, rhatany, &c, have also been employed as injections, and have yielded good results. Creosote taken inwardly and applied externally has been recommended, and even iodide of iron has been used for injections with vari- ous results. Should the discharge still persist, we may try bougies; these may either be introduced, as usual, simply to isolate the surfaces, or be covered with astringent ointments—viz., alum, or nitrate of silver. Gelatinous bougies, either plain or anoint- ed, will often melt away in the urethra ; this is a very great drawback to their use. When I simply had in view to keep the affected surfaces asunder and isolated, I used dry lint in longish pledgets, which answered very well. In very bad case's, it BLENNORRHAGIA. 103 will be found necessary to cauterize the urethra with nitrate of silver, by means of Lallemand's porte caus- tique. If even this should fail, there is nothing left but blisters, which may be applied to the pubes, the groins, or the perinaeum, but never on the penis it- self. Finally, I am bound to state that certain dis- charges, which had defied all therapeutical means, have disappeared after moderate sexual intercourse. Chronic discharges will sometimes resist all the remedies that are used against them ; the cause of this very unpleasant persistence may then be looked for in peculiar states of the system, which are far from allowing of easy removal; such as a lymphatic tem- perament, scrofula, urethral lesions, tubercles in the canal, in the prostate gland, or in the bladder, ring- worm, rheumatic taint, &c. These causes may, in- dependently of any other, keep up a blennorrhagic discharge, and it is therefore important to remove them ; or if this be found impossible, at least to mo- dify them by the therapeutical means adapted to each affection. It is very rare, indeed, that a blennorrha- gic discharge is kept up by secondary or tertiary sy- philitic symptoms ; but it is well for you to know that this has happened. I shall refer to this circum- stance when I speak of syphilis ; I cannot enter into it at present. There is no doubt that organic lesions of the textures of the urethra are the most frequent causes of the very prolonged gleety discharges, and these lesions, if traced back, will generally be found to have followed attacks of urethritis. But the study of these pathological alterations would naturally lead to the consideration of strictures, which I cannot dis- cuss now without encroaching upon the order we have adopted. I will therefore leave them unno- ticed for the present, and begin in my next lecture the study of other accidents more immediately con- nected with blennorrhagia. The first of these will be the blennorrhagic affection of the testis. 104 BLENNORRHAGIC AFFECTION LECTURE XI. BLENNORRHAGIC AFFECTION OF THE TESTIS. Many different names have been given to this affec- tion—viz., venereal tumour of the testis, venereal obstructions, hernia humoralis, gonorrhoea fallen into the scrotum, blennorrhagic orchitis, urethral orchitis, hydrorchitis, &c. None of these appellations is strictly applicable, if due regard be paid to the na- ture and seat of the disease ; but this will become apparent as we proceed. The epididymis is the principal and very often the only part affected, but the inflammation, in some few cases, spreads to the other, elements of the testis ; thus it may attack singly, either the epididy- mis, the vas deferens, the body of the testis, or the tunica vaginalis ; or else it may affect two of these parts at the same time, and even sometimes involve them all together. Just in the same way we see in- flammation single out the trachea, the bronchi, the parenchyma of the lungs, the pleura, or attack two, three, or all of these organs at the same time. Ure- thral blennorrhagia is by far the most frequent cause of epididymitis, while it is worthy of remark, that balanitis and balano-posthitis never give rise to it. Swediaur erroneously imagined that the disease un- der consideration was always the result of virulent blennorrhagia ; it is very probable that this mistake arose from the fact that urethral chancres, situated in the balanic region of the urethra, produce disease of the testis by giving rise to a blennorrhagic discharge. As regards the different regions of the urethra, it may be noticed that epididymitis seldom appears when OF THE TESTIS. 105 the urethritis still occupies the balanic part of the canal, and that there is more likelihood of its occur- rence when the inflammation has reached the prostate gland, which extension may take place between the second and fourth week after the onset of the disease. I have here the authority of Hunter, who was well ac- quainted with these facts. Epididymitis generally comes on when the acute stage is over, and when there is but a small amount of discharge left. Circumstances favourable to the development of the blennorrhagic affection of the testis. First and foremost, I must mention the long con- tinuance of blennorrhagia, as greatly predisposing to the disease ; and in the face of such a fact, it is hardly to be credited that men of high standing and character could advise surgeons to let blennorrhagia take its course undisturbed. The peculiar disposition and structure of the testes, their occasional large volume, the length of the vas deferens, the thickness of the cord and variococele, have, one and all, been reckoned among the circumstances favourable to epi- didymitis. Experience has shown that the left testis is oftener attacked than the right, but statistical re- ports do not agree in this respect; those whose right epididymis gets inflamed generally wear the scrotum on that side. Both epididymes may become affected at the same time, or successively ; the same side may experience several relapses, and one attack of epi- didymitis predisposes to subsequent ones in the same organ. To complete the list of the causes which I have mentioned, I must add, ill-timed sexual inter- course, masturbation, protracted continence, undue excitement of the generative organs, their sudden exposure to cold, bruises, pressure, contusion, long- continued erect posture, horse-riding, fatiguing walks, straining, wrestling, and constipation. Authors on this subject have regarded blennorrhagic epididymi- 106 BLENNORRHAGIC AFFECTION tis as an accident resulting from the treatment, and attributed the testicular affection to a sort of reper- cussion, arrest, or metastasis of the inflammation; even copaiba and cubebs have been accused of caus- ing the mischief. But by careful investigation, I have found that most of the patients who suffer from epididymitis have used no treatment, or have been satisfied with linseed tea and slops. It must be con- fessed on the other hand, that an ill-judged treatment, the too frequent use of catheters and bougies, may favour the transmission of urethritis to the elements of the testis ; but the most frequent cause lies in the blennorrhagia itself; and it is therefore evident that all those means which are resorted to in order to re- move it, act as prophylactics to the affection of the testis. Premonitory symptoms.—The testicles feel heavy and dragging ; there is uneasiness and dull pain in the groins; frequent desires for micturition ; and shootings through the whole scrotum. Pressure on the epididymis causes intense pain ; the spermatic cord feels thickened ; a tumour, formed by obstruc- tion in the epididymis, becomes apparent; and this swelling looks flattened from side to side, on account of the pressure of the patient's thighs. There is pain along the cord, and the course of the crural nerve, as well as in the lumbar region. Febrile reaction may or may not occur, and the mischief is generally con- fined to the epididymis, with an occasional effusion into the tunica vaginalis, which latter is then merely an epiphenomenon, unconnected with any inflamma- tion of the tunica itself, being only a lesion of secre- tion. This passive hydrocele, the size of which is very variable, exercises a certain compression on the testis in front, while the inflamed epididymis does the same posteriorly, so that the body of testicle ex- periences a pretty considerable pressure on all sides. The effused liquid is quite transparent, and the tunica OF THE TESTIS- 107 perfectly sound ; tapping and post-mortem examina- tion have proved me this. The inflammation of the tunica is extremely rare ; I only remember two cases where it occurred. The pain is then more acute and superficial ; there is more fever, and the slightest motion causes great suffering; the transparency is lost ; the subscrotal cellular tissue gets involved ; the scrotum turns of a bright red, and a puncture gives issue to a purulent and flaky fluid. The body of the testis itself may, in some rare instances, be attacked ; the pain is then still more intense, and of a strangulating kind ; the elasticity of the organ disappears, it forms a uniform mass with the epididymis, becomes heavy, and loses all fluctuation ; the uneasiness in the groin increases, inflammatory fever is set up ; hiccough, syncope, nausea, and vomiting come on ; the sensi- bility of the organ becomes exaggerated ; and the cord feels extremely tense. The inflammation of the body of the testis does not materially increase the volume of the whole tumour, because the tunica al- buginea resists the enlargement, and this is likewise the cause of the strangulating pain felt in didymitis. The blennorrhagic affection of the testis is an acute disease ; it will reach its highest point of in- tensity in three or four days, and the acuity is in- creased when the testis itself becomes engaged. The symptoms are less distressing when patients have experienced former attacks, and in these cases they may assume an indolent character. The gene- ral duration is from thirty to thirty-five days, and the manner in which the disease terminates is as fol- lows :—by delitescence, when the inflammation gives way very early, and by simple resolution, a little later ; when it becomes chronic the lymph gathers in different parts of the organ, and forms indurated no- dules, which, in lymphatic or scrofulous subjects, are any thing but satisfactory ; you will generally find these kernels in the epididymis. In simple hyper- 108 BLENNORRHAGIC AFFECTION trophy, the testis feels smooth, uniform, and soft, but in the case just mentioned it is hard and rugged. Suppuration is rare, and its occurrence is always a bad sign, for it generally points to the presence of tubercles; yet it may sometimes merely destroy the subscrotal cellular tissue, and do no further mischief, while the epididymis hardly ever suppurates. We may therefore look upon epididymitis as a trifling affection, when it is free from complications; the effusion which sometimes accompanies it is gradually absorbed as the epididymic inflammation declines, but it will sometimes persist, and become the excit- ing cause of a hydrocele. Vaginalitis may end either in resolution, or in adhesion of the two serous layers after the absorption of the liquid, or, which is more frequently the case, in suppuration and abscess. Or- chitis or didymitis also ends either by resolution or suppuration, but the resolution often goes beyond the natural limits, and produces atrophy. Before I speak of the treatment, I will just mention a few peculiari- ties resulting from a deviation in the normal descent of the testis. When the testis remains in the inguinal canal it is liable to different lesions, which might be mistaken for a suppurating bubo; so that you must always ascertain, before you make any incisions, whether both testes have descended into the scrotum. I was once, myself, on the point of evacuating the pus of what appeared a bubo, when I noticed that the cor- responding half of the scrotum was empty ; and an- other time, I was preparing to open a tumour in the perinaeum, which I took for an abscess of Cowper's glands, when I made the same discovery. In this latter case the testis had descended lower than usual. I remember a case, where a testis, arrested in the in- guinal canal, became inflamed by hard riding, and another, where inflammation took place, as a result of blennorrhagia. There is even a case mentioned, OF THE TESTIS. 109 where the testis got into the crural canal, and appeared on the internal and anterior aspect of the thigh ; if this had been attacked with inflammation, I need not tell you how disastrous the results of an incision would have been. In cases where the testis remains within the abdomen, its inflammation may be mistaken for peritonitis, enteritis, abscess in the iliac fossa, &c. This inflammation is, however, extremely rare, for the testis thus imprisoned in the abdomen is almost completely atrophied.—(Mackenzie.) The blennorrhagic inflammation of the elements of the testis may be followed by plastic indurations or alterations, which might be confounded with a can- cerous sarcocele ; therefore, when we wish to draw the prognosis of an affection of the testicles, we may at once take a favourable view of the case, when we discover that blennorrhagia has preceded it. But bear in mind, that didymitis may become the exciting cause of the evolution of tubercles in the body of the testis, and that the inflammation of this organ may become the origin of divers kinds of degeneration within its texture. Even syphilitic sarcocele may spring up when the diathesis is syphilitic ; but when the poison of lues is put into play, the inflammation ceases: the same remarks apply to the cancerous dia- thesis. To resume : I beg you will recollect the two following axioms :—First, blennorrhagic epididymitis has hardly any tendency to end by suppuration ; didy- mitis or orchitis has. Secondly, epididymitis leaves the epididymis in a state of hypertrophy ; orchitis leaves the body of the testicle in a state of atrophy. Treatment of epididymitis.— This may be either prophylactic or abortive ; either adapted for the acute or the declining period. The prophylaxisconsistsingettingridoftheblennor- rhagia as soon as possible ; and whilst we are attempt- ing to do this, to remove all causes which might aid the development of epididymitis, by advising rest, 110 BLENNORRHAGIC AFFECTION the use of a suspensory bandage, attention to the bowels, and the avoidance of any excitement of the generative organs. The disease may be nipped in the bud in the following manner :—Rest in the hori- zontal posture, elevation of the scrotum, the applica- tion of a thick layer of knife-grinder's clay to the tes- ticles, ice, lotion of acetate of lead, and cold injec- tions. In the acute stage, when the inflammation is fairly developed, when there is congestion and an effusion of plastic lymph, we must have recourse to the following means :—Rest, decubitus, elevation of the scrotum (congestion in the veins of the cord, and an increase of inflammation in the testes, will arise, if they be allowed to remain pendent), frictions with equal proportions of belladonna and laudanum on the scrotum, along the spermatic canal, in the lumbar region, or on the internal and anterior part of the thighs, to relieve pain ; low diet, diluent drinks, and local abstraction of blood (if the inflammation runs high, without febrile reaction), either along the course of the spermatic cord, from the perinaeum, or around the root of the scrotum, but never from this organ itself. I have mentioned before why I object to this. The opening of a few veins of the scrotum with the lancet has been advised, but you obtain very little blood in this manner. Warm baths are useful, but you must watch their effects ; hip-baths should be eschewed altogether—they favour conges- tions.—(Lisfranc.) Saline purgatives act in the same way as bleeding, since they produce a serous deriva- tion from the intestinal canal. When there is much fever, it is advisable to bleed from the arm ; vene- section very often relieves pain, and should never be omitted when the body of the testis shares in the in- flammation. The treatment which I have just de- scribed proves insufficient with some patients: I would then recommend to apply the same means, with renewed vigour, and if, in spite of all, suppura- OF THE TESTIS. Ill tion takes place, to give exit to the matter without delay. M. Vidal has revived a practice formerly in- troduced by Jean Louis Petit—viz., to free the ten- sion of the tunica albuginea, by an incision into the same, whenever he makes out that the body of the testis is involved. I think this a very judicious course, although some surgeons exaggerate the dan- ger of it; indeed, the fibrous coat of the organ sel- dom escapes in the tapping of small hydroceles. This incision is to be made with a lancet, and may be from half an inch to an inch in length. Some practitioners apprehend a hernia of the seminiferous vessels, but experience has shown that this fear is groundless. If the effusion in the tunica vaginalis is inconsiderable, and there is but little pain, you may await its absorption ; but when the hydrocele is large, and there is much tension, you should tap. As soon as you have ascertained the presence of abscess, you must give exit to the matter, to pre- vent the encroachments of the purulent sac. But it may now be asked, what is to be done about the dis- charge, whilst we are treating the testicular compli- cation ? As long as we are combating the acute stage of orchitis, we must refrain from the anti-blen- norrhagic remedies, although the discharge may be going on. If it has completely ceased, you must not, like some practitioners, endeavour to re-establish it. This is detestable practice ; for besides increas- ing the inflammation of the testes by this uncalled-for intervention, it not unfrequently provokes irritation and inflammation of the prostate gland, and of the neck of the bladder. Catheterism, often repeated, and the introduction of the matter of another blennor- rhagic patient, are used for the purpose of recalling the discharge. Both these modes are dangerous, but the latter is extremely so ; for who can vouch for the non-existence of urethral chancres in the patient from whom the matter is taken ? 112 BLENNORRHAGIC AFFECTION A word about compression,as practised by Friecke, of Hamburg. At the very onset it is a very good thing, particularly when combined with proper hy- gienic precautions, and low diet. Strips of adhesive plaster are first applied around the root of the testis, to prevent it from slipping from those which are to be carried, in a circular manner, to its lower part, a portion of which is left bare. To this, other bands are to be applied in a longitudinal direction, and se- cured by circular ones upon them. If an hour after the compression has been effected the pain is gone, the pressure may be allowed to continue ; but if there be much and increasing suffering, it must be given up, for fear of gangrene. At all events, patients who submit to this mode of treatment must be closely watched, the loose parts re-applied, and strangulation of the upper strips prevented. Compression must be avoided when there is the slightest inflammation in the cord, for the part of the latter which is beyond the reach of the pressure becomes doubly inflamed by the violence done to the part constricted. I would advise Friecke's method in that peculiar kind of epi- didymitis which I have called sympathetic. Treatment of the declining stage.—You must not be in too great a hurry to give up emollient applica- tions, low diet, &c, and do not begin discutients until the pain is gone and the heat abated. These may consist of Goulard's extract, solution of sal ammoniac, aromatic fomentations, frictions with mer- curial, belladonna, iodide of potassium, or iodide of lead ointments. Do not use Vigo's plaster* too soon, for it is very apt to recall the inflammation ; give in these cases a fair trial to compression, for with all * Emplastrum Vigo cum mercuric- is an old preparation lately revived (Zimmerman mentions it in his Traits de l'Ex- perience). It is composed of simple plaster, yellow wax, Bur- gundy pitch, ammoniacum, bdellium, olibanum, mercury, styrax, and oil of lavender. OF THE TESTIS. 113 the precautions I have mentioned, it may assist re- markably. When you order mercurial frictions see how far your patients are affected by them, and recollect that some persons are fearfully salivated by a very small dose. Soap, as well as conium plaster, I have found to answer very well in some cases. Plasters, besides the effect produced by the drugs they con- tain, act by keeping the parts in a sort of vapour- bath, formed by the retained perspiration. If resolu- tion were not brought about by these means, calomel and conium in repeated small doses might be tried. When all these remedies fail you may suspect the existence of a symptomatic hydrocele, which it is im- portant to get rid of. An iodine injection, and the iodide of potassium internally, will probably effect this. When a scrofulous diathesis is in the way of the cure, give cod-liver oil, steel and bitters, and order sea-bathing, with a generous diet. If the tu- mour assumes a carcinomatous degeneration, we must have recourse to amputation. But whilst the patients are undergoing this treatment, what must be done for the discharge if it still persist ? When the declining period of epididymitis has arrived, I pay great attention to the urethral discharge, besides treating the affection of the testis; for were we to neglect this we would allow the primary cause of the disease to continue. I advised you to overlook for awhile the blennorrhagic discharge at the first onset of the epididymitis, because the means employed to control this complication would be in the way of the other anti-blennorrhagics ; but when the affection of the testis is on the decline, the two treatments may be used at the same time, and the sooner you conquer the discharge, the sooner you get rid of the epididy- mitis. Functions of the organ.—The use of a suspensory bandage must be kept up some time after the cure, and sexual intercourse should be refrained from for 10* 114 BLENNORRHAGIA a long period after the cessation of the inflammation. Seminal constipation may become a cause of excite- ment, and of a re-appearance of inflammatory symp- toms ; we could not then consistently advise conti- nence. The seminal fluid will, in these cases, assume a rusty colour, which is owing to lacerations of the ejaculatory vessels, just as they occur around the anus after long constipation ; these solutions of continuity are the result of the distended state of the spermatic vessels. W7hen this rusty colour persists for some time it indicates a fungous state of the lining mem- brane of the seminiferous vessels. Blennorrhagia in the female. I shall be able to begin to-day the study of blen- norrhagia in the female. It may have its seat on the vulva, in the urethra, the vagina, or the uterus re- spectively, or on two, three, or all these parts together. Before I enter into details, I must apprise you that women give many more blennorrhagias than they get in return, that they not easily contract the disease during the menstrual period, and that they often are shielded in the interval by leucorrhoeal discharges. I have described, when I was occupied with general considerations on this subject, the symptoms common to all blennorrhagias: I will now merely mention those which are peculiar to the different parts of the female organs. 1. Blennorrhagia of the vulva.— It may be confined to the surface of the mucous membrane, may reach deep within it, settle in mucous glands and follicles, or, lastly, may have its seat in the vulvar glands, which I compared to Cowper's. The patients, be- fore any thing becomes apparent, experience an un- usual excitement of the parts, and are inclined for sexual intercourse ; pruritus, heat, tumefaction, and redness soon come on, and at first there is only an IN THE FEMALE. 115 exaggeration of the usual secretion, which takes place at the meeting of the nymphae, but it soon becomes irritating, and increases the inflammation; then the discharge turns muco-purulent, and more and more characteristic, as a greater number of follicles get involved. If the inflammation travels into the sub- stance of the parts, swelling and obstruction oc- cur, which easily pass into the phlegmonous state ; the nymphae, in these cases, acquire an exaggerated size, they project beyond the vulva, and experience a strangulation which might be compared to para- phymosis. A true phlegmon may follow this state, and with pregnant women the blennorrhagic inflam- mation may run along the genito-crural fold, as far as the anus, and give rise to a very inconvenient and foetid discharge. The inflammation of the vulva may reach the ducts of the vulvar glands, so well de- scribed by M. Huguier, and even the parenchyma of the gland ; its volume then increases, it may be felt within the labium, and the inflammation may end in abscess or in resolution. When a chronic obstruc- tion persists, cysts will form in the gland, on account of the impervious state of the ducts. Vulvitis fre- quently gives rise to an extreme sensibility of the vulva, particularly with young women ; and when the inflammation of the vulva goes on for some time, the vulvar opening becomes the seat of a regular atre- sia. Blennorrhagic vulvitis is very troublesome ; it excites the generative tendency, and tortures the ima- gination, particularly in dreams. Before mentioning the other varieties of blennor- rhagia in women, allow me a few words about the treatment of vulvitus. As prophylactic, I recom- mend cleanliness ; for this disease may, like blen- norrhagia in man, arise from a neglect of hygienic measures. At first, advise low diet, the isolation of the affected surfaces, lotions with a solution of ni- trate of silver, two parts of the salt to one hundred 116 BLENNORRHAGIA parts of water, and entire baths. If the inflamma- tion has reached deep, we ought to insist upon low diet, the application of leeches to the inguinal re- gions, and the use of lotions of nitrate of silver. Finally, if phlegmon set in, we should repeat the abstraction of blood, and as soon as fluctuation is ascertained, make an incision ; for the suppuration has a tendency to destroy the cellular tissue, and to run towards the rectum and perinaeum ; and from this peculiarity very troublesome recto-vulvar fistulae may arise. If the abscess is situated in the vulvar gland, an opening should likewise be made ; but if you sus- pect the existence of a cyst, around which the inflam- mation might have spread, you may wait a little be- fore freeing the pus. Recto-vulvar fistulae belong to general pathology, yet I will venture to tell you, in a few words, how I treat the disease. I use, first, compression along the whole course of the fistula, when recent; a little later I employ injections, with strong solutions of nitrate of silver, or cauterization of the tract with the solid nitrate. This cauterization must be very rapid, because the tissues will contract at the first touch, and prevent the stick of nitrate of silver running all along the fistula. I have also seen good results from the scarification of the membrane lining the fistulous tract. Blennorrhagic urethritis in women.—Women are just as subject as men to urethral blennorrhagia, and it may be said that in this respect the former are quite peculiarly situated ; for they are never affected by this kind of blennorrhagia but in consequence of sexual intercourse ; whereas vulvitus and vaginitis may spring up independently of coitus ; and therefore you easily understand why the urethral variety is so much more rare than the others. I might explain the rarity of urethritis by noticing—first, that the vagina and the cervix uteri are the only parts exposed to the contact of the blennorrhagic matter in coitu ; and IN THE FEMALE. 117 secondly, that the emissiones urinae have a powerful cleansing action. Symptoms. — Titillation, itching, irritating and burning urine, frequent micturition, pain and heat in the part. Afterwards, if the disease be not checked, dysuria, and sometimes even retention. When the cervix vesicae shares in the inflammation, the mictu- rition is still more frequent and painful, and the last drops are mixed with blood. The least pressure on the urethra causes excessive agony, and thereby sexual intercourse is rendered impossible. The in- flammation runs through the same stages as have been described when speaking of urethritis in man, chordee excepted. It may terminate in resolu- tion, or pass into a chronic state ; but this latter is very little minded by women, as they are more accustomed to discharges. Urethritis may cause in this as well as in the other sex thickening of the lining membrane of the], urethra, and eventually stricture, which, however, with women, is extremely rare. Treatment.—We find here the same indications in both sexes. The abortive means, and cauterization with the porte caustique, may succeed very well. But women seldom apply for medical aid until when the disease is fully developed,—so that the abortive treat- ment is seldom called for. The other remedies will be as before mentioned—copaiba, cubebs, &c. If you have to treat a decidedly acute case, you must use antiphlogistics and emollients first, and take up anti-blennorrhagics afterwards. When speaking of vulvitus, I omitted to mention, that after a chronic case we often are consulted about obstinate secretions, which proceed from between the nymphae and the carunculae myrtiformes; and these secretions become very apparent when pressure is made on the part. Astringent lotions and caustics do no good here, because the mischief lies in deep- 118 BLENNORRHAGIA IN THE FEMALE. seated glands, with very narrow ducts. There is no other way but to incise deeply, and either cauterize or isolate the cut surfaces with lint. The analogue of this disease may be found among men, espe- cially in those who are affected with hypospadias. By this incision we rid our patients of an extremely disagreeable oozing, which, in general, has proved as troublesome to the sick as to their medical at- tendant. To return to urethritis : I must warn those who, in a medico-legal case, have an investigation to make, that all traces of a discharge per urethram may be effaced, for the time being, by a micturition imme- diately preceding the examination. To make sure of the case, a finger should be introduced into the vagina, and pressure made from below upwards all along the canal of the urethra ; if urethritis exist, the meatus will discharge a small amount of muco-puru- lent matter. Blennorrhagic bubo, which is rare with men, is still more so with women. We have seen, moreover, that blennorrhagia situated in the balanic region commonly produces it; and this region does not exist in the female sex. On the other hand, no- tice, in conclusion, that vulvitus, which is analogous to balano-posthitis, leads as little to bubo as this latter affection. When we meet again I shall take up vaginal blen- norrhagia. VAGINAL BLENNORRHAGIA. H9 LECTURE XII. VAGINAL BLENNORRHAGIA. This is, in fact, a vaginal blennorrhagic catarrh, and is of very common occurrence. The inflammation is mostly superficial, but it may occupy the follicles, the whole thickness of the mucous membrane, and the sub-mucous cellular tissue. The symptoms are, heat and pain, greatly increased during defecation and micturition, and more or less unfitness for coitus. Yet, you must bear in mind that this vaginal blen- norrhagic catarrh may set in and continue for some time without attracting much attention on the part of the patient. The disease is often confined to that portion of the vaginal mucous membrane which is reflected on the cervix uteri, and it then bears much analogy with balano-posthitis in man, which, as you know, occupies the cul-de-sac formed by the reflec- tion of the mucous membrane of the glans on the pre- puce. When the whole vagina is engaged, erosions and granulations soon follow the redness of the part, pus may be detected in the discharge, and the gran- ulations may increase to such a degree as to assume the character of vegetations. The tricomonas* has been discovered in the pus, and its presence has by some been looked upon as depending on the spe- cificity of the disease: but I cannot admit this, for we do not find it, in the discharge of the male ure- thra, brought on by the contact of this very vaginal pus. The matter finds a ready exit with women who * Tricomonas—a name given by M. Donne, in 1836, to an animalcule found in the pus of vaginitis. He named it thus, as. he thought it resembled the monas by its trunk, and the trichoda by its cilia. 120 VAGINAL BLENNORRHAGIA. have had children ; but with others it will be neces- sary to make a manual examination, to ascertain its existence, as it accumulates in the vagina, and never appears at the vulva but on defecation or micturition. Whenever it is desirable, for some reason or other, accurately to trace the part whence the discharge arises, the speculum should be used, except during phlegmonous vaginitis, or excessive sensibility of the organs. But wThen this sensibility is unconnected with inflammation, you must gradually accustom the parts to the contact of foreign bodies by pledgets of lint, &c, and by cautious increase of their size you will succeed in accomplishing the tolerance of the speculum. Not a very long time ago it required a consultation of three medical men to decide upon its application; but in our days it is in common use, without any such preliminaries ; still I would advise certain precautions, which you will do well to re- member. Leave your patients the free choice of the persons who are to be present; always insist upon the assistance of a third party ; avoid making unne- cessary preparations, and do not resort to any thing like entreaties, but show firmness. Let the speculum be warm, and wTell anointed, and use the bivalve variety. I have had one made, in which the pivot on which the valves turn corresponds to the entrance of the vagina, a part which is the least sensitive of the whole canal. The index and middle finger of the left hand are applied to the sides of the fourchette, and the ring-finger depresses it; the closed speculum is placed on a level with the plane of the vagina, and rests on the ring-finger. As you pass along the canal, you turn the valve on your right, superiorly, and to your left; the other valve lies in the opposite direction. By this turn, you bring the greater diameter of the instrument on a level with that of the vagina. As you advance along the latter, you must turn the handle of the speculum towards the patient's left VAGINAL BLENNORRHAGIA. 121 thigh, so that one of the valves may correspond with the anterior part of the vagina ; the other with the posterior. When you get near the cervix (the exact situation of which is ascertained beforehand, by a manual examination), you may withdraw a little, and in pushing slightly forward, the valves will seize the neck of the uterus as the cup takes hold of the ball in the toy so named. In this manner you will get a good view of the parietes of the vagina and the cer- vix, and be able to withdraw the instrument without the slightest injury to the part. Treatment. — The abortive means which I have mentioned so frequently may do exceedingly well here, when we are applied to early. It will consist, as you know, of strong injections of nitrate of silver, or brushing the part with the same salt in a solid state. I was the first to use this treatment in vaginal and uterine blennorrhagia. Glass syringes should be used for the injections, and the pelvis kept elevated, for the liquid would otherwise hardly penetrate, and would run out as soon as injected. See, also, that every trace of the solution be carefully cleansed away, to prevent indelible stains on the linen. WThen you use the solid nitrate, introduce it as far as the neck, and withdraw it on touching the parietes of the vagina in a spiral manner. Rest, and low diet, added to this treatment, will, in most cases, be suffi- cient to effect a cure. The keeping the inflamed surfaces asunder by plug- ging was introduced by me originally, and has since been much recommended by Hausmann. I perform it generally by means of a small bundle of lint, to which a thread is connected ; the latter is allowed to hang out of the vulva, and the patients can change the plug, when saturated, without being in need of any assistance. But we are seldom consulted at an early stage; advice is sought when the parts are ready to run into a phlegmonous state. We must 11 122 UTERINE BLENNORRHAGIA. then at once energetically use antiphlogistics, emol- lient and sedative injections, as bran-water, mucilage of quince or linseed, and fomentations of poppy- heads, &c. ; but be careful to apply the leeches on a part not likely to come in contact with the muco-puru- lent matter, for the co-existence of a concealed chancre might cause a syphilitic inoculation. As soon as you have got rid of the acute symptoms, it will be advis- able to prescribe the astringent injections—viz., a solu- tion of nitrate of silver, two parts of the salt to one hundred of water; to advise rest of the generative organs, and the exhibition of steel. Alum, acetate of lead, and sulphate of zinc, may also be used as in- jections. In chronic cases, I find it useful to plug the vagina with lint, imbibed with astringent solu- tions ; and when the discharge continues very obsti- nately, I look for granulations or ulcerations, which I destroy forthwith with the solid nitrate. Mere hypersecretion, which is often a sequela of vaginitis, may be controlled by any mildly astringent or tonic injections, as a decoction of walnut-leaves &c. Copaiba and cubebs, taken internally, are of no use here ; the mode of action of these substances, on which I dilated some time ago, sufficiently ac- counts for this. M. Piorry has tried the injection of both drugs, mixed with water, or other menstrua, but obtained no satisfactory results. Remember, when your patients are convalescent, to advise a continuance of injections of cold water, sea-bathings, &c. If you notice that you have to deal with scrofulous, lymphatic, or chlorotic subjects, you must use means to modify these different states, for they are extremely prone to keep up the discharge. Uterine Blennorrhagia.—It is now proved that blennorrhagia may reach the uterus, and even run along the Fallopian tube to the ovary. There is no difference between simple uterine catarrh and uterine blennorrhagia, so that I need not insist upon the de- UTERINE BLENNORRHAGIA. 123 scription of the latter disease. I will, however, trouble you with a few words about the conse- quences of it—viz., hypertrophy of the mucous mem- brane, granulation and ulceration of the cervix. These do not constitute distinct symptoms of uterine blennorrhagia; they are mostly owing to a peculiar pathological state of the surfaces. It has long been held that they were the result of the irritating nature of the uterine discharge, just as herpes labialis is the result of coryza, and it was moreover alleged that the posterior lip of the os tincae was more often affected, as being more constantly in contact with the secre- tion. These views are not correct; for, in the first place, we often find ulcerations on the anterior lip, and secondly, were we even to grant that the dis- charge does the mischief, it would remain to be proved that the posterior lip, except in the dorsal decubitus, is the lowest part of the os, for in the stand- ing or sitting posture the fundus leans forward, and the anterior lip becomes thereby the lower one. Yet, without denying in toto the influence of the discharge on these ulcerations, I am more inclined to attribute them to the pressure which the posterior lip experi- ences from the recto-vaginal septum, in women with whom constipation is an habitual state, and whose rectum contains scybala. Notice that these erosions are irregular in shape and not circumscribed, whilst a chancre in this situation, as in all others, would be more or less regular and isolated. Baglivi has tried to aid us in the diagnosis between blennorrhagic vaginitis and uterine catarrh, asserting that the latter is essen- tially chronic, and the former acute, but it is no such thing ; it is lucky, however, that we have nothing to do with the causes in order to effect a cure, for as soon as the inflammation of vagina or uterus is de- veloped, we must pay attention to the symptoms before us, and act in accordance with them, lne only distinction which it is important to make, is to 124 UTERINE BLENNORRHAGIA. find out whether we have simple blennorrhagia and chancre to deal with. Treatment of uterine blennorrhagia.—If you are con- sulted in time, use the abortive treatment; here, how- ever, I prefer the solutions of nitrate of silver to the solid salt, for with the latter we succeed in touching but a few points of the affected surface. It was with me that injections into the cavity of the uterus originated. I have used a great variety of them—viz., nitrate of silver, the liquid nitrate of mercury, iodides, alum, zinc, and emollient solutions, and I have never wit- nessed any serious accidents from them. But still it must not be overlooked that very fearful hysteri- cal symptoms may follow such injections, and they may completely simulate an attack of metro-perito- nitis. These frightful manifestations will subside altogether in a couple of hours. It has been con- tended thatthe injection mightescape into the abdomen, —and experiments have been made on the dead sub- ject to prove this,—but the liquids were thrown in with such force, that they would have ruptured the uterus if they had not entered the Fallopian tube ; and besides, the absence of contractility in the dead fibre must also be taken into consideration. I make the injections in the following manner. A very small canula is introduced within the neck of the organ, and it must be so small that it may move quite freely in the cavity of the cervix ; as much liquid as a common tea-spoon will hold is then pressed gently into the uterus ; it moistens its mucous membrane, and flows back again by the sides of the canula and the tube connected with it; it is therefore quite im- possible, in this manner, that any part of the injection should pass along the Fallopian tubes. M. Vidal one of my colleagues, has repeated these experiments, and used the same solutions; in the account of them he has however, forgotten to mention whence they originated. If it is desirable that none of the liquid remain within AFFECTION OF THE OVARY. 125 the uterus, you must use a double tube, to allow of a current to and fro. Another mode which I have found very useful, is, to place a small sponge soaked in the medicated liquid within the cervix; the solu- tion is then squeezed out by pressure on the uterus, and is diffused through the cavity without giving rise to the symptoms which injections are apt to bring on. I have known the disease persist in spite of all these means, and indeed the uterine, howsoever produced, are the most tenacious discharges of all; search must then be made for ulcerations on the neck of the uterus, and if found, cauterize them with the nitrate of silver or the liquid nitrate of mercury. These caustics may even be carried within the cavity of the cervix, but before applying them, care should be taken to remove the muco-purulent matter, which, in the uterus, is very dense and adhesive, whilst the secretion of the vagina is generally thinner. M. Recamier has proposed, in cases of persisting dis- charges, combined with a fungous mucous membrane, to introduce a curette into the uterus, and scrape the parietes; and Hausmann advises to plug the vagina under the same circumstances. In fine, you will do well to use your best exertions to free your patients from this distressing complaint, and to effect this you must not only attempt all the means I have enume- rated, but likewise look to their general health, to the enforcement of hygienic measures. As to the latter, you must see that the wearing of thin shoes and stockings in damp weather, and sudden changes from a dry and warm abode to a cold and damp one, be carefully avoided, and warmth to the legs and feet be duly attended to. Blennorrhagic affection of the ovary.—This is very rare : it may be sympathetic, or the result of an ex- tension of the inflammation through the Fallopian tubes by the mechanism of conception. The symp- toms are, pain in one iliac fossa, or in both, as also 11* 126 ANAL BLENNORRHAGIA. in the hypogastric region; if, during a vaginal ex- amination, the uterus be pushed to the side where the pain is complained of, the latter diminishes, as by this displacement the ligament is slackened ; but if the uterus be pressed to the opposite side, the ten- sion of the ligament will increase the pain. M. Vidal has observed cases of blennorrhagic ovaritis at the Hopital de Lourcine (the Paris Lock Hospital), but I can offer you no post-mortem examinations on the subject. It appears that the disease generally termi- nates in resolution. I am rather disposed to think that many ovarian dropsies and other affections of this organ may have blennorrhagic ovaritis as their primary cause. Let me mention, in conclusion, that this disease is exactly the analogue of epididy- mitis. Anal blennorrhagia.—This is extremely uncom- mon, although muco-purulent -discharges from the lower part of the rectum are of frequent occurrence ; but these are generally caused either by haemorrhoids, eczema, or prurigo ani. An unnatural connexion with such predispositions is very likely to bring on a discharge which has nothing to do with blennor- rhagia ; but the latter disease, engendered by actual contagion in this region, is excessively rare, particu- larly as the mucous membrane here is not very sen- sitive. The disease is ushered in by heat and itching in the part, difficulty of defecation, &c.: if the affection remain unchecked, the eonstipation be- comes more painful, and perinaeal abscesses form. The passage of faecal matter is calculated to keep up the disease, but I have generally succeeded in con- trolling it in those cases which have come under my care. At the onset, I cauterize superficially with the nitrate of silver, and throw up injections of cold water; to this I add mild purgatives, as magnesia or sulphur; and in the phlegmonous stage, antiphlo- gistics and emollients are to be used, as I several BLENNORRHAGIC OPHTHALMIA. 127 times have had occasion to mention. Nasal and buccal blennorrhagias have been admitted, but their existence is far from being proved ; people affected with blennorrhagia may experience an attack of coryza without the nasal secretion being necessarily of a blennorrhagic nature. The buccal variety is just as hypothetical; at least, I have never seen it, and yet, if such a thing existed, it would be the most easy of detection. Blennorrhagic ophthalmia.—I will enter this day upon a very interesting topic—viz., blennorrhagic ophthalmia. This is a very fearful disease, and one which ought to be combated with the greatest energy. The general opinion is, that ocular blennorrhagia is exclusively the result of the direct application of the pus to the eye. I myself thought so once, but ex- perience has made me alter my views on this subject. Remember that purulent ophthalmia occurs only with urethral blennorrhagia, and that balano-posthitis, vul- vitis, and uteritis, never produce it: this is a very curious fact. Yet vaginitis, simple uteritis, and vul- vitis, may bring on urethritis, and the latter may then engender blennorrhagic ophthalmia; it seems as if there were something peculiar in the inflammation of the urethral raucous membrane. Another fact is, that this ocular affection is more frequent in men than in women. So, then, we start with two well-settled points—viz., blennorrhagic ophthalmia is always con- nected with urethral blennorrhagia, and it is more frequent in the male than in the female sex. First variety : blennorrhagic ophthalmia communi- cated by contagion.—It is a fact beyond doubt, that pus resulting from urethral blennorrhagia applied to the conjunctiva produces blennorrhagic ophthalmia. It has been said that the pus never reaches the globe of the eye, and is generally applied to the eyelids only ; but it is obvious that a very small extent of conjunctiva coming in contact with the pus by the 128 BLENNORRHAGIC OPHTHALMIA. play of the eyelids is sufficient to spread the disease. The urinary functions are likely in one sex to cause the hand to be soiled with pus, Avhereas in the other it is not the case ; hence the greater frequenc/of the affection among men. Look at new-born children ; does not the contact of the puriform matter of the uterus and vagina with their eyes engender a great many blennorrhagic ophthalmias ? Those who will needs ascribe the affection before us to a general dis- position, acquired by the effect of the disease on the system, have had their patients watched very closely during the whole day, and observed the most scrupu- lous cleanliness, and still the eyes became affected ; but who knows whether these restrictions were en- forced at night ? I cannot admit such cases as having any weight in the question ; and besides, there are some others which it is impossible to explain on mere constitutional influence. For instance : a blen- norrhagic patient loses both eyes by an ophthalmia of the same nature ; his brother, who slept with him, experiences the same ocular affection, but gets cured, and not the slightest discharge from the generative organs could be found. Is not this direct contagion? A woman by accident used, as a wash for her eyes, a solution of acetate of lead, which her husband, affected with urethral blennorrhagia, had unfortu- nately been employing as a lotion ; violent ophthal- mia came on, and on examination she was found quite free from any discharge whatsoever. Welsh admits all this, but denies auto-contagion. He says that he has seen the blennorrhagic pus of a patient applied to the subject's own eye without doing any harm. This case goes for nothing ; for there must be, beforehand, a certain predisposition in the eye to take the disease, even when exposed to contagion. The muco-purulent matter secreted by the conjunc- tiva, being applied to the urethra, will o-ive rise to urethritis: this fact has even led some to think that BLENNORRHAGIC OPHTHALMIA. 129 urethritis was the result of Egyptian ophthalmia ; whilst others have contended that Egyptian ophthal- mia was, on the contrary, the result of urethral blen- norrhagia, and that the ocular affection had spread from the eyes of one individual to the eyes of another. There is, in fact, so much similarity between these diseases, that it is difficult to decide which was the original affection. This variety of blennorrhagic ophthalmia occupies, generally, but one eye ; yet the other may suffer, either by sympathy or the contact of pus. This last mode of transmission is pretty fre- quent, since patients are very apt to lie on the sound side, to avoid pain, and they thereby favour the trickling of the matter from the inflamed eye to the healthy one, particularly those whose ossa nasi are rather depressed. The ocular disease may be com- municated by contagion, when the blennorrhagia is merely of a few days' standing, and the eye may suffer severely without the organs of generation being affected in the least; indeed, I cannot help thinking that many of the purulent ophthalmias which we receive in our hospitals have very often urethritis as their primary cause. As for the disease spreading by a sort of aura blennorrhagica, I must say that such a thing is quite improbable, for there would be very few patients of this house who would escape ophthalmia, living, as they do, in a regular blennorrhagic atmosphere. Second variety: metastatic blennorrhagic ophthal- mia.—It is generally acknowledged, that there are patients who suffer from the ocular disease, as a result of urethral blennorrhagia, quite independently of con- tagion. I am ready to agree to this, not because I am told that these individuals could not possibly carry the pus to their eyes, for there is no certainty about this, but from the aspect, rise, and progress of the disease. I may notice here, that blennorrhagic ophthalmia, which springs up without contagion, is often connected, although not necessarily so, with a rheumatic diathesis. 130 BLENNORRHAGIC OPHTHALMIA. Having now stated the two varieties I acknow- ledge, I can take up the symptoms of the first. I have already stated, and I must repeat, that a dis- charge of a very recent date may contaminate the eye ; and, moreover, that the infecting properties of the pus are retained for months afterwards; in fact, as long as the matter remains irritating. I am, of course, understood to speak of the muco-purulent discharge of urethral blennorrhagia alone, both as to the variety by contagion and by metastasis. Oph- thalmia by contagion is very rapid in its progress; it attacks usually one eye only, but the other may- suffer consecutively, whether by sympathy, contact of the matter, or metastasis. Some patients experi- ence first great heat in the eye, others pruritus ; they soon complain of a sensation of sand in the organ, the conjunctiva gets vascular, but the inflammation is still confined to the mucous membrane lining the lower lid ; it then reaches the inferior oculo-palpebral sinus, and thus it ascends towards the upper lid. The matter secreted is at first mucus, and afterwards it be- comes muco-purulent. There is no secretion at the very beginning ; but this dry period is so short, that it mostly passes unnoticed. The whole eye, as I mentioned, is not invaded at once; but the entire organ soon gets involved; the mucous membrane is injected, and turns of a brick-red ; the inflammation attains a high degree of intensity the temple and eye experience as yet little pain ; the lachrymal secretion is abundant, bursts forth in gushes, and causes a severe scalding—the analogue of ardor urinee; the sub-mucous cellular tissue gets involved in the mis- chief, and presents at first simple, then phlegmonous, oedema ; it is quite a repetition of balano-posthitis ; the lid swells, becomes convex, reddens highly, and looks erysipelatous ; its own weight bears it down- wards, and causes it to cover the lower lid, which latter is thus pressed against the globe of the eye • BLENNORRHAGIC OPHTHALMIA. 131 real trichiasis ensues, which tends to increase the irritation ; if the lower lid should likewise swell, then will its margin be on a level with the tumefied upper palpebrae, and ectropium is often the result of this state of things. The infiltration soon invades the whole of the sub-mucous cellular tissue, the puffed- up mucous membrane forms a thick rim around the cornea, and we have chemosis. As the disease pro- ceeds, pain in the head comes on, and phlegmonous symptoms appear. There is but little intolerance of light at this period ; but the deeper parts of the organ at length begin to suffer, and the cornea gets involved. The appearance of the secretion passes through the same stages which we noticed in urethral blennor- rhagia ; it is first of a light yellow, gets then a little deeper, then brownish, and in bad cases, sanguineous and very thick. We shall see a little later how the nature of the pus has been taken advantage of to aid the prognosis. The twro palpebrae may get quite glued together, and they form internally a cavity, where the pus and tears lie stagnant. The eye re- mains in contact with these irritating substances, and the disease is so much the more destructive as the palpebral aperture is narrower; whilst balano-pos- thitis is just in the same way the more troublesome as the preputial opening is smaller. Patients do not find their sight impaired up to a certain period of the disease, and the cornea is perceived clear and bril- liant in the middle of the conjunctival swelling; but it is at last attacked also, after a resistance due to the difference of texture. It loses its transparency ; a plastic effusion takes place; it becomes twisted and of an opal colour; it softens, and little purulent de- posits form between its layers ; these abscesses burst either externally or internally, and more or less com- plete perforations ensue, the consequences of which vary according to their size and the nature of the substances injured. The cornea is Avith some patients 132 BLENNORRHAGIC OPHTHALMIA. very quickly destroyed; it perishes in some degree forthwith, particularly when the chemosis is fully de- veloped. The inflamed parts undergo transformations which you should be acquainted with ; the mucous membrane assumes a granular and rugged appear- ance ; the granulations become larger as the disease advances ; but they attain a considerable size only in cases of long standing, and which have been neg- lected. The ophthalmia can run through all its stages, destroy the eye, and spread to the internal parts of the organ in twenty-four or forty-eight hours, but it takes mostly five or six days. If the disease have resulted from contagion, and if one eye only is attacked, the progress will be the faster; and when nothing is done to stay the mischief, the eye is sure to be lost. The favourable signs pointing to the de- cline of the inflammation are the decrease of size in the lids, the cessation of febrile symptoms, the dimi- nution of the secretion, its change from pus to muco- purulent matter, the fading of the redness, the les- sening of the chemosis, and the easy separation of the lids. If the affection has been transmitted by con- tagion, there is no danger of a relapse ; it does not kindle again at the slightest provocation, as Ave find it doing in cases of metastasis. Differential diagnosis.—The principal guide to the diagnosis is the existence of a urethral blennorrhagia or contagion from one individual to another. There is no sign, except these two circumstances, which may assist the inquirer in distinguishing this disease from Egyptian ophthalmia ; the general aspect of these affections, their progress, the nature of the pus, their intensity, are pretty much the same. Some importance has been attached, by M. Lerios, to the swelling of peri-auricular glands, as pointing to non- virulent affections ; but dwelling upon these signs is of no use, since there is no such thing as virulent blennorrhagia. BLENNORRHAGIC OPHTHALMIA. 133 Prognosis.—This is in general unfavourable. Mr. Lawrence states that the eye was lost in nine cases out of fourteen. Whilst I was an interne, under Dupuytren, I never saw one eye saved, the perfora- tions always destroyed the organ; but matters have changed for the better since that time, and we now preserve as many eyes in this disease as we lost at that period. The surgeon must watch his patient closely, and he will be amply remunerated for his trouble, by the satisfaction he will feel in sa\'ing a valuable organ placed in such jeopardy. Besides the \-arieties of blennorrhagic ophthalmia hitherto mentioned, there is one alleged to spring up as a consequence of a constitutional blennorrhagic infection. I have only to state that it can have no existence, since we do not admit of a constitutional taint being ever the result of blennorrhagia properly so called. Third variety: sympathetic blennorrhagic ophthal- mia.—When one eye is affected by contagion, the other may partake in the disease, independently of purulent contact, and of the state of the constitution. This may readily be admitted, since we often see a simple ocular inflammation of one eye, without any secretion, pass to the other, Avhen contagion, metasta- sis, or the general state of the system, are out of the question: and do we not sometimes see these pheno- mena occur after the operation for cataract performed on one eye only ? Authors have admitted an oph- thalmia sympathetic with articular inflammation, but I think this the mere coincidence of a catarrho-puru- lent ophthalmia, or an effect of a general state of the system favouring the development of catarrho-puru- lent inflammation of several mucous membranes at the same time as the urethral or the ocular. But in the greater number of cases there is another and very remarkable diathesis in the system—namely, the ten- dency to rheumatic inflammation; and many blennor- 12 134 BLENNORRHAGIC OPHTHALMIA. rhagic ophthalmias spring up under its influence. Abernethy admitted an irritative state of the constitu- tion, to explain the occurrence of the ocular affection; these rheumatic ophthalmias have, in later times, been attributed to metastasis. The origin of this latter opi- nion may be found in the moveable and oscillating character of rheumatism. But, I might ask, is metas- tasis acknowledged for rheumatism itself? I am afraid we must accuse strumous, lymphatic, and gouty con- stitutions more than metastasis. Some authors have thought that the mischief is caused by the use of bal- sams and injections, but I repeat here what I said be- fore, about epididymitis—namely, that most of those who suffer both from the testicular and ocular affec- tions, have used no treatment at all. In fact, there are patients who, with every blennorrhagia, experi- ence gouty and rheumatic pains, and even blennor- rhagic ophthalmia, showing plainly that these different and simultaneous affections depend more on a pecu- liar diathesis than on metastasis. The ophthalmia under consideration may result from a mere gleet, and it has been observed that both eyes are mostly affected in these cases, either together successively, or alter- nately. This fact militates greatly with the attempt that has been made to establish a distinction between blennorrhagia and Egyptian ophthalmia, in saying that one eye only Avas attacked in the former, and both in the latter. You remember that I stated that in blen- norrhagic ophthalmia, by contagion, one eye only is most frequently affected. Duration.—This variety lasts much longer than the disease arising by contagion; it is more subject to re- lapses ; passes easily from one eye to the other, as we have seen epididymitis pass from one testicle to the other; and is very often accompanied by articular inflammations. This arthritis may either succeed or precede it, or spring up at the same time ; oscillations between the ocular and urethral blennorrhagia are BLENNORRHAGIC OPHTHALMIA. 135 sometimes noticed; and, indeed, ocular and urethral blennorrhagia, as well as the articular affection, may very well co-exist. Symptoms.— When the morbid agent acts upon the Avhole of the ocular mucous membrane, we have pretty nearly the same symptoms as with the ophthal- mia from contagion, and it is very difficult, at the very onset of the disease, to distinguish one of these varie- ties from the other. But the difference soon becomes apparent; the vessels of the sclerotica get injected, the globe of the eye is tender and painful, and the pain reaches very deep ; the colour of the cornea changes, owing to the inflammation of the membrane which lines its posterior aspect; the iris soon partakes in this discoloration ; the secretion of aqueous humour increases remarkably; and a sort of hydr-ophthal- mia takes place. Photophobia comes on, and if the inflammation penetrates more deeply, there may be photopsia ; the secretion of tears is much augmented ; and an effusion of an albuminous liquid takes place in the anterior chamber. From this you perceive that in this sympathetic blennorrhagic ophthalmia there is as little tendency to suppuration as in rheumatic ar- thritis; indeed the inflammation of the membrane, se- creting the aqueous humour, may well be compared to synovitis in the joints. Still there may be very unpleasant results from the inflammation of the iris in this variety ; puckering, permanent contractions, and irregularities of the free margin ; and even real cata- ract from pseudo-membranes formed by the morbid secretion, may remain permanently. The disease ge- nerally begins by a catarrhal state of the conjunctiva, and then extends to the iris, but the globe itself is sometimes attacked first. Prognosis.—If catarrho-rheumatic ophthalmia be not immediately recognised, and properly treated, it may turn out a very serious business; but when it is well understood, and adequate means are used to con- 136 TREATMENT OF trol it, there is much less danger than when the dis- ease has been transmitted by contagion. Suppura- tion and the destruction of the eye is then much less to be apprehended. I have not time to enter upon the treatment of blennorrhagic ophthalmia ; I will do so at our next meeting, when I hope to begin blen- norrhagic arthritis. LECTURE XIII. TREATMENT OF BLENNORRHAGIC OPHTHALMIA. When you have to deal with this sad affection you must be mindful of the rapidity with Avhich it may de- stroy the precious organ of sight; the slightest delay may be fatal to it. The patients ought to be kept very quiet,—any sort of excitement may have the most baneful influence ; the head should be raised, the eyes completely shut out from the light, and the diet very low. The first thing to be done is to use the solid nitrate of silver; it ought to be rubbed over the affected surfaces so as to produce a white film, but not to destroy the tissues. The lids should be everted, if practicable, and the eye copiously washed with Avater after the cauterization is effected. Some surgeons have advised anointing the cornea, in order to protect it from the caustic, but this precaution is not necessary Avhen care is taken to irrigate the part thoroughly after the use of the nitrate. There might, however, be danger to the cornea if the cauterization were not conducted with skill, and if the subsequent ablutions, intended to remove the excess of the salt, were neglected. You should endeaA-our to watch your patient after this first cauterization, and you will perceive that the secretion is momentarily suspended BLENNORRHAGIC OPHTHALMIA. 137 by it, but when the crust formed by the caustic falls off, the pus reappears, though it is then lighter in colour, and easily turns sero-sanguineous: these ef- fects are exactly analogous to those which follow ure- thral injections in abortive doses. So long as little white streaks, the result of the cauterization, remain visible, and so long as the secretion is not again puru- lent, you may judge that the influence of the nitrate is continuing; but when the streaks have disappeared, and the secretion re-assumes its primary character, you may infer that the effects of your cauterization are over, and you may then repeat it; indeed, it can safely be used three times a-day. With children,— with persons whose eyes are very small, or in whom there is the slightest fear of injuring the organ, the nitrate of silver should be used in solution, applied, as usual, with the brush, and the parts well washed with plenty of water, as before mentioned. The eye must be cleansed frequently during the day,—it else would remain too long in contact Avith the purulent matter; but this should be done with great neatness and gentleness, by carefully separating the lids, and injecting between them, with a glass syringe, the li- quid intended to wash away the pus. Soothing fo- mentations of poppy-heads and quince-seeds should be applied to the eye, but let it be done very lightly; and eschew poultices altogether, for they favour oedema of the part. I have used, with much success, frictions of belladonna ointment, at a little distance from the organ; but I would advise you, at this stage of the affection, to avoid mercurial frictions, for they are apt to increase the secretion rather than prevent or diminish it. When the disease is on the decline, mercury is, on the contrary, very useful. When blennorrhagic ophthalmia is complicated Avith chemosis, the latter should be removed whilst it is merely the result of oedema, for you will find when it becomes phlegmonous that the conjunctiva gets so 12* 138 TREATMENT OF distended that the membrane can hardly be seized with the forceps. The excision is therefore to be made early by means of a toothed forceps and curved scis- sors; and this operation is followed by such excellent results, that some surgeons (Jameson) have felt dis- posed to rely on it, exclusively of all other treatment, because they consider that it contributes to disperse the serous or sero-sanguineous congestions of the part, by the local abstraction of blood which accompanies it. I think, however, that the excision should be pre- ceded by the cauterization, for the blood resulting from the use of the scissors would interfere Avith the action of the caustic. When the chemosis has reached the phlegmonous state it can no longer be excised; you must then have recourse to scarifications, but their effects are very inferior to those of excision. In the interval between the cauterizations with the solid ni- trate of silver, I inject into the eye, three or four times a-day, a Aveak solution of the same salt, and I pay- great attention to those remedies which are addressed to the system at large, for they powerfully aid the to- pical applications. If there is much febrile reaction I bleed from the arms, and this I do several times if found necessary. Leeches may be placed on the course of the jugular vein, in the canine fossa, or be- hind the ears, but a sufficient number of them should be used, to avoid subsequent effusion. Do not be afraid to debilitate your patients—on the contrary, you had better administer saline purgatives, which will act in the same Avay as bleeding, by causing se- rous evacuations. Mercurials must not be used in this stage, for they have a tendency to excite vascu- larity in mucous membranes, and would thereby do harm. As to the revulsives on the surface, you had better avoid pediluvia with mustard, for the essential oil of this seed is apt to rise and irritate the eyes. Sinapisms are better, and blisters are very good when judiciously applied—that is, towards the decrease of BLENNORRHAGIC OPHTHALMIA. 139 the inflammation, not too near the eye, and in such a place as not to cause the necessity of rollers around the neck, which might increase the congestion of the organ. The nape is an excellent situation for a blister. Treatment of the urethral discharge.—Those Avho attribute the ocular mischief to metastasis, endeavour to re-establish the discharge, either by taking pus from the eye, in order to inoculate the urethra with it, or by obtaining purulent matter from another indi- vidual, for the same purpose, or by leaving catheters in the canal. I need not repeat here what I said be- fore, about the danger of using the pus of another, as we can never be sure that there are no latent chan- cres in the urethra Avhich yields the pus. As for the discharge itself, there is no doubt that it always dimi- nishes a little when the eye gets affected, but it never ceases altogether from that cause, so that these prac- tices need not detain us an instant. I use copaiba simultaneously with the means already enumerated, not as having any effect on the ophthalmia; for when the ocular affection is the result of contagion from an- other individual, I do not use it; but in order to con- trol the urethritis, as in doing sol remove the chance of relapse as regards the eye.......If you have to deal with that variety of the disease which is con- nected with rheumatism, if the membrane secreting the aqueous humour throws out plastic lymph, and the different humours of the eye get dim, it wrould be advisable, besides using the means I just mentioned, to combat the photophobia and photopsia, and to pro- mote the absorption of the plastic element by appro- priate means. I have obtained very satisfactory re- sults from belladonna, both as an ointment, rubbed in by the side of the eye, and administered inter- nally; mercury, in small doses, carried to salivation, Avill control the fibrinous effusions, so that its use is clearly indicated. Colchicum may here advantage- 140 BLENNORRHAGIC ARTHRITIS. ously be added, as well as blisters; but I will reserve what I have to say on this head until I take up blen- norrhagic rheumatism. If I Avere to meet with a case where the inflammation produced a sort of strangula- tion of the lids, I do not think I would hesitate in free- ing the external commissure with the knife, so as to facilitate the application of the remedial means. When this species of ophthalmia is complicated by serous effusion and hypersecretion of the aqueous hu- mour, it has been advised to puncture the cornea, as the distension, which is the principal cause of the pain, is thereby much relieved. The same practice has been followed when the anterior chamber is the seat of hypopium, or when a little abscess forms at the surface of the iris. BLENNORRHAGIC ARTHRITIS. Gonocitis, or blennorrhagic white swelling of the knee.—This complication has long remained unno- ticed ; we must go as far back as SAvediaur to get a positive account of it. It must not be overlooked, that Hunter had remarked a connexion between blen- norrhagia and arthritis in a man who regularly expe- rienced rheumatic pains Avhenever he caught a gonor- rhoea ; but he attaches no importance to the fact. Musgrave, in a Avork published in 1723 ("De Arthri- tide Symptomatica"), speaks of a venereal arthritis; but it is difficult to make out to what kind of accident his description refers; indeed, we may consider Swe- diaur as the first who placed rheumatic arthritis among the complications of blennorrhagia. If I am asked whether blennorrhagic arthritis has any peculiar dif- ferential signs which may assist in distinguishing it from other articular inflammation, I can only answer that I was induced to admit such a variety as blen- norrhagic arthritis from the fact, that with some indi- viduals one or more joints are invariably attacked as soon as they take a blennorrhagia, without their hav- BLENNORRHAGIC ARTHRITIS. 141 ing ever before experienced any articular uneasiness, or feeling any pain in the joints between the different attacks of urethritis. Such cases have led me to look upon blennorrhagia as an occasional cause of rheuma- tic arthritis; the urethral discharge, according to these views, may be looked upon as an efficient cause. Let us see Avhich are the predisposing causes. This dis- ease is peculiar to adults, and is observed as late as forty or fifty; a lymphatic temperament, scrofula, and the male sex, predispose greatly; and all ordinary causes of rheumatism must be added to the list. Some have also included those therapeutic agents Avhich are capable of giving a sudden check to the blennorrha- gia, as also the use of injections; but the actual state of the urethral discharge likely to produce arthritis has hitherto been but little studied; for my part, I firmly believe that this variety of arthritis does not occur without the existence of urethral blennorrhagia; hence its rare occurrence in Avomen. M. Baumet has fancied there is a peculiar syphilitic stamp in blennor- rhagic arthritis, and grounds his belief upon the fact, that the articular affection is much benefited by mer- curial frictions; but arthritis never follows a urethral chancre, unless the latter is connected with a bond fide blennorrhagia. As to the period when the joints commonly become painful, I Avould say, that it is to be looked for from the second to the fourth week, and sometimes later. From the close connexion between the two affections, it will be understood how a ure- thral discharge can follow an attack of arthritis; in- deed, this is a common occurrence with some people after each attack of gout or rheumatism. M. Foucard, who has written a paper on the subject, has admitted a metastatic arthritis resulting from a discharge brought on by rheumatism; but he does not recognise the ex- istence of a blennorrhagia of a rheumatic nature. You will be pleased to notice, that it is not indispensable for the development of the arthritis, that the urethral 142 BLENNORRHAGIC ARTHRITIS. discharge be very abundant; it would seem, on the contrary, that it is towards the decline of the blennor- rhagia that the joints get affected; and hence has arisen the idea, that the articular inflammation de- pended on the suppression of the discharge; but what- ever cause may be admitted, it is worthy of notice that the discharge generally continues unaltered for a little time after the onset of the articular affection, and that it gets greatly modified subsequently. I have the authority of M. Velpeau regarding this fact. Seat of the rheumatism.—All the articulations,—all the different fibrous structures of the system,—may be attacked, not excluding the spinal dura-mater or the pericardium; but the most common seat of this variety of arthritis is either one or both knees. M. Cloquet is inclined to believe that it is the coxo-femo- ral articulation which gets affected in women ; and as to men, I have noticed that the tibio-tarsal very often suffers. M. Gibert places the disease in the calcane- ous articulation; but it might be asked Avhether the os calcaneum articulates with itself? The pain is, hoAvever, often referred to the tendo-Achillis; in fact, all the joints of the body may become affected one after the other, or several at the same time ; all the elements of an articulation are liable to get inflamed, and this inflammation may produce those lesions which are the peculiar characteristics of white swelling. The attack is mostly sudden, but sometimes preceded by the usual premonitory symptoms of rheumatism ; and there may be severe febrile excitement, although the disease is mostly subacute. The joints become pain- ful, swollen, misshapen; the integuments retain their natural colour; but it happens at times that the veins of the skin get turgid, and that the part assumes a pinkish hue, whilst the most constant phenomenon is hydrarthrosis. This affection is very rapid in its pro- gress; indeed, it may cause very severe lesions in four or five days. M. Velpeau has recorded a case BLENNORRHAGIC ARTHRITIS. 143 of arthritis, resulting from a urethral inflammation, which proved very serious in a short time, and he mentions that the urethritis was brought on by the in- troduction of the catheter. The disease may terminate favourably in six weeks or two months, but there is generally a great tendency to the chronic state when the beginning has been slow and insidious. The modes of termination may be— first, resolution; secondly, the passage to a state of chronic hydrarthrosis; thirdly, either intra or extra capsular suppuration—this latter event is, however, very rare; fourthly, degeneration of the soft parts of the articulation, or of the cartilages; fifthly, and lastly, white swelling. The discharge persists for the most part, yet it may experience oscillations depending on the slightest causes; its cessation has, however, very little effect on the articular affection. Allow me a few more words on the differential diagnosis of blen- norrhagic rheumatism. The only real difference be- tAveen this variety of rheumatism and all the others, is to be found in the cause \AThich gives rise to it, and in the investigation of this cause we are assisted nei- ther by the seat, the symptoms, nor the progress of the disease, we have no guide but the coincidence of the arthritis with blennorrhagia. The fact of a single articulation being affected, the chronic tendency, the hydrarthrosis, the simultaneous occurrence of a double blennorrhagic ophthalmia, might be quoted as point- ing to the blennorrhagic variety of rheumatism; but the latter often attacks several joints at the same time, is very acute, and causes but little effusion, all of Avhich symptoms again point to common acute rheu- matism, so that it is very difficult, if not impossible, to form an opinion based upon the arthritic symptoms alone. A question which has often suggested itself to me is, whether, in many cases Avhich exhibit the peculiarities last described, we might not suppose that the usual causes of rheumatism have been in play 144 BLENNORRHAGIC ARTHRITIS. during the existence of urethral blennorrhagia. As for the articular pains of secondary syphilis, they are so easily distinguished from the affection we are con- sidering, that I need not dwell upon this subject just at present. The prognosis is here pretty much the same as in common rheumatism, yet hydrarthrosis oftener follows the blennorrhagic variety; before giving an opinion, you should carefully observe the tempera- ment of your patient. Treatment.—I have admitted an acute and a chronic form; in the acute, febrile reaction should be subdued by rest and antiphlogistics. General and local bleed- ings are useful: still you must not abstract too much blood, for fear of serous effusions. Emollient and se- dative applications, fomentations and embrocations, Avith belladonna, will constitute the topical means. Do not be sparing in saline purgatives, you will find the serous dejections which follow their use very effec- tive in subduing inflammation. Colchicum has been much praised by some, and run down by others, still it often produces very satisfactory results: I give from half a drachm (by weight) to two drachms and a half a-day, and seek the tolerance of the drug. I have also given nitrate of potash in large doses—viz., from one to five drachms per diem; this mode of adminis- tering the salt has been used with great success by Messrs. Martin Solon, and Gendrin. When this arti- cular affection begins in a slow, insidious manner, or when it is on the decline, Ave must omit antiphlogis- tics, and I would then strongly advise repeated blis- tering; it is one of the most powerful means of com- bating this disease. Colchicum, nitre, Ioav diet,rest, and bitter infusions, are likewise indicated. The vesicating plaster should be mixed with camphor, in order to prevent the pe- culiar action of cantharides on the urinary oro-ans; and it may here be noticed that the meloe is most likely to act on the bladder when applied to the knee. I VIRULENT DISEASES. 145 gave formerly the disulphate of quinine a fair trial, and used it in large doses, but without benefit. When the inflammation is subdued, and the elements of the joint are merely thickened, we should have recourse to compression, either with linen rollers or adhesive plaster. Plasters and liniments of a detergent and resolvent nature may also be tried ; equal parts of tinc- ture of squills, camphorated spirits, and Sydenham's laudanum, make a very good liniment. Benefit has also been derived from camphorated and mercurial ointments, as well as those of the iodides of lead or potassium, and of belladonna. Simple or medicated vapour douche, issues, moxas, and lastly iodide of potassium internally, when the means I first enume- rated have failed, must be given a fair trial. Mer- cury taken to salivation has been useful in some cases of acute and very painful rheumatic arthritis, but this cannot be attributed to any specific action, as common arthritis yields to the same remedy. Some authors, as I have mentioned before, consider blennorrhagic arthritis as the result of metastasis, and they accordingly advise the re-establishment of the urethral discharge; whilst others, on the contrary,use copaiba and cubebs in large doses to combat both the arthritis and the blennorrhagia. M. Velpeau belongs to the latter section, and gives the two substances in the form of an electuary. As for myself, I look upon the discharge as the focus from which the articular in- flammation has sprung, and I endeavour to stop it as soon as possible, in order to remove the cause which keeps up the affection of the joints, and leads to re- peated relapse. ORDER OF VIRULENT DISEASES. I will now direct your attention to the second or- der of diseases arising from sexual intercourse—viz., the truly syphilitic ; they have likewise been called large pox, morbus pustularum (thus named in the 13 146 VIRULENT DISEASES. epidemic of the fifteenth century), the French, the Nea- politan disease, &c. It was Frascator who first used the name of syphilis, a term of Avhich he does not give the origin, and which was a sort of epitome of all the others. Fallopius derives it from w^im*, as the disease seemed to originate in friendly inter- course ; Bousquillon, from o-iqkos, misshapen, on ac- count of the deformities which the disease sometimes produced. Whatever may be the etymology of the word, it is the term which in our days has been com- monly adopted, although Swediaur restricted its use to designate the disease when it affects the system at large, and he was in the habit of giving especial names to every one of the primitive accidents. As for myself, I shall comprise under the term syphilis, all the casualties connected with the virulent dis- eases. Syphilis is a malady peculiar to man; it never springs up spontaneously in the human econo- my, and is always the result of contagion at its first development. The affection is, in fact, essentially and fatally contagious; it acknowledges a specific and virulent cause ; the virus is of a peculiar kind, always identical with itself, and it produces, when in contact with the economy, local effects, in the exter- nal characters of Avhich the cause Avhich has given birth to them can be discovered. These local effects may react upon the system, and develop constitutional symptoms, which, under certain circumstances, are hereditarily transmissible,but which then do not repro- duce the specific cause which has been their origin. This specific contagious cause may take effect several times upon the same individual, Avhen it is placed under favourable circumstances ; but the general in- fection occurs but once. This disease is, moreover- distinguished by requiring most frequently a special medication. You will alloAv me now to dwell upon each of these points in particular; and first, as to syphilis being peculiar to man, it will suffice to say VIRULENT DISEASES. 147 that there is no disease transmissible from animals to man which bears the slightest resemblance to syphilis. Some authors, among whom was the elder Cullerier, were inclined to admit its spontaneous occurrence in some individuals, and they were driven to this opi- nion by puzzling cases, in which they could find no other explanation of the phenomena before them ; but I can distinctly say that there is hardly one case in a thousand where there is any difficulty of re-as- cending to the cause, and even that many cases will often admit of explanation in divers ways indepen- dently of spontaneity. It may, in fact, happen,— and Wiseman was well aware of this peculiarity,— that one individual, having been exposed to con- tagion, may experience no effects from the same, and nevertheless transmit the virus to another Avithout having himself experienced any attack ; so that were we to confine ourselves to the examination of the tAVo latter persons, we should be led to admit that the disease sprung up spontaneously, but in carrying our inquiry further, we should soon change our opi- nion. I think, therefore, that we are justified in maintaining that no one can be affected with syphilis unless he have been subjected to infection. Every one agrees now in thinking that the disease does not exist in the lower animals ; Hunter has experiment- ally established this fact, and my own inquiries' have led to the same result. M. Ausias thought he had succeeded, by inoculation, in establishing a chancre in one of them, but far from being a chancre, it was merely a foul ulcer, kept up by constant irritation; so that there is no doubt that syphilis is peculiar to man, and that it is the result of contagion. Let us now endeavour to trace the source of this contagious cause. Syphilis affects man as the result of the application, on the living texture, of a virus ever identical—viz., the syphilitic A'irus. It will not be necessary to point out at present what the ancients thought of this virus; 148 VIRULENT DISEASES. I mentioned their opinions at the beginning of this course. It exists in the chancre whilst the latter is in the stage of development, and there must be ulcer- ation to allow of reproduction : the necessity of ul- ceration for transmission was well known to Alexan- der Benedetti, and to Fernel. But the next question is this :—Are there in this virus sufficiently obvious characters to alloAv it to be easily recognised ? The most contradictory ones have been attributed to it; and these contradictions arise from the circumstance that this virus must be studied and observed in the pus— a vehicle, the qualities of which may vary ad infinitum. We all know that the pus which contains the poison may have an acid or alkaline reaction; that it may be loaded with organic detritus; that it may be serous, creamy, more or less thick, coagulable, acrid, cor- rosive, animalized; that it may contain helminths, &c. It would, then, be hardly logical to attribute all these characters to the syphilitic virus. The only constant and pathognomonic fact is, that the latter possesses the power of reproducing itself by inocula- tion when favourably circumstanced. The purulent matter, which is the vehicle of the virus, may be mixed with different substances, which vary accord- ing to the seat of the chancre. The purulent mat- ter may be found in the urine, saliva, milk, per- spiration, spermatic fluid, &c.; but this admixture always happens after the secretion of the latter pro- ducts. It may now be easily conceived that the virus will be found in these vehicles in different propor- tions ; but notice that it is merely in suspension, and never intimately mixed with these secretions ; so that the latter will act in the same way on the tissues upon which they are applied, however largely diluted they may be, provided the quantity of fluid, be it ever so little, contain a molecule of the virus; the degree of virulence will then ever be the same. It has been VIRULENT DISEASES. 149 asked, whether the syphilitic virus has been gradu- ally diminishing in intensity. There is no doubt that the disease, as we see it in our days, is far from pre- senting the violent character which it is reported to have had in the epidemic of the fifteenth century; but even supposing that all the sufferings which have been described are to be attributed to syphilis, it would appear that the improvement in the symptoms is owing to a great number of circumstances, inde- pendent of the virus itself—viz., the better morals and customs of the people, the better treatment, civili- zation, &c. It must, moreover, be noticed, that at the time of the epidemic, and long afterwards, the individual affected with syphilis was scouted, ill- treated, shunned, driven to conceal his disease, and thereby he lost the benefit of a sound treatment; in- deed, people situated in this manner, in our own days, often present all the symptoms noticed in the fifteenth century. We may safely assume, I think, that the intensity has not diminished, but that the effects have been attenuated by the favourable cir- cumstances Avhich surround the patients. Let us now examine the mode of action of this virus. We must seek it first in the virulent matter itself, and then in the tissues whereupon it has been deposited. Virulent pus contains two elements, the purulent and the virulent: the first is the vehicle, and I have already stated that it may be mixed with other substances. These two elements brought in contact with a surface which has not been denuded, may act as simple irritants, and give rise to an in- flammation unconnected with specificity; it is in this manner that virulent pus, applied to a non-ulcerated mucous surface, may give rise to simple blennorrha- gia. But the pus, besides its specific effect, requires the assistance of certain extraneous circumstances, in order to produce its effect; and this fact has led some to deny, in toto, the specific nature of the virus. 13* 150 VIRULENT DISEASES. Let us examine these extraneous circumstances for a moment. In the first instance, it is not necessary that the ulcerated surface which secretes the pus , should have any particular seat to render the puru- lent matter virulent. I have found chancres in vari- ous parts of the system, and the contagious nature was ever the same ; a state of erethism, of excite- ment, of excessive vitality of tissue, is no more indis- pensable than a special situation ; nor need the viru- lent matter be warm or recently secreted. This has been put beyond all doubt by my experiments. I have, namely, preserved such pus in phials for three, ten, and fifteen days, and chancre was produced just the same, by inoculation with the lancet; so that it is clear that the matter may remain so many days on the tissues without losing its inoculating properties; and immediately a circumstance favourable to its ac- tion arises, the chancre appears. Thus may be ex- plained the development of a chancre fifteen or twenty days after sexual intercourse, which unusual fact had been attributed to incubation. Chemical or organic alterations prevent the action of the virus; gangrene also destroys the virulence of the pus; and certain chemical agents do the same. Let us now see how the tissues on which the virus is deposited must be circumstanced, in order to insure its action. The age, sex, temperament, and previous diseases, have nothing to do with the action of the virus, and no one is refractory to the local effects of the poison. This is an immutable law, admitting of no restric- tion ; people may, as I before mentioned, get so used to the intercourse with females suffering from a blennorrhagic discharge as to escape unhurt • but this never happens with chancre. The most favour- able circumstance for the action of the poison is its application on an ulcerated surface, or on a simple solution of continuity ; but inoculation may happen independent of this by the introduction of the virus VIRULENT DISEASES. 151 into the follicles of the part; their surface looks at first irritated, erosion then takes place, and inocula- tion ensues. Another favourable circumstance is the more or less stagnation of the matter upon the part; this permanent contact is, in fact, necessary on the non-denuded surfaces. As the pus may then remain a certain time in contact with the tissues without producing any effect, we may easily understand that in this state it may be communicated to another indi- vidual, which latter will present all the phenomena of syphilis, while the former may escape unhurt. These are the cases which, as already said, led some authors to believe that syphilis could spring up sua sponie. The action of the virus is very powerful when the solution of continuity is recent, and when the surface is not bathed by fluids, as pus, &c. The genital organs are certainly the most exposed to the infection, owing to their peculiar structure, the deli- cacy of their tissues, the great number of follicles Avhich they contain, their functions, the protracted contact with the virulent matter, and the difficulty experienced in examining them completely. Mode of Propagation.—There was a time when people believed that syphilis could be inhaled with the air, but we are now better informed, and we know that there is no contagion but that resulting from the direct application of the virus. The most common mode of transmission is sexual intercourse ; after this must be reckoned unnatural connexion, which gives rise to anal, buccal, nasal chancres, &c. But it must not be supposed, when we find a chan- cre in a region at a distance from the genital organs, that that region has actually and necessarily been subjected to intercourse with diseased generative organs, because the virulent matter is often carried by the finger to different parts of the body, where these chancres spring up. A medical man may be- come affected with a digital chancre by a vaginal or 152 VIRULENT DISEASES. anal examination ; the disease may be caught by using canulae, forks, sheets, masks, &c, which had previously been in contact with primary specific ul- cerations. Indeed, the mode of propagation is a very important subject, particularly in a medico-legal point of view. I must not forget to mention, that transmission by surgical instruments, and the dif- ferent parts entering into the dressing of ulcers, &c, is very possible. It has been maintained, that one or more anterior attacks of the disease Avere circum- stances favourable to a subsequent infection ; but experience has shown, that the infection of the con- stitution having once taken place, it could not hap- pen a second time ; or, in other Avords, that the sys- tem can be tainted but once. As for the local affec- tion, it can only be favoured by the existence of weak cicatrices, which may be the consequence of pre- vious chancres, or simple wounds ; but it is evident that the predisposition in these cases has no con- nexion with the nature of the disease. The action of the virulent matter may be reckoned from the moment Avhen it came into contact with the living textures, and those who take the trouble of closely examining its progress, will easily folloAV the evolution of the same. But there are twro theories opposed to this view,—one is the theory of general; the other, of local incubation. The supporters of the first hold that the pus brought into contact Avith the tissues is absorbed at once ; that it immediately affects the system during a time more or less pro- longed, called incubation ; that the action of the poi- son then retraces its steps, as it were, to produce its effects on the spot A\diere it was originally applied, and that this incubation may vary from two, eight, ten, to thirty days. But how could it be proved that there has been general infection before the local mani- festation ; the time which elapses generally between the application and the effects is no argument be- INOCULATION. 153 cause we sometimes see these effects arising immedi- ately ; and besides there is not one symptom point- ing to this general infection. No proof can be given to support this doctrine: the only semblance of truth in it is the analogy with the cowpock virus; but even this latter is not satisfactorily proved to act first on the system, and I have quoted Eichhorn, not long ago, on this subject.* If so much as thirty days of incubation were a common thing, there would be very few persons who could boast of being free from fear on the subject of syphilis; and we know, more- over, that this immediate absorption cannot be the same with all individuals, since the virulent agent always begins by modifying the tissues with which it comes in contact, which modification may retard, or altogether prevent, the absorption. Hunter, Bell, &c, supported the second theory—viz., the local in- cubation of the purulent matter ; they thought that the latter remained a certain time on the texture be- fore it produced any local effects. As for myself, I believe that the virulent cause acts immediately it is applied, whilst I admit that this action may be more or less prolonged, according to the nature and state of the textures ; but I will develop these views when we meet again. LECTURE XIV. PHENOMENA RESULTING FROM THE INOCULATION OF VIRULENT MATTER J DURATION AND PROGRESS OF THE SPECIFIC PERIOD ; PHAGEDENIC CHANCRE J IN- DURATED CHANCRE. I was mentioning, at the close of my last lecture, that the two theories of incubation could not be relied on, and that I considered the virus to act immediately after its application. If the consecutive effects of * Vide Lecture IX. 154 INOCULATION OF the purulent matter placed beneath the epidermis be closely Avatched, the following results will become apparent:—First. There is slight irritation produced by the Avound of the lancet; tAventy-four hours after- wards, an inflammatory areola forms around the inoculated spot, and the latter swells into a papula; on the second day, the epidermis which covers the latter is raised by a small collection of serum, which soon turns dull and purulent; at the end of the third day, the pustule becomes larger and umbilicated, like that of small-pox, and the surrounding areola in- creases as the collection of pus becomes more abun- dant. If at this time the pustule be opened, a small ulcer will be found underneath, of such a shape as if the soft parts had been punched out; its edges are sharp, undermined, and seemingly ready to fall in, which circumstance makes the sore look smaller than it really is ; and the fundus is grey and pultaceous. Towards the sixth or seventh day the pus dessicates, crusts form, and their accumulation gives to the ulcer the appearance of ecthyma, and may even go so far as to resemble rupia ; the epidermis Avhich surrounds the circumference of the crust is soon raised by a renewed suppuration, which dries in its turn, and thus the ulceration goes on, keeping up its primary form, unless it experience some deviation from in- cluding tissues, differing from those in which it took its origin. We see, then, that chancre may assume the shape of ecthyma or rupia, and it is clear that in such cases no decided diagnosis can be given without the assistance of inoculation. There are, further, two questions of some importance, which must be answered before we leave this subject- namely, at what period does the specific purulent matter thus artificially produced become inoculable ? And, next, how long will a chancre go on yielding inoculable pus ? As to the first question, I may de- duce from experiments, carefully made, that two days VIRULENT MATTER. 155 will suffice to give specific properties to the pus ; I have, in fact, produced a chancre with matter taken from an inoculation of two days' standing. As to the second inquiry, it must be remarked that the ulcera- tion continues progressing until a certain period, when it becomes stationary, although still yielding inoculable pus ; the first division or progress of the ulceration may be called the stage of development; the following division is the stage of rest or statu quo ; and we shall see, a. little later, that there is a third stage, which I call the stage of reparation ; it is in this period that the pus loses its inoculating properties. Some authors have attempted to explain the production of virulent pus, in supposing that the purulent matter acquires its poisonous properties after it is secreted, and in consequence of a peculiar modi- fication then effected. But this hypothesis cannot be admitted, because the virulence is ever the same, whether the sore be carefully covered to protect the matter from any extraneous influence, or left entirely to itself. This idea arose from the earlier experi- ments which Avere made concerning inoculation, for in these the pus of bubo was used, and produced no effect on a first trial, whilst, some days afterwards, matter taken from the same bubo, being again inocu- lated, produced a chancre. It Avas natural to infer from these results, that some change in the nature of the pus had in the interval taken place. But the supporters of this opinion forgot that the matter had, in the first instance, been taken from the purulent de- generation of the cellular tissue situated around the glands, and that the really specific pus lay within the latter. This I easily proved by first evacuating the purulent matter, and then making a second incision into the glands to obtain the syphilitic virus, which, being inoculated, yielded positive results. Neither is the virulent character, as some have thought, a result of changes going on merely upon the surface 156 DURATION AND PROGRESS of the ulcer, for I have sliced off layer after layer, but the virulence of the matter remained unaltered. The truth is, that the virus develops itself in a rather limited space, which gets gradually larger as the chancre increases ; and the longer the ulceration lasts, the more extensively the poison spreads through it; but the textures around the ulcer remain perfectly healthy. The virulence is, in fact, the result of in- terstitial elaboration, which takes place within the thickness of the tissues. Duration and progress of the specific period.—This stage may vary from two to eight weeks. I have seen well-defined chancres which ceased to yield specific purulent matter after the eighth day of their real existence, but I am not aAvare that this ever happened in a shorter time. I might almost say that the maximum is so much as seven years, for I have known a patient to suffer from a well-marked ulcera- tion for so long a time, without interruption. There is no doubt that a primary syphilitic ulcer may heal spontaneously, without the slightest therapeutical interference : that mercurial treatment is not only useless, but it may aggravate the disease; and it is therefore a great mistake to look upon it as a touch- stone of the nature of the ulceration. When the chancre has reached the stationary period, it may re- main in statu quo for an indefinite space of time ; it then passes into the suppurative stage, or that of re- paration, which is the last: its further progress is then similar to that of any common ulcer. This division into three stages is very important: first, as a point of doctrine, and secondly, with reference to forensic medicine ; for if it were necessary to go back to the original source of the contagion, it might hap- pen, in the inquiry, that the very chancre which was inoculable on one day, is no longer so on the next, owing to its attaining the period of reparation : it would, however, be a great error to conclude, from OF THE SPECIFIC PERIOD. 157 this circumstance, that this chancre has not been the source and fountain head of the mischief. As soon as the period of reparation is fairly established, there is no relapse or renewal of the inflammation to be apprehended unless a fresh contagion take place ; this rule will hold still better when the cicatrix is firm and complete. All primary ulcers do not begin in the same way. I have shown, by experiments, that the starting point might be a pustule; but it often happens that the pustular stage passes unnoticed, and nothing but an ulceration is seen. A chancre may assume the ap- pearance of a furunculus, or simulate an abscess ; this should be remembered Avhen a diagnosis is at- tempted. The development of chancre is preceded by no general premonitory symptoms, but a slight sensation of heat, some itching, and an increase of sensibility, manifest themselves on the part which is to become the seat of the lesion ; yet it must not be forgotten that herpes is ushered in precisely in the same way. It often happens that patients take no notice of the ulceration until it has existed some time, and has acquired a certain development ; they gene- rally reckon the onset of the disease from the time when they have become conscious of there being something wrong about their generative organs, but we ought to look upon this as the fictitious beginning ; the real commencement of the disease is the implan- tation of the virus. All parts of the body may become affected by the contact of syphilitic matter ; but it will be useful to divide chancres, as to their seat, into two great classes, the visible and the latent chancre,—the first plainly discoverable by the eye, the other cognisable only by certain signs. Chancrous ulceration takes place either on the skin or the mucous membrane ; the cutaneous chancre has a great tendency to get covered with crusts, and to assume the look of 14 158 PROGRESS OF CHANCRE. ecthyma ; whilst the chancre situated on a mucous membrane is constantly bathed in its own secretion, and never forms any scab. Besides the information which we derive from the secretion of the sore, we may also gather much from those peculiarities of the ulceration which depend on the seat of the chancre, and the functions of the organ on Avhich it may chance to be placed. The increasing and stationary periods which I have mentioned do not always proceed in the regular manner I have described ; they are sub- ject to variations, with Avhich it is useful to be ac- quainted. The first deviation from the usual course of things is that state of ulceration called phagedaena, wdiich, as you know, invades the neighbouring tissues. This species of chancre has itself several varieties— viz., the gangrenous, pultaceous, serpiginous, &c. The phagedaenic character does not arise from any peculiarity in the virus itself, but from some cause inherent to the individual affected, or from an acci- dental one. Phagedaenic sores mostly attack sub- jects passed the age of puberty or those who habitu- ally or accidentally indulge in spirituous liquors. This latter circumstance explains why they are more frequently met with in England than in France. Phagedaena may also acknowledge the following causes :—Warm Aveather, stimulating and irritating food, uncleanliness, mercurial treatment used at the wrong time, rancid mercurial ointment, the previous or present existence of secondary symptoms, &c. When the textures which form the fundus of the phagedaenic chancre get inflamed, they often run into gangrene; specificity is then destroyed, and when the crusts fall off a simple ulcer remains. The base of a diphtheritic, phagedaenic chancre is covered by a greyish, tough, and adhesive membrane, from which the purulent matter oozes; specificity is in such a case kept up for a long time, and this variety resembles hospital gangrene very much; it PHAGEDENIC CHANCRE. 159 often assumes, likewise, a serpiginous character, healing in one place, whilst it is extending in another. Notice that the really serpiginous chancre is very apt to run along the surface, and penetrates but little in depth. When a phagedaenic chancre is situated on the glans, it merely destroys the cortex of the organ, as it Avere ; its progress is slow, and it might not inappropriately be called a decorticating chancre. When it is placed behind the corona, it not unfre- quently severs the same entirely from the corpus cavernosum. To the causes favouring phagedaena, I must not omit to add, bad food, cold and damp dwelling, privations of every sort, weakstate of health, scrofula, phthisis, scurvy, herpes, ringworm, scabies, a deranged state of the digestiATe organs, &c. Characters of the phagedenic chancre.—The base is soft, greyish, and pultaceous ; the margins are un- dermined, thin, irregular, and bending down upon the sore; the ulceration includes the sub-cutaneous or sub-mucous cellular tissue, and extends particu- larly towards the dependent parts ; there is much pain, also a sense of burning and of pinching, Avhich becomes intolerable when a nervous filament gets denuded. The suppuration is abundant, thin, serous, loaded with detritus of organic matters ; if there have been granulations they disappear, just as it happens in hospital gangrene; here and there, sphacelated spots may be seen, which leave behind them an ugly-looking ulceration; the surrounding skin is pink or purple, getting perforated in different places ; and the system must inevitably suffer if this state of things continue for a certain time. Feverishness comes on, first only at night, afterwards it extends also over the day ; the skin becomes dry and hot, the pulse small and frequent; there is loss of sleep and appetite ; the patient is attacked by diarrhoea and colliquative sweats ; the former sometimes comes on suddenly along with vomiting ; the ulcer dries up, 160 INDURATED CHANCRE. and the unfortunate sufferer dies, in spite of all the care, solicitude, and skill of his medical attendant. I have found ulcerations of the colon, and even of the rectum, every time I have had an opportunity of making a post-mortem examination in such cases. Phage- daenic chancre may be complicated by erysipelas, strumous thickening, and a herpetic state ; it some- times destroys a Avhole organ, and may give rise to very dangerous haemorrhage. The ulceration will often lose the phagedaenic character altogether, but it is then kept up by the cause Avhich had produced the phagedaena; if, for instance, the exciting cause was scrofula, we perceive scrofulous symptoms taking the place of the phagedaenic. I can safely deduce from numerous observations that a chancre, Avhich at its onset becomes phagedaenic, does not taint the system; the constitutional phenomena which often follow this species of chancre are mostly owing to the feeble state of the patients; they get then af- fected Avith ecthyma, rupia, eczema, impetigo, and other eruptions, but these complications are to be looked upon as the manifestations of the general state under the influence of which phagedaena has occurred. Indurated chancre is the next species. This is the most important, as being almost always followed by secondary symptoms ; the induration is formed by a certain congested state of parts around the sore, and this engorgement favours the deposition and distri- bution of the virus. However, if no such induration appear after a week's full development of the chancre, there is no likelihood of its occurring at all, and in such cases we can venture upon a tolerably accurate prognosis as to the probability of constitutional infec- tion. Chancre may spring up in anybody, but there are doubtless some people Avho seem to possess an immunity as to the indurated species ; it is, however not known which peculiar temperament or idiosyn- INDURATED CHANCRE. 161 crasy is either favourable or unfavourable to the in- duration ; all we know is, that the aptitude for the development of an indurated chancre is lost after the latter has once existed upon an individual. It there- fore affects a man but once in his life, and herein we cannot help noticing a striking analogy between this disease and that from vaccine matter. An indurated chancre may have its seat in any part of the frame ; it is generally solitary, slow of growth, cold and indolent, it suppurates very little, and shows no disposition to spread ; notice that this apparent benignity of nature makes some patients entirely overlook this species of chancre. Its essential character is a well-defined, hard base; the induration is elastic, cartilaginous, and circumscribed ; Bell has very justly compared the feel of it to that of a split pea placed between the textures. The surrounding parts are perfectly sound, and when the skin or mucous membrane in the vicinity of the induration is stretched by the finger, Ave see the indurated nucleus assume a purple colour, and take the appearance of cartilage. The fundus of the ulcer is grey and diphtheritic ; the margins are adhe- rent and rounded off, instead of sharp and under- mined, as in the common chancre ; the centre is gene- rally more or less depressed, but it has been seen on a level with the margins, and in this latter case the chancre is quite superficial, so much so as to simulate simple balano-posthitis. Mr. Puche, being deceived by a case like this, set down the latter affection among the virulent diseases. But the indurated chancre may also rise above the surface: it then constitutes a special variety, which is pretty often met with ; and Avhen the induration is situated be- tween homogeneous textures, it presents a round and regular base, which is always of a wider extent than the ulcer itself. The induration never com- mences before the ulceration, and when Robinson announced the contrary proposition, it is probable 14* 162 INDURATED CHANCRE. that he had to do with ulcerations occurring on cica- trices, or persisting indurations from former sores ; or else that he was misled by follicular cutaneous chan- cres, surrounded by a very hard inflammatory areola. The induration may be situated on the skin, mucous membrane, or in the cellular tissue immediately under either of these organs, but it is far from being equally well defined in these different situations. The par- ticular regions where an indurated chancre happens to be situated have also much to do Avith its charac- ters : the latter are, for instance, much less marked at the anus, and behind the vulva, than in other parts. The indurated chancre, placed on the preputial mu- cous membrane, just behind the corona glandis, may be looked upon as the type of this species, for in that situation it has almost always a cartilaginous feel, and assumes the shape of a semicircular crest; and another peculiarity of this part of the generative organ well worth noticing is, that it abounds in ramifications of lymphatic vessels. As to the nature of the indura- tion, I am inclined to believe that it is caused by a plastic effusion into the lymphatic capillaries. We have, on this head, the advantage of some very care- ful investigations of Messrs. Marchal de Calvi and Charles Robin: these physiologists have found within the induration a fibro-plastic tissue, filiform fibrous bodies, containing a nucleus, nucleoli, and small globules, but I cannot say that, their labour has thrown much light on the subject. One thing, how- ever, appears certain—namely, that induration is the reverse of phagedaena ; that it is a sort of barrier to local destruction, and the first sign of general infec- tion ; indeed it might well be called a sort of inlet for the syphilitic virus. The exact time when the induration sets in is not quite determined ; I can state, for ray part, that I never saw it before the fourth or fifth day of the existence of the chancre ; it never begins the very first day of the application INDURATED CHANCRE. 163 of the virus, and rarely comes on after the fifteenth. Still, you must notice, Avith reference to the latter circumstance, that the induration may be concealed for a long time, buried in an inflammatory congestion or in oedema, and show itself only Avhen these have disappeared. We shall consider, at our next meeting, the devia- tions which may occur in the progress of the indu- rated chancre. LECTURE XV. DEVIATIONS FROM THE USUAL PROGRESS OF INDURATED CHANCRE ; GENERAL DIAGNOSIS ; URETHRAL AND ANAL CHANCRES ; PROGNOSIS. We have to consider, this day, the deviations to which the usual course of an indurated chancre is liable. They are generally owing to those peculiar dispositions which were mentioned with reference to phagedaena, and likewise to an excess of inflamma- tion, which may bring on gangrene. The latter oc- casions a pretty extensive loss of substance ; but the mischief is sometimes very trifling, in which case we merely perceive a few brownish spots towards the centre of the ulceration, these sphacelated points being the result of interstitial gangrene. But you must carefully notice, that this destruction occurs after the induration, at a time when the system is already affected, whilst the constitution does not suf- fer from a chancre which becomes phagedaenic at the very onset. The period of reparation, or healing of the sore, will, as well as the period of development, p-resent certain aberrations from the usual course : the granulation may attain an exaggerated size ; the 164 GENERAL DIAGNOSIS base of the ulcer may be covered with "vegetations, or cauliflower excrescences ; these may become fun- gous, and mucous tubercles may spring up ; but all these changes and deviations have no relation what- ever to the specific nature of the disease. Another very curious fact is, that the primary sore may under- go such alterations as to become a secondary ulcer or a raucous tubercle, without any other secondary manifestations; and this transformation has misled some Avriters so far as to make them believe that mu- cous tubercles sometimes appear as primary symp- toms. Cicatrization generally proceeds from the cir- cumference to the centre, but in phagedaenic sores it may begin in the middle, or on several points of the base at the same time, which points subsequently coalesce. The cicatrix may be either depressed or elevated with regard to the surrounding parts, and it is important for you to bear in mind (particularly in a medico-legal point of vieAv) that there is no espe- cial sign peculiar to the cicatrix of a syphilitic ulcer, and that it is quite possible that all traces of the ulceration be completely effaced. On the other hand, it must be mentioned, that an indurated kernel may remain, which will serve as a guide ; but even this is a deceptive sign, as the cicatrix might present a certain thickness, independent of the specific na- ture of the previous ulceration. General diagnosis.—I have stated several times already, that it is not prudent to rely on the origin, seat, form, base, extent, or duration of a sore, to give a distinct diagnosis as to its specific nature. Allow me to take a rapid glance at each of these characters. Some persons put a certain stress on the origin of the ulcer, as a guide for discrimination, but they forget that there are hundreds of ways in which, by contact, the disease may be communicated ; in fact, it has been caught (and this is authentic) by merely shaking hands with a friend. Doubts, on the other OF CHANCRE. 165 hand, of the venereal nature of an ulceration some- times arise from the unimpeachable source from which the disease has been contracted ; but this is no crite- rion, for certain things happen which are no doubt extremely startling. For instance, a married man comes to consult me about a well-characterized chan- cre, and vows that the coitus has been strictly matri- monial. What are Ave to think here ? We may think Avhat we please, but it is a rule with nre to tell the party that it is no chancre; and I Avell remember being one day mercilessly caught in a flagrant contradiction on an occasion like this ; but morality required that I should give an opinion contrary to my conviction. Neither will the seat of the ulcer decide the question; of course the parts of generation are oftener the locus electus than any other ; but a chancre, when the virus is duly applied, may develop anywhere ; and I re- member how long it puzzled us, some time ago, to explain how a well-defined chancre contrived to fix itself on a young apothecary's nose ; indeed, I can safely say that I know hundreds of ways in which the disease may reach numerous and distant parts. As to shape, we have here again to contend Avith an enormous variety ; and it is strange, forsooth, to see some peopje deliberately fix a certain figure for a pri- mary sore. You may rest secure that, according to the time elapsed, the degree of inflammation, the dia- thesis, the dressings, &c, the shape may alter con- siderably. Certain features of the sore are, however, pretty constant,—viz., a greyish, soft, and adhering fundus, covered, for the most part, with a film of suppuration. I know nothing that so much resem- bles a chancre as an aphthous ulceration : endeavour to compare the twTo when an opportunity offers, and you will acknowledge the truth of this assertion. The next thing to be considered is the. extent of the sore ; but this as well as its duration, is subject to great variety, and aids the diagnosis very little in- 166 GENERAL DIAGNOSIS deed; the duration must, of course, depend on the numerous complications Avhich may occur ; and you know that these will vary according to the idiosyn- crasy of the patient. The influence of remedies upon the healing of the sore may sometimes afford us some light; I do not mean to say that this mode of inves- tigation is entirely to be relied upon, but it has some value Avhen aided by other circumstances. I well recollect a patient, under the late M. Boyer, who had an obstinate ulcer on the leg. He always re- jected, Avith indignation, any idea of syphilitic taint; but M. Boyer, who had his doubts on the subject, proposed to him, in order to settle the question, to give him up one-half of the sore, which he would dress- with mercurial ointment, whilst the other half might be treated as heretofore. The patient con- sented, and his surgeon was shrewd enough to choose the upper part of the sore, so that the discharge should nicely gravitate to the lower part, and keep his ground pretty clear. FiA^e or six days after the first application, the upper part was almost cicatrized, while the lower had made no progress. But the ac- tion of remedies is, for all that, very fallacious, as simple ulcers will often rapidly heal under mercurial dressings, and specific ones continue unchanged in spite of them. I confess, however, that by the care- ful study of the characters hitherto enumerated, in grouping them together, and well weighing their relative value, a diagnosis of an inductive nature might be attempted. But the only way of arriv- ing at a satisfactory certainty in the matter, of being able, in a court of law, to swear that an ulcer, Avhere- soever situated, is of a syphilitic nature, is to prac- tise inoculation. Of course it is not necessary, in common cases, to have recourse to it; we are justifi- able in using this test only in such cases when a de- cided opinion is required. It will now be useful to consider the principal errors of diagnosis which must be guarded against. OF CHANCRE. 167 Chancres may be confounded with common ulcera- tions, which, from some cause or other, have been made to deviate from their usual course. Corrosive sublimate, for instance, applied to a simple sore, will give it very much the appearance of chancre ; herpes, cauterized by subacetate of lead, will be affected in the same way ; and such a sore will even assume an indurated base, which has deceived many; so that every induration which is met with must not be at once set down as a specific one. The substances just mentioned keep up the ulceration by their irrita- ting properties, and the sore, as soon as they are left off, re-assumes its former non-specific appearance. It often happens that the different sorts of dressings, applied successively, prolong a virulent ulceration ; you will often remark that cicatrization is favoured by leaving them off altogether. A region where much uncertainty of diagnosis prevails is the verge of the anus; fissures about this opening are often pronounced specific when they are the result of mere irritation and straining of the part; whilst chancres there situ- ated are often mistaken for common ulcerations or excoriations. The other day, a surgeon of this city, not accustomed to suspect a syphilitic taint, laid open what he thought a mere fissure, to hasten its cicatri- zation ; but this operation only facilitated the inocu- lation of the poisonous matter still more, and it was in this hospital that, by the proper means, the man's ulceration healed up. Another source of error is the resemblance Avhich divers dartrous ulcers bear to chancre ; with a little patience, and by remembering the folloAving facts, a pretty correct distinction may be made :—Herpes preputialis, vulvae, scroti or ani, always begins with a little itching ; then are formed a group of vesicles, the contents of which, at first clear, and soon after opaque, ooze through the pari- etes, and, on drying, form a yellow crust; the maxi- mum duration of the whole is one week. In eczema 168 GENERAL DIAGNOSIS. the vesicles are smaller than in herpes, there is no scab, the surface is red, the secretion slight, and there is no deep ulceration ; when situated on the skin, a little desquamation takes place ; but on mu- cous membranes there is a slight secretion. It is, how- ever, with pustulo-crustaceous ringworm that the di- agnosis is most difficult, and it is often impossible to decide without inoculation. Chancre has also been confounded with cancer; but the distinction is here much more easy than in the cases I stated just now. It must, however, be confessed, that cancerous growths will often spring up in those very regions Avhich are the most frequently the seat of syphilitical ulceration—viz., the lips, the glans penis, the vulva, the tongue, &c. ; and nothing, in fact, resembles scirrhus more than a specific induration. Still, in carefully noting the following distinctions, indepen- dently of the assistance we get from the consideration of age, sex, the seat of the sore, heredity, &c, a tole- rably accurate diagnosis may be made. Chancre. Cancer. 1. Exposure to contagion. 1. No fact pointing to a conta- gious origin. 2. Relative rapidity of deve- 2. Slow evolution. lopment. 3. Early obstruction of lymph- 3. Lymphatic vessels & glands atic vessels and glands. tardily affected. 4. Ulceration preceding indu- 4. Ulceration^/owmg- indura- ration. tion. 5. Indolent state of the sore 5. Symptoms becoming more increasing with its conti- acute from the duration of nuance. the ulceration. 6. Inoculation possible within 6. Inoculation never yields a certain period. any results. Besides these differences, you must notice that the obstruction of the posterior cervical glands, so com- mon in chancre, is neA'er met with in cancer ; and we might lastly look upon the treatment as affording SEAT OF CHANCRE. 169 means of distinction, but it will be hardly necessary to have recourse to this expedient, now that Ave can decide the matter by inoculation. This reminds me of a gentleman, whose penis I was called to ampu- tate ; it had been condemned by two medical men, and I was merely requested to attend as an operating surgeon. The affection was, according to them, a cancerous induration of the glans and prepuce ; but I was led to differ with them by divers considerations, —first, the age (sixty-five); then the short time the tumour had existed (three months), &c. I proposed to excise a portion of the prepuce, and save the glans ; this was consented to, and I was delighted to find a few weeks afterwards a fine crop of second- aries appear all over the gentleman. I may mention, by the way, that any induration which has lasted more than six months Avithout giving rise to second- aries, is certainly not of a syphilitic nature. Peculiarities relative to the seat of Chancre*—Be- fore entering upon these, I must state, with reference to diagnosis, that when a chancre has merged, as it often does, into a simple unspecific ulcer, it is not only difficult, but sometimes impossible, to give a decided opinion with reference to the former nature of the ulceration. Let us noAV consider the urethral chancre, of which Ave have a few very well-marked examples in the house. It is generally situated near the meatus, and is visible without separating its lips; but since the posterior limits along the urethra can- not be seen, it is difficult to say how far the ulcera- tion extends backwards. But how can any diagnosis be attempted when a urethral chancre is quite con- cealed within the canal ? How shall we distinguish it from blennorrhagia? Both give rise to a secretion, and both may produce ardor urinae. Yet the dis- charge resulting from chancre is sanious, rusty, and becomes sanguineous by pressure ; it is, in fact, sero- purulent, while the blennorrhagic secretion is muco- 15 170 ANAL CHANCRES. purulent. The pain in blennorrhagia is pretty exten- sive ; in chancre it is fixed in one spot, or may be altogether absent; the thickening of the urethra is limited in chancre, but diffuse in blennorrhagia. The usual seat of the urethral chancre is the balanic re- gion ; in order to ascertain its existence, you must not apply your pressure laterally, but from above downwards in the natural situation of the organ. A sort of speculum has been contrived by M. Segalas to allow of the urethra being viewed ; but I cannot say that it fully answers the purpose. Notice that the secretion from the meatus may be sanious with- out being of a specific nature ; and besides, the ulce- ration within the urethra may be either venereal or not; so that the foregoing characters cannot always yield a sure and undoubted diagnosis ; and here, to cause all error to vanish, we must have recourse to our great criterion,—viz., a timely inoculation. Anal chancres.—These are mostly the result of un- natural connexion : but the fact of this having hap- pened must not be deduced from the infundibuliform shape of the anus, as some authors have done ; for this peculiar appearance is often merely the result of emaciation, as we see it in phthisical patients. The development of a chancre in this region requires a previous erosion of the part; these erosions are mostly situated on the coccigeal or perinaeal commissure of the verge of the anus, and these are likewise the points on which chancres are generally met with. They have also been found on the internal sphincters, and have been mistaken for fistulae. I must state, in conclusion, that a syphilitic ulceration about the lower end of the rectum is not a proof of unnatural con- nexion, for the purulent matter may, particularly in women, find its way along the short perinaeum to the rectal extremity ; that some pus may also be carried accidentally by the hand to the anal region, and there cause specific ulcerations ; so that you must be guard- PROGNOSIS OF CHANCRE. 171 ed in your opinion in such cases. Chancres have likewise been found in the vagina, uterus, and many other parts of the body ; it will be sufficient for you to know that they may spring up in these various re- gions, and by investigating carefully you will be able to attempt a fair diagnosis. I fully believe that if a chancre escape observation, it must be owing to im- perfect investigation. Prognosis.—The precise time when a chancre Avill heal cannot be foretold, but the indurated species is, ceteris paribus, the soonest cicatrized. After this, the normal chancre—namely, that which presents no deviation from the usual course, may be mentioned as holding out the best prospect; and the duration of phagedaenic, diptheritic, or pultaceous chancres will depend on the cause which has made them assume these peculiar characters ; the more difficult this cause is of removal, the more will the healing of the chancre be retarded. When you perceive that the appearance of the sore improves under the means you are using, you may judge favourably of the issue of your treatment; at all events, you will do well to let your patient be placed in as favourable hygienic conditions as possi- ble. Before you venture on a prognosis of the case, you should take certain circumstances and sequelae in account—viz., the unavoidable stagnation of the mat- ter from the peculiar disposition of some parts (for this state of things may give rise to other chancres), also the likelihood of lymphatic and glandular in- flammation when the chancre is circumscribed, and shows no tendency to spread. An indurated chancre infallibly produces a congested state of the neigh- bouring lymphatic glands; phagedaenic chancres, or those presenting simple inflammation, are less likely to cause adenitis, but still they may do so. I think I can venture to lay down as a rule, that adenitis is as frequently a sequel of the indurated chancre as it is rare to find it the consequence of a phagedaenic one. 172 TREATMENT OF CHANCRE. The specific induration of a chancre is a proof of the syphilitic taint of the system, whilst constitutional in- fection scarcely ever follows a non-indurated chan- cre ; and when this apparently does occur, it is mostly because the induration has not been properly looked for. WThen the lymphatic glands have escaped, not- withstanding the existence of an indurated chancre, it may confidently be foretold that there will be no se- condary symptoms; and the supposition that a pre- vious attack of syphilis predisposes to a second is quite erroneous ; on the contrary, I would rather say that the system having once been under the influ- ence of syphilis, is less liable to contract the disease over again. It has, likeAvise, been maintained that, speaking generally, secondaries are pretty certain where no mercurial treatment is used ; I cannot agree with this opinion, and I must say that I never answer for an immunity from secondary symptoms, where a regular mercurial treatment has been used ; but when no mercury has been given I have more confidence, and I answer to those who consult me on this head, and who are about to marry—" Go and enter upon matrimony, if you have not undergone a mercurial treatment." At our next meeting I shall consider the treatment of chancre. LECTURE XVI. TREATMENT OF CHANCRE ; PROPHYLAXIS; ABORTIVE AND SUBSEQUENT TREATMENT. I eeg now to draw your attention to the prophylactic means instituted in this country in order to protect those who indulge in promiscuous intercourse. Go- vernment have taken upon themselves the sanitary TREATMENT OF CHANCRE. 173 measures which are thought necessary in this matter, and certain regulations have been framed, and are in force, for the detection of disease among those unfor- tunate females Avho get themselves duly registered and enrolled. Before I enter into the merits of this law, and before I discuss its efficacy in preventing contagion, I must say that prostitutes are taxed with doing more harm than Ave have a right to accuse them of. It is true, no doubt, that diseases resulting from sexual intercourse are extremely frequent, and you are, I dare say, sufficiently acquainted with this fact (and if you had any doubts about it before you were in the habit of coming here, I am sure that the crowTded state of this hospital, and the throngs you see at my dispensary, have strangely modified your opinions on this head); but remember that this is not all to be attributed to the women of the town; much mischief is done by those who are beyond the pale of the law, and whom the world hardly suspects to create so much misery. Do not believe, however, that the examinations to which regular prostitutes submit are a sufficient guarantee of these women's innocuity— far from it; the intention of the enactment is good, but it is not half carried out. If it were rigorously adhered to, AVe ought to have less complaints arising from sexual intercourse here than in other countries, Avhere no such regulations exist; but it is not so. In England, for instance, the amount is very large, and I have had occasion of personally convincing myself of the fact; still we are hardly below their number. This ought not to be the case; we should be much better off in this respect. The great mistake in France is, that no notice is taken of the discharges which most of these unfortunate females have upon them ; the whole attention of the examining surgeon is con- centrated in the search of a chancre, and failing the discovery of the same, the woman is pronounced sound, and only those Avho have a tangible chancre 15* 174 TREATMENT OF CHANCRE. upon them are forced to repair to the hospital. But I have no hesitation in stating that uterine catarrh, which is so often overlooked, is far more dangerous than chancres and secondary ulcerations, so far as contagion is concerned. These discharges are ex- tremely infectious, and I think it highly improper that women thus affected should be allowed to go at large —indeed, I hold that those who take the disease from registered females might almost impeach the chief of the police for creating a false security. I must add, however, that the use of the speculum, lately intro- duced, has rendered the examinations much more ef- ficacious; noAV, at least, we can ascertain the state of the parts a little further than the nymphae ; but for- merly the external organs only were examined, and when these were sound the girl was looked upon as innocuous, however deeply the upper part of the va- gina and the cervix might have been diseased. But in spite of this improvement much remains to be done; houses of ill fame are visited by the surgeon once a week, and other places of somewhat higher preten- sions, once a fortnight; now, this is quite useless, with reference to contagion, for Ave know that eight hours are sufficient for an inoculated chancre to pro- duce infectious pus. But allowing even two or three days for the evolution of the disease, it will neverthe- less appear that a girl perfectly sound when the sur- geon leaves her may have infected more than half a dozen men by the time he comes again. It is of no use going on in this Avay : if the system is to yield any good results, examinations ought to take place every morning, and I think that if the men who fre- quent such places were subjected to them also, it would probably be the means of ridding the commu- nity of the disease altogether. The very idea of such frequent examinations is extremely painful; but we must make our minds up to look upon them as the sick man does upon a seton, which, though any thing TREATMENT OF CHANCRE. 175 but agreeable, is used to eradicate a disease still more unpleasant than the remedy. Precautions necessary for avoiding the contagion.— Those who are so situated as possibly to be instru- mental to the propagation of the disease ought to be scrupulously cleanly, so as to neutralize the virus, at least temporarily. Lotions with the chlorides of soda or of lime, or with any other astringent liquids, and the cauterization of any little ulcerations or abraded surfaces, will be extremely beneficial. The indivi- duals Avho are apprehensive of contagion ought, on the contrary, to adopt the opposite course, since the smegma is a sort of protection, owing to its unctuous nature ; and ablutions post coitum, with the aboAre- mentioned lotions, will be very useful. The artificial means which are sometimes resorted to are any thing but trustworthy; their porous nature or their rupture may prove very treacherous ; and besides this, inocu- lation will sometimes take place on such parts as are unprotected by them—viz., the scrotum, pubis, root of penis, &c. The shorter the contact the better. A great point, when there is any doubt in the matter, is to examine the parts which have been exposed to con- tagion as soon as possible, in order to take the dis- ease at its very onset, and use lotions which are likely to neutralize the virus. Still this precaution cannot be entirely relied upon, and must not create an unfounded security. Calderon has published the results of experiments which he made upon himself with a certain soap, which he thought effectual in de- stroying the specific virus; but it was tried, and found wanting. Experiments have likewise been made by myself on this subject. I mixed up inoculable pus with acids, aromatic Avines, or tannin, and found that it thereby lost all its virulent properties. This evi- dently points to a chemical action. I then inoculated purulent matter of the same nature, and tried after- Avards to destroy its specificity by means of the same 176 TREATMENT OF CHANCRE. substances I had used before ; but I never succeeded, except when I completely destroyed the textures. Now what are we to infer from this ? Why, it shows plainly that prophylactic lotions are not of much avail, and that mercurial ointment, applied as a measure of precaution, before we know the exact seat of the ulcer, is just as useless. Nothing short of actual cauteriza- tion will do any good; so that I would lay it down as a rule, that whenever there is apprehension, the parts ought to be Avell washed post coitum, in order mechanically to remove any stagnant purulent matter, and then proceed to cauterize every little fissure, ero- sion, or solution of continuity whatsoever which may be discovered. If fears are entertained that any virus has penetrated Avithin the canal of the urethra, in- jections of cold water, and ablution by means of micturition, are the only means which I would re- commend. Abortive treatment.—When the results of contagion have become manifest, its effects should be prevented; you must, in fact, stop the ingress of the virus, and do your best to destroy it instanter. It has now been fully demonstrated, that chancre is at first a strictly local affection, and that it may remain so for four or five days; its destruction prior to the expiration of this time prevents the general infection. Talking of the local character of chancre, I cannot help noticing that the very people who are inclined to consider cancer as, primarily, a local affection, will needs have that chancre is the result of constitutional taint. The tAvo means which have been proposed to destroy a chancre are excision or cauterization. Excision may be had recourse to \vhen the knife will not interfere with important parts, and when the ulceration is neither very extensive nor of long standing, or when the very parts on which the chancre is situated re- quire removal; for instance, phimosis Avith a chancre situated on the extremity of the prepuce, Avill evi- TREATMENT OF CHANCRE. 177 dently be much benefited by the excision of the ul- cerated parts. Cauterization, on the other hand, is indicated when the chancre has only existed three or four days, when it is strictly circumscribed, and is not situated too near very important organs ; if you have to do with very large ulcers, you must not think of cauterization. When the ulceration is only of one or two days' standing, nitrate of silver will be sufficient, provided it reach deep; but it is for the most part ineffectual ; it will be much safer to have at once recourse to the potassa fusa cum calce (pate de Vienne). Benjamin Bell finds fault with this method; but the failures he met with were princi- pally owing to the want of discrimination with regard to the cases which were fit for the abortive treatment. Yet I cannot see, even were the system already con- taminated, that any harm can occur from changing, by cauterization, a virulent ulcer into a simple one ; I really think that we are justified in using the caustic pretty freely whenever wTe are consulted within the tenth day of the application of the virus. When you use the pate de Vienne, it will be proper to apply it to an area double the size of the contaminated spot. The paste must be of such a consistence as not to run on the neighbouring parts, and a good precau- tion is, to protect the surrounding textures Avith adhe- sive plaster. The result is generally an eschar, which falls Avhen the cicatrization is complete; yet it sometimes happens that pus is secreted beneath ; but this is the exception. I will venture to say, that if a patient comes to me no more than four days after coitus, I can promise him that this treatment will free him from the liability to secondary symptoms. Mercury is of no use in these cases; and if there were any doubt about this, the fact of a person under the influence of this metal readily contracting chancre would soon remove it. It is very unfortunate that we so seldom have the satisfaction of destroying the 178 TREATMENT OF CHANCRE. virus by these means, as patients generally apply too late. I wish every one Avere well acquainted with the immense advantage of attacking the disease early; it would save many a pang and agonizing hour. Indeed, if it were in my power I would have this fact, and the importance of prophylactic means, put up as a warning in all appropriate places. When the disease has made such progress that it is no longer safe to use the abortive method, we must have recourse to means calculated to prevent local complications, and to bring the chancre round to a simple ulcer. The treatment of the chancre ought to be strictly local, until certain appearances point out to constitutional infection ; and one great point is, to gain free access to the seat of ulceration. Now phimosis may prevent this, and it is important that you should know which is the most eligible practice in such a case. I hold that it is quite sufficient, when the phimosis is quite uncomplicated with oedema, inflammation, or gangrene, to throw in between the prepuce and glans such lotions as would be applied to the sore were it quite uncovered, the more so as there is a risk of producing paraphimosis in forcibly pushing the prepuce backwards. If, on the other hand, there were any appearance of pre- putial sloughing, which resisted the means employed to stay it, the best plan would be to act exactly as if there were no chancre in the case, and operate for phimosis. I know that the inoculation of the wound is sure to follow such a course, but this chance must be encountered in order to avoid a dangerous and extensive sphacelus ; this inoculation is moreover far from being certain, as gangrene generally destroys specificity. When a chancre is complicated with re- ducible paraphimosis, it will be advisable to attempt the reduction, for the strangulation is sure to cause some unfavourable deviation in the progress of the chancre. When the constriction is considerable, TREATMENT OF CHANCRE. 179 when we have failed in our endeavours to reduce, and that the strangulating or strangulated parts look gangrenous, we should at once free the constriction with the knife. It is far wiser to take the chance of inoculation as to the wound we inflict, than to lay ourselves open to all the casualties of extensive sloughing, or phagedaena. We should not omit to use sedative, emollient, and antiseptic applications in such cases. I have said that cauterization is to be used in the abortive treatment, but we may likewise use it in the subsequent stage, for it may advan- tageously be employed, in the ordinary progress of the sore, as a direct sedative, and it will often relieve pain when other means have failed. Cauterization with the nitrate of silver is likewise very useful in the period of reparation for subduing exuberant gran- ulations, and it succeeds very well, when lightly ap- plied, in hastening cicatrization,—in promoting, as it were, the desiccation of the sore, and forming an artificial epidermis. With regard to the local appli- cations best fitted for these sores, I would remind you that in simple and healthy ulcerations it is not advisable to change the dressings too often, because this practice often retards or impedes cicatrization. But it is the reverse with primary ulcers : here the change ought to be frequent and in keeping with the amount of the discharge ; from this rule the indurated chancre is to be excepted, for here we have but little suppuration, save it be complicated by gangrene or phagedaena. You must avoid tearing away the dressings so as to make the ulcer bleed, nor must you allow the surrounding skin to get undermined, for these accidents would only promote fresh inocu- lations ; the more specificity an ulcer presents, the more urgently are detergent means called for. The best kind of dressings are those which readily imbibe the purulent matter ; lint, dipped in the fluids you wish to apply, fully answers the purpose, but you 180 TREATMENT OF CHANCRE. must avoid what is called English lint, its texture is too firm for this sort of ulcers. Some people use mercurial ointments and cerates, but these applica- tions do no good—on the contrary, they will often produce irritation and eczema around the sore, favour its extension, and produce very unpleasant compli- cations. Any other kind of ointment ought, if possi- ble, to be likewise avoided, for greasy applications alloAv the pus to escape toAvards the surrounding parts, and thereby cause inoculations. I generally use aromatic wine.* It has the advantage of neu- tralizing the secretions, of diminishing their amount, and of astringing, or, as it were, tanning the sur- rounding parts. Lotions Avith the bichloride of mer- cury have at one time been highly recommended; but I think that, as a general rule, they are very un- advisable. When you perceive irritation about the sore, or there is much pain, sedative applications should be had recourse to ;f but it often happens that syphilitic ulcerations resist all these means, and the best plan then is, to be contented A\Tith applying dry lint, which often succeeds very well when all the methods just enumerated had failed. An excess of inflammation will often bring on phagedaena ; anti- septic, emollient, and sedative applications, must then be used ; but you should be very sparing of poultices, for they favour the accumulation of fluids towards the generative organs. If you find it neces- sary to abstract blood, you must see that the leech- bites be not exposed to contact Avith the purulent matter ; and to put such an accident entirely out of the question, it will be found prudent to apply the leeches at some distance from the sore. I have * Aromatic wine (Parisian codex), two pounds; tannin, two drachms. Mix. t Aromatic wine (Parisian codex), two pounds; solid opium, one ounce. Cut the opium into the Avine, and strain. (Used in painful ulcerations.)—Hopital du Midi. TREATMENT OF CHANCRE. 181 already pointed out Avhat line of practice I would have you follow in phimosis and paraphimosis. When gangrene comes on, you may use, besides, soothing and sedative lotions, antiseptic and cam- phorated applications, chloride of lime or soda, quinine in powder, weak solutions of nitrate of mer- cury, &c, without forgetting to favour the fall of the eschar; thereby we often stay a gangrenous ten- dency, which threatened to destroy the surrounding tissues to a great extent. Treatment of the purely phagedaenic chancre.—First of all you must look for the constitutional peculiarity which gives the chancre this character; try to find out in the previous history, in the idiosyncrasy, in the temperament, in the hygienic conditions, in the excesses and habits of your patient, the cause of the tendency of the ulceration: these questions t to sway your treatment. Topically, you had better use cauterization at once, as it powerfully effects the modification of the surfaces; thereby you will conquer the destructive bias of the disease. You have seen me cauterize in the wards whenever the inflammation did not run too high; I use either nitrate of silver, or liquid nitrate of mercury, pate de Vienne, or actual cautery. The potassa fusa cum calce Avill destroy the surfaces the most readily, and will annihilate the disease completely ; but it must be handled pretty boldly ; for if the specific character is not quite destroyed, the result is any thing but satisfactory, as the ulcer, when the eschar falls, is as bad as before, and much larger ; in fact, we must always contrive to reach the healthy tissues, and too timid a hand will often do more harm than good. I remember a man who was a full year under treatment in this house for a phagedaenic ulcer; nothing would do, and tired of the hospital, he left us. Two years afterwards he came back ; the ulceration had invaded a great part of the thigh. This was a favourable case 16 evi ou % 182 TREATMENT OF CHANCRE. for summary treatment, and I did not hesitate to cau- terize largely. I fearlessly went a full inch be- yond the sore on all sides ; the genius of the dis- ease was conquered, the ulceration was transformed, and the sore soon healed. Of course so severe a proceeding can only be followed when the ulcers are situated on resisting surfaces, and where delicacy of structure does not predominate. The whole secret is, to destroy the ulcer altogether, and the hot iron will often be the most effectual means of accomplish- ing this when the ulceration proves very unmanage- able. The most appropriate dressings after cauteri- zation will include the aromatic wine, Avith opium, lotions with tannin, in a rather concentrated state, &c. Where there is a scorbutic tendency, I apply the extract of rhatany in solution ; also lotions with the tartrate of iron and potash, fifteen parts of the salt to one hundred of water. Where I have to deal with a scrofulous diathesis or a lymphatic tempera- ment, I use a lotion of four parts of tincture of iodine to one hundred parts of water, and I have even ap- plied the tincture quite pure ; but I see that the time is up ; I must conclude this subject Avhen Ave meet again. LECTURE XVII. CONTINUATION OF THE LOCAL TREATMENT OF CHAN- CRE ; TREATMENT OF PHAGEDENIC ULCERATIONS ', BUBO. I considered, the last time we met, the divers dress- ings which have been found to answer best in the local treatment of phagedaenic chancres, and I men- tioned that I use tincture of iodine with patients of a scrofulous tendency. When I have to deal with TREATMENT OF CHANCRE. 183 scorbutic subjects, I generally cover the whole of the ulcer with powdered Peruvian bark ; in cases which exhibit an herpetic diathesis, the extract of rhatany, diluted with water into a lotion, will be found useful. I have also tried sulphur ointment, sulphurous and al- kaline baths, lotions of bicarbonate of soda and potash, powdered starch, and dry lint. When I find any irritation about the sore, I cover it Avith emollient or carrot poultices. It is, however, extremely difficult to foretell which applications will be the most effi- cient ; the peculiar aspect of the case will determine the choice. We should, in fact, have a good many resources at our command, so as to suit the different exigencies Avhich may arise. Certain applications will sometimes do Avonders in one case, and be quite powerless in the other ; it is therefore evident that we must guard against the natural bias of attributing unfailing properties to a substance with which we have succeeded once or twice. I recollect that when I began life I had seen M. Boyer carry every thing before him in similar cases with carrot poultices and baths of the decoction of sempervivum tectorum, and I thought that I would enjoy the same triumphs by treading the same path ; but I was soon undeceived. We are too apt to consider as a panacea any thera- peutical agent which has once proved very benefi- cial ; indeed, I fell into this error myself with the tincture of iodine. I advise you, however, to keep up your patient's courage as well as your own, and steadily endeavour to hit upon the proper course. A mixture of powdered Peruvian bark and charcoal has often done good in very extensive ulcerations, com- plicated by a scorbutic taint. With gangrenous-look- ing sores use chloride of soda, one part of the latter to four of water. It has been proposed to cover the ulcerated surface with melted wax ; but this proceed- ing is prejudicial and uncertain. Creosote and the 184 TREATMENT OF CHANCRE. bark of monesia* have also been extolled. Ether has likeAvise been tried, as capable of destroying the helminths pervading the purulent matter of phagedae- nic ulcers ; but it does not answer so well as it was expected. Erysipelas occurring around a phagedae- nic ulcer has, to my knowledge, entirely neutralized its destructive tendency, and I have known it also arrest gangrene ; so that the effect of erysipelas, arti- ficially produced by means of cantharides in powder, might, in some cases, be tried. You must, above all, be prepared with a large amount of patience and per- severance, hail the least improvement, keep up your patient's spirits, and make things bear a cheerful aspect: dejection and fear will counteract any means you may use. Hippocrates says,—"Go on with a remedy as long as you find it efficacious ;" and I beg to add, go on with it as long as you find it do the least good. Compression with plates of lead has had good results in some cases. It should be applied to the surface of the ulceration, and a little beyond the same ; it limits the obstruction, and favours circula- tion. Mercurial ointment, which for a long time was universally used in these cases, is very injurious. Not only is the local effect any thing but satisfactory, but, by being absorbed, it deprives the mass of the blood of a large quantity of fibrin—a principle so ne- cessary for cicatrization. I would finally add, that none of the remedial means enumerated ought to be cried up, to the exclusion of the others; for it is very uncertain which of them will answer best in a given case. Topical applications for the Indurated Chancre.— If mercurial applications are, as a general rule, unad- visable in the other varieties of chancre, they are, on the contrary, very beneficial in the indurated species, provided the latter be not complicated by gangrene * Called by some mohica and buranhem, and said to be yielded by a Brazilian tree. PHAGEDENIC ULCERATIONS. 185 • or phagedena, in which cases the before-mentioned appropriate dressings are to be had recourse to. I generally use an ointment, with a certain proportion of calomel or white precipitate, Avhich proportion I increase when I find the chancre getting indolent. As for the treatment of that kind of chancre Avhich I have looked upon as a type being devoid of compli- cations and induration, it will be sufficient to pre- scribe a soothing and unstimulating diet, rest, and the mildest possible applications. Should a little in- flammation arise, the usual antiphlogistic means and purgatives are called for. Phagedenic Ulcerations.—Whatever the exciting cause of these ulcerations may be, whether a scrofu- lous, dartrous, or scorbutic diathesis, I have always found that they are invariably connected Avith great deficiency in the constituents of the blood ; the glo- bules, in particular, were constantly below the normal standard. This fact naturally led me to try the ad- ministration of iron in large doses (from fifteen grains to eleven drachms per diem). I formerly was afraid to give more than a course of ten or twelve of Val- let's pills,* or go beyond eight or ten grains of car- bonate of iron per diem ; but I now increase the dose until I perceive some effects. The preparation to which I give the preference is the tartrate of iron, because, of all the others, it is the most soluble, and since it is the chalybeate salt which has succeeded * Pilules de Valid.—Take of crystallised sulphate of iron, recently prepared, according to the method of Bonsdorff (for this method, see "Bulletin de Therapeutique," 1838, vol. xiv., p. 307), 500 parts; carbonate of soda (pure), 588 parts; pure white honey, 306 parts; syrup, q. s. Mix in a proper manner (see the same work, p. 309), evaporate to the consistence of extract, and keep in very carefully stopped bottles. With one drachm of this mass, and q. s. of some inert powder, make twelve pills, each of which will contain about eleven grains of carbonate of iron, and seven grains of the protoxide of the same metal. 16* 186 PHAGEDENIC ULCERATIONS. best in my hands. I know that so much as eleven drachms a day, as before mentioned, is, therapeuti- cally speaking, too much ; but I must say that I put more reliance on my experience than on chemical calculations; we must be content, in certain circum- stances, to follow an empirical course, and I may say that by this medication I have obtained extraordinary results. When the constitution of a patient, suffer- ing from a phagedaenic ulceration, is already tainted by syphilis, Ave may try to subdue the phagedaena by mercury—indeed, this metal has been used in these cases with advantage independently of any syphilitic diathesis ; it then acts, as it were, by causing a great disturbance of the Avhole system, but it must be ad- ministered cautiously. When I make up my mind to try mercury, I use Sedillot's pills* in increasing doses (from six or eight to forty or fifty in one day). This medication has often caused the rapid deter- gence of the ulceration, and subsequent cicatrization. If the mercury were to disagree, it must be given up immediately. You should also pay great attention to the diet; where you see that bad, umvholesome, or insufficient food is keeping the energies of the system below par, you must give your remedies a fair chance by ordering good nourishment and wine ; but where, on the contrary, excesses are indulged in, Avhere luxuries and excitement surround your patient, you must advise forbearance. As for the indurated chan- cre, the mercurial treatment, either topically or inter- nally, is the rule; with other kinds of chancre it should be used only exceptionally. I give tartrate of iron, at the same time, in drachm doses, as pro- moting a healthful tonicity of the system. This * Pilules de Sedillot.—Take of the stronger mercurial oint- ment, two drachms and a half; medicinal soap (prepared with oil of sweet almonds and liquid caustic soda), two drachms; powdered liquorice, one drachm. Mix, and make five-grain pills. Dose, five or six in die. BUBO. 187 would be the place for considering the mode of ad- ministration of mercury with reference to the treat- ment of indurated chancre ; but to avoid repetition I will postpone this subject until we take up second- ary symptoms, and I come now to a very interesting portion of the course—namely, bubo. Adenitis, or Inflammation of the Lymphatic Vessels and Glands.—Adenitis, or bubo, belongs to the class of successive accidents, and has its anatomical seat in the lymphatic vessels or glands. Buboes have been divided into superficial and deep, according to the stratum of glands affected; also into inflammatory, sympathetic, and virulent, as referring to the cause which gave rise to them. The peculiar mode of pro- duction was likewise made the basis of a third divi- sion—viz., 1. The spontaneous bubo, the develop- ment of which is not preceded by any primary mani- festation. 2. The consecutive bubo, which follows some venereal accident. 3. The constitutional bubo, resulting from the infection of the system. This division is of some importance, but the elements upon Avhich it is based should be properly defined ; I shall soon have an opportunity of entering into all the merits of the question. Before I commence the consideration of buboes as we see them in the wards, I will just take a glance, first, at the general causes which give rise to them, and see, in the second place, what influence these causes may have on adenitis, which is the immediate result of a syphilitic accident. Children are doubt- less more subject to adenitis than adults : the former suffer principally in the sujora-diaphragmatical gan- glionic system; the latter in the sw6-diaphragmati- cal; and this will at once appear perfectly natural, when we consider that the systems here spoken of seem to take their development in the same ratio as the functions become more active- Irritation is, with children, chiefly seated about the head : dentition, 188 CAUSES OF BUBO. and the so frequent affections of ears, eyes, mouth, &c, are a striking proof of the fact. We therefore find, with them, the chain of cervical glands becoming affected in preference to any other. When puberty comes on, a great activity of nutrition, increase, and development, may be noticed to be set up within the pelvis ; the generative organs are becoming fit for their ultimate functions ; and lymphatic irritation is then very apt to manifest itself in the inguinal glands. When there has been no glandular congestion or ob- struction in childhood, the same may take place after puberty ; the seat of the irritation will, however, be in the groin for the young man, while it would have been in the neck for the child. The king's evil may then affect either region, according to the time of life ; this must be carefully borne in mind. Women seem, at first sight, to be more likely to suffer from adenitis than men, from the greater delicacy of their lymphatic system ; but not being exposed to the same fatigues, vicissitudes of temperature, as men are, nor indulging in the excesses which the latter sometimes commit, we find them very rarely troubled Avith bu- boes. There are many causes which predispose to affections of the glandular system ; among these may be mentioned, a lymphatic temperament, scrofula, hereditary syphilis, unAvholesome food, cold and damp habitations, local irritation, &c. A primary syphilitic ulcer is another cause ; it may give rise to adenitis, independently of any virulence, and act sim- ply as an irritant ; it will then produce a non-specific bubo, just in the same way as blennorrhagia and simple ulcerations may do. Finally, I must add the most obvious cause of all—viz., the special action of the syphilitic virus, carried into the gland by the cir- culating fluids. Now, keeping the predisposing causes in mind, let us see by what process an ade- nitis follows the existence of chancres. The differ- ent ulcerations which may attack the generative or- CAUSES OF BUBO. 189 gans do not at all produce buboes with the same readiness. First, as to the seat of these ulcerations, it must be noticed, that a bubo will be more likely to arise when they are placed on parts abundantly sup- plied by lymphatics ; chancres on the frenum or mea- tus, for instance, are the most likely to produce ade- nitis. I have already mentioned that buboes are more frequent with men than women ; one of the causes of this difference might be, that chancres in women are always situated at a great distance from the urethra. The different kinds of chancre Avhich I have de- scribed are not equally apt to produce bubo ; regular and circumscribed chancres, for instance, are more likely to give rise to adenitis than phagedaenic ones. Of all, however, the indurated chancre is the one Avhich will be the most likely to cause the affection of the inguinal glands ; and of the twTo sets of the latter, the superficial will generally be attacked when the corresponding chancre presents no complication. Bubo will generally be found to spring up on the sides where the chancre is situated, but it is not very rare to see the contrary take place; this is, then, the result of the anatomical interlacement of lymphatic vessels. Adenitis rarely occurs at the end of the first week which follows the contagion ; the usual period of its appearance is from the third to the fifth Aveek. It may assume the acute or chronic form. The acute is mostly the result of the won-indurated chancre, and it almost always suppurates, after hav- ing passed through the different inflammatory grada- tions by which suppuration is generally preceded. The purulent matter secreted is generally inoculable, but at other times it yields no results on inoculation ; it is, in the latter case, phlegmonous, non-specific pus, and we are then entitled to suppose that the chancre had acted merely as an irritant, and that its secretion had not been absorbed. When, on the other hand, the purulent matter secreted by the bubo 190 CAUSES OF BUBO. is inoculable, we perceive in the ulcer resulting from the same all the characters of chancre ; it is, in fact, a glandular chancre. In case of non-inoculable pus we find the ulcer assume the appearance and the usual progress of a simple .sore. Adenitis, Avhich is the result of absorption from a non-indurated chan- cre, attacks only one gland in the superficial set; the pus secreted, as already mentioned, is inoculable, and when it happens that other glands, in the vicinity of the single one first affected, become involved on account of the irritation caused by the one originally inflamed, Ave obtain no positive results by inoculating the purulent matter they may secrete ; except the ulcers resulting from the glands secondarily attacked have been inoculated by the pus of the original soli- tary ulceration. You will find all these remarks in John Hunter's works : this great pathologist had long ago observed all these peculiarities. It is by no means rare to see several glands attacked when there exists a plurality of chancres. Now, as to the ade- nitis, which is the sequel of an indurated chancre, you will be pleased to notice that with this kind of bubo matters proceed very differently ; the only simi- larity between the species and the one I have just been describing is, that they are both seated in the superficial glands; but the bubo resulting from an indurated chancre (contrary to that which follows a non-indurated one) attacks several glands at the same time, springs up in both inguinal regions, is generally of an indolent character, hardly ever passes into an inflammatory state, except there be scrofulous compli- cations ; the pus obtained from it, if any, is never inoculable ; it mostly gives no pain, and has a pecu- liar elastic feel. The other kinds of bubo are gene- rally the result of a scrofulous diathesis ; they may be either acute or chronic, but they acknowledge no particular starting point, or exciting cause, as the two preceding kinds do ; the inflammation usually attacks CAUSES OF BUBO. 191 the deep glands first; the obstruction and congestion can even sometimes be felt to exist originally in the glands of the iliac fossa, and the disease proceeds, in fact, from within, outwards, all the glandular organs of this region, superficial and deep, agglomerate into masses, which gradually inflame and suppurate. Bu- boes, the purulent matter of which is not inoculable, are often the result of blennorrhagia, or a simple ul- ceration, or merely of coitus; yet these causes may, of course, be combined with and rendered more effec- tive by a scrofulous diathesis, or a lymphatic tempera- ment. Nothing shows, finally, how totally indepen- dent of any syphilitic taint these affections are, than to watch the patients who have had them, and to perceive that no secondary symptoms ever make their appearance. But if this be true, what shall we think of what has been called a spontaneous bubo—namely, that which is believed to spring up as a primary symptom ? The fact is, that there is no such thing as a syphilitic bubo without a previous chancre. Au- thors were driven to admit this primary adenitis from coming into contact with cases where the existence of the bubo which they had before them could not be explained in any other way they could think of, and they came to accuse a coitus, which might have taken place some weeks before, of all the mischief; but if the different circumstances which I have mentioned to-day be taken into consideration, it will readily be seen how a bubo may occur without any previous and appreciable local manifestation ; as, for instance, a lymphatic temperament, scrofula, excessive coitus, &c. And, besides all this, I may well ask those wTho have contended that they saw buboes as primary sy- philitic manifestations, whether they were quite sure that there had not been some previous inlet for the poison ? Did they fully ascertain the non-existence of urethral chancres, of those situated in the anal region, on the thigh, the finger, &c, Avhich either 192 CAUSES OF BUBO. escape the medical man's attention, or who are wil- fully concealed by the patients. You must, more- over, not forget that most of those buboes which have been called primary Avere nearly all simple glandular inflammations ; and of all the cases which have been brought forward, there are only three which will bear serious discussion, and these three are weakened by many doubtful circumstances ; the very frequency of these primary buboes is ap argument against their real existence. Do not think for a moment that this is an idle question; it is particularly important to have clear and fixed opinions about it, were it merely for restoring peace of mind to your patients. As for myself, I declare that I do not believe that there is such a thing as a primary syphilitic bubo; for the occurrence of it there must necessarily pre-exist some morbid ingress, independent of the glandular inflam- mation. There are, likewise, buboes which arise under the influence of a constitutional syphilitic taint: from this fact we may see that there are two kinds of buboes which take their development through the medium of the system at large—first, the bubo Avhich is the sequel of an indurated chancre ; its seat is in the groin, and it never yields inoculable pus; se- condly, the bubo arising from the infection of the constitution, and whose seat is in the posterior cer- vical glands. Of the latter, a greater or lesser num- ber may be attacked ; they present a resisting and an elastic feel ; they are indolent; without adherence to the parts beneath ; remain circumscribed ; and do not suppurate. It will be needless for me to dwell at length on the differential diagnosis of bubo ; I will merely say, that the greatest care and prudence is re- quired, to come to a satisfactory decision ; and I may add, by way of warning, that the most skilful sur- geons have plunged their bistoury into herniae, aneu- risms, and other tumours situated in the groin, think- ing they were opening buboes. You will probably PROGNOSIS OF BUBO. 193 not find much difficulty in ascertaining the true na- ture of any inguinal swelling about which you may be consulted, if you will take the trouble of atten- tively grouping together the different data which I have enumerated. At our next meeting we shall consider the prognosis and treatment of buboes. LECTURE XVIII. PROGNOSIS OF BUBO ; TREATMENT ; CONSTITUTIONAL SY- PHILIS ; HEREDITY. I reviewed, last time we met, the different kinds of buboes which have been observed ; and I will now merely recall to your mind, that the truly syphilitic bubo cannot exist without some previous specific ul- ceration ; there must, in fact, be a gate for the poison to enter, before the groin can specifically suffer. Adenitis may, no doubt, occur immediately after, or even before, impure connexion ; but there is then nothing specific in it, and a lymphatic temperament, scrofula, or mere debility, may be the only causes of the swelling. As to the prognosis of these affections, I can deduce, from carefully made observations, that a bubo seated in the superficial stratum of glands, affecting one of them only, and acute in its character, will generally suppurate, and that the pus secreted Avill possess all the properties of the purulent matter of the corresponding chancre, which latter, in such a case, is of the non-indurated kind. Secondly, that multiple buboes, of an indolent character, will hardly ever suppurate, and that in the event of any pus being secreted, the same is not inoculable ; this second kind of bubo is connected Avith the indurated chancre. I need not say a word about what is called 17 194 PROGNOSIS OF BUBO. a primary bubo, for this kind of inguinal swelling has nothing to do with syphilitic adenitis. As to the probable time which these tumours will take to run through their stages, it must be carefully noted that the bubo, Avhich is the result of absorption, and which, after suppuration, yields inoculable pus, is but a glandular chancre, which, as to its duration, is of course subject to the same laAvs as the ordinary chancre, the inguinal ulceration being liable to the same deviations as the primary sore—namely, phage- daena, gangrene, &c. A bubo, on the other hand, which is the result of an indurated chancre, is very indefinite as to its duration ; it, however, proves very often extremely tedious, and the patients are apt to forget everything about it, until it finally disappears. Now a very interesting point is the discussion of the sequelae of these two kinds of buboes. From all I have said hitherto, you will easily guess that the suppurative adenitis, which is the result of the ab- sorption of the virus by the lymphatics, and which is connected with a non-indurated chancre, is never followed by secondary symptoms. It is therefore not only useless, but positively injurious, to subject a patient, with an adenitis of this kind, to a mercurial treatment. The fact of suppurating buboes never being followed by constitutional taint, had even led some practitioners to advise the artificial establish- ment of several such emunctories, but experience and good sense have demonstrated the uselessness of such means. A bubo, which is the result of an in- durated chancre, is unavoidably followed by the infection of the system ; provoking the suppuration of it by setons, blisters, &c, will be of no avail; the constitutional taint cannot be prevented. Suppura- tion is hardly at the command of our art, and is by no means favourable, even when artificially excited, and used as a part of the treatment. The bubo has little TREATMENT OF BUBO. 195 to do with the subsequent infection ; the indurated chancre is the only cause of the mischief. Treatment of Bubo; Prophylaxis.—Bubo is a sequel of chancre ; therefore the simplest course to be pursued for avoiding or preventing the former, is to destroy the latter. Thus Ave see that the abortive method which I mentioned some time since, in speaking of the treatment of chancre, " kills two birds with one stone." As a preventive, you will find steady compression, applied to the glands of the groin, very useful, as it in some degree atrophies the lymphatic system, and prevents the development of bubo. It has likewise been proposed by M. Dide to divide the lymphatic vessels which lie between the primary sore and the groin : the idea is not bad, but as nobody is inclined to try it, we are without facts on this head. Even AA'hen a certain degree of inflammation has sprung up in the groin, it is, in some cases, yet time to prevent suppuration, and this end may be attained by rest, cold applications, and compression ; but these means wTill not succeed when the bubo is the result of the direct conveyance of the purulent matter along the lymphatics. Mercurial plasters or frictions, and mercury internally, have been recom- mended as abortive means, but I am ready to con- demn this practice with regard to buboes, as I did Avhen discussing the treatment of chancre ; yet I have often succeeded in forestalling a bubo, by cauterizing gently over the glandular region. MM. Raynaud and Malapert have used, with a view of nipping the disease in the bud, blisters, followed by caustic appli- cations ; but the diagnosis of the different kinds of buboes was very unsettled when this method was introduced, and the statistics Avhich were then framed have now very little value. These gentlemen used to apply, on the surface, denuded by the blister, a pledget of lint dipped in a strong solution of corro- 196 TREATMENT OF BUBO. sive sublimate (twenty parts of the salt to thirty of water) ; this Avas allowed to remain from ten to twelve minutes, and formed an eschar, which, by means of poultices, fell off some time afterwards. The results obtained were confined to non-specific buboes, and attributed to the neutralizing and the caustic effect of the mercurial salt. As for myself, I am in the habit of using a peculiar treatment for each of the species of buboes which I have described to you. When the glandular obstruction is of an in- flammatory and a non-specific character, I generally succeed with very simple treatment—viz., rest, soothing applications, and antiphlogistics. When the adenitis is the result of the absorption or regular conveyance of the virus along the lymphatics into the inflamed gland, suppuration is inevitable; I have then recourse to a complete and deep cauterization with the potassa fusa cum calce, for I think it impor- tant forthwith to destroy the glandular chancre, just as I am in the habit of doing to primary sores. I have repeatedly had opportunities of convincing my- self of the excellent effects of this method. It must be remembered, that the proceeding advised by MM. Raynaud and Malapert does not neutralize the sy- philitic virus, nor does it prevent suppuration; it may, perhaps, centralize the inflammation, but the operation is extremely painful; patients will seldom submit to it, and it leaves indelible marks. I have therefore no hesitation to give my cauterization the preference. The caustic ought to be applied to the very surface of the bubo, and allowed to remain about ten minutes ; the eschar will then fall after a period which varies very much, according to the amount of the suppuration. I have said that emol- lient applications and antiphlogistics were to be used Avhen the adenitis is of the simple inflammatory kind, but it may be asked, whether these means are equally advisable in bubo from absorption ? They decidedly TREATMENT OF BUBO. 197 are very beneficial in this latter form also, for such a bubo generally involves the surrounding cellular tissue, and forms there a small phlegmon, which may be controlled by antiphlogistics. But it must not be forgotten that leech-bites will get inoculated if the purulent matter is of a virulent nature ; leeches are then to be used with great caution, and to be entirely eschewed when suppuration and the breaking of the abscess are near at hand. If you use them at all, put them on the bubo itself, for its texture will, in any way, be ultimately destroyed and sacrificed by suppuration. I may just mention that care should be taken to employ linseed poultices quite fresh, and to avoid the rancid applications sometimes used. As an ointment, I would recommend equal parts of ex- tract of belladonna and mercurial ointment, and finally, great attention to the state of the bowels. But none of the preceding means will be called for when indolent buboes (mostly followed by secondary symptoms) are treated. The general treatment will suffice to get rid of them, still it does no harm to hasten resolution by discutient applications. When the suppurative stage has arrived, it will in general be advisable to let out the matter at once, for Ave are not always certain as to the nature of the pus which has been secreted ; it may either be virulent or not, and, in the first case, the sooner it is freed the better ; and, besides, we ought always to be apprehensive of the burrowing of the purulent fluid, whatever its nature may be. If you have to deal with a bubo Avhich has sprung up under the influence of a lym- phatic temperament, or which is the result of simple inflammation, you may use the bistoury ; but with an adenitis which is caused by the direct absorption of the virulent matter, the potassa fusa cum calce should be preferred, and applied to that portion of the skin which possesses the most vitality. Recourse may also be had to a number of punctures or to a single 198 TREATMENT OF BUBO. one ; the former will do well when the accumulation of the purulent matter is considerable, the latter, when it is rather circumscribed. MM. Raynaud and Malapert have here also imagined a peculiar method, and tried, by irritating applications, to excite a sort of purulent perspiration ; it may perhaps answer now and then, but if the skin be much inflamed, we can hardly expect much good, either from this practice or from the plurality of punctures : it is then much wiser to make a free and large opening, including the whole of the thinned integument. In inguinal buboes, the incision should run along the greater diameter of the abscess—viz., in an oblique direc- tion ; but cervical ones should be opened vertically. I must not omit to add, that very inflamed, loose, or brownish-looking edges should invariably be clipped off, or removed by caustic. When the inguinal swelling is of a lymphatic or scrofulous nature, it will be well to treat it in the same Avay as strumous enlargement of the anterior cervical glands—viz., with blisters, caustic, and irritating applications, mercurial oint- ment, repeated vesications, and regular compression, by means of leaden discs or little boards. When suppuration is fully established, I endeavour to de- stroy, Avith the pate de Vienne, the glandular mass lying at the bottom of the ulcer. I need not point out to you the different internal anti-strumous reme- dies in common use, you will readily perceive in a given case what constitutional treatment is most ad- visable. But it is sometimes very difficult to ascertain the existence of a purulent sac ; the matter lies often very deep, and the fluctuation is in vain sought for; but the pus, although at a great depth, will almost always find its Avay to the surface, and by carefully examining the integuments about the sac, a small softened spot may frequently be discovered where fluctuation is found, and this being gently opened will sometimes give exit to an enormous quantity of pent CONSTITUTIONAL SYPHILIS. 199 up matter, just on the same principle as the water spouts from an artesian Avell. I shall refrain from speaking of purulent diffusion, burroAving, or fistulae, all of which may follow a bubo, as these properly belong to general surgery. I will at once take up the consideration of secondary syphilis. Constitutional Syphilis.—A great many names have been given to this affection ; among them may be noticed the following: — Lues venerea (Fernel); confirmed syphilis (Jean de Vigo); constitutional syphilis (Hunter); syphilis (Swediaur) ; general pox, successive accidents, secondary symptoms, re- newed venereal disease. The name of constitutional syphilis, given by Hunter, seems to me the most appropriate, and I have therefore adopted it. In an early part of this course I endeavoured to treat of the causes of contagion, and the requisites necessary for the same to take effect, I will now proceed to inves- tigate those which may be looked upon as giving rise to constitutional syphilis. I must distinctly state, before I enter upon the subject, that every one is not likely to contract this secondary affection ; some people are refractory to it, whilst it may be said that no one is inaccessible to chancre. There are people Avho have had chancres repeatedly, and Avho never suffered from secondary symptoms; whilst there are others with Avhom a single chancre will suffice to give rise to them. From this fact it may, I think, be inferred, that for the manifestation of constitutional syphilis, certain peculiarities lying within the individual, which have as yet escaped detection, are indispensable, and that syphilis is, in this respect, on a par with other contagious diseases. It would be idle to ascribe any influence to age, sex, temperament, climate, &c. ; the predisposition to constitutional infection lies in a principle which this very infection neutralizes, and the former, being once destroyed, there is no possibility for a further poisoning 200 CONSTITUTIONAL SYPHILIS. of the system. We find in these facts a repetition of the phenomena of the vaccine matter. An opi- nion might be ventured, that this principle easily passes into a state of fermentation by the excite- ment of the syphilitic virus, and that this fermen- tation (the source of the secondary manifestations) destroys the properties of the principle. This idea finds some support in the fact, that the virus is no longer inoculable when it has fairly penetra- ted into the economy. Another fact to be noticed is, that chancres occurring after the system has once been tainted are very apt to take on induration. We may then safely believe that there are two circum- stances which, as it were, insure against the renewed development of the syphilitic accidents which result from chancre—viz., the previous existence of an in- durated one, and what I call a syphilitic diathesis— that is, a peculiar state of the system existing between the accession of the virus and the secondary symp- toms. It will now be incumbent upon me to review the other modes of constitutional infection which have been adopted by authors. BernardinTomatino was the first who admitted the possibility of constitu- tional symptoms, irrespective of any primary sore. Hunter, Bell, Taba, and several other pathologists, have allowed themselves to be guided by the ideas of their predecessors, without taking the trouble to examine their doctrines very minutely. All the ex- amples of primary general infection are weakened by divers sources of error and deception. I do not mean to discuss every one of the opinions which have been put forward in this matter; but I will just quote a few, in order to show upon what unsatis- factory bases they rest. 1st. It has been maintained that pus from a chancre, deposited on a denuded surface, may be absorbed without acting on the ulceration at all, and without CONSTITUTIONAL SYPHILIS. 201 producing any chancre. My experiments on inocu- lation set this question entirely at rest. 2dly. It used likewise to be thought, and it is believed even now by some people, that secondary ulcerations might be contagious, because certain secondary accidents and mucous tubercles were found to have propagated the disease. But this was jumping at a conclusion, without thinking that a primary sore (as before mentioned) may get transformed in situ into a mucous tubercle or innocuous secondary ulcer, and that, besides this fact, it may very easily happen for a new chancre to be contracted, and be exactly seated on the mucous tubercle already existing. The same observation applies to vegetations. 3dly. Constitutional symptoms in children, at the breast of a nurse, have likewise been adduced to prove the possibility of their development inde- pendent of primary manifestations; but who can vouch that those were not the result of heredity ? who could venture to say that he knew every thing about the parents' antecedent state of health, &c. ? and who could assert that the nurse was not herself suffering from a primary ulcer, which had been the means of creating a small one of the same nature in some part or other of the body of the child, where it had re- mained unnoticed? Every time that such nursing cases have come before me, I have generally been able to trace the real source of the mischief, and I have always succeeded in explaining very puzzling phenomena without laying any blame on the milk. I am ready to admit that certain medicines may be transmitted to the sucklings by the mammary secre- tion ; but the same law does not exist for the sy- philitic virus. And besides all this, I may ask whethex it is strictly logical to infer, that because two individuals, who are habitually in contact with each other, suffer from the same disease, the latter must needs have been communicated from one of these 202 HEREDITARY SYPHILIS. parties to the other ? May not the source of their respective affections be widely different? 4thly. Blennorrhagia has also been looked upon as capable of generating secondary syphilitic symptoms; but this opinion will not detain us a moment, for we know noAv that blennorrhagia cannot produce any syphilitic accident, except when it is symptomatic of chancre. We may then pretty confidently state that chancre is the sine qua non of the production of secondary symptoms, and that the indurated species is almost certain to cause them. To this rule there is but one exception, and that is hereditary taint; this is the only case in which the infection of the system may exist independently of any primary sore. Heredity, in this respect, is certain from the mother to the child; but the influence of the father is not quite so decisive. This transmission from parents to children is now admitted by all pathologists; still Hunter and Broussais have denied it. According to the numerous observations which have been made, it may be inferred that the infection of the system, if it occur at all, takes place pretty early after con- tagion, and that the appearance of secondaries has nothing to do with the length of time a chancre may remain unhealed. Chancres have been known to last four, five, and six months, without being fol- lowed by any constitutional manifestation; whilst chancres, on the other hand, which were destroyed five or six days after exposure to contagion, were, notwithstandingthis precaution,followed by secondary symptoms. This latter circumstance evidently proves that the poisoning of the system had already taken place. The virulent absorption may be said to take place after the fourth or fifth day which follows ex- posure to contagion. Hereditary Syphilis.—We all know that the trans- mission of the disease from parents to children is an undeniable fact; but it is nevertheless often- HEREDITARY SYPHILIS. 203 times very difficult to reascend to the actual source of the mischief, when both the de jure father and the mother are quite free from any syphilitic ac- cident : there is no choice left in cases of this de- scription, and we are involuntarily driven to suspect that a third party has been concerned. I am pre- pared to look very suspiciously on the birth of children, who all, in succession,bear syphilitic erup- tions, as well as on the occurrence of several miscar- riages when the father is quite sound. It has often struck me that there is much similarity betAveen the transmission of phthisis and syphilis, and I leave you, when I shall have discussed the laws and pecu- liarities of heredity in the latter, to establish a useful comparison for yourselves. Now to return to syphilis. Supposing a female to be fecundated by an infected agency, how will she be affected by carrying a poisoned foetus ? According to certain well-observed facts, we may infer that the mother can receive the germs of the disease from her child, so that in such a case she suffers from the syphilitic infection by the instrumentality of the foetus in utero. It had hitherto been believed that the mother received the infection directly from the father, and that she transmitted to her offspring the diathesis Avith Avhich she became imbued ; but this never happens except the mother has been subjected to the contagion of primary sores, and she herself has had an indurated chancre as well as secondary syphilitic symptoms consequent upon such chancre. I am ready to acknowledge that a woman may give birth to an infected child without experiencing any inconvenience herself; the father, in such a case, transmits the poison by reason of the secondary symptoms which are upon him at the time. If he had had primary symptoms he would have diseased the mother direct, and the effect (as before mentioned) may still have reached the child. A man who has constitutional syphilis upon him, of 204 HEREDITARY SYPHILIS. howsoever long standing it may be, should not marry, for his progeny runs great risks; his wife, however, is by no means so much in danger, for the embryo may or may not contaminate her. I well remember a case of this description, where a gentleman with certain secondary manifestations was advised by his medical attendant to postpone engaging in wedlock; he disregarded the advice, married, and, nine months after, he had the mortification of seeing a well-defined eruption upon his child ; his Avife, however, escaped unhurt. This is so interesting a subject, that we must not hurry over it; I will therefore stop here, and continue it when we meet again. LECTURE XIX. CONTINUATION OF HEREDITARY SYPHILIS; MECHANISM OF THE INFECTION J PREMONITORY SYMPTOMS OF SE- CONDARY SYPHILIS ; ERUPTIONS, ETC. ; MUCOUS PA- PULES OR CONDYLOMATA. I avas mentioning, at our last meeting, how dangerous for the offspring it is when a man marries, with lin- gering secondary symptoms upon him; you may rest assured that the possibility of transmission has no end so long as the secondary period exists, and that as long as an infected father is under the influence of constitutional syphilis, the germ which is by him con- veyed into the uterus carries along with it the syphi- litic diathesis; and it must be noticed, that evident manifestations upon the father are not absolutely ne- cessary— the diathesis is quite sufficient to produce upon the offspring the effect I have mentioned. When the secondary period is passed, and the tertiary mani- festations begin to appear, the disease is no longer HEREDITARY SYPHILIS. 205 transmissible; the children are then born Avith ano- ther disposition—viz., the scrofulous ; and the tertiary symptoms of the mother have the same influence on the child as those of the father. Remember, before we proceed any farther, that there is no such thing as an infection of the child by the mother, she having been contaminated by the father; but that, as I said before, the husband procreates an infected child, which may then propagate the secondary poison to the mother; for where there are no children the mother does not suffer. But suppose the mother to conceive whilst herself and the father are quite free from the syphilitic diathesis, and that this diathesis subse- quently happens to arise with the father, can it be transmitted to the child ? I do not hesitate in answer- ing this question in the negative, and I must look upon that opinion as very absurd, which supposes that the father can contaminate the foetus through the mem- branes. In order that a child, the offspring of healthy parents, should be at all infected, after it has existed more or less time in utero, the mother must, by direct inoculation, become affected with an indurated chan- cre, and all its consequences; then the foetus may in- herit the diathesis of the mother. The latter might perhaps transmit the diathesis to a first foetus by means of a second germ (the first being quite healthy), in a case of super-foetation ; but even under these circum- stances it would be still by the instrumentality of the mother that this first foetus would become contaminated. It is therefore evident that the mother, in order to in- fect her child, must haAre upon herself a secondary syphilitic affection, either acquired whilst the foetus is in utero, or before that event. But we unfortunately do not know what is the latest period of pregnancy in which a Avoman, who happens to take the disease, can contaminate her offspring; in other words, we do not know whether a diathesis contracted during the eighth or ninth month of conception may still be trans- 18 206 MECHANISM OF THE INFECTION. mitted to the foetus. The child may, moreover, be infected by direct contagion on its passage through the vagina, if the mother has, in that region, or in any part of the track along Avhich the foetus has to be expelled, primary inoculable sores; or if it were received at its birth by a person, in the same state as the mother ; but this kind of infection is not inevi- table. Mechanism of the Infection.—The virulent absorp- tion has been first attributed exclusively to the lym- phatic system, then to the veins; but noAV-a-days all pathologists agree that both systems are concerned in it. The lymphatics are the first to be affected, but through the medium of the blood; it is a sort of fer- mentation, and the result is a morbid chair cou/ante. This state of the system is that to Avhich I have given the name of syphilitic diathesis. It would seem, judg- ing from the manifestations of the disease, that it pro- ceeds from the surface to the parts situated within, traversing the body layer by layer, as it were. The contamination is first seated in the blood; it is a re- gular toxaemia, and from this poisoning all the diffe- rent manifestations spring. Every organ becomes modified under its influence: this modification hap- pens but once, and it cannot be renewed. Then the economy is under the influence of the diathesis just mentioned, which latter is capable of producing the most varied manifestations. But these, as soon as the infection has taken place, must appear within a cer- tain period, if the regular progress of the disease has not been hindered by a mercurial treatment. I have never seen, in Paris, more than six months elapse be- tween the contagion and the manifestation of second- ary symptoms; they may confidently be looked for within this period ; but of course there must be, as I so often have said, an indurated chancre as the pri- mary accident, and it is then certain that before six months are expired constitutional symptoms will ap- SECONDARY SYPHILIS. 207 pear; but this rule does not hold good when a specific treatment has been used. As soon as the latter has been interposed in the regular progress of the disease, it can no longer be foretold at what time, and how, the secondary manifestations will appear, one of the links of the usual chain of accidents may be destroyed by the treatment, and thus we sometimes see tertiary symptoms occur without any previous secondary ones. It may easily be conceived that a mercurial treatment being used when the manifestations are just about ap- pearing, they may be arrested and retarded for an indefinite space oftirae—viz., one, ten, twenty, orthirty years, or even, perhaps, for ever. You will perceive, as Ave proceed, that in the chain of symptoms two links, which ever retain the same relation with each other, are constantly apparent. The first of these concerns mucous membranes and the skin (secondary symp- toms); the other, fibrous tissues and splanchnic organs (tertiary symptoms); and, as I have mentioned before, an intervening mercurial treatment may more or less destroy one of the links in the succession of symptoms. The latter cannot be classified with any degree of re- gularity, except by following this division and I can fearlessly say, that the close observation of the phe- nomena presented by patients proves more and more the correctness of this classification. This clear and distinct order of things is so much the more satisfac- tory' to behold, as the greatest confusion on this head reigns in the writings of a great many authors on the subject, not excepting very recent ones. Symptoms premonitory of secondary manifesta- tions.—When the diathesis is once established, the manifestations generally appear within the period AA'hich I have been at some pains to establish. (I may mention here, as a parenthesis, that there is not much to fear, with reference to secondaries, Avhen a whole year has elapsed since the contagion without any sign of them, and that no mercurial treatment has 208 SECONDARY SYPHILIS. been used.) It may be said that the infection is of itself sufficient for the production of the secondary symptoms ; but it cannot be denied that there are cer- tain adjuvant causes, the study of which has hitherto been too much neglected. These causes are far from being all known; but among them we may reckon, the hygienic condition of the patient, errors of diet, alcoholic excesses, climate, sudden changes of tempe- rature, particular seasons, dissipation, unAvholesome food, anxiety of mind, &c. In the absence of these, the manifestations will be slower in appearing. Cer- tain local peculiarities likewise exercise some influ- ence—as, for instance, the irritating action of the pipe on a lip which already bears some mucous tubercles, suction on a nipple in the same condition, in nurses labouring under the diathesis (this is very important to notice; for a nurse may look quite healthy Avhen engaged at first, and suction may bring forward se- condary manifestations, the diathesis lying latent within her), neglect of cleanliness, and the use of those little wrarming boxes Avhich our market-women are in the habit of keeping under their gowns whilst sitting in the open air, alcoholic beverages Avith people whose pharyngeal mucous membrane is thickened by mucous tubercles, &c. But I must confess that, with regard to local exciting causes, we have yet a great deal to learn, and that investigations on the subject are, in- deed, very much needed. Let us now consider the mode of evolution of the symptoms which announce secondary syphilis. Hitherto we had no other proof of the general infection than the indurated chancre and the adenitis which succeeded it; but our atten- tion is soon called to other manifestations,—these are the secondary accidents. They may arise in any part of the frame, and even on the primary sore itself, which is then transformed in situ into a secondary ulcer. This fact overthrows the axiom which has been often repeated—viz., that a primary accident PREMONITORY SYMPTOMS. 209 occurs where the contact takes place, and a secondary one at a distance from it. The manifestations of con- stitutional syphilis may appear in the second or third week after contagion; but the general rule is about the sixth week, and it frequently happens that they do occur in the third month. The complexion then begins to alter; the skin loses its natural brilliancy, and assumes a dull earthy hue; the eye gets dim ; the patient loses all bodily and mental vigour, becomes inactive and sad; the hair gets dry, and loses its smoothness; giddiness and headache set in; there is great uneasiness about the neck, and a peculiar supra- orbital pain. The head symptoms generally begin in the evening, and leave off towards morning; reclining and the warmth of the bed increase them greatly. It is not quite correct to give these symptoms the name of nocturnal pains; for they are entirely dependent on the bed and the horizontal posture, since bakers and gay people, who go to rest by day, have them imme- diately they lie down. The supra-orbital region seems to be the point the most liable to these pains; and Avhen the latter are very acute, the patient feels as if his eyes were being driven out of their sockets. The affected parts do not, however, present any redness or swelling, nor are they painful to the touch. The headache is sometimes strictly symmetrical, and by occupying one side of the head only, it entirely si- mulates hemicrania or intermittent facial neuralgia; but Avith all this there is no apparent lesion observa- ble yet. If the disease be allowed fo proceed, the neuralgia, which had begun in the fifth pair, attacks the seventh, and produces paralysis of the face; and if Ave were not guided by the chain of preceding symp- toms, we might easily ascribe the whole mischief to rheumatism. I have often treated cases of this sort, and I almost always succeeded in curing them by iodide of mercury. I have even met with instances where the seventh pair was primarily attacked, with- 18* 210 SECONDARY SYPHILIS. out any previous neuralgia. After all these symptoms, sub-sternal pains come on, Avhich latter Baglivi looked upon as symptoms of latent syphilis; then circa-arti- cular uneasiness, accompanied with great lassitude in the limbs, just the same as happens before eruptive fevers. These articular pains are not situated in the centre of the joint, but all around it; they are fuga- cious and intermittent; they do not produce any swel- ling or redness in the part, and are not augmented by pressure ; they are vague, erratic, and nocturnal, pre- senting the same characters as the cephalalgia which I mentioned a little while ago. Just about this time the posterior cervical glands begin to get involved. This symptom is sure to be present, at least, ninety times upon one hundred cases. These glands are situated at the back of a vertical line falling from the posterior margin of the ear, and their being attacked is a fact the more characteristic of S}'philis, as they are found nearer the vertebral groove and the root of the hair; those situated on a level with the mastoid process have the most value in a diagnostic point of view. The hand must be Avell practised to recognize them easily, and they might readily be confounded with periostitis. This peculiar adenitis presents, how- ever, a very small volume, the glands feel elastic, roll under the skin, are not painful, and never suppurate. After a little time, alopecia comes on ('Axa?™*/*, the falling of the hair; *aa«;m£, fox). This symptom has been looked upon by some authors as a sign of inve- terated syphilis, and by patients as an effect of mer- cury, at the time when this metal w7as invariably ad- ministered at the very outset of the primary symp- toms; but you see that the latter were not quite cor- rect, for mercury does not cause alopecia, but syphilis will. This symptom, as I before mentioned, is an- nounced by a stiffness and dryness of the hair; it falls at the least touch, and adheres in great quantity to the patient's nightcap; but this falling off is general ERUPTIONS. 211 all over the head, whilst common baldness is always partial at first, and attacks only the vertex. Whilst all these symptoms succeed one another, certain changes take place in the circulation. The pulse loses its energy, and a bruit de souffle is heard both in the cardiac region and about the carotids; in the latter, it may go so far as to simulate the bruit de dia- ble. These are evident signs of pretty advanced chlo- roanaemia. The globules are diminished in quantity, the skin and mucous membranes are shining and dis- coloured; there is great debility, dilatation of the pupil, &c. Attention should be paid to this anaemic state, so as not to be tempted to commence the treat- ment by bleeding, as some practitioners do. This state of the blood explains many of the symptoms be- fore enumerated. For the generality of observers there is not yet any sign of constitutional syphilis, yet if the disease go on unchecked, certain manifestations come on, succeeding each other regularly on the dif- ferent tissues of the economy, and leave no longer any doubt as to the nature of the affection. These are the strictly so-called secondary symptoms, and may occupy either the skin or mucous membrane, or even sometimes both of them at the same time. These cu- taneous phenomena have in this country been grouped together.under the name of syphilides, and they may be looked upon as a kind of elimination, as if the sys- tem were making an effort to drive the toxic principle to the surface. The earliest eruptions on the skin are exanthematous, and assume either the aspect of ery- thema and its varieties, or that of more or less con- fluent roseola rubeolica, with a tendency to spread, and to simulate measles, by affecting, in isolated patches, a certain crescentic form. There is even a very early period when nothing but maculae are no- ticed. The pressure of the finger causes them to dis- appear altogether; but as soon as it is removed, they re-assume their former shape and colour. This cry- 212 SECONDARY SYPHILIS. thematous eruption is generally apyretic, without local heat or itching; but there might, however, be fever, independently of syphilis, and it must then be looked upon as a concomitant phenomenon ; the patient might even have bronchitis or coryza upon him at the time, and these would be sufficient to give rise to some feverishness. I insist upon these circumstances, for such secondary eruptions might, by an inexperienced hand, be mistaken for measles or scarlatina. Fever- ish symptoms are very rare in constitutional syphilis, but I must say that I have observed them now and then. The cutaneous phenomena appear sometimes suddenly; at other times they come on gradually, and take two or three weeks in coming out. This dura- tion is quite uncertain—a circumstance in which they differ Avidely from the regular exanthemata, which last, as you know, a definite and fixed period of time. If syphilitic exanthemata are not checked by treatment, they will turn into a severer form of eruption, Avhich I shall describe a little later. It is now necessary that I should qualify certain assertions I made with regard to secondary manifestations, as some present pecu- liarities which you should know. And, first, as to the obstruction of the posterior cervical glands, which certainly are of great value in diagnosis, it must be noticed that patients beyond forty are seldom, affected with it; and that, in case it does not appear within twTelve months after contagion, it never occurs at all. The same remarks apply to alopecia; for it is observed within the same period as the glandular enlargement in the neck, but that period once passed, it is no longer to be expected. So that you see it cannot be looked upon as one of the later manifestations, as some have thought; of course you understand that I mean the falling of the hair, as before described, for calvities or common baldness may occur at any time. When the exanthematous eruption has appeared, it will go on for more or less time, but it then presents certain CONDYLOMATA. 213 undulations,—it is, namely, observed to fade away for a little Avhile, then it reappears, and it may thus go on with interruptions for two, six, or twTelve months; but after a year or two it entirely dies away. In half the cases the eruption remains quite unnoticed, and it very often fades away without the patient being aware that it ever had any existence; but some time after—say a year—another and deeper eruption makes its appearance, and here you must be careful not to take this for the first manifestation, for you would then fall into the error of believing that you had to do with a tertiary symptom, the second having been absent altogether. If the disease go on undisturbed, the ex- anthematous stage makes room for another—viz., the papulous; the affected spots get circumscribed, and rise above the level of the skin; they project more or less 0Arer it, and vary in size from the head of a pin to a largish patch. A papulous eruption has peculiar characters, which vary according to the seat of the papulae; it springs up very easily indeed in those re- gions where the skin is in the vicinity of mucous mem- branes, and is not bound down by the epidermis, and likewise where it is bathed with an abundant follicu- lar secretion—as, for instance, the verge of the anus, the genito-crural fold, the internal surface of the pre- puce, the umbilicus, the lips, the meatus auditorius, the velum pendulum palati, the tonsils, &c. Such a mucous tubercle begins by slight redness ; the epithe- lium then becomes softened, loses its connexions with the parts beneath, disappears, and leaves an erosion ; the eroded surface soon turns very red, projecting and granular, and gets covered with a pultaceous secre- tion, Avhich is, for the most part, extremely foetid, par- ticularly in the anal and the genital regions. These mucous tubercles are first composed of isolated pa- pules, which, by uniting into groups, form large patches; they are flattened, irregular, separated by fissures, and their edges are very sharp. Mucous pa- 214 SECONDARY SYPHILIS. pulae may become very prominent, and from the state of simple hypertrophy, they often pass into that of ve- getations. Their surface in such a case contracts a good deal; little transparent and globular granulations form, they rise by degrees, and in uniting they give origin to a sort of raspberry vegetation. Mucous tu- bercles have received a good many different names; they have been called, at their first appearance, moist, flat pustules: then, when they acquired a little deve- lopment, mucous tubercles; then they were, a little later, confounded Avith vegetations, strictly so called, and got the name of condylomata. I beg to find fault with the word tubercle, because, in syphilitic diseases, it always designates accidents involving the whole thickness of the skin, without any other peculiar ap- pearances; it is, in fact, a mere transitory state. Mu- cous tubercles, then, or patches, or still better, mucous papules, never yield any inoculable pus; they do not give rise to any neighbouring adenitis; they consist merely of a hypertrophied engorgement of the most superficial parts of the skin, and are susceptible of cure by a specific treatment; whereas such treatment is found poAverless in destroying vegetations, even when the latter are situated on a recent mucous pa- pule. Mercury will, in such a case, contribute to the disappearance of the base; but the vegetation re- mains unaltered. Amongst the exciting causes of mucous papules, independently of the specific ones, we must reckon, want of cleanliness, and the contact and frequent friction of two cutaneous surfaces. This latter effect has misled M. Velpeau so far as to make him suppose that the mucous papule of one side can produce another by contact on the opposite side. But more of this when we meet again. SECONDARY ERUPTIONS. 215 LECTURE XX. SECONDARY ERUPTIONS; GENERAL CHARACTERS AND DIFFERENTIAL DIAGNOSIS. I was mentioning, in the last lecture, that want of cleanliness, independent of specificity, is a common exciting cause of mucous papules or patches; that their secretion, on being inoculated, is not capable of reproducing the same papular evolution ; and that M. Velpeau was not quite correct in supposing that mere contact from one surface thus affected with an oppo- site healthy one, is sufficient to give rise to such pa- pules. It will be needless for me to dwell on the numerous local irritants which may favour the ap- pearance of these sores ; your own observation will be sufficient in the cases you may have to treat; and I will now proceed to take a glance at the papular eruptions, not situated in the regions bordering on mucous membranes, but disseminated all over the body. Here we meet with the same papular form, but as the surfaces affected are neither moistened nor irritated by any secretion, the epidermis has a ten- dency to dry up, and to fall off in little scales ; the denuded papule then presents a reddish summit, sur- rounded by a white rim, to which latter Bell attached great importance as a peculiar diagnostic sign. The papular eruption may assume the shape of lichen or psoriasis guttata; the papulae are then larger than usual, and more separated from one another. When the infection of the system is of some standing, or there has been an intervening mercurial treatment, the eruption affects a circular form, and ooks like psoriasis gyrata. Most frequently, several different 216 SECONDARY ERUPTIONS. shapes are observable in the same eruption ; the latter may then be appropriately called polymorphous, and it is not rare to see, in the later stage, black crusts appear, Avhich look very much like the lepra nigri- cans. W7hen a syphilitic eruption occurs on the palm of the hands or soles of the feet, it likewise, as- sumes the papular form, but the papule gets, in such a case, covered by a very hard epidermis„and maybe called a horny secondary eruption (syphilide cornee).* In the hairy scalp, the papule exudes a thick secre- tion, forming a yellowish granular crust, which is, in fact, an impetiginous scab ; but notice that the latter is not the result of a pustule, and does not consist of dried purulent matter. In the study of constitutional syphilis we cannot help remarking that the eruption is generally of a dry nature with good constitutions, and suppurative with bad ones, and that either cir- cumstance has much influence on the form of the eruption. The papular form may be followed by the suppurative—namely, the vesicular and pustular, all of which, with their usual \arieties, may succeed one another. Among the vesicles, you may sometimes meet with eczema, herpes, &c. ; still, eczema is rather rare. In the pustules may be noticed the psy- draceous, achoroid, varicelliform, &c. Notice, by the way, that secondary accidents never reappear in the same shape ; their form is different as they suc- ceed one another, and they commonly proceed from the surface of the body to deeper parts. All these cutaneous phenomena occupy, at first, but the superficial part of the skin, but the sores reach gradually deeper and deeper, and as this oc- curs, they become less confluent than they were at first; they get separated from one another, form dis-- tinct groups, and the original roseola or raucous pa- pule is no longer to be seen. We have, then, more * Syphilide, a very useful term introduced by Alibert, to de- signate syphilitic, eruptions. SECONDARY ERUPTIONS. 217 or less deep pustules, either of a circular or crescen- tic form, ecthyma, furunculus, tuberculo-crustaceous sores, &c. In general, we find the earlier eruptions settle on the flexion of limbs, and the later ones on the extension of the same ; this is particularly the case Avith the inferior extremities. It is toAvards this late period that rupia commonly makes its appear- ance, but-it does not, in these cases, commence with a bulla, as is usual with rupia. I have generally found it to begin by a slight redness, on which a vesi- cle sprung up; this soon became a vesico-pustule, which burst after a little time. The disc formed by the crust then goes on increasing, owing to continual addition of neAv crusts formed underneath by suppu- ration. You must here take note of the fact, that when the disease is once fairly established in the sys- tem, its manifestations may vary according to a great number of influences, either external or internal, ac- cording to peculiarities of constitution, to idiosyn- crasy, mode of life, &c. The description of the sores, Avhich I mentioned in the last place, must be looked upon as very late manifestations, and it is, in- deed, not rare at all to see them four, ten, fifteen- ay, even thirty years after the primary accidents. They, however, generally occur in broken-down con- stitutions, particularly where the treatment has been carelessly or injudiciously conducted ; they contain a second morbid element over and above syphilis—viz., scrofula, a scorbutic diathesis, &c, and the secret of the treatment lies principally in keeping an eye upon the latter affections. The last link in the chain of se- condary accidents, the one which makes its appear- ance towards the decline of the very latest eruptions, •is the true syphilitic tubercle, seated in the thickness of the skin ; it looks very much as if it were attached to the inner surface of the integuments and projected frora within ; it has ranch tendency to involve the sub^aneous cellular tissue. This tubercle may re- 19 218 GENERAL CHARACTERS OF main perfectly dry, and cause merely desquamation of the epidermis, or it may turn into a pustule, and take the form of ecthyma or rupia. Suppuration being once thoroughly established within it, the tuber- cle breaks, the matter is freed, and a deep ulceration remains. The sore has generally very sharp margins, its fundus is pultaceous and yellowish grey, it is per- fectly circumscribed, and it has all the characters of a primary chancre ; so much so, that nothing but its inaptness to yield inoculable matter can distinguish it from the latter. These ulcerations may become ser- piginous, and thus extend pretty far, but the phage- daenic tendency is no longer the same; it is much less violent than with primary sores. General characters of syphilitic eruptions and sores. —Before entering upon these characters, I must just say a Avord about a certain form of sore which I have but seldom observed—I mean, pemphigus. It very often fixes on the sole of the foot, and rarely appears without some other accidents characteristic of sy- philis. When thus accompanied, it is very easy to distinguish the peculiar nature of this pemphigus. It sometimes attacks newly-born children, and the affec- tion has been carefully studied by a German author, who, however, very justly warns us about too lightly deciding upon hereditary syphilis, in seeing pemphi- gus upon a child. Now let us take a general view of syphilitic eruptions. In the first place, they pre- sent, on the whole, the same characters as common eruptions ; they are either composed of vesicles, pa- pules, pustules, &c. In this respect the diagnosis is entirely guided by ordinary rules; but there are means of ascertaining the specific nature of the erup- tion. To do this we must study the precedents of the case, in order to fix upon the accident which has been the fountain-head of the mischief—namely, the indurated chancre. We inquire whether the patient has or has not had suppurating buboes; whether he SYPHILITIC ERUPTIONS. 219 has suffered from obstructed glands, without suppu- ration : we try to find out whether there are still traces of adenitis, either on the posterior part of the neck, or in other regions. In this manner we often reascend from one accident to the other, until we reach the very outset of the disease, unless a mercu- rial treatment has intervened ; for in such a case the chain and succession of symptoms is interrupted. Sy- philitic eruptions, Avhich you will bear in mind can never spring up spontaneously—viz., without the ex- istence of a primary accident, are not preceded by any febrile phenomena ; the eruption may be said to be apyretic, indolent, involving in a very short time the whole body, and appearing, in some degree, by successive instalments. They do not, as has been asserted, affect the face in preference to any other part, but they spread indistinctly all over the frame. The smell which they have been supposed to emit is far from being a specific one ; in fact, there is none at all, except when the suppuration is very abundant, or when the eruption includes parts where it causes a muco-purulent secretion, as, for instance, mucous pa- pules or patches do ; but I repeat it, there is nothing specific in the smell, nor to the copper colour men- tioned by Swediaur, or the ham-like hue spoken of by Fallopius (which latter has been with reason looked upon as an important sign), as an absolute and constant character. In the secondary exanthe- matous eruptions, which generally come on in the earlier period, there is as much redness as with the common exanthemata, and no alteration in the cuta- neous pigment is yet observable ; so that no reliance can be put on the colour, and it often happens that men, accustomed to treat skin diseases, mistake sim- ple or resinous eruptions for syphilitic exanthemata. At first the redness is a mere congestion, which readily disappears under the finger ; a little later, it becomes an actual stain, on which pressure has no 220 GENERAL CHARACTERS OF effect. These purplish-brown stains are also met with in psoriasis, in lepra, and in other diseases; but they generally are surrounded by a much darker areola in secondary syphilis than in any other affec- tion. The seat of the cutaneous manifestations is not of much value as to the diagnosis ; for they may spring up anywhere, as well on the genital organs as in other places; and you recollect, no doubt, that I mentioned before, that they sometimes simulate a primary sore. Nothing, in fact, resembles more an indurated chancre than an ulcerated mucous tubercle, seated on the thickness of the skin or mucous mem- brane, particularly when it happens to be solitary, and to be placed on the generative organs. As to shape, you will find that secondary eruptions gene- rally present rounded and well-defined patches, the colour of which may in the centre be more or less deep. When the disease is of some standing, they will form distinct groups, which assume the annular or the crescentic form ; also that of the figure eight. When they take the shape of segments of circle, they are more defined than in common eruptions. Se- condary cutaneous manifestations have very little ten- dency to suppuration, unless the subject be constitu- tionally predisposed to pyogeny, and when matter does form, it is generally small in quantity, and far from lau- dable in its nature. The eruptions Avhich do not sup- purate will in time disappear altogether, and thus ter- minate by resolution or desquamation. The scales in these cases are less brilliant, and thinner: they dry more quickly, fall off more frequently in a furfura- ceous form, than in unspecific affections, and the scales sometimes come off in large shell-like pieces. Syphilitic patches sometimes get covered with crusts of various dimensions, and of a dark-greenish or blackish hue; their surface is cracked and broken, and generally thicker than in common eruptions. These crusts are sometimes so adhering, that they re- SYPHILITIC ERUPTIONS. 221 main fixed on the spot, notwithstanding cicatrization; they are, in some degree, grooved in the scar, and in some cases the crust is loosened, by gradually turning up at the margins, as the cicatrix is progressing from the circumference to the centre, and it finally falls off when cicatrization is complete. In cachectic sub- jects there is much tendency to frequent haemorrhage. The crusts sometimes accumulate, layer after layer, and form distinct prominences, which constitute the affection known under the name of rupia. When, by the falling of the crust, the ulceration becomes appa- rent, it assumes generally a rounded form ; its fun- dus is greyish and pultaceous ; it is surrounded by a darkish areola ; and there is a certain induration in the margin. The tendency to phagedaena is rare, but still it does sometimes happen that these ulcera- tions make great havoc, by extending very rapidly. Bear in mind that secondary syphilitic ulcers cannot spring up spontaneously, as it Avere ; they are always preceded either by some eruption, as ecthyma, rupia, papules, or tubercles ; such ulcers rarely follow vesi- cles or psydraceous pustules. One of the most im- portant characters of secondary eruptions (which, in- deed, I ought to have mentioned sooner) is a total absence of pruritus, whereas itching is a very fre- quent symptom of the other kinds of eruptions. When, however, the syphilitic rash includes naturally pruriginous regions, as the anus, the genito-crural fold, the axilla, &c, there may be a good deal of itching, but the latter is then produced more by the irritative properties of the secretion, than by the erup- tion itself. The cicatrices left after secondary eruptions are very peculiar in one respect—viz., they may exist without any previous abrasion of surface; this is more especially the case in the papular and tubercu- lous forms. It seems that, in such cases, a .plastic effusion takes place, and causes a certain hardness of 19* 222 SYPHILITIC ERUPTIONS. the part; when this fibrinous secretion becomes ab- sorbed, a regular cicatrix ensues, and may be looked upon as the result of a kind of atrophy or falling in of the textures, brought about by an obliteration of the vessels. In some cases, the tubercle assumes a fibrinous nature, and forms a prominent thickening, which consists principally of nodules. The second- ary syphilitic cicatrices are in general round, of a pur- plish colour, and arborescent; after a little time they turn whitish, and soon get depressed, they have, however, been seen on a level with the skin, and very rarely prominent. I must distinctly state that these cicatrices do not possess an unmistakeable cha- racter, there is always a doubt in the matter; and it would be very presumptuous to risk a decided opi- nion as to their nature, particularly in a court of jus- tice. The cicatrices which follow the pustules pro- duced by frictions with tartar-emetic—those of ordi- nary rupia and ecthyma, as Avell as those resulting from burns—have a great resemblance with the cica- trices caused by secondary syphilitic ulcerations; so that you see how wary we should be when a decided opinion is required. Now, to sum up, it is evident that we cannot rely on any absolute, well-defined character which might assist us in distinguishing venereal eruptions from ordinary ones. We must, then, take advantage of all the circumstances of the case, the precedents, &c.; and if I were to give the preference to some characters above others, I would say that the absence of pruritus is of much wTeight, for it hardly ever occurs in syphilis, and it may be looked upon as the essence of common eruptions; next to pruritus, I would place the copper colour; but this peculiar hue of the cutaneous phenomena is liable to lead us into error, for ephelis and pityriasis present almost the same tint. This is all I have to offer you regarding secondary eruptions. Next time we meet, I shall consider syphilitic iritis. SYPHILITIC IRITIS. 223 LECTURE XXI. SYPHILITIC IRITIS ; ONYCHIA ; AFFECTIONS OF MUCOUS MEMBRANES ; PROGNOSIS OF SECONDARY SYMPTOMS. I come now to the consideration of syphilitic iritis. The parts of the eye which are most often attacked under the influence of secondary symptoms, are the conjunctiva and iris. The mucous papules which sometimes form on the conjunctiva do not present any thing very peculiar, and I may therefore pass them over without any comment. In order to be convinced that there is such a thing as iritis of a purely syphilitic nature, it will be sufficient to watch the evolution of secondary accidents, and to notice the close relation they bear to the different forms of iritis. The lesions which the iris presents are but the repetitions of the cutaneous lesions ; for iritis may be either exanthematous, papular, vesico-pus- tular, tuberculo-ulcerations, &c. The syphilitic af- fection of the iris often occurs at a very early period of the secondary manifestations, and its outset is marked by inflammatory phenomena. The vessels of the part get congested ; there is haemostasis and the coloration changes ; a blue iris becomes green, and a black one turns of a fawn colour; a vascular areola forms under the conjunctiva—its nature may be distinguished by its deep situation and its radiated form ; this is, in fact, a roseola attacking the ins. Lesions of sensibility may, in this early stage, already be noticed ; there is, namely, headache and photo- phobia, but these lesions are much milder than in unspecific iritis. They may even be entirely absent, and the affection then assumes a chronic form; it 224 SYPHILITIC IRITIS. has even happened that the inflammation which cha- racterizes the outset of the disease, depended on a complication, acknoAvledging a cause entirely inde- pendent of syphilis. The symptoms, with most pa- tients, become aggravated during the night, through an increase of the inflammation. Photopsia comes on, and if the iritis is allowed to progress unchecked, certain modifications arise both in the sensibility and in the different lesions Avhich have already taken place. The dimension of the pupil and its shape are altered, the first is contracted by an increase of sen- sibility ; the second is changed owing to an altera- tion of texture. The figure of the pupil is still regu- lar, however : it is merely contracted by reason of an alteration in its vitality, and this is principally caused by an affection of the ciliary nerves. Mydriasis, or anaesthesia of the iris, occurs very rarely in this disease ; but the change of shape may persist, and the iris retain its faculty of dilatation and contraction only on certain points of its surface ; its margins get angular and irregular, on account of an effusion of plastic lymph, which then takes place. Notice here the analogy between these phenomena and the for- mation of a papule on a cutaneous surface. Some German oculists, among whom I must mention Beer, maintain that an ovoid form of the pupil is a pathog- nomonic sign of the syphilitic nature of the affec- tion : this oval pupil has, according to them, its larger extremity externally and inferiorly, and the smaller internally and superiorly. They suppose, also, that in rheumatic iritis the longer diameter of the oval is horizontal; and that just as the syphilitic or rheumatic elements are combined in a varying proportion, so does the greater diameter of the oval alter in its direction. But you know that the altera- tion in the shape of pupil is caused by lesions which may fix in any part of the iris ; and this fact is suffi- cient to show that there cannot be any thing decidedly ONYCHIA. 225 characteristic in any particular shape. The surface of the iris sometimes secretes a plastic fluid analogous to the epidermoid secretion of the skin, which fluid is effused into the aqueous humour of the eye, and renders it dim ; the iris, at the same time, mostly forms adhesion with the lens. If the individual af- fected with iritis has pyogenic tendencies—if he has been a long time labouring under the syphilitic dia- thesis, the disease becomes more serious; the iris swells, projects either forwards or backwards, and its surface gets studded with those tumefied points which have by some been called condylomata. With pyogenic individuals these prominences in- crease in volume, and at last suppurate. Here we have, then, a true pustule, which is perfectly analo- gous to the pustulous syphilitic eruption on the skin. These pustules may be as many as three in number ; they may terminate either by resolution, ulceration, or purulent effusion ; if by the latter, hypopium is the result, and if ulceration take place, it may destroy the iris. When the latter has passed into this tume- fied state, the margins of the pupil become very irregular and fretted, adhesions with the capsule of the lens take place, the cornea and chambers of the eve lose their relative situation, and the axis of vision is destroyed. You see, then, that the lesions which we observe in syphilitic iritis are very similar to those which we find in common iritis; there is indeed much analogy in the symptoms, but the precedents of vour patient must partly guide you, and it is useful to observe, moreover, that syphilitic iritis is an apyretic affection, and is rarely followed by sympa- thetic symptoms in the economy. Yet with respect to the latter, I must say that I have -en patients evidently labouring under a secondary affection of the eve, suffer from fever and vomiting. oiia-We find here the same phenomena which we observed in iritis, and in the cutaneous 226 SECONDARY AFFECTION OF eruptions ; for onychia is, in fact, only an affection of the skin which surrounds the nail; and in this cutaneous attachment may be developed either ecthyma, papules, vesicles, &c. The matrix suffers, and the secretion of the nail gets greatly vitiated ; it grows thick and nodulated; and this alteration is somewhat analogous to what takes place in inveterate psoriasis. There is also a great similarity between onychia and alopecia ; they both depend on morbid changes interfering with the secretion of those cuti- cular appendages. Secondary Affection of Mucous Membranes.—The manifestations of the mucous membranes are the same as those of the skin (this fact has been recognised but very lately); they have long been classed under the generic name of ulcerations, just in the same way as all skin diseases used to be looked upon as pus- tular ; but on examining carefully, we find upon mucous membranes erythema, papules, pustules, tubercles, mere circles, full patches, &c. The cheeks, the tongue, the velum, the tonsils, the anus, &c, are liable to these manifestations, and the forms which affect mucous membranes are generally the same as those Ave find on the skin ; but ulceration seems to occur at once when a mucous membrane suffers, both on account of the redness, which is its natural colour, and because the epithelium gives way so soon, that the crustaceous period hardly exists at all. Secondary ulcerations seldom settle on the pharynx, and do not often reach beyond the isthmus- faucium. They are generally ushered in by uneasi- ness, heat, and tingling in the part, along with a difficulty of swallowing ; there is also a perforating sort of pain in the ears, and a partial deafness. This is the erythematous period. This erythema often passes unnoticed ; for it is very difficult to distinguish it from the natural redness of the mucous membrane ; but the affected parts soon become prominent; their MUCOUS MEMBRANES. 227 surface turns a whitish-grey, and looks very much like a mucous texture which has been cauterized with the nitrate of silver. These eruptions are gene- rally painless; but there is sometimes a feeling of tightness all around them—disphonia, dysphagia, or even aphonia, may occur in succession. If the mu- cous tubercles are seated in the nasal fossae, there will be obstruction in the nares, and when headache is combined with these symptoms, we might easily be led to believe that we have to do with a mere coryza. Aphonia is almost a certain sign that the arytenoid cartilages are involved. In these se- condary eruptions, the affected spot is distinctly limited, and the surrounding parts are perfectly healthy. There is no inflammatory areola, except in cases of ulcerating tubercles, in which the tissues around are a little congested and inflamed ; but there is no febrile reaction even Avhen the ulceration reaches very deep. Tubercular ulcerations, which generally extend to a great depth, are apt to spread very rapidly, and they often invade the parts situated behind the posterior pillar of the velum. As this kind of ulceration involves the whole thickness of the parts, it takes rather a long time to appear ; there is mostly a fixed and constant pain accompanying it, and the functions of the organ on which the ulcera- tion is seated are much disturbed. Audition is im- perfect, and there is occasionally dysphagia, as well as dysphonia ; but the affection is at this period not yet thoroughly manifest to the eye. But if thera- peutical means do not stay the progress of the dis- ease, the destruction of parts comes on, and proceeds with a rapidity which hardly any effort of ours can check. The velum is perforated or torn, the palatine arch crumbles, the spongy bones get detached, and are expelled through the nares along with the vomer ; the chordae vocales and the bony structures of the larynx are destroyed, the internal ear suffers; in a 228 PROGNOSIS OF short time the organs themselves disappear, and the functions which they had to perform are entirely abolished ; phonation, audition, deglutition, and free respiration are gone, and the individual stands before us a wretched victim of this fearful destruction. The mucous membrane of other regions may also become the seat of analogous accidents—the anus, vagina, cervix uteri, are all liable to them; but such lesions have been but little studied in these parts, and it is probable that they would, if Avell understood, lead to clearer notions as to the ulcerations situated on the neck of the uterus. When you are consulted about a loss of the olfactory poAvers, obstruction of nasal fossae, and difficulty of deglutition, you must carefully investigate the case, and neglect no circumstance Avhich may aid the diagnosis. Prognosis of Secondary Symptoms.—These symp- toms are, on the whole, far from being very serious, for they are easily and rapidly curable; but if not very dangerous in themselves, they are very un- pleasant, and when we consider that the cause which produces them is indestructible, the prognosis assumes a certain degree of gravity in so far as the future is concerned. We can, of course, control the eruption and the ensuing ulcerations, but we are powerless as regards the diathesis, and the primary infection which has produced them. The opinion which I hold with regard to the persistence of the diathesis, when once fairly established, is no doubt very far from advantageous to myself, as bearing upon worldly in- terests ; but I have hitherto found no reason to change it; and to support opposite views is to give the public very erroneous notions of our science. No doubt it would be more gratifying both for the medical man and his patient, if the former could promise a radical cure by means of the therapeutic agents he employs; but when this kind of deception is indulged in, it comes to pass that patients neglect SECONDARY SYMPTOMS. 229 the manifestations which must come on sooner or later, they being lulled into a dangerous ignorance and security by the assurance that they are all right as to the future ; and many an organ has been de- stroyed in this way, as medical aid is not sought in time. When I dismiss rny patients, I always tell them that they stand under the influence of a sy- philitic diathesis, and I recommend them to apply to a medical man immediately they perceive any thing wrong about their health. I harbour the firm belief, that neither the duration of treatment nor its early application will protect from the diathesis ; for I have seen patients who, after an anti-syphilitic course, have remained perfectly well for ten, twenty, thirty —ay, even forty years, when, after such a long time, they experienced attacks of an unmistakable nature. Notice carefully that these were not eruptions, sore- throat, &c, which are all early symptoms, but tuber- cles, osseous affections, splanchnic diseases, &c. Many of these patients had been treated by such men as Cullier, Alibert, Biet, Dupuytren, &c. Divers preparations of mercury and of gold have been used to eradicate the disease, but they have failed in de- stroying the diathesis ; and when this latter has been supposed to be overcome, it was because no distinc- tion had yet been made between the indurated and the ordinary chancre. Of course, I need not repeat that the latter is comparatively harmless as to se- condary symptoms. The prognosis as regards these symptoms, is also much influenced by the age of the patient; it is, in general, very serious with young children hereditarily affected, and likewise with preg- nant women. Scrofula, phthisis, scurvy, the herpetic venom, a chlorotic state, are, one and all, very untoward compli- cations ; they are, in fact, additional enemies which the medication must combat. As to hygienic cir- cumstances, you will, of course, understand at once 20 230 TREATMENT OF that cold weather, dampness, sudden variations of temperature, excesses, debauchery, &c, render the prognosis very unfavourable. The appearance of a renewed crop of symptoms where a mercurial treat- ment had been gone through for similar eruptions is of a very bad omen—first, on account of the relapse, and secondly, because mercury has so impoverishing an influence 'on the blood. Excuse me if I stop so abruptly; but I will continue this subject at our next lecture. LECTURE XXII. TREATMENT OF SECONDARY SYPHILIS ; ACTION OF MER- CURY ; ANTI-MERCURIAL MEDICATION ; DOSES, ETC. I proceed with the consideration of secondary symp- toms ; and I would first direct your attention to the fact that the earlier manifestations are always less serious than the subsequent ones ; and that the further we proceed along the links of secondary accidents, the more serious the prognosis becomes. But still when the transitory and tertiary symptoms come on, they need not be looked upon Avith very great anx- iety, except where no means have been used to ar- rest them. Iodide of potassium is all-powerful in controlling these affections, and in a very short time too. The particular seat of any syphilitic manifesta- tion may add somewhat to the gravity of the case, particularly as refers to the tertiary forms, and it often happens that they leave after them indelible marks, and great deformity. Important functions may either be altered or entirely abolished by the destruction of certain organs; thus patients may get afflicted with deafness, dysphonia, aphonia, difficulty of degluti- tion, of pronunciation, &c. I need not insist any SECONDARY SYPHILIS. 231 longer upon the prognosis of secondary symptoms; you see that they are powerfully influenced by a great variety of circumstances. Treatment of Secondary Syphilis.—We have here, as well as in all other diseases, two indications to ful- fil—first, to master the diathesis, and, secondly, to destroy the manifestations. As for the diathesis, I have repeatedly stated that it can be prevented but by the destruction of the chancre Avithin the first five / days of its existence ; when this period is passed, we are never sure of preventing the general infection, and Hunter was mistaken wThen he thought he could arrest the chain of secondary accidents by his anti- syphilitic treatment. But I need not enter into this question again, I have sufficiently dilated upon it in speaking of primary sores. Treatment.—There is hardly any remedy which has not been tried in this disease. Before I give you the list of them, it is but fair that you should knoAV that secondary manifestations may disappear sua sponte, without the intervention of any specific treatment. Among the means Avhich have been em- ployed, I may mention low diet, with the avoidance of much liquid ; the same, with an abundance of fluids ; either of Avhich may be carried on for a longer or shorter period. Attention to diet is, in fact, ex- tremely useful, and it ought to be particularly nutri- tious with individuals who suffer from debility. Antiphlogistic means are of great assistance, as long as they are not directed against the constitutional syphilis itself, but against local inflammations ; they are then very useful. But whenever we have the mere secondary accidents to contend with, antiphlo- gistics should be avoided, for I am convinced by ex- periments that the blood in constitutional syphilis becomes very poor, so that it would be senseless to abstract any, and thereby increase the evil. Sudo- rifics had a great run at one time : guaiacum, sarsa- 232 TREATMENT OF SECONDARY SYPHILIS. parilla, sassafras, squills, &c, have by turns been extensively used ; they may all be said to possess the same amount of efficacy—viz., very little. I gene- rally give them to my patients when I wish to keep them under my observation, but they never arrest any of the accidents. They may, however, be used as vehicles for other more useful substances. Purga- tives are sometimes necessary to keep the primae viae free, but they possess no curative property. Among the number of remedies that have been employed, there are some Avhich are well calculated to fulfil cer- tain indications, they may be used as adjuvants, cor- rigents, &c. Opium is one of them. But the most powerful medication, the only one capable of keeping secondary syphilis in abeyance, is mercury. In order to watch the effects of this metal, we should first tho- roughly understand its peculiar action, both in a pa- thogenic and therapeutic point of view. You all know that the action of mercury on the economy has been differently interpreted by divers observers; it has successively been looked upon as an excitant, stimulant, depressent, antiphlogistic, anaplastic, alte- rative, modifiant, &c. Some have maintained that it acts from one molecule to another—viz., that it gra- dually passes through the A'essels containing the sy- philitic virus, and carries it along Avith itself out of the system ; above all it is anti-syphilitic. Its patho- genic action is any thing but constant. Some people are very easily brought under the influence of mer- cury, whilst others are quite refractory to it by what- ever channel it may be introduced into the system. This metal, placed on an absorbing surface, may act directly on the same, and be absorbed a little while afterwards ; or it may be absorbed without any local action whatsoever, and the local phenomena then occur after absorption. W7hen applied to the skin, it may produce either eczema or erythema, but these eruptions have then no particular character, and the ACTION OF MERCURY. 233 local irritation is an obstacle to absorption. These effects are observed as well on mucous membranes as on the skin. When the mercury is absorbed, it may produce stimulating effects, which bring forth a regu- lar mercurial pyrexia: this is always to be looked upon as a very untoward circumstance, for the spe- cific action is thereby very much impaired. When the mercury is absorbed, it sometimes reacts on the channels through which it has passed ; this effect is a sort of contre-coup. The first symptoms of the ac- tion of mercury on the system, are those of inflamma- tion and increase of secretion, coinciding with a dimi- nution of fibrine in the blood ; but if the inflamma- tion continue, a plastic reaction ensues, the fibrine, on the contrary, is relatively augmented, and the plas- ticity of the blood is heightened. Mercurial fever is generally followed by diarrhoea, resulting from a spe- cies of gastro-enteritis set up by the mercury ; but the most common effect is mercurial stomatitis, or ptya- lism. Symptoms.—Patients, before they notice any thing abnormal, complain of a metallic taste in the mouth; the breath is disagreeable, and even foetid ; the teeth feel uncomfortable, and are acutely sensitive ; they give the patient the idea that they are longer ; they lose their firmness ; the gums seem to grasp them but feebly ; the salivary secretion increases ; the gums turn of a bright red, swell, and become very soft; the last molar or Avisdom tooth, if it have come out, is the first to suffer. I must not forget to mention that these mercurial effects are intimately connected with the presence of the teeth, for stomatitis does not occur when the teeth are quite gone, or before they are cut. Wherever the least pressure is exercised there will be a certain tendency to the development of these symptoms, so that they will generally appear first on the side whereon the patient is in the habit of lying. As the affection advances, a greyish-blue, pseudo- 20* 234 ACTION OF MERCURY. membranous secretion takes place along the margin of the gums ; the tumefaction of the latter goes on increasing; the swelled parts ulcerate; and this generally takes place first around the neck of the last molar. The internal surface of the cheeks retains the impress of the teeth on a level with the meeting of the upper and lower ; the ulceration soon involves the cheeks themselves; the tongue swells, its sides are marked by indentations produced by the pressure of the teeth, and it may even share in the ulceration inArolving the neighbouring parts; indeed, it is not rare to see the cheeks, tongue, and gums, attacked by gangrene, and whilst all this is going on, the sur- rounding textures sympathize, and there is oedema of the cellular tissue and hypersecretion of the salivary glands. These are, however, not yet affected with inflammation ; the abundant secretion is principally OAving to irritation of the orifices of their ducts, and you should bear in mind that the inflammation does not primarily originate in the glands. Patients will sometimes eject a great quantity of a glairy, adhe- sive saliva, which at last comes to resemble diluted mud. Lf the inflammation is very violent it will re- act sympathetically upon the system, and general in- flammatory phenomena become apparent. An expe- rienced eye will never confound the mercurial effects with those of syphilis, but there are cases where both' are combined in such a manner as to be distinguished with much difficulty. Mercurial ulcerations may, for instance, simulate mucous tubercles or patches. The only way to settle the question is, to suspend the ad- ministration of the mercury ; the mercurial symptoms will then disappear, and the syphilitic ones remain and be easily recognised. The effects of mercury in regular doses are generally felt towards the beginning of the second Aveek. Mercurial stomatitis cannot appear three or four months after the administration of the metal has been stopped, and those who still ACTION OF MERCURY. 235 hold this as possible have probably not sufficiently distinguished mercurial from scorbutic stomatitis. When you wish to increase the dose, you must watch the effect of moderate ones for eight or ten days ; and you may fully believe me when I say, that the untoward or pathogenic effects of mercury are not the result of its prolonged administration, but that they arise principally from too large doses, continued for a week or two. The metal, the effects of which we are studying, may act on the nervous centres and produce what is called mercurial tremor, but this affection is very rare, when the mercury is given as an anti-syphilitic; you know that it is, on the contrary, very common with gilders and looking-glass makers, who are subjected to the influence of the metal in its vaporized form. Mercury may bring on apoplexy ; I remember a very clear case illustrating this fact. The patient sank under the symptoms, and by the chemical analysis of the substance of the brain metal- lic mercury was discovered. Some people will tell you that mercury will bring on mental derangement: there is nothing very positive known on this head ; but still, as its influence is well ascertained to extend sometimes to the brain, it might act upon the intel- lect by its effects on the encephalon. I am inclined to believe that this mercurial madness is perhaps only a sort of hydrargyrophobia, just as syphilitic aliena- tion may merely be syphilophobia. Both hydrargyro- mania and syphilomania are, however, extremely rare. Wre have seen that certain mercurial manifes- tations, among which are eruptions, salivation, diar- rhoea, &c, have generally appeared about eight or ten days after commencing use of mercury; but a long-continued mercurial course may impress upon the economy much deeper pathological alterations These are of a slower growth, and present a series of quite different symptoms. Mercurial tremor, mercu- rial paralysis, and mercurial madness, belong to the 236 ANTI-MERCURIAL MEDICATION. latter category. When the system is fully under the influence of the metal, the syphilitic eruption may of course be modified by this circumstance; and we often see it in such cases assume more of the vesicu- lar form, and cause a little pruritus, preserving, however, the general characters of a syphilitic erup- tion. If you should be so situated as to feel rather at a loss how to distinguish in a given case a mer- curial from a syphilitic eruption, you will be greatly assisted by noticing the folloAving contrasted charac- ters :—When the two eruptions exist at the same time upon one individual, if you give up the mercury there is no tendency in the secondary eruption to fade away ; on the contrary, it will increase in intensity ; but the mercurial manifestations will diminish rapidly, and disappear from the tenth to the fifteenth day. If, on the other hand, you were to keep on the mercury, you would see the mercurial eruption make rapid pro- gress, whilst that resulting from syphilis would gra- dually disappear. I have several times tried this method, and found it answer remarkably Avell. Anti-m.ercurial medication.—If you find mercury doing mischief, I need hardly say that the first thing to be done is to leave it off, and thereby do away with the origo mali. Then the prima vice are to be attended to, and recourse be had to sulphur, either internally, or in the form of baths. This substance is very useful, provided there be no mercurial diar- rhoea present, I generally give one drachm of sub- limed sulphur, mixed with water, and one ounce of honey. I prescribe likewise acid drinks, of which a very good one is, the nitric acid lemonade, which seems to promote the plasticity of the blood. As to local applications, I know no better than hydrochloric acid, brushed, in a concentrated state, over the mer- curial ulcerations. The cauterization is to be per- sisted in until it produces a sanguineous oozing. The pain is very intense, but of short duration, and DOSES. 237 the patients experience great relief immediately after- wards. The hydrochloric acid may also be given in the form of gargle ; five ounces of lactuca sativa de- coction, eighty minims of dilute hydrochloric acid, with about five ounces of honey, make a very excel- lent gargarism. When you cauterize with the con- centrated acid, you must be careful to avoid the teeth, for it softens them very rapidly ; and common clean- liness as regards the latter and the gum should be particularly enforced. When there is much diarrhoea opium is indicated. I have always found it an excel- lent adjuvant and the best corrigent, and I cannot agree with those who have maintained that opium interferes with the specific action of mercury—the experience of every practitioner will at once settle the matter. Doses.—The pathogenic accidents I haA'e enume- rated should always be prevented in the administra- tion of mercury ; indeed, there are few surgeons nowT- a-days who, in conformity Avith ancient customs, push it to profuse salivation, in the treatment of syphilitic diseases—most of them, like myself, only aim at its therapeutic action. The doses are strictly relative— the susceptibility of individuals should be studied, and the amount of mercury regulated thereby. WTe should always begin with a dose which is not likely to produce any unpleasant effect: this may be either one grain of the proto-iodide of mercury, or one grain of the bichloride of the same metal, or the fric- tion of one drachm of mercury ointment per day. The effect of these doses ought then to be Avatched : if they produce salivation, fever, or diarrhoea, the mer- cury must be stopped and these complications re- moved. If no disturbance is produced by the doses I just named, they may be persisted in as long as we see the disease gradually receding and improving ; but if the affection has not received any check after the first five or six days, the doses should be gradu- 238 MERCURIAL TREATMENT ally increased, the results watched, and the remedy proceeded with as if the latter dose had been the one given at the outset. But I perceive that I must put off the conclusion of this subject to our next lec- ture. LECTURE XXIII. MERCURIAL TREATMENT OF SYPHILIS. I left off, the last time I had the pleasure of address- ing you, at the consideration of the doses of mercury, and begged you would increase the doses I then mentioned if they produced no curative or pathogenic effect. But if you should notice your patient to be suffering from mercurial disturbances before any therapeutic action is visible, although you may have begun with very small doses, you must not at once pronounce him refractory to the metal. You should first inquire whether these pathological effects are not, in some degree, due to the form in which you are giving the remedy, or to the channel through which you are introducing it into the economy. If I am asked hoAv long the mercury is to be continued to cure syphilis, I am driven to answer, that se- condary manifestations are easily enough controlled, but that concerning the diathesis, which I have so often mentioned, it is hardly known how far we are to push the mercury; in fact, there is no such thing as an absolute rule in this respect. M. Lagneau, in slight cases of syphilis, used to be satisfied with a sort of half treatment. Hunter was in the habit of regulating his doses of mercury according to the size and number of the ulcerated surfaces. Dupuy- tren continued the treatment until all manifestations had disappeared, and for as much time after this as OF SYPHILIS. 239 they had taken to recede. Many administer just one hundred and ten pills, and promise their patients perfect safety when they have swallowed that num- ber. But you have already heard me say that it is not in our power to destroy the diathesis ; there are too many examples which prove this position to allow one moment's doubt about it. The length of the time for which the treatment is to be continued, is about six months : perseverance in the remedy for this period has seemed to me to retard the manifestations the most effectually. So then I would advise you to persist for about half a year, but I am sorry I cannot promise you that this will certainly and truly prevent the tertiary or other forms of secondary symptoms from appearing. I am every day more convinced of this melancholy fact. The channels through which you introduce the mercury into the system may be chosen among all the absorbent surfaces of the body ; you may take either the skin or mucous membranes. The skin, however, cannot be so much relied on as the mucous membranes, and the former should be taken ad- vantage of only when the latter are out of order. WTien the skin is to be the inlet, we generally choose the axilla the groin, or the internal surface of the thighs. Cyrilla used to order the frictions to be made on the plantar aspect of the feet. But, as I said before, mucous membranes ought to be preferred, and the gastro- intestinal answers best. If the stomach cannot bear the administration of the remedy, Clark's method may be employed—y'\z., the application of the mer- cury to the mucous membrane of the mouth ; and should the state of the mouth not allow of this, that of the rectum might be tried, and mercurial prepara- tions be throAvn up in solution. As a last resource, inhalations might be used, but as a general rule, and wherever it is practicable, the stomach will be the most advisable channel ; we are then much surer of what we are doing, and the effect is much more cer- tain than when other methods are employed. 240 MERCURIAL TREATMENT I come noAv to consider under which chemical forms the mercury is the most advantageously adminis- tered. First, you will be pleased to notice that the different preparations act entirely in virtue of the mercury they contain, and whether the latter acts in the metallic state or not, is an unsettled question. But I must say that I am inclined to believe that its power resides principally in its metallic action, espe- cially when I remark the regularity of the latter, and the ever-repeated identity of its effects. M. Mialhe contends that all preparations of mercury pass into the state of bichloride within the stomach previous to their absorption into the system. I am, hoAvever, not favourable to this opinion (although I cannot pretend to having made many chemical experiments on the subject), because we know that every mer- curial preparation, be it absorbed by the stomach, the skin, or mucous membrane, acts ever in the same way, and produces effects exactly identical. I firmly believe that mercury once fairly admitted in the system, under whatever form it may be, is freed from the previous combinations, and acts solely through its metallic properties. The chemical forms which are generally adopted in the administration of mer- cury may be divided into two categories: the first contains the soluble, the second the insoluble prepa- rations. The soluble compounds are easily diffused, and may be given in almost every form ; this is a great advantage. But it must be observed that there is always a certain local irritation to be dreaded from the administration of bichloride, cyanide, biniodide, or bitartrate of mercury. This irritation is not only very unpleasant in itself, but it may prevent the general action of the mineral. This special effect of mercury is much more easily produced by other pre- parations, which have not the unpleasant conse- quences of the above. I generally give the preference to the insoluble compounds : for they act more readily OF SYPHILIS. 241 as direct salivating agents, and when rapidly ab- sorbed, they produce ptyalism in a very short time, particularly when given in repeated small doses. I have been at some pains in finding out those mer- curial preparations which, besides acting locally in a slight manner, had undoubted general effects. In the course of these investigations, I noticed that the biniodide is less active, and less likely to produce salivation, than calomel; that the bichloride and the cyanide are more soluble than the biniodide ; that the proto-iodide, considered as a specific agent, has as much action as the bichloride, and is less irritating than the latter. But here I might be met by M. Mialhe's theory, and I shall be told that the proto- iodide will undergo a transformation, and become bichloride in the stomach. But in admitting, for a moment, the truth of the theory, it is evident that the bichloride would be absorbed in its nascent state, molecule after molecule, gradually as it is being formed ; by this means it would remain less time in contact with the stomach, and would thereby produce less irritation. But 1 beg you Avill observe, that I am far from rejecting all preparations of mercury except the proto-iodide ; for it is not to be denied that, in the treatment of secondary syphilis, we may find individuals who will bear one preparation very well, and be very refractory to all others ; so that we ought to be prepared to use any preparation of mercury, and in ordinary cases we should give the preference to that chemical combination which, on trial, proves the most advantageous. As to the pharmaceutical forms, I need hardly say that mer- cury is employed in the form of ointment, bath, vapour, plaster, pill, &c. When the ointment is used, it is generally the stronger ointment, recently prepared; and from one to two drachms may be rubbed-in daily. The frictions should be made every other day, and on those parts of the body most 21 242 MERCURIAL TREATMENT favourable to absorption. It is very advisable to begin by rubbing-in on the internal aspect of one limb, and the day after the next to do the same on another limb, and thus go on changing, in order to avoid irritation. Calomel may likewise be used for frictions, and the ointment may consist of equal parts of the chloride of mercury and axunge. Vigo's plaster may also be applied over a large surface, and Avill be found very advantageous. Mercurial baths may be prepared by adding to the usual amount of water to such a purpose from three drachms to two ounces of bichloride of mercury; but I must add, that these baths are far from offering a form of admi- nistration which may fully be depended upon. Fumi- gations of cinnabar are much better, as they possess a very favourable local action. From two drachms to one ounce may be used for fumigation. The tem- perature should be gradually raised, but should not be higher than 100° or thereabouts, and the inhala- tion may be continued during fifteen or twenty minutes. As a remedy addressed to the whole system, pediluvia of from four to eight grains of cor- rosive sublimate to the pint of water are given ; but, as stated before, there is not much reliance to be placed on this kind of medication. When you give the mercury via the digestive organs, you may use Van Swieten's mixture, which contains about eight grains of bichloride to fourteen ounces of Avater. From two to six spoonfuls may be taken daily, in either milk or treacle. M. Mialhe has proposed the following formula :—Distilled Avater, sixteen ounces ; chloride of sodium and hydrochlorate of ammonia, of each fifteen grains ; one white of egg ; bichloride of mercury, six grains. Three tablespoonfuls may be taken in the day, each of which contains about one- fifth of a grain of corrosive sublimate. The action of mercurial solutions is much surer and more energetic than that of other hydrargyric preparations; but it is OF SYPHILIS. 243 also more trying, and their metallic taste is extremely disagreeable. They may likewise give rise to colic and cramps of the stomach, which place us under the necessity either of altering the form of the remedy, or changing the medication altogether. Mercury is also advantageously given in syrup, especially with children. When the patients are subject to consti- pation, the sirop de cuisinier* should be used as a vehicle. The following is Larrey's formula; it is still used with some benefit:—Sirop de Cuisinier, sixteen ounces; hydrochlorate of ammonia, bichlo- ride of mercury, extract of opium, of each from five to six grains. From three to six tablespoonfuls may be taken in the day. This same sirop de cuisi- nier may be used as a menstruum for the biniodide of mercury, in the same doses as the ^bichloride. The cyanide may also be given in the same way ; but the proportion must be a third less than that of the foregoing substances. The best, the most exten- sively used, and the most easily tolerated form, is, without doubt, the pilular; and when we prescribe the insoluble preparations of mercury, Ave have no choice, and pills must be used; but for the soluble ones it is a matter of preference. I generally give the proto-iodide of mercury, first advised by Biett. I may notice, in passing, that the substances used for your pill mass should be readily soluble ; for if they were not so, they would interfere with the action of your principal ingredient. I generally use the fol- lowing formula :—Proto-iodide of mercury, extract of lactuca sativa, of each forty-five grains ; extract of opium, fifteen grains ; extract of conium, one drachm and a half; make five-grain pills, of Avhich six or eight may be taken in the day, increasing the num- ber gradually. Some apothecaries leave out the * An antisyphilitic syrup, prepared with sarsaparilla, the leaves of borage and white roses, senna, aniseed, honey, and sugar. 244 MERCURIAL TREATMENT lactuca ; but I think that therein they are wrong ; for it is a hygrometric and soothing substance, which facilitates the solution and absorption of the proto- iodide. The latter is apt to determine diarrhoea and colic, and the opium is of use in preventing this effect. The conium is an excipient, which is not supposed to have much action, but it is by some considered as a good solvent. Dupuytren's pills are composed as follows: extract of guaiacum, extract of opium, q.s.; bichloride of mercury, the fifth of a grain. Make one pill. Take from one to four in the day. The pills of Belloste contain mercury, aloes, rhubarb, scammony, black pepper, honey, &c. This is a bad preparation, because the purgative action interferes with the mercurial effect. As I mentioned before, Sedillot's pills are composed of three parts of strong mercurial ointment, two of medicinal soap, and one of powdered liquorice. Two or four may be given every day. I have administered as many as sixty per diem without any pathogenic manifestation ; and I may add, that thirty or forty of Sedillot's pills had no effect on certain secondary accidents, Avhich were greatly moderated by five or six pills of proto-iodide. In England the blue-pill is much used : it consists of metallic mercury, triturated in equal proportion with conserve of roses: from two to four are taken in the day.^ Most practitioners will give them fasting, but it is far better to take them two or three hours after a meal, when the stomach is still a little excited. Mercury has also been given in a great many other forms—as, for instance, Keyser's pills,* Lagneau's lozenges,! Olivier's biscuits,! mercurial cigars, &c. * Acetate of the protoxide of mercury, twelve grains; manna, three drachms. Mix, and make seventy-two pills. f Powdered sugar, nine ounces; mercury, obtained from cinnabar, two ounces; gum Arabic, in powder, one ounce. Mix, and triturate until the extinction of the mercury is ef- OF SYPHILIS. 245 As adjuvants the bitters may be mentioned—as sar- saparilla, hop, quassia, saponaria, dulcamara, &c. The syrups most in use are, the syrup of gentian, of quinine, Peruvian bark, de cuisinier, and the anti- scorbutic syrup, &c. However, one of the most effi- cacious adjuvants is iron, whether you employ Vallet's pills, or any other chalybeate preparation. I am very fond of giving the tartrate of iron and potash in solution, in doses of fifty to sixty grains. Some have tried a combination of gold and mercury—five parts of the latter to one of the former, in two-grain pills. The chryso-hydrargyric pills are less likely to pro- duce salivation than the purely mercurial prepara- tions, and they are of course less active. I have given as many as twenty a-day. Patients of mine who had sore mouths from the proto-iodide of mer- cury were ordered this auro-mercurial medication, and I was glad to observe the stomatitis disappear- ing along with the syphilitic accidents. Pure gold has been tried at Montpellier, and according to the accounts I have seen, it has yielded good results; but Messrs. Cullerier and Biett, as well as myself, have obtained no effect whatever from its use. Silver has been given by M. Sera, of Montpellier ; and this gentleman tells us that he obtained cures with it. I have given large doses without any sort of result. I will, next time we meet, conclude this subject by reviewing the empirical preparations of mercury. fected; and then add vanilla, in powder, half an ounce; water, q. s. Make lozenges of twelve grains. % Biscuits prepared with flour, milk, butter, and sugar, weighing about two; drachms, each of which contains one- fifth of a grain of bichloride of mercury. 21* 246 TREATMENT OF LECTURE XXIV. CONTINUATION OF THE TREATMENT OF SECONDARY SYPHILIS ; TERTIARY SYMPTOMS, SYPHILITIC SARCO- CELE. The different infusions or ptisans which by turns have had a run for the cure of syphilis, contain, almost all of them, sarsaparilla. In Pollini's Ave find sulphuret of antimony and sarsaparilla; in Vigarou's, crude antimony, sarsaparilla, guaiacum, bitters, purgatives, &c, &c. The opera dancer's ptisan is principally made with sarsaparilla ; Arnoud's with the latter and mezereon; Feltz's is composed of sarsaparilla, ichthyo- colla, and sulphuret of antimony, Avhich latter must be tied up in a bag, and all the substances boiled together. (I need not tell you that this sulphuret contains arsenic.) As to the far-famed Rob de Laf- fecteur, which is reputed to be a strictly vegetable preparation, you are, I dare say, aware that it in- cludes bichloride of mercury, and, according to cir- cumstances, more or less box-wood, saponaria, trea- cle, &c, &c. Of course this preparation will effect cures wherever a mercurial course is indicated. The corrosive sublimate has, by careful analysis, been dis- tinctly found in this quack medicine, and the impu- dence with which it is set forth as a vegetable prepa- ration is barefaced enough. It has been publicly- stated that I recommend the Rob of Laffecteur, but I need hardly say that this assertion is a pure inven- tion of the vendor. The article on this nostrum in the " Dictionnaire de Medecine," has evidently, I am sorry to say, been written by a venal hand. The cures which have been boasted of principally related SECONDARY SYPHILIS. 247 o patients who were affected with ulcerations, the nature of which was unknown ; and as some years ago every ailment which was not understood was re- puted syphilitic, the Rob got credit for more than it deserved. In fact, many cures have been attributed to it when a change of diet was the principal agent of recovery. Zettman's ptisan is likewise composed of sarsaparilla and divers other substances, among which are cinnabar and proto-chloride of mercury ; this latter preparation, as you see, contains mercury enough, but I do not think that the form under which the metal is administered is a very advanta- geous one. There are certain secondary manifesta- tions which may be greatly benefited by topical ap- plications which you should be acquainted with. Thus, besides the general treatment, which must al- ways be mercurial, you may apply to mucous papules alkaline chlorides and powdered calomel. I would, for instance, recommend Labarraque's liquid one part, water three parts, and the lotion to be used three »times a-day ; the affected surfaces to be then wiped dry and powdered with calomel. The sore places should also be isolated by means of lint. Eight or ten days are sufficient for the cure of the local affec- tion. For dry papules it is advisable to use fumiga- tions of cinnabar ; when patients cannot bear them, the papules should be covered with Vigo's plaster. In this manner we can in eight or ten days remove sores which the patient is very anxious to conceal from the public eye. The crusts which form on the scalp and the squamous papules are much improved by vapour baths to the part. Pustulo-crustaceous and suppurating eruptions are greatly benefited by mucilaginous and gelatinous and bran baths, or cata- plasms of fecula. When the irritation has disap- peared, the emollient applications may advantage- ously be replaced by an ointment containing either calomel or opium; and compression with strips of 248 TERTIARY SYMPTOMS. Vigo's plaster, with mercury, has also succeeded very well in my hands. When you have to deal with sores situated on mucous membra'nes, either in the mouth, nose, throat, vagina, or uterus, &c, you will find the following preparation very useful, either as a lotion or an injection: decoction of cicuta, seven ounces, bichloride of mercury, from three to four grains. It often happens, likewise, that cauterization Avith the nitrate of silver, or the liquid nitrate of mer- cury, proves highly beneficial. The topical means, which I have just enumerated, very often destroy the local manifestations in a short time, and this rapidity of cure very often deceives patients, and induces them to give up the internal medication. You should be prepared for this, and it will sometimes be neces- sary, when you have refractory people to deal with, to withhold your topical applications, and allow the local accidents to get Avell of themselves, so that the patient may be induced to go on with the internal use of mercury. Having now, gentlemen, laid before you the lead- ing facts connected Avith secondary syphilis, I will, Avith your permission, close our course with the study of tertiary symptoms. This classification is by no means arbitrary, and I Avould not trouble you with it, if it had not an immediate practical bearing, and if it were not in some degree a necessary division, as much Avith reference to the treatment as to the prog- nosis. Tertiary manifestations are mentioned in Thierry's work, and hinted at by Hunter. They have, like the primary and the secondary accidents, a peculiar stamp, Avhich distinguishes them from all others, and never directly follow the chancre which is the pri- mary origin of them. They are, in fact, always pre- ceded by some secondary manifestation, except in those cases where the patient has undergone a treat- ment capable of destroying a link in the chain of ac- SYPHILITIC SARCOCELE. 249 cidents, making him in some degree leap over it. These tertiary symptoms are never seen in children, immediately after birth, as an hereditary manifesta- tion, unless the father or the mother, who have trans- mitted the taint, underwent a treatment for secondary symptoms during the gestation. Tertiary symptoms almost never come on before the sixth month after the primary sore. Still it may happen once in a thousand cases that they appear towards the fourth or fifth month ; when the half-year is over, there is no limit Avithin which the tertiary symptoms might be included—they may come on after many years. These tertiary manifestations are as rare as the se- condary are common ; but still you can never pro- mise a patient that he will be free from the former. Syphilis, in this tertiary period, is no longer heredi- tarily transmissible, but it then modifies the system in a different manner—namely, it engenders scrofula. M. Lugol's and my own observations fully verify this assertion. The seat of these tertiary symptoms is generally the sub-cutaneous or sub-mucous cellular tissue, the bones, the fibrous textures, lymphatics, the testes, the liArer, lungs, brain, heart, muscles, &c.; but I have generally found that serous membranes remain free from tertiary lesions. Pains in the bones sometimes come on very early, but the ear- liest tertiary manifestation is doubtless syphilitic sarcocele; and it is rare for the testicles to be tar- dily attacked. This affection has also been called albuginitis, syphilitic testicle, &c. This lesion of the testes was well known to Hunter and Dupuy- tren, but Astruc, long before them, had a notion of its nature, for he made a distinction between orchitis resulting from chancre and orchitis following blennor- rhagia ; and Bell in his turn took advantage of As- truc's observation, in order to attempt the differen- tial diagnosis between the two affections. Syphilitic sarcocele generally begins in one testis, and succes- 250 TERTIARY SYMPTOMS. sively invades both of them ; it may also attack both testes at once, and it is very rare to see one testis escape entirely. There are hardly any premonitory symptoms ; slight and nocturnal pains in the loins are sometimes experienced, but they are extremely rare, and the affection comes on, and reaches a great development quite unperceived by the patient. When his attention begins to be attracted to the part, he finds the testicle already of a considerable size, heavy, and pretty hard ; but the size is not invaria- bly increased in every case. With some patients, I have known the disease to run through all its stages without creating any uneasiness ; the erections, however, get less frequent, the venereal appetite less imperative, and the seminal fluid gradually dimi- nishes in quantity. If the disease is allowed to pro- ceed undisturbed, the testis ceases to increase, it then diminishes in size, by the resorption of the plastic effusion, and the patients are delighted to see their affection thus apparently declining ; but the decrease soon outruns the normal bounds ; the testis gets atro- phied, and disappears more or less completely ; this atrophy is always preceded by a fibro-plastic degene- ration. The latter takes place in the following man- ner:—It begins with the body of the testicle (pro- vided the patient be not labouring under any other diathesis than the syphilitic); two or three points are generally attacked at once; but up to this time the organ retains its normal shape and aspect: nothing out of the way can yet be felt by the hand, except the testis be well isolated from the scrotum, when thin, hard, and fibrous zones will be noticed to sur- round the body of the testis. Kernels of a greater or lesser consistence soon form, and from them proceed radiations exactly as the osseous radii are given off by an ossified point in the cranium. The whole body of the testis gets thus involved, and the tumour be- comes homogeneous, hard, resisting, heavy, and pyri- SYPHILITIC SARCOCELE. 251 form. The epididymis, which at the outset was in a pretty normal state, and could readily be distin- guished, is now flattened against the posterior part of the testicle, and it can no longer be felt. Notice that the reverse takes place in tubercular sarcocele, for in this affection the epididymis has a very thick and distinct outline. Whatever development the tumour may take, no other element of the testicle undergoes any morbid change, and the vas deferens as well as the prostate gland remain free from altera- tion. I need not say that these two organs are at- tacked very early in tubercular sarcocele ; in the lat- ter affection we likeAvise see the other parts entering in the formation of the cord suffer greatly, whereas nothing of the kind is seen in syphilitic orchitis. I must here state, that the pyriform shape, which has always been looked upon as a diagnostic sign of syphi- litic sarcocele, is not always present; for instance, it does not appear when one or tAVo points only of the body of the testis are engaged. Notice also, that in the syphilitic affection we have none of those ine- qualities which the fibrous nuclei produce in the tu- bercular sarcocele. I have seen patients with whom the nucleus was situated in the centre of the corpus testis, and surrounded by healthy textures, so that a certain degree of pressure Avas required to ascertain its presence. If there is a little effusion in the tunica vaginalis, it is of a passive character, and gives way gradually as the principal affection is receding. The progress of syphilitic orchitis is mostly slow, in- lent, and ill-defined ; so much so that patients, as before mentioned, perceive the lesion only after it has existed five or six months. It may last six or ten years, and I cannot tell at what period the dis- ease, left to itself, would stop. Syphilitic sarcocele never brings on suppuration ; whereas cancer, or the tubercular degeneration, are sure to produce it. Re- solution is possible, and then the organ returns to its 252 DIFFERENTIAL DIAGNOSIS. normal state ; sometimes, however, there is a power- ful resorption of the plastic matter after the testis has attained a certain Arolume, and atrophy is the ultimate result. I have known cases where the disease re- mained quite stationary when it had reached a cer- tain point, and all the means in the world could not make it recede one inch. In such a case, the sper- matic vessels are replaced by a nodulated tissue, which has entirely annihilated them. The fibro- plastic degeneration may turn into cartilaginification ; and I have seen cases where an osseous shell was formed around the organ. It is quite indispensable to be aware of all these different modifications, in order to be able to adopt a rational line of treatment, and not to attribute to the inefficacy of the remedies we employ that Avant of success which depends mainly on the peculiar kind of lesion which we have to treat. You will be pleased to observe, that in all those cases of degeneration, the spermatic secretion is less abundant, that the number of animalculae dimi- nishes as the lesion becomes more extensive, and that the fluid Avhich is looked upon as semen is no more than prostatic mucus. Differential diagnosis.—The affections which might be confounded with syphilitic sarcocele are tuber- cles, cancer, and some idiopathic diseases of the tes- ticles. As for blennorrhagic epididymitis, I can hardly understand how it can have been mistaken. I Avill not say a word about hernia, varicocele, and simple hydrocele, for their characters are too opposed to the plastic sarcocele to allow of any error being committed. You will, perhaps, allow me quickly to run over the characters of epididymitis, without, how- ever, comparing the same with those of sarcocele; the mere enumeration of them will suffice for the di- agnosis. The blennorrhagic testicle is always pre- ceded by blennorrhagia, and has its seat in the epi- didymis ; as a general rule, we may say that the vas DIFFERENTIAL DIAGNOSIS. 253 deferens suffers likewise ; the body of the testis is seldom attacked, and always subsequently to the affec- tion of the epididymis ; the progress of the disease is acute and well-defined ; its duration is limited ; and the simplest medication—viz., antiplogistics, emol- lient applications, and resolvents—make it disappear; it may affect both testicles, but rather successively than simultaneously. But if it is an easy matter to distinguish epididymitis from syphilitic sarcocele, it is rather more difficult to establish clear distinctions between the latter and tubercular or cancerous sarco- cele ; yet if you will take the trouble of grouping together the characters peculiar to the three affec- tions which I have been at some pains to describe to you, you will, for the most part, be able to diagnose pretty accurately. As for heredity, it may exist in the precedents of each of the three diseases to which I am now alluding—viz., tubercle, cancer, and sy- philis. Syphilitic sarcocele may come on very early in life, but I have never noticed it before puberty. Tubercular sarcocele is also a disease of youth ; it mostly comes on toAvards tAventy or twenty-five. Of course there is hardly any limit for the syphilitic af- fection of the testicle ; it may attack patients of thirty or forty years of age and more. Cancer seldom ap- pears in this region before thirty. Now, if we wish to inquire into the usual history of these three dis- eases, we shall find that the tubercular or cancerous testicle have constantly tangible precedents which can be laid hold of. It is true that accidental blows and repeated blennorrhagic attacks may provoke the development of tubercles in this organ, but these are mostly exciting causes, which attract the attention of patients to an affection which had long been latent with them. As for the syphilitic sarcocele, it is often ezsv independently of heredity, to reascend by a ham of evidence to the primary accident, which has been the starting point of all the phenomena. Plas- 22 254 DIFFERENTIAL DIAGNOSIS. tic sarcocele occupies distinctly the body of the testi- cle, whilst the tubercular disease generally begins with the epididymis; the corpus testis is indeed sometimes involved in the latter affection, but the epididymis invariably suffers first, and, besides, an additional sign of the tubercular character is, that the vas deferens and the prostate gland always par- ticipate in the mischief; whereas the vas deferens is never affected in syphilitic sarcocele. Cancerous sarcocele generally begins by the body of the testis, and the cord may suffer also; it is not, however, the whole vas deferens which is attacked in this affec- tion of the cord, but its vascular elements only—viz., lymphatics, veins, &c. The vas deferens never gets involved, except when the cancer is complicated by tubercles. Now let us glance at the progress of these three diseases. They all three begin in a very indolent manner. Two of them, the tubercular and the cancerous sarcocele, become painful as they pro- ceed, whereas the syphilitic, which may have given a little pain at the beginning, becomes more and more indolent as it advances, and the affected testis even loses at last all sensibility. If Ave inquire about the diverse forms Avhich these diseases will assume, we shall find that both the syphilitic and tubercular sarcocele may, at the outset, present similar inequali- ties, but cancer is regular and uniform at the very beginning. The syphilitic sarcocele, which might have been very nodulated at the outset, tends gradu- ally, as it goes on, to uniformity of shape ; it be- comes, in fact, homogeneous, as the plastic effusion begins to surround the whole body of the testis ; it then assumes the pyriform shape ; and this symptom is so well knoAvn, that pathologists have given it as a pathognomonic sign of syphilitic sarcocele; the tu- bercular sarcocele becomes more nodulated as it grows, and the cancerous just the same. I am sorry to break off here, but I will conclude this interesting rubject in my next lecture. SYPHILITIC SARCOCELE. 255 LECTURE XXV. TREATMENT OF SYPHILITIC SARCOCELE ; TERTIARY MUS- CULAR AFFECTIONS; ELASTIC TUMOURS; LESIONS OF THE FIBROUS AND OSSEOUS TEXTURES. Having settled the question of shape, as regards tu- bercular, cancerous, and syphilitic sarcocele, I Avill now proceed with noticing the amount of pain expe- rienced in these affections. Syphilitic sarcocele is sometimes painful at the outset; the testis feels heavy and dragging, but is less annoying as the disease goes on; the tubercular sarcocele begins indolently, but becomes very painful A\Then it gets soft; the cancerous causes lancinating pains, and gradually softens down. The tubercular affection will inevitably suppurate; the cancerous Avill ulcerate, then secrete pus, turn fungous, and invade the neighbouring parts. The syphilitic sarcocele never suppurates, and when it has lasted a certain time, its size diminishes; or the tumour may remain stationary, and undergo a fibrous, fibro-carti- laginous, or osseous transformation. You must here notice a very interesting difference between the tuber- cular and syphilitic sarcocele, with regard to their re- spective tendency to involve neighbouring parts. The morbid influence of tubercular sarcocele may run along the inguinal region, ascend through the vessels, and proceed in the direction of the vertebrae, from one lumbar lymphatic gland to another, whereas the sy- philitic sarcocele never leaves the testicle. Further, as to contemporaneous affections in the viscera, I need hardly say that the tubercular sarcocele is likely to co-exist with tubercles in the lungs; that the cancer- ous is often perfectly independent of any carcinoma- 256 PROGNOSIS OF tous affection in other parts of the economy, and that the syphilitic will mostly be accompanied by sundry symptoms of a tertiary nature, which will be of great assistance for the diagnosis. I Avould also direct your attention to the informa- tion we derive from the fact of both testicles being affected simultaneously, or one testis only being at- tacked. I think I can deduce from my experience, that tubercular sarcocele occupies almost constantly both organs ; that the syphilitic sarcocele resembles the tubercular in this respect; but that I have always seen the cancerous confined to one testis only. The duration of tubercular and cancerous sarcocele is in- definite, but when the syphilitic has reached a certain period, it stops short, and then decreases, disappears altogether by absorption, or degenerates into ivory exostosis or eburnation. Treatment.—Formerly very little trouble used to be taken as to the diagnosis of these various affections of the testes, and when a practitioner Avas puzzled about the nature of a tumour in the scrotum, the mer- curial treatment was resorted to in order to ascertain whether it was of a syphilitic nature or not. But you are aware that it is rather dangerous to give attenua- ting medicines to patients who might be phthisical, and it is, besides, very likely that this mode of inves- tigation has often proved a total failure. But in our times Ave have an excellent touchstone in the iodide of potassium, the effect of which upon tertiary symp- toms is far more conclusive than the former modes of distinction. I must not omit to mention that there are cases of idiopathic orchitis which resemble syphi- litic orchitis very much, both in shape and progress, but as there is no sort of inconvenience in giving the iodide of potassium, there can be no harm to resort to it in order to set the question at rest. Prognosis of Plastic Sarcocele, and General Consi- derations on Elastic Syphilitic Tumours,—Plastic de- PLASTIC SARCOCELE. 257 generation of the testicle is not a very dangerous af- fection, in so far that it does not endanger the patient's life ; if we look upon it as producing certain peculiar and very disagreeable modifications of the organ, it becomes rather a serious matter; but the prognosis Avill greatly vary according to the time when the treat- ment is begun. It may, in general, be said, that the more the plastic degeneration is recent and circum- scribed (and thereby the more unlikely to become organised), the less serious it is. If, however, whilst the patient is being treated, and resolution is going on, the hard nuclei are noticed to retain their indura- tion, the ultimate result should then be looked upon with distrust; for in many of these cases there is a total annihilation of the substance of the testicle, and an actual atrophy has taken place. But if, on the contrary, the normal consistence and elasticity return in the same ratio as resolution is going on, the prog- nosis will be favourable. The surgeon should be fully aware, that when syphilitic sarcocele has reached a certain period, the plastic effusion may get organised and that therapeutical means have then no longer any power over it; and it would, in such circumstances, be perfectly useless to persevere in the treatment for a long time. The rule laid down for the diseases of bone holds good in this stage of the testicular affec- tion ; for you all know that no applications in the world could promote the resolution of an ivory exos- tosis. In the disease which occupies us, the organi- zation of the effused lymph, the cartilaginification, and the degeneration, correspond, in some manner, to the stages which, in the diseases of bone, lead to ivory exostosis. The plastic degeneration which we have studied in the testicle may take place in other organs and in other textures; for instance, m the muscles, where I have had several times occasion to observe it As soon as this syphilitic degeneration begins, the muscular tissue, which seems to undergo a sort of 22* 258 PLASTIC SARCOCELE. coagulation, contracts; but this contraction is hardly noticeable as long as the muscle gets passively shorter. The phenomena which I have pointed out as marking this affection in the testicle reappear in such a case. There is first a simple plastic degeneration, which may, by proper treatment, entirely disappear, without any sort of deformity being left behind; but if the disease is allowed to reach the organised period, the result may be either a complete atrophy, through re- sorption, or a fibrous, fibro-cartilaginous, or osseous transformation. In the latter of these two cases there is shortening of the affected muscle. This degenera- tion generally invades the flexor muscles, as, for in- stance, the biceps, &c. We have now an example in the house, where this plastic alteration is situated in the anterior part of the leg, causing a flexion of the foot; I have also observed the same affection in the gastroc- nemii. I remember a celebrated singer, who consulted me for such a syphilitic contraction of the biceps, which interfered with the proper action of the arras on the stage. He was put on the iodide of potassium and progressed very nicely, so much so that resolu- tion gradually ensued ; and whilst the public Avere ap- plauding his splendid vocal feats, I used to join them enthusiastically, enraptured as I Avas with the vigorous action of the arms and the triumph of the iodide. This complaint is not painful at all, and the patients become aware of it merely by the difficulty they expe- rience in performing the different motions of the limbs. I have seen, in the course of my practice, cases of complete atrophy of the flexor muscles of both legs. Since I have called the attention of the profession to this pathological alteration, a work has been published by M. Bouisson, of Montpellier, upon these plastic degenerations of muscles, consequent upon tertiary sy- philis, for which no small praise is due to him. I have even met with a case of plastic alteration of the fibres of the heart, which has been published in the EVOLUTION AND PROGRESS. 259 Clinique Iconographique. The patient had both ter- tiary tubercles upon him, and some of those which, as you may recollect, I called tubercles of transition; he Avas suddenly seized with general powerlessness and died almost instantly. The skin, after death, be- came quickly covered with large ecchymoses, as is the case Avith people who have died of suffocation. At the post-mortem, we found the fibres of the heart degenerated and shortened over a pretty large extent; the muscular tissue had partly disappeared, the lesion being in the second stage. Tertiary syphilis often produces another alteration, which bears to plastic degeneration the same relation as suppurative syphi- litic eruptions bear to dry ones, I mean—namely, the elastic tumour, or the tubercle of the cellular tissue. These tumours may spring up wherever there is cel- lular tissue, be the latter sub-cutaneous or sub-mu- cous; and they have been found wherever areolar textures exist. They may develop around the cord, between the epididymis and the testicle; in short, Avithin all the cellular elements of the liver, lungs, brain, testicle, &c. Evolution and Progress.—The elastic tumour,yield- ing to the hand a sensation as if it were filled with gum, is an essentially tertiary accident; it never ap- pears before the fifth month after the contagion, which is the primary cause of the tertiary affection; but it may also come on thirty or forty years afterwards. It mostly begins with a hard kernel, of a small size, situated in the deeper layers of the skin ; it grows very slowly, so much so, that I am not quite sure of the size which it may reach; but this development takes place without any local or general reaction, and in the cases I have observed, the tumour seldom went beyond the size of a walnut, and mostly remained much below it. These tubercles or elastic tumours are not confluent, and this fact is sufficient to establish a distinction between them and molluscum, which, ge- 260 EVOLUTION AND PROGRESS. nerally, is remarkably confluent. When it settles on the testicle, it is mostly solitary, all the surrounding parts remaining perfectly sound. I have found such tumours in the brain, and M. Cullerier has reported a case where this organ was similarly affected. The disease, Avhen situated in the lungs, has, perhaps, more tendency to the deposition of numerous tuber- cles of this kind. WTien an elastic tumour is left to itself, or treated by mercury, it will inevitably suppu- rate ; and before the use of the iodide of potassium was introduced, it Avas looked upon as incurable. Thus M. Cullerier always advised the cauterization of such tumours, and I was in the habit of advocating their removal with the knife. As the syphilitic tu- bercle grows, it becomes rather painful; this is almost always owTing to inflammatory action set up within it; before this complication occurs it lies quite free in the cellular tissue, and adheres to the skin only in one point; but when inflammation sets in it gets con- founded Avith the surrounding tissues, its mobility is lost, the skin covering it becomes red, swells, softens, and ulcerates, on one or several spots, and a deep ulcer follows the plenteous discharge of purulent mat- ter. The edges of the sore get undermined, and the neighbouring parts are involved in a destruction which varies according to the organs whereon the tumour has settled. It would be impossible for me to give you an account of all these lesions, as they affect every one of the viscera. I will just attempt a sketch of the state of the larynx when thus attacked. The first symptoms are, in such a case, a gradual difficulty of phonation, which may go so far as to produce a total extinction of voice; but when suppuration comes on we have all the inflammatory symptoms of chronic laryngitis, and even of phthisis laryngea—viz., puru- lent or muco-purulent expectoration,dysphonia, or total aphonia, the detachment and expectoration of the bones or cartilages of the larynx, and the occurrence of aerial FIBROUS AND OSSEOUS LESIONS. 261 fistulae. But those symptoms, which apparently are extremely serious at the very outset, are far less im- portant than they become towards the last; for at the beginning the dysphonia and aphonia are merely symptoms of compression or obstruction; and since a judicious treatment can modify this state of things Avithout any loss of substance taking place, the organ may regain its normal vigour. But when the disease has made further progress, the phenomena then percep- tible are the result of the destruction of several parts of the larynx, the treatment then can promote the heal- ing up of the ulcers, but cannot restore the parts of the organ which have been loosened and expectorated. I must not omit to point out that the heart also may, at the beginning, be affected with signs of compres- sion or congestion; and it may happen that, these being neglected, suppuration of the organ ensue. And here I must solemnly Avarn you not to confound the suppuration of a few syphilitic tubercles in the lungs with phthisis. In the latter disease I need not tell you what fate awaits the unfortunate sufferers; whereas the cure in the syphilitic affection is ex- tremely probable, and the prognosis is any thing but gloomy. You will be able to distinguish these affec- tions by the history of the disease, the actual cutane- ous manifestations, or even by the treatment. I have dwelt principally on the larynx, heart, and lungs, but all other organs may be affected in the same way. Lesions of the Fibrous and Osseous system.— ihe first phenomena which raise a suspicion that such le- sions have taken place, are the characteristic tertiary pains in the bones, which are widely different from the rheumatic pains of the second syphilitic period. These pains are very tardy, and generally have their seat on those points which are subsequently to become involved in organic lesions: they mostly occur on he Swing bones ;-internal and anterior part of the ut Cranium, clavicle, the ulna, almost through its 262 PECULIAR CHARACTERS. whole length, the lower part of the radius, either the superior or inferior part of the fibula, inferior maxilla, metacarpus and metatarsus, malar bones (rarely), ver- tebrae, nasal fossae (often). The humerus, femur, and pelvis, are mostly exempted, but it is not rare to see the ribs affected. Although such osteocopes may be looked upon as constituting per se manifestations of tertiary syphilis, and their origin is sufficiently clear, still they are so intimately linked with other lesions, that the study of their aetiology in an especial manner will, I think, be useful. These symptoms Avere hardly described before the fifteenth century, either as deno- ting latent lesions, or as being of a syphilitic origin. This shows evidently that they passed unnoticed; but we may of course admit that they existed before the fifteenth century, and we can only account for their not being mentioned, by supposing that attention was not directed towards them. It has long been held that osseous pains were the effect of mercury; but to prove this assertion to be untrue, you need but recol- lect that they were described during the epidemic of the fifteenth century—a period when mercury was not used for diseases affecting the system at large. And to make this still more evident, it may be added, that at the time when mercury was laid aside for a milder treatment (which did not happen many years ago), I have watched patients through the Avhole series of se- condary accidents, and seen them get at last affected with the tertiary osteocopes. Moreover, it is well knoAvn that in England, calomel is used as a purga- tive in ordinary cases, and it has been observed that those persons who make much use of this salt are never afflicted with osseous pains. Some people have also attributed the pains in the bones to mercury and syphilis combined; but here again we must notice that a well-regulated external application of mercury is very likely to prevent those pains altogether. Peculiar characters.—The part affected neither NODES. 263 changes in size, nor colour, nor temperature. The pain arises without any exciting cause ; it lies very deep, and is much excited and increased by pressure ; Avhereas this same pressure has no effect on secondary rheumatic pains, except that it sometimes eases them. The tertiary osseous pains are fixed and circumscribed, whereas the rheumatoid are more diffused and metas- tatic ; they have, however, this in common,—that they increase by the decubitus and by the heat of the bed ; in fact, they are nocturnal; and I need not re- peat how I understand this expression. If these os- teocopes are allowed to proceed undisturbed, they will certainly end in an organic lesion of the part, whilst the secondary rheumatismal pains will, after a certain time, disappear, Avithout leaving any trace whatever. The tertiary pains are incipiently intermittent and noc- turnal, but they soon make their appearance during the day, at first but slightly, but they gradually tor- ment the patient day and night, and produce other accidents. But I must stop here, and proceed with this subject at my next lecture. LECTURE XXVI. NODES ; SYPHILITIC EXOSTOSIS, OSTEITIS, CARIES, AND NECROSIS. I concluded, the last time we met, with the consi- deration of the principal characters of osteocopes ; it will now be useful to inquire how long they may last without bringing on organic lesions. I can de- duce from my experience and the practice of others, that these pains may extend over so much as two years without any lesion of the osseous textures; this, however, may be looked upon as the exception, 264 NODES. the rule is, that osteocopes which last, unchecked, for six months, are very near producing troublesome alterations in the osseous tissues. The lesion is first situated in the periosteum, and it may be said that periostosis is much more frequent than exostosis. This affection of the periosteum, which is called nodes, may be divided into three varieties: the elastic, the phlegmonous, and the plastic. The first of these presents a tumour with an immovable base ; it is more or less circumscribed, of a circular shape, and the integuments, which easily glide over it, are not changed in colour or temperature. You, doubtless, remember that elastic tumours unconnected with bone adhere, on the contrary, to the inner surface of the skin, are very moveable, and may be easily iso- lated by making pressure behind them, in all of which particulars they differ from the first variety of nodes. The latter, moreover, are preceded by osteo- copes, but there is no pain before the appearance of the cutaneous tumour; none, in fact, is experienced until suppuration comes on. These doughy or elastic nodes (they give the hand the sensation of confined gum) are the result of the effusion of a thickish fluid under the periosteum ; they are generally painless, fluctuating, and tend to resolution ; this variety is the most easy of cure, and the least painful. The phlegmonous nodes (second variety) are preceded by inflammatory action ; they give exquisite pain, and mostly suppurate ; the purulent matter accumulates between the bone and periosteum ; both the pre- monitory pain, and that which follows the complete development of the affection, are extremely severe ; the integuments turn red, become hot, and adherent; and an abscess speedily forms. The plastic nodes (third variety) begin like the doughy or elastic, but are a little more painful; the skin remains unaffected ; the tumour is at first fluctuating, afterwards, how- ever, it acquires a little consistence, gets gradually NODES. 265 hard, passes through the different stages of plastic sarcocele, and at last emerges into ossification and eburnation. This is a species of exostosis resembling an epiphysis, and this leads us naturally to the study of exostoses. You are aware that in general pathology two kinds are admitted, one being an exostosis growing as a sort of epiphysis ; the other, the parenchymatous exostosis. In the first kind, a plastic effusion occurs between the periosteum and the bone, or within the cells of the periosteum. The latter gets a little thickened, and shows a tendency to lose its con- nexion with the bone, by the infiltration of the lymph in its intimate texture. This effused matter becomes thick, undergoes a fibrous transformation, and turns into cartilage, Avhich is the nidus wherein new bone is generated. It is within this cartilage that the cal- careous matter which is to constitute the exostosis is deposited. The latter, thus adventitiously formed, may be generated within the substance of the perios- teum, and be separated from the bone by a layer of the osseous investment just named ; or else it may rest directly on the bone itself. The latter, if the disease be confined to the periosteum, may remain perfectly healthy, although covered by this new for- mation ; but adhesions at length take place, and the bone gets involved in the morbid process. It is pro- bable that in such a case, the parenchymatous exos- tosis—viz., that generated by the bone itself—com- bines with the exostosis which has been shown to grow in the manner of an epiphysis. The latter variety is generally circumscribed, symmetrical, rarely mul- tiple, and the skin Avhich covers it, as well as the bone below it, remains in a perfectly normal state. The surface is rarely uniform, mostly irregular, raised, knotty, and stalactiform. When these bony growths have once reached the state of eburnation they give no more pain, and remain stationary. The paren- 23 266 SYPHILIS AND STRUMA. chymatous exostosis (or second species) is much more rare than the periosteal variety ; it is seated in the thickness of the bone, and is the result of regular osteitis. The inflammation is, however, circum- scribed, and has no tendency to what is called hyper- ostosis, as is noticed in scrofula ; it is, on the con- trary, simple and well defined. The compact por- tion of the bone is affected in this kind of exostosis, whereas the spongy texture suffers in struma. The osteocopes are here extremely severe, because the inflammation occupies a very compact fibrous tex- ture, which circumstance gives rise to a sort of stran- gulating sensation. Swelling of the bone occurs, and a plentiful deposition of calcareous matter takes place within the tumour. Scarpa used to explain the mechanism of exostosis in such cases, by sup- posing that there was softening of the bone, resorp- tion of the calcareous portion already present, and a deposit of new earthy matter after the absorption of the original calcareous constituent. I must say that there are no facts which prove the accuracy of this theory. The most generally received opinion is, that a certain divarication takes place in the fibrous meshes of the part, that a plastic effusion occurs in the intervals of the fibres, and that a deposition of calcareous matter afterwards fills up these very inter- vals. This deposit of phosphate of lime becoming at length very large, and too bulky, gets finally atrophied, or else destroys the subjacent healthy structure, and remains stationary. This is the period of eburnation, or ivory exostosis. Syphilis and Struma.—You will do well to notice that syphilis may be combined with scrofula, the latter being either congenital, or acquired in conse- quence of the syphilitic taint; it is clear that in such cases the manifestations will bear a double character, and it is of some importance to distinguish accurately the respective symptoms peculiar to each of these SYPHILITIC EXOSTOSIS. 267 affections. Now just notice that scrofulous disease of the bones is almost painless at the beginning ; that unpleasant sensations come on but very gradually, and that it is only in the very latest periods that the pain becomes acute ; whilst the very reverse happens with syphilitic osteitis, for at the closing period— namely, that of. eburnation—the pain entirely disap- pears. Scrofula attacks very commonly the ends of bones, where the cancellated tissue is very abundant, whereas tertiary syphilis occupies the whole thick- ness of the compact texture. If the two diatheses are combined, the lesions do not affect the body of the long bones exclusively where there is much com- pact tissue, nor altogether the extremities or spongy texture of the same bones, but they are generally situated on intermediate points, which are then more or less near the middle or extremities of the bone, as syphilis or scrofula predominates. Thus may white swelling be of a syphilitic nature. Therefore you see that the form, seat, or intensity of the mani- festations you have to treat are not sufficient to estab- lish the diagnosis ; the present state and the accurate history of the case must be taken into account. Progress of Syphilitic Exostosis.—Chronicity is the rule here, and an acute stage the exception ; nor does the disease pursue a regular and steady course ; its onset is, on the contrary, marked by intermit- tence ; so that the regularity of progress, which has been looked upon as a pathognomonic sign of the affection, cannot be depended on. This affection, it watched from the very beginning, will be perceived to have a constant tendency to ossification and ebur- nation ; but this termination is not actually unavoid- able ; for resolution may occur either spontaneously, or by the assistance of art; and it is, m fact, not very difficult to bring it about, provided we be con- sulted early. Exostosis of a venereal nature may likewise terminate in suppuration, wheresoever its 268 CARIES AND NECROSIS. seat may happen to be ; but this process occasions much less pain when the disease has attacked the cancellated structure of the bone, than when it af- fects the compact portion. In such cases there is complete destruction of the organic portion of the bone, and nothing but the calcareous constituents are left. Caries and Necrosis.—Syphilitic osteitis sometimes ends in decided necrosis; the disease then lasts until the sequestrum is thrown off. But you must here remark that certain portions of the osseous system are more predisposed than others to caries and necrosis of a syphilitic nature. First and foremost are all the bones of the face ; and among those of the head, it is the ethmoid which is the most frequently attacked. The vomer is the bone the most frequently necrosed in tertiary syphilis ; and this necrosis is brought about in two ways—first, by the destruction of the perios- teum, caused by the presence of tertiary, sub-mucous tubercles ; secondly, by the direct affection of the bone. In both cases, however, a sequestrum is formed, which is not long in being eliminated. When the vomer is necrosed, the nose falls in, the nares are turned directly forwards, instead of looking downwards, and the tip* of the nose mounts upwards. In secondary syphilis, a quite different part of the nose suffers—namely, the alae, and they are frequently entirely destroyed after cicatrization ; the tip of the nose then turns downAvards, and the organ becomes crooked. When the tertiary symptoms settle upon the vomer, the patient is seized with frequent noc- turnal headaches and sharp pains at the root of the nose ; these pains are generally much increased by pressure, but when the mischief is going on far back within the nose, pressure has no effect. Patients are then troubled with coryza, which resists all ordinary means; the secretion of the part becomes muco- purulent, and even altogether purulent. The pus is PALATINE OSTEITIS. 269 thrown off from ulcerated surfaces, and often contains an osseous detritus ; it exhales a very shocking smell, owing to the peculiar nature of the ulcerations, and likewise because it often remains stagnant for a long time. When the two nasal bones get attacked, we perceive the skin covering them turning red, and the tumefaction which ensues causes an ugly deformation of the part, which latter is extremely painful and very sensitive to the touch. Notice that the pain may, as is the case in secondary symptoms, be sharpest at night. The inflamed points yield a false and crepi- tating fluctuation, which indicates the presence of air in the cellular tissue ; and this air may be looked upon as a sign of the perforation of the nasal bones. The frontal sinuses may be affected in the same man- ner, and occasion symptoms of a similar nature. Palatine Osteitis.—This inflammation is very fre- quent, and passes through the same stages which I have just described with reference to the nasal bones ; it generally settles in the median line, and has its seat at the junction of the two halves of the palatine process of the superior maxilla. This medio-palatine osteitis, which is by no means rare, mostly terminates by suppuration ; the mucous membrane is raised by a collection of pus beneath it; and the prominence, which is the result of the suppuration, has a fluctua- ting and crepitating feel ; and when perforation of those bones takes place, it mostly proceeds from the nose into the mouth. This syphilitic osteitis often attacks the incisive alveoli in subjects with whom no scrofulous complication exists ; these sockets_ swell the gums get of a vivid red, and puffed up; the two central incisors get loosened and longish ; all the four incisors are loon involved in the mischief; and if no means be taken to stay the progress of the dis- ease the alveoli will lose their connexion with the rest of the bone ; they get as loose as the teeth them- 23* 270 BONES OF THE CRANIUM. selves, and act at last as foreign bodies. The ordi- nary therapeutical means are powerless to arrest this destruction ; the best practice is, to remove the de- tached portion of bone, so as to prevent the irritation which its presence is causing. Bones of the Cranium.—Although these bones are almost completely formed of compact tissue, they are by no means exempt from tertiary syphilis, and any part of them may suffer. These cranial affections have mostly been observed to end in caries and ne- crosis, and very rarely in eburnation. The symptoms are the same as those I have enumerated when de- scribing the disease as affecting the nasal and palatial bones ; with this difference, however, that an organ of the most vital importance lies in the immediate vicinity of the cranial bones. Allow me now to give you a comparative table illustrating the differences existing between the syphilitic affections of the bones and the osseous lesions occurring in scrofula. Syphilitic Affections of Bone. 1. Very rare with young people. 2. Syphilitic precedents. 3. Compact texture of bones attacked. 4. Superficial part of the bone. 5. Little tendency to hyper- ostosis. 6. The pains which precede the development of the af- fection increase and become very intense, until they de- crease again, and entirely disappear in thelater periods of the disease. 7. A tendency to circumscrip- tion. 8. Exostosis. Scrofulous Affections of Bone. 1. Very frequent in youth. 2. Scrofulous precedents. 3. Spongy or cancellated tex- ture of bones attacked. 4. Deep parts of the bone. 5. Much tendency to hyper- ostosis. 6. The tumefaction precedes the pain, but the latter soon increases and becomes more and more intense as the dis- ease advances. 7. A tendency to diffusion. 8. Hyperostosis. ACTION OF THE OSSEOUS AFFECTION. 271 9. Tendency to ossification 9. Tendency to softening, to and eburnation, but very suppuration, caries, and ne- little to suppuration. crosis, and not to ossifica- tion. 10. A chain of syphilitic 10. A chain of scrofulous symptoms, either concomi- symptoms widely differing tant or antecedent. from those of syphilis, either concomitant or antecedent. 11. Rapid cure under appro- 11. Very difficult cure, often priate treatment. incomplete, and sometimes impossible. Syphilis may, hoAvever, be superadded to scrofula ; we must then, in combating any lesion, endeavourto find out to which of the two diatheses it is mostly owing, and select our therapeutic means accordingly. Action of the Osseous affection on the neighbouring parts.—Osteitis, and the subsequent exostosis, may, by their development, act upon parts, and organs in their immediate vicinity, and thereby occasion symp- toms of a very serious nature. I have mentioned already how the elastic tumours can act on the ner- vous centres, and I must here add, that the affections of the bones act much more mischievously upon the same nervous centres than the tumours do. The pressure or irritation may be situated either on the origin of the nerves, or on some point of the cerebro- spinal system. The symptoms are of course ex- tremely various. I have pretty frequently met with cases of syphilitic disease of the bones, composing the orbit, and mydriasis or dilatation of the pupil was generally the consequence of the same. When the disease is situated at the base of the cranium, there is paralysis of the fifth pair: but the motor oculi may also experience compression ; and when this happens, all the recti muscles, except the exter- nal, are paralyzed. The patients see very well when their eyes are directed straightforward ; but when they attempt to give a lateral glance, one of the eyes 272 ACTION OF THE OSSEOUS AFFECTION. remains unmoved, whilst the other obeys the will; the parallelism of the eyeballs is lost, and diplopia is the result. If the patients attempt to look upAvards, the inferior oblique muscle on each side fails to act, and there is again a want of parallelism, and conse- quent diplopia ; but the latter is then of a super- posed nature. I even recollect having seen cases of, polyopia resulting from tertiary lesions. The facial nerve is sometimes paralyzed in a similar manner under the influence of tertiary symptoms ; but this paralysis is always accompanied by deafness, whilst the affection of the same nerve, resulting from se- condary symptoms, has (as you probably recollect) no such complication. With secondary symptoms, the lesion of the facial nerve produces only a singing in the ears, which depends either on inflammation of the mucous membrane lining the Eustachian tube, or on slight congestion, or on extensive irritation in the throat. The eighth pair may likewise suffer com- pression from the same causes; obstinate vomiting then sets in, and is controlled with much difficulty. Another consequence of this species of compression is epilepsy ; but this otherwise formidable disease is, in such cases, easily got rid of. The fits commonly seize the patient when the osseous growth producing the compression gets more considerable and irritating. I must not omit to mention paraplegia as a casual effect of tertiary syphilis in the bones ; the nervous disturbance is then the result of an osseous lesion, which latter begins by circumscribed nocturnal pains, and develops very sloAvly. Paraplegia may also be produced by a cutaneous elastic tumour; but I need hardly say that the latter is never preceded by the gnaAving pains which generally usher in osteitis. It is very important to establish a correct differential diagnosis between these osseous lesions and the re- sults of an elastic tumour of the skin, for suppuration and the train of symptoms following compression are LACHRYMAL TERTIARY AFFECTIONS. 273 almost inevitable in the latter case, whilst in osteitis these results may be avoided. I must break off here for this day. When we meet again I will go on with the treatment of tertiary syphilis. LECTURE XXVII. TERTIARY AFFECTIONS OF THE LACHRYMAL APPA- RATUS ; TREATMENT OF TERTIARY SYMPTOMS. Before I enter upon the treatment of tertiary symp- toms, I will say a few Avords on the affections of the lachrymal apparatus, and syphilitic cachexia. Tertiary Affections of the Lachrymal Apparatus.— When the lachrymal apparatus becomes affected in consequence of facial osteitis, the existence of which is concomitant with other tertiary accidents, there can be no doubt about the nature of the affection ; but it sometimes happens that the osteitis occupies only that portion of the superior maxilla which gives support to the nasal duct, and then the pain may be very slight, and pass entirely unnoticed. The first symp- tom which attracts attention is an obstruction of the lachrymal sac, and a tumour about the inner canthus of the eye ; and if the disease be not promptly ar- rested, it may end in caries of the bones. It is of vital importance accurately to ascertain the nature of the dis- ease, for in tertiary syphilitic affections of the sac there is no need of operation, and setons or canulas would increase the mischief, and hasten caries and necrosis. Intra-orbital exostosis, or more frequently periostosis, is also pretty often met with. The development of this affection is marked at the outset by symptoms which are more or less apparent, and they mostly 274 SYPHILITIC CACHEXIA. end in exophthalmia. Some patients suffer from ampliopia, partial amaurosis, or complete blindness, before the eye protrudes. The periostosis is com- monly situated on the roof of the orbit, projects from under the orbital arch, and has a tendency to depress the eye ; if suppuration takes place, the destruction of the greater part of the upper lid is sure to follow, and the cicatrix which is left is sunk and sometimes very deep. Now, it may fairly be asked, as we have pretty well exhausted the list of tertiary affections, whether there is such a thing as a fourth degree in the succession of syphilitic sequelae. To this I am bound to answer in the affirmative. That quater- nary state may be called syphilitic cachexia ; but this period does not present very distinct characters ; it is, in fact, tertiary syphilis having reached a very high degree of intensity. It is, however, a very mistaken notion to imagine that this state is the result of seve- ral syphilitic affections ; one is quite sufficient; and, as I have often before stated, the real infection of the system does not happen twice. But I am glad to say that in our times this melancholy syphilitic ca- chexia is very rare. That wretched state may re- sult— 1st. From an originally bad or Aveak constitution. 2d. From complications and morbid tendencies independent of syphilis, as scrofula, scurvy, the her- petic diathesis. 3d. From an ill-timed and badly managed treat- ment. 4th. From the persistence of certain syphilitic ac- cidents. 5th. From any cause which tends to Aveaken the constitution. 6th, and lastly. From a peculiar temperament, which renders the patient quite refractory to treat- ment. If I were to attempt a description of syphilitic ca- TREATMENT OF TERTIARY SYMPTOMS. 275 chexia, I should fail to convey to you a clear notion of it, because its characters are not sufficiently well defined; it might indeed be called an exaggeration and an accumulation of all the forms which we have hitherto studied, combined with loss of flesh, pale- ness, flabbiness of all textures, sallow hue of the skin, weakness of the intellectual faculties, scorbutic mani- festations, and, finally, hectic or continued fever, with exacerbations towards the evening. This fever very often persists when the external cachectic symp- toms have entirely disappeared; and it is useful to know that it is sometimes symptomatic of an internal suppuration which escapes our notice. To all these symptoms aphonia is soon added ; diarrhoea, profuse sweats, and defective nutrition come on, and death at last releases the wretched being from his sufferings. But, I repeat it, this species of cachexia is now very rare, and, I may add, that it will become still more so, thanks to the progress made in the therapeutics of venereal diseases. Treatment of Tertiary symptoms; Prophylaxis.— Let it, in the first place, not be believed, that an in- dividual who is placed under the influence of the sy- philitic diathesis will inevitably be attacked by ter- tiary symptoms. Should, however, the disease be abandoned to itself, there is much likelihood that he will not escape them. In order to ward off these ter- tiary symptoms, you should see that the treatment of primary and secondary accidents be conducted with the greatest care, and in accordance with a well-de- vised method. Those practitioners who have laid all the blame of tertiary symptoms on mercury were greatly mistaken ; but still, as soon as the tertiary period has evidently set in, mercury should be left off, and recourse be had to iodide of potassium. We know that mercury, taken in time, may prevent or retard secondary manifestations: thus it may be looked upon as a sort of prophylactic as regards 276 TREATMENT OF them ; so may likewise iodide of potassium be look- ed upon as a prophylactic as regards tertiary symp- toms ; but mind that you expect no more from the iodide than you do from mercury—namely, the modi- fication and mitigation of the symptoms, without com- plete eradication of the diathesis. Now-a-days, to render the treatment of secondary syphilis complete and rational, it should always be followed by the exhibition of iodide of potassium. This substance is, however, not only useless, when employed against secondary symptoms and those of transition, but very often hurtful; yet, when second- aries have been of long standing, it may produce beneficial effects ; it is also useful, as an adjuvant of mercury, in those affections which in some degree lie between the secondary and strictly tertiary manifesta- tions ; and finally, it is indispensable for combating the symptoms of a decided tertiary nature. WTalsh was the first practitioner who used iodide of potas- sium as an anti-syphilitic agent; before him, this peculiar power was pe^iectly unknown. But his ex- periments were more calculated to cause the entire rejection of the remedy, than to favour its gene- ral adoption, for he gave it for all affections which were then looked upon as syphilitic—blennorrhagia, epididymitis, chancres, &c. I have been at much pains to ascertain its action, and after many trials, I have arrived at the conviction, that its effects are limited to accidents of transition between the second- ary and tertiary periods, and to the tertiary symp- toms themselves. It is likewise a mistake to suppose that the iodide of potassium cannot act unless the pa- tient have previously been subjected to a mercuria course Any syphilitic accidents should be treated according to*the medication essentially fit for them, without paying much regard to the means used ante- riorly In order to become well acquainted with the proper manner of administering the iodide of potas- TERTIARY SYMPTOMS. 277 sium, we should take the trouble of studying its ef- fects independently of its curative action. First let us see how it acts on the skin. It may produce on the cutaneous surface divers psydracious and acnoid eruptions. The pustules are generally surrounded by a vividly red areola, and the usual seat of these eruptions is below the umbilical region, as the nates, thighs, &c, whereas the common acne (not to men- tion its other characters) is mostly situated in the upper half of the body. To these peculiarities it may be added, that the pustules will fall in immediately the administration of the iodide is interrupted. Ex- anthemata, impetigo, and lichen, are very apt to be produced by the use of this salt; and what you ought to keep especially in mind is, that ecchymosis, and purpura in the inferior extremities, are sometimes caused by the action of the iodide of potassium. The effects of the latter on mucous membranes should also becarefully observed. It may cause inflammation of the conjunctiva, the sub-mucous cellular tissue lying under which gets then infiltrated and puffed up ; the eyelids turn red and cedematous, and when the in- flammation and effusion are not arrested, the internal parts of the eye become involved in the affection, and photophobia is the result of this state of things. The normal mucous secretion is always a little increased, but it does not take the muco-purulent character, as is the case in catarrhal ophthalmia. Coryza of a more or less severe nature often exists at the same time : it is preceded and accompanied by headache, and a pretty abundant raucous secretion ; but this coryza never reaches the suppurative state ; it never pro- duces more than a catarrho-serous flux. These affec- tions never give rise to any fever, and they disap- pear as soon as the iodide is given up. This coryza is an accident which Ave should not overlook, for it is of importance to avoid it when we have to treat a ter- tiary affection of the nasal fossae. As for the effect 24 278 TREATMENT OF of the iodide on the intestinal canal, I have to state that persons enjoying good health can bear very large doses of it; I have given as much as fifteen drachms a-day. M. Puche has often given ten drachms per diem, after commencing with six; and it has been noticed that it improves the appetite of the persons who use it. With some patients a certain pleurody- nic sensation, corresponding to the cardiac extremity of the stomach, is felt after its ingestion, but it never causes vomiting. The sub-mucous cellular tissue of the stomach may, by the use of this iodide, undergo the same modifications which we have noticed the conjunctiva to be subject to—a sort of hyper-secre- tion and intestinal ptyalism takes place, and much of the fluid which ought to have been secreted by the skin is rejected by the mouth. This liquid has a slight taste of iodine ; it is not fetid in the least; the gums are not swollen, and there is no fcetor in the breath, as happens in mercurial ptyalism. The same effect may be produced on the other portions of the intestinal canal ; the patients are then seized with abundant serous diarrhoea. The iodine is eliminated from the system by the kidneys; half an hour after the ingestion of it, its presence may be ascertained in the urine, and it should be remembered, that the presence of iodine in the blood increases the renal secretion. I have even observed a case of polydip- sia which went on as long as the iodide was used, but disappeared Avhen the latter was discontinued, and gradually sprang up again as the use of the salt was resumed. The effects of the iodide of potassium on the cir- culation are of a sedative kind; it diminishes the number of arterial pulsations and lowers their force, but they may regain their normal standard if the re- medy act beneficially on the system : the same arte- rial energy may also reappear when the iodide causes a slight phlegmasia. This salt is somewhat anaplastic, TERTIARY SYMPTOMS. 279 for it has rather a tendency to liquefy the blood, and may even produce the peculiar hemorrhages of pur- pura. When the effect of the iodide on the nervous system is carefully watched, it is found to cause a certain excitement of the nervous centres, followed by a little uncertainty in the movements and in the intelligence. Doses and Forms.—If the efficacy of the iodide of potassium has ever been doubted, it is because no one would venture to give it in doses sufficiently large to test it fairly. Most practitioners confined themselves to three or four grains a-day—no wonder that no effects were produced. The daily dose ought to be fifteen grains to begin with ; two or three days afterwards, forty-five grains may be given every day in three distinct doses. If the remedy has no patho- genic effect we must be guided by the therapeutic action, so that if the curative effect be not apparent at all in three or four days, the dose should be aug- mented. The influence produced on the osteocopes may very well serve as a criterion of the action of the remedy, provided these osseous pains do not arise from suppuration, and they be strictly a result of the diathesis. I have had patients in whom the removal of these pains required as much as one drachm and a half, two drachms, and even three drachms per diem. When a certain dose has once been fixed upon, it ought to be persevered in as long as the therapeutic effect is evident, and so long as the pathogenic action is not alarming. But the medical attendant must in this matter, as in many others, use his judgment, and regulate the modifications which the treatment is to undergo, according to the peculiar circumstances of the case. Forms _The iodide of potassium has been given in capsules, in solution, in syrup, &c ; rarely in the form of pill, for this salt is very deliquescent; I generally give it in syrup, and I have found bitters 280 FORMS OF to be the best adjuvants—viz., syrup of gentian, of saponaria, of quassia, de cuisinier, of sarsaparilla, &c. One pint of syrup is to be used for one ounce of the iodide, which will give about twelve grains to the spoonful; the same quantity may also be given in the sweetened mistura acaciae, or in the syrup of poppies, or of lactucarium. As to the diet, it ought to be of a tonic and regenerating nature—chops, steaks, wine, porter, &c. You see, therefore, that Ave know pretty well which ought to be the daily dose of the iodide, but Ave are not so well informed as regards the absolute quantity which can be given with safety ; it is impossible to fix this beforehand. Neither do we know exactly how much time this medication may be continued in order to free patients from the possibility of a relapse. I will merely repeat here Avhat I said about the mercurial medication— namely, that the iodide must be kept on for as long a time as will fairly warrant us in supposing that it has done its duty ; but you must recollect that neither this salt nor mercury is a certain and unfailing pro- tection against relapses. Yet I must say that patients who have persevered with the iodide for three or six months have remained a long time without fresh attacks, and they will perhaps never experience any. There is no occasion for fearing (as some practi- tioners do) that glandular organs will be in danger of undergoing the process of absorption by the use of iodide of potassium. This apprehension is quite unfounded. If these organs are not. diseased, they will not diminish under the use of the iodide, as this substance exercises its activity only upon tissues attacked with tertiary affections. You must be care- ful to modify the treatment just described according to certain peculiar manifestations. For instance, when you have to contend against syphilitic sarco- cele, and the same is exempt from complications, it will be sufficient to use the general treatment. But IODIDE of POTASSIUM. 281 when there is much inflammation, you must have recourse to antiphlogistics and emollient applications ; and if it were noticed that the testicle is suffering both from syphilis and struma, anti-scrofulous remedies should be added to the usual treatment of such cases. The plastic effusion will be efficiently con- trolled by rubbing the part with the mercurial oint- ment, and covering the whole with a soothing cata- plasm ; and much benefit will likewise be derived in these cases by the methodical compression with strips of plaster, Avhich was spoken of when I considered epididymitis. If you have elastic tumours of the testis to treat, the best practice is to open them as soon as fluctuation is detected, and you should have recourse to sedative applications when you perceive that they are surrounded by an inflammatory areola. But when the ulceration presents no redness, nor any symptoms of irritation, a very good wash may be made with a solution of iodine, in the proportion of one-half or a whole drachm to twelve ounces of distilled water; and when this solution is being pre- pared, a certain quantity of iodide of potassium should be added, to prevent the precipitation of the iodine. If the granulations of the tertiary ulcerations are too prominent, they should be destroyed with the pate de Vienne, or any other caustic. When elastic tumours are not situated in the scrotum or testicle, they may be attacked by very energetic means—viz., mercurial frictions, Vigo's plaster, blisters followed by irritative dressings, as advised by Malapert, &c.; and where suppuration has occurred, the matter should be freed without delay. As for the elastic tumours situated on the mucous membrane of the nasal fossae Or mouth, they may be very beneficially acted upon by lotions containing a solution of iodine, in the proportion of from two to six parts of this sub- stance to one hundred of distilled water ; in fact, the 24* 282 TREATMENT OF NODES. proportion of the iodine may be increased as long as no pain is produced by the application. The muscular retraction, or plastic degeneration of the muscles, requires local applications besides the internal remedies. Topically, I use circular com- pression, carefully applied with strips of Vigo'splaster. Next time we meet I shall take up the treatment of Nodes, and conclude the course with a short re- capitulation. LECTURE XXVIII. TREATMENT OF NODES.--GENERAL RECAPITULATION. You probably remember that I divided nodes into three kinds—first, the acute or elastic; secondly, the fluctuating; and thirdly, the plastic. The first re- quires antiphlogistics and soothing applications ; but if, in spite of these, suppuration comes on, exit should be given to the matter, in order to prevent the mis- chievous effects of its remaining in contact with the bone. But this evacuation should, as much as possi- ble, be practised by sub-cutaneous incisions, so as not to bring the surface of the bone in contact with the external air. Exostosis will require the internal treat- ment chiefly, though there is no doubt that repeated blisters hasten resorption considerably. But if the periostosis has already arrived at the plastic state, the treatment must be of a very energetic nature ; for when ossification and eburnation have taken place, our art is powerless. To combat these exostoses ef- fectually in their early stage, we should ha\"e recourse to mercurial ointment, to deobstruants, to compres- sion, &c. WTien the tertiary symptoms consist only GENERAL RECAPITULATION. 283 in osteocopes, they will generally give way in about a week's time, where adequate means be used ; if it happen otherwise, you may suspect some local inflam- mation to be going on. If the patient, affected with osteocopes, is in a state which counter-indicates the general treatment,—if he be labouring under an attack of blennorrhagia,—it will be advisable to use merely topical applications for a little while, and among these you will find blisters very well calculated to remove pain; they should therefore be continued until you are able to have recourse to the internal medication. In this respect exostosis may be classed with perios- tosis. But when exostosis has reached the stage of eburnation,it is impossible to effect its resorption, and no reliance must be placed on the iodide of potassium. The surgeon's knife is then the only resource; the exuberant portion of the bone must be removed, if it prove at all inconvenient; and this operation Avill in general have to be performed on the tibia, forearm, clavicles, or sternum. If excision is resorted to, it should not be delayed, and be done before the exos- tosis, if it is of the nature of an epiphysis, be adherent to the bone ; there is no difficulty whatever in the re- moval. If the osteitis has suppurated, the matter should not be allowed to stagnate, but be removed by repeated dressings; any detritus which could irri- tate the soft parts, by acting as a foreign body, should be carefully taken away; in fact, the usual rules of sound surgical practice, unconnected with syphilis, should be strictly adhered to. Allow me now, gen- tlemen, before finally closing this course of lectures, to recapitulate, in a few Avords, the precepts which I have endeavoured to inculcate into your minds. The great class of venereal diseases comprises two very distinct orders—first, the non-virulent diseases, the type of Avhich is blennorrhagia ; the second, the virulent diseases, the type of which is chancre. First order.—The blennorrhagic affections do not 284 GENERAL RECAPITULATION. taint the constitution, are not transmissible by here- dity, and never yield any positive results by inocula- tion either on the skin or mucous membranes; they are contagious in the manner of irritants, the simple catarrho-phlegmonous discharge being the most com- mon form. Second order.—The virulent affections owe their origin to a peculiar principle, to an ulceration which can be reproduced at will, and inoculable within a certain period. The ulceration always springs up at the very spot where the vrirulent matter has been im- planted, and its evolution takes place in a variable space of time. The virulent effect may remain strictly local, and merely give rise to consecutive phenomena, of which the most common is the suppuration of the inguinal glands; but it may penetrate into the eco- nomy, and determine in the same a set of characte- ristic symptoms. The general infection of the sys- tem is the result of an idiosyncrasy Avhich does not invariably exist in every individual. The most tan- gible phenomenon of this infection is the specific in- duration of the chancre. There is no such thing as a specifically indurated chancre, without subsequent symptoms of constitutional syphilis. Once or twice in a hundred cases the induration may be ill-defined and pass unnoticed; but if the attention be directed to the inguinal glands (which inevitably suffer by the infection), the existence of an indurated chancre may, by their state, be inferred ; for a bubo, consecutive to such a chancre, never suppurates specifically. There is no constitutional syphilis without a primary- local accident. When the infection has taken place, we may look for the secondary manifestations within a twelvemonth. But if a mercurial treatment be used, these manifestations may be prevented or retarded for more or less time, or perhaps for ever. When no treatment, hoAA^ever, has intervened, there is an admi- rable order in the succession of the manifestations, GENERAL RECAPITULATION. 285 which is denied only by those people who will not be convinced. Primary, consecutive, secondary, tran- sitory, and tertiary accidents follow each other with the most perfect regularity. But I repeat it,—a treat- ment breaks up the order altogether. If a mercurial course has been gone through, the secondary manifes- tations may, under its influence, be retarded for a va- riable time ; but it does not destroy the diathesis, and merely postpones the secondary symptoms. On the other hand, you will remember that the mercurial treatment does not prevent tertiary accidents, and these may even appear whilst the secondary symptoms are being kept off by mercury; the latter may then make their appearance after the tertiary accidents have dis- appeared, and thus the order of the manifestations may be totally inverted. Constitutional syphilis can be contracted but once,—the diathesis can never be doubled. The diathesis persists, but the manifesta- tions are not certain or inevitable. This diathesis is not incompatible with health. Syphilitic cachexia is very rare. The non-virulent affections require no spe- cific medication, neither do the virulent primary acci- dents ; mercury is used for the latter only in excep- tional cases—namely, where the chancre is indurated. Constitutional syphilis demandsa mercurial treatment; but Avhen the later secondary symptoms and the ter- tiary have come on, mercury should be abandoned, and iodide of potassium be taken up. The latter is then the medication par excellence. WheneA'er we have to treat any peculiar disorder or affection of the viscera, along with syphilis, we should never lose sight of the indications Avhich belong to that intercur- rent disease, and should even delay the specific medi- cation, if found necessary. It is now my pleasing duty to thank you for your kind attention. I am proud of having seen you here in such numbers, A\'hen the country offered so many attractions, and the toils of the winter were calling 286 GENERAL RECAPITULATION. for relaxation. I hope that the practical results of these lectures will be the alleviation of human suffer- ing wheresoever you are scattered. With my best wishes I bid you farewell. APPENDIX. The reporter of these lectures made a collection of the Formulae which he saw in use at the Hopital du Midi, while attending the wards in the summer of 1847. A great many of them are interspersed in the Lectures; he thinks, however, that presenting them in a synoptical form will promote convenience. NON-VIRULENT DISEASES. 1. Injection for Balano-posthitis.—Make three in- jections a-day between the glans and prepuce with the following fluid:—Distilled water, three ounces; nitrate of silver, two scruples. 2. Abortive Treatment of Blennorrhagia.—Make one injection only with the following liquid:—Dis- tilled water, one ounce; nitrate of silver, fifteen grains. And take every day, in three doses, the following powder: Cubebs, one ounce; alum, thirty grains. 3. Injection for Blennorrhagia when the period for the Abortive Treatment is passed.—Make three injec- tions daily with the following liquid:—Rose water, six ounces and a half; sulphate of zinc, and acetate of lead, of each, fifteen grains. 4. Internal Treatment of Blennorrhagia.—Take one tablespoonfulof the following emulsion three times a-day:—Copaiba, syrup of tolu, and syrup of poppies, of each, one ounce; peppermint Avater, two ounces; gum arabic, a sufficient quantity; orange-flower water, two drachms. 288 FORMULA. 5. Acute stage of Blennorrhagia.—Twenty leeches to the perinaeum; bath after the leeches; refreshing drinks; rest in bed; low diet; suspensory bandage. Take one of the following pills four times a-day :— Expressed and inspissated juice of lettuce (lactuca sativa), and camphor, of each, forty-five grains; make twenty pills. 6. Gleet.—Make every day three injections with the folloAving liquid:—Rose water, and Roussillon wine, of each, six ounces; alum and tannin, of each, ten grains. 7. Subacute Epididymitis.—Rub the testis twice a day with the following ointment:—Stronger mercu- rial ointment, and extract of belladonna, equal parts of each: a poultice to the part after the ointment, and rest. 8. Acute Epididymitis.—Fifteen leeches to the pe- rinaeum, and the same number in the groin correspond- ing to the affected epididymis; bath after the leeches; barley-water for common drink; low diet, rest, and poultice. 9. Chronic Epididymitis.—Apply Vigo's plaster to the testes, and Avear a suspensory bandage.—(Simple plaster, yellow wax, pitch, ammoniacum, bdellium, olibanum, mercury, turpentine, liquid styrax, and volatile oil of lavender, are the component parts of Vigo's plaster.—Reporter of Lectures.) VIRULENT DISEASES. PRIMARY SYMPTOMS. CHANCRES. 10. Abortive Treatment of Chancre.—Within the first five days of the contagion, destroy the chancre with potassa fusa cum calce (pate de Vienne). FORMULAE. 9 11. Regular non-indurated Chancre.—Frequent dressing with the aromatic wine,* extreme cleanliness, occasional light cauterization with the nitrate of silver. Rest, demulcent drinks; when there is inflammation, antiphlogistics, purgatives, and emollient applica- tions. (N.B. No mercury.) 12. Phagedenic Chancre.—Complete cauterization with the nitrate of silver, the liquid nitrate of mercury, the potassa cum calce, or the hot iron, according to circumstances. Afterwards lotions with aromatic wine, three ounces; extract of opium, three grains; or, aro- matic wine, eight ounces ; tannin, thirty grains; or dis- tilled water, three ounces; tartrate of iron and potash, four drachms; or,in the scrofulous diathesis, distilled water, three ounces; tincture of iodine, one drachm; or, sulphur ointments, and sulphureous baths. Inter- nally: tartrate of iron and potash, one ounce; distilled water, eight ounces. One ounce three times a-day. 13. Indurated Chancre.—Three dressings a-day with the following ointment:—Calomel, one drachm; axunge, one ounce. (N.B. Mercury is used internally for the indurated chancre: as to the mode of adminis- tration, see secondary syphilis, No. 21, as the metal is given in the same manner in both cases.) BUBOES. 14. Acute non-Specific Adenitis, vet Inflamed Bubo. —Twenty leeches on the tumour, emollient cata- plasms, barley-Avater as ordinary drink, rest, broths. * Aromatic wine (Parisian codex). Aromatic species (viz. the dried tops of the sage, balm, thyme, wild thyme, marjoram, hyssop, peppermint, wormwood), two parts: vulnerary spirit (viz., alcoholic distillation of anthyllis vulneraria, origanum, gnaphalium dioicum, arbutus uva ursi, and several others, known under the name of vulnerary flowers, and largely ex- ported through Europe by the Swiss for popular purposes), one part; red wine, sixteen parts. Macerate for a few days, then filter. 25 290 FORMULA. If fluctuation be detected, let out the purulent matter by a free incision. 15. Abortive Treatment of the Bubo Consecutive, by absorption of the Virus, to the non-indurated Chan- cre.—Deep cauterization of ten minutes' duration, with the potassa fusa cum calce, and await the fall of the eschar. (N.B. Analogous to the early destruction of chancre.) 16. Bubo Consecutive to the non-Indurated Chan- cre, which inevitably Suppurates.—Use antiphlogistics according to circumstances, and then free the puru- lent matter by cauterization with potassa fusa; gradu- ally destroy afterwards, by the use of caustics, the glandular mass which lies at the bottom of the open bubo. To the poultices used after cauterization may be added an ointment, of equal parts of extract of belladonna and mercurial ointment. 17. Horse-shoe Bubo and Gangrene.—Horse-shoe and phagedaenic ulcers in the groin, resulting from a suppurating bubo, require the dressings mentioned in No. 12. Gangrene: Chloride of lime, one ounces distilled water, three ounces. This lotion is to be used seA'eral times a-day. Or, powdered charcoal, poAvdered Peruvian bark, equal parts of each, to be thickly applied to the sore. PREPUTIAL COMPLICATIONS. 18. Phimosis.—Inject between the glans and pre- puce the aromatic wine Avith opium, as mentioned in No. 12, and use emollient and sedative applications; if gangrene be imminent, operate. 19. Paraphimosis.—Keep the organ raised, and surround it with cold compresses. Bland diet, re- freshing drinks; endeavour to reduce or free the con- striction by an incision, according to circumstances. After the strangulation is relieved, use emollient and antiseptic applications combined with opium. FORMULA. 291 SCROFULOUS COMPLICATIONS. 20. Order every day the following emulsion in three equal doses;—Iodine, three grains; oil of sweet almonds, one ounce; gum arabic, a sufficiency; al- mond emulsion, three ounces. SECONDARY SYPHILIS. 21. Order every day three tumblers of decoction of saponaria leaves, and put into each tumbler one table- spoonful of sirop de cuisinier (N.B. Sirop de cuisinier: sarsaparilla, borage and white rose leaves, senna, ani- seed, honey, and sugar); and take every day one of the following pills:—Proto-iodide of mercury, inspis- sated juice of lactuca sativa, of each forty-five grains; extract of opium, fifteen grains; extract of hemlock, one drachm and a half. Mix, and make sixty pills. 22. Slight Stomatitis.—To gargle three*times a-day with the folloAving liquid;—Decoction of lactuca sa- tiva, five ounces; honey, one ounce and a half; alum, one drachm and a half. 23. Mercurial Stomatitis.—To gargle three times a-day with the following liquid:—Decoction of lac- tuca sativa, five ounces; honey, four drachms; hydro- chloric acid, fifteen drops. 24. Salivation.—Order every day one drachm of flowers of sulphur, incorporated with honey. As a common beverage, the nitric acid lemonade. Gargle three times a-day with decoction of lactuca sativa, five ounces; honey, four drachms; hydrochloric acid, fifteen drops. 25. Mucous Patches in the Mouth.—Gargle three times a-day with decoction of hemlock, six ounces and a half; bichloride of mercury, three grains. 26. Mucous Tubercles around the Anus (Condylo- mata).—Put twenty leeches to the perinaeum. Take every evening a small enema of a decoction of poppy- 292 FORMULA. heads, cold, and mixed with twenty drops of lauda- num. As an habitual beverage, take linseed tea, sweetened with sugar and almond emulsion. 27. Vegetations.—Put twice a-day on the vegeta- tions the following powder:—Powdered savine, oxide of iron, calcined alum, of each one drachm. TERTIARY SYPHILIS. 28. Order one tumbler of decoction of saponaria three times a-day. In each tumblerful put a table- spoonful of the following syrup:—Syrup of sarsapa- rilla, one pint; iodide of potassium, one ounce. INDEX. Abscess, urethral, 61, 99 of the urethra, 99 Adenitis, or inflammation of the lymphatic vessels and 187 Anal blennorrhagia, 126 Anti-blennorrhagic action, 70 Appendix, 287 Arthritis, blennorrhagic, 140-145 seat of the rheumatism in, 142 treatment of, 144 Blennorrhagia, 18-145 absolute diagnosis of, 41 accidents which may complicate, 39 cause of rheumatic arthritis in, 141 chronic stage in, 101 defence of the new doctrine in, 74-91 differential diagnosis of, 40 duration of, 37 elements of the rational diagnosis in, 41 false, 46 general action on the system in, 70 history and nomenclature of, 24 hygiene preventives in, 42-43 in the female, 114-126 localities of, 27 not produced by incubation, 35 of the vulva, 114 ordinary mode of transmission of, 34 paraphimosis in, 51 phimosis in, 16, 50 26 294 INDEX. Blennorrhagia, predisposing causps of, 29 prognosis in, considered generally, 42 progress of, 37 special causes of, inquiry into, 30 structural alterations in, 38 treatment of, considered generally, 42, 92-103 abortive, 43, 95 therapeutic means in, 44 when fairly developed, 66-74, 92-103 when ihe disease is on the decline, 100-103 urethral description of, 55 uterine, 122 vaginal, 119 „ Blennorrhagic affection of the testis, 104-114 premonitory symptoms of, 106 treatment of epididymitis in, 109 what favourable to its deve- lopment, 105 affection of the ovary, 135 arthritis, 140-145 ophthalmia, 127-140 treatment of, 136-140 urethritis in women, 116 symptoms and treatment of, 117 Bones of the cranium, 270 Bubo, or adenitis, 187-199 causes of, 187 how divided, and mode of production, 187 prognosis in, 193 treatment of, 195 Calomel used for frictions, 242 Cancer, sometimes confounded with chancre, 168 Caries and necrosis, 268 Chancre, 19, 31-33,156-186 anal, 170 confounded with cancer, 168 diagnosis in, 164 indurated, 160 deviations from usual progress of, 163 topical applications for, 184 not produced by incubation, 36 peculiarities relative to the seat of, 169 phageda?nic, characters of the, 159 prognosis in, 171 INDEX. 295 Chancre, treatment of, 172-186 abortive, 176 prophylactic, 172 purely phagedaenic, 181 urethral, 169 Chordee, frequent cause of rupture, 64 Copaiba, how used, 72 casualties to which it may give rise, 72 eczema produced by the use of, 72 formulas for the administration of, 93 mode of administration, and its doses, 92 pain in the lumbar region caused by the use of, 73 Corpora cavernosa, induration of the, 64 Cranium, bones of the, 270 Cystitis, at the neck of the bladder, 99 Differential diagnosis in syphilitic sarcocele, 252 Dysuria, a symptom of blennorrhagia, 60 Elastic syphilitic tumours, general considerations on, 256 a tertiary accident, 259 Empirical preparations of mercury, 246 Epididymitis, treatment of, 109 the declining stage, 112 Erections, how controlled, 97 Eruptions, exanthematous, 211 papulous, 213 secondary, 215 syphilitic, general characters of, 218 Exostosis, syphilitic, progress of, 267 False blenorrhagia, 46 progress and complications of, 47 prognosis in, 49 symptoms of, 46 treatment of, 49 Febrile reaction in urethral blennorrhagia, 60 Female, blennorrhagia in the, 114-126 Fibrous and osseous system, lesions of the, 261 Formulae for non-virulent diseases, 287 virulent diseases, 288 General recapitulation, 282 Gonocitis, or blennorrhagic white swelling of the knee, 140 Hemorrhage, urethral, 98 296 INDEX. Iritis, syphilitic, 223 Inflammation of the lymphatic glands, 60 prostate gland, 62 Inoculation of virulent matter, 154 Mechanism of syphilis, 206 Mercurial treatment of syphilis, 238 Mercury, doses of, 237 chemical forms of, most advantageous, 240 empirical preparations of, 246 Mucous membranes, secondary affections of, 226 papules, 214 Necrosis and caries, 268 Nodes, 264 treatment of, 282 Non-virulent diseases, formula? for, 287 Onychia, 225 Ophthalmia, blennorrhagic, 127-140 communicated by contagion, 127 metastatic, 129 diagnosis, differential, in, 132 prognosis in, 133 sympathetic, 133 duration of, 134 prognosis in, 135 symptoms of, 135 treatment of, 136-140 Osseous and fibrous system, lesions of the, 261 affection, action of the, on the neighbouring parts, 270 Osteitis, palatine, 269 Ovary, blennorrhagic affection of the, 125 Palatine osteitis, 269 Paraphimosis, 51 treatment of, 54 Phagedaenic ulceration, 185 Phimosis, 46, 50 operation for, 51 treatment of, 53 Porte caustique of Lallemand, 99 Retention of urine, 97 INDEX. 297 Ricord's new doctrine, defence of, 74-91 Rupture of the urethra, 64 Sarcocele, syphilitic, 249 diagnosis in, 252 treatment of, 255 evolution and progress of, 259 plastic, prognosis in, 256 treatment of, 255 Sedillot's pills, 186 Sores, syphilitic, general character of, 218 Struma and syphilis, 266 Syphilides, or eruptions on the skin, 211 Syphilis, 145 constitutional, 199 duration and progress of, 156 causes of, 199 * etymology of, unknown, 146 hereditary, 202 mechanism of the affection, 206 mercurial treatment of, 238 propagation of, 151 secondary, symptoms premonitory of, 207 action of mercury in, 233 symptoms, 233 anti-mercurial medication in, 236 prognosis in, 228 treatment of, 231, 246 Syphilitic sarcocele, 249 Tertiary manifestations, 248, 261 syphilitic sarcocele the earliest, 249 accident, an elastic tumour, 259 affections of the lachrymal apparatus, 273 muscular affections, 258 osteocopes, 262 peculiar characters of, 262 symptoms, prophylactic treatment of, 275 Testis, blennorrhagic affection of the, 104-114 Treatment of blenorrhagia, 42, 44, 66-74, 92-103 when the disease is on the decline, 100-103 Tubercular sarcocele, 255 Ulcerations, phagedaenic, 185 secondary, 226 298 INDEX. Urethral blennorrhagia, description of, 55 accidents, complicating, 60 symptoms of, considered generally, 36 hemorrhage, 98 Urethritis in women, blennorrhagic, 116 symptoms, and treatment of, 117 Uterine blennorrhagia, 122 treatment of, 124 catarrh, 174 Vaginal blennorrhagia, 119 treatment of, 121 Vallet's pills, 185 Venereal, the history of, 13-17 accidents, the use of the speculum when begun in, 20 Benedict, Fernel, and John Hunter, on the, 15 defence of the new doctrine in, 74-91 modern classification of, 18 supposed always to have existed, 14 the study of it, as it regards morals and hygiene, and legal medicine, 14 virulent, 74 Virulent diseases, formulas for, 288 order of, 145 matter, phenomena resulting from the inoculation of, 153 THE END. JOHN HUNTER'S COMPLETE WORKS. The attention of the profession is particularly called to this great •work so essential to a medical library. The publishers have but a fetv copies on hand; and as it is probable that it -will not be re-printed, no~j> is the time to secure it. This is the only complete edition of the works of the distinguished physiologist and surgeon ever published. LECTURES ON THE PRINCIPLES OF SURGERY: A Treatise on the Teeth ; Treatise on Venereal Diseases; Treatise on Inflammation and Gunshot Wounds; Observations on Certain Parts of the Animal Economy; and a full and Comprehensive Memoir. Each of the Works is edited by men of celebrity in Medical Science, and the whole under the superintendence of JAMES F. PALMER, Of the St. George's and St. James's Dispensary. 4 vols. 8vo. Price $12,00. "One distinctive feature of the present edition of Hunter's works has been already mentioned, viz.: in the addition of illustrative notes, which are not thrown in at hazard, but are written by men who are. already eminent for their skill and attainments on the par- ticular subjects which they have thus illustrated. By this means, whilst we have the views of John Hunter in the text, we are en- abled, by reference to the accompanying notes, to see wherein the author is borne out by the positive knowledge of the present day, or to what extent his views require modification and correction. The names of the gentlemen who have in this manner assisted Mr. Palmer, are guarantees of the successful performance of their task," —Med. Gaz. 299 COLLES'S LECTURES ON SURGERY. The high reputation attained by Prof. Colles in the treatment of venereal diseases, has given him a European celebrity identified with medical literature; and his peculiar views on that subject, in hia " Lectures on Surgery," are written with a freedom and force that commands universal approbation. To be without the work is to be ignorant of the wisest men's opinions. THE COURSE OF LECTURES ON SURGERY, Delivered in the Royal College of Surgeons in Ireland, By the iate ABRAHAM COLLES, M.D., For Thirty-four years Professor of Surgery in the College. From notes collected and repeatedly revised by SIMON M'COY, ESQ., F.R.C.SJ. Price §1,75. " Even without the precious impress of Mr. Colles's name, any practical, man looking over these pages would at once perceive that he was reading the doctrines of a master in the art."—Brit, and For. Med. Rev. "We feel assured that no medical library in the kingdom will long remain devoid of these volumes."—Dublin Hospital Gazette. " These Lectures contain much valuable and practical matter."— Med. Chir. liev. " We have no hesitation in affirming that they constitute a better body of surgery than is to be found in any volume which has been offered to the American profession in so accessible a form."—West. Journ. Med. and Surg. " We have concluded our perusal of these lectures with a very high opinion of the judgment and surgical acumen of the late Pro- fessor Colles, and can confidently recommend the work as one re- plete with sound doctrines and practical facts.—Land. Med. Gaz. " The volume before us is evidently the work of a man of acca- rate observation and extended experience: not the closet production of a compiler who has acquired his knowledge of diseases only from the recorded observations of others."—J\T. Y. Journ. of Med. " They are characterized by great vigor of thought, with a singu- lar simplicity of expression, which will fix the attention of the most careless reader. . . « Those who wish to study surgery, stripped of its technical ver- biage, must read these lectures as they fell from the lips of this dis- tinguished Irish professor."—N. O. Med. and Surg. Journ. 300 * \ - , >*■ '■• : f